Minimizing the use of general anaesthesia for loop cervical excisions: audit of practice at a North West London Hospital, U.K.
Obinna Mba, Dalia Aziz, Moon Courquin, Panos Sarhanis.
The NHSCSP guideline Colposcopy and Programme Management 2010 recommends that ≥ 80% of cervical excisions for CIN should be performed under local analgesia in outpatient. General anaesthesia should be used where appropriate and the indication clearly documented.
To evaluate the use of general anaesthesia (GA) for loop cervical excisions (LLETZ) at Central Middlesex Hospital (CMH), and to determine the indications for the use of GA for LLETZ.
Data was obtained through compuscope; a standard, computerised data management system used in colposcopy clinics in the North West London Hospitals NHS Trust. Study period: 01/04/2011 – 31/03/2012. 56 LLETZ procedures occurred during the study period; 40 under local anaesthesia(LA) & 16 under GA.
The rate of use of GA for LLETZ was 29%.
The indications were: patient request (50%), wide lesions (12.5%), patients requiring additional procedures (12.5%), mechanical difficulties (12.5%), repeat LLETZ (6.25%), others (6.25%).
In patients under 30 years, 31% of the LLETZ was done under GA. In this patient category, ‘patient request’ accounted for 50% of LLETZ.
The GA rate for loop excisions at CMH is 29%. This is above the recommended level by the NHSCSP (< 20%) but, there appeared to be clear clinical indications in majority of these cases.
Patient’s request accounted for half of the loop excisions done under GA (50%).
The age distribution of patients who had GA LLETZ were: < 30 years (31%), 30-39 years (38%), 40-49 years (31%).
Utilize the weekly colposcopy MDT to minimise the number of LLETZ performed under GA. The target is to achieve the recommended rate (<20%) in the next twelve months.
Facilitated patient counselling on the benefits of LLETZ under LA (and the potential risks of GA). Special counselling sessions for certain patient categories e.g. the anxious, needle-phobic. There are inherent cost-benefits in this.
Appropriate patient information leaflets. This should also highlight the unit’s latest patient satisfaction survey results which showed that ‘pain or discomfort’ was not a concern for those who had LLETZ under LA.
Consider offering ‘LA LLETZ under sedation in day-case theatre’ for selected patients who would otherwise insist on GA.
Consider doing more ‘wide lesions’ under LA by appropriately experienced colposcopists. A re-audit is planned in twelve months.
NHS Cervical Screening Programme. Colposcopy and Programmes Management. NHSCSP Publication No 20. May 2010.