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

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32 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)
© Queen’s Printer and Controller of HMSO 2002. All rights reserved. Health Technology Assessment 2002; Vol. 6: No. 30 TABLE 15 Named intraoperative analgesics used routinely for day surgery in the three specified clinical areas Analgesic Respondents (%) Urology Orthopaedics Paediatrics Opioid analgesics Fentanyl 50 43 37 Alfentanil 26 13 11 Morphine 1 5 4 Remifentanil 4 2 0.5 Pethidine 1 0.5 5 Tramadol 0 1 0 Diamorphine 0 1 0.6 Cyclimorph 0 0.5 0 Codeine 0.2 0.2 0.3 NSAIDs Diclofenac 7 16 25 Ketorolac 6 13 1 Tenoxicam or piroxicam 0.5 2 0 Ibuprofen 0 0 0.6 Other analgesics Paracetamol 0 0 5 Ketamine 0 0 1 No analgesic given None 5 1 6 TABLE 16 First- and second-line treatment anti-emetics in the three specified clinical areas Anti-emetic Respondents (%) Urology Orthopaedics Paediatrics First-line Second-line First-line Second-line First-line Second-line choice choice choice choice choice choice Ondansetron 23 42 30 42 49 16 Cyclizine 33 16 36 16 21 12 Prochlorperazine 16 8 15 8 7 2 Metoclopramide 11 5 11 4 6 7 Droperidol 4 4 3 4 2 4 Granisetron or tropisetron 1 2 1 0 0 0 Betamethasone or dexamethasone 0.5 2 0.5 0 0.6 0 Normal saline 0 0.5 0 0 0 0 Trimeprazine 0 0 0 0 0 0.5 No treatment 5 21 3 26 12 55 33
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 22 and 23: 8 Literature review included in the
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
Page 69 and 70: 140 120 100 80 60 40 20 0 No. of pa
Page 71 and 72: 250 200 150 100 50 0 No. of patient
Page 73 and 74: TABLE 37 Deterministic sensitivity
Page 75 and 76: 20 15 10 5 0 -5 Difference in varia
Page 77 and 78: Patient admitted for day surgery an
Page 79 and 80: 500 400 300 200 100 0 -100 -200 -30
Page 81 and 82: Recruitment to the CESA RCT The stu
Page 83 and 84: TABLE 49 The occurrence of any PONV
Page 85 and 86: 60 50 40 30 20 10 0 No. of patients
Page 87 and 88: a scale effect for scenario A, but
Page 89 and 90: The mean CVs for avoidance of PONV
Page 91 and 92: 1.80 The new variable cost and tota
Page 93 and 94: 100 90 80 70 60 50 40 30 20 10 0 Su
Page 95 and 96: 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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