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

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8 Literature review included in the following sections. A standard method of data extraction and assessment was used (available from the authors on request). The studies were categorised using accepted hierarchies of evidence from the NHS Centre for Reviews and Dissemination report published in 1996 39 (see appendix 3). RCTs and observational studies were assessed using a published checklist 39 (see appendix 3). Patient-based outcome studies were assessed on two levels. First, the study design was assessed using the checklists for RCTs and observational studies. Second, an attempt was made to assess the quality of the instruments used in the study. Criteria are less well developed for this aspect of studies, and it was not feasible to subject each instrument to a formal quality assessment. The checklist proposed by Fitzpatrick and co-workers 49 was used to assess the quality of these studies (see appendix 3). The quality of costing and economic studies was assessed (see appendix 3) using the British Medical Journal 35-point checklist. 50 All the papers retrieved for the economics literature review were screened for inclusion using the following criteria: • An evaluation was included of anaesthetic techniques, procedures or agents in the context of day surgery. • Papers that reported evaluations of anaesthetic techniques, procedures or agents for inpatient surgery were excluded. This was to ensure that any comparisons made of extracted cost or patient outcome data were generalisable to the setting of day surgery and not influenced by factors specific to inpatient surgery (e.g. organisation of pre-, peri- and postoperative care, use of different or additional drugs and procedures that may affect the outcomes and resource use associated with general anaesthesia). • The evaluation included cost and outcome data for comparison of specific anaesthetic techniques, procedures or agents for general anaesthesia. Sufficient data were reported to extract costs and outcome data relevant to comparisons of anaesthetic techniques, procedures and agents for the literature review or the economic model. • The evaluations were based on primary data collection or systematic review. Studies included in the review The following studies were included in the final review: • 89 adult clinical outcome studies 29,30,51–137 • 30 paediatric clinical outcome studies 13,138–166 • 9 meta-analyses 40–48 • 39 adult patient-based outcome studies 19,21,33,77,79,89,108,167–198 • 13 paediatric patient-based outcome studies 147,199–210 • 24 costing and economic studies. 22,28,29,84,86,99,125,126,129,175,211–224 Tables summarising these studies are given in appendices 4 to 9. A list of excluded studies is given in appendix 10. Clinical reviews Many studies have examined different techniques of anaesthesia for day or short-stay procedures. Unfortunately, the number of different variables examined has also been considerable, including onset of anaesthesia, quality of surgical conditions, cardiovascular effects and respiratory effects. Postoperatively, many different techniques have been used to assess recovery and evaluate sideeffects. Unfortunately, the number of drugs available also means that most studies cannot be compared directly because they use different combinations of drugs, or because they use the same drugs but given in different ways (e.g. fixed dose, dose according to body weight). Recovery has been measured in a variety of different ways, with some studies using simple tests, such as time to eye opening, and some using complex computerdriven psychometric tests, making direct comparison difficult. The quality of the studies reported varies considerably. There are few truly convincing RCTs. Most were randomised, or pseudo-randomised. Few studies were fully blinded. Commonly, blinded recovery assessments were carried out, but the group allocation was otherwise open. For the purposes of this review, the measurement of clinical outcomes has been grouped into five areas of recovery assessment, • Early recovery – time to eye opening – time to protrude tongue on command – time to awaken. • Intermediate recovery – time to give the correct date of birth, location, day and date – time to full orientation when the patient is fit to move from first to second stage recovery.
