Title: : Audit of outcomes after Open Abdominal Gynaecology Surgery in patients given a General Anaesthetic (GA) and a Subarachnoid Block (SAB) with intrathecal opioid compared with patients not treated with a SAB, in a large tertiary-referral teaching hospital.

Background: A survey of anaesthetists who anaesthetise for open abdominal gynaecology surgery showed that 66% of them used a Spinal followed by a GA, while 44% gave a GA without a Spinal. Similar smaller audits (1,2) had shown that patients who received Intrathaecal Opioids had a decreased length of stay in hospital, earlier mobilisation and better satisfaction scores . An Enhanced Recovery After Surgery (ERAS) programme in Gynaecology patients is being planned across the health board. A need was felt to audit how anaesthetic technique affected patient outcomes. 

Method: Over a period of 6 months, Anaesthetists filled in an audit form about their anaesthetic technique for patients undergoing open abdominal gynaecology surgery. We asked nursing staff to collect outcome data on another form. 109 forms were completed and analysed.

Results: Of 109 patients, 47 had a SAB with Intrathaecal opiate followed by a GA (Spinal Group) and 62 had a GA with no SAB (GA Group). Mean maximum pain scores over 24 hours were 4.7/10 in Spinal Group and 5.6/10 in GA group. This difference did not reach statistical significant. The median Morphine requirement of the Spinal Group was 23 mgs, while the median Morphine requirement of GA group was 40 mgs. This was also not statistically significant (P value 0.0941). Opiate induced side effects (nausea, vomiting and sedation) were also not significantly different between groups. Both groups needed, on average, one antiemetic over 24 hours. There was no difference in time taken to mobilise patients or the length of hospital stay between the two groups. 
There was a slight difference in satisfaction scores with the spinal group tending to have better satisfaction but this did not reach statistical significance.

Discussion: Anaesthetic technique does not seem to affect pain scores significantly and opiate usage over 24 hours was not significantly different. One explanation is that Anaesthetic techniques used in both groups were not standardised and therefore there was significant variation within the groups. There was no difference between the groups in the timing of patient mobilisation, with patients rarely being mobilised on the day of surgery. This is most likely due to nursing attitudes and workload, however, the fact that PCA Pumps were prescribed in 81%, may have contributed. 

Conclusion: From our results we cannot conclude that one anaesthetic technique provides better outcomes to the other. There seems to be a slight trend towards the Spinal Group using less total opiate over 24 hours and having better pain scores. Further data is needed to better inform the optimal anaesthetic technique to implement ERAS in the hospital.

(1)	S. Sullivan et al. Outcomes after hysterectomy in patients treated with general anaesthesia (GA) and spinal compared with patients without spinal anaesthesia. Wishaw General Hospital

(2)	A.Singh et al. Outcomes of hysterectomy in patients treated with GA and SAB in comparison to patients without SAB. 29/9/2015 Scottish Society of Acute Pain.

Audit of outcomes after open abdominal gynaecology surgery in patients given a general anaesthetic (GA) and a subarachnoid block (SAB) with intrathecal opioid compared with patients not treated with a SAB, in a large tertiary-referral teaching hospital