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Evidence-based Anaesthesia and Intensive Care
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Book description

A comprehensive 2006 volume on the theories and applications of evidence-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 of the largest in the collaboration and, as coordinators of the group, the editors of this book have gathered a formidable set of contributions from around the world. The first half of the 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.

Reviews

'The text is invariably well written and is extremely engaging in style. … I believe that this book will be welcome to researchers and educators in anaesthesia; it represents an extremely thorough and compact drawing-together of the currently available evidence in our specialty and will be a very useful means of rapidly becoming conversant with the evidence base of issues of interest. Medicolegal practitioners will also find the book useful in supporting their assessment of the standard of care and causation.'

Source: ESA Newsletter

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Contents


Page 1 of 2


  • 1 - Introducing evidence-based anaesthesia
    pp 1-2
    • By Ann Møller, The Cochrane Anaesthesia Review Group, Department of Anaesthesiology, Herlev University Hospital, Herlev, Denmark, Tom Pedersen, The Cochrane Anaesthesia Review Group, Centre of Head-Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
  • View abstract

    Summary

    This introductory chapter reviews the book Detecting Deception: Current Challenges and Cognitive Approaches. The goal of evidence-based medicine (EBM) is to produce systematic reviews and clinical guidelines that summarize scientific knowledge about a topic in a single publication that preferably is updated regularly. This book aims to meet the needs of health professionals in anaesthesiology as medicine moves to be evidence-based. It has been a tool to understand the basic and advanced use of evidence-based methodology. The book explores clinical and statistical heterogeneity, how papers can be read and their results interpreted. The book details how to practice EBM in preoperative evaluation, regional and general anaesthesia, fluid therapy and the use of antiemetics; and how to use EBM in the subspecialities in anaesthesia, postoperative pain therapy, critical care and emergency medicine. The book provides an exciting agenda for research and clinical work in the field of evidence-based anaesthesia.
  • 2 - How to define the questions
    pp 3-6
    • By Ann Møller, The Cochrane Anaesthesia Review Group, Department of Anaesthesiology, Herlev University Hospital, Herlev, Denmark
  • View abstract

    Summary

    The practice of evidence-based medicine (EBM) begins with the formulation of a clinical question. Clinical questions consist of three parts: the patient or population, the interventions to be compared and the clinically relevant outcomes. This chapter describes a strategy for formulating answerable clinical questions. The formulation of the clinical question is the starting point; whether you intend to use EBM in the handling of an individual patient, if you are writing a clinical guideline for the department you work in, or you are preparing a systematic review. When performing a systematic review, the approach could be to include a wide group of patients and if plausible, plan some subgroup analysis in advance if there is a suspicion that some groups will be different from the others. Spending time and energy, formulating the clinical question before undertaking the literature search, and appraisal, are likely to improve the outcome of the process.
  • 3 - Developing a search strategy, locating studies and electronic databases
    pp 7-18
    • By Tom Pedersen, The Cochrane Anaesthesia Review Group, Centre of Head-Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
  • View abstract

    Summary

    This chapter shows how to conduct a comprehensive, objective and reproducible search for studies. It is always necessary to strike a balance between comprehensiveness and precision when developing a search strategy. Developing a search strategy is an iterative process in which the terms that are used are modified, based on what has already been retrieved. An electronic search strategy should generally have three sets of terms: terms to search for the health condition of interest; terms to search for the intervention(s) evaluated and terms to search for the types of study design to be included. Searches of electronic databases are generally the easiest and least time-consuming way to identify an initial set of relevant reports. The chapter discusses how and where the reviewers should look for studies that may be eligible for inclusion such as The Cochrane Library, MEDLINE, EMBASE and other relevant databases that identify appropriate MeSH terms.
  • 4 - Retrieving the data
    pp 19-27
    • By John Carlisle, Department of Anaesthetics, NHS Torbay Hospital, Torquay, Devon, UK
  • View abstract