• Late recovery – time to walk unaided – ability to walk in a straight line – time to discharge home. • Psychomotor recovery – digital symbol substitution test –P-deletion test (and its variants) – dot tracking on a computer screen –Trieger dot test –critical flicker fusion threshold – mood adjective checklist – perceptual accuracy tests – picture cards recall – word association or recall – perceptual memory – pegboard test – simple reaction time – choice reaction time – body sway coordination tests – finger tapping –Maddox Wing – Aldrete score (postanaesthesia recovery score looking at activity, respiration, circulation, consciousness and colour). • Unwanted side-effects –PONV – pain (visual analogue scale (VAS) scores) – anxiety (VAS scores). Adult clinical review This section examines research on the impact of anaesthesia techniques in day surgery on adult clinical outcomes. Summary of clinical evidence Eighty-nine comparative studies of anaesthesia in adult day surgery were included in the review (see appendix 4 for a summary of each study). The anaesthetics compared in these studies are summarised in Table 1 (the sum is more than 89 because more than one comparison was carried out in some studies). Evidence for clinical differences The 89 studies were graded for quality of evidence, 84 were grade I, four were grade II-1a and one was grade II-1b. Most studies were small RCTs, with patient groups smaller than 50 in 36 of the studies. The studies came primarily from the USA or Canada (30), the UK (23), Sweden (7), Finland (9) and Denmark (5). The outcome measures most commonly used were times to different stages of emergence and recovery and PONV. Forty-five studies did not report the time to, or readiness for, discharge from hospital. Fiftyseven studies reported PONV rates in hospital. Only four studies reported Aldrete scores. © Queen’s Printer and Controller of HMSO 2002. All rights reserved. Health Technology Assessment 2002; Vol. 6: No. 30 A range of pain scores and use of analgesics were reported. Induction of anaesthesia The equivalence of doses for induction of anaesthesia is difficult to address. Few of the studies compared two induction agents with all else remaining constant. The interpretation of the studies must, therefore, allow for this matter. The intravenous agents may also not have been given in equipotent doses, and in some cases a fixed dose was given without regard to body weight or habitus. The accurate direct comparison of intravenous and inhalational agents is actually impossible. These agents are given in different ways, and thus onset pharmacokinetics cannot be compared. Inhalational agents can be compared directly with one another by using the concept of minimum alveolar concentration (MAC). Intravenous agents can be compared directly for induction and also for maintenance (minimum infusion rate (MIR)). It is not possible to compare the MAC with the MIR because they are only equipotent at one point: 1.0 × MAC = 1.0 × MIR, by definition. The log dose–response lines may not, however, be parallel and so 2.0 × MAC is unlikely to be equipotent to 2.0 × MIR. Furthermore, the relationship between the MAC for anaesthesia and the MAC at which the patient recovers consciousness (MAC awake) varies between volatile anaesthetic agents. Propofol and thiopentone Of the 16 studies 61,65,66,77,85,87,88,91,102,111,118–121,136 that compared the two induction agents thiopentone and propofol, in only six was the remainder of the process of anaesthesia kept constant in the two groups. Whether considering only these six studies or taking all 16 together, however, the conclusion remains the same. In no case was thiopentone better than propofol. Five studies found no difference between the two agents, but in all other studies propofol was superior to thiopentone with respect to early, intermediate, late and psychomotor recoveries. Propofol and etomidate Two studies compared these two induction agents. 65,97 The first study is not a well-performed study. Propofol was administered not as a bolus, but using a target controlled system in the first group. Etomidate was administered as a bolus of 0.25 mg/kg in the second group, and anaesthesia continued in that group using isoflurane. Early recovery was more rapid in the etomidate group, but there was otherwise no difference between the groups. In the second study, propofol was 9
Page 1 and 2: Which anaesthetic agents are costef
Page 3: Which anaesthetic agents are costef
Page 6 and 7: NHS R&D HTA Programme The NHS R&D H
Page 8 and 9: Contents Appendix 6 Adult patient-b
Page 11 and 12: Background The aim of the project w
Page 13: • The incidence of PONV was low d
Page 16 and 17: 2 Introduction dizziness or disorie
Page 18 and 19: 4 Introduction a reduced incidence
Page 20 and 21: 6 Introduction willingness to pay f
Page 24 and 25: 10 Literature review TABLE 1 Compar
Page 26 and 27: 12 Literature review intermediate a
Page 32 and 33: 18 Literature review Patient-based
Page 34 and 35: 20 Literature review TABLE 5 contd
Page 36 and 37: 22 Literature review No studies fol
Page 38 and 39: 24 Literature review (30%) and meth
Page 40 and 41: 26 Literature review • There are
Page 42 and 43: 28 National survey of anaesthetic p
Page 50 and 51: 36 Economic evaluation methods (inc
Page 52 and 53: 38 Economic evaluation methods The
Page 54 and 55: 40 Economic evaluation methods Tabl
Page 56 and 57: 42 Economic evaluation methods simi
Page 58 and 59: 44 Economic evaluation methods Prob
Page 61 and 62: Recruitment to the CESA RCT The stu
Page 63 and 64: Clinical outcome data PONV by anaes
Page 65 and 66: The findings from the logistic regr
Page 67 and 68: TABLE 29 The length of stay and pri
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TABLE 37 Deterministic sensitivity
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20 15 10 5 0 -5 Difference in varia
