Informed consent for clinical anaesthesia research

Aspects of Anesthesia for Lung Transplantation

Anesthesia for lung transplantation is both a demand ing and rewarding experience. Success requires team- work, experience, knowledge of cardiorespiratory patho physiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to life- threatening perioperative events. Specific issues in clude management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hyperten sion, and acute right ventricular failure. Recent ad vances include greater understanding of dynamic hyper inflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.

Consent for Anesthesia Clinical Trials on the Day of Surgery

Background

Opportunities for anesthesia research investigators to obtain consent for clinical trials are often restricted to the day of surgery, which may limit the ability of subjects to freely decide about research participation. The aim of this study was to determine whether subjects providing same-day informed consent for anesthesia research are comfortable doing so.

Methods

A 25-question survey was distributed to 200 subjects providing informed consent for one of two low-risk clinical trials. While consent on the day of surgery was permitted for both studies, a preadmission telephone call was required for one. The questionnaire was provided to each subject at the time of discharge from the hospital. The questions were structured to assess six domains relating to the consent process, and each question was graded on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Overall satisfaction with same-day consent was assessed using an 11-point scale with 0 = extremely dissatisfied and 10 = extremely satisfied.

Results

Completed questionnaires were received from 129 subjects. Median scores for satisfaction with the consent process were 9.5 to 10. Most respondents reported that the protocol was well explained and comprehended and that the setting in which consent was obtained was appropriate (median score of 5). Most patients strongly disagreed that they were anxious at the time of consent, felt obligated to participate, or had regrets about participation (median score of 1). Ten percent or less of subjects reported negative responses to any of the questions, and no differences were observed between the study groups.

Conclusion

More than 96% of subjects who provided same-day informed consent for low-risk research were satisfied with the consent process.

Clinical trials research in pediatrics: strategies for effective collaboration between investigator sites and the pharmaceutical industry

There is a paucity of clinical trials work in children, which leads to the frequent use of off-label and unlicensed medications in this very vulnerable group. Clinical trials work in children may be more difficult than in adults, and there are certainly ethical constraints. However, the differences between adults and children, and at different stages of childhood development, mandate strategies to improve this situation rather than continually relying on extrapolation from adult studies. Therefore, new strategies have to be established between the pharmaceutical industry and pediatric centers to facilitate effective trials work. These must be based on a clear and mutual understanding of the differences between working with children and adults. Disease phenotypes may be completely different in children; for example, wheeze in infants is not miniature adult asthma. Clinical trial design must be practical, and a trial is more likely to succeed if a simple design is utilized, with minimal interference with school work and the work of carers. The new UK initiative, 'Medicines for Children', should go a long way towards addressing the problem, and increase the evidence base for the utilization of medications in pediatric practice.

A preadmission telephone call to initiate the consent process for clinical anesthesia research

Consent for a clinical anesthesia research trial is frequently sought in hospital on the day of surgery. This time is often associated with increased anxiety, diminished privacy, and limited opportunity for reflection. Our objective was to determine whether a preadmission telephone call on the day before surgery resulted in greater satisfaction compared to the traditional practice of initiating the consent process on the day of surgery. We randomized 124 patients eligible for participation in a minimal-risk clinical anesthesia trial to receive either a preadmission telephone call on the day before surgery to initiate consent (Telephone group; n = 62), or no telephone call (Control group; n = 62). In the Telephone group, 21 patients (33.9%) were successfully contacted by telephone, whereas 41 patients (66.1%) were not contacted. Both the Telephone and Control groups reported similar understanding regarding the purpose of the trial. Both groups similarly agreed that the time and setting of recruitment and consent were appropriate. Patients in both groups reported having enough time to consider their participation in the trial. Few patients in either group reported feeling anxious at the time of consent or pressured to participate in the trial. Finally, patients in both groups were equally satisfied with the consent process.

IMPLICATIONS

A preadmission telephone call on the day before surgery to initiate the consent process for a minimal-risk clinical anesthesia research trial does not improve satisfaction among consenting patients compared to initiating consent in hospital on the day of surgery, and can be an impractical method to initiate the consent process.

Factors that influence parents' assessments of the risks and benefits of research involving their children

OBJECTIVE

The ability to assess accurately the risks and benefits of a study are important to ensure that the subject can make an informed decision regarding his or her own or his or her surrogate's participation. This study was designed to examine factors that influence parents' assessments of the risks and benefits of anesthesia and surgery research involving their children.

METHODS

The study population consisted of parents of 505 children who had been approached to participate in 1 of several ongoing clinical studies. Regardless of their decision to allow or decline their child's participation in a study, parents completed a questionnaire that elicited information regarding their perceptions of the risks and benefits of the study and factors that had influenced their decision.

RESULTS

Factors that influenced positive risk/benefit assessments by the parents included use of a placebo, the designated risk category of the study, the clarity of information given, the parents' perceptions of the amount of time provided to make a decision, and the amount of privacy afforded them in making a decision. Furthermore, positive risk/benefit assessments were associated with low decisional uncertainty and greater trust in the medical system.

CONCLUSIONS

Identification of factors that influence parents' perceptions of the risks and benefits of a research study is important as a means to optimize the manner in which consent information is disclosed and to ensure that parents and subjects can assess accurately the relative importance of the risks and benefits.

Are Patients Comfortable Consenting to Clinical Anesthesia Research Trials on the Day of Surgery?

