Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK

BACKGROUND AND OBJECTIVE: In October 2000, we conducted a national postal survey of day case consultant anaesthetists in the UK to explore the range and variation in practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). This paper reports the findings of this national survey of paediatric day case anaesthetic practice carried out as part of a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). METHODS: The survey used a structured postal questionnaire and collected data on the duration of surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flow rates used for general anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia. RESULTS: The overall response rate for the survey was 74 and 63% for the paediatric section of the survey. Respondents indicated that 19% used premedication, 63% used propofol for induction, 54% used isoflurane for maintenance, 24% used prophylactic antiemetics and 85%, used a laryngeal mask. The findings of this national survey are discussed and compared with published evidence. CONCLUSIONS: This survey identifies the variation in clinical practice in paediatric day surgery anaesthesia in the UK.     

Regional anaesthesia for limb surgery--before or after general anaesthesia. A survey of anaesthetists in the Oxford region

We conducted a postal survey of 221 anaesthetists in the Oxford region to determine their views and actual clinical practice regarding regional anaesthesia in adult patients undergoing limb surgery, when a combined regional and general anaesthetic was planned. Of the 162 respondents (73.3%), 142 (87.6%) regularly practised regional blocks for limb surgery in adult patients. For all the regional anaesthetic techniques in question, more anaesthetists felt it was safer to perform these blocks before induction of general anaesthesia than after induction. However, their actual practice varied markedly from their views, with more anaesthetists performing these blocks after general anaesthesia. Overall, trainees performed blocks before induction of general anaesthesia more often than consultants (p = 0.047).     

A survey of anaesthesia for caesarean section

In 1993 a postal survey of maternity hospitals within the UK was carried out to obtain data on the types of anaesthesia used for caesarean section. The poor response rate (79/226, 35%) reflects the paucity of data available in many centres. The data returned indicated a wide range of anaesthetic practice: from units with a general anaesthesia rate less than 10% to those with a general anaesthesia rate approaching 90%. Overall, during the 11-year period covered by the survey there was a significant reduction in the percentage use of general anaesthesia (77% in 1982 declining to 44% in 1992), but because of a 51% increase in the caesarean section rate the real reduction in the actual number of general anaesthetics used was modest (13%). If this holds true nationally, then factors other than a simple change from general anaesthesia to regional anaesthesia must contribute to the reduced maternal mortality from anaesthetic causes.     

Use of anaesthetic rooms in obstetric anaesthesia; a postal survey of obstetric anaesthetists and departments in the United Kingdom

BACKGROUND: Use of anaesthetic rooms has been much discussed in the UK in recent years, but attitudes and practices of obstetric anaesthetists regarding their use for caesarean section have never been sought. METHOD: A postal survey was conducted to discover the extent of use of anaesthetic rooms versus operating theatre for induction of anaesthesia and reasons for using or not using them. Questionnaires regarding individual practices were sent to 400 randomly selected members of the Obstetric Anaesthetists' Association ( approximately 25% of UK membership). Questionnaires regarding departmental policies were sent to 100 "clinicians responsible for surveys" (approximately 38% of departments providing obstetric anaesthesia in the UK). RESULTS: For elective caesarean section, 70% of individual clinicians never used an anaesthetic room, 9% rarely, 5% usually, 9% for all regional anaesthetics and 6% always. For emergency caesarean section the corresponding figures were 83%, 5%, 5%, 3% and 2% respectively. Use of the anaesthetic room was independent of the seniority of anaesthetists. In 68% of departments it was standard practice or policy to induce all anaesthetics for caesarean section in the operating room. Conversely, only 1% of departments had a policy to induce all anaesthetics in the anaesthetic room. Patient safety was the usual reason given for anaesthetising in the operating room. CONCLUSION: The majority of obstetric anaesthetists have abandoned the use of anaesthetic induction rooms, the main reason being patient safety. For the same reason, two-thirds of departments providing obstetric anaesthesia consider induction of anaesthesia in the operating room their standard practice.     

