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Lectura Crítica de Artículos en Anestesiología

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by Alejandro Mena on 2 December 2011

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Transcript of Lectura Crítica de Artículos en Anestesiología

Lectura Crítica de Artículos Anesth Analg. 2001 Mar;92(3):787-94.
Evidence-based medicine in anesthesiology.
Pronovost PJ, Berenholtz SM, Dorman T, Merritt WT, Martinez EA, Guyatt GH.
SourceDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland 21289-7294, USA. ppronovo@jhmi.edu

¿Qué se requiere para aplicar medicina basada en la evidencia en anestesiologia?

Definir una pregunta clínica que incluya la poblacion en cuestion, la intervencion a realizar y el outcome buscado.
Entrenar médicos, residentes y estudiantes en busqueda de literatura.
Acceso eficiente a la literatura científica.
Evaluar críticamente la literatura encontrada.
Decidir si es posible aplicar la evidencia disponible en nuestro medio.
Integrar al paciente en la toma de decisiones y discernir ventajas y desventajas en las opciones terapeuticas disponibles.





The number of systematic reviews pertaining to anesthesiology is increasing, and the Cochrane collaboration has recently created an anesthesiology work group to conduct systematic reviews that are relevant to anesthesiology Anesth Analg. 2001 Mar;92(3):787-94.
Evidence-based medicine in anesthesiology.
Pronovost PJ, Berenholtz SM, Dorman T, Merritt WT, Martinez EA, Guyatt GH.
SourceDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland 21289-7294, USA. ppronovo@jhmi.edu


Grading of Recommendations Assessment, Development,
and Evaluation (GRADE) offers a transparent
and structured process for developing and
presenting summaries of evidence, including its
quality, for systematic reviews and recommendations
in health care. ¿Que manera tenemos nosotros de asegurarnos la calidad de la informacion que utilizaremos para nuestra
actividad profesional? GRADE approach

Grading of Recommendations Assessment, Development and Evaluation Sequential process for developing guidelines First steps
1. Establishing the process


2. Systematic review

3. Prepare evidence profile for important outcomes

4. Quality of evidence for each outcome

5. Relative importance of outcomes

6. Overall quality of evidence

7. Balance of benefits and harms

8. Balance of net benefits and costs

9. Strength of recommendation

10. Implementation and evaluation

•Developed by a widely representative group of international guideline developers

•Clear separation between quality of evidence and strength of recommendations

•Explicit evaluation of the importance of outcomes of alternative management strategies

•Explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings

•Transparent process of moving from evidence to recommendations

•Explicit acknowledgment of values and preferences

•Clear, pragmatic interpretation of strong versus weak recommendations for clinicians, patients, and policy makers

•Useful for systematic reviews and health technology assessments, as well as guidelines

¿ Cuales son las ventajas del sistema GRADE ? Calidad de la evidencia fuerza de la recomendacion Sistema GRADE Limitaciones del estudio
Evidencia indirecta
Inconsistencia de resultados
Imprecisión
Sesgos de publicación
Fuerte




Debil High quality— Further research is very unlikely to change our confidence in the estimate of effect

Moderate quality— Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

Low quality— Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Very low quality— Any estimate of effect is very uncertain Alejandro Mena ¿Por qué deberíamos utilizar la MBE en la anestesiología? 1) Tranquilidad moral y profesional , al ofrecer la mejor opción segun la evidencia disponible. 2) Homogeineizar la manera de trabajar de los diferentes anestesiólogos. 3) Justificación de nuestras intervenciones y decisiones frente a la Gerencia Hospitalaria y frente
a la Justicia. Sistemas Sinopsis Revisiones sistemáticas y guias de práctica clínica Estudios Primarios Categorias de recursos de información clínica Calidad de la evidencia Fuerza de las recomendaciones Limitaciones de los estudios Inconsistencia de Resultados Variabilidad de resultados : discordancia entre los RR u Ods Ratios Heteroigeneidad: mayor al 20 % Impresicion de los resultados Amplios intervalos de confianza



