ESRA UPDATES Journal Club invites leading experts in (regional) anaesthesia to select one (or more) article(s) which for him/her were/are important, interesting or changed his/her clinical practice. This choice can be a general big, randomized study but can also be very personal. For this edition our choice went to the program director of regional anesthesia of the University Hospital of Lausanne, Prof Eric Albrecht. He is the principal author of more than 100 peer-reviewed articles published in high profile journals and three French-language books. So, who else better than to ask which articles changed his clinical practice.
«The year 2021 is filled with many valuable articles. Making a selection was difficult and complex. However, after careful consideration, I finally selected four articles that bring evidence and guidance to, I hope, our clinical practice and our way we conduct research and read the literature.
The first article is a large randomised controlled trial performed by Dr Neuman and colleagues and published in the New England Journal of Medicine [1]. In this multicenter study including 1600 patients, the authors investigated whether a spinal anaesthesia would decrease the mortality or improve the recovery after hip fracture surgery, as compared with general anaesthesia. Main outcomes were death within 60 days after surgery, inability to walk 3 metres without the assistance of another person at 60 postoperative days, and delirium in the immediate postoperative period. Unfortunately, spinal anaesthesia was not superior to general anaesthesia whatever the outcome considered. Indeed, patients of both groups had a mortality rate of approximately 4% and inability to walk independently at 60 days of about 15%; the incidence of postoperative delirium was around 20% in both groups. While these results are undoubtfully very disappointing for any physician passionate by regional anaesthesia, one should not forget that spinal anaesthesia provides successful postoperative pain relief, as compared with general anaesthesia, that can be extended up to 24 postoperative hours, when long-acting opioids are administered in the intrathecal space [2]. As a reminder, a dose of 100 mcg of intrathecal morphine is a ceiling dose for analgesia and a threshold dose for increased postoperative nausea and vomiting [2].
A remarkable publication is a systematic review and meta-analysis on the impact of peripheral nerve blocks in patients undergoing total hip or knee arthroplasty, published in Regional Anesthesia and Pain Medicine [3]. After including 122 studies, this international group of experts concluded that peripheral nerve block improves postoperative outcomes following total hip and knee arthroplasty. Indeed, the use of a PNB was associated with lower odds ratios for several complications such as cardiac complications, respiratory failure or cognitive disorder, among others.
Another important publication is the attempt to standardise the nomenclature in regional anaesthesia through a Delphi method including members of the American and European Societies of Regional Anaesthesia and sixty international collaborators [4]. Following the introduction of ultrasound-guided regional anaesthesia in our clinical practice, new blocks are continuously described, which, sometimes, carry different names or describe different target location, bringing confusion in teaching, training and research projects. This initiative is of uttermost importance as the harmonisation and standardisation of nomenclature will ease the dissemination of knowledge in regional anaesthesia, resulting in improving education, research, and ultimately patient care. After several rounds, this large group of experts established a list of 20 blocks for the abdominal wall, parasternal and chest wall blocks; that was part I. The second part will be published in 2022 and will cover the upper and lower limb blocks.
Finally, I would like to highlight an article published in Anaesthesia and written by Dr J.B. Carlisle on the “zombie” trials, that I think any physician should be aware of [5]. While the terminology might be intriguing, Dr Carlisle described a very worrisome and alarming problem, which is the fabrication of false data. Based on the analysis of the summary baseline data and then the individual patient data of all randomised controlled trials submitted to Anaesthesia, Dr Carlisle concluded that 44% of the submitted trials had false data. We shape our clinical practice on robust evidence, provided by the scientific literature. Knowing that close to 50% of the trials submitted contain erroneous data is troublesome. Before transferring the evidence of a research report into the clinical practice, it is mandatory to seek confirmation and wonder whether the research question is logical, coherent, and supported by the methodology.»
Prof. Dr. med. Eric Albrecht Program Director |1 Regional Anaesthesia |2 Clinical Research Department of Anaesthesia University Hospital of Lausanne and University of Lausanne Lausanne, Switzerland
REFERENCE LIST
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