Evidence-Based Practice of Anesthesiology

608 Pages·2004·3.47 MB·English

by  Lee A. Fleisher

Fleisher: Evidence-Based Practice of Anesthesiology, 1st ed.
Copyright © 2004 Saunders, An Imprint of Elsevier
Evidence-Based Practice of Anesthesiology
Edited by:
Lee A. Fleisher, MD
Professor and Chair, Department of Anesthesiology, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania
Dedication
This book is dedicated to my wife, Renee, and my children, Jessica and
Matthew, who are my inspiration and who allow me the time and provide the
support for my academic pursuits, and to the many residents at the
University of Pennsylvania and Johns Hopkins University who have asked
insightful questions and strove to know the evidence supporting the best
perioperative practices.
Lee A. Fleisher
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EVIDENCE-BASED PRACTICE OF ANESTHESIOLOGY
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NOTICE
Anesthesiology is an ever-changing field. Standard safety precautions must
be followed, but as new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current product
information provided by the manufacturer of each drug to be administered to
verify the recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the treating physician, relying
on experience and knowledge of the patient, to determine dosages and the
best treatment for each individual patient. Neither the Publisher nor the editor
assumes any liability for any injury and/or damage to persons or property
arising from this publication.
The Publisher
International Standard Book Number 0-7216-9409-8
Printed in the United States of America
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Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com
Fleisher: Evidence-Based Practice of Anesthesiology, 1st ed.
Copyright © 2004 Saunders, An Imprint of Elsevier
Preface
Evidence-based medicine has been the buzz word of the last decade and the
focus of improving care for our patients by applying “Best Practices” to medical
care. The underlying concept is that a systematic review of the literature or
“evidence” will allow the practitioners to apply the most effective treatments. In
defining evidence, it is important to recognize that there are multiple forms and
the ability to generalize information generated in clinical trials and studies
depends on multiple factors. The highest form of evidence includes randomized
controlled trials. Although the internal validity of this form of evidence is
extremely high, the external validity may be limited by the population studied
(inclusion and exclusion criteria) and the care may not reflect what is done in
clinical practice. Cohort studies frequently are considered lower levels of
evidence but may be the only evidence available in the perioperative literature.
Although many guideline committees do not consider information provided by
cohort studies sufficient to dictate practice, they may provide some support for
clinical care until other forms of evidence become available. Therefore, it is
important to understand both the evidence and how different forms of evidence
can be applied to clinical practice.
As part of the move toward evidence-based medicine, there has been the
development of practice guidelines and advisories. The American Society of
Anesthesiologists has developed a vigorous methodologic approach to
guideline development. These guidelines emphasize randomized trials and
have been of great assistance to anesthesia practice but are limited in their
scope of topics that have been addressed. There are also guidelines developed
by non-anesthesia societies that help dictate practice. For example, the
American College of Cardiology/American Heart Association Guidelines on
Perioperative Cardiovascular Evaluation have been used in many
circumstances to determine the extent of cardiac evaluation before noncardiac
surgery. Yet, large gaps in the literature remain, and traditional reviews and
book chapters are not always structured to answer specific questions of care.
My goal in developing Evidence-Based Practice of Anesthesiology is to provide
a structured way of looking at many of these important questions. Each of the
authors was asked to provide an overall background or introduction to the
question, outline the options for treatment, review the evidence, identify areas of
uncertainty, outline available guidelines, and finally, provide their own
recommendations. Depending on the strength and extent of evidence, each
author outlined the available evidence in different ways. The goal is to try to
provide the reader with a basis upon which they can formulate their own
perioperative approach to complex problems while understanding the published
literature. The list of topics is wide but not exhaustive and therefore may change
in importance over time. Therefore, suggestions for new topics should be sent
to me for any future editions. It is also important to recognize that the evidence
itself is constantly changing. It will be necessary for the reader to understand
how any new evidence will influence the recommendations. The areas of
uncertainty outlined in each chapter also represent fertile areas that may
warrant future evaluation for those who are excited by asking and answering
questions.
I wish to express my gratitude to the numerous people who helped in the
development and production of this book. My administrative assistant, Juanita
Taylor, worked diligently to ensure that the multitude of authors, chapters, and
titles were always up-to-date and complete and was invaluable in ensuring the
timely completion of this book. I also want to express my gratitude to Andrew
Rowlingson, Christine Atchison, Elizabeth White, Amy Westermann, and Ann
Cartarius of The Johns Hopkins Department of Anesthesiology Perioperative
Clinical Investigation Unit who ensured that my clinical investigations continued
while I focused on completing the editing of this book. I am especially indebted
to Allan Ross at Elsevier Health Sciences, who helped me develop the ideas
and layout for this book and my subsequent editor, Natasha Andjelkovic, as well
as my developmental editors, Agnes Byrne and Denise LeMelledo, who helped
in the production of this book.