Admission to hospital after day case surgery

This paper reports a 5-year experience of a surgical day case unit. Over 10,000 patients were treated in the three specialties of gynaecology, orthopaedics and general surgery. Seventy patients (0.7%) were admitted to the inpatient beds of the hospital directly from the day case unit. These patients were reviewed to determine if any avoidable factors had played a part. Two-fifths of the admissions after suction termination of pregnancy were of patients of more than 12 weeks' gestation. Admission was necessary on 10 occasions after orthopaedic and general surgical operations when the procedure was too extensive or too painful to allow the patient to be discharged home. Complications of anaesthesia, either local (n = 5) or general (n = 15), constituted the largest cause for admission. Postoperative nausea, vomiting and drowsiness became less frequent after a change in technique to the use of a short-acting anaesthetic agent (12 in the 3 years before; two in the 2 years after). Day case surgery is safe and should rarely be followed by the need for hospital admission. Based on our experience, we recommend the use of short-acting agents for general anaesthesia, and we advise against day case surgery in patients who require a general anaesthetic for longer than 60 min, or who need extensive surgery.     

Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons

INTRODUCTION

Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting.

METHODS

With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids.

RESULTS

We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73–85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model.

CONCLUSIONS

Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.     

Regional anaesthesia practice for arteriovenous fistula formation surgery

We conducted a survey and semi-structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty-five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill-mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as ‘regional anaesthesia dominant’ or ‘local anaesthesia/mixed’; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians’ beliefs and preferences, resource considerations and patients’ treatment preferences; (4) anaesthetists’ preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource-related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.     

Anaesthesia for magnetic resonance imaging: a survey of current practice in the UK and Ireland

The lack of information about standards for anaesthetic practice in magnetic resonance imaging is of concern, since increasing requests are being made for this service, often in units not designed for the purpose. An overview of current practice was sought by conducting a postal survey of magnetic resonance units in the UK and Ireland. Replies were received from 100 units (79%), 46 of which had an anaesthetic service provided. A wide diversity of practice and opinion on the conduct of anaesthesia in this field was evident from the replies received. The survey highlighted particular areas of concern about the personal safety of anaesthetists within such units, including exposure to magnetic fields, noise and unscavenged anaesthetic gases. The evidence for such concerns is reviewed.     

Delegation in paediatric anaesthesia: a postal survey

BACKGROUND: We wished to determine a consensus view from UK paediatric anaesthetic consultants of what practical skills are safe and appropriate for an anaesthetic trainee to perform during an initial 3-month module in paediatric anaesthesia. METHODS: A postal survey was sent to all UK and Ireland members of the Association of Paediatric Anaesthetists (APA). This questionnaire was designed to determine which tasks were delegated to trainee anaesthetists. Two hundred and four questionnaires were despatched, replies were received from 165 consultant anaesthetists (80% response rate). RESULTS: More than 50% of the APA respondents would always or regularly allow an anaesthetic trainee in their first 3-month module in paediatric anaesthesia to perform; an ilioinguinal block, a penile block and a caudal (but not in a neonate). CONCLUSIONS: Anaesthetic registrars undertaking an initial module in paediatric anaesthesia should learn basic airway management, ilioinguinal blocks, penile blocks and caudals (but not neonatal caudals).     

Pyloric stenosis in full term babies. A postal survey of the management by paediatric anaesthetists

We report the results of a postal survey of the management of full term babies with pyloric stenosis by specialist paediatric anaesthetists. The conclusions from the survey are that the most likely anaesthetic techniques used are: rehydration and at least partial correction of electrolyte and acid-base abnormalities before surgery; aspiration of stomach contents before induction of anaesthesia; a rapid sequence induction; extubation of the trachea with the baby awake and on its side; and infiltration of the wound at the end of surgery with local anaesthetic.     

