Premedication for anxiety in adult day surgery

 

Abstract

Background

Since the early 1980s, it has become more and more common to carry out surgical procedures on a day case basis. Many patients are anxious before surgery yet there is sometimes a reluctance to provide sedative medication because it is believed to delay discharge from hospital.This is an updated version of the review first published in 2000 (previous updates 2003; 2006).

Objectives

To assess the effect of anxiolytic premedication on time to discharge in adult patients undergoing day case surgery under general anaesthesia.

Search methods

We identified trials by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009 Issue 1 ); MEDLINE (1980 to January 2009); EMBASE (1980 to January 2009). We also checked the reference lists of trials and review articles and handsearched three main anaesthesia journals.

Selection criteria

We included all identified randomized controlled trials comparing anxiolytic drug(s) with placebo before general anaesthesia in adult day case surgical patients.

Data collection and analysis

We collected data on anaesthetic drugs used; results of psychomotor function tests where these were used to assess residual effect of premedication; and on times from end of anaesthesia to ability to walk unaided or readiness for discharge from hospital. Formal statistical synthesis of individual trials was not performed in view of the variety of drugs studied.

Main results

We included 17 studies. Methodological quality of included studies was poor. Of these 17, only seven studies specifically addressed the discharge question; none found any delay in premedicated patients. Two other studies used clinical criteria to assess fitness for discharge, though times were not given. Again, there was no difference from placebo. Eleven studies used tests of psychomotor function with or without clinical measures as indicators of recovery from anaesthesia. In none of these studies did the premedication appear to delay discharge, although performance on tests of psychomotor function was sometimes still impaired. Three studies showed no impairment in psychomotor function, six showed some impairment which had resolved by three hours or time of discharge and two showed significant impairment.

Authors' conclusions

We found no evidence of a difference in time to discharge from hospital, assessed by clinical criteria, in patients who received anxiolytic premedication. However, in view of the age and variety of anaesthetic techniques used and clinical heterogeneity between studies, inferences for current day case practice should be made with caution.

 

Plain language summary

Premedication for anxiety in adult day surgery does not delay discharge of patients.

Day case surgery, where patients are sent home on the same day as the operation, is a common clinical practice which is no longer confined to simple procedures. Premedication with drugs to reduce anxiety prior to general anaesthesia may be withheld from patients due to concerns that they may delay recovery after surgery. This may reduce the efficiency of day surgery units and has important economic considerations. It may also lead to unanticipated hospital admission which can be unacceptable for patients. However, some patients would still like the option of anxiety reducing medication.

We identified 17 studies which compared premedication with a placebo prior to day case surgery. Twelve studies involved benzodiazepines (sedatives), two involved opioids (painkillers), two involved beta-blockers, one compared a benzodiazepine with a beta-blocker and one involved a herbal medication. In general, the studies were of poor quality and many used anaesthetic techniques which are no longer common. Only seven studies directly measured time to ambulation or discharge and found that this was not affected by the use of premedication. Some studies used specific tests to assess for residual effects of the premedication. Although these were often impaired after surgery, this did not appear to delay discharge.

 

摘要

背景

先驅藥物用在成人門診手術焦慮

從西元一九八零年代早期起，越來越多的手術採取一日門診手術方式進行，許多病人在術前會覺得焦慮，然而有時醫師會不想給予鎮靜藥物，因為他們相信鎮靜藥物會延遲出院時間。

目標

評估抗焦慮之先驅藥物，對於成年病患接受全身麻醉的門診手術後出院時間的影響。

搜尋策略

我們以電腦搜尋以找出試驗：the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009 Issue 1)、MEDLINE (1980年 −2009年1月)、 EMBASE (1980 年 −2009年1月)。我們也檢查了試驗與回顧文章的參考資料，並且人工搜尋3個主要的麻醉期刊。

選擇標準

我們納入所有成人的一日手術在全身麻醉前隨機給予抗焦慮藥物且有利用安慰劑作為控制組的試驗

資料收集與分析

我們收集使用的麻醉藥物資料，用來評估殘餘影響的精神運動功能測試結果，和從麻醉結束到在不需要輔助下有行走能力或可以出院的時間。因有鑑於各種試驗藥物間的變異性，並沒有實行各試驗間正式的統計合成。

主要結論

我們納入了17個試驗。所納入的研究的方法學品質較差。在這17個試驗當中，，只有7個試驗特別設計了評估是否可以出院的問題，沒有任何一個試驗發現在先驅藥物的病人有延遲出院的問題。 另外2個試驗利用臨床的標準來評估出院的合適性，雖然它們並沒有記錄時間，再者，給予先驅藥物的病人與安慰劑組並沒有差異。11個試驗使用精神運動功能做為從麻醉恢復的指標，在這當中，雖然精神運動功能的測試有時會受到影響，但沒有任何試驗顯示給予先驅藥物會延遲出院時間。3個試驗顯示對精神運動功能沒有影響，6個顯示對精神運動功能有影響但會在3個小時或出院時緩解，兩個試驗顯示有重大的影響。

作者結論

根據臨床標準，我們發現沒有證據顯示在接受預先給予抗焦慮藥物的病人在出院時間上有差異。然而，考慮到年齡以及使用的麻醉技術差異，以及研究之間的異質性，目前推論到實際應用上仍應小心謹慎。

翻譯人

本摘要由臺灣大學附設醫院許彥鈞翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

在成人的門診手術中，術前投予抗焦慮先驅藥物並不會延遲出院時間。一日手術(病人在開刀當日返家) 是一個常見的臨床作法，它已經不侷限於簡單的術式。由於擔心全身麻醉前使用抗焦慮藥物可能會延遲手術後恢復時間，因此病人也許會拒絕服用。可能會降低手術室使用效率，同時也是一個重要經濟上考量。 這可能會造成無法預期住院，對於病人來說可能無法接受。不過，一些病人依然喜歡採用減少焦慮藥物方案。 我們搜尋了17個試驗，將一日手術前使用先驅藥物與安慰劑比較。12個使用 benzodiazepines (鎮靜劑)、2個使用 opioids (止痛藥)、2個使用betablockers、1個進行benzodiazepine 與 betablocker的比較、而1個使用草藥。一般來說，這些研究品質較差，並且很多使用了已經不常見的麻醉技術。只有7個研究直接測量了直到可以步行及出院的時間，並且發現並不會受到使用前驅藥物的影響。一些研究使用特定的測試方式評估前驅藥物的殘效。儘管可能對於手術後有妨礙，不過似乎並不會延遲出院。