Background: Pre-hospital emergency anaesthesia (PHEA) is an advanced clinical intervention delivered by expert pre-hospital care services, operating on a regional basis, throughout the UK. Historically PHEA has been a controversial issue, but it is now widely accepted that PHEA is indicated for a small but significant number of patients. In the UK the most common indication for PHEA is trauma caused by road traffic collisions. PHEA consists of the initial induction of anaesthesia and intubation with subsequent maintenance of anaesthesia. PHEA is always delivered by the intravenous route (total intravenous anaesthesia - TIVA). The conduct and delivery of PHEA is not without risk. Current guidelines are available to reduce risk and optimise patient safety and outcome. They make recommendations for how PHEA should be conducted and consistently state that PHEA should be delivered to the same standard as in the hospital setting with equipment and monitoring also meeting stringent hospital standards. No research has been conducted which investigates how PHEA is currently maintained following pre-hospital induction and intubation nor how closely this reflects published guidelines.
Objectives: The aim of this study was to build a picture of how emergency anaesthesia is maintained following pre-hospital induction by services across the UK, and to identify to what extent current practice reflects guidelines for PHEA.
Methods: This has been investigated by conducting a scoping review and performing an analysis of secondary data. The initial scoping review was split into two separate streams of evidence. The first research strand sought to identify literature which describes the way in which PHEA is maintained in the UK. The second research strand sought to collate recommendations guiding the maintenance of PHEA. Secondary data analysis was then performed upon a dataset collected by senior clinical researchers from EMRTS, Cymru (a UK pre-hospital care service). The nationally representative and up-to-date dataset contained variables further describing the maintenance of PHEA in the UK.
Results: Most pre-hospital care services operating in the UK can provide PHEA (n=32, 78%). Of these, 87.5% (n=28) can provide PHEA during road or air transport. PHEA is most commonly maintained using bolus administration of anaesthetic agents (n=24, 75%). Most UK pre-hospital teams have a range of anaesthetic agents available, but midazolam and morphine are together the combination of drugs used most frequently for the purpose of maintaining PHEA (n=16, 50%). Free text responses indicate that if the patient were haemodynamically unstable, boluses of ketamine would be preferred. The reported average compliance with safety recommendations for TIVA was 17%.
Conclusions: UK practice conforms well with national PHEA guidelines. The findings illustrate a variation in practice, which is likely to be appropriate and is supported by major professional bodies. The results do however suggest poor compliance with some of the published recommendations for TIVA. Questions remain regarding the relevance and applicability of the TIVA guidelines to the field of pre-hospital emergency medicine.
Recommendations: Further research is required to further analyse the practice of PHEA in the UK and to build the evidence base surrounding pre-hospital emergency medicine, and PHEA in particular, with a view to establishing the subspecialties own comprehensive yet specific standards of practice.