Tamaño de muestra pequeño y bajo numeros de eventos Sesgo de publicacion Funnel Plot Evidencia indirecta Tiene relación con la formulación de la pregunta, la población de los estudios primarios , características de los pacientes, diferencias en las intervenciones y en los outcomes. Calidad de la evidencia

Efectos deseados y no deseados

Costos

Valores y preferencias del paciente Referencias Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knotterus A.
GRADE guidelines: A new series of articles in the Journal of Clinical Epidemiology.
J Clin Epidemiol. 2010 Dec 23. [Epub ahead of print]
Guyatt G, Oxman AD, Akl E, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, Debeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ.
GRADE guidelines 1. Introduction-GRADE evidence profiles and summary of findings tables.
J Clin Epidemiol. 2010 Dec 30. [Epub ahead of print]
Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, Alderson P, Glasziou P, Falck-Ytter Y, Schunemann HJ.
GRADE guidelines 2. Framing the question and deciding on important outcomes.
J Clin Epidemiol. 2010 Dec 30. [Epub ahead of print]
Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH.
GRADE guidelines 3: rating the quality of evidence - introduction.
J Clin Epidemiol. 2011 Jan 3. [Epub ahead of print]
Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, Montori V, Akl EA, Djulbegovic B, Falck-Ytter Y, Norris SL, Williams JW Jr, Atkins D, Meerpohl J, Schünemann HJ..
GRADE guidelines 4: rating the quality of evidence - risk of bias.
J Clin Epidemiol. 2011 Jan 19. [Epub ahead of print]
Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, Alonso-Coello P, Djulbegovic B, Atkins D, Falck-Ytter Y, Williams JW Jr, Meerpohl J, Norris SL, Akl EA, Schünemann HJ.
GRADE guidelines 5: rating the quality of evidence - publication bias.
J Clin Epidemiol. 2011 Jul 29. [Epub ahead of print]
Guyatt G, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, Devereaux P, Montori VM, Freyschuss B, Vist G, Jaeschke R, Williams JW Jr, Murad MH, Sinclair D, Falck-Ytter Y, Meerpohl J, Whittington C, Thorlund K, Andrews J, Schünemann HJ.
GRADE guidelines 6. Rating the quality of evidence - imprecision.
J Clin Epidemiol. 2011 Aug 10. [Epub ahead of print]
Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, Alonso-Coello P, Glasziou P, Jaeschke R, Akl EA, Norris S, Vist G, Dahm P, Shukla VK, Higgins J, Falck-Ytter Y, Schünemann HJ; The GRADE Working Group.
GRADE guidelines: 7. Rating the quality of evidence - inconsistency.
J Clin Epidemiol. 2011 Jul 30. [Epub ahead of print]
Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, Alonso-Coello P, Falck-Ytter Y, Jaeschke R, Vist G, Akl EA, Post PN, Norris S, Meerpohl J, Shukla VK, Nasser M, Schünemann HJ; The GRADE Working Group.
GRADE guidelines: 8. Rating the quality of evidence - indirectness.
J Clin Epidemiol. 2011 Jul 29. [Epub ahead of print]
Guyatt GH, Oxman AD, Sultan S, Glasziou P, Akl EA, Alonso-Coello P, Atkins D, Kunz R, Brozek J, Montori V, Jaeschke R, Rind D, Dahm P, Meerpohl J, Vist G, Berliner E, Norris S, Falck-Ytter Y, Murad MH, Schünemann HJ; The GRADE Working Group.
GRADE guidelines: 9. Rating up the quality of evidence.
J Clin Epidemiol. 2011 Jul 29. [Epub ahead of print]
Guyatt GH, Oxman AD, [...], Schünemann HJ; The GRADE Working.
GRADE guidelines: 10. Rating the quality of evidence for resource use.
[coming up next to the J Clin Epidemiology] Muchas Gracias por su Atención hola que tal bien y vos hola
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