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Recommendations for the Safe Transfer of<br />
Patients with Brain Injury<br />
2006<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland,<br />
21 Portland Place, London W1B 1PY<br />
Telephone 020 76311650 Fax 020 7631 4352<br />
www.aagbi.org<br />
May 2006
MEMBERSHIP OF THE WORKING PARTY<br />
Dr PA Farling<br />
Dr PJD Andrews<br />
Dr S Cruickshank<br />
Dr I Johnston<br />
Dr B Matta<br />
Prof DK Menon<br />
Dr E Moss<br />
Dr MP Parris<br />
Dr M Power<br />
Dr M Smith<br />
Dr DK Whitaker<br />
Ex Officio<br />
Professor M Harmer<br />
Professor WA Chambers<br />
Dr A W Harrop-Griffiths<br />
Dr RJS Birks<br />
Dr IH Wilson<br />
Dr DE Dickson<br />
Dr D Bogod<br />
Chairman of Working Party and Immediate<br />
Past President Neuroanaesthesia Society of<br />
Great Britain & Ireland<br />
Chairman Neuro-intensive Care & Emergency<br />
Medicine Section, European Society of Intensive<br />
Care Medicine<br />
Immediate Past Honorary Treasurer Neuroanaesthesia<br />
Society of Great Britain & Ireland<br />
Council Association of Anaesthetists of Great Britain<br />
& Ireland<br />
Honorary Secretary Neuroanaesthesia Society of<br />
Great Britain & Ireland<br />
Intensive Care Society<br />
Royal College of Anaesthetists<br />
Group of Anaesthetists in Training<br />
Honorary Secretary Intensive Care Society of Ireland<br />
President Neuroanaesthesia Society of Great Britain<br />
& Ireland<br />
President Elect Association of Anaesthetists of<br />
Great Britain and Ireland<br />
President<br />
Honorary Secretary<br />
Honorary Secretary Elect<br />
Honorary Treasurer<br />
Honorary Treasurer Elect<br />
Honorary Membership Secretary<br />
Editor-in-Chief Anaesthesia<br />
The Joint Royal Colleges Ambulance Liaison Committee has endorsed this document.<br />
Significant contributions were received from The Society of British Neurological<br />
Surgeons and from Dr Stephen Hancock, Consultant Paediatric Intensivist.<br />
The Association of Anaesthetists of Great Britain and Ireland wishes to record its<br />
sincere thanks for the support and advice given by the Neuroanaesthesia Society of<br />
Great Britain and Ireland in publication of this document.<br />
© This document was first published in December 1996 by the Association of<br />
Anaesthetists of Great Britain and Ireland, 9 Bedford Square London WC1B 3RA<br />
© Copyright of the Association of Anaesthetists of Great Britain and Ireland. No part of<br />
this book may be reproduced without the written permission of the Association of<br />
Anaesthetists.
CONTENTS<br />
Section I Summary and Recommendations 02<br />
Section II Background 03<br />
Section III Introduction 04<br />
Section IV Organisation and Communication 05<br />
Section V Staffing Requirements and Standards 07<br />
Section VI Preparation for the Transfer 08<br />
Section VII The Transfer 11<br />
Section VIII Equipment and Drugs 13<br />
Section IX Education and Training 15<br />
Section X Resource Implications for Transfer of Patients 17<br />
with Brain Injuries<br />
References 18<br />
Appendices 19<br />
1
SECTION I - SUMMARY AND RECOMMENDATIONS<br />
1. High quality transfer of patients with brain injury improves outcome.<br />
2. There should be designated consultants in the referring hospitals and<br />
the neuroscience units* with overall responsibility for the transfer of<br />
patients with brain injuries.<br />
3. Local guidelines on the transfer of patients with brain injuries<br />
should be drawn up between the referring hospital trusts, the<br />
neurosciences unit and the local ambulance service. These should<br />
be consistent with established national guidelines. Details of the<br />
transfer of responsibility for patient care should also be agreed.<br />
4. While it is understood that transfer is often urgent thorough<br />
resuscitation and stabilisation of the patient must be completed<br />
before transfer to avoid complications during the journey.<br />
5. All patients with a Glasgow Coma Scale (GCS) less than or equal to<br />
8 requiring transfer to a neurosciences unit should be intubated and<br />
ventilated, as should any patients with the indications detailed in<br />
Appendix 1.<br />
6. Patients with brain injuries should be accompanied by a doctor with<br />
appropriate training and experience in the transfer of patients with<br />
acute brain injury. They must have a dedicated and adequately<br />
trained assistant. Arrangements for medical indemnity and personal<br />
accident insurance should be in place.<br />
7. The standard of monitoring during transport should adhere to<br />
previously published standards.[1]<br />
8. The transfer team must be provided with a means of communication<br />
- a mobile telephone is suitable.<br />
9. Education, training and audit are crucial to improving standards of<br />
transfer.<br />
* Throughout this document the term acute neuroscience unit is taken<br />
to include neurology, neurosurgery, neuroanaesthesia, neurocritical<br />
care and neuroradiology.<br />
2
SECTION II - BACKGROUND<br />
In 1996 the Association of Anaesthetists (AAGBI) and the<br />
Neuroanaesthesia Society (NASGBI) published Recommendations for<br />
the Transfer of Patients with Acute Head Injuries to Neurosurgical<br />
U n i t s. Since 1996 a number of organisations have published<br />
guidelines relating to transfer.[2-8] However, it was felt that it would<br />
be beneficial to provide an up-to-date resource to be distributed to<br />
members of the AAGBI. The National Service Framework for long term<br />
conditions has implications for neurological patients.[9] Changes in<br />
clinical practice, for example the development of intrava s c u l a r<br />
treatment of subarachnoid haemorrhage,[10] will increase the number<br />
of transfers of patients with non-traumatic brain injury. It wa s ,<br />
therefore, considered appropriate to extend the scope of the guideline<br />
to include all patients with acute brain injury. Ideally the transfer of<br />
paediatric patients will be undertaken by staff experienced in the<br />
transfer of critically ill children.<br />
Supplementary electronic material can be obtained from many of the<br />
sources that are detailed in the References section of this document.<br />
3
SECTION III - INTRODUCTION<br />
Patients with neurotrauma or other acute brain injury often receive<br />
their initial treatment at a local hospital, which may not have a<br />
neurosciences unit. As a result, many patients with serious brain<br />
injuries have to be transferred urgently between hospitals by road<br />
ambulance, or occasionally by air. In some areas Critical Care<br />
Networks and transfer groups have been established according to<br />
national directives.[11] While no precise time targets have been set<br />
between injury and surgery, a maximum of 4 hours is aimed at because<br />
it is clear that the sooner an expanding haematoma is evacuated, the<br />
better for the patient.<br />
Transfer of patients with brain injury is potentially hazardous if poorly<br />
executed.[12] Patients can come to harm as a result and ultimate<br />
neurological outcome may be adversely affected. This can be avoided<br />
if sound principles are applied. The main causes of secondary brain<br />
damage are raised intracranial pressure (ICP), hypotension, hypoxia,<br />
hy p e rcarbia, cardiovascular instability and hy p e r pyrexia. Most<br />
principles of safe transfer are common to all seriously ill patients but<br />
there are some specific features that apply in particular to those with<br />
acute brain injury. These principles apply equally to transfer of patients<br />
both within and between hospitals.<br />
These recommendations are provided for those responsible for<br />
planning, managing and undertaking transfer of brain injured patients.<br />
They aim to supply not only practical guidelines for ensuring safe<br />
transfer of individual patients, but also principles of organisation to<br />
assist in local negotiation when establishing new or improving existing<br />
transfer arrangements.<br />
4
SECTION IV - ORGANISATION AND<br />
COMMUNICATION<br />
Safe transfer of patients with brain injuries requires an effective<br />
partnership between the referring hospitals, the neurosciences unit and<br />
the ambulance service.<br />
Local guidelines should be agreed between the referring hospitals and<br />
the neurosciences unit in advance. They should be subject to regular<br />
review and audit. The guidelines will include:<br />
• which patients should be referred,<br />
• when a transfer should be made,<br />
• who is responsible for accepting the patient,<br />
• the preparations and arrangements for the journey itself so that there<br />
is no unnecessary delay,<br />
• when the responsibility for the patient is transferred from the<br />
referring to the receiving team.<br />
Anaesthetists should be involved in agreeing local guidelines that are<br />
consistent with established national and international guidelines.<br />
Guidelines do not replace clinical judgement but they provide a safe<br />
framework within which judgement can be exercised.<br />
Every hospital to which the ambulance services take patients with<br />
serious brain injuries must have facilities for resuscitation and<br />
diagnosis, including 24-hour access to computerised tomography.<br />
Appropriate staff and equipment should be available to ensure a safe<br />
transfer to the neurosciences unit when necessary. There should be a<br />
designated consultant within that hospital who has ove ra l l<br />
responsibility for secondary transfers and a consultant at the<br />
neurosciences unit who has ove rall responsibility for receiv i n g<br />
transfers. These duties should be recognised in job plans.<br />
Education and training are crucial to improving standards of transfer.<br />
Appropriate resources must be provided by those who plan and<br />
5
purchase these services. They must be available to all professionals<br />
who share responsibility for the safety of the patient. There are obvious<br />
advantages in having a common philosophy of care and standardised<br />
terminology, such as those provided by the Advanced Trauma Life<br />
Support (ATLS) system and the GCS. A modified GCS should be used<br />
for paediatric patients.[3]<br />
Good verbal and written communications are vital. This is especially<br />
so at the time of referral and when a patient is handed over at the end<br />
of the transfer. They will include precise details of where, within the<br />
neurosciences centre, the patient is to be taken. The ambulance<br />
service appreciate an early warning to facilitate their arrangements.<br />
6
SECTION V - STAFFING REQUIREMENTS AND<br />
STANDARDS<br />
Expediency should not dictate the level of expertise available for the<br />
transfer of patients. Critically ill patients with acute brain injuries must<br />
be accompanied by a doctor with suitable training, skills,<br />
competencies and experience of brain injury transfer.<br />
It must be recognised that a trainee alone in an ambulance is working<br />
in an unsupervised capacity. Changes in working patterns may reduce<br />
the availability of trainees for transfers and consultant time for transfers<br />
must be built into manpower projections. Account should be taken of<br />
shift arrangements when deciding who should accompany the patient.<br />
A dedicated trained assistant must be provided for the escorting doctor.<br />
This might be an appropriately trained operating department<br />
practitioner, nurse or paramedic.<br />
Employers must ensure that there is appropriate medical indemnity<br />
i n s u rance for such transfers. In addition, the Association of<br />
Anaesthetists (AAGBI) recommends that doctors are members of<br />
medical defence organisations. Adequate death and personal injury<br />
insurance must also be provided for the members of the transfer team<br />
by the employer; existing employer insurance may be inadequate and<br />
local arrangements should be clarified. Details of appropriate<br />
insurance schemes are available from the AAGBI (www.aagbi.org) and<br />
such cover is a benefit of membership.<br />
7
SECTION VI - PREPARATION FOR THE TRANSFER<br />
Many critical care networks have reached consensus with local<br />
ambulance providers to ensure that all Trusts have common standards<br />
of transfer equipment. These developments are highly desirable, and<br />
likely to result in better organisation and delivery of patient care<br />
The decision to transfer a patient with a brain injury must be made by<br />
senior medical staff at the referring hospital in consultation with senior<br />
staff at the neurosciences unit, who should provide written advice on<br />
neurosurgical management. Thorough resuscitation and stabilisation<br />
of the patient before transfer is the key to avoiding complications<br />
during the journey. The fundamental requirement before transfer is to<br />
ensure satisfactory oxygen delivery. A mean blood pressure greater<br />
than 80 mmHg (paediatric values - appendix III), PaO2 greater than 13<br />
kPa and PaCO2 between 4.5 – 5.0 kPa should be achieved.<br />
Monitoring should include:<br />
pupillary size and reaction to light<br />
ECG<br />
pulse oximetry<br />
invasive blood pressure<br />
urine output by urinary catheter<br />
capnography<br />
central venous pressure monitoring where indicated<br />
temperature (preferably core and peripheral)<br />
Investigations undertaken prior to transfer should include:<br />
arterial blood gas estimation<br />
chest, lateral cervical spine pelvis, and other appropriate X-rays [13]<br />
haematology FBC and coagulation screen<br />
biochemistry blood sugar<br />
other investigations as appropriate<br />
blood should be cross matched if appropriate, and sent in the<br />
transferring ambulance (not in a separate taxi)<br />
8
A p p ropriate re s p i ra t o ry support must be established. Tra ch e a l<br />
intubation during transfer is difficult and dangerous. All patients with<br />
a GCS of 8 or less require intubation prior to transfer. In addition,<br />
whatever the baseline GCS, intubation should be considered if the<br />
GCS has fallen by 2 or more points. Intubation is essential if there is a<br />
fall of 2 or more points in the motor score. Intubation requires<br />
adequate sedation and muscle relaxation to avoid an increase in (ICP),<br />
and measures to prevent aspiration of gastric contents. This will<br />
normally involve rapid sequence induction with in-line stabilisation of<br />
the cervical spine. After intubation, appropriate drugs should be<br />
employed to maintain sedation, analgesia and muscle relaxation,<br />
(preferably administered by syringe driver), while avoiding hypotension<br />
and reduced cerebral perfusion pressure (CPP). Patients should be<br />
ventilated with the aim of achieving a PaO2 greater than 13 kPa and a<br />
PaCO2 of 4.5 – 5.0 kPa unless there is clinical or radiological evidence<br />
of raised intracranial pressure when more aggressive hyperventilation<br />
