BJA
Correspondence
Declaration of interest None declared. D. Leslie* M. Oliver M. R. Stacey Cardiff, UK *E-mail: [email protected] 1 Friedman Z, Siddiqui N, Mahmoud S, Davies S. Video-assisted structured teaching to improve aseptic technique during neuraxial block. Br J Anaesth 2013; 111: 483–7 2 Temple J. Time for training: a review of the impact of the European Working Time Directive on the quality of training, 2010. Available from www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20Ver sion.pdf (accessed 28 July 2013) 3 Jaques H. Better training, better care. BMJ Careers 2012. Available at http://careers.bmj.com/careers/advice/view-article.html?id=20008602 4 Schuwirth LWT, van der Vleuten CPM. Challenges for educationalists. Br Med J 2006; 333: 544–6 5 Kathirgamanathan A, Woods L. Educational tools in the assessment of trainees in anaesthesia. Contin Educ Anaesth Crit Care Pain 2011; 11: 138– 42
6 Ram P. Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility. Med Educ 1999; 33: 447– 54 7 Van der Vleuten CPM. The assessment of professional competence: developments, research and practical implications. Adv Health Sci Educ 1996; 1: 41– 67
doi:10.1093/bja/aeu070
Regional anaesthesia Editor—After the publication of the study comparing general anaesthesia (GA) with regional anaesthesia (RA) for total knee arthroplasty,1 we felt the need to make some additional points regarding the methodology of the study. We read with interest the decision to administer i.v. opiate to the GA group only, while not offering the same to the RA group. We are very pleased that this was noted in your editorial as a potential factor influencing the pattern of data observed.2 Given the importance of opiate usage in conventional RA practiced in the UK and elsewhere, we would go further and say that this decision by the study designers amounts to bias. The more favourable feedback from patients after operation in the opiate/GA group is highly predictable and it brings into question how this aspect of the study was sanctioned by an ethics committee. Secondly, with reference to the national joint registry in this country, the decision to exclude patients with high BMIs seems an unfortunate one. The average BMI for men and women undergoing total knee replacement (TKR) in England, Wales, and NI, is over 30.3 In addition, a case – control study conducted in Sweden (in one of the two hospitals involved in the above study)4 concludes a positive association between high BMI and TKR. It is therefore hard to accept their sample population as a realistic reflection of the general population undergoing such surgery. Comorbidity-related issues such as BMI are central to influencing decisions surrounding anaesthetic technique. We feel it is unfortunate that this article has been accompanied by an editorial and may give the unwarranted conclusion that RA is a poor choice for primary knee arthroplasty. We suspect that this manuscript was too late to have included reference to the recent large observational study5 suggesting advantages of RA over GA for hip and knee arthroplasty.
Declaration of interest None declared. A. P. Reed Peterborough, UK E-mail: [email protected] 1 Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anesthesia or spinal anaesthesia for total knee arthroplasty. Br J Anaesth 2013; 111: 391– 9 2 McCarteny CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111: 331–3
763
Downloaded from http://bja.oxfordjournals.org/ at Universitaets- und Landesbibliothek Duesseldorf on March 25, 2014
Regular use allows trainees to develop a portfolio of procedures, ensuring they can demonstrate consistent levels of performance, and therefore competence, without the need for consultant presence. It also overcomes the sometimes artificial nature of pre-planned WPBAs. Also providing evidence of competence, and training for the individual operator, videos can be subsequently used as teaching tools for other trainees to demonstrate particular expertise or common pitfalls. The use of recordable video sport glasses could easily be disseminated to all practical procedures in anaesthesia, and indeed to all medical and surgical specialities, where demonstration of adequate technical skills is required. Round-theclock availability of the glasses is enabling trainees to use any performance of practical procedures as a training opportunity, overcoming the barrier posed by increased out-of-hours work. The purpose of assessment in medical practice is two-fold: to provide evidence of developing competence, and to determine fitness for professional practice. The quality of an assessment tool is dictated by its reliability, validity, educational benefit, and cost.7 We firmly believe that this method of assessment fulfils all of these criteria. Our experience so far suggests it is reliable, valid, and certainly of more educational benefit than current assessment tools. The high definition video produced by these glasses represents excellent value, with negligible running costs. We conclude that this more than justifies the initial, relatively low cost of purchasing the glasses. In conclusion, changes to medical training are both inevitable and necessary. We believe that video analysis of practical procedures using recordable video sports glasses would be the most valid, reliable, non-intrusive, and educationally beneficial way of improving assessment, and therefore training.