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Patient admitted for day surgery an
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500 400 300 200 100 0 -100 -200 -30
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Recruitment to the CESA RCT The stu
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TABLE 49 The occurrence of any PONV
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60 50 40 30 20 10 0 No. of patients
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a scale effect for scenario A, but
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The mean CVs for avoidance of PONV
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1.80 The new variable cost and tota
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100 90 80 70 60 50 40 30 20 10 0 Su
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The structure and content of this d
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nurses to have an in-depth knowledg
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agent used (see appendix 18). It wa
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Furthermore, anaesthetists operate
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The CESA project was designed to as
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practice, such as the use of midazo
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1. Royal College of Surgeons of Eng
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60. Cheng KI, Chu KS, Fang YR, Su K
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112. Raeder J, Gupta A, Pedersen FM
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162. Viitanen H, Baer G, Annila P.
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220. Rosenberg KM, Bridge P, Brown
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The range of databases interrogated
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24. preferen$.mp. [mp=title, abstra
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110 Appendix 2 TABLE 65 contd Summa
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112 Appendix 3 Quality assessment o
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TABLE 69 Summary of paediatric pati
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TABLE 69 contd Summary of paediatri
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TABLE 70 Characteristics of cost or
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TABLE 71 Quality of cost or economi
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TABLE 71 contd Quality of cost or e
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Abbott J, Abbott P. Psychological a
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Hall JE, Stewart JIM, Harmer M. Sin
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Struys M, Versichelen L, Thas O, He
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182 Appendix 11
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184 Appendix 11
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186 Appendix 11
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188 Appendix 11
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The aim of this study was to develo
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anaesthetics in day surgery, using
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© Queen’s Printer and Controller
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Background The empirical study quan
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Satisfaction with care Nearly all (
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TABLE 76 Reason given for preferenc
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TABLE 79 Comparisons with previous
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TABLE 80 Reason given for preferenc
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TABLE 81 Reason given for willingne
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Background Variable costs account f
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TABLE 85 Unit costs for the purchas
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Background The empirical study requ
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Ethical approval This was covered b
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20 15 10 5 0 -5 -10 -15 True weight
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15 10 5 0 -5 -10 True weight - Dion
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224 Appendix 19 • patients aged o
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All staff unit costs were for the y
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Background Fixed costs account for
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232 Appendix 22 March, Tuesday 15 A
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234 Appendix 23 TABLE 96 Reasons fo
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Patients were coded using the OPCS
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Q03.4 punch biopsy of cervix Q03.5
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This section displays the associati
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given in Table 103 confirm the age
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TABLE 107 Occurrence of PONV by dur
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248 Appendix 27 TABLE 113 Frequency
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This section displays the associati
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The adverse events observed in the
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262 Health Technology Assessment Pr
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264 Health Technology Assessment Pr
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