Evaluation of the impact of high altitude on pre-hospital anaesthetic administration: a scoping review.
BJA open · 2026-08-24 · Scoping review
Abstract
BACKGROUND: Increasing high-altitude travel and habitation drive demand for care in these environments. High altitude presents unique challenges to anaesthetic administration as hypobaric hypoxia affects physiology, pharmacology, and equipment performance, yet no guidelines exist. This scoping review aimed to identify anaesthetics used at HA, evaluate the impact of high altitude on anaesthetic use, and highlight research gaps. METHODS: This review followed Arksey and O'Malley's methodological framework and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. MEDLINE, Embase, and Web of Science were searched (October 2024 to May 2025). English-language studies, published after 1980, involving human participants receiving any anaesthetic agent above 1500 m were included. Critical appraisal is undertaken using Critical Appraisal Skills Programme checklists. RESULTS: A total of 21 articles (14 original studies, three case reports/series, and four letters to the editor; n=3162) were included. Mean study altitude was 2922 m (95% confidence interval [CI] 2412-3432), with a range of 1610-4500 m. Participants were predominantly female (78.9%) with a mean age of 20.7 years. CIs for sex distribution and age could not be calculated because participant-level variance data were not consistently reported. Techniques included general, neuraxial, analgesic, and local modalities. Inhalational agents showed unreliable performance, whereas propofol-fentanyl and ketamine were safe when titrated. Neuraxial anaesthesia required higher doses. Methoxyflurane was effective. Sensitivity to nitrous oxide, opioids, and benzodiazepines seems increased. Lidocaine half-life was prolonged. CONCLUSIONS: Anaesthesia at high altitude remains complex and high-risk. Evidence indicates general anaesthesia should be avoided where possible; Total i.v. anaesthesia may be a practical option where general anaesthesia is required, although the available evidence is limited. Neuraxial techniques are effective in-hospital but impractical pre-hospital. Methoxyflurane and ketamine seem promising for field use at high altitude, whereas nitrous oxide, opioids, and benzodiazepines may carry increased risks. Altitude-specific research and expert consensus are urgently required.
Tags
Anaesthetics · Analgesics · Fentanyl · Ketamine · Lidocaine · Methoxyflurane · Nitrous oxide · Propofol