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

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Literature review
No studies followed up these results after discharge
to examine whether there were any real differences
from the patient’s perspective.
It is clear from this review that researchers and
clinicians believe cognitive failure is the most
important patient-based outcome for investigation.
However, it is not clear whether patients are of the
same view. In-depth interviews with day-surgery
patients suggest that the mode of anaesthesia and
the recovery profile are not patients’ principal
areas of concern. 191 In the descriptive studies the
issues addressed were principally PONV and pain,
but it is not clear whether the patients or the
researchers had set this agenda.
Paediatric studies
Methods
Four RCTs and nine descriptive studies were included
in this review. The Post Hospital Behaviour
Questionnaire (PHBQ) developed by Kotiniemi
and co-workers 202 is the method primarily used
to assess the impact of anaesthesia on paediatric
patient-based outcomes. It is widely used in
behavioural paediatrics. The PHBQ consists of
28 items used by parents to judge the impact of
hospitalisation on their child’s behaviour. It has
been used extensively by child psychologists to
assess the impact of psychological therapy on
ameliorating the psychological effects of hospitalisation.
208 It is suggested that this method is
reliable, valid and sensitive to subtle changes in
children’s behaviour, although it is also sensitive
to the questionnaire format, the study design,
the subject’s age and the length of hospitalisation.
The PHBQ was used in the two paediatric RCTs
that evaluated the effect of different anaesthetic
interventions, in order to assess changes in a
child’s behaviour. 201,203 It was also used in three
of the descriptive studies. 99,148,208 One further
study developed a paediatric pain score for
use by parents. 210
The types of surgery examined were day and
inpatient surgery, and some studies also included
medical patients. The ages of patients ranged
from 4 months to 13.4 years. The length of
assessment was usually 2 weeks to 1 month,
with some studies looking at changes up to
3 months. The comparative studies compared
the following alternatives:
• inpatient versus day surgery
• thiopentone versus halothane versus rectal
methohexitone for induction
• premedication regimens versus
no premedication.
Results
In a small RCT, Payne and co-workers 203 looked at
behavioural changes in children following minor
surgery in four comparable groups receiving different
premedication. The parents assessed behaviour
2 weeks postoperatively. The study found that
intravenous or oral midazolam provided some
benefit to the child with behavioural changes,
such as night crying being less frequent or severe.
A small RCT by Kotiniemi and co-workers 201 evaluated
a child’s behaviour at 1 day, 1 week and 1
month while investigating three different anaesthetic
induction agents (intravenous thiopentone,
inhalational halothane and rectal methohexitone).
The study showed that there was no statistically
significant difference between the groups in the
proportion of children who showed postoperative
behavioural problems, although there was a trend
to those children receiving inhalational induction
having more negative memories of anaesthesia.
Three descriptive studies used the PHBQ to
evaluate a child’s behaviour following day
surgery. 148,200,208 Multiple regression analysis
revealed that the principal factors affecting
the behaviour reported by parents were pain at
home, PONV in hospital, age more than 5 years
and the administration of postoperative opioids. 202
Kotiniemi and co-workers 202 suggested that pain
and other unpleasant experiences in hospital
predict the occurrence of behavioural
problems up to the fourth week.
Vernon and co-workers 208 recognised that a
combination of illness and hospitalisation is a
psychologically upsetting experience for children
in general, resulting in increased separation
anxiety, increased sleep anxiety and increased
aggression toward authority. Furthermore, a survey
done in the UK by Selby and co-workers 205 revealed
a higher incidence of minor morbidity following
day surgery than had been previously reported
when 266 children (aged 5 years and over) were
interviewed by an anaesthetist regarding minor
sequelae after day surgery. This suggests that
the trauma that children experience during
hospitalisation may not be detected by studies
using clinicians’, nurses’ or parents’ assessments
of their experiences.
A survey by Sikich and co-workers 206 evaluated
parental perceptions, expectations and preferences
for postanaesthetic recovery of children. They
highlighted that parents were concerned about
the level of pain and vomiting postoperatively.
Speed of discharge was not viewed as a high
priority for parents.