Thank you for taking the time to complete this survey. The aim is to gather a snapshot of current approaches to analgesia in emergency laparotomy. You will be asked to consider two hypothetical patients and answer questions relating to choice of analgesia for them, as well as supplementary questions relating to the provision of analgesia in your hospital. The survey takes approximately 5 minutes to complete.

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* 1. Patient 1: 

35 year old male with 24 hours of abdominal pain and vomiting due to undergo emergency laparotomy for perforated bowel, presently three hours post-admission, and being brought to the operating theatre from A&E.

PMHx: BMI 23, Crohn’s disease. Otherwise fit and well, non smoker, <5 units alcohol per week

DHx: Prednisolone 30mg PO OD commenced 4 weeks prior for flare. NKDA

Clinical state pre-op: Pain prior to IV opiate at rest 6/10, currently 2/10 with 10mg IV morphine and 1g IV paracetamol. HR 110/min, BP 93/46 (2000ml balanced crystalloid given so far), temperature 38.6, RR 22/min, SpO2 94% (5L/min oxygen via Hudson mask), awake but drowsy, and orientated to time, person, and place, 250 ml residual urine on catheterisation.

Investigations: Hb 134g/L Plt 220 WCC 19.7 (neutrophilia) CRP awaited, INR 1.2 APTTr 0.95, Na 131 K 4.6 Ur 5.7 Cr 87. ABG (40% O2): pH 7.30, pO2 9 kPa, pCO2 3.1 kPa, BE -8.7 HCO3 15.3 Lactate 4.1. CT (with contrast) chest/abdomen shows free intra-abdominal air and bibasal atelectasis, nil else of note.

What would be the primary analgesia plan that you would discuss with the patient?

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* 2. If you plan to use a regional anaesthetic (including epidural) would you commence an infusion/bolus during surgery?

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* 3. What additional analgesia would you consider in the intra-and post-operative period?

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* 4. Would you have concerns regarding performing a central neuraxial or other regional anaesthetic technique in this patient? If yes, please outline your concerns below.

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* 5. Patient 2:

64 year old for exploratory laparotomy for small bowel obstruction. He is also being treated for a new lower respiratory tract infection.

PMHx: BMI 33, COPD (no hospital admissions), HTN, AF, previous open cholecystectomy (20 years ago) with multiple re-explorations for bile leak and reconstruction

DHx: Inhalers, occasional rescue antibiotics and steroids, Rivaroxaban (prophylactic dose - last taken 24 hours ago), Amlodipine 10mg OD, commenced on Doxycycline 200mg OD by his GP 3 days ago.

Clinical state pre-op: Pain at rest 2/10, nauseous with high NG output (altered small bowel contents), HR 82 AF, BP 156/89, SpO2 90% (60% O2 via venturi mask), orientated.

Investigations: Hb 171g/L Plt 140 WCC 6.9 CRP 42, INR 1.3 APTTr 1.2, Na 139 K 5.2 Ur 5.6 Cr 70 (Creatinine clearance >30ml/min). ECG - AF. CT (with contrast) chest/abdomen shows dilated loops of small bowel, empty distal colon, left lower zone consolidation in chest, no PE.

What would be the primary analgesia plan that you would discuss with the patient?

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* 6. If you plan to use a regional anaesthetic (including epidural) would you commence an infusion/bolus during surgery?

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* 7. What additional analgesia would you consider in the intra- and post-operative period?

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* 8. Would you have concerns regarding performing a central neuraxial or other regional anaesthetic technique in this patient? If yes, please outline your concerns below.

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* 9. In your hospital where would a surgical patient with an epidural be cared for postoperatively?

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* 10. Which of the following best describes your role?

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* 11. Which hospital do you work at? (Optional, and specific information will not be used in any publication).

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* 12. Are you responsible for emergency surgery as part of your job plan and/or on-call commitments?

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