Consent for clinical anesthesia research trials is often sought on the day of surgery when patients are most anxious and have little privacy or time for reflection. We conducted a retrospective survey of patients' perceptions and concerns regarding consent for clinical anesthesia trials on the day of surgery. Questionnaires were mailed to 175 patients who had participated in 1 of 6 negligible- or minimal-risk clinical anesthesia trials within the preceding year. Seventy-six patients responded (43%). Most patients (80%) reported that they understood the purpose of their trial, did not feel obligated (61%) or pressured (67%) to participate, and were satisfied (mean visual analog scale: 71 mm) with the recruitment and consent process on the day of surgery. Few patients (7%) believed that their well-being was put at risk because of their participation in the trial.

IMPLICATIONS

This retrospective survey suggests that patient recruitment and consent for negligible- or minimal-risk clinical anesthesia research trials is appropriate when performed on the day of surgery.

Permission and assent for clinical research in pediatric anesthesia

IMPLICATIONS

This article discusses the process and specific nature of informed consent for clinical research in pediatric anesthesia. For informed consent to be meaningful, permission from the child's proxy must be obtained and the child's assent must be tailored in a manner that is sensitive to the abilities of children.

Factors that influence parents' decisions to consent to their child's participation in clinical anesthesia research

There is concern that the environment in which consent for anesthesia research is sought may be coercive. We therefore designed this study to determine the factors that parents consider in consenting to their child's participation in clinical anesthesia research. The study sample consisted of 246 parents who had been approached for permission to allow their child to participate in a clinical anesthesia study. Parents were asked to complete a questionnaire detailing the reasons for their decision to consent or decline their child's participation. There were no differences in the demographics of the consenters (n = 168) and nonconsenters (n = 78). Perceived risk and the importance of the study were the primary factors in the parents' decisions to consent or decline. Only 2.8% of nonconsenters strongly considered a lack of privacy as a deciding factor; 15.3% stated that they had insufficient time in which to make a decision, and 0% reported having felt pressured. Furthermore, only 3.1% of consenters strongly considered an obligation to consent. Results of this survey highlight factors that influence parents' decisions to consent to their child's participation in clinical anesthesia research. We hope that this information will be important to researchers in providing an appropriate environment for obtaining consent for clinical anesthesia research studies.

IMPLICATIONS

Parents who are approached for permission for their child to participate in a research study must be fully informed and under no pressure to consent. This study describes factors that influence parents' decisions to consent to their child's participation in clinical anesthesia research.

Laryngeal mask insertion with a laryngoscope in paediatric patients

PURPOSE

To assess epiglottic position after laryngeal mask airway (LMA) insertion with or without the use of a laryngoscope.

METHODS

A double-blind randomized study. In 48 children an LMA (#2 for 6-20 kg, #2.5 for 20-30 kg) was inserted either blindly or with the help of a laryngoscope and its position assessed using fibreoptic endoscopy.

RESULTS

An unobstructed view of the glottis, as assessed by fibrescope, was observed in 10 of 25 patients in the laryngoscope group, but only in 1 of 22 patients in the blind insertion group (P = 0.005).

CONCLUSION

This technique offers an alternative when the standard technique has failed, or when LMA insertion precedes bronchoscopy or intubation via the laryngeal mask.

Surgical patients' attitudes regarding participation in clinical anesthesia research

We designed a questionnaire to identify the factors influencing both day of admission surgery (DAS) and ambulatory (AMB) patients in their decision whether to participate in and give informed consent for clinical anesthesia research. On the day of surgery, 276 patients were approached to complete a questionnaire and a visual analog scale (VAS) to assess anxiety. The data collected were observational and are presented as percentages for each group (DAS and AMB). One hundred eighty-two patient (60 DAS and 122 AMB) completed questionnaires. Both DAS and AMB patients desired 20-30 min to read a consent form. Preferred conditions for enrollment by both groups were as follows: interview at the time of preadmission testing; after consulting with their physician; in a private setting while dressed in street clothes; and with assurance that the investigator would also participate in the study, if eligible. Unacceptable conditions were as follows: research associated with any risk and interview in the operating room holding area. All patients responded that they were capable of making the decision whether to participate in research on the day of surgery. Most AMB and DAS patients found it acceptable to be recruited on the day of surgery, if approached appropriately.

Midazolam coinduction does not delay discharge after very brief propofol anaesthesia

Previous reports have demonstrated synergism of midazolam and propofol for induction of anaesthesia in humans. We tested the hypothesis that in the presence of alfentanil, the combination of midazolam with propofol for a very brief operative procedure would not affect the recovery phase. During pre-oxygenation, 64 outpatients scheduled for dilatation and curettage received placebo, or low-dose midazolam (0.03 mg.kg-1), or high-dose midazolam (0.06 mg.kg-1) iv, in a randomized double-blind manner. They then received alfentanil 10 micrograms.kg-1 iv, followed by titrated doses of propofol iv for induction and maintenance of anaesthesia. Ventilation with 70% N2O in O2 by mask was controlled to achieve a PETCO2 30-40 mmHg. Outcome measures were: propofol dose (induction and maintenance), time until eye-opening to command, and time to discharge-readiness. Propofol induction dose was decreased by increasing doses of midazolam (P = 0.00005). Midazolam delayed time to eye-opening (P = 0.02) but not time to discharge-readiness. This study had an 80% power to detect a 39 min difference in time to discharge-readiness. We conclude that midazolam propofol co-induction in the presence of alfentanil delays eye-opening, but does not delay discharge after anaesthesia.