    Summary

    This chapter discusses the methods of data retrieval and storage that help us to subsequently extract and analyse outcomes, bias and confounding factors, with particular reference to the systematic review of experimental studies. It helps us to begin by planning, piloting and redrafting our data extraction form. We can retrieve the data for each study into a separate paper, record, and then compare the results and integrate them, usually systematically by transferring the extracted data into a program like RevMan. The electronic retrieval form is a convenient place to record our search strategies. It is both easy to copy and to erase electronic files. A simple solution to keeping track of multiple versions of our file on various media is to name each saved file with the date and place that it is stored.
  • 5 - Critical appraisal and presentation of study details
    pp 28-38
    • By Helen Handoll, Teesside Centre for Rehabilitation Sciences, University of Teesside, The James Cook University Hospital, Middlesbrough, UK
  • View abstract

    Summary

    This chapter focuses on the critical appraisal of randomised controlled trials of treatment or preventive interventions and the presentation of study details from these in systematic reviews. Critical appraisal of study reports for systematic reviews is generally a two-stage process. Firstly there is "study selection" where potentially eligible studies are checked to see if they meet the pre-specified inclusion criteria of the review. Then there is "quality assessment" of and data collection from the studies that meet the inclusion criteria. The format and content of text and tables presenting the details of studies included in literature reviews and other work depend on the aims, destination and readership of the intended report. The critical appraisal of studies and the succinct presentation of study details are essential components of evidence-based anaesthesia. Both assist the interpretation of the evidence from studies in terms of its validity and, if valid, its applicability.
  • 6 - Outcomes
    pp 39-45
    • By Ann Møller, The Cochrane Anaesthesia Review Group, Department of Anaesthesiology, Herlev University Hospital, Herlev, Denmark
  • View abstract

    Summary

    This chapter describes types of outcome data, deals with evaluation of outcome data, and explains the difficulties with the use of surrogate outcomes. Typical clinically relevant outcomes in the field of anaesthesia could be perioperative mortality, major postoperative complications such as respiratory failure, myocardial infarction, infections, and surgical complications needing secondary surgery. The concept of Patient Oriented Evidence that Matters (POEMs) has mostly been used in journals and articles about general practice, but the idea can be transformed to other specialities as well. A surrogate endpoint can be defined as a laboratory or physiologic measurement used as a substitute for an endpoint that measures directly how a patient feels, functions, or survives. In conclusion, the major purpose of clinical trials is to support decision-makers in health care with reliable documentation of high scientific and methodological quality.
  • 7 - The meta-analysis of a systematic review
    pp 46-60
    • By Nathan Pace, Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
  • View abstract

    Summary

    Meta-analysis (MA) uses numerical tools to synthesize effect measures from the data discovered in the literature search of randomised controlled trials (RCTs) for a systematic review (SR). The MA of an SR should be conducted to minimise bias, bias being any deviation of the results from the true state of nature. In MA, the statistical approach is known as parameter estimation. Heterogeneity of MA may be explored by seeking factors in some studies that systematically modify the treatment effect. MA of RCTs has been criticised as an incautious synthesis of disparate data. Also, there are specific examples of discrepancies between meta-analytic summary statistics and the results of subsequent large RCTs evaluating the same therapies. The results of MA are tentative and provisional. Each updating of SR may require revision of the MA if additional relevant studies are found.
  • 8 - Bias in systematic reviews: considerations when updating your knowledge
    pp 61-76
    • By Harald Herkner, Editor Cochrane Anaesthesia Review Group, Specialist Internal Medicine, Intensive Care Medicine, Cochrane Anaesthesia Group, Department of Emergency Medicine, Vienna General Hospital/Medical University of Vienna, Währinger Gürtel, Vienna, Austria
  • View abstract

