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

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National survey of anaesthetic practice for paediatric and adult day surgery
Use of supplementary anaesthetic
techniques
The use of supplementary therapies and techniques
for day surgery may be expected to vary
from patient to patient. Estimates for the likelihood
that an anaesthetist would use prophylactic
anti-emetics, local anaesthetics, non-depolarising
neuromuscular blocking agents, suxamethonium
or laryngeal masks in a sample of the UK population
of day patients were used to develop an
economic model of how a patient would be
anaesthetised for day surgery. Consultant anaesthetists
were asked to estimate the percentage of
patients in whom they would routinely use each of
these therapies or techniques (Table 14). Paediatric
day patients undergoing circumcision were less
likely to be given a prophylactic anti-emetic than
were adult day patients undergoing cystoscopy
or arthroscopy. Adult day patients undergoing
arthroscopy and paediatric day patients undergoing
circumcision were more likely to be given
a local anaesthetic. There is a small chance of
day patients being given a non-depolarising
neuromuscular blocking agent or suxamethonium,
and a very high likelihood of them having a
laryngeal mask inserted.
Intraoperative analgesics
In general, respondents indicated that intraoperative
analgesics would be used. Respondents
reported that intraoperative analgesics would not
be given in 5% for urology, 1% for orthopaedics
and 5% for paediatrics. The majority of respondents
(73% for urology, 43% for orthopaedic,
50% for paediatrics) followed the survey
directions and named just one intraoperative
analgesic (Table 15). The remaining respondents
who answered the question named between
two and four analgesics they would routinely
use for urology (26%), orthopaedics (59%) and
paediatrics (44%). The responses were weighted
accordingly, and are shown in Table 15. The most
popular combination of analgesic was fentanyl and
a non-steroidal anti-inflammatory drug (NSAID),
such as diclofenac or ketorolac, which 11% of
respondents said they used for urology, 31% for
orthopaedics and 18% for paediatrics.
Of those respondents who used opioid analgesics,
45% for urology, 54% for orthopaedics and 33%
for paediatrics indicated they gave a prophylactic
anti-emetic. Of those respondents who used nonopioid
analgesics, 26% for urology, 43% for
orthopaedics and 26% for paediatrics indicated
they gave a prophylactic anti-emetic.
Treatment anti-emetics
Respondents were asked to name their first- and
second-line choice of anti-emetic for the treatment
of PONV (Table 16). One respondent named many
agents for the treatment of PONV for urology and
orthopaedic patients. It was not possible to read
one respondent’s named drug. These two answers
were excluded from the analysis. Table 16 summarises
the popularity of each type of named
anti-emetic as a first- or second-line agent for this
sample of anaesthetists. Cyclizine and ondansetron
were favourite choices as first- or second-line
treatment anti-emetics. Interestingly, a notable
number (46%) of anaesthetists did not indicate a
second-line anti-emetic for paediatric day patients.
Implications for the
empirical study
This survey of anaesthetic practice generated an
excellent response rate and represented the views
of anaesthetists across the UK. The main areas
of day-case anaesthetic practice explored were:
premedication, induction, maintenance, prophylactic
and treatment anti-emetics, analgesia, local
anaesthesia and length of time for day procedures.
The probabilities of using the named therapies for
TABLE 14 Likelihood of using supplementary anaesthetic techniques in the three specified clinical areas
Anaesthetic Use (%) (95% CI; n)
technique
Urology Orthopaedics Paediatrics
Prophylactic anti-emetic 32 (26.0 to 38.3; 162) 41 (34.7 to 47.0; 176) 24 (18.1 to 29.0; 159)
Local anaesthetic 26 (21.1 to 31.5; 167) 77 (72.5 to 80.9; 183) 80 (75.7 to 83.8; 166)
Non-depolarising
neuromuscular
blocking agent
4 (2.3 to 5.3; 170) 6 (3.9 to 8.1; 182) 6 (4.1 to 8.0; 165)
Suxamethonium 0.7 (0.4 to 1.0; 172) 0.7 (0.4 to 1.0; 184) 2.5 (1.3 to 3.7; 168)
Laryngeal mask airway 86 (82.3 to 89.1; 171) 93 (91.6 to 95.1; 184) 85 (81.9 to 88.3; 166)