is justified (but not below 4 kPa). If hyperventilation is used the FIO2<br />
should be increased.<br />
Inspired oxygen should be guided by blood gas estimations before<br />
departure. Expired carbon dioxide should be monitored continuously.<br />
A chest drain should be inserted if a pneumothorax is present or<br />
considered a potential problem, eg due to fractured ribs. Underwater<br />
seals should normally be replaced by leaflet valve (Heimlich type)<br />
drainage systems. Chest drains should not be clamped.[2] A large bore<br />
orogastric tube should be passed and left on free drainage (not<br />
nasogastric in case the patient has a base of skull fracture).<br />
Intravenous volume loading should be undertaken with crystalloid or<br />
colloid initially to maintain or restore satisfactory peripheral perfusion,<br />
blood pressure and urine output. 5% Dextrose should be avoided and<br />
blood products should be given as required. Hypovolaemic patients<br />
tolerate transfer poorly and the circulating volume should be normal or<br />
supra-normal before transfer, preferably with a haematocrit over 30%.<br />
A central venous catheter may be useful to optimise filling pressures<br />
and for the administration of drugs and fluids during the transfer.<br />
9
A patient who remains hypotensive despite resuscitation must not be<br />
transported until all possible causes of the hypotension have been<br />
identified and the patient stabilised.<br />
Correction of major haemorrhage takes precedence over transfer. It is<br />
important that these measures are not omitted in an attempt to speed<br />
transfer of the patient, as resultant complications may be impossible to<br />
deal with once the journey has begun.<br />
Persistent hypotension will adversely affect neurological outcome.<br />
When other causes of hypotension have been excluded, consider the<br />
judicious use of inotropes/vasopressors to offset the hypotensive effects<br />
of sedative agents.<br />
If the patient has had a seizure, loading with anticonvulsant agents<br />
(usually phenytoin) should be considered prior to transfer. Unstable or<br />
compound long bone fractures should have preliminary toilet and be<br />
splinted to provide neurovascular protection and analgesia.<br />
If the transfer team has not been involved in the initial stages they<br />
should familiarise themselves with treatment already given and<br />
independently assess the general status of the patient before departure.<br />
All lines and tubes must be fixed securely and ready access to them<br />
ensured.<br />
The transfer team should confirm the availability of an appropriate<br />
transfer vehicle and check the function of all equipment, including<br />
battery charge status.[14] Oxygen requirements for the journey<br />
including possible delays should be estimated and should include<br />
driving gas requirements of the ventilator. A minimum reserve of<br />
oxygen and drugs should be one hour or twice the estimated journey<br />
time. If transfer times are unduly long, it may be necessary to arrange<br />
for back up oxygen supplies to be made available en route if possible.<br />
Before departure, case notes, X-rays, a referral letter and investigation<br />
reports should be collated and any required blood or blood products<br />
collected. The neurosciences unit should be contacted and informed of<br />
the estimated journey time.<br />
10
SECTION VII - THE TRANSFER<br />
The transfer team should be relieved of all other duties, be<br />
appropriately dressed, equipped and insured. Ideally, the transfer team<br />
should be involved in the initial resuscitation and management of the<br />
patient. If this is not possible, they should receive a formal hand-over<br />
from the resuscitation team. All notes (or photocopies), X-rays, CT<br />
scans, blood results and cross-matched blood should accompany the<br />
patient. The duty consultant anaesthetist in the referring hospital<br />
should be made aware of the planned transfer. All monitoring<br />
equipment should be checked, connected to the patient and securely<br />
mounted so that it cannot fall on to the patient during transfer or cause<br />
injury to ambulance occupants in the event of an accident.<br />
The patient should be transferred onto the transport trolley/stretcher,<br />
properly secured and padded with due regard to any possible spinal<br />
injury.[2, 15] The patient should be positioned with a 20° head up tilt.<br />
The development of ambulance trolleys that allow this degree of tilt,<br />
while maintaining spinal immobilisation, should be encouraged. Most<br />
transfers will be by land ambulance but for transfers over longer<br />
distances local protocols may include transfer by air.[16]<br />
During transfer, patient management will be centred upon maintaining<br />
oxygenation and adequate blood pressure and minimising rises in ICP.<br />
Monitoring ECG, invasive blood pressure, SpO2, PECO2, temperature,<br />
pupillary size and reaction to light, and the administration of drugs<br />
and other infusions should be continued.<br />
A paper record must be maintained during the transfer. This may be<br />
aided by a dictaphone or by the electronic memory in monitors. The<br />
development of standardised documentation is encouraged and many<br />
critical care networks have developed local transfer documentation.<br />
Transfers should be undertaken smoothly and not at high speed.<br />
The transfer team should be equipped with a mobile telephone to<br />
contact the neurosciences unit and their base hospital en route.<br />
11
A patient who has been made physiologically stable before departure<br />
is more likely to remain so for the duration of the transfer, although<br />
there is still the need for constant vigilance and prompt action to deal<br />
with complications. If, despite thorough preparation, there is a need to<br />
perform any procedure during the transfer this should be done with the<br />
ambulance brought to a halt.<br />
Staff at the neurosciences unit should be available to receive a<br />
comprehensive hand-over following which they assume responsibility<br />
for the patient’s care. Notes, X-rays, scans and a copy of the transfer<br />
record should be left with the receiving staff. The neurosciences unit<br />
should be prepared to provide the transfer team with refreshments.<br />
A protocol should be established to ensure the immediate return of the<br />
referring team with their equipment to their hospital. Often a contract<br />
exists with a local taxi firm for this purpose. Personal injury insurance<br />
should also cover the return journey.<br />
The referring team should keep a copy of the summary and transfer<br />
record for audit purposes.<br />
The relatives should be notified about the transfer by the referring<br />
hospital, but they should not normally accompany the patient in the<br />
ambulance.<br />
12
SECTION VIII - EQUIPMENT AND DRUGS<br />
All equipment must be serviced regularly, ch e cked daily and<br />
rechecked immediately before any transfer. If the ambulance ventilator<br />
is to be used then it must be checked before departure, as should the<br />
ambulance oxygen supply and suction. It is advisable before<br />
purchasing any new equipment to consult the ambulance service, to<br />
ensure that it is compatible with the oxygen and power supply in their<br />
vehicles.<br />
The patient should receive the same standard of phy s i o l o g i c a l<br />
monitoring during transfer as they would receive in an intensive care<br />
unit. The transfer team must be familiar with all of the equipment and<br />
drugs in the transfer kit and the transfer vehicle.<br />
Essential equipment to go with the patient in the ambulance<br />
The following equipment should be readily available, purpose<br />
designed, dedicated for transfers and be stored in a suitable container<br />
which should have some form of seal, which when broken, would<br />
indicate that the equipment has been used and requires restocking and<br />
checking:<br />
1. Portable mechanical ventilator with airway pressure and minute<br />
volume monitor, and disconnect alarm<br />
2. Adequate supply of oxygen for the journey, including unforeseen<br />
delays (see Section VI)<br />
3. Portable battery powered multifunction monitor to include:<br />
• ECG<br />
• invasive blood pressure monitoring<br />
• non invasive blood pressure monitoring as a backup<br />
• central venous pressure monitoring<br />
• pulse oximetry<br />
• capnography<br />
• temperature<br />
13
4. Other equipment<br />
• suction<br />
• battery powered syringe pumps<br />
• battery powered IV volumetric pumps (infusion by gravity is<br />
unreliable during transfer)<br />
• intubation equipment<br />
• self-inflating bag, valve and mask<br />
• venous access equipment<br />
• chest drain equipment<br />
• DC defibrillator<br />
• spare batteries<br />
• warming blanket<br />
5. An adequate supply of essential drugs to go with the patient<br />
• Hypnotics, eg propofol or midazolam<br />
• muscle relaxants, eg atracurium, vecuronium,- suxamethonium<br />
may be required for re-intubation<br />
• analgesics, eg alfentanil, fentanyl,<br />
• anticonvulsants, eg diazepam, thiopentone<br />
• mannitol 20%, furosemide<br />
• vasoactive drugs, eg ephedrine, dopamine, noradrenaline<br />
• resuscitation drugs as in hospital resuscitation boxes<br />
• intravenous fluids<br />
6. Communication equipment<br />
It is essential that the transfer team should be able to communicate<br />
easily with the designated consultant or his deputy in the referring<br />
hospital and the neurosurgical team during the transfer. The benefits of<br />
a mobile telephone which can be pre-programmed with useful<br />
numbers outweigh the minimal risk of it interfering with electronic<br />
equipment.[17]<br />
7. Paediatric equipment<br />
The transfer of paediatric patients will require size specific equipment<br />
and staff experienced in the transfer of critically ill children.[6,7,18]<br />
14
SECTION IX - EDUCATION AND TRAINING<br />
Good practice depends upon sound education, adequate resources of<br />
expertise, time for training and a commitment to quality throughout all<br />
levels of the organisation. Ensuring and facilitating good educational<br />
standards and arrangements will be a function of the consultant<br />
responsible for inter-hospital transfers.<br />
The fundamental requirement is that every doctor, nurse and<br />
paramedic likely to be involved in the transfer of seriously brain<br />
injured patients has had formal training in the theoretical and practical<br />
aspects of the subject. This will include:<br />
• the principles of managing a patient with an acute brain injury;<br />
• the principles and practice of ATLS;<br />
• the adverse physiological changes associated with moving the<br />
patient;<br />
• manual handling of the patient;<br />
• practical aspects of working in an ambulance or aircraft;<br />
• knowledge of the equipment and drugs used in transfer;<br />
• the legal and safety aspects of transfer;<br />
• communications.<br />
The setting in which this education is provided will vary locally.<br />
Learning opportunities will range from mandatory induction courses<br />
for new hospital staff to formal multidisciplinary training courses on<br />
transfer medicine. The latter are now run in a number of centres, and<br />
m ay be particularly appropriate for consultants responsible for<br />
developing and maintaining the standards of transfer.[19] All doctors,<br />
nurses and other allied health professionals who are new to a hospital<br />
should attend teaching sessions to learn local arrangements and<br />
policies and meet the staff involved.<br />
Much of the educational value of any training post comes from gaining<br />
clinical experience under supervision. The designated tra n s f e r<br />
consultant should be aware of the educational opportunities offered by<br />
transfers of patients with brain injuries to the neurosciences unit. It is<br />
15
important to involve those who take part in regular interdepartmental<br />
audit. This will include A&E personnel, anaesthetists, paramedics, etc.<br />
Participation of the neurosciences unit in such audit is particularly<br />
valuable.<br />
The quality of transfer should be audited, and critical incidents<br />
recorded. Such information is invaluable in refining and improving<br />
local transfer protocols. Appropriate audit tools for transfer are<br />
available from the Royal College of Anaesthetists.[20]<br />
16
SECTION X - RESOURCE IMPLICATIONS FOR T R A N S F E R<br />
OF PATIENTS WITH BRAIN INJURIES<br />
Without adequate resources it is not possible to have a good quality<br />
transfer service. Each organisation that provides acute healthcare<br />
should recognise that this requires specific funding which should be<br />
considered in discussions with purchasers. Resources include staff and<br />
equipment that may be similar to, and shared with, those used for other<br />
secondary transfers including the movement of ICU patients within the<br />
hospital. It should be recognised that there are significant resource<br />
implications to the transferring hospital on-call anaesthetic team.<br />
Hospitals involved in transfer of patients with brain injuries should set<br />
aside a budget for this work. The budget will include the capital<br />
equipment, the cost of which will depend upon its complexity and the<br />
demand placed upon it, as well as the cost of servicing, maintenance,<br />
insurance and renewal/upgrading at appropriate intervals. Portable<br />
equipment will need regular battery replacement and will have a<br />
shorter life than static equipment. There must be adequate provision for<br />
clothing and personal insurance.<br />
The responsibilities of the designated consultant for transfers include<br />
logistics, training, audit and liaison between the parties involved and<br />
may require dedicated programmed activities in job plans. Rotas of<br />
doctors and nurses must take account of this work and allow staff of<br />
adequate seniority to be released from other duties.<br />
Retrieval teams have been set up in some regions eg Northern Ireland<br />
[21] and are of particular importance in paediatric practice.[22]<br />
However, the speed of transfer required for head injuries may not<br />
permit a team to travel from the neuroscience centre. In addition, on<br />
a rare occasion two transfers may be required simultaneously, hence<br />
the referring hospitals will have to maintain the capability to transfer<br />
transfer patients with a time-critical lesion. This means that any unit<br />
potentially admitting children with head trauma should have a<br />
contingency to undertake such a transfer and have an appropriate kit<br />
with paediatric equipment ready for use. In an ideal world the funding<br />
of suitably situated retrieval teams would not be an issue.<br />
17
REFERENCES<br />
1. Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of<br />
monitoring (3rd ed). London: Association of Anaesthetists of Great Britain and Ireland, 2000.<br />
