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

Alfentanil maintenance was compared with either
halothane or enflurane, 55 and patients in the
alfentanil group demonstrated a more rapid early
recovery. Three groups in which alfentanil,
fentanyl and enflurane were used for maintenance
anaesthesia were examined in a second study. 80
Alfentanil was better than fentanyl, and both these
agents were better than enflurane with respect to
early, intermediate or late recovery. When remifentanil
was compared to alfentanil 59 no difference
was found with respect to early, intermediate or
late recovery, although the patients in the remifentanil
group performed better on psychomotor
testing. Finally, fentanyl and low-dose ketamine
were compared in one study. 70 Early recovery was
better in the ketamine group, but no other
differences were found.
Postoperative nausea and vomiting
Fifty-nine studies considered PONV. The variety
of comparisons of induction and maintenance
agents used makes it very difficult to draw firm
conclusions. Forty-eight of the studies used
propofol TIVA in one group. In only two studies
was the rate of PONV lower in the comparator
group than in the TIVA group, and in 21 studies
the TIVA group showed a lower rate of PONV
than the other group. It would appear that the
least PONV is achieved using propofol administered
by TIVA. Induction of anaesthesia using
propofol was superior to induction of anaesthesia
using a barbiturate or an inhalational agent.
Patients who received induction of anaesthesia
with desflurane were the most likely to suffer
PONV. Finally, four studies examined the effects
of N 2O on PONV. Three studies found there to
be no difference between N 2O or oxygen-enriched
air, and in one study the patients who received
N 2O had more PONV.
A meta-analysis of PONV in day surgery compared
propofol with other anaesthetics for induction and
maintenance, although the results were presented
only graphically. 44 This study appears to suggest
that the use of propofol can reduce PONV rates
in day surgery, although it was not possible to
ascertain the actual reduction.
Paediatric clinical review
This section examines research on the impact of
anaesthesia techniques in day surgery on clinical
outcomes in paediatric patients.
Summary of clinical evidence
Thirty comparative studies of anaesthesia in
paediatric day surgery were included in the review
(see appendix 5 for details of each study). The
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Health Technology Assessment 2002; Vol. 6: No. 30
anaesthetics compared in these studies are
summarised in Table 4 (the sum is more than 30
because more than one comparison was carried
out in some studies).
Evidence for clinical differences
The 30 studies were graded for quality of
evidence, and 27 were found to be grade I and
three grade II-1a. Most studies were small RCTs,
with patient groups smaller than 50 in 25 of
the studies. The studies came from the USA or
Canada (14), Finland (5), the UK (4), Japan (2),
Australia (1), France (1), Sweden (1), Turkey (1)
and Taiwan (1). The outcome measures most
commonly used were times to different stages
of emergence and recovery, and PONV. Seven
studies did not report the time to, or readiness
for, discharge from hospital. Only one study
did not report the rate of PONV in hospital, 155
although only nine studies reported the rate
of PONV after discharge. Only seven studies
reported Aldrete scores (postanaesthesia
recovery score looking at activity, respiration,
circulation, consciousness and colour).
A range of pain scores and the use of
analgesics were reported.
Optimal induction
Most studies investigated induction in terms of the
time spans involved. Parameters such as the time to
loss of eyelash response and the time to intubation
were used as measures of induction times. Nine
studies 13,138,143,147,149,151,153,164,166 showed that sevoflurane
provided a more rapid induction than
halothane. Another study provided evidence that
sevoflurane provided a more rapid induction than
halothane, but the difference was not statistically
significant. Kotiniemi and Ryhanen 148 reported
that thiopentone provided a more rapid induction
than halothane. The impact of different induction
regimens on outcome measures is discussed below.
Thiopentone versus propofol
Six studies examined induction anaesthesia,
three of which looked at propofol versus
thiopentone. 139,146,157 Cheng and co-workers 139
reported a reduction in PONV in hospital with
propofol, but Runcie and co-workers 157 and
Hannallah and co-workers 146 did not find this.
Runcie and co-workers 157 reported that early
recovery was more rapid with propofol than with
thiopentone, but earlier discharge occurred only
in older children. However, the time from eye
opening to discharge was 88 minutes for propofol
compared with 117 minutes for thiopentone
(p = 0.004). It is unlikely that these 29 minutes
are clinically significant and can be translated
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