This book was designed for both the novice and consultant to help them
approach difficult management decisions by understanding the available
evidence. I have learned from these experts and have attempted to translate the
evidence into clinical practice and improve my patients' care. I hope you will feel
that your patients also benefit from the knowledge provided.
Lee A. Fleisher, MD
Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com
Fleisher: Evidence-Based Practice of Anesthesiology, 1st ed.
Copyright © 2004 Saunders, An Imprint of Elsevier
Foreword
This book is just what I want to read, and it appears just when I want to read it.
When I look at the outline of questions and topics that Dr. Fleisher chose to
present, it is obvious that those are the very questions I want answered; at least
one of those questions seems to nag at me every day. Rather than just
presenting the reader with a problem and laying out the evidence, and then
leaving the reader in a dilemma of having to make the choice, the authors state
the actions they would take and explain why. This in no way restricts the
readers, however; it just gives them an idea of what the experts in the field
would do in a given situation. It is clear that Dr. Fleisher selected the authors
carefully to have a balanced presentation by the experts in their fields. He did
an outstanding job of editing this book (I am, of course, biased since he is my
coeditor on Essence of Anesthesia Practice, and I know the great work he did
on that book).
An example of why I think this is such an outstanding work is the chapter
“Should a child with respiratory tract infection undergo elective surgery?” Drs.
Easley and Maxwell not only introduce the problem but also give the evidence
that proceeding immediately increases risk. They present the evidence that
delaying surgery may decrease risk, and rather than leave the reader in the
lurch, conclude that they would delay surgery for 2-4 weeks in patients with
upper respiratory infection and symptoms and for 4-6 weeks in those with acute
lower respiratory infection. They state clearly that this is their opinion and that
the existing evidence is not conclusive enough to be definitive. They then offer
the references if one wants to pursue the question in greater detail.
This book is a great educational tool for the private practitioner, who wants to
know what the expert in the field would do in a given situation. It is also a great
book for the resident and faculty member who can learn how to handle a wide
range of important issues, such as how to handle perioperative hypothermia,
whether the choice of muscle relaxant affects outcome, what to do to prevent
peripheral nerve injuries, or whether patients with obstructive sleep apnea
should be admitted to the ICU.
I intend to buy two copies of this book one to keep at home and use to prepare
for the next day, and one to keep at work. I plan on relying heavily on this book
for teaching in the operating room. I think it is a superb addition to our
educational armamentarium and hope you enjoy it as much as I did.
Michael F. Roizen, MD
Professor of Anesthesiology and Internal Medicine, State University of New York
Upstate Medical Center, Syracuse, New York
Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com
Fleisher: Evidence-Based Practice of Anesthesiology, 1st ed.
Copyright © 2004 Saunders, An Imprint of Elsevier
Contributors
Sherif Afifi, MD, FCCM
Department of Anesthesiology and Critical Care Medicine, Rush Medical
College, Chicago, Illinois
Seth Akst, MD, MBA
Department of Anesthesiology, The Johns Hopkins University School of
Medicine, Baltimore, Maryland
James F. Arens, MD
The University of Texas MD Anderson Cancer Center, Houston, Texas
Barbara Armas, MD
Department of Anesthesia, Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Daniel Bainbridge, MD, FRCPC
Department of Anesthesia and Perioperative Medicine, London Health Science
Center, University of Western Ontario, London, Ontario, Canada
Jane Ballantyne, MD
Department of Anesthesiology, Harvard Medical School; Massachusetts
General Hospital Pain Center, Boston, Massachusetts
Sheila R. Barnett, MD
Assistant Professor of Anesthesiology, Harvard Medical School, Boston,
Massachusetts and Department of Anesthesiology, Beth Israel Deaconess
Medical Center, Boston, Massachusetts
Yaakov Beilin, MD
Department of Anesthesiology, Mount Sinai School of Medicine, The Mount
Sinai Hospital, New York, New York
Elliott Bennett-Guerrero, MD
Department of Anesthesiology, Duke Clinical Research Institute, Duke
University, Durham, North Carolina
David Bevan, MB