2. Intensive Care Society. Guidelines for the transport of the critically ill adult. Intensive Care<br />
Society 2002 h t t p : / / w w w. i c s . a c . u k / d ow n l o a d s / icstransport2002mem.pdf<br />
3. NICE Guidelines. Head injury: triage, assessment, investigation & early management of head<br />
injury in infants, children & adults. HMSO 2003 http://www.nice.org.uk<br />
4. Early management of patients with head injury. SIGN publication No.46 Aug 2000 ISBN<br />
1899893 27 X 2000 www.sign.ac.uk<br />
5. Brain Trauma Foundation: American Association of Neurological Surgeons’ joint section on<br />
neurotrauma & critical care: Guidelines for the management of severe head injury. J<br />
Neurotrauma 1996; 13: 641-734<br />
6. Paediatric Intensive Care Society. Standards for paediatric intensive care, including standards<br />
of practice for the transport of the critically ill child. Bishop’s Stortford: Saldatore Ltd, 1996.<br />
7. Paediatric Intensive Care Society. Standards document 2001<br />
8. Warren J, Fromm RE, Orr RA et al. Guidelines for the inter-and intrahospital transport of<br />
critically ill patients. Critical Care Medicine 2004; 32: 256-262<br />
9. National Service Fra m e work for long term conditions.<br />
h t t p : / / w w w. d h . g ov. u k / P u b l i c a t i o n s A n d S t a t i s t i c s / P u b l i c a t i o n s / P u b l i c a t i o n s Po l i cy A n d G u i d a n c e /<br />
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4105361&chk=jl7dri<br />
10. Molyneux A. International Subarachnoid Aneurysm Trial (ISAT) Lancet 2002; 360: 1267-74<br />
11. Neuroscience Critical Care Report progress in developing services Aug 2004<br />
http://www.modern.nhs.uk/criticalcare/5021/7117/20040%20DoH-Neurosciences.pdf<br />
12. Andrews PJD, Piper IR, Dearden NM. Secondary insults during intrahospital transport of<br />
head-injured patients. Lancet 1990; 335: 327-330.<br />
13. Morris CG Mullan B. Clearing the cervical spine after polytrauma. Anaesthesia 2004; 59:<br />
755-61<br />
14. Medical vehicles and their equipment - Road ambulances EN 1789:1999<br />
http://www.cenorm.be<br />
15. http://www.vca.gov.uk/vehicle/ambul.shtm<br />
16. Air, water and difficult terrain ambulances – Part 2: Operational and technical requirements<br />
for the continuity of patient care EN 13718-2:2002 http://www.cenorm.be<br />
17. New advice issued on the use of mobile phones in hospitals. Ref 2004/0287<br />
http://www.dh.gov.uk<br />
18. Guidance on the Provision of Paediatric Anaesthetic Services Chapter 7, Guidelines on the<br />
Provision of Anaesthetic Services, Published by the Royal College of Anaesthetists, January<br />
2005 http://www.rcoa.ac.uk/docs/Paeds.pdf<br />
19. Mark J. Transfer of the critically ill patient. Anaesthesia News July 2004 ISSN0959-2962<br />
20. Raising the Standard: A compendium of audit recipes (February 2000) Section 9: Anaesthesia<br />
outside theatres http://www.rcoa.ac.uk/docs/section9.pdf<br />
21.The Northern Ireland Critical Care Transfer Service. www.nisca.org/niccats<br />
22. Children’s Acute Transport Service www.cats.nhs.uk<br />
18
APPENDIX I<br />
INDICATIONS FOR INTUBATION AND<br />
VENTILATION FOR TRANSFER AFTER BRAIN INJURY<br />
• GCS 8 or less<br />
• Significantly deteriorating conscious level (i.e. fall in motor score of<br />
two points or more)<br />
• Loss of protective laryngeal reflexes<br />
• Hypoxaemia (PaO2 < 13 kPa on oxygen)<br />
• Hypercarbia (PaCO2 > 6 kPa)<br />
• Spontaneous hyperventilation causing PaCO2 < 4.0 kPa<br />
• Bilateral fractured mandible<br />
• Copious bleeding into the mouth (e.g. from skull base fracture)<br />
• Seizures<br />
An intubated patient should be ventilated with muscle relaxation, and<br />
appropriate sedation and analgesia. Aim for a PaO2 > 13 kPa, PaCO2<br />
4.5 – 5.0 kPa unless there is clinical or radiological evidence of raised<br />
intracranial pressure when more aggressive hyperventilation is justified<br />
to a PaCO2 of not less than 4 kPa. If hyperventilation is used the FIO2<br />
should be increased.<br />
19
APPENDIX II<br />
TRANSFER CHECKLIST FOR NEUROSURGICAL PATIENTS<br />
SYSTEM<br />
CHECKLIST<br />
Respiration PaO2 > 13 kPa?<br />
PaCO2 < 5 kPa?<br />
Airway clear?<br />
Airway protected adequately?<br />
Intubation and ventilation required?<br />
Circulation BP mean > 80 mmHg? (adults)<br />
Pulse < 100/min? (adults)<br />
Peripheral perfusion?<br />
Two reliable large iv cannulae in situ?<br />
Estimated blood loss already replaced?<br />
Arterial line?<br />
Central venous access if appropriate?<br />
Head injury GCS?<br />
GCS trend (improving/deteriorating)?<br />
Focal signs?<br />
Skull fracture?<br />
Seizures controlled?<br />
Raised ICP appropriately managed?<br />
Other injuries Cervical spine injury (cervical spine protection), chest<br />
injury, fractured ribs, pneumothorax excluded?<br />
Intrathoracic, intra-abdominal bleed?<br />
Pelvic, long bone fracture?<br />
Extracranial injuries splinted?<br />
Escort<br />
Doctor & escort adequately experienced?<br />
Instructed about this case?<br />
Adequate equipment and drugs?<br />
Can use equipment and drugs?<br />
Sufficient oxygen supplies?<br />
Case notes and X-rays?<br />
Transfer documentation prepared?<br />
Where to go in the neurosurgical unit?<br />
Telephone numbers programmed into mobile phone?<br />
Mobile phone battery fully charged?<br />
Name and bleep number of receiving doctor?<br />
Money in case of emergencies?<br />
20
APPENDIX III<br />
ADDITIONAL INFORMATION FOR PAEDIATRICS<br />
Most paediatric critical care networks operate an emergency retrieval<br />
service [22]. The most appropriate method of transfer to the<br />
neurosurgical centre or PICU should be identified according to the<br />
clinical situation. The choice is between an emergency retrieval and<br />
one way transfer by the referring hospital team.<br />
The local referring hospital team should always transfer time critical<br />
cases to avoid delay:<br />
• rapidly expanding space occupying lesion e.g. extradural<br />
• penetrating injury<br />
• uncontrollable bleeding from skull base<br />
If CT scanning is unavailable in the referring unit for any reason then<br />
a time critical one way transfer should also occur.<br />
Age specific mean arterial blood pressure targets to maintain CPP [22]<br />
Age<br />
Mean arterial blood pressure (mmHg)<br />
< 3months 40 - 60<br />
3 months – 1 year 45 -75<br />
1 – 5 years 50 - 90<br />
6 – 11 years 60 - 90<br />
12 – 14 years 65 - 95<br />
21
21 Portland Place, London W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org<br />
Designed and produced by the r2 Partnership Ltd
AAGBI SAFETY GUIDELINE<br />
Suspected Anaphylactic Reactions<br />
Associated with Anaesthesia<br />
4<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
21 Portland Place, London, W1B 1PY<br />
Telephone 020 7631 1650 Fax 020 7631 4352<br />
info@aagbi.org<br />
www.aagbi.org July 2009
This guideline was originally published in Anaesthesia. If<br />
you wish to refer to this guideline, please use the following<br />
reference:<br />
Association of Anaesthetists of Great Britain and Ireland.<br />
Suspected anaphylactic reactions associated with anaesthesia.<br />
Anaesthesia 2009; 64: pages 199-211<br />
This guideline can be viewed online via the following URL:<br />
http://www3.interscience.wiley.com/cgi-bin/fulltext/121583621/<br />
PDFSTART
GUIDELINES<br />
Suspected Anaphylactic Reactions<br />
Associated with Anaesthesia<br />
Association of Anaesthetists of Great Britain and Ireland<br />
Membership of the Working Party: N J N Harper, Chairman;<br />
T Dixon; P Dugué; D M Edgar; A Fay; H C Gooi; R Herriot;<br />
P Hopkins; J M Hunter; R Mirakian; R S H Pumphrey;<br />
S L Seneviratne; A F Walls; P Williams; J A Wildsmith; P Wood.<br />
Ex Officio: A S Nasser 1 , R K Powell 1 , R Mirakhur 2 , J Soar 3 ,<br />
Executive Officers, AAGBI<br />
1 British Society for Allergy and Clinical Immunology<br />
2 Royal College of Anaesthetists<br />
3 Resuscitation Council UK<br />
This is a consensus document produced by expert members of a Working Party<br />
established by the Association of Anaesthetists of Great Britain and Ireland<br />
(AAGBI). It updates and replaces previous guidance published in 2003.<br />
Summary<br />
(1) The AAGBI has published guidance on management of anaphylaxis<br />
during anaesthesia in 1990, 1995 and 2003. This 2008 update was<br />
necessary to disseminate new information.<br />
(2) Death or permanent disability from anaphylaxis in anaesthesia may be<br />
avoidable if the reaction is recognised early and managed optimally.<br />
(3) Recognition of anaphylaxis during anaesthesia is usually delayed<br />
because key features such as hypotension and bronchospasm more<br />
commonly have a different cause.<br />
Re-use of this article is permitted in accordance with the Creative Commons Deed,<br />
Attribution 2.5, which does not permit commercial exploitation.<br />
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(4) Initial management of anaphylaxis should follow the ABC approach.<br />
Adrenaline (epinephrine) is the most effective drug in anaphylaxis and<br />
should be given as early as possible.<br />
(5) If anaphylaxis is suspected during anaesthesia, it is the anaesthetist’s<br />
responsibility to ensure the patient is referred for investigation.<br />
(6) Serum mast cell tryptase levels may help the retrospective diagnosis of<br />
anaphylaxis: appropriate blood samples should be sent for analysis.<br />
(7) Specialist (allergist) knowledge is needed to interpret investigations for<br />
anaesthetic anaphylaxis, including sensitivity and specificity of each<br />
test used. Specialist (anaesthetist) knowledge is needed to recognise<br />
possible non-allergic causes for the ‘reaction’. Optimal investigation<br />
of suspected reactions is therefore more likely with the collaboration<br />
of both specialties.<br />
(8) Details of specialist centres for the investigation of suspected<br />
anaphylaxis during anaesthesia may be found on the AAGBI website<br />
http://www.aagbi.org.<br />
(9) Cases of anaphylaxis occurring during anaesthesia should be reported<br />
to the Medicines Control Agency and the AAGBI National<br />
Anaesthetic Anaphylaxis Database. Reports are more valuable if the<br />
diagnosis is recorded following specialist investigation of the reaction.<br />
(10) This guidance recommends that all Departments of Anaesthesia<br />
should identify a Consultant Anaesthetist who is Clinical Lead for<br />
anaesthetic anaphylaxis.<br />
Introduction<br />
The AAGBI published its first guidelines on suspected anaphylactic reactions<br />
in 1990. Subsequent revisions were published in 1995 and 2003. The current<br />
guidelines incorporate advice from a large number of clinical immunologists,<br />
allergists and anaesthetists throughout the UK. In common with the 1995 and<br />
the 2003 editions, this report is published jointly with the British Society for<br />
Allergy and Clinical Immunology (BSACI).<br />
This document is intended to be concordant with, and complementary<br />
to, the 2007 Scandinavian Clinical Practice Guidelines, the 2008 Resuscitation<br />
Council UK guidelines and the BSACI guidelines: Investigation of<br />
suspected anaphylaxis during anaesthesia.<br />
These guidelines apply only to suspected anaphylactic reactions associated<br />
with anaesthesia and it is presupposed that the patient is in the care of a<br />
trained anaesthetist.<br />
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Objectives<br />
(1) To clarify the definitions used in allergy and anaphylaxis.<br />
(2) To review the epidemiology of anaesthesia-related anaphylaxis.<br />
(3) To provide advice on the recognition of anaesthetic anaphylaxis.<br />
(4) To make recommendations on the immediate management and initial<br />
investigation of suspected anaesthetic anaphylaxis.<br />
(5) To make recommendations concerning the further investigation of<br />
suspected anaesthetic anaphylaxis.<br />
(6) To assist anaesthetists in obtaining access to a specialist centre for<br />
comprehensive investigation of suspected anaesthetic anaphylaxis.<br />
(7) To assist anaesthetists to provide appropriate information to the<br />
specialist centre.<br />
(8) To make recommendations about the reporting and collection of data<br />
on anaesthetic anaphylaxis in Great Britain and Ireland.<br />
Definitions<br />
The term ‘anaphylaxis’ has been used for all types of acute life-threatening<br />
illness triggered by abnormal sensitivity (hypersensitivity) to a trigger agent,<br />
and for apparently spontaneous attacks with similar features (idiopathic<br />
anaphylaxis). This has made it difficult to define. The EAACI Nomenclature<br />
Committee proposed the following broad definition [1]:<br />
Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity<br />
reaction.<br />
Minor, localised or non-systemic reactions are outside the definition of<br />
anaphylaxis. Anaphylaxis may be divided into ‘allergic anaphylaxis’ and<br />
‘non-allergic anaphylaxis’. The clinical features of allergic anaphylaxis<br />
and non-allergic anaphylaxis may be identical. The EAACI committee<br />
proposed the term ‘allergic anaphylaxis’ should be used only when the<br />
reaction is mediated by an immunological mechanism (such as IgE, IgG, or<br />
complement activation by immune complexes). An anaphylactic reaction<br />
mediated by IgE antibodies, such as to amoxicillin, is referred to as ‘IgEmediated<br />
allergic anaphylaxis’.<br />
The term ‘anaphylactoid’ reaction had been introduced for non-<br />
IgE-mediated anaphylactic reactions but the EAACI committee has<br />
recommended this term should no longer be used. This proposal has not<br />
been universally accepted. An authoritative recent American practice<br />
parameter [2] states: ‘Anaphylaxis is defined … as a condition caused by an<br />
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IgE-mediated reaction [2]. Anaphylactoid reactions are defined as those<br />
reactions that produce the same clinical picture as anaphylaxis but are not IgE<br />
mediated.’ In these guidelines we will follow the European (EAACI)<br />
nomenclature.<br />
Anaphylaxis is not a homogeneous process: the pathways, mediators,<br />
time course and response to treatment depend on the trigger agent, its route<br />
and rate of administration, the nature of the patient’s hypersensitivity and<br />
the state of health of the patient, including incidental pathology such as<br />
respiratory or cardiovascular disease and the effects of concomitant<br />
medication such as b-blockers and ACE inhibitors. Although anaphylaxis<br />
commonly involves respiratory, cutaneous and circulatory changes, variations<br />
such as shock with gastrointestinal disturbance or shock alone are<br />
possible. Alternatively, reactions may be fatal without significant shock<br />
except as the terminal event following respiratory arrest [3]. Angioedema<br />
and urticaria may be features of anaphylaxis but commonly result from<br />
mechanisms other than anaphylaxis.<br />
Intravascular volume redistribution is an important component of<br />