    Summary

    This chapter is divided into two sections: bias within single studies and bias between studies in systematic reviews. Systematic reviews aim at avoiding many of the biases contained in traditional narrative reviews, but nevertheless there is still potential for numerous biases even in elaborate systematic reviews. Randomised controlled trials (RCTs) are considered the potentially most unbiased form of clinical epidemiological study designs if conducted appropriately. There are currently two methods to assess study quality: composite scales and the component approach. There are several methods to detect publication bias, including simple graphical and more complex statistical methods. There is empirical evidence that studies with significant results are published or cited earlier and more frequently than those with non-significant or unfavourable results. Limited evidence exists for outcome reporting bias, duplicate publication bias, language bias and database bias.
  • 9 - The Cochrane Collaboration and the Cochrane Anaesthesia Review Group
    pp 77-87
    • By Tom Pedersen, The Cochrane Anaesthesia Review Group, Centre of Head-Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark, Ann Møller, The Cochrane Anaesthesia Review Group, Department of Anaesthesiology, Herlev University Hospital, Herlev, Denmark
  • View abstract

    Summary

    The Cochrane Collaboration is an international non-profit and independent organisation, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide. The Collaboration is supported by hundreds of organisations from around the world, including health service providers, research funding agencies, departments of health, international organisations and universities. It is a major focus of activity, and a rich source of information within the evidence-based medicine (EBM) movement. The main goal of Cochrane Anaesthesia Review Group (CARG) is to conduct systematic reviews of randomised controlled trials and other controlled clinical trials of interventions. The CARG maintains a register of more than 25000 randomised controlled trials and clinical controlled trials related to anaesthesia, perioperative medicine, intensive care medicine, pre-hospital medicine, resuscitation and emergency medicine. The necessity of The Cochrane Collaboration and EBM has become widely recognised by health professionals and lay people alike.
  • 10 - Integrating clinical practice and evidence: how to learn and teach evidence-based medicine
    pp 88-102
    • By Steven Knight, Department of Anaesthetics, Wythenshawe Hospital, Manchester, UK, Andrew Smith, Department of Anaesthetics, Royal Lancaster Infirmary, Lancaster, UK
  • View abstract

    Summary

    The principles of evidence-based medicine (EBM) are well described and the integration of these principles into practice is an important part of the daily work of clinicians. However, three conditions need to be satisfied before EBM will work in practice. This chapter explores some of the obstacles to these conditions, and offers some strategies and practical suggestions to help learn and teach evidence-based anaesthesia. A systematic review and a study using a validated questionnaire have demonstrated significant increases in knowledge and skills of participants in EBM courses. It is important to regard the process of EBM as an integral part of clinical practice and education, rather than it being an "optional extra". The process of implementing evidence-based practice can be made easier by using sources of pre-appraised evidence that present summaries of critically appraised evidence, systematic reviews and other collations of information.
  • 11 - Involving patients and consumers in health care and decision-making processes: nothing about us without us
    pp 103-116
    • By Nete Villebro, Department of Anaesthesiology, H:S Bispebjerg University Hospital, Copenhagen, Denmark, Janet Wale, Cochrane Consumer Network, Perth, Australia
  • View abstract

    Summary

    This chapter highlights the concept of the informed patient who takes an active role in shared decision-making with their health care providers, in the context of anaesthesia. A well informed patient is able to discuss openly with their physician the benefits and possible harms of treatment together with any alternatives. Information and effective communication are crucial to informed patient consent and shared decision-making that incorporates a sense of feeling respected and able to make a meaningful contribution to the decision-making process. Evidence-based health care is dependent on an effective transfer of information and its incorporation into practice. In anaesthesia, clinical governance and financial management are vital factors in the availability and practice of effective health care. Cochrane systematic reviews play an important part in directing research and a considered view of the outcomes that are measured is important.
  • 12 - Evidence-based medicine in the Third World
    pp 117-126
  • View abstract

