Letter to the Director
Is there a real consensus among anesthetists and surgeons about the neuromuscular block? Methodological considerations about the ACHILLES study
¿Existe realmente consenso entre los anestesistas y los cirujanos sobre el bloqueo neuromuscular?: consideraciones metodológicas sobre el estudio AQUILES
Servicio de Anestesiología y Reanimación, Hospital de la Plana, Villareal, Castellón, Spain
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Methodological considerations about the ACHILLES study" "tieneTextoCompleto" => true "saludo" => "To the Director," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "602" "paginaFinal" => "603" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Nicolau Gozalbo, L. Vives Piqueres" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Nicolau Gozalbo" "email" => array:1 [ 0 => "nicolau_ana@gva.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Vives Piqueres" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de la Plana, Villareal, Castellón, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Existe realmente consenso entre los anestesistas y los cirujanos sobre el bloqueo neuromuscular?: consideraciones metodológicas sobre el estudio AQUILES" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">First, we would like to congratulate Errando-Oyonarte et al. on their article “<span class="elsevierStyleItalic">Recommendations on the use of deep neuromuscular blockade by anaesthesiologists and surgeons. AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad) Consensus</span>”, recently published in this journal.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> We believe that a study of this type was necessary in Spain. However, we would venture some observations about the methodology used.</p><p id="par0010" class="elsevierStylePara elsevierViewall">First, the authors defined consensus as 70% or more of agreement. However, they do not estimate the median and/or mean, the coefficient of variation, or the interquartile range. These would show the pattern of change in opinion over the 2 rounds or waves of Delphi and the degree of dispersion.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> There is actually no consensus in the literature on the required number of Delphi rounds, but it does seem essential to achieve a certain convergence of opinion among the panellists.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> In the case of the ACHILLES study, for example, there are several items in recommendation 3 (“deep NMB until the end of surgery optimises intraoperative working conditions,...”) where no consensus was achieved, as can be seen in Table 1 and, particularly, in Table 2. According to the authors, some anesthetists would be reluctant to recommend this due to the need for additional monitoring of patients and changes in the anaesthesia protocol. However, the <span class="elsevierStyleItalic">p</span> value obtained suggests that surgeons do not see the benefits of general anaesthesia with deep NMB after surgery, either. Ideally, the pattern of panellist responses over the 2 rounds should be analysed and evaluated; however, there is no mention of such an analysis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The same is true of recommendation 4 (“it is recommended to use quantitative monitoring and NMB reversers to improve the safety and predictability of deep NMB”). The authors claim that in the absence of quantitative monitoring devices, none of the clinical indicators presented were adequate for evaluating neuromuscular block reversal. The results, however, tell a different story: there is no consensus on any clinical monitoring indicators. Again, we are not shown the responses in the first round, and are therefore unable to judge whether a third round would have been needed to reach consensus. Similarly, Table 3 shows items in which no consensus was reached.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors also draw attention to possible statistically significant differences between the opinions held by anesthetists and surgeons, although no mention is made in the study of the methodology used to detect differences of opinion between these 2 groups. If this statistical power has not been calculated, we cannot correctly interpret the data when these differences do not arise. In other words, are there no differences of opinion between the 2 groups of specialists? Or is the study incapable of detecting them due to the small sample size or to a far larger than anticipated difference between the opinions of both groups? Either way, we do not believe this to be crucial. What is important, though, is to understand the extent to which the iterative Delphi process applied to 2 specialist groups is able to modify the opinions previously held on each of the items in the questionnaire. For example, how many opinions held by the surgeons were changed as a result of the responses of the anaesthesiologists, and vice versa? Does the existence of a common working space, such as the operating room, and shared problems (and solutions) prompt anesthetists and surgeons to reach agreement on procedural strategies? Have the authors really achieved consensus between 2 such different groups? Or would they have obtained similar results if they had performed 2 separate studies—one in anesthetists and another in surgeons?</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, we do not fully understand why the panellists rated their opinion on a 7-point Likert scale (a 9-point scale is the norm<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a>) if the data were ultimately divided into 3 categories. This arrangement clearly facilitates the statistical analysis, but a graphic (histogram) display of the opinions in all categories would give a far more intuitive understanding of the degree of agreement or disagreement on the recommendations put forward. In any event, if opinions were rated on a scale of 7, it would be logical to show the full results, and then divide them into groups if needed, but not the other way round.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We hope these observations will be of interest to your readers.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nicolau Gozalbo A, Vives Piqueres L. ¿Existe realmente consenso entre los anestesistas y los cirujanos sobre el bloqueo neuromuscular?: consideraciones metodológicas sobre el estudio AQUILES. Rev Esp Anestesiol Reanim. 2017;64:602–603.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recomendaciones sobre el uso de bloqueo neuromuscular profundo por parte de anestesiólogos y cirujanos. Consenso AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.L. Errando-Oyonarte" 1 => "C. Moreno-Sanz" 2 => "P. Vila-Caral" 3 => "J.C. Ruiz de Adana-Belbel" 4 => "E. Vázquez-Alonso" 5 => "J.M. 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