Peripheral nerve block in orthopaedic surgery: multicentric evaluation of practicing professionals and impact on the activity of the recovery room

Objectives

Since the last national survey on evaluation of professional practice in France, many peripheral nerve blocks techniques were developed. The aim of this study was to assess the place of such techniques and their impact on the stay in recovery room after orthopaedic surgery.

Study design

Prospective, multicentric study.

Patients and methods

Consecutive patients receiving a regional anaesthetic technique for orthopaedic surgery over a 15-day period were included in this multicenter study (four private clinics, two non-university and three university hospitals). Characteristics of blocks, duration of stay and activity of nurses in post-anaesthetic care unit (PACU) were recorded for each patient.

Results

A total of 289 blocks performed in 283 patients were analyzed. A regional anaesthetic technique was performed alone or associated with a light sedation (58 and 8% respectively) or with a general anaesthesia (44%). A continuous peripheral nerve block (mainly for femoral and iliofascial blocks) was performed in 25% of patients, mostly in university hospital and private clinics (35 and 26% respectively), but only in 3% of cases in non-university hospital. Mean duration of PACU stay was 64 ± 67 minutes. This time was longer when regional anaesthesia was associated to or performed after general anaesthesia. Workload of nurses was a simple supervision in 47% of the cases (in 61% of patients receiving regional anaesthesia alone vs 21% in those with general anaesthesia, p < 0.05).

Conclusion

This survey confirms that peripheral nerve block became widely used in orthopaedic surgery. This decreases the medical workload in PACU, especially for distal upper limb surgery. Regional anaesthetic techniques must be well taught during formation cursus of residents.     

The use of regional anaesthesia in patients at risk of acute compartment syndrome

A delay in the diagnosis of an acute compartment syndrome can be devastating to the patient. The increasing use of regional anaesthesia in the management of orthopaedic and trauma patients raises concerns about the potential for delay in the diagnosis of acute compartment syndrome. We undertook a postal survey to assess the usage of regional anaesthesia in patients with lower limb fractures. The study showed that regional anaesthesia is being used in patients at risk of compartment syndrome and without compartment pressure monitoring equipment being available. The anaesthetists questioned had seen cases of acute compartment syndrome being masked by regional anaesthesia. We recommend that there is an urgent need to establish joint guidelines between the orthopaedic and anaesthetic communities on the usage of regional anaesthesia in patients with lower limb fractures to reduce further morbidity from delays in the diagnosis of compartment syndrome.     

Day case surgery guidelines

Day surgery is an ever expanding and evolving specialty, clearly defined in the UK as an admission and discharge on the same day for a selected surgical procedure, although definitions in other countries vary. Ongoing improvements in surgical and anaesthetic techniques with the advent of integrated care pathways have encouraged this to continue and encompass a wider range of patients and more complex procedures. There are clear benefits to day case surgery including quicker recovery and improved patient outcomes. Service delivery is more efficient and a more streamlined service can be achieved. Best practice tariffs have also been used to incentivize day case procedures. Common day case procedures include inguinal hernia repairs, laparoscopic cholecystectomy, tonsillectomy, pinnaplasty, and varicose vein surgery. Patient selection and pre-assessment are vital considerations for day case surgery and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommends that anaesthesia in day surgery should be consultant-led. Regional and local techniques avoid the complications of a general anaesthetic and shorter recovery times are ideal and facilitate a timely discharge. Day case surgery guidelines are a vital resource in aiding the provision of an efficient service and improving service delivery and patient satisfaction.     