BJA
Correspondence
3 The National Joint Registry. Available from http://www.njrcentre.org .uk/njrcentre/Default.aspx 4 Franklin J, Ingvarsson T, Englund M, Lohmander LS. Sex differences in the association between BMI and total hip or total knee joint replacement resulting from osteoarthritis. Ann Rheum Dis 2009; 68: 536– 40 5 Memtsoudis SG, Sun X, Chiu Y,et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anaesthesiology 2013; 118: 1046–58
1 Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anesthesia or spinal anaesthesia for total knee arthroplasty. Br J Anaesth 2013; 111: 391– 9 2 McCarteny CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111: 331–3 3 Joshi G, Ogunnaike B. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005; 23: 21– 36
doi:10.1093/bja/aeu071 doi:10.1093/bja/aeu072
Editor—The study by Harsten and colleagues1 2 demonstrated that patients having spinal anaesthesia (SA) had worse pain control at 6 h, more opioid consumption, more nausea, vomiting, and dizziness when compared with those having general anaesthesia (GA). All of these findings could be explained by the lack of appropriate pain relief as the spinal anaesthetic wore off. The patients having a GA were given oxycodone intraoperatively, whereas those having SA did not have any i.v. analgesia. The SA group were unsurprisingly in severe pain at 6 h and were probably playing catch up with analgesia for a considerable period of time. This explains the higher number of patient-controlled analgesia doses requested but not administered in the SA group. The poor pain control in the spinal anaesthetic group may have led to patients overcompensating and consuming more opioids when compared with the GA group. Poor pain control and higher opioid use may explain the higher incidence of postoperative nausea and vomiting in the SA group. Inadequate postoperative pain relief results in delayed recovery and poor patient satisfaction.3 This is perhaps why most patients who had SA preferred to have GA in the future. The length of stay (LOS) was shorter in the GA group (46 h) when compared with the SA group (52 h). This is clearly not clinically significant. The statistics used for calculating the sample size is not very clear and one can only assume that the sample size was calculated on the assumption that the difference in the LOS between the two groups was 24 h. This assumption has led to the underestimation of the sample size required. A number of other outcomes have been studied and corrections have not been made for multiple testing. Nausea, vomiting, and dizziness were assessed at fixed times on days 1 and 2 as opposed to fixed time periods after the end of surgery. There are a number of methodological flaws in this study that make the validity of this study questionable.
Declaration of interest None declared. M. Chincholkar Salford, UK E-mail: [email protected]
764
Anaesthesia for elective total knee arthroplasty Reply from the authors to Dr Reed Editor—We thank Dr Reed for his letter on our clinical investigation.1 2 We agree that the administration of i.v. oxycodone to our target-controlled infusion (TCI) anaesthesia group could have influenced the postoperative pain scores. However, administering i.v. opioids towards the end of a TCIanaesthetic is almost to be considered as the modus operandi for TCI anaesthesia due to the fact that remifentanil has a very short-lasting analgesic effect. Hence, this could almost be considered as a part of the TCI technique. Whether patients with a BMI of 35 or more should have been excluded or not in this study is an interesting and relevant question. By excluding patients with a BMI exceeding 35, one might argue that our sample population does not perfectly reflect the general population undergoing total knee replacement. It is true that our study was written before the publication of the study by Memtsoudis and colleagues.3 However, as pointed out by an editorial4 in the same issue of Anesthesiology, the trial by Memtsoudis and colleagues is observational rather than experimental in nature. As such, treatment assignment was non-random, creating the real possibility that the authors’ findings may reflect the confounding effects of differences in patient severity rather than effects attributed to anaesthesia type per se.