    Summary

    This chapter focuses on the differences between the West and the Third World, such as poverty, age of the population, disease burden, lack of skilled staff and equipment. The Third World has a predominantly young population. Birth rate is higher than in the West, but there is high mortality amongst the under 5 years old, and since the HIV/AIDS epidemic a high mortality in early middle life. Evidence-based medicine starts with a clinical problem, and with the formation of a question regarding optimal care. The mother to child transmission (MTCT) studies for Sub-Saharan Africa can only be done in the Third World situation. The teaching of non-physician anaesthetists, who give the majority of anaesthetics in many countries, is often hampered by the absence of any studies as to what is the best in the conditions in which they are working.
  • 13 - Preoperative anaesthesia evaluation
    pp 127-134
    • By Maurizio Solca, Anaesthesia and Intensive Care Medicine, Azienda Ospedaliera di Melegnano, Presidio Ospedaliero di Cernusco sul Naviglio, Ospedale “A. Uboldo”, Cernusco sul Naviglio (MI), Italy
  • View abstract

    Summary

    Preoperative assessment encompasses surgical and anaesthesia evaluation, preoperative testing, patients' preparation for surgery and obtaining informed consent. This chapter presents a summary of published evidence-based literature on the subject, which have been revised using the same methodology of the AGREE instrument. The collection of anaesthesia history can be facilitated by a structured, ad hoc questionnaire: its use is strongly encouraged by the Italian and British Society Guidelines. Preoperative tests should be ordered only after the patient's assessment, and only those relevant to the particular case. Recently, a very exhaustive evaluation of the available evidence on the subject has been published by the National Institute for Clinical Excellence (NICE) in the UK. The abridged version of the NICE Guidance presents possible combinations of the four dimensions, patients' age, physical status, grade of surgery and coexisting disease.
  • 14 - Regional anaesthesia versus general anaesthesia
    pp 135-150
    • By Mina Nishimori, Department of Anesthesia/Critical Care, Massachusetts General Hospital, Boston, MA, USA, Jane Ballantyne, Department of Anesthesia, Massachusetts General Hospital, Pain Center, Boston, MA, USA
  • View abstract

    Summary

    The debate over the theoretical superiority of regional over general anaesthesia has persisted throughout most of the twentieth century, and there is still no satisfactory answer to the question of whether avoidance of general anaesthesia saves lives or reduces morbidity. This chapter reviews and analyses the evidence supporting an effect on surgical outcome of anaesthetic choice. For carotid endarterectomy, using regional anaesthesia rather than general anaesthesia enables keeping patients awake during carotid artery clamping. The chapter summarizes the key evidence supporting advantages or disadvantages of intraoperative neuraxial anaesthesia on postoperative outcomes. It also discusses selected topics regarding postoperative outcome after sole regional anaesthesia versus general anaesthesia. Meta-analysis and systematic reviews are cited, and emphasis is given to randomised controlled trials (RCTs). Evidence suggests the possibility of reduced mortality among several specific patient populations such as hip fracture surgery under spinal anaesthesia.
  • 15 - Fluid therapy
    pp 151-168
    • By Peter Choi, Department of Anesthesia, Vancouver Hospital, University of British Columbia, Vancouver, British Columbia, Canada, J Mark Ansermino, Department of Pediatric Anesthesia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
  • View abstract

    Summary

    The use of intravenous (IV) fluids for volume resuscitation and fluid replacement in the surgical or critically ill patient has been studied and practiced for nearly 90 years. Four systematic reviews have pooled data from randomised controlled trials (RCTs) comparing isotonic crystalloids to colloids in clinically heterogeneous populations. Human albumin has received the most attention and controversy amongst IV fluids. Amongst patients with penetrating injuries requiring surgery, initial fluid resuscitation with hypertonic saline dextran (HSD), compared with isotonic crystalloids, appears to increase the survival rate to hospital discharge. A large number of RCTs have been conducted in the field of fluid therapy; however, most of them have been small and not powered to detect differences in clinical outcomes. The publication of the Saline versus Albumin Fluid Evaluation (SAFE) Study has demonstrated the feasibility of conducting large multicentre RCTs to answer questions on fluid therapy.
  • 16 - Antiemetics
    pp 169-183
    • By John Carlisle, Department of Anaesthetics, NHS Torbay Hospital, Torquay, Devon, UK
  • View abstract