Department of Anesthesia, University Health Network, Mount Sinai Hosptial,
University of Toronto, Toronto, Ontario, Canada
Sanjay M. Bhananker, MBBS, MD, DA, FRCA
Department of Anesthesiology, University of Washington School of Medicine,
Harborview Medical Center and Children's Hospital and Regional Medical
Center, Seattle, Washington
Lynn M. Broadman, MD
Department of Anesthesiology, Ruby Memorial Hospital, Morgantown, West
Virginia
Daniel R. Brown, MD, PhD
Department of Anesthesiology, Mayo College of Medicine, Mayo Clinic,
Rochester, Minnesota
Robert H. Brown, MD, MPH
Department of Anesthesiology, Duke University Medical Center, Durham, North
Carolina
Robert A. Caplan, MD
University of Washington, Virginia Mason Medical Center, Seattle, Washington
Jeffrey L. Carson, MD
Department of Anesthesia, Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Caroline Carwood, MD
Department of Anesthesiology, Harvard Medical School; Massachusetts
General Hospital Pain Center, Boston, Massachusetts
Davy Cheng, MD, MSc, FRCPC
Department of Anesthesia and Perioperative Medicine, London Health Sciences
Center, University of Western Ontario, London, Ontario, Canada
Rose Christopherson, MD, PhD
Department of Anesthesiology, Oregon Health and Science University, Portland
VA Medical Center, Portland, Oregon
Grace L. Chien, MD
Department of Anesthesiology, Oregon Health and Science University, Portland
VA Medical Center, Portland, Oregon
Dorothy S. Chung, MD, PhD
Department of Anesthesiology, The Johns Hopkins University School of
Medicine, Baltimore, Maryland
Frances Chung, FRCPC
Department of Anesthesia, Toronto Western Hospital, University of Toronto,
Toronto, Ontario, Canada
Neal H. Cohen, MD, MPH, MS
Department of Anesthesia and Perioperative Medicine, School of Medicine,
University of California San Francisco, San Francisco, California
Richard T. Connis, PhD
American Society of Anesthesiologists, Chicago, Illinois
Douglas B. Coursin, MD
Department of Anesthesiology, University of Wisconsin Hospital, Madison,
Wisconsin
Edward T. Crosby, MD
Department of Anesthesiology, Ottawa Hospital, University of Ottawa, Ottawa,
Ontario, Canada
Michele Curatolo, MD, PhD
Department of Anesthesiology, Division of Pain Therapy, University Hospital of
Bern, Bern, Switzerland
Clifford S. Deutschman, MD, MS, FCCM
Departments of Anesthesia and Surgery, Hospital of the University of
Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania
Karen B. Domino, MD, MPH
Department of Anesthesiology, University of Washington School of Medicine,
Seattle, Washington
Todd Dorman, MD, FCCM
Department of Anesthesiology, The Johns Hopkins University School of
Medicine, Baltimore, Maryland
Peter J. Duffy, MD
Department of Anesthesiology, Ottawa Hospital, University of Ottawa, Ottawa,
Ontario, Canada
R. Blaine Easley, MD
Department of Anesthesiology and Critical Care, The Johns Hopkins Medical
Center, Baltimore, Maryland
John E. Ellis, MD
Department of Anesthesia and Critical Care, University of Chicago, Chicago,
Illinois
Kristin Engelhard, MD
Department of Anesthesia, London Health Sciences Center and University of
Western Ontario, London, Ontario, Canada
Lucinda L. Everett, MD
Department of Anesthesiology, Children's Hospital and Regional Medical
Center, University of Washington, Seattle, Washington
James Y. Findlay, MBChB, FRCA
Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester,
Minnesota
Michael G. Fitzsimons, MD
Department of Anesthesia and Critical Care, Harvard Medical School,
Massachusetts General Hospital, Boston, Massachusetts
Lauren H. Fleischer, MD
Department of Anesthesiology, State University of New York at Stony Brook,
Stony Brook, New York
Lee A. Fleisher, MD
Department of Anesthesiology, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania
Nicole Forster, MD
Department of Anesthesia, London Health Sciences Center, University of
Western Ontario, London, Ontario, Canada
Amanda A. Fox, MD
Department of Anesthesia, Harvard Medical School, Brigham and Women's
Hospital, Boston, Massachusetts
Stephen E. Fremes, MD
Division of Cardiovascular Surgery, Sunnybrook and Women's College Health
Sciences Center, University of Toronto, Toronto, Ontario, Canada
Tong J. Gan, MB, FRCA
Department of Anesthesiology, Duke University Medical Center, Durham, North
Carolina
Adrian W. Gelb, MB, ChB
Department of Anesthesia, London Health Sciences Center, University of
Western Ontario, London, Ontario, Canada
Ralph Gertler, MD
Department of Anesthesiology, University of Texas Southwestern Medical
Center of Dallas, Dallas, Texas
Satyajeet Ghatge, MD
Department of Anesthesiology, The University of Texas Medical School at