Declaration of interest None declared. A. Harsten Hasssleholm, Sweden E-mail: [email protected] 1 Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anesthesia or spinal anaesthesia for total knee arthroplasty. Br J Anaesth 2013; 111: 391– 9 2 McCarteny CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111: 331–3 3 Memtsoudis SG, Sun X, Chiu Y, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anaesthesiology 2013; 118: 1046–58
Downloaded from http://bja.oxfordjournals.org/ at Universitaets- und Landesbibliothek Duesseldorf on March 25, 2014
Poor pain control rather than anaesthetic technique influences outcome in total knee arthroplasty
Correspondence
Declaration of interest None declared. D. Leslie* M. Oliver M. R. Stacey Cardiff, UK *E-mail: [email protected] 1 Friedman Z, Siddiqui N, Mahmoud S, Davies S. Video-assisted structured teaching to improve aseptic technique during neuraxial block. Br J Anaesth 2013; 111: 483–7 2 Temple J. Time for training: a review of the impact of the European Working Time Directive on the quality of training, 2010. Available from www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20Ver sion.pdf (accessed 28 July 2013) 3 Jaques H. Better training, better care. BMJ Careers 2012. Available at http://careers.bmj.com/careers/advice/view-article.html?id=20008602 4 Schuwirth LWT, van der Vleuten CPM. Challenges for educationalists. Br Med J 2006; 333: 544–6 5 Kathirgamanathan A, Woods L. Educational tools in the assessment of trainees in anaesthesia. Contin Educ Anaesth Crit Care Pain 2011; 11: 138– 42
6 Ram P. Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility. Med Educ 1999; 33: 447– 54 7 Van der Vleuten CPM. The assessment of professional competence: developments, research and practical implications. Adv Health Sci Educ 1996; 1: 41– 67
doi:10.1093/bja/aeu070
Regional anaesthesia Editor—After the publication of the study comparing general anaesthesia (GA) with regional anaesthesia (RA) for total knee arthroplasty,1 we felt the need to make some additional points regarding the methodology of the study. We read with interest the decision to administer i.v. opiate to the GA group only, while not offering the same to the RA group. We are very pleased that this was noted in your editorial as a potential factor influencing the pattern of data observed.2 Given the importance of opiate usage in conventional RA practiced in the UK and elsewhere, we would go further and say that this decision by the study designers amounts to bias. The more favourable feedback from patients after operation in the opiate/GA group is highly predictable and it brings into question how this aspect of the study was sanctioned by an ethics committee. Secondly, with reference to the national joint registry in this country, the decision to exclude patients with high BMIs seems an unfortunate one. The average BMI for men and women undergoing total knee replacement (TKR) in England, Wales, and NI, is over 30.3 In addition, a case – control study conducted in Sweden (in one of the two hospitals involved in the above study)4 concludes a positive association between high BMI and TKR. It is therefore hard to accept their sample population as a realistic reflection of the general population undergoing such surgery. Comorbidity-related issues such as BMI are central to influencing decisions surrounding anaesthetic technique. We feel it is unfortunate that this article has been accompanied by an editorial and may give the unwarranted conclusion that RA is a poor choice for primary knee arthroplasty. We suspect that this manuscript was too late to have included reference to the recent large observational study5 suggesting advantages of RA over GA for hip and knee arthroplasty.
Declaration of interest None declared. A. P. Reed Peterborough, UK E-mail: [email protected] 1 Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anesthesia or spinal anaesthesia for total knee arthroplasty. Br J Anaesth 2013; 111: 391– 9 2 McCarteny CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111: 331–3
763
Downloaded from http://bja.oxfordjournals.org/ at Universitaets- und Landesbibliothek Duesseldorf on March 25, 2014
Regular use allows trainees to develop a portfolio of procedures, ensuring they can demonstrate consistent levels of performance, and therefore competence, without the need for consultant presence. It also overcomes the sometimes artificial nature of pre-planned WPBAs. Also providing evidence of competence, and training for the individual operator, videos can be subsequently used as teaching tools for other trainees to demonstrate particular expertise or common pitfalls. The use of recordable video sport glasses could easily be disseminated to all practical procedures in anaesthesia, and indeed to all medical and surgical specialities, where demonstration of adequate technical skills is required. Round-theclock availability of the glasses is enabling trainees to use any performance of practical procedures as a training opportunity, overcoming the barrier posed by increased out-of-hours work. The purpose of assessment in medical practice is two-fold: to provide evidence of developing competence, and to determine fitness for professional practice. The quality of an assessment tool is dictated by its reliability, validity, educational benefit, and cost.7 We firmly believe that this method of assessment fulfils all of these criteria. Our experience so far suggests it is reliable, valid, and certainly of more educational benefit than current assessment tools. The high definition video produced by these glasses represents excellent value, with negligible running costs. We conclude that this more than justifies the initial, relatively low cost of purchasing the glasses. In conclusion, changes to medical training are both inevitable and necessary. We believe that video analysis of practical procedures using recordable video sports glasses would be the most valid, reliable, non-intrusive, and educationally beneficial way of improving assessment, and therefore training.