    Summary

    This chapter discusses three groups of interventions that reduce the number of people who experience postoperative nausea or vomiting (PONV). It concentrates on the eight drugs that reliably reduced PONV from the 60 patients assessed in the Cochrane Systematic Review. The chapter lists the drugs in order, with the drug that has the most certain antiemetic effect first and the drug that has the least certain antiemetic effect last. There is less known about the effects of drugs used to treat PONV than there is about drugs used to prevent PONV. Omission of nitrous oxide (N2O) from the inhalational maintenance of anaesthesia reduces PONV. Maintenance of general anaesthesia with intravenous propofol instead of a volatile agent reduces the risk of PONV. There is less direct evidence for using regional analgesia instead of systemic analgesia and reducing opioid use, although there is substantial indirect evidence that this limits PONV.
  • 17 - Anaesthesia for day-case surgery
    pp 184-204
  • View abstract

    Summary

    This chapter summarises the results of a systematic literature search published between the dates of 1990 and July 2005. Day-case surgery, known as ambulatory surgery in North America, has grown substantially in the last 20 years. Despite increasing demand for day-case surgery and advances in surgical technique, patient selection remains important to reduce postoperative complications. In 2003, the UK National Institute for Clinical Excellence (NICE) published guidelines for routine preoperative testing. The ideal anaesthetic for day-case surgery would provide rapid recovery, quick return to "street fitness" and be free of side-effects. Other considerations include turnover times and cost-effectiveness. Postoperative pain is one of the most frequently occurring adverse events after day-case surgery. Postoperative nausea and vomiting (PONV) is an important cause of morbidity following day surgery and along with pain is a major cause of unexpected admission.
  • 18 - Obstetrical anaesthesia
    pp 205-222
    • By Stephen Halpern, University of Toronto, Obstetrical Anaesthesia, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON, Canada
  • View abstract

    Summary

    This chapter discusses the effect of neuraxial analgesia on caesarean section rates, instrumental delivery rates and the duration of labour. Neuraxial analgesia effectively relieves labour pain and is often chosen by parturients because of the known efficacy of the technique. Although in most cases, randomised controlled trials (RCTs) are the strongest study design in the sense that, when properly performed, they result in the least amount of bias, there are a number of barriers to consider when studying labour analgesia. The duration of first and second stage of labour has been compared in RCTs in patients who received neuraxial analgesia and opioid analgesia controls. Conversely, neuraxial analgesia may cause an increase in the incidence of instrumental vaginal delivery. When deciding which type of analgesia to offer a parturient, the benefits and risks must be assessed. Neuraxial analgesia provides the most complete analgesia when compared to any other mode of treatment.
  • 19 - Anaesthesia for major abdominal and urological surgery
    pp 223-246
    • By Paul Myles, Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia, Kate Leslie, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital and Department of Pharmacology, University of Melbourne, Melbourne, Australia
  • View abstract

    Summary

    This chapter describes many evidence-based interventions relevant to anaesthesia for abdominal surgery. The two most common analgesic therapies after abdominal surgery are patient controlled analgesia (PCA) and epidural analgesia. It has been suggested that a strategy of targeting tissue oxygen delivery, so-called "optimisation" or "goal-directed" therapy, can improve postoperative outcome. Patients undergoing major abdominal surgery are particularly at risk of hypothermia, because of the potential for significant heat loss. There is substantial evidence in the literature that maintenance of normothermia during major abdominal surgery may lead to improved outcomes. Major abdominal surgery patients, in particular cancer patients, are at relatively high risk of deep venous thrombosis (DVT) and pulmonary embolism. There is a large amount of evidence derived from randomised trials and meta-analyses of trials in abdominal surgical practice to guide anaesthetic practice.
  • 20 - Anaesthesia for paediatric surgery
    pp 247-270
    • By Neil S Morton, Department of Paediatric Anaesthesia and Pain Management, Royal Hospital for Sick Children, Glasgow, Scotland
  • View abstract

