The Clinical Studies Corner –  Perioperative Routines and Praxis

The Clinical Studies Corner – Perioperative Routines and Praxis

  • Issue 61

Jan Jakobsson | Sweden

A web-based survey about perioperative routines and praxis for Day Case Anaesthesia in the Scandinavian countries.

Day/ambulatory surgery is increasing. More patients and procedures are nowadays done on a day case basis. Shortening hospital stay has many advantages but calls also for an adequate perioperative management in order to maintain quality of care. Day surgery has been shown reassuringly safe. There are 2 recent papers from Denmark describing the safety associated with day surgery in the Copenhagen area [1][2]. There is however no evidence based best day case anaesthetic technique or general guidelines/standard recommendations. We performed a web-based survey during the spring 2014 in the five Scandinavian countries. A link to a web-based questionnaire was published after approval from the steering committees for the Swedish, Danish, Norwegian and Finland’s Society of Anaesthesia and Intensive Care and send directly to Anaesthesiologist on Iceland.

The responses are given as number of anaesthesiologists having the queried intervention as part of his/her day case practice. For questions around drugs and techniques, e.g. choice of airway both number of responders and the responders estimated use of the requested drug, technique or intervention is presented. There were in all 666 responses; 212 from Finland, 204 from Sweden, 139 from Denmark, 97 from Norway and 14 from Iceland. Of the responders 303 (46%) were involved and practices day surgical anaesthesia at least part of their working hours. Day case anaesthesia was part of the everyday work for 86% of anaesthesiologists working in rural, 82% working in private units, 57% working in central, and 29% of responders working in University hospital.

Preoperative assessment was most commonly done by paper review within a week before surgery (46%), in conjunction with the surgical consultation in 12%, on the day of surgery in 17%, and during a visit at a preoperative assessment unit in 10%. A structured leaflet for patients’ preoperative self-assessment was used as the basis by 93% of the participants, with some differences between countries; Norway 97%, Finland 98%, Denmark 79%, Iceland 58% and Sweden 99%. Screening was done by a nurse in 49%.

There was no BMI-limit for day care patients in 72% of responses. When there was a limit, BMI 40 was the mean limit for local anaesthesia and BMI 37 the mean limit for general anaesthesia. There was no upper age limit for day care patients in 96%. A lower age limit for day surgery was reported by 24% participants. The need of an individual assessment concerning patients BMI and age was emphasized. Routinely systematically preoperative scoring for PONV risk was done by less than half of responders (43%). Preoperative oral analgesics were administrated routinely by 249 (82%) of responders involved with day case anaesthesia; 245 provided paracetamol, 121 a traditional non-selective NSAID, 66 a Coxib, and 78 opioid on routine basis. The routine preoperative/preventive use of paracetamol was uniform across countries while routine use of NSAIDs differed 32 % in Finland and 85 % in Norway. The preoperative use of non-opioid analgesic was relatively uniform across the different levels of hospitals studied. Other drugs administrated preoperatively were steroids, gabapentin. Ninety-five % of responders stated that anxiolytic premedication was not routinely administered to adults but offered to around 33% of the children.

General anaesthesia was the most commonly used technique provided to in average 68% of day care patients, spinal anaesthesia used in average to 17% cases and a combination of local anaesthesia +/- sedation in 23%. Propofol was by far the most commonly used agent for induction, 300 out of the 303 responding anaesthesiologists working with day case. The second most common induction agent was sevoflurane used in average in 10 % and third occasional use of thiopentone. Total Intravenous Anaesthesia (TIVA) was the most common main anaesthetic technique, 284 of the 303 responders involved in day surgery used an intravenous technique to in average 59% of cases, followed by 252 responders using sevoflurane to in average 45% of patients, and 87 responders used desflurane to in average 17% of cases (Table 1). Isoflurane was not use by any of the anaesthesiologists when involved with day case surgery. Main anaesthetic choice differed however between countries, TIVA was more commonly used in Norway and Denmark, while inhaled anaesthesia based on sevoflurane was more common in Sweden and Finland. Spinal anaesthesia was most commonly used in Finnish day case anaesthesia practice.

Two hundred and thirty eight responders used routinely remifentanil and fentanyl to in average of 58 and 55 % of cases respectively. Alfentanil was used as intraoperative opiod by 125 responding anaesthesiologists to in average 18 % of cases. A combination of opioids was used by 91 in half of cases.

Laryngeal mask airway (LMA) was the preferred airway; 293 responses average usage 74%. Intubation was routinely used by 280 responders; average use 26%. Lma was used for shoulder surgery by 175 responders for in an average of 72% of cases, and among 151 responders for breast surgery in average of 80% of cases. Forty three responders used a Lma for laparoscopic procedures in about 65 % of cases, among 34 used Lma for in average 77% of patient doing tonsillectomy and among 91 responders used in average a Lma during GA for 60 % of cases in prone position. There was no clear differences in the use of Lma between the countries studied.

Most responders, 86% used structured pain rating methods. VAS was used in 65% and a numeric rating scale in 26% departments. Structured discharge criteria were common, (93% of responses) and written information around surgical procedure was provided at discharge by 88% of responders. Explicit written information about pain management was less frequently provided (74% of responders). Oral information about pain management was mainly given by a recovery room nurse 64% or by the surgeon 21%. Take home pain medication was provided by 80% of responders at discharge. Seventy-eight % of responders expected the surgeon to prescribe further analgesics at discharge. Opioid was not uncommonly provided as take home medication as well as by prescription; codeine was most common prescribed followed by oxycodone. Sixty-six % of the responders do not send home any patients without an escort from friends/relatives and 22% demand the patients not to be alone the first night after day surgery.

Our Scandinavian survey does not provide and firm statistics or evidence based practice but provide a pattern around what is common use. Preoperative assessment and information is of importance. There are without doubt many options in how to perform the preoperative exchange of information. Paper based questioner filled in by patients in advance is obviously common practice, the possibilities to use web-based techniques are of interest but data transfer security may be an obstacle. Likewise paper or multi-media information/education of patients around procedure and anaesthesia is time effective but further studies are needed in order to assess its impact on outcome[3]. Multimodal analgesia has indeed become standard of care for management of postoperative pain[4]. The preoperative administration of paracetamol was common but the combination with NSAID, selective or traditional none-selective was, less common. Short term perioperative NSAID, especially naproxen therapy seems a reasonable safe option[5]. The use of ultra-sound guided blocks has also increased[6]. Questions around blocks were unfortunately not included. There is still no firm evidence showing clear benefit with one anaesthetic technique over the other[7]. Gupta et al concluded that skill and equipment may be of more importance than actual drug choice[8]. There was a markedly higher huge of spinal anaesthesia among Finish responders. Finland has had a tradition in research around anaesthetics and techniques facilitating the use of spinal in day case surgery [9][10][11]. The laryngeal mask airway has become a commonly used alternative to standard facemask during day surgery. Its use as an alternative to intubation e.g. for maintenance of airway in prone position is a matter of dispute and there is an obvious lack of scientific firm data to support its safe use [12][13].

We found a variable praxis with regard to anaesthetic techniques; drugs used and airway management. There seems to be no firm consensus or best practice in the Scandinavian countries around anaesthesia for day case surgery. Further studies around outcome measures, morbidity but also data around the quality of recovery/resumption of activities of daily living following day surgery are warranted. Follow-up enabling “open comparisons” would be of interest.

Jan Jakobsson, MD, Adj. Professor
Depart Anaesthesia & Intensive Care,
Danderyds Hospital

Table 1. Main anaesthetic/main anaesthetic technique (number of responders (average % of cases))








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