BJA
Correspondence
3 The National Joint Registry. Available from http://www.njrcentre.org .uk/njrcentre/Default.aspx 4 Franklin J, Ingvarsson T, Englund M, Lohmander LS. Sex differences in the association between BMI and total hip or total knee joint replacement resulting from osteoarthritis. Ann Rheum Dis 2009; 68: 536– 40 5 Memtsoudis SG, Sun X, Chiu Y,et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anaesthesiology 2013; 118: 1046–58
1 Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anesthesia or spinal anaesthesia for total knee arthroplasty. Br J Anaesth 2013; 111: 391– 9 2 McCarteny CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111: 331–3 3 Joshi G, Ogunnaike B. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005; 23: 21– 36
doi:10.1093/bja/aeu071 doi:10.1093/bja/aeu072
Editor—The study by Harsten and colleagues1 2 demonstrated that patients having spinal anaesthesia (SA) had worse pain control at 6 h, more opioid consumption, more nausea, vomiting, and dizziness when compared with those having general anaesthesia (GA). All of these findings could be explained by the lack of appropriate pain relief as the spinal anaesthetic wore off. The patients having a GA were given oxycodone intraoperatively, whereas those having SA did not have any i.v. analgesia. The SA group were unsurprisingly in severe pain at 6 h and were probably playing catch up with analgesia for a considerable period of time. This explains the higher number of patient-controlled analgesia doses requested but not administered in the SA group. The poor pain control in the spinal anaesthetic group may have led to patients overcompensating and consuming more opioids when compared with the GA group. Poor pain control and higher opioid use may explain the higher incidence of postoperative nausea and vomiting in the SA group. Inadequate postoperative pain relief results in delayed recovery and poor patient satisfaction.3 This is perhaps why most patients who had SA preferred to have GA in the future. The length of stay (LOS) was shorter in the GA group (46 h) when compared with the SA group (52 h). This is clearly not clinically significant. The statistics used for calculating the sample size is not very clear and one can only assume that the sample size was calculated on the assumption that the difference in the LOS between the two groups was 24 h. This assumption has led to the underestimation of the sample size required. A number of other outcomes have been studied and corrections have not been made for multiple testing. Nausea, vomiting, and dizziness were assessed at fixed times on days 1 and 2 as opposed to fixed time periods after the end of surgery. There are a number of methodological flaws in this study that make the validity of this study questionable.
Declaration of interest None declared. M. Chincholkar Salford, UK E-mail: [email protected]
764
Anaesthesia for elective total knee arthroplasty Reply from the authors to Dr Reed Editor—We thank Dr Reed for his letter on our clinical investigation.1 2 We agree that the administration of i.v. oxycodone to our target-controlled infusion (TCI) anaesthesia group could have influenced the postoperative pain scores. However, administering i.v. opioids towards the end of a TCIanaesthetic is almost to be considered as the modus operandi for TCI anaesthesia due to the fact that remifentanil has a very short-lasting analgesic effect. Hence, this could almost be considered as a part of the TCI technique. Whether patients with a BMI of 35 or more should have been excluded or not in this study is an interesting and relevant question. By excluding patients with a BMI exceeding 35, one might argue that our sample population does not perfectly reflect the general population undergoing total knee replacement. It is true that our study was written before the publication of the study by Memtsoudis and colleagues.3 However, as pointed out by an editorial4 in the same issue of Anesthesiology, the trial by Memtsoudis and colleagues is observational rather than experimental in nature. As such, treatment assignment was non-random, creating the real possibility that the authors’ findings may reflect the confounding effects of differences in patient severity rather than effects attributed to anaesthesia type per se.
Declaration of interest None declared. A. Harsten Hasssleholm, Sweden E-mail: [email protected] 1 Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anesthesia or spinal anaesthesia for total knee arthroplasty. Br J Anaesth 2013; 111: 391– 9 2 McCarteny CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111: 331–3 3 Memtsoudis SG, Sun X, Chiu Y, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anaesthesiology 2013; 118: 1046–58
Downloaded from http://bja.oxfordjournals.org/ at Universitaets- und Landesbibliothek Duesseldorf on March 25, 2014
Poor pain control rather than anaesthetic technique influences outcome in total knee arthroplasty
