BOOK REVIEW |
Evidence-Based Practice of Anesthesiology. L. A. Fleisher (editor). Published by Saunders, Philadelphia. Pp. 476; indexed. Price £46.99. ISBN 0-7216-9409-8
E-mail: nev.w.goodman{at}bris.ac.ukA better example of the rhetorical trick that is evidence-based medicine would be difficult to find. Not that the book that Fleisher has assembled and edited is bad. It is well written, thoughtful, useful, and every chapter is well researched. But it is not, by what the term has come to mean, evidence-based any more than any large textbook is an evidence-based textbook of anaesthesia. As Fleischer writes in the preface, the underlying concept of evidence-based medicine is the systematic review, the essence of which is that all the available evidence is sought, by an explicit search strategy, and then the results combined by meta-analysis. On the contrary, this is a book of expert-written reviews, the very sort of thing that the evidence-based medicine gurus deride. The book should be called, ‘Clinical problems and solutions in anesthesia’, or something similar. Most of the chapters will have appeared in the programmes of ‘Current controversy’ meetings, and that is their main use.
The authorship of 128 is heavily North American: the exceptions are just two from Switzerland, one from Sweden, one from Ireland, and one from the UK—and he is retired. This gives a heavy US bias to the practice of anaesthesia (an arterial catheter for total hip arthroplasty?), but there are plenty of references from non-US journals, and while it is not evidence-based in the true sense, lots of evidence has been amassed.
Most chapters pose a question: ‘What drugs decrease postoperative bleeding?’; ‘Should additives be used for peripheral nerve blocks?’ The chapters are grouped as preoperative preparation, perioperative management, regional anaesthesia, monitoring, and then some sub-specialty groupings. The pattern of each chapter is introduction, options, evidence, uncertainties, controversies, guidelines (which are, when they exist, published guidelines of American societies), and a box giving the nitty-gritty: the author's recommendations. It is not a book for reading, but a book for consulting when the question arises—which these questions do, commonly.
A theme is the paucity of evidence for lots of anaesthetic decisions, and the poverty of the evidence that does exist: ‘Evidence to support the indications for the preoperative ECG is imperfect at best because available studies differ in fundamental respects’; ‘Given the low frequency of this event [aspiration], solidly documented evidence for the efficacy of recommended measures is difficult to obtain’; ‘Unfortunately, much of the data available on anesthetic technique and blood loss are reported as a secondary outcome variable.’ These critical comments on what information we do have are important and necessary.
The appearance of the text is rather dense, with the conventional double column layout, lots of tables and algorithms, but few illustrations. It is US letter size, so best read in comfort the night before the case.
As a contributing author to Tràmer's ‘Evidence based resource...’,1 which is evidence-based, I feel this book, good though it is, is flying under a false flag. The flyer for a recently published book proclaims that it ‘examines and provides guidance for a number of problematic clinical scenarios in paediatric anaesthesia’: evidence-based does not appear in its title, so do we infer that its solutions are not based on evidence? I cannot forgive the evidence-based medicine movement for stealing the word, a carefully considered action that made honest intellectual objections to its methodology difficult, and instantly dismissible: who, after all, professes to practise medicine that is not based on evidence?
Fleisher asks that suggestions for new topics be sent to him for future editions. The format is a good one, and I hope there are future editions. Perhaps by then there will be more evidence to reach firmer conclusions for some of his current questions, but unless his authors do explicit systematic reviews, the title should be changed.
Bristol, UK
References
1 Tràmer M. Evidence Based Resource in Anaesthesia and Analgesia, 2nd Edn. London: BMJ Books, 2003
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