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Evidence Based Medicine in Peri-operative Care

Evidence Based Medicine in Peri-operative Care. Wimonrat Sriraj M.D. Department of Anesthesiology, Faculty of Medicine, Khon Kaen University. Phuket 17/07/2008. Outline. What When Which Where How to Example. Evidence-based medicine. Phuket 17/07/2008.

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Evidence Based Medicine in Peri-operative Care

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  1. Evidence Based Medicine in Peri-operative Care Wimonrat Sriraj M.D. Department of Anesthesiology, Faculty of Medicine, Khon Kaen University Phuket 17/07/2008

  2. Outline • What • When • Which • Where • How to • Example Evidence-based medicine Phuket 17/07/2008

  3. What evidence-based medicine is ? “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” Sackett, et al 2001 Phuket 17/07/2008

  4. Peri-operative anesthesia care • Preanesthetic evaluation • Preanesthetic preparation • Anesthetic management Choice of Anesthesia Monitoring during anesthesia Prevention & management of anesthetic-related complication • Postanesthesia care • Postoperative pain management Phuket 17/07/2008

  5. Best evidence • Research, Practice guideline • Type of research eg. Systematic review, RCT, etc. • Source eg. Journal, Organization • Critical appraisal • Internal validity : Appropriate methodology Minimal bias • Result : Magnitude, Precision Clinical VS Statistical significance • External validity : Generalizability , Applicability Phuket 17/07/2008

  6. Pre-filtered Journal American College of Physicians BMJ Publishing Group Phuket 17/07/2008

  7. Level of evidence for recommendation Phuket 17/07/2008

  8. Searching for systematic review • PubMed, At www.pubmed.com • restrict to : Meta-analysis [pt] Review [pt] Phuket 17/07/2008

  9. Searching for systematic review • PubMed, At www.PubMed.com • restrict to : Meta-analysis [pt] Review [pt] • The Cochrane library, At www.thecochranelibrary.com Search by review group/ topic - Anesthesia group - Pain, palliative and supportive care group - Others eg. Pregnancy and childbirth group Phuket 17/07/2008

  10. Choice of Anesthesia “Caesarean section” • Efficacy, safety Maternal & Neonatal effect • Feasibility, practicality • Patient preference Phuket 17/07/2008

  11. RAVS GA for C/S • Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005;60(7):636-53. • Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev. 2006 Oct 18(4): CD 004350 • Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev. 2004 Oct 16(2): CD 003765 Phuket 17/07/2008

  12. Choice of Anesthesia Phuket 17/07/2008

  13. Maternal effect 1 Phuket 17/07/2008

  14. Maternal effect 2 Phuket 17/07/2008

  15. Neonatal effect 1 Phuket 17/07/2008

  16. Neonatal effect2 Phuket 17/07/2008

  17. Neonatal effect3 • Reynolds F, Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60(7): 636-53. • More neonatal acidosis in Regional anesthesia • Umbilical pH difference -0.015 ( 95% CI -0.029, -0.001) • Base deficit difference 1.109 ( 95% CI 0.434, 1.784 mEq/l) Phuket 17/07/2008

  18. Patient value Phuket 17/07/2008

  19. Patient value Phuket 17/07/2008

  20. Authors’ conclusion • In terms of major maternal & neonatal outcomes : Not enough evidence to show that either RA or GA is superior to each other • In low to intermediate income countries, the least expensive method should be chosen Phuket 17/07/2008

  21. Professional experience Clinical expertise Clinical circumstance Patient preferences Costs Organizational issues Politics etc. ACQUIRE ASSESS APPRAISE Decision making APPLY Evidence-based Practice (EBP) The right question ASK Systematically search for the best evidences Critically appraised for validity & applicability Judiciously applied to the appropriate patients

  22. Choice of regional anesthesia Phuket 17/07/2008

  23. Spinal VS Epidural anesthesia for C/S • No difference in terms of • Failure rate, Need for intraoperative analgesia • Need for conversion to GA, Maternal satisfaction • Need for neonatal intervention • Spinal anesthesia • Reduce time from start anesth to start operation weighted mean difference 7.91 minute (95%CI – 11.59, -4.3) • Increase need for treatment of hypotension RR 1.23 (95%CI 1.00-1.51) Phuket 17/07/2008

  24. Ambulatory anesthesia • Rapid recovery • Less nausea & vomiting • Good postoperative pain Regional VS General anesthesia

  25. Ambulatory anesthesia Anesthesia Analgesia 2005; 101(6): 1634-42

  26. Outcome of interest • Induction time • Incidence of nausea & vomiting • Postop pain : VAS, rescue analgesics • Ability to bypass PACU • Time in PACU, Time until discharge • Patient satisfaction

  27. Finding • RA • Need more induction time ~ 8.1 minute • Less postop pain • PONV : PNB less but not with CNB • More ability to bypass PACU • Time for ambulatory unit stay : not reduce • CNB associate with delay discharge time ~ 35 minute

  28. Implication for practice • RA : Advantage but need more time Busy ambulatory unit : ??? • GA : Techniques, anesthetic drugs, Prevention of PONV , severe P/O pain Cost effective, Policy, Patient value

  29. Decision making • Efficacy & safety • Evidence based medicine • (Best) Evidence , Expertise, Patient value • Clinical circumstance • Policy • Etc.

  30. Thank You

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