Pros and Cons, Evaluating the Evidence Behind Common Practices

Uday Agrawal, MD

Is direct laryngoscopy obsolete with advances in video laryngoscopy? Do peripheral nerve blocks mask acute compartment syndrome? This engaging workshop session, Anesthesia & Analgesia (A&A) Journal Club: How to Read and to Apply Various Types of Papers, at the 2025 Annual Meeting, presented by IARS and SOCCA, on Friday, March 21, tackled these questions head-on by reviewing the Pro-Con articles written by Aziz and Berkow and Samet et al. While the specific answers that arose during the discussion merit consideration, the primary takeaway from the session led by A&A Editors Adam Milam, MD, PhD; Amanda Kleiman, MD; David Hao, MD; Elizabeth Whitlock, MD, MS; Jaideep Pandit, MA, BMBCh, DPhil, FRCA, FFPMRCA, DM, MBA; Karsten Bartels, MD, PhD, MBA; and Lee Goeddel, MD, MPH was the overall framework and approach to critically appraise conflicting evidence to inform clinical practice.

Aziz and Berkow present a debate for the argument that “Videolaryngoscopy should be standard of care for tracheal intubation.” They begin their discussion by noting that “standard of care” is in fact a legal designation with specific connotations but advocate that every airway practitioner should be proficient with the use of videolaryngoscopy. Regarding the benefits of videolaryngoscopy, they summarize evidence from observational trials, clinical trials, metaanalyses, and Cochrane reviews demonstrating that use of videolaryngoscopy is associated with reduced risk of intubation failure, fewer attempts at intubation, and a lower rate of hypoxemia. However, they note several limitations of the technology including the lack of universal access or success (e.g., in the case of an airway with secretions or even sun glare), a prolonged time to intubation, and increased risk of pharyngeal injury. They discuss numerous other factors and conclude that videolaryngoscopy is an important tool for anesthesiologists and other airway providers to become facile with, but equally important is the ability to execute a backup plan, which may include alternative approaches such as direct laryngoscopy or fiberoptic intubation. Importantly, they leave the provider to decide – what technique should I use on my first pass at intubation?

Samet and coauthors have the additional challenge of discussing not only a controversial multidisciplinary topic, but one associated with an exceedingly rare and catastrophic event. They focus on the statement, “Peripheral nerve blockade should be provided routinely in extremity trauma, including in patients at risk for acute compartment syndrome.” They cite evidence noting that peripheral nerve blockade not only improves analgesia compared to opioid-based management, but that opioid-based management itself may also impede detection of acute compartment syndrome. Moreover, they note patient selection based on risk factors, a more dilute mixture of local anesthetic, and a dedicated acute pain service may further reduce the risk of delayed diagnosis or treatment for acute compartment syndrome. On the contrary, they note that while it is a late and not a perfectly sensitive or specific symptom of compartment syndrome, the onset of severe pain may be impacted by peripheral nerve blockade or may manifest as “rebound pain” following peripheral nerve blockade leading to concern for acute compartment syndrome and unnecessary fasciotomy. Even in the cases where a more dilute local anesthetic strategy is intended, unintentional dense blockade may occur and not all hospitals have the resources for specialized acute pain services to help manage these blocks. In conclusion, they note the need for additional large studies and alternative, robust techniques to diagnose acute compartment syndrome and – again – leave the decision to perform a peripheral nerve block on the individual provider.

Together, these articles highlight important questions faced by anesthesiologists in every day clinical practice. How do we evaluate the strength of evidence? Are there sources of bias in the research? Did the study populations include patients like the one in front of me? How do we perform high-quality research on rare events? Most importantly, how can we reconcile all this information to care for our patients? Dr. David Hao, an anesthesiologist and chronic pain physician at Massachusetts General Hospital, offered useful tools during the session to help with critical appraisal of the evidence including a worksheet by the Center for Evidence Based Medicine and the GRADE approach to evaluating studies and noted that perhaps the way we traditionally think about levels of evidence should be more fluid.

In breakout groups, the moderators utilized these tools to develop a structured approach for reading through evidence and discussed the importance of evaluating references to support specific claims, examining our own biases, and imagining what types of studies would be needed to change our viewpoints.

Critical appraisal of evidence is both challenging and important. For ongoing practice in structured approaches, consider the Pro-Con series in A&A or the Depth of Anesthesia podcast by Dr. Hao to continue to challenge the way we think.