anaphylactic shock. Cardiac output may be decreased as a result of reduced<br />
coronary artery perfusion pressure as well as impaired venous return. Local<br />
release of mediators may cause coronary artery spasm and there may be<br />
features of acute left or right ventricular failure. Myocardial ischaemia with<br />
ECG changes is expected within minutes of anaphylactic shock becoming<br />
severe.<br />
Asphyxia may be due to upper airway occlusion caused by angioedema,<br />
or bronchospasm with mucus plugging of the lower airways; the latter most<br />
commonly occurs in patients taking daily treatment for asthma. Both these<br />
processes may occur simultaneously in patients reacting to foods, latex,<br />
b-lactam antibiotics or aspirin.<br />
Anaphylaxis usually resolves in 2–8 h but secondary pathology arising<br />
from the reaction or its treatment may prolong this. Resolution is complete<br />
except when cerebral hypoxia at the peak of the reaction has caused<br />
significant brain damage, or when disordered clotting leads to bleeding.<br />
Acknowledgements<br />
The involvement of the British Society for Allergy and Clinical Immunology<br />
and the Clinical Immunology and Allergy section of the British<br />
Society for Immunology is gratefully acknowledged. In addition, the<br />
working party wishes to acknowledge the assistance of the following:<br />
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Sr Alex Farragher Specialist Immunology Nurse<br />
Mr Chris Hirst AAGBI Anaphylaxis website designer<br />
Dr David Noble<br />
Dr Martin Shields<br />
References<br />
1 Johansson SGO, Bieber T, Dahl R, et al. Revised nomenclature for allergy for<br />
global use: Report of the Nomenclature Review Committee of the World<br />
Allergy Organization, October 2003. Journal of Allergy and Clinical Immunology<br />
2004; 113: 832–6.<br />
2 Joint Task Force on Practice Parameters. The diagnosis and management<br />
of anaphylaxis: an updated practice parameter. Journal of Allergy and Clinical<br />
Immunology 2005; 115: S483–523.<br />
3 Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal<br />
reactions. Clinical and Experimental Allergy 2000; 30: 1144–50.<br />
Epidemiology<br />
Geographical variation<br />
Most reports on anaesthesia-related anaphylaxis originate from France,<br />
Australia, New Zealand and the United Kingdom. Other case series have<br />
been described from Scandinavia and the USA. The true incidence and<br />
their associated morbidity and mortality remain poorly defined. Both the<br />
accuracy and completeness of reporting is not optimal.<br />
10% of anaesthesia-related reactions reported to the UK Medicines<br />
Control Agency (MCA) were fatal. These data should be interpreted with<br />
caution because it is likely that many less-severe reactions are not reported<br />
[1]. Reactions that are accepted as side-effects of certain drugs, for instance,<br />
histaminergic reactions due to atracurium and mivacurium, may be underreported.<br />
During a time period of over 6 years only 361 reactions were<br />
reported to the MCA. In a 2-year period 789 reactions were reported in<br />
France in a comparable population where there is a well-established culture<br />
of reporting anaesthesia-related reactions [2].<br />
Based on studies in Australia and France, the incidence of anaphylaxis<br />
during anaesthesia has been estimated at between 1 in 10 000 and 20 000<br />
[3, 4]. The true incidence of anaphylaxis during anaesthesia in the UK is<br />
not known. By extrapolating the French and Australian data to the UK, it is<br />
estimated that there are approximately 500 severe reactions in the UK each<br />
year. Anaphylactic reactions are more common when drugs are given<br />
intravenously.<br />
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In one large study an immune basis was demonstrated in two-thirds of<br />
patients investigated for anaphylaxis [2]: the remainder comprised nonallergic<br />
anaphylaxis and mechanisms other than anaphylaxis. The tests<br />
currently available for the diagnosis of anaesthetic anaphylaxis are imperfect.<br />
Skin tests and blood tests have limited sensitivity and specificity and their<br />
positive and negative predictive value varies between drugs.<br />
Patient characteristics (age, sex, ethnicity, smoking etc)<br />
Neuromuscular blocking drugs and latex appear to cause anaphylaxis more<br />
commonly in female patients. There appears to be a connection between<br />
smoking and antibiotic anaphylaxis, possibly because smokers may become<br />
sensitised by exposure to repeated courses of antibiotics for respiratory tract<br />
infections. Individuals with a history of atopy, asthma or allergy to some<br />
foods appear to be at increased risk of latex allergy but not anaphylaxis to<br />
neuromuscular blocking drugs or antibiotics [2, 5]. Anaphylaxis associated<br />
with radiographic contrast media appears to be associated with atopy [6].<br />
Patients with asthma or taking b-blocking drugs may suffer a more severe<br />
reaction. Some of these reactions may be refractory to conventional<br />
therapy.<br />
Possible environmental sensitising agents<br />
The prevalence of anaphylactic reactions to neuromuscular blocking agents<br />
(NMBAs) is reported to be at least six times more frequent in some<br />
countries [7, 8]: it is considerably more common in Norway than in<br />
Sweden. Quaternary ammonium ions (QAI) are proposed to be the<br />
allergenic epitopes in NMBAs. Common environmental chemicals such as<br />
toothpastes, washing detergents, shampoos, and cough medicines share<br />
these allergenic epitopes with the NMBAs [8]. Numerous possibilities exist<br />
for a predisposed individual to become sensitised to QAIs and thus be at risk<br />
of developing anaphylaxis to NMBAs during anaesthesia. In a recent<br />
Scandinavian survey, use of certain cough medicines was found to be the<br />
only significant difference in environmental chemical exposure [8]. In<br />
Norway, but not Sweden, cough syrups containing pholcodine are available<br />
without prescription. IgE-antibodies to pholcodine were seen in 6% of a<br />
general population (blood donors) in Norway but not in Sweden (0%).<br />
Muscle relaxants<br />
Approximately 60% of cases of anaesthesia-related anaphylaxis are thought<br />
on the basis of skin tests to be due to neuromuscular blocking agents.<br />
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Mivacurium and atracurium are associated with non-allergic anaphylaxis in<br />
which release of mediators (notably histamine) from mast cells exactly<br />
imitates allergic anaphylaxis. Cisatracurium, although sharing a benzylisoquinolinium<br />
structure, is not associated with non-allergic anaphylaxis,<br />
although several cases of allergic anaphylaxis have been reported. It is<br />
generally accepted that succinylcholine is the NMBA most likely to<br />
be associated with allergic anaphylaxis, although rocuronium has been<br />
implicated in a similar number of cases in France.<br />
The prevalence of sensitisation to NMBAs in the community is higher<br />
than the incidence of reactions would suggest. In one study, approaching<br />
10% of the general population exhibited skin reactivity to NMBAs, an<br />
incidence that far exceeds the incidence of anaphylaxis on administration of<br />
these drugs during anaesthesia [9]. A previous history of specific drug<br />
exposure is not necessary, particularly for neuromuscular blocking drugs. A<br />
history of previous exposure is found in fewer than 50% of patients who are<br />
allergic to neuromuscular blocking drugs. Conversely, an uneventful<br />
exposure may sensitise an individual to subsequent administration of the<br />
drug.<br />
Cross-sensitivity between different NMBAs is relatively common,<br />
probably because they share a quaternary ammonium epitope. If anaphylaxis<br />
to an NMBA is suspected, the patient should undergo skin prick<br />
testing with all the NMBAs in current use. If a patient demonstrates a<br />
positive skin prick test (SPT) to an NMBA, the patient should be warned<br />
against future exposure to all NMBAs if possible. If it is mandatory to use an<br />
NMBA during anaesthesia in the future, it would seem appropriate to<br />
permit the use of an NMBA which has a negative skin test, accepting that a<br />
negative skin test does not guarantee that anaphylaxis will not occur.<br />
The apparent excess of cases of anaphylaxis to rocuronium in some<br />
countries should be interpreted with caution until much more data have<br />
been collected. Large sample sizes are needed to estimate the true incidence:<br />
if the true incidence is 1 in 5000, a sample size of 7 million would be<br />
needed to have a 95% chance of being within 5% of the true value [10].<br />
There is a need for further epidemiological studies.<br />
Latex<br />
Latex hypersensitivity is the second most common cause of anaesthesiarelated<br />
anaphylaxis in many studies (up to 20% of cases). However, the<br />
incidence of anaphylaxis to latex is considerably less than would be<br />
suggested by the prevalence of positive skin tests or positive IgE tests. It<br />
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appears that the incidence may be waning, at least in some countries;<br />
possibly as a result of a change or decline in the use of latex gloves. Certain<br />
patient groups are more susceptible to latex anaphylaxis (see Appendix II).<br />
Antibiotics<br />
Approximately 15% of anaesthesia-related anaphylactic episodes are due to<br />
antibiotics. This proportion has increased in recent years and may merely<br />
mirror increased exposure to antibiotics in the community [2, 11]. The<br />
pre-operative history is important. Although only a minority of patients<br />
who report allergy to antibiotics have a true allergy, the consequence<br />
of anaphylaxis to intravenous antibiotics may be catastrophic, and selfreporting<br />
should be taken seriously. Skin testing is only approximately 60%<br />
predictive of clinical hypersensitivity. Penicillins and cephalosporins which<br />
share the b-lactam ring are responsible for approximately 70% of antibioticinduced<br />
anaphylaxis. Many antibiotics possess a b-lactam ring:<br />
• Benzylpenicillin, phenoxymethylpenicillin<br />
• Flucloxacillin, temocillin<br />
• Amoxicillin, ampicillin, co-amoxiclav<br />
• Co-fluampicil<br />
• Piperacillin, ticarcillin,<br />
• Pivmecillinam HCl<br />
• Cephalosporins<br />
• Aztreonam<br />
• Ertapenem, imipenem with cilastatin, meropenem<br />
The structure of the side chains attached to the b-lactam ring is also<br />
important in determining the response of the immune system. First<br />
generation cephalosporins and cefamandole share a similar side chain with<br />
penicillin and amoxicillin. A recent meta-analysis suggested that patients<br />
who are allergic to penicillin or amoxicillin have a higher incidence of<br />
allergic reactions to first generation cephalosporins and cefamandole, but<br />
not other cephalosporins [12]. The issue is complicated because the<br />
classification of cephalosporins relates to their antimicrobial activity rather<br />
than their chemical structure.<br />
First generation cephalosporins<br />
• Cefalexin (cephalexin)*<br />
• Cephaloridine<br />
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• Cephalothin<br />
• Cefazolin<br />
• Cefradine (cephradine)*<br />
• Cefadroxil*<br />
Second generation cephalosporins<br />
• Cefaclor*<br />
• Cefamandole<br />
• Cefuroxime*<br />
Third generation cephalosporins<br />
• Cefixime*<br />
• Cefotaxime*<br />
• Cefpodoxime*<br />
• Ceftazidime*<br />
• Ceftriaxone*<br />
Fourth generation cephalosporins<br />
• Cefepime<br />
• Cefpirome<br />
*Listed in the British National Formulary.<br />
Local anaesthetics<br />
Anaphylactic reactions to local anaesthetic drugs are very uncommon. Local<br />
anaesthetic esters are more likely than amides to provoke a Type lV allergic<br />
reaction. Preservatives such as methyl-paraben or metabisulphites may be<br />
responsible in some cases. It has been suggested that inadvertent intravascular<br />
injection of a local anaesthetic or the systemic absorption of adrenaline<br />
may be responsible for many of the reported reactions. Reactions occurring<br />
in the dental chair may also be associated with idiopathic angioedema or<br />
latex allergy.<br />
Opioids<br />
Opioids are an uncommon cause of anaesthesia-related anaphylaxis.<br />
Diagnosis is difficult and the true incidence is unknown. Morphine,<br />
pethidine and codeine are well-known to cause non-specific histamine<br />
release which precludes diagnostic skin testing. The diagnosis of opioid<br />
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anaphylaxis often rests on a careful history and the exclusion of other<br />
possibilities. Challenge testing may be appropriate in some cases but may be<br />
performed only in specialist centres.<br />
Anaesthetic induction agents<br />
Anaphylaxis to propofol is very uncommon. The antigenic determinant<br />
may be the isopropyl groups. It has been stated that patients with egg allergy<br />
or soy allergy should avoid propofol but there is no strongly-supportive<br />
evidence. It has been suggested that propofol anaphylaxis is more likely if<br />
lignocaine is added to reduce pain on injection: there is no evidence to<br />
support this suggestion. Anaphylaxis to thiopental has become extremely<br />
uncommon, probably reflecting the decline in its use. A small number of<br />
cases of midazolam anaphylaxis have been reported.<br />
Non-steroidal anti-inflammatory drugs (NSAIDs)<br />
Several mechanisms may be responsible for reactions to NSAIDs.<br />
Inhibition of the PGE 2 pathway leads to excessive leukotriene synthesis<br />
and subsequent mediator release, causing urticaria or bronchospasm. IgEmediated<br />
reactions may also occur in relation to some NSAIDs. Fatal<br />
anaphylaxis has been described after oral administration of NSAIDs.<br />
Halogenated volatile anaesthetics<br />
There are no published reports of anaphylaxis to halogenated volatile<br />
anaesthetics. The rare fulminant form of hepatitis associated with halothane<br />
has an immune basis which is unrelated to anaphylaxis.<br />
Colloids<br />
Intravenous colloids are responsible for approximately 4% of all perioperative<br />
anaphylactic reactions. In one study, gelatin solutions were<br />
responsible for 95% of the intravenous colloid reactions. It has been stated<br />
that the incidence may be greater with the urea-linked gelatins compared with<br />
the modified fluid gelatins. Intravenous gelatin solutions should be avoided in<br />
patients with a history of allergy to gelatin-containing vaccines. Anaphylaxis<br />
to intravenous dextrans has been reported, with an incidence similar to the<br />
modified fluid gelatins. Anaphylaxis to hydroxyethyl-starch is rare.<br />
Antiseptics and disinfectants<br />
Reactions to chlorhexidine have come into greater prominence in recent<br />