Anaesthesia for caesarean section — a German survey

Background: Anaesthetic practice for caesarean section has changed during the last decades. There is a world-wide shift in obstetric anaesthetic practice in favour of regional anaesthesia. Current data concerning anaesthetic practice in patients under-going caesarean section from Germany are not available. A comparison with figures from the UK, USA, Norway and other European countries might be of general interest.
Methods: Questionnaires on the practice of anaesthesia for caesarean section and anaesthetic coverage of the obstetric units were sent to 1178 university, tertiary care, district, community and private hospitals in Germany.
Results: The 532 completed replies of this survey represent 46.9% of the German obstetric units. Most hospitals (42.3%) have delivery rates between 500 and 1000 per year. General anaesthesia is the most common anaesthetic technique for elective (61%), urgent (83%) and emergency caesarean section (98%). Epidural anaesthesia is performed in 23% of scheduled and 5% of non-scheduled caesarean sections, and spinal anaesthesia in 14% and 10%, respectively. Acid aspiration prophylaxis before elective caesarean section is used in 68.7% of the departments. The majority of the departments provide a 24-hour anaesthetic coverage; however, in only 6.2% of the units, this service is assigned to obstetric anaesthesia, exclusively.
Conclusion: Compared to data from 1978, anaesthetic practice for caesarean section has changed with an increase in regional anaesthesia. However, German anaesthetists prefer general anaesthesia for caesarean section. In contrast, anaesthetists in other countries predominantly use regional techniques, and the difference to German practice is striking. International consensus discussion and recommendations as well as comparable European instruments of quality control in obstetric anaesthesia are desirable.     

Survey of cancellation rate of hypertensive patients undergoing anaesthesia and elective surgery

Hypertension is the commonest avoidable medical indication forpostponing anaesthesia and surgery. There are no universallyaccepted guidelines stating the arterial pressure values atwhich anaesthesia should be postponed. The aim of this studywas to determine the extent of variation across the South-Westregion of the UK in the anaesthetic management of patients presentingwith stage 2 or stage 3 hypertension. Each anaesthetist in theregion was sent a questionnaire with five imaginary case historiesof patients with stage 2 or stage 3 hypertension. They wereasked if they would be prepared to provide anaesthesia for eachpatient. The response rate was 58%. We found great variabilitybetween anaesthetists as to which patients would be cancelled.Departmental protocols may aid general practitioners and surgeonsin the preparation of patients for surgery, but such protocolsmay be difficult to agree in the light of such a wide variationin practice. Br J Anaesth 2001; 86: 789–93     

Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northern-European countries

BACKGROUND: For colorectal surgery, evidence suggests that optimal management includes: no pre-operative fasting, a thoracic epidural analgesia continued for 2 days post-operatively, and avoidance of fluid overload. In addition, no long-acting benzodiazepines on the day of surgery and use of short-acting anaesthetic medication may be beneficial. We examined whether these strategies have been adopted in five northern-European countries. METHODS: In 2003, a questionnaire concerning peri-operative anaesthetic routines in elective, open colonic cancer resection was sent to the chief anaesthesiologist in 258 digestive surgical centres in Scotland, the Netherlands, Denmark, Sweden and Norway. RESULTS: The response rate was 74% (n = 191). Although periods of pre-operative fasting up to 48 h were reported, most (> 85%) responders in all countries declared to adhere to guidelines for pre-operative fasting and oral clear liquids were permitted until 2-3 h before anaesthesia. Solid food was permitted up to 6-8 h prior to anaesthesia. In all countries more than 85% of the responders indicated that epidural anaesthesia was routinely used. Except for Denmark, long-acting benzodiazepines were still widely used. Short-acting anaesthetics were used in all countries except Scotland where isoflurane is the anaesthetic of choice. With the exception of Denmark, intravenous fluids were used unrestrictedly. CONCLUSION: In northern Europe, most anaesthesiologists adhere to evidence-based optimal management strategies on pre-operative fasting, thoracic epidurals and short-acting anaesthetics. However, premedication with longer-acting agents is still common. Avoidance of fluid overload has not yet found its way into daily practice. This may leave patients undergoing elective colonic surgery at risk of oversedation and excessive fluid administration with potential adverse effects on surgical outcome.     

