Objective: Endovascular aneurysm repair (EVAR) is increasingly used in the management of patients with abdominal aortic aneurysms (AAA), including in the emergency setting for ruptured AAA. The lower mortality amongst patients undergoing emergency EVAR under local anesthesia (LA) observed in the IMPROVE trial has sparked renewed interest in the anesthesia choice for EVAR. This systematic review evaluates the effect of mode of anesthesia on outcomes after EVAR. Design: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was inhospital/30-day mortality and both emergency and elective EVAR were included. The relative risk of death was estimated for each individual study without adjustment for potential confounding factors. Setting: Hospitals. Participants: A total of 39,744 patients from 22 non-randomized studies were included in the analysis. Interventions: None Measurements and Main Results: Sixteen studies in 23,202 patients compared LA to GA and reported in-hospital/30-day mortality. The unadjusted risk of death after emergency EVAR with LA was lower than with GA. Trends in elective surgery were less clear. Conclusions: There is some evidence across both emergency and elective settings to suggest that mode of anesthesia may be associated with improved outcomes. In particular, 3 LA appears to have a positive effect on outcome after emergency EVAR. Due to the lack of randomized trial data, a significant risk of confounding remains. The optimal mode of anesthesia for EVAR should be further investigated and the reasons why particular anesthesia techniques are chosen for particular patients identified.

Background Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery. Methods Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts. Results Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies. Conclusion There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.

Usage of a calibrated measuring tape produced accurate estimates of tidal volumes required for lung protective ventilation in healthy volunteers.

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