Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery

Cochlear implantation under local anesthetic: A systematic review and meta-analysis

OBJECTIVES

As the population ages and implantation criteria are relaxed, more patients with complex comorbidities are becoming eligible for cochlear implantation (CI). These patients have higher risks associated with general anesthesia. This systematic review assesses outcomes and complications following CI under local anesthetic to examine utility for patients deemed not suitable or at high risk for general anesthesia.

METHODS

A systematic review and meta-analysis performed according to the 2020 PRISMA guidelines. Databases searched were MEDLINE, PubMed, EMBASE, CINAHL, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. There were no limitations on year of publication or language.

RESULTS

Then, 132 unique were identified. After screening abstracts and full texts for eligibility criteria a total of 18 articles were included. In the nine studies where audiological data were reported, all patients demonstrated improvement in audiological outcomes following implantation under local anesthetic (LA). Only minor complications of transient vertigo, wound infection, facial nerve paralysis, confusion, and tinnitus were reported but all were transient. Meta-analysis showed surgical time was significantly shorter under LA.

CONCLUSIONS

CI under LA is safe for patients with comorbidities which preclude them from general anesthesia, with minimal complications and an improved cost-effectiveness profile. However, larger scale, robust trials are required to assess this further.

Individualised care or anaesthetist preference: an uncomfortable question

There is widespread variation in how anaesthesia is provided to individual patients even for the same types of surgery. This variation exists within departments, between hospitals, and between countries. Patient and surgical factors are often cited as a justification for variation. Local and national norms, guidance, and standards, and the positive or negative roles of key opinion leaders likely all play a part. Although clinicians may disagree where the line falls between warranted and unwarranted variations, at least some of this variation is down to anaesthetist preference, not individualised patient care.

A systematic review of reporting quality for anaesthetic interventions in randomised controlled trials

Interventions from randomised controlled trials can only be replicated if they are reported in sufficient detail. The results of trials can only be confidently interpreted if the delivery of the intervention was systematic and the protocol adhered to. We systematically reviewed trials of anaesthetic interventions published in 12 journals from January 2016 to September 2019. We assessed the detail with which interventions were reported, using the Consolidated Standards of Reporting Trials statement for non‐pharmacological treatments. We analysed 162 interventions reported by 78 trials in 18,675 participants. Detail sufficiently precise to replicate the intervention was reported for 111 (69%) interventions. Intervention standardisation was reported for 135 (83%) out of the 162 interventions, and protocol adherence was reported for 20 (12%) interventions. Sixty (77%) out of the 78 trials reported the administrative context in which interventions were delivered and 36 (46%) trials detailed the expertise of the practitioners. We conclude that bespoke reporting tools should be developed for anaesthetic interventions and interventions in other areas such as critical care.

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.

Protocol for a systematic review of reporting standards of anaesthetic interventions in randomised controlled trials

INTRODUCTION

There is significant variation in how anaesthesia is defined and reported in clinical research. This lack of standardisation complicates the interpretation of published evidence and planning of future clinical trials. This systematic review will assess the reporting of anaesthesia as an intervention in randomised controlled trials (RCT) against the Consolidated Standards of Reporting Trials for Non-Pharmacological Treatments (CONSORT-NPT) framework.

METHODS AND ANALYSIS

Online archives of the top six journals ranked by impact factor for anaesthesia and the top three general medicine and general surgery journals will be systematically hand searched over a 42-month time period to identify RCTs describing the use of anaesthetic interventions for any invasive procedure. All modes of anaesthesia and anaesthesia techniques will be included. All study data, including the type of anaesthetic intervention described, will be extracted in keeping with the CONSORT-NPT checklist. Descriptive statistics will be used to summarise general study details including types/modes of anaesthetic interventions, and reporting standards of the trials.

ETHICS AND DISSEMINATION

No ethical approval is required. The results will be used to inform a funding application to formally standardise general, local, regional anaesthesia and sedation for use in clinical research. The systematic review will be disseminated via peer-reviewed manuscript and conferences.

PROSPERO REGISTRATION NUMBER

CRD42019141670.