years. There appears to be a significant difference in incidence between<br />
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countries [13]. Reactions range from contact dermatitis to life-threatening<br />
anaphylaxis. Anaphylaxis has occurred when chlorhexidine was used as an<br />
antiseptic for urological and gynaecological procedures as well as insertion<br />
of central venous and epidural catheters. The chlorhexidine coating of<br />
certain central venous catheters has been implicated in such reactions. It is<br />
prudent to allow skin disinfectant to completely dry before beginning an<br />
invasive procedure. Anaphylaxis to polyvinylpyrrholidine as povidoneiodine<br />
or as an excipient for oral medicines occurs but is rare.<br />
Miscellaneous agents<br />
Many agents to which patients may be exposed during anaesthesia may be<br />
associated with anaphylaxis, including aprotinin, protamine, heparins,<br />
radiological contrast material, dyes and oxytocin. Anaphylaxis to glycopyrronium<br />
and neostigmine may occur very rarely.<br />
References<br />
1 Axon AD, Hunter JM. Editorial III: Anaphylaxis and anaesthesia – all clear now?<br />
British Journal of Anaesthesia 2004; 93: 501–4.<br />
2 Mertes PM, Laxenaire MC, Alla F. Anaphylactic anaphylactoid reactions<br />
occurring during anaesthesia in France in 1999–2000. Anesthesiology 2003; 99:<br />
536–45.<br />
3 Fisher MM, Baldo BA. The incidence and clinical features of anaphylactic<br />
reactions during anesthesia in Australia. Annales Francaises d’Anesthesie et de<br />
Reanimation 1993; 12: 97–104.<br />
4 Laxenaire MC. Epidemiology of anesthetic anaphylactoid reactions. Fourth<br />
multicenter survey (July 1994-December 1996). Annales Francaises d’Anesthesie et<br />
de Reanimation 1999; 18: 796–809.<br />
5 Laxenaire MC, Mertes PM. Anaphylaxis during anaesthesia. Results of a<br />
two-year survey in France. British Journal of Anaesthesia 2001; 87: 549–58.<br />
6 Lang DM, Alpern MB, Visintainer PF, Smith ST. Increased risk for anaphylactoid<br />
reaction from contrast media in patients on beta-adrenergic blockers or<br />
with asthma. Annals of Internal Medicine 1991; 115: 270–6.<br />
7 Laake JH, Rottingen JA. Rocuronium and anaphylaxis – a statistical challenge.<br />
Acta Anaesthesiologica Scandinavica 2001; 45: 1196–203.<br />
8 Florvaag E, Johansson SG, Oman H, et al. Prevalence of IgE antibodies to morphine.<br />
Relation to the high and low incidences of NMBA anaphylaxis in Norway<br />
and Sweden, respectively. Acta Anaesthesiologica Scandinavica 2005; 49: 437–44.<br />
9 Porri F, Lemiere C, Birnbaum J, et al. Prevalence of muscle relaxant sensitivity<br />
in a general population: implications for a preoperative screening. Clinical and<br />
Experimental Allergy 1999; 29: 72–5.<br />
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10 Fisher M, Baldo BA. Anaphylaxis during anaesthesia: current aspects of diagnosis<br />
and prevention. European Journal of Anaesthesiology 1994; 11: 263–84.<br />
11 Moss J. Allergy to anesthetics. Anesthesiology 2003; 99: 521–3.<br />
12 Pichichero ME, Casey JR. Safe use of selected cephalosporins in penicillinallergic<br />
patients: a meta-analysis. Otolaryngology-Head and Neck Surgery 2007; 136:<br />
340–7.<br />
13 Garvey LH, Roed-Petersen J, Menne T, Husum B. Danish Anaesthesia<br />
Allergy Centre – preliminary results. Acta Anaesthesiologica Scandinavica 2001; 45:<br />
1204–9.<br />
Recognition and clinical diagnosis of anaphylaxis<br />
In a closely monitored patient such as during anaesthesia, when a fall in<br />
blood pressure, change in heart rate or difficulty with ventilation are<br />
noticed, anaphylaxis is so rarely the cause that inevitably treatment is given<br />
for another diagnosis before anaphylaxis is recognised; the response to this<br />
treatment has commonly delayed or even prevented recognition of the true<br />
cause. It is therefore probable that many grade I and II acute allergic<br />
reactions to anaesthetic drugs are missed. Conversely, a cause other than<br />
allergic anaphylaxis seems more likely in around one-third of the patients<br />
referred to specialist centres for investigation of suspected anaphylaxis<br />
during anaesthesia.<br />
Previous history<br />
Any clue that appropriately raises anticipation of anaphylaxis will be helpful.<br />
A previous history of reaction to anaesthetic drugs, antibiotics, other drugs,<br />
chlorhexidine or latex should obviously lead to appropriate avoidance.<br />
Because it is always possible the wrong trigger factor was identified, the<br />
exact details of exposure leading to any previous reaction should be sought<br />
during the pre-operative assessment. Cross-reactivity between non-anaesthetic<br />
drugs such as pholcodine or environmental chemicals containing<br />
quaternary ammonium groups such as cosmetics and detergents has been<br />
proposed as the source of sensitivity to opioids and muscle relaxants: a<br />
history of cutaneous sensitivity to cosmetics or rashes from cough medicines<br />
should raise caution.<br />
Anaphylaxis to amoxicillin and cephalosporins is commonest in asthmatic<br />
smokers who have had multiple courses of these antibiotics without<br />
reacting: the symptoms of anaphylaxis in such a patient are likely to be<br />
initially misinterpreted (quite reasonably) as those expected from anaesthesia<br />
in an asthmatic smoker.<br />
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Clinical features<br />
Although anaesthesia-related anaphylaxis usually results from intravenous<br />
drug administration, administration by other routes, for example cutaneous,<br />
mucosal ⁄ vesical peritoneal, intra-articular or intramuscular may be responsible.<br />
Clinical features include hypotension, tachycardia or bradycardia;<br />
cutaneous flushing, rash or urticaria; bronchospasm; hypoxia; angioedema<br />
and cardiac arrest. If an adverse event such as hypotension or bronchospasm<br />
occurs during anaesthesia it is appropriate to suspect anaphylaxis unless<br />
there exists a significantly more likely cause.<br />
Tachycardia is not invariable: bradycardia is seen in approximately 10%<br />
of patients with allergic anaphylaxis during anaesthesia. Hypotension is the<br />
sole clinical feature in approximately 10% of patients and is likely to be<br />
exaggerated in patients undergoing anaesthesia with neuraxial blockade.<br />
Widespread flushing or urticaria is seen in the majority of patients but the<br />
absence of cutaneous signs does not exclude anaphylaxis. Bronchospasm<br />
may be more common in patients with pre-existing asthma.<br />
Clinical features<br />
Allergic<br />
anaphylaxis<br />
(n = 518), n (%)<br />
Non-allergic<br />
anaphylaxis<br />
(n = 271), n (%)<br />
Cardiovascular 387 (74.7) 92 (33.9)<br />
Arterial hypotension 90 (17.3) 50 (18.4)<br />
Cardiovascular collapse 264 (50.8) 30 (11.1)<br />
Bradycardia 7 (1.3) 2 (0.7)<br />
Cardiac arrest 31 (5.9) –<br />
Bronchospasm 207 (39.8) 52 (19.2)<br />
Cutaneous signs 374 (71.9) 254 (93.7)<br />
Angioedema 64 (12.3) 21 (7.7)<br />
Clinical features of allergic anaphylaxis and non-allergic anaphylaxis occurring during<br />
anaesthesia in France between 1st Jan 1999 and 31st Dec 2000. Mertes PM et al. Anesthesiology<br />
2003; 99: 536–45.<br />
The clinical features usually occur within a few minutes but may be<br />
delayed by up to an hour. Substances to which the clinical reaction may be<br />
delayed include latex, antibiotics, intravenous colloids and Cidex OPA<br />
(used to disinfect surgical instruments). However, an immediate response<br />
does not exonerate these substances. The clinical features of anaphylaxis<br />
to neuromuscular blocking agents usually develop rapidly. Deflation of a<br />
surgical tourniquet may induce anaphylaxis if the allergen has been<br />
sequestered in the limb.<br />
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Immediate management<br />
These management guidelines presuppose that the patient is in the care of an<br />
appropriately-trained anaesthetist and full resuscitation facilities and appropriate vital<br />
signs monitors are available.<br />
There is a wide spectrum of severity and combinations of clinical<br />
features. Although management should be tailored to the individual patient,<br />
there is consensus that adrenaline should be given as early as possible. In<br />
addition to having alpha-agonist activity, adrenaline is a valuable betaagonist<br />
which is inotropic and a bronchodilator, and reduces further<br />
mediator release.<br />
Other causes of hypotension or difficulty in ventilation should be<br />
excluded, for example a misplaced tracheal tube or equipment failure.<br />
Immediate management<br />
1 Use the ABC approach (Airway, Breathing, Circulation). Teamworking<br />
enables several tasks to be accomplished simultaneously.<br />
2 Remove all potential causative agents (including IV colloids, latex and<br />
chlorhexidine) and maintain anaesthesia, if necessary, with an inhalational<br />
agent.<br />
3 Call for help and note the time.<br />
4 Maintain the airway and administer oxygen 100%. Intubate the trachea if<br />
necessary and ventilate the lungs with oxygen.<br />
5 Elevate the patient’s legs if there is hypotension.<br />
6 If appropriate, start cardiopulmonary resuscitation immediately according<br />
to Advanced Life Support Guidelines.<br />
7 Administer adrenaline intravenously. An initial dose of 50 lg (0.5 ml of<br />
1 : 10 000 solution) is appropriate (adult dose). Several doses may be<br />
required if there is severe hypotension or bronchospasm.<br />
8 If several doses of adrenaline are required, consider starting an intravenous<br />
infusion of adrenaline (adrenaline has a short half-life).<br />
9 Administer saline 0.9% or lactated Ringer’s solution at a high rate via an<br />
intravenous cannula of an appropriate gauge (large volumes may be<br />
required).<br />
Secondary management<br />
1 Administer chlorphenamine 10 mg IV (adult dose).<br />
2 Administer hydrocortisone 200 mg IV (adult dose).<br />
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3 If the blood pressure does not recover despite an adrenaline infusion,<br />
consider the administration of an alternative intravenous vasopressor<br />
according to the training and experience of the anaesthetist, for example<br />
metaraminol.<br />
4 Treat persistent bronchospasm with an intravenous infusion of salbutamol.<br />
If a suitable breathing-system connector is available, a metered-dose<br />
inhaler may be appropriate. Consider giving intravenous aminophylline<br />
or magnesium sulphate.<br />
5 Arrange transfer of the patient to an appropriate Critical Care area.<br />
6 Take blood samples (5–10 ml clotted blood) for Mast Cell Tryptase as<br />
follows:<br />
a Initial sample as soon as feasible after resuscitation has started – do not<br />
delay resuscitation to take the sample.<br />
b Second sample at 1–2 h after the start of symptoms.<br />
c Third sample either at 24 h or in convalescence (for example in a<br />
follow-up allergy clinic). This is a measure of baseline tryptase levels as<br />
some individuals have a higher baseline level.<br />
d Ensure that the samples are labelled with the time and date.<br />
7 Liaise with the hospital laboratory (see Appendix lll: Mast cell Tryptase).<br />
Drug doses in children<br />
Adrenaline<br />
Intramuscular<br />
> 12 years: 500 lg IM (0.5 ml of a 1 : 1000 solution)<br />
300 lg IM (0.3 ml of a 1 : 1000 solution) if the child is small<br />
6–12 years: 300 lg IM (0.3 ml of a 1 : 1000 solution)<br />
Up to 6 years: 150 lg IM (0.15 ml of a 1 : 1000 solution)<br />
Intravenous<br />
Intravenous adrenaline may be used in children in acute areas such as<br />
operating theatres or intensive care units by those familiar with its use and if<br />
IV access is already available. Great care should be taken to avoid dose<br />
errors when preparing drug dilutions. Prepare a syringe containing 1 ml<br />
of 1 : 10 000 adrenaline for each 10 kg body weight (0.1 ml.kg )1 of<br />
1 : 10 000 adrenaline solution = 10 lg.kg )1 . Titrate to response, starting<br />
with a dose of one-tenth of the contents of the syringe, i.e. 1 lg.kg )1 .<br />
Often a child will respond to as little as 1 lg.kg )1 . In smaller children,<br />
further dilution may be needed to allow dose titration (check carefully<br />
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for decimal point and concentration errors). The intramuscular route is<br />
preferred where there is no venous access or where establishing venous<br />
access would cause a delay in drug administration.<br />
Hydrocortisone<br />
> 12 years: 200 mg IM or IV slowly<br />
6 to 12 years: 100 mg IM or IV slowly<br />
6 months to 6 years: 50 mg IM or IV slowly<br />
< 6 months: 25 mg IM or IV slowly<br />
Chlorphenamine<br />
> 12 years: 10 mg IM or IV slowly<br />
6 to 12 years: 5 mg IM or IV slowly<br />
6 months to 6 years: 2.5 mg IM or IV slowly<br />
< 6 months: 250 lg.kg )1 IM or IV slowly<br />
Later investigations to identify the causative agent<br />
Any patient who has a suspected anaphylactic reaction associated with<br />
anaesthesia should be investigated fully, but investigations should not<br />
interfere with the immediate treatment of the patient. The anaesthetist who<br />
administered the anaesthetic or the consultant anaesthetist in charge of the<br />
patient is responsible for ensuring that the reaction is investigated.<br />
The patient should be referred to a specialist Allergy or Immunology<br />
centre that has appropriate experience of investigating this type of problem.<br />
Anaesthetic departments should identify a lead anaesthetist for anaesthetic<br />
anaphylaxis. Referral pathways should be agreed prospectively with the appropriate<br />
specialist centre.<br />
Criteria for referral to a specialist centre for investigation<br />
Patients in whom allergic or non-allergic anaphylaxis is suspected should be<br />
referred to a specialist clinic for investigation. A patient should be referred if<br />
there is any of the following:<br />
1 Unexplained cardiac arrest during anaesthesia.<br />
2 Unexplained, unexpected hypotension (for example a decrease of<br />
mean arterial pressure of more than 30 mmHg) which requires active<br />
treatment.<br />
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3 Unexplained, unexpected bronchospasm, particularly if the bronchospasm<br />
is severe, causes a significant decrease in oxygen saturation and is<br />
relatively resistant to treatment.<br />
4 Widespread rash, flushing or urticaria.<br />
5 Angioedema.<br />
A detailed analysis of events surrounding the suspected anaphylactic<br />
reaction must be undertaken. The time of onset of the reaction in relation to<br />
induction and other events is the most important information. All drugs and<br />
other agents to which the patient was exposed before and during the<br />
anaesthetic as well as their timing in relation to the reaction must be recorded.<br />
Details sent to the specialist centre along with a letter of referral must<br />
include:<br />
• A legible photocopy of the anaesthetic record<br />
• A legible photocopy of the recovery room chart<br />
• Legible photocopies of drug charts<br />
• A description of the reaction and time of onset in relation to induction<br />
• Details of blood tests sent and their timing in relation to the reaction<br />
• Contact details of the surgeon and the general practitioner<br />
A standard referral proforma is useful (see Appendix S1 in Supporting<br />
Information).<br />
Tests performed at the specialist centre<br />
Skin tests<br />
Patients should be referred for skin testing as soon as possible after the<br />
clinical event. Skin testing can be performed as soon as the patient has made<br />
a full clinical recovery and the effects of any antihistamine given to treat<br />
the reaction have fully worn off. Skin tests can provide confirmation of<br />
sensitisation to a specific drug but must be interpreted within the clinical<br />
context. There are a variety of techniques and several different criteria are<br />
used for positivity [1–4] so skin testing must be performed by suitably<br />
trained and experienced personnel.<br />
A histamine solution and physiological saline are used as positive and<br />
negative controls respectively. Drugs with anti-histamine activity must be<br />
discontinued a few days before testing. There is no need to discontinue oral<br />
or inhaled steroids.<br />
Skin prick tests are usually done on the volar surface of the forearm. A<br />
drop of the drug is placed on the skin and the skin pricked through the drop<br />
with a lancet. The results are read after 15–20 min.<br />
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Intradermal tests may be performed where skin prick tests are negative.<br />
Although they are more sensitive, they are less specific, more difficult to<br />
interpret and more likely to precipitate a systemic reaction. Intradermal tests<br />
are usually performed on the forearm or back. 0.02 to 0.05 ml of a dilute<br />
solution is injected intradermally and the results read after 20–30 min.<br />
Both skin prick tests and intradermal tests are widely used in the diagnosis<br />
of IgE mediated allergic reactions though the diagnostic value of a positive<br />
test for most drugs is limited due to lack of subsequent challenge data. If the<br />
mechanism is unknown a negative test is unreliable.<br />
All drugs used during anaesthesia may be tested and lists of non-irritant<br />
dilutions have been compiled for both skin prick tests and intradermal tests<br />
[5]. Skin tests are most useful for latex, beta lactam antibiotics and NMBAs.<br />
They are also useful for induction agents, protamine [6] and chlorhexidine.<br />
Intradermal testing may be more reliable for propofol [2]. Skin tests are not<br />
usually performed for opioids because false positive results are common.<br />
However, skin prick testing appears to be informative for the synthetic<br />
opioids fentanyl and remifentanil. Skin tests are not useful for NSAIDs,<br />
dextrans or iodinated radiological contrast media [6] because anaphylaxis to<br />
these agents is not usually IgE-mediated.<br />
Patch tests are the mainstay of diagnosis for contact allergic reactions and<br />
may be useful for diagnosing exanthematous drug rashes but are not helpful<br />
in eliciting the cause of suspected anaphylactic reactions occurring during<br />
anaesthesia.<br />
References<br />
1 Pepys J, Pepys EO, Baldo BA, Whitwam JG. Anaphylactic ⁄ anaphylactoid<br />
reactions to anaesthetic and associated agents. Anaesthesia 1994; 49: 470–5.<br />
2 Fisher MMcD, Bowey CJ. Intradermal compared with prick testing in the<br />
diagnosis of anaesthetic allergy. British Journal of Anaesthesia 1997; 79: 59–63.<br />
3 Berg CM, Heier T, Wilhelmsen V, Florvaag E. Rocuronium and cisatracuriumpositive<br />
skin tests in non allergic volunteers: determination of drug concentration<br />
thresholds using a dilution titration technique. Acta Anaesthesiologica Scandinavica<br />
2003; 47: 576–82.<br />
4 Leynadier F, Sansarricq M, Didier JM, Dry J. Prick tests in the diagnosis<br />
of anaphylaxis to general anaesthetics. British Journal of Anaesthesia 1987; 59:<br />
683–9.<br />
5 Prevention of allergic risk in Anaethesia. Societe Francaise d’Anesthesie et de<br />
Reanimation, 2001. http://www.sfar.org/allergiefr.html [accessed 8 October<br />
2008].<br />
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6 Fisher M, Baldo BA. Anaphylaxis during anaesthesia: current aspects of diagnosis<br />
and prevention. European Journal of Anaesthesiology 1994; 11: 263–84.<br />
Blood tests<br />
Appropriate further blood investigations depend on the drug in question,<br />
and the experience of the specialised laboratory service. Blood samples<br />
for specific IgE tests may be taken at the time of the reaction, or soon<br />
afterwards during that hospital admission. If the results are negative these<br />
tests should be repeated when the patient is seen at the specialist centre in<br />
case the initial results might be falsely negative due to possible consumption<br />
of relevant IgE antibodies during the reaction. The most commonly used<br />
test for allergen-specific IgE uses target allergen or drug bound onto a<br />
three-dimensional sponge-like solid matrix or ‘CAP’ and a fluorescent<br />
detection system. The Radio-AllergoSorbent Test (RAST) uses a radioactive<br />
detection system: it is now rarely used but the name has persisted in<br />
common use.<br />
Specific IgE antibodies against succinylcholine (thiocholine ester) can be<br />
assayed in serum but the sensitivity is relatively poor (30–60%). Tests for<br />
serum IgE antibodies against other neuromuscular blocking drugs are not<br />
available in the UK. Specific IgE antibodies against several antibiotics can<br />
be assayed. These include amoxicilloyl, ampicilloyl, penicilloyl G, penicilloyl<br />
V and cefaclor, however the diagnostic value of these tests is less well<br />
defined. Tests for specific antibodies against latex, chlorhexidine and bovine<br />
gelatin are available.<br />
The presence of drug-specific IgE in serum is evidence of allergic<br />
sensitisation in that individual and provides a possible explanation of the<br />
mechanism and specific drug responsible for the reaction. It is not in itself<br />
proof that the drug is responsible for the reaction. It is important to<br />
emphasise that attribution of cause and effect is a judgement made after<br />
considering all the clinical and laboratory information relevant to the<br />
reaction.<br />
Experimental tests<br />
There is much research into ways of improving the in vitro elucidation of<br />
anaphylaxis. In addition to tissue-bound mast cells, circulating basophils are<br />
also involved in anaphylaxis. During anaphylaxis, proteins such as CD63<br />
and CD203c become newly or increasingly expressed on the surface of<br />
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basophils. These can be detected by flow cytometry which forms the basis<br />
of experimental drug-induced basophil stimulation tests.<br />
Appendix I<br />
Frequently asked questions<br />
Should I give a test dose of IV antibiotic?<br />
No. Predictive testing would require serial challenges with increasing doses,<br />
starting with a minuscule dose and allowing at least 30 min between each<br />
dose. This approach is impossible within the constraints of an operating list.<br />
Should I avoid cephalosporins in a patient who gives a history suggestive of penicillin<br />
allergy?<br />
Most patients who give a history of a penicillin-related rash are not allergic<br />
to cephalosporins. However, there are now many suitable alternatives to<br />
cephalosporins and, unless there are compelling bacteriological indications,<br />
it would be appropriate to consider avoiding first and second generation<br />
cephalosporins. If there is a convincing history of penicillin-related<br />
anaphylaxis, the case for avoiding first and second generation cephalosporins<br />
is stronger.<br />
Should I use crystalloid or colloid in the immediate management of anaphylaxis?<br />
There is no evidence that one is better than the other. If an IV colloid has<br />
already been given to the patient before the appearance of clinical signs of<br />
anaphylaxis, it should be discontinued and either replaced by crystalloid or<br />
replaced by a colloid of a different class; e.g. replace a gelatin-based colloid<br />
with a starch-based colloid.<br />
Should I give an H2-blocking drug as part of the immediate management of<br />
anaphylaxis?<br />
There is no evidence to support the use of H2-blocking drugs in this<br />
situation.<br />
What should I do if a patient with a convincing history of cardio-respiratory collapse<br />
during a previous anaesthetic presents for emergency surgery without having been<br />
investigated for anaphylaxis?<br />
1 Covert cardiac or respiratory disease should be sought in accordance with<br />
normal pre-operative practice.<br />
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2 It may be possible to exclude latex allergy by taking a detailed history<br />
from the patient. If this is impossible, a latex-free environment should be<br />
provided.<br />
3 Inhalational agents are likely to be safe unless the previous collapse was<br />
due to malignant hyperthermia.<br />
4 If previous records are available:<br />
a It would be appropriate to avoid all drugs given during the previous<br />
anaesthetic before the onset of cardio-respiratory collapse, with the<br />
exception of inhalational agents.<br />
b If the patient received a neuromuscular blocking drug before the<br />
collapse, then all neuromuscular blocking drugs should be avoided if<br />
possible because cross-sensitivity is common.<br />
5 If previous records are not available:<br />
a It would be appropriate to avoid all neuromuscular blocking drugs if<br />
possible (the anaesthetist will need to assess the balance of risks).<br />
b Drugs used in local and regional anaesthesia are likely to be safe;<br />
allergy to amide local anaesthetic drugs is extremely rare.<br />
c It would be appropriate to avoid chlorhexidine preparations if possible;<br />
allergy to povidone iodine is less common than allergy to chlorhexidine.<br />
d The previous reaction may have been the result of non-allergic<br />
anaphylaxis; it would be appropriate to avoid drugs that are known to<br />
release histamine, for example morphine.<br />
6 There is no evidence that pre-treatment with hydrocortisone or<br />
histamine-blocking drugs will reduce the severity of anaphylaxis.<br />
What should I say to a patient who wishes to be screened for anaesthetic allergy<br />
pre-operatively?<br />
Unless there is a history suggestive of previous anaesthetic anaphylaxis, preoperative<br />
screening is of no value. The sensitivity and specificity of skin<br />
tests and blood tests is relatively low. If the pretest probability is very low,<br />
i.e. there is no positive history, neither a negative test nor a positive test is<br />
likely to be predictive of outcome.<br />
Should I avoid propofol in patients who are allergic to eggs, soya or nuts?<br />
There is no published evidence indicating that propofol should be avoided<br />
in patients who are allergic to eggs, soya or nuts. Propofol contains purified<br />
egg phosphatide and soya-bean oil. It is likely that the manufacturing<br />
process removes or denatures the proteins responsible for egg allergy and<br />
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Suspected anaphylactic reactions associated with anaesthesia<br />
.....................................................................................................................................<br />
soya allergy. However, a cautious approach would seem to be appropriate<br />
in patients with egg allergy or soya allergy.<br />
I don’t have a specialist allergy centre nearby. Should I do my own skin-testing?<br />
The results of skin tests are very technique-dependent and their interpretation<br />
requires specialist training and experience.<br />
Appendix II<br />
Latex allergy<br />
Latex is a natural rubber derived from the sap of a tree (Hevea brasiliensis)<br />
found in Asia which contains several water-soluble proteins, designated<br />
Hev b 1- Hev b 13. Patient contact with natural rubber latex (NRL) during<br />
anaesthesia may occur via several routes including the airway, mucous<br />
membranes, surgical wounds and parenteral injection. An anaphylactic<br />
reaction to NRL during anaesthesia may be immediate, or may be delayed<br />
for up to an hour. The clinical manifestations of NRL anaphylaxis during<br />
anaesthesia tend to be less severe than anaphylaxis due to neuromuscular<br />
blocking drugs.<br />
Classification of latex reactions<br />
1 Systemic reaction: a Type 1 hypersensitivity reaction involving<br />
specific IgE to Hev proteins, mostly to Hev b 5&6. This is the most<br />
severe but least frequent reaction and occurs in genetically predisposed<br />
individuals. The symptoms consist of itching, swelling, rhinitis,<br />
asthma and anaphylaxis. This allergy is life long. A proportion of<br />
sensitized individuals also react to certain fruits cross reacting with<br />
latex proteins.<br />
2 Contact dermatitis: a delayed Type IV hypersensitivity reaction<br />
consisting of an eczematous reaction starting 24–48 h after repeated<br />
skin or mucosal contact with additives used during rubber production.<br />
This is a T cell-mediated, non-life-threatening reaction. It may,<br />
however, predispose the individual to a more severe systemic<br />
reaction.<br />
3 Clinical non-immune-mediated reaction: irritant dermatitis resulting<br />
from a mild irritant effect of the powder in the gloves and that of<br />
disinfectants, sweating etc. This is the most frequent reaction, is limited<br />
to the contact area and is characterised by itching, irritation and blistering<br />
at the side of contact.<br />
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High risk individuals<br />
Approximately 8% of the population is sensitized to latex but only 1.4% of<br />
the population exhibits latex allergy. The following groups are at increased<br />
risk:<br />
• Patients with atopy<br />
• Children undergoing multiple surgical procedures, such as spina bifida,<br />
or children undergoing surgery at a very young age<br />
• Patients with severe dermatitis of their hands<br />
• Healthcare professionals<br />
• Patients with allergy to fruits; most frequently banana, chestnut and<br />
avocado<br />
• Industrial workers using protective gear<br />
• Occupational exposure to latex<br />
Pre-operative assessment<br />
A history of pre-operative symptoms suggestive of latex allergy is present in<br />
approximately a quarter of patients who develop intra-operative NRL<br />
anaphylaxis. A thorough history, including an occupational history, should<br />
be part of the pre-operative assessment. It is useful to ask specifically<br />
whether contact with balloons, condoms or latex gloves provokes itching,<br />
rash or angioedema.<br />
Pre-operative testing<br />
If the clinical history is positive or equivocal, the patient should be referred<br />
for testing before the surgical procedure and surgery should proceed only in<br />
an emergency. In the preoperative situation, it is particularly important to<br />
exclude IgE-mediated sensitivity. The choice of test: either a blood test for<br />
latex-specific IgE, or skin testing may depend on local availability. Current<br />
tests have a sensitivity of approximately 75–90%; skin prick testing may be<br />
more sensitive than blood tests for specific IgE. It is important that skin<br />
prick tests are performed by trained staff. It may be appropriate to proceed<br />
to challenge testing in some patients.<br />
Peri-operative precautions<br />
• If NRL allergy is diagnosed pre-operatively, avoidance is mandatory.<br />
• Care should be taken to avoid introducing additional, unrelated hazards<br />
when latex precautions are implemented in the operating theatre.<br />
• Latex allergy should be recorded in the case-notes and on the patient’s<br />
wrist bracelet.<br />
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Suspected anaphylactic reactions associated with anaesthesia<br />
.....................................................................................................................................<br />
• The surgical team and the nursing and anaesthetic support teams should<br />
be alerted.<br />
• There is no evidence that premedication with an anti-histamine or<br />
steroid is useful.<br />
• The operating theatre should be prepared the night before to avoid<br />
the release of latex particles and the patient should be scheduled first<br />
on the list. Evidence is limited regarding the need for this degree of<br />
caution in operating theatres where all latex gloves are of the nonpowdered<br />
type.<br />
• A ‘Latex allergy’ notice should be placed on the doors to the anaesthetic<br />
room and operating theatre.<br />
• Staff traffic should be limited.<br />
• Absolute use of synthetic gloves when preparing equipment and during<br />
anaesthesia, surgery and postoperative care.<br />
• Non-essential equipment should be removed from the vicinity of the<br />
patient.<br />
• The anaesthetic and surgical areas must contain only latex free products.<br />
• Only latex-free dressings and tapes should be applied.<br />
• Equipment in resuscitation boxes and trolleys must contain only latex<br />
free material.<br />
Postoperative investigation of possible latex anaphylaxis<br />
If skin testing and specific IgE testing is negative or equivocal in the<br />
presence of a suggestive history, it may be appropriate for the patient<br />
to proceed to a provocation test with the finger of a latex glove. This<br />
procedure must be performed by trained staff and resuscitation facilities<br />
must be available. Patch testing by an expert is useful in the diagnosis of<br />
delayed (Type lV) hypersensitivity to rubber.<br />
Hospital Latex-Allergy Policy<br />
It is recommended that all hospitals have a latex-allergy policy which<br />
should address the following:<br />
• A named clinical lead for latex allergy<br />
• Instructions for accessing latex-allergy testing<br />
• Latex allergy precautions in the ward and clinic settings<br />
• Latex allergy precautions in the operating theatre environment<br />
• Avoidance of latex sensitization in employees<br />
• Liaison with pharmacy and equipment-procurement departments<br />
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Further reading<br />
Demaegd J, Soetens F, Herregods L. Latex allergy: a challenge for anesthetists. Acta<br />
Anaesthesiologica Belgica 2006; 57: 127–135.<br />
Mari A, Scala E, D’Ambrosio C, Breitenerder H, Wagner S. Latex allergy with a<br />
cohort of non at risk subjects with respiratory symptoms: prevalence of latex<br />
sensitization and assessment of diagnostic tools. International Archives of Allergy and<br />
Immunology 2007; 143: 135–143.<br />
Bousquet J, Flahault A, Vandemplas O, Ameille J, et al. Natural rubber latex allergy<br />
among health care workers: a systematic review of the evidence. The Journal of<br />
Allergy and Clinical Immunology 2006; 118: 447–54.<br />
Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reactions<br />
occurring during anesthesia in France in 1999-2000. Anesthesiology 2003; 99:<br />
536–545.<br />
Suli C, Lorini M, Mistrello G, Tedeschi A. Diagnosis of latex hypersensitivity:<br />
comparison of different methods. European Annals of Allergy and Clinical<br />
Immunology 2006; 38: 24–30.<br />
Appendix III<br />
Mast cell tryptase<br />
1 Mast cells are found within many tissues including lung, intestine and<br />
skin. Tryptase is a protease enzyme which acts via widespread protease<br />
activated receptors (PARs). There are two types of tryptase; a and b,<br />
each of which has several subtypes. Mature b-tryptase is stored in<br />
granules in mast cells and is released during anaphylaxis by a calciumdependent<br />
mechanism. a-tryptase is secreted constitutively by mast cells<br />
and is the form normally found in the blood in health. a-tryptase is<br />
elevated in systemic mastocytosis. Pro-b-tryptase is also secreted<br />
constitutively by mast cells.<br />
2 The normal functions of tryptase include modulation of intracellular<br />
calcium ion and intestinal chloride ion transport in addition to<br />
mediating relaxation of smooth muscle in vascular endothelium and<br />
bronchial smooth muscle. In inflammation, tryptase stimulates the<br />
release of pro-inflammatory interleukins and stimulates further tryptase<br />
secretion by neighbouring mast cells.<br />
3 A variety of pathways may combine to produce anaphylaxis, depending<br />
on the trigger and the susceptibility of the patient. Typically anaphylaxis<br />
results from mast cell activation, and typically this will cause release of<br />
mast cell b-tryptase into the circulation.<br />
4 Anaphylaxis may be caused by basophil or complement activation, both of<br />
which are not associated with a rise in mast cell tryptase. A raised tryptase<br />
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.....................................................................................................................................<br />
concentration is therefore a marker of anaphylaxis, but anaphylaxis does<br />
not always cause a raised concentration. The greater the rise in concentration,<br />
the greater the probability this was caused by an anaphylactic<br />
reaction but a normal concentration does not disprove anaphylaxis.<br />
5 A rise in serum tryptase simply indicates mast cell degranulation and<br />
does not discriminate between allergic and non-allergic anaphylaxis. It<br />
has been stated that the rise in serum tryptase concentration may be less<br />
marked in non-allergic anaphylaxis.<br />
6 During anaphylaxis, tryptase peaks by approximately 1 h and its half-life<br />
in the circulation is about 2 h: the concentration therefore falls rapidly<br />
following an anaphylactic reaction.<br />
7 The most widely used assay for tryptase is the ImmunoCAP Ò<br />
fluorescence enzyme immunoassay (FEIA) which measures the sum<br />
of a and b-tryptase concentrations. A raised resting concentration is<br />
usually due to a-tryptase, secreted constitutively by the increased<br />
numbers of mast cells in systemic mastocytosis.<br />
8 Although the current tryptase assay has a high specificity, its sensitivity is<br />
relatively low and some cases of anaphylaxis may be missed.<br />
9 The sensitivity and specificity of the tryptase assay depends on the cutoff<br />
point that is chosen to indicate anaphylaxis. Because there is a wide<br />
variation in the base-line plasma concentration of tryptase, the change<br />
in tryptase concentration is more helpful than the absolute concentration<br />
in reaching a diagnosis.<br />
10 Intravenous fluid replacement is usually required during treatment of a<br />
reaction. This fluid will dilute the blood and causes a fall in the<br />
concentration of tryptase measured. This must be taken into account<br />
when evaluating the measured concentration.<br />
11 Following death, the circulation stops and tryptase is no longer removed<br />
from the circulation; samples taken postmortem are helpful in evaluating<br />
whether the terminal events were related to anaphylaxis. A raised<br />
tryptase concentration found at autopsy has lower predictive value than<br />
a sample taken during life. b-tryptase may be raised in trauma or<br />
myocardial infarction.<br />
Further reading<br />
Fisher MM, Baldo BA. Mast cell tryptase in anaesthetic anaphylactoid reactions.<br />
British Journal of Anaesthesia 1998; 80: 26–29.<br />
Enrique E, Garcia-Ortega P, Sotorra O, Gaig P, Richart C. Usefulness of UniCAP<br />
Tryptase fluoroimmunoassay in the diagnosis of anaphylaxis. Allergy 1999; 54:<br />
602–606.<br />
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.....................................................................................................................................<br />
Payne V, Kam PCA. Mast cell tryptase: a review of its physiology and clinical<br />
significance. Anaesthesia 2004; 59: 695–703.<br />
Brown SGA, Blackman KE, Heddle RJ. Can serum mast cell tryptase help diagnose<br />
anaphylaxis? Emergency Medicine Australasia 2004; 16: 120–124.<br />
Appendix IV<br />
Useful websites<br />
http://www.aagbi.org<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
http://www.bsaci.org<br />
The British Society for Allergy and Clinical Immunology<br />
http://www.immunology.org<br />
The British Society for Immunology<br />
http://www.resus.org.uk<br />
Resuscitation Council UK<br />
http://www.eaaci.net<br />
The European Academy of Allergology and Clinical Immunology<br />
http://www.mhra.gov.uk<br />
The Medicines and Healthcare products Regulatory Agency<br />
Supporting Information<br />
Additional Supporting information may be found in the online version of<br />
this article:<br />
Appendix S1 Anaesthetic Anaphylaxis Referral Form.<br />
Please note: Wiley-Blackwell are not responsible for the content or<br />
functionality of any Supporting materials supplied by the authors. Any<br />
queries (other than missing material) should be directed to the<br />
corresponding author for the article.<br />
Ó 2009 The Authors<br />
Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland 27
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
Storage of Drugs in<br />
Anaesthetic Rooms<br />
Guidance on best practice from<br />
the RCoA and AAGBI
Storage of Drugs in Anaesthetic<br />
Rooms<br />
1<br />
Guidance on best practice from the RCoA and AAGBI<br />
The Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) recognise<br />
that secure drug storage makes an important contribution to patient safety, and the safety of the public, but patient safety must<br />
always be the priority. The RCoA and AAGBI support a system of standard operating procedures (SOPs) that makes patient safety<br />
paramount, and recognises that even short delays in accessing drugs may result in an adverse patient outcome. All drugs and<br />
medicines § need to be stored safely. The Royal Pharmaceutical Society (RPS) recognises that there are special requirements for<br />
the storage of drugs in operating theatre departments, and recommends that there should be a system of Standard Operating<br />
Procedures (SOPs) covering each of the activities concerned with medicines use to ensure the safety and security of medicines<br />
stored and used in operating departments. 1<br />
A particular situation not mentioned in the RPS document is that anaesthetic rooms, which function as a form of ‘annexe’ to the<br />
main operating theatre, are usually a place in which drugs and fluids are stored. During the conduct of an anaesthetic and surgery<br />
the anaesthetic room may temporarily and intermittently be unoccupied when the patient is in theatre. Care Quality Commission<br />
(CQC) inspectors have in recent months identified a need for guidance as to whether the storage of drugs and fluids in unlocked<br />
cupboards in temporarily unoccupied anaesthetic rooms is acceptable.<br />
The Health and Social Care Act 2008 2 demands that patients and healthcare staff be protected ‘against the risks associated with<br />
the unsafe use and management of medicines by means of the making of appropriate arrangements for the obtaining, recording,<br />
handling, using, safe keeping, dispensing, safe administration and disposal of medicines’.<br />
There is clear guidance on the storage of Controlled Drugs such as morphine, cocaine, and fentanyl in this setting, 3 but there is<br />
currently no specific advice on best practice for the storage of non-controlled drugs and fluids in anaesthetic rooms. The Royal<br />
College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) convened a working<br />
party to address this issue. This document is the report of the working party.<br />
Guidance<br />
1 Patient safety must be the paramount consideration. Immediate access to a variety of drugs can sometimes be essential, such<br />
that even short delays in drug availability can make a difference to patient outcome.<br />
2 It is not possible to provide a definitive list of ‘emergency drugs’ that should be immediately available at all times, as these<br />
vary depending on patient condition and the surgical procedures being performed. There are few drugs commonly stored in<br />
anaesthetic room drug cupboards that will not be needed urgently on occasion.<br />
3 Local SOPs should exist for the safe storage of drugs (both controlled and non-controlled medicines) and fluids in operating<br />
theatre departments. These should be adequately risk-assessed and agreed by pharmacists, anaesthetists, nurses, operating<br />
department practitioners and ratified by the organisations medicines management committee. The Accountable Officer for<br />
medicines within the organisation should endorse these. 4<br />
4 Decisions about drug security in anaesthetic rooms must reflect a balance between patient safety, staff protection and security.<br />
We understand that this may mean that in defined circumstances, drug cupboards (excluding those containing Controlled<br />
Drugs) may remain unlocked when the anaesthetic room is temporarily unoccupied and the operating theatre is in use.<br />
5 Even if anaesthetic room drug cupboards cannot, in the interests of patient safety, be locked during surgical procedures,<br />
practices can be followed that may minimise medicines security risks, e.g. drugs and fluids prepared in advance for procedures<br />
can be kept in closed cupboards.<br />
6 An unoccupied anaesthetic room should ideally remain visible at all times to those in the operating theatre, usually through<br />
windows in the door.<br />
7 Anaesthetic room drug cupboards must be locked when the operating theatre is unoccupied.<br />
§<br />
For the purposes of this paper the terms drugs, medicines and fluids are used interchangeably.<br />
<br />
In this guidance, the term ‘drug cupboard’ includes all forms of drug and fluid storage, including refrigerators.
Storage of Drugs in Anaesthetic<br />
Rooms<br />
2<br />
Guidance on best practice from the RCoA and AAGBI<br />
8 It is common practice to prepare a selection of ‘emergency drugs’ that should be immediately available during the course of<br />
an anaesthetic. These will often accompany the patient from the anaesthetic room into the operating theatre but, if this is not<br />
possible, they should be stored in the anaesthetic room in a manner that maintains their immediate availability. They should be<br />
adequately labelled, and disposed of appropriately if not used.<br />
9 Certain rarely-used emergency drugs may be stored in a central location, serving the entire theatre suite, e.g. dantrolene and<br />
intralipid. Local SOPs should be compliant with relevant legislation and should ensure that the locations of these drugs are<br />
conspicuously signposted.<br />
10 We support the use of effective access control systems for all routes that allow entry into operating departments, limiting access<br />
to only those with legitimate reasons for access.<br />
References<br />
1 The safe and secure handling of medicines: a team approach. RPSGB, London 2005 (http://bit.ly/1R893Hc).<br />
2 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (http://bit.ly/1Zr5Lny).<br />
3 Controlled Drugs (Supervision of management and use) Regulations 2013: Information about the Regulations. DH, London 2013 (http://bit.ly/1R88CNa).<br />
4 Patient Safety Alert (NHS/PSA/D/2014/005). Stage Three: Directive: Improving medication error incident reporting and learning, 20 March 2014.<br />
MHRA and NHSE, London (http://bit.ly/1Zr6h4T).<br />
The RCoA and AAGBI would like to thank the following organisations for providing beneficial comment on this document:<br />
The Royal Pharmaceutical Society (RPS)<br />
The Association for Perioperative Practice (AfPP)<br />
The College of Operating Department Practitioners (CODP)<br />
The Association of Physicians’ Assistants (APA)<br />
The Care Quality Commission (CQC)<br />
Members of the Working Party<br />
Dr Richard Marks, Vice-President, Royal College of Anaesthetists (Chairman)<br />
Dr William Harrop-Griffiths, Council Member, Royal College of Anaesthetists<br />
Mr Mike Zeiderman, National Professional Advisor for Surgical Specialities, CQC<br />
Dr David Selwyn, Chair of Clinical Director Network<br />
Dr Kathleen Ferguson, Council Member AAGBI, Representative of SALG<br />
Ms Katharina Floss, Critical Care Pharmacist, John Radcliffe Hospital<br />
June 2016<br />
Latest review date June 2019<br />
© The Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2016<br />
Churchill House, 35 Red Lion Square, London WC1R 4SG<br />
020 7092 1500 standards@rcoa.ac.uk www.rcoa.ac.uk
Recommendations for standards of monitoring<br />
during anaesthesia and recovery 2015<br />
Published by<br />
The Association of Anaesthetists of Great Britain & Ireland<br />
December 2015
This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please use the<br />
following reference:<br />
Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring<br />
during anaesthesia and recovery 2015. Anaesthesia 2016; 71: 85-93.<br />
This guideline can be viewed online via the following URL:<br />
http://onlinelibrary.wiley.com/doi/10.1111/anae.13316/full
Anaesthesia 2015<br />
Guidelines<br />
doi:10.1111/anae.13316<br />
Recommendations for standards of monitoring during anaesthesia<br />
and recovery 2015 : Association of Anaesthetists of Great Britain<br />
and Ireland*<br />
M. R. Checketts, 1 R. Alladi, 2 K. Ferguson, 3 L. Gemmell, 4 J. M. Handy, 5 A. A. Klein, 6 N. J. Love, 7<br />
U. Misra, 8 C. Morris, 9 M. H. Nathanson, 10 G. E. Rodney, 11 R. Verma 12 and J. J. Pandit 13<br />
1 Consultant, Department of Anaesthesia, Dundee, UK, and Chair of Working Party, AAGBI<br />
2 Associate Specialist, Department of Anaesthesia, Tameside Hospital, Ashton-under-Lyne, UK and Representative,<br />
Royal College of Anaesthetists<br />
3 Consultant, Aberdeen Royal Infirmary, Aberdeen, UK<br />
4 Consultant, Department of Anaesthesia, North Wales Trust, North Wales, UK<br />
5 Consultant, Department of Anaesthesia and Intensive Care, Chelsea and Westminster Hospital, London, UK<br />
6 Consultant, Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK<br />
7 Consultant, Department of Anaesthesia and Intensive Care Medicine, North Devon District Hospital, Barnstaple,<br />
Devon, UK, and Representative, Group of Anaesthetists in Training, AAGBI<br />
8 Consultant, Department of Anaesthesia, Sunderland Royal Hospital, Sunderland, UK<br />
9 Consultant, Department of Anaesthesia and Intensive Care, Royal Derby Hospital, Derby, UK<br />
10 Consultant, Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK<br />
11 Consultant, Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee, UK<br />
12 Consultant, Department of Anaesthesia, Derby Teaching Hospitals, Derby, UK<br />
13 Consultant, Department of Anaesthesia, Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK<br />
Summary<br />
This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The<br />
aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient<br />
undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at<br />
anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during<br />
anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation<br />
and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of monitoring<br />
depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon<br />
dioxide monitoring have been updated.<br />
.................................................................................................................................................................<br />
*This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists of<br />
Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board of Directors. Date of review: 2020.<br />
Accepted: 13 October 2015<br />
This Guidelines is accompanied by an editorial by Lumb and McLure, Anaesthesia, doi:10.1111/anae.13327.<br />
.................................................................................................................................................................<br />
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs<br />
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is<br />
non-commercial and no modifications or adaptations are made.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 1
Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015<br />
Recommendations<br />
The Association of Anaesthetists of Great Britain & Ireland<br />
regards it as essential that minimum standards of<br />
monitoring are adhered to whenever a patient is anaesthetised.<br />
These minimum standards should be uniform<br />
regardless of duration, location or mode of anaesthesia.<br />
1 The anaesthetist must be present and care for the<br />
patient throughout the conduct of an anaesthetic.*<br />
2 Minimum monitoring devices (as defined in the<br />
recommendations) must be attached before induction<br />
of anaesthesia and their use continued until<br />
the patient has recovered from the effects of<br />
anaesthesia. The same standards of monitoring<br />
apply when the anaesthetist is responsible for<br />
local/regional anaesthesia or sedative techniques.**<br />
3 A summary of information provided by all monitoring<br />
devices should be recorded on the anaesthetic<br />
record. Automated electronic anaesthetic<br />
record systems that also provide a printed copy<br />
are recommended.<br />
4 The anaesthetist must ensure that all anaesthetic<br />
equipment, including relevant monitoring equipment,<br />
has been checked before use. Alarm limits<br />
for all equipment must be set appropriately before<br />
use. The appropriate audible alarms should be<br />
enabled during anaesthesia.<br />
5 These recommendations state the monitoring<br />
devices that are essential (‘minimum’ monitoring)<br />
and those that must be immediately available during<br />
anaesthesia. If it is absolutely necessary to continue<br />
anaesthesia without an essential monitor, the<br />
anaesthetist should note the reasons in the anaesthetic<br />
record.<br />
6 Additional monitoring may be necessary as judged<br />
appropriate by the anaesthetist.<br />
7 Minimum monitoring should be used during the<br />
transfer of anaesthetised patients.<br />
8 Provision, maintenance, calibration and renewal of<br />
equipment are the responsibilities of the institution<br />
in which anaesthesia is delivered. The institution<br />
should have processes for taking advice from<br />
departments of anaesthesia in matters of equipment<br />
procurement and maintenance.<br />
9 All patient monitoring equipment should be<br />
checked before use in accordance with the AAGBI<br />
guideline Checking Anaesthetic Equipment 2012 [1].<br />
*In hospitals employing Physician Assistants (Anaesthesia)<br />
[PA(A)s], this responsibility may be delegated<br />
to a PA(A), supervised by a consultant anaesthetist in<br />
accordance with guidelines published by the Royal<br />
College of Anaesthetists [2].<br />
**In certain specific well defined circumstances, intraoperative<br />
patient monitoring can be delegated to a<br />
suitably trained non-physician health care worker during<br />
certain procedures performed under regional or<br />
local anaesthesia.<br />
• What other guideline statements are available on<br />
this topic?<br />
The European Board of Anaesthesiology (2012),<br />
the American Society of Anesthesiologists (2011)<br />
and the Australian and New Zealand College of<br />
Anaesthetists (2013) have published guidelines on<br />
standards of clinical monitoring. Lessons learned<br />
from the 2014 joint Association of Anaesthetists of<br />
Great Britain and Ireland’s and Royal College of<br />
Anaesthetists’ 5 th National Anaesthetic Project on<br />
accidental awareness during general anaesthesia<br />
were considered by the working party when updating<br />
this guideline.<br />
• Why were these guidelines developed?<br />
It was necessary to update the 2007 4 th edition of<br />
the guideline to include new guidance on monitoring<br />
neuromuscular blockade, depth of anaesthesia<br />
and cardiac output.<br />
• How and why does this statement differ from existing<br />
guidelines?<br />
Capnography monitoring is essential at all times in<br />
patients with endotracheal tubes, supraglottic airway<br />
devices and those who are deeply sedated. A<br />
peripheral nerve stimulator must be used whenever<br />
neuromuscular blocking drugs are given. A quantitative<br />
peripheral nerve stimulator is recommended.<br />
Depth of anaesthesia monitoring is recommended<br />
when using total intravenous anaesthesia with neuromuscular<br />
blockade.<br />
2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015<br />
Introduction<br />
The presence of an appropriately trained and experienced<br />
anaesthetist is the main determinant of patient<br />
safety during anaesthesia. However, human error is<br />
inevitable, and many studies have shown that adverse<br />
incidents and accidents are frequently attributable, at<br />
least in part, to error by anaesthetists [3, 4].<br />
Monitoring will not prevent all adverse incidents<br />
or accidents in the peri-operative period. However,<br />
there is substantial evidence that it reduces the risks of<br />
incidents and accidents both by detecting the consequences<br />
of errors, and by giving early warning that the<br />
condition of a patient is deteriorating [5–11].<br />
It is appropriate that the AAGBI should define the<br />
standards of monitoring for use by anaesthetists in the<br />
United Kingdom and Ireland. Newer monitoring<br />
modalities such as derived electroencephalogram<br />
(EEG) depth of anaesthesia and cardiac output monitors<br />
are not established as routine and the Working<br />
Party considered their place in contemporary anaesthesia<br />
practice in Appendices 1 and 2.<br />
The anaesthetist’s presence during<br />
anaesthesia<br />
An anaesthetist of appropriate experience, or fully<br />
trained Physician Assistant (Anaesthesia) PA (A) under<br />
the supervision of a consultant anaesthetist, must be<br />
present throughout general anaesthesia, including any<br />
period of cardiopulmonary bypass. Using both clinical<br />
skills and monitoring equipment, the anaesthetist must<br />
care for the patient continuously. The same standards<br />
must apply when an anaesthetist is responsible for a<br />
local/regional anaesthetic or sedative technique for an<br />
operative procedure. In certain well-defined circumstances<br />
[12], intra-operative patient monitoring can be<br />
delegated to a suitably trained non-physician health<br />
care worker during certain procedures performed under<br />
regional or local anaesthesia. When there is a known<br />
potential hazard to the anaesthetist, for example during<br />
x-ray imaging, facilities for remotely observing and<br />
monitoring the patient must be available.<br />
Accurate records of the values determined by<br />
monitors must be kept. Minimum monitoring data<br />
(heart rate, blood pressure, peripheral oxygen saturation,<br />
end-tidal carbon dioxide and anaesthetic vapour<br />
concentration, if volatile anaesthetic agents or nitrous<br />
oxide are used) must be recorded at least every five<br />
minutes, and more frequently if the patient is clinically<br />
unstable. It is recognised that contemporaneous<br />
records may be difficult to keep in emergency circumstances,<br />
but modern patient monitoring devices allow<br />
accurate records to be completed or downloaded later<br />
from stored data. Automated electronic anaesthetic<br />
record systems that can also make hard copies for the<br />
medical notes are recommended.<br />
Local circumstances may dictate that handing over<br />
of responsibility for patient care under anaesthesia to<br />
another anaesthetist may be necessary. If so, a detailed<br />
handover must be delivered to the incoming anaesthetist<br />
and this should be recorded in the anaesthetic<br />
record. A handover checklist is useful, and one example<br />
of this is the ‘ABCDE’ aide memoir suggested in<br />
the NAP5 report [13–15]. When taking over care of a<br />
patient (including when returning after relief for a<br />
break), the incoming anaesthetist should conduct a<br />
check to ensure that all appropriate monitoring is in<br />
place with suitable alarm limits (see below).<br />
Very occasionally, an anaesthetist working singlehandedly<br />
may be called on briefly to assist with or<br />
perform a life-saving procedure nearby. Leaving an<br />
anaesthetised patient in these circumstances is a matter<br />
for individual judgement, but another anaesthetist or<br />
trained PA(A) should be sought to continue close<br />
observation of the patient. If this is not possible in an<br />
emergency situation, a trained anaesthetic assistant<br />
must continue observation of the patient and monitoring<br />
devices. Any problems should be reported to other<br />
available medical staff in the area. Anaesthesia departments<br />
should therefore work towards having an additional<br />
experienced anaesthetist available (e.g. a ‘Duty<br />
Consultant’ or ‘floating registrar’ of appropriate seniority)<br />
to provide cover in such situations.<br />
Anaesthesia departments should make arrangements<br />
to allow anaesthetists working solo during long<br />
surgical procedures to be relieved by a colleague or PA<br />
(A) for meal and comfort breaks [16]. The 1998 European<br />
Working Time Regulation Legislation states that<br />
an individual should have an uninterrupted break of<br />
not less than 20 minutes if the working day exceeds<br />
six hours [17]. To meet this requirement, the presence<br />
of an additional experienced anaesthetist in the theatre<br />
suite, as described above is desirable.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 3
Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015<br />
Anaesthetic equipment<br />
It is the responsibility of the anaesthetist to check all<br />
equipment before use, as recommended in the AAGBI<br />
guideline Checking Anaesthetic Equipment 2012 [1].<br />
Anaesthetists must ensure that they are familiar with<br />
all the equipment they intend to use and that they<br />
have followed any specific checking procedures recommended<br />
by individual manufacturers.<br />
Oxygen supply<br />
The use of an oxygen analyser with an audible alarm<br />
is essential during anaesthesia. The anaesthetist should<br />
check and set appropriate oxygen concentration alarm<br />
limits. The analyser must be placed in such a position<br />
that the composition of the gas mixture delivered to<br />
the patient is monitored continuously. Most modern<br />
anaesthetic machines have built-in oxygen analysers<br />
that monitor both inspired and expired oxygen concentrations.<br />
Breathing systems<br />
During spontaneous ventilation, observation of the<br />
