Burden of proof.
Burden of proof.
复制标题
举证责任。
DOI：
10.1097/aln.0b013e3181b16466
复制
发表时间：
2009
期刊：
影响因子：
8.8
通讯作者：
Smiley,RichardM
中科院分区：
文献类型：
--
作者：
Smiley,RichardM
2009年初，为期两天的产科麻醉研讨会刚刚结束，我和我的同事在瑞士巴塞尔登上了有轨电车，开始了各自的回家之旅。会议的最后讨论之一是关于剖宫产脊麻期间低血压的治疗/预防，我谈到了支持注射苯肾上腺素的证据，以及我个人使用这种药物的做法。在电车上，我问我的同事，他在剖腹产时通常用什么来治疗低血压，他回答说：“像我团队中的大多数人一样，服用麻黄素或苯肾上腺素。”接下来的一个月，当我在继续医学教育课程上开始演讲时，我问了由麻醉师和CRNAs组成的听众：“你们治疗剖宫产低血压的一线药物是什么，麻黄素还是去氧肾上腺素？”90%的人对麻黄素有反应。第二周，我们的一位现任院士问我：“如果他们问我在剖腹产时会用什么药来治疗低血压，我会怎么说？”他在我们机构做过住院医生，对苯肾上腺素输注的证据和我们使用苯肾上腺素的做法都非常熟悉，即将参加ABA理事会的口试。苯肾上腺素是一个可以接受的答案吗？来自以非产科麻醉提供者为主的观众的反应可能并不那么令人震惊，尽管有一个事实，即在欧洲，1，2美国3-5和亚洲6，7，有十多年精心设计的随机盲目研究提供了相当一致的证据，支持苯肾上腺素至少与麻黄素一样安全有效，可能比麻黄素更适合用于治疗或预防剖腹产低血压。并不是每个麻醉师或CRNA都阅读每一本杂志，正确地解释证据，愿意根据现有信息改变他或她的实践，甚至相信循证实践的原则。这位同事的问题反映了我们所有人在接近口试时的恐惧和不安全感，即使我们认为自己知道一道临床问题的答案。我们想知道那些董事会考官知道(或不知道)什么，他们会接受什么答案。然而，我的同事在有轨电车上的评论更令人惊讶，因为他们来自《本刊》的主编，他的临床实践现在和过去都主要是产科麻醉。几周后，艾森纳奇博士给我发来电子邮件，告诉我他已经开始使用苯肾上腺素输液，并说服了他所在机构的几名同事也这样做，并邀请我写这篇社论。在本期《麻醉学》中，Ngan Kee等人写道。腰麻下注射苯肾上腺素和麻黄素预防和治疗剖宫产术中低血压的随机盲法临床试验报告。8如何预防或治疗剖宫产脊麻期间低血压的问题几十年来一直是产科麻醉的中心问题。这个问题的答案被称为产科麻醉的“圣杯”。几十年来，麻黄素一直是首选药物，这是基于对绵羊的经典研究，这些研究表明纯α-肾上腺素能激动剂对子宫胎盘血流有有害影响。10在20世纪90年代和21世纪初的多份报告中，许多由颜基博士和他在香港的同事1，3-6，11-14证明了苯肾上腺素或其他字母激动剂(如间氨基酚)在预防母体低血压及其…方面是安全的，通常比麻黄素更有效
In early 2009, a two-day symposium on Obstetric Anesthesia had just ended, and my colleague and I stepped onto the tram in Basel, Switzerland, to begin our respective journeys home. One of the final discussions at the conference had concerned treatment/prevention of hypotension during spinal anesthesia for cesarean delivery, and I had spoken about the evidence in favor of phenylephrine infusions, and my personal practices in utilizing the drug. On the tram, I asked my colleague what he generally used to treat hypotension during cesareans and he responded “Boluses of ephedrine or phenylephrine, as does most of the rest of my group.” The following month, as I began a lecture at a CME course, I asked the audience, composed of a mixture of anesthesiologists and CRNAs,“What is your first-line drug to treat hypotension at cesarean section, ephedrine or phenylephrine?” Ninety percent responded ephedrine. The next week, one of our current departmental Fellows, who had done his residency in our institution and was quite familiar with both the evidence for and our practice in using phenylephrine infusions, and who was about to sit for his oral ABA Board examination asked me,“What do I say if they ask me what drug I would use for hypotension during cesarean section. Is phenylephrine an acceptable answer?” The response from the audience of predominantly non-obstetric anesthesia providers is perhaps not so shocking, despite the fact that there exists over a decade of fairly consistent evidence from well-designed, randomized, blinded studies in Europe, 1, 2 the United States 3–5 and Asia 6, 7 supporting the proposition that phenylephrine is at least as safe and effective and probably preferable to ephedrine for the treatment or prevention of hypotension at cesarean section. Not every anesthesiologist or CRNA reads every journal, interprets evidence correctly, is willing to change his or her practice based on the available information, or even believes in the principle of evidence-based practice. The question from the Fellow reflects the fear and insecurity that all of us felt as we approached our oral exam, even when we thought we knew the answer to a clinical question. We wondered what those Board examiners knew (or didn’t know) and what they would accept as answers. The comments of my colleague on the tram, however, were a bit more surprising, as they came from the Editorin Chief of this Journal, whose clinical practice is and has been predominantly in obstetric anesthesia. A few weeks later Dr. Eisenach emailed me to tell me that he had started using phenylephrine infusions, had convinced several colleagues at his institution to also do so, and invited me to write this editorial.In this issue of ANESTHESIOLOGY, Ngan Kee et al. report on a blinded, randomized clinical trial comparing phenylephrine infusion to ephedrine infusion for the prevention and treatment of hypotension at cesarean section under spinal anesthesia. 8 The question of how to prevent or treat hypotension during spinal anesthesia for cesarean section has been a central question in obstetric anesthesia for decades. The answer has been called the “Holy Grail” of obstetric anesthesia. 9 For decades ephedrine was the drug of choice, based on classic studies in sheep that suggested deleterious effects of pure alpha-adrenergic agonists on uteroplacental blood flow. 10 Multiple reports in the 1990s and early 21st century, many by Dr. Ngan Kee and his colleagues in Hong Kong 1, 3-6, 11–14 have demonstrated that phenylephrine or other alphaagonists (eg, metaraminol) are safe and generally more effective than ephedrine at preventing maternal hypotension and its …