This page intentionally left blank Evidence-Based Anaesthesia and Intensive Care A comprehensive volume on the theories and applications ofevidence-based anaesthesia and critical care.Coming from the internationally renowned Cochrane Collaboration – the global force in evidence-based medicine – this promises to be an authoritative guide for anaesthetists. The Cochrane Anaesthesia Review Group is one ofthe largest in the collaboration and,as Co-ordinating Editors ofthe group,the editors ofthis book have gathered a formidable set of contributions from around the world.The first halfofthe book provides an introduction to evidence-based medicine and applies the principles to anaesthesia and critical care,including critical appraisal,meta-analysis,interpreting results and controlling bias.The second half shows how to practise this in preoperative evaluation,regional and general anaesthesia, postoperative pain therapy,critical care and acute medicine.Medical professionals working in anaesthesia and surrounding specialties worldwide will find this book immensely useful. Ann Mølleris a specialist in Anaesthesiology and Co-ordinating Editor ofthe Cochrane Anaesthesia Review Group.Her specific areas ofresearch interest are evidence-based medicine, surgery,anaesthesia and smoking intervention. Tom Pedersenis Director ofCentre ofHead-Orthopaedics,Rigshospitalet,Copenhagen and Co-ordinating Editor ofthe Cochrane Anaesthesia Review Group.His specific areas ofresearch interest are patient safety,quality assurance and evidence-based health economics. Evidence-Based Anaesthesia and Intensive Care Edited by Ann Møller and Tom Pedersen Co-ordinating Editors,Cochrane Anaesthesia Review Group,Rigshospitalet,Blegdamsvej Copenhagen,Denmark Project co-ordinator Jane Cracknell Co-ordinator & Managing Editor,Cochrane Anaesthesia Review Group,Rigshospitalet, Blegdamsvej,Copenhagen,Denmark cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521690256 © Cambridge University Press 2006 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2006 isbn-13 978-0-511-24918-1eBook (EBL) isbn-10 0-511-24918-7 eBook (EBL) isbn-13 978-0-521-69025-6paperback isbn-10 0-521-69025-0 paperback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guaranteethatanycontentonsuchwebsitesis,orwillremain,accurateorappropriate. Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time ofpublication.Although case histories are drawn from actual cases,every effort has been made to disguise the identities ofthe individuals involved.Nevertheless,the authors,editorsandpublisherscanmakenowarrantiesthattheinformationcontained herein is totally free from error,not least because clinical standards are constantly changing through research and regulation.The authors,editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use ofmaterial contained in this publication.Readers are strongly advised to pay careful attentiontoinformationprovidedbythemanufacturerofanydrugsorequipmentthat they plan to use. Contents Foreword vii George Hall Contributors ix 1 Introducing evidence-based anaesthesia 1 Ann Møller and Tom Pedersen 2 How to define the questions 3 Ann Møller 3 Developing a search strategy,locating studies and electronic databases 7 Tom Pedersen 4 Retrieving the data 19 John Carlisle 5 Critical appraisal and presentation ofstudy details 28 Helen Handoll 6 Outcomes 39 Ann Møller 7 The meta-analysis ofa systematic review 46 Nathan Pace 8 Bias in systematic reviews:considerations when updating your knowledge 61 Harald Herkner 9 The Cochrane Collaboration and the Cochrane Anaesthesia Review Group 77 Tom Pedersen and Ann Møller 10 Integrating clinical practice and evidence:how to learn and teach evidence-based medicine 88 Steven Knight and Andrew Smith 11 Involving patients and consumers in health care and decision-making processes:nothing about us without us 103 Nete Villebro and Janet Wale v vi Contents 12 Evidence-based medicine in the Third World 117 Ruth Hutchinson 13 Preoperative anaesthesia evaluation 127 Maurizio Solca 14 Regional anaesthesia versus general anaesthesia 135 Mina Nishimori and Jane Ballantyne 15 Fluid therapy 151 Peter Choi and J Mark Ansermino 16 Antiemetics 169 John Carlisle 17 Anaesthesia for day-case surgery 184 Kevin Walker and Andrew Smith 18 Obstetrical anaesthesia 205 Stephen Halpern 19 Anaesthesia for major abdominal and urological surgery 223 Paul Myles and Kate Leslie 20 Anaesthesia for paediatric surgery 247 Neil S Morton 21 Anaesthesia for eye,ENT and dental surgery 271 Mathew Zacharias and Robyn Chirnside 22 Anaesthesia for neurosurgery 282 Divya Chander and Adrian W Gelb 23 Cardiothoracic anaesthesia and critical care 293 R Peter Alston 24 Postoperative pain therapy 307 Timothy Canty and Jane Ballantyne 25 Critical care medicine 321 Harald Herkner and Christof Havel 26 Emergency medicine:cardiac arrest management,severe burns, near-drowning and multiple trauma 343 Stephen Priestley and Michael Ragg Glossary ofterms 373 Index 391 Foreword George Hall Evidence-based medicine has become the new religion for many in the healthcare professions.It is greeted by the believers as the answer to all their clinical problems while the sceptics view this new upstart with grave suspicion and delight in finding discrepancies between the conclusions of evidence-based medicine and large randomised controlled trials. Like many new ideas in medicine, evidence-based practice has matured over the past decade so that a more balanced view of the strengths and weaknesses of this technique is now possible.Ann Møller and Tom Pedersen are authorities in evidence-based medicine as applied to anaesthesia and in this book have assembled a group ofdistinguished authors. The first part of the book describes the underlying principles used in evidence- based medicine with a critical evaluation ofpotential errors and pitfalls.The teaching ofevidence-based medicine is a particularly important topic as it is used increasingly in undergraduate medicine.There remains fierce debate over its role in education. The second part ofthe book explores the use ofevidence-based anaesthesia.Many key topics in the specialty are covered and the authors have published extensively in their areas of expertise.Thus this book not only covers the theoretical basis of the subject but also provides practical help for the anaesthesiologist.Unfortunately for the editors and the authors I have no doubt that a second edition will be essential in only a few years time.The “evidence”is always evolving and older studies are found to be no longer relevant to modern anaesthesia. Ann Møller and Tom Pedersen are to be congratulated on this tome.Although I am unconvinced by all the arguments for,and analysis of,evidence-based medi- cine I have little doubt that the book will be a sine qua nonfor all departments of anaesthesiology and for many anaesthesiologists. George M Hall Chairman and Professor ofAnaesthesia, St George’s Hospital Medical School London,UK vii