Aanesthetic Agents for Day Surgery - NIHR Health Technology ...

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Background The aim of the project was to provide robust evidence on the relative costs, patient benefits and acceptability of different anaesthetic agents, by assessing the relative cost-effectiveness of different anaesthetic agents in adult and paediatric patients undergoing day surgery. Objectives The objectives were to identify and value resource use, impact on patients and relative value for money associated with different anaesthetic agents in day surgery. Methods The study consisted of three parts: • A literature review of clinical outcomes, patient-based outcomes and economic data. • A national survey of 270 anaesthetists (October 2000) to determine anaesthetic practice in adult and paediatric day surgery. • A prospective randomised controlled trial (RCT) to compare the cost-effectiveness of anaesthetic regimens (CESA). The trial was carried out at St. Mary’s Hospital, Manchester, and at Arrowe Park and Clatterbridge Hospitals, Wirral. The sample comprised adult general, orthopaedic and gynaecology patients, and paediatric general and ear, nose and throat (ENT) patients. Results Literature review The large number of RCTs available that investigated clinical outcomes involved the use of various anaesthetic combinations and approaches. There were few good comparative studies of patient-based outcomes and economic evidence. No optimal regimen was identified for adults or children on the basis of clinical outcomes, patient acceptability or efficiency. © Queen’s Printer and Controller of HMSO 2002. All rights reserved. Executive summary Health Technology Assessment 2002; Vol. 6: No. 30 National survey The national survey of anaesthetists (response rate 76%) indicated the following in adult urology, adult orthopaedic and paediatric general day-case surgery, respectively: • use of premedication, 6%, 12% and 19% • propofol as the preferred induction agent, 78%, 81% and 51% • isoflurane as the preferred maintenance agent, 52%, 54% and 45% • use of prophylactic anti-emetics, 32%, 41% and 24% • use of a laryngeal mask airway, 86%, 83% and 85%. CESA RCT Recruitment to the CESA RCT was 73% (adult study) and 75% (paediatric study). Ninety-five adult patients and 25 paediatric patients were withdrawn, leaving 1063 adult patients (265 propofol/propofol, 267 propofol/isoflurane, 280 propofol/sevoflurane, 251 sevoflurane/ sevoflurane) and 322 paediatric patients (159 propofol/halothane, 163 sevoflurane/sevoflurane) remaining in the study until discharge. Fifteen per cent of adults and 19% of children were lost to follow-up 7 days after discharge. Interventions (comparators) The anaesthetics in the adult treatment arm were: • Total intravenous anaesthesia (TIVA): propofol induction, propofol maintenance. • Intravenous/inhalational anaesthesia (mixed): propofol induction, isoflurane/nitrous oxide (N 2O) maintenance. • Intravenous/inhalational anaesthesia (mixed): propofol induction, sevoflurane/ N 2O maintenance. • Total inhalational anaesthesia: sevoflurane/ N 2O induction, sevoflurane/N 2O maintenance. The anaesthetics in the paediatric treatment arm were: • Intravenous/inhalational anaesthesia: propofol induction, halothane maintenance. • Total inhalational anaesthesia: sevoflurane/ N 2O induction, sevoflurane/N 2O maintenance. iii
Page 1 and 2: Which anaesthetic agents are costef
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48 Results of the adult economic ev
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82 Discussion respondents. The anti
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84 Discussion Interpretation of the
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88 Discussion In addition, it was n
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90 Conclusions Many adults and pare
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This report was commissioned by the
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96 References 32. Simpson RB, Russe
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98 References 87. Korttila K, Nuott
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100 References 138. Ariffin SA, Why
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102 References 191. Otte DI. Patien
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104 References 253. Barber J, Thomp
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106 Appendix 1 25. ambulatory surge
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TABLE 65 Summary of adult clinical
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Hierarchy of evidence Grade I: prop
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TABLE 66 contd Summary of adult cli
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TABLE 67 Summary of paediatric clin
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TABLE 68 Summary of adult patient-b
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176 Appendix 10 Chilvers CR, Kinaha
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178 Appendix 10 Lowry DW, Carroll M
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Membership Dr John Sear (Chair), Re
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192 Appendix 13 Interviews A pilot
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194 Appendix 13 hypothetical CV res
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200 Appendix 16 theme occurred. Som
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202 Appendix 16 The majority of par
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206 Appendix 16 “No, I felt rushe
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208 Appendix 16 Five patients gave
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212 Appendix 17 • the patient had
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220 Appendix 18 TABLE 89 Limits of
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Background Semi-fixed costs account
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Quality assurance is defined as “
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288 randomised to propofol/propofol
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240 Appendix 25 V41.2 anterior atta
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242 Appendix 26 TABLE 98 Occurrence
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244 Appendix 26 TABLE 104 Occurrenc
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The adverse events observed in the
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252 Appendix 29 TABLE 116 Occurrenc
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Members Chair, Professor Kent Woods
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Members Chair, Professor Bruce Camp
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