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Anaesthetic outcomes patients don't want

 

Clinical bottom line

The outcomes patients undergoing anaesthesia most want to avoid are vomiting, gagging on the endotracheal tube, pain and recall.


Reference

A Macario et al. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesthesia & Analgesia 1999 89: 652-658.

Study

This Stanford Study began with a literature search for anesthetic outcomes and complications to generate a comprehensive list of clinical anaesthetic outcomes. Nine of a long list of possible outcomes was selected to give patients a questionnaire that was not overly long, and that represented a range of severity. Simple descriptions of each outcome were then developed for each. For vomiting and a normal outcome, for example:

These were included in a survey instrument in three parts, intended to flow one to the next:

  1. Standard demographic items
  2. A rankings section
  3. A relative value section

The rankings and relative value section included 10 items:

Patients were asked to rank order the 10 possible postoperative outcomes, with 1 the most undesirable and 10 the most desirable. They were then asked in the relative value section to distribute an imaginary $100 on their preferences such that the more money they spent on it, the less likely it was to occur.

A random number generator was used to select a target 100 patients, over the age of 18, who were scheduled for surgery either in an outpatient centre of a main hospital suite.

Results

There were 101 patients, ranging in age from 19 to 83 years, 40% of whom were men. Same-day discharge occurred in 38%, and 77% had a history of previous surgery. Clinical outcomes experienced by patients included pain (76%), nausea (60%) sore throat (48%), shivering (45%), residual weakness (34%), vomiting (32%) and somnolence (31%). Gagging on the endotracheal tube and recall without pain were rare, at 5% and 2% respectively.

Before the operation, patients ranked vomiting, gagging, pain and nausea as the worst outcomes (lower rank score, Figure 1), and also gave these four outcomes a high relative value (Figure 2). A normal outcome was ranked the most useful outcome, and none of the $100 was spent to avoid it.

Figure 1: Ranking anaesthesia outcomes


Figure 2: Relative value of anaesthesia outcomes


Comment

This is a terrific paper giving some real insight into what patients want, or rather don't want, from anaesthesia. It has internal validity, in that the rank of 10 and relative value of zero for a normal outcome means that patients understood the survey instrument. The general methods used could easily be transferred to other areas.

Those outcomes that patients wished to avoid were, for the most part, frequent occurrences - particularly pain, and nausea and vomiting. Of course anaesthetists know this, and there are many clinical trials, and systematic reviews of clinical trials examining just these points. But clinical trials of efficacy are not the same as clinical effectiveness. There is a hole in our experience and our research here.