the metablog

Thoughts, news and musings from the metajournal team.

Are there any truly universal anaesthesia rules?

It’s not uncommon to hear anaesthesiologists drop verbal markers of universal truths into their clinical utterances: always, every, never. Often it's the most banal practices ("always attach the cannula tegaderm so") that generate our greatest passions.

However there are few, if any, universalisms in anaesthesia. Almost every rule has caveats and exceptions, reflecting the shades-of-grey reality of patient needs and human physiology.

When clinicians decree something is always or never so, they are often confusing truth with convention. Sometimes confusing an absolute with what is instead dogma. A minority reveal the rigidity of their thinking, impeding rather than enhancing the performance of their practice.

Rules are still useful. They are important guardrails, a mental model to keep us on the road of safety unless there is very good reason to cautiously edge onto the gravely shoulder, or even turn down a completely new path. But always with the understanding of the compromise we have intentionally made, reminding us of the cost that may need to be paid.

Universal anaesthesia rules become a problem when we dogmatically extol them without understanding the foundations of why – or use them as a blunt tool to browbeat our colleagues and assistants.

Rules are shortcuts to express the tension between the benefits and risks of different anaesthetic decisions. All difficult airways in specialty exams might require mandatory awake fiberoptic intubation, but in a real world of patient refusals and modern airway toys & techniques, it is a more nuanced decision. In fact, patient refusal might be the closest we get to an absolute rule – but even this is a negotiable area of greys.

As a mental model for normalising risk, rules are an efficient way to communicate our prioritisation of the risk-benefit tension. A tool for education and standard setting, without requiring the immediate overhead of qualifying and rationalising.

First learn the rules. Then master the rules. And only then can you break the rules.

The danger comes when we confuse the mental model – the guardrails – for the reality. Misidentifying a tool to guide perception and practice, as something we mistakenly believe reality can be bent to. When we make this error, reality has a nasty habit of reasserting itself with unsentimental brutality.

I made my mistakes so you don’t have to. Don’t repeat my mistakes. Make your own mistakes. Make better mistakes.

Browse articles by Journal, Year or Issue

As well as suggesting interesting articles online or in your weekly emailed metajournal, you can now also browse articles by journal, year or even just scroll through a single journal issue. Simply click on the journal name or issue date above an abstract to focus your abstract browsing.

So whether you want to see the latest articles from the British Journal of Anaesthesia, the top articles of 2017 from the American Journal of Emergency Medicine, or simply browse through the October issue of Current Opinion in Anesthesiology, metajournal can keep you up to date.

Metajournal.com browse medical abstracts by journal, year or issue

Of course, signed-in users can also search across any of these scopes – say, if you want to see the top remifentanil abstracts from IJOA, or find that elusive C-MAC c-spine article you vaguely remember seeing in a 2017 Am J Emerg Med issue – just hit the Search... button.

The 4th Horseman: Research Fraud & Mountains of Fujii

The fourth and final horseman of the medical research apocalypse is the scourge of medical research fraud. Although certainly not a new problem, the scale and potential impact of research deceit is unlike anything faced previously.

Academic fabrication, falsification, and plagiarism (FFP) make up the breadth of academic fraud – and sadly, anesthesia is the number one specialty by volume. In 2012 our eyes were opened to the sheer scale of the problem as the largest medical research fraud in history was exposed.

Trust, responsibility and the Fujii fraud

Medical research involves a lot of trust. The trust of patients and the public, the trust of publishers and the trust of the research-consuming clinician. Unfortunately we often overlook our responsibility to ensure that our trust is not misused.

"...with increasing amazement, we notice that the results reported by Fuji et al. are incredibly nice ..." wrote Kranke, Apfel and Roewer in their April 2000 letter, politely challenging Yoshitaka Fujii's PONV research.1

And so began the very slow unravelling of the biggest academic fraud in the history of medicine. Despite a meaningless response from Fujii to that first challenging letter, there was no investigation or further questioning from the various anesthesia journals. In fact Anesthesia & Analgesia went on to publish another 11 articles by Fujii over the next decade.2,3

Read more...


  1. Kranke P, Apfel CC, Roewer N, Fujii Y. Reported data on granisetron and postoperative nausea and vomiting by Fujii et al. Are incredibly nice! Anesth Analg. 2000 Apr;90(4):1004-7. 

  2. To their credit A&A were instrumental in ultimately uncovering the fraud and have lead the charge in undoing the damage inflicted by Fujii. Shafer SL. Fujii Statement Of Concern. Anesth Analg. 2012 Mar 7. 

  3. Yentis SM. Lies, damn lies, and statistics. Anaesthesia. 2012 May;67(5):455-6. 

The 3rd Horseman: Significance & Relevance

Arguably the most important piece of the evidence-based-medicine puzzle is when we ask ourselves:
"Is this evidence significant? – Is this relevant to my patients and my practice?"

When we talk about the 'quality' of a published research work we largely mean what the epidemiologists refer to as 'internal validity' – the extent to which the study's conclusions are actually warranted given the methodology and results. Internal validity looks only at the study design, conduct and interpretation, and takes into account bias and confounders. While important, internal validity is not alone sufficient.

The significance of a piece of evidence to medicine in general, along with it's relevance to our own practice, is referred to as the external validity. I think that for your and my practice this is often what matters most.

Really, external validity just describes how well the results and conclusions can be generalized to situations and people beyond those in the study.

I think of significance as the cumulative generalizability of a piece of evidence for the specialty and for wider medicine, integrated with how well the evidence agrees with what is already known. Relevance describes how applicable the evidence is to my hospital, my practice – and my patients.

It has significance for you, and relevance for me.

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The 2nd Horseman: Quality Evidence

Our understanding of what makes for quality medical research has improved dramatically over the past three decades. We understand that research must be ethical; should be reproducible; free of bias, so that we may make accurate conclusions; and that confounders be minimised and controlled for. We understand that prospective is best, and large blinded randomized trials are king.

We can articulate that a study must be appropriately powered to answer the question we are asking – but also not over-powered so that we waste resources and goodwill, or continue a study after an answer is known.

Read more...

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