Aspiration and regurgitation prophylaxis in paediatric anaesthesia

BACKGROUND: Surveys of aspiration prophylaxis in paediatric anaesthesia do not exist. METHODS: A postal survey was sent out to all UK members of the Association of Paediatric Anaesthetists (APA) to assess current practice. We asked about minimum fasting times for liquids and solids/milk, their routine acid aspiration prophylaxis and perceived risk factors for emergency and elective surgery in children those less than 1 year old and those aged 1-14 years. We also asked if the APA member had more than 10 years experience in paediatric anaesthesia. RESULTS: One hundred and two (55.1%) APA members replied out of a total of 185 questionnaires sent. Eighty-eight (88/102) were considered valid. Fasting in emergencies is approximately 4 h for solids/milk and 2 h for clear liquids. Fasting for elective surgery is between 5 and 6 h for solids/milk and 2 h for clear liquids. Pharmacological methods to reduce the risk of aspiration are not used. Mechanical methods vary from 40-50% for cricoid pressure and 20-30% for nasogastric aspiration if a tube is present. The presence of a hiatus hernia is perceived by over 80% as a risk factor, previous aspiration by over 60%, difficult intubation, cerebral palsy and sepsis by 20-30%. CONCLUSION: Perceived risk factors vary with "experience": hiatus hernia, difficult intubation and cerebral palsy are less important whereas previous aspiration and renal failure appear to be more important for paediatric anaesthetists with less than 10 years in paediatric anaesthetic practice.     

Carbon dioxide—a survey of its use in anaesthesia in the UK

A random postal survey of 1528 anaesthetists in the UK was performed to assess their use of carbon dioxide in anaesthesia and opinion on its safety. Of 1100 replies (72% response rate), 60.9% used it daily and 77.1% would object to its exclusion from future anaesthetic machines. There was no consistent age-related trend with regard to its use or opinion on its removal. 62.9% of anaesthetists did not regard its presence on the anaesthetic machine as hazardous, but 81.8% agreed that a limit to the maximum flow of carbon dioxide delivered to one litre/minute would improve safety.     

Regional anaesthesia for limb surgery: a review of anaesthetists' beliefs and practice in the Oxford region

We conducted a postal survey of 210 anaesthetists in the Oxford region to determine their views and practice regarding the timing of regional anaesthesia when combined with general anaesthesia for adults undergoing limb surgery and to compare the results with those obtained in a similar survey conducted in 2001. Of the 151 respondents (72% response rate), 102 (68%) regularly combined regional and general anaesthesia for adult limb surgery. Over 80% believed that central neuraxial blocks should be performed before general anaesthesia. This matched their current practice, marking a change from 2001. Significantly fewer anaesthetists believed it necessary to perform peripheral nerve blocks before general anaesthesia than in 2001, marking another significant change in practice. Overall, the results indicate an increased popularity of regional blocks in combination with general anaesthesia when compared with 2001 practice, which we believe is related to high quality advanced training modules now on offer to senior trainees in the Oxford region.     

A survey of pre-operative fasting regimens before regional ophthalmic anaesthesia in three regions of the United Kingdom

A postal and telephone survey of the practice of fasting before regional ophthalmic anaesthesia with and without sedation was sent to 50 hospitals in three regions of the United Kingdom. Responses were received from 100% of hospitals. In most hospitals (58%), local anaesthetic blocks were performed by both surgeons and anaesthetists, with surgeons alone providing ophthalmic anaesthesia in only 14%. Eighty-six per cent of hospitals surveyed had a formal policy regarding pre-operative fasting, with 44% allowing patients to eat and drink freely until their operation. In those hospitals where a fast was imposed, the most common fasting periods were 6 h for food and 2 h for fluids. Twenty-six per cent of respondents would be prepared to give intravenous sedation to a non-fasted patient during eye surgery: small doses of benzodiazepine were the most frequently suggested method. National evidence-based guidelines for ophthalmic regional anaesthesia are needed.