Letter to the Director
Response to the letter to the editor: “Is there a real consensus among anaesthetists and surgeons about the neuromuscular block? Methodological considerations about the ACHILLES study”
Respuesta a la carta al director: «Existe realmente consenso entre los anestesistas y los cirujanos sobre el bloqueo neuromuscular: algunas consideraciones metodológicas sobre el estudio AQUILES»
C.L. Errandoa,
, C. Moreno-Sanzb, P. Vila-Caralc, J.C. Ruiz de Adana-Belbeld, E. Vázquez-Alonsoe, J.M. Ramírez-Rodríguezf, G. Veiga-Ruizg, E. Guasch-Arévaloh, J.I. Lora-Tamayo D’Ocóni
Corresponding author
a Servicios Quirúrgicos, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
b Servicio de Cirugía General y Aparato Digestivo, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
c Servicio de Anestesiología y Reanimación, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
d Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Getafe, Getafe, Madrid, Spain
e Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Granada, Granada, Spain
f Servicio de Cirugía, Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain
g Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario Santa Lucía, Cartagena, Murcia, Spain
h Servicio de Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain
i Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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"apellidos" => "Lora-Tamayo D’Ocón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Servicios Quirúrgicos, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General y Aparato Digestivo, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Granada, Granada, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Cirugía, Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario Santa Lucía, Cartagena, Murcia, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Respuesta a la carta al director: «Existe realmente consenso entre los anestesistas y los cirujanos sobre el bloqueo neuromuscular: algunas consideraciones metodológicas sobre el estudio AQUILES»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We thank Nicolau Gozalbo and Vives Piqueres for their letter to the director regarding our article on the consensus among surgeons and anaesthesiologists on the use of deep neuromuscular blockade (NMB).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">First, we will comment on the methodological issues raised, and secondly on aspects that could be considered clinical. The Delphi method is a structured process of building consensus among groups of experts from various fields, and is currently the most widely used method of selecting quality indicators in health sciences.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Defining consensus as 70% or more of agreement is standard in Delphi studies, although as Boulkedid et al. observe in their systematic review on the use of the Delphi method in healthcare, there is no consensus on the definition of what is considered consensus.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> To avoid bias, this definition must be established a priori, as was done in the AQUILES study.</p><p id="par0020" class="elsevierStylePara elsevierViewall">True enough, statistics of central tendency (mean, median) or dispersion (standard deviation or interquartile range) and the statistical significance of the comparison of each questionnaire item between rounds are not shown in our article. These were omitted to save space and focus attention on the most significant results. This information was obtained and presented to the scientific committee of the AQUILES study, but it was not considered relevant enough to include in the article, given the limited space and the amount of information presented. The information is available to readers.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors also query the statistical power of the study to evaluate differences of opinion between anaesthesiologists and surgeons, and the potential effect of conducting the study with these 2 groups of specialists. Regarding this point, we believe this multidisciplinary approach to be one of the most interesting aspects of the AQUILES project, since it enables us to evaluate the surgical situation from the perspective of the 2 main specialist fields involved. Logically, there is no way of knowing whether the results would have been different if the study had been conducted with specialists from only 1 of these fields. However, the scientific committee of the AQUILES study and the scientific societies involved intentionally set themselves the challenge of working with these 2 groups in order to reach a consensus on fundamental issues affecting patients requiring general anaesthesia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, on the issue of the Likert scale used in the study, a 7-point scale was chosen because it is the scale most frequently used in this type of study. Again, there is no consensus on the best scale, and scales of ranging from 4 to 9 points have been reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">3,4</span></a> The 7-point Likert gives an odd number of responses, and is wide enough to allow participants to refine their opinion while being easy to use.</p><p id="par0035" class="elsevierStylePara elsevierViewall">With regard to recommendation 3 in particular: “deep NMB until the end of surgery optimises intraoperative working conditions...”, Table 1 gives the results of the panellists as a whole (both anaesthesiologists and surgeons), and shows that consensus is greater than 70% on 9 of the possible benefits of NMB.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding the benefits of deep NMB after surgery (Table 2), in this case no consensus is reached at all, and the <span class="elsevierStyleItalic">p</span> values show that there are no statistically significant differences between specialties. Results from round 1 were similar, insofar as no consensus was reached on any of the items. This suggests the need for pragmatic clinical studies to provide scientific evidence on the potential clinical benefits of deep NMB after surgery, since, in the opinion of both anaesthesiologists and surgeons, there is no consensus regarding the benefits of this anaesthesia strategy (see below).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recommendation 4, meanwhile, “it is recommended to use quantitative monitoring and NMB reversers to improve the safety and predictability of deep NMB”, is an amalgam of several questions. Specifically, the panellists were asked the following question: “In the absence of quantitative monitoring devices, please indicate the extent to which the clinical indicators are suitable for evaluating neuromuscular block reversal”. The responses showed that, in the opinion of the panellists, none of the clinical indicators presented were considered adequate to evaluate NMB reversal (the highest percentage of agreement (26%) was achieved on: “Ask the patient to raise their head for 5 seconds”). However, there was wide consensus on the benefits of quantitative monitoring and the use of fast-acting reversers, as shown in Table 3.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Another explanation for the lack of consensus on the foregoing items could be that anaesthesiologists are more involved in and have a deeper understanding of the technical aspects of these perioperative stages than surgeons. Interestingly, fewer responses were obtained from the latter on this point.</p><p id="par0055" class="elsevierStylePara elsevierViewall">With regard to the relevance and of the items in the questionnaire and their potential for bias, we would point out that they were formulated and revised up to 7 times by the committee of experts made up of experienced surgeons and anaesthesiologists before being submitted to the panellists. An alternative approach would have been to conduct a pilot study of a round of questions with fewer participants. This would have enabled us to make structural changes or include additional explanatory text.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We take this opportunity to again thank the authors for their observations and their interest in our manuscript. Their contribution has enriched the debate surrounding an issue that, as stated in our article, calls for further research and the creation of consensus protocols that will improve the efficacy, safety and effectiveness of surgical procedures and ensure the best possible outcomes.</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: Errando CL, Moreno-Sanz C, Vila-Caral P, Ruiz de Adana-Belbel JC, Vázquez-Alonso E, Ramírez-Rodríguez JM, et al. Respuesta a la carta al director: «Existe realmente consenso entre los anestesistas y los cirujanos sobre el bloqueo neuromuscular: algunas consideraciones metodológicas sobre el estudio AQUILES». 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