    Summary

    This chapter covers selected topics which illustrate the basis for modern general paediatric anaesthesia practices. Many paediatric procedures can be undertaken on a day case basis which has tremendous benefits for children and families. Clear written, verbal and pictorial information concerning fasting, surgery, anaesthesia, analgesia and postoperative care are an essential part of obtaining informed consent from parents and children. The use of topical local anaesthesia of the skin with EMLA cream or amethocaine gel allows painless venous access after 60 and 45 minutes. Sevoflurane is now the most often used agent for induction in children because it is more pleasant and less irritant than other volatile agents. Regional anaesthesia produces excellent postoperative analgesia and attenuation of the stress response in infants and children. Although formal evidence-based systematic reviews or meta-analyses are relatively few, there is now a fairly robust basis for modern paediatric anaesthesia techniques and practices.
  • 21 - Anaesthesia for eye, ENT and dental surgery
    pp 271-281
  • View abstract

    Summary

    Anaesthesia for ENT surgery has to specifically address the problems of a shared airway, perioperative bleeding and postoperative pain and discomfort. Tonsillectomy is one of the common operations. Endotracheal anaesthesia has been the standard for many years, but this trend has changed since the introduction of reinforced Laryngeal mask airways (LMAs). The common drugs used for pain control following tonsillectomy are opioids, paracetamol and NSAIDs. Cataract surgery is one of the main areas where anaesthetists are involved in ophthalmic surgery. The increasing use of topical anaesthesia for cataract extraction has caused renewed interest in analgesia and sedation during cataract surgery. Dental anaesthesia aims to provide an unrestricted operating field, a safe stable airway and protection from aspiration of blood and fluid from the mouth. The reinforced LMA was specifically designed for use in oral surgery, and has extra flexibility and increased length than the classic LMA.
  • 22 - Anaesthesia for neurosurgery
    pp 282-292
  • View abstract

    Summary

    This chapter reviews basic neurophysiological principles and specific approaches to the management of intracranial pressure (ICP) as they relate to clinical neuroanaesthesia. It also reviews intraoperative management of the patient with a supratentorial mass lesion. There are six interrelated components that are important to the practice of neuroanaesthesia. They are maintenance of cerebral perfusion pressure (CPP), cerebral blood flow (CBF), cerebral blood volume (CBV), intracranial pressure (ICP), CO2 responsiveness (CO2R) and cerebral oxygen metabolism (CMRO2). The common types of neurosurgery can be divided into excision of intracranial mass lesions, especially supratentorial tumours, decompressive procedures in major head trauma and aneurysm clipping. The chapter focuses on managing elevated ICP as this is a problem common to all types of intracranial surgery, and then specifically the management of supratentorial masses. Management of the patient for neurosurgery requires a good understanding of the interrelationships of neurophysiology, pathophysiology and pharmacology.
  • 23 - Cardiothoracic anaesthesia and critical care
    pp 293-306
    • By R Peter Alston, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
  • View abstract

    Summary

    This chapter focuses on the adult cardiothoracic anaesthesia and critical care, and assesses their impact on practice. A recent meta-analysis found that, in the treatment of pneumothorax or for minor resections, video-assisted thorascopic surgery (VATS) was associated with a shorter hospital stay, less pain and less analgesic administration than conventional thoracotomy. Currently, by far the most controversial aspect of cardiac anaesthesia is the use of spinal or epidural analgesia. Combinations of glucose, potassium and insulin (GKI) have long been advocated to improve outcome from heart surgery. A meta-analysis found that there had been no therapeutic trials of fresh frozen plasma (FFP) and that the prophylactic intraoperative administration of FFP was not associated with reduced blood loss. Finally, there are many important aspects of cardiothoracic anaesthesia and critical care that have not been subjected to randomised controlled trials (RCTs) far less meta-analysis.
  • 24 - Postoperative pain therapy
    pp 307-320
    • By Timothy Canty, Arnold Pain Management Center, Beth Israel Deaconess Medical Center, Boston, USA, Jane Ballantyne, Massachusetts General Hospital Department of Anesthesiology, Boston, USA
  • View abstract

    Summary

    This chapter reviews alternative and adjunctive modes of delivering postoperative analgesia, and summarises what is known about efficacy and outcome. It presents the evidence for the commonly utilised analgesic modalities as they pertain to postoperative outcome in light of our overall goal of rapid return to normal physiologic function after surgery and the increasing movement towards a multimodal approach to analgesia. Randomised trials and meta-analyses overwhelmingly support the superior analgesic efficacy of epidural analgesia compared with "conventional analgesia" and patient-controlled analgesia (PCA) administered opioids. Multiple studies, and meta-analyses, confirm an average 30-50% opioid-sparing effect of NSAIDs. The focus of postoperative pain trials has been on assessing new modes of analgesia with particular regard both to their analgesic efficacy and to their ability to improve surgical outcome. Epidural analgesia offers a number of distinct benefits and appears to hasten recovery.
  • 25 - Critical care medicine
    pp 321-342
    • By Harald Herkner, Editor Cochrane Anaesthesia Review Group, Specialist Internal Medicine, Intensive Care Medicine, Cochrane Anaesthesia Group; Department of Emergency Medicine, Vienna General Hospital/Medical University of Vienna, Austria, Christof Havel, Department of Emergency Medicine, Vienna General Hospital/Medical University of Vienna, Austria
  • View abstract

    Summary

    This chapter discusses respiratory support including indication and conditions requiring respiratory support. Respiratory support strategies vary to a great extent between the extreme obstructive lung disease (OLD) and acute respiratory distress syndrome (ARDS). The chapter gives a short overview of the principals of antimicrobial therapy. It also concentrates on the two indications, which are common in intensive care medicine: cardiac arrest and septic shock. In severe sepsis, coagulation abnormalities often develop following endothelial damage or organ dysfunction. Current intensive care medicine includes some key interventions which are merely related to the therapy of severe sepsis and septic shock, although the spectrum of intensive care is rather wide. Research in intensive care is hampered by heterogeneity and relatively low patient numbers in particular departments, which requires usually more complicated multi-centre studies.
  • 26 - Emergency medicine: cardiac arrest management, severe burns, near-drowning and multiple trauma
    pp 343-372
    • By Stephen Priestley, Emergency Medicine, Sunshine Hospital, St Albans, Melbourne, Australia, Michael Ragg, Emergency Medicine, Geelong Hospital, Geelong, Australia
  • View abstract

    Summary

    The management of cardiac arrest, drowning, burns and multiple trauma all require specific knowledge and skills in order to achieve best outcomes. Although adrenaline has been used in cardiac arrest management for many years, there has been recent interest in the use of vasopressin in adult cardiac arrest. The fluid management of the patient with severe burns remains controversial. From an evidence based perspective, there is very little high level evidence looking at near-drowning. There are a large number of studies, systematic reviews and meta-analyses examining the question of the most appropriate fluid choice in patients requiring fluid resuscitation. There is an increasing focus on the utility and safety of blood substitutes in the resuscitation of haemorrhagic shock secondary to trauma and in perioperative transfusion therapy. There are multiple strategies to diagnose shock and monitor resuscitation in multiple trauma patients.

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