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The first edition of this book was reviewed in a leading anaesthetic journal1 with the following final paragraph: “this is neither a textbook nor a comprehensive reference book. It is a set of personal essays about EBM and anaesthesia by leading workers in the field. Its strength is that it begins with a robust critique of EBM but it is able to leave the reader feeling that EBM is a useful tool that has much to offer to us.”
What of this second edition? Again, the first part starts with a critical appraisal of evidence-based medicine, followed by discussion of the utility of large randomised trials, systematic reviews, and meta-analyses. The second part covers 7 topics within anaesthesia and perioperative care: acute pain; peripheral treatment of postoperative pain; epidural analgesia in obstetric practice; intravenous fluids for resuscitation; postoperative nausea and vomiting; propofol for anaesthesia and sedation; and the prevention of complications associated with use of central venous catheters. The third part covers the dissemination of the messages of EBM, health economic issues, and the defining of research agendas (as typified by the use of epidural analgesia) based on the results of systematic reviews.
There is little doubt that readers of this book will be polarised into 2 main groups: the believers (to whom the word will be seen written down in black and white, and for whom this collection of essays will embody the messages that EBM tries to engender) and the sceptics (those who will be critical of EBM practising clinicians; who decide that meta-analyses are the work of non-clinical epidemiologists and statisticians, and who ignore the inter-individual variability of disease and accordingly the need for individualised treatments).
Where does the truth lie? Certainly many clinicians (and many pharmaceutical companies) are guilty of basing too much credence on underpowered, biased studies that often suit their own ideas or hopes. Properly conducted, systematic reviews allow these inadequate studies to form a greater part of the evidence base. Two useful examples in this book are the chapters by Halpern and Leighton describing the utility of epidural analgesia for labour and delivery, and the erudite work of Tramèr on postoperative nausea and vomiting. The former touches on the issue of randomised controlled trials without a placebo group (at least this has a sound ethical basis!). The issue of postoperative nausea and vomiting is more complex; what you get depends on what you seek. How can we compare studies in different patient groups who have different underlying risks, and how can we compare prevention versus treatment once nausea/vomiting occur?
Thankfully, those authors who contributed to the first edition have taken notice of some of the concerns levelled against EBM and tried to put reasoned arguments for their own particular cases. The new contributors add to our wealth of developing (NOT DEVELOPED) knowledge. There is much still to learn.
If practising anaesthetists were to read this book without prejudice, then they will gain much. If they are already prejudiced, then perhaps the clear exposition of the different chapters will provide light to guide their thoughts. For the reviewer, there is still a feeling that clinical acumen MUST play some role in treatment—but we should be prepared to be critical of our own practice and view open-mindedly the summated wisdom of others. Only then will advances be made for the good of all.