Decision-Making in Anaesthesia and Intensive Care

 

Mohamed Ezzat Moemen

Professor and founder of anaesthesia and intensive care,

specialties, faculty of medicine,

Zagazig university, Egypt.

 

Correspondence: Prof. M Ezzat Moemen

Postal address: 2 Gamal el-din Wassel street, first zone, Nasr city, Cairo, 11371, Egypt.

Cellular: (20) 124051079,

E-mail: ezzatmoement@yahoo.com

Website: http://www.ezzatmoemen.com

Abstract

Current education and training in anaesthesia and intensive care do not provide junior staff decision-making abilities to meet the challenges they would face overtime. Decision-making skills are acquired through a systematic approach combining a sound knowledge of Evidence-based Medicine and prior clinical experience.

Evidence is derived from the electronic information revolution, based on information technology including the internet and the inter-linked web pages. State-of-the art decision-making is obtained from the evidence pyramid, and the strength of evidence is obtained from the evidence hierarchy. Evidence builds up, but can never replace our expertise or judgement. The practice of Evidence-based Medicine, classically, crosses a route of five steps. The ASA has formulated evidence-based practice guidelines for a variety of areas of anaesthesia and intensive care that help in  proper decision-making.

Introduction:

Education and training of junior staff within anaesthesia and intensive care specialties, is based on theoretical knowledge, procedural skills and clinical experience, to develop the capacity of safe perioperative patient management. However, current education and training do not provide them with proper decision-making abilities to meet the challenges they would face overtime. They work in stressful environment, with significant time and space pressures and inadequate resources. So, they only develop the skills of constant re-evaluation of prior decisions to gain   flexibility in decision-making. In a recent review, the authors reported that non-knowledge-based skills form the core of much intensive care practice. ⁽¹⁾ An intensevist needs a broad range of experience to be able to treat the spectrum of diseases that can result in critical illness, but subspecialty knowledge is often required for specific cases. ⁽¹⁾

In both fields of anaesthesia and intensive care, such concepts should be replaced by the application of Evidence-based Medicine (EBM), in order to acquire the skills of proper decision-making for better perioperative patient management. Medical decision-making is a systematic approach combining a sound knowledge of EBM, and prior clinical experience.

Evidence-based medicine (EBM)

Although the exact timing EBM started is not clear, it first appeared in medical literature in 1992 ⁽²⁾ in response to the electronic information revolution. The first textbook on EBM in anaesthesia and analgesia was published in 2000. ⁽³⁾

According to the American Medical Colleges in 1999, “EBM comprises a set of skills that medical students are expected to acquire, with emphasis on information gathering and analysis, and consisting of understanding certain rules of evidence to correctly interpret literature on causation, diagnosis, prognosis, and treatment strategies”.

EBM is a method of decision-making based on evidence derived from the electronic information revolution, which delivers an explosion in the amount of published medical research. It aims to provide the best diagnostic, preventive, therapeutic or prognostic option for a given patient in a given situation. So, the concept is simply that absence of evidence or proof does not mean that evidence or proof is absent. The evidence or proof is some-where, and we have to search for it, mostly through electronic media, but paper sources as recent books and periodicals are not obsolete.

Information technology:

Information can be defined as a message that can be received and understood. It is clearly related to knowledge and communication. An information society is a society in which the creation, distribution, and manipulation of information is becoming a significant economic and cultural activity. The world is now amidst an all-purpose technological revolution based on information technology, defined as computers, computer software, and telecommunication equipment. A global computer communication network has now arisen benefiting the human mankind, thus allowing the civil society to communicate.

The internet in a worldwide publicly accessible network of interconnected computer networks that transmit data by packet switching using a standard protocol. It is a network of millions of smaller networks that carry various information and services such as electronic mail, online chat, file transfer, and the interlinked web pages, and other documents of the  world wide web (www).

Through the internet, large databases such as MEDLINE give access to the primary literature, as it indexes over 3500 journals and contains over 12 million references since 1964. Also, the COCHRANE library provides access to systematic reviews which help to summarize the results of countless studies since 2000 ⁽⁴⁾.

The number of systematic reviews on anaesthesia and intensive care-related topics is increasing, but is still small compared with other specialties. One reason is that management issues often overlap with other specialties. Another reason is that both anaesthesia and intensive care are non-therapeutic specialties, and therefore the outcomes by which to compare with control groups of patients are lacking ⁽⁵⁾.

State-of-the art decision-making

Evidence is obtained from the internet in light of the interface between the physician, the patient, and the society. The physician has his training and experience. The patient carries his identity, his disease, and comorbidities. The society has its fingerprints on the physician and the patient, through the environment and culture in the form of values and beliefs. The evidence formulates such an interface between the physician, the patient, and the society by equating risks versus benefits to facilitate a state-of-the art decision-making.

Through continuous explosion of information, evidence builds up, but it can never replace our skills, judgement, and expertise ⁽⁶⁾. This is a human contribution in decision-making, denoting that the physician can accept, modify, or even reject the evidence. Again, the patient, through his human contribution, can give his preference to clinical options of any medical service he receives.

The classic EBM steps

The practice of EBM crosses a route of five steps to realize its goals, starting by, and ending with, the physician-patient interface. First, a formulated problem through patient identity, disease, and comorbidities, should be converted by the physician to a well-built clinical question. Second, so long as there is a question, there should be an answer. Third, this answer should be based on the best available evidence, manipulated by the physician’s expertise and the patient’s preference. Forth, this evidence should be appraised for its validity and applicability. Fifth, returning to the patient, the evidence should be integrated and applied in clinical practice for a diagnostic, preventive, therapeutic, or prognostic purpose. When interpreting the results of a study, physicians should consider the inclusion and exclusion criteria. They should look for how similar their patient to the evidence study is.

The evidence pyramid and hierarchy

The evidence pyramid serves as a guide to the hierarchy of evidence available. Hierarchy classes like Ia, Ib, IIa, IIb, III, and IV represent the statistical strength of the evidence. Other classifications are provided by different authorities. Meta-analysis of systematic reviews of randomized controlled trials (RCTs) occupies the apex of the evidence pyramid, and represents the top evidence. In its absence, you can move down the pyramid to the same analysis including only one RCT, then to the same analysis including non-RCTs. Still down, you get a weaker evidence of the cohort studies where a large group of patients with a specific condition is compared with another group of patients without the condition, but differing in ways other than the variable under study. Case control studies, case series, and case reports follow, representing weaker evidences. The most unreliable evidence of the expert opinion or the experimental animal research occupies the bottom of the pyramid. It is important to note that as you move up the pyramid, the amount of available literature decreases, but increases in its relevance to the clinical setting.

Evidence-based anaesthesia and intensive care

If we understand how we make critical decisions, and what influences these decisions, then perhaps we can modify these decision-making patterns, and thus reduce the potential for diagnostic error ⁽¹⁾. All clinicians should aim to recognize and reduce medical errors and improve patient safety, as errors still remain a major cause of increased morbidity ⁽⁷⁾. While many of these errors can be overcome with increasing use of protocols and guidelines, based on EBM, the final common factor in diagnostic error, is the clinician decision-making ⁽¹⁾. This is because, clinical evidence to guide patient management, may be incomplete, non-existent, or its relevance to the problem at hand may be questionable. A significant problem facing an anaesthetist or intensevist is the lack of good quality evidence to guide many complex clinical decisions.

The nature of critical care medicine makes RCTs difficult or impossible. In such situations, only multicenter studies are available to draw sound conclusions. Where greater guidance is lacking, the scope of physicians to make their own decisions becomes, necessarily, greater ⁽¹⁾.

It is important to remember that the American Society of Anesthesiology (ASA) has formulated evidence-based practice guidelines for a variety of specialty areas. These guidelines can be accessed through the ASA website http://www.asahq.org. Such guidelines should be followed as much as possible. They are “systemically developed recommendations to assist decision-making for proper care in specific clinical circumstances'' ⁽⁸⁾. Proponents of using these guidelines report that they improve patient outcome and reduce cost. Critics caution that, although beneficial, guidelines should serve as “tools”, not rules ⁽⁴⁾. Anyhow, these ''tools'' or rules represent algorithms that cover different areas during the management of the patient during his critical illness.. They also cover areas in the practice of anaesthesia including, preoperative patient evaluation and preparation together with perioperative patient management including dealing with complications.

 The question remains: would the adoption of EBM for decision-making improve patient outcome? We think that it should, whenever we follow the dynamics of EBM over the progress of evidence though the electronic information sources modified by the physicians’ expertise, and the patient preference.

Currently, however, there are many areas in the fields of anaesthesia and intensive care that need more evidence-based research to solve controversies. In the field of anaesthesia, examples include cost-effectiveness of preoperative screening clinic, the optimal evaluation of the patient with obstructive sleep apnea, the optimal timing for preoperative smoking cessation, the optimal perioperative management for latex allergy, the optimal treatment for aspiration, the best strategy to prevent postoperative nausea and vomiting, the optimal preoperative haemoglobin, the safety of regional anaesthesia in  patiens on anti-platelet therapy ,the optimal management of postdural puncture headache ,the safety of fast track cardiac surgery, and the effectiveness of pre-emptive analgesia ⁽⁹⁾ .In the field of intensive care, examples include invasive versus non-invasive ventilation for chronic obstructive pulmonary disease, the use of nitric oxide in acute respiratory distress syndrome, baro- versus biotrauma in ventilator-induced lung injury ⁽¹⁰⁾ , selective bacterial decontamination of the gut in sepsis, and invasive versus non-invasive monitoring of cardiac output. Further meta-analysis of  RCTs, and   lower hierarchy  classes  through the evidence  pyramid  are needed to provide  the best  possible  evidences  to  solve  such  controversies.

References

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2-      Evidence-based Medicine Group. Evidence-based medicine: A new approach to teaching the practice of medicine. JAMA 1992; 268: 2420-5.

3-      Tramer M (Editor). Evidence-based resource in anaesthesia and analgesia. London: BMJ Books 2000.

4-      Scott R Schulman, Connie Schardt, Thomas O Era. Evidence-based medicine in anesthesiology. Curr Opin Anaesthesiol 2002; 15: 661-8

5-      Lee A, Lurn ME. Measuring anaesthetic outcomes. Anaesth Intensive Care 1996; 24: 685-93.

6-      Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingston 2000.

7-      Robertson MS. Thoughts about thinking the challenges for EBM and medical education (Editorial). Anaesth Intensive Care 2007; 35: 665-6.

8-      Institute of Medicine. Clinical Practice Guidelines: Directions for a new program. Washington DC: National Academy Press: 1990.

9-      Evidence-Based Practice of Anesthesiology. Lee A. Fleisher (Editor), Saunders , 2004:1-457.

10- Eighth Pulmonary Medicine Update Course. Hussein Sabri (Director). New Kasr El-Eini Specialized Hospital, Cairo University; Cairo,  Egypt. 6-7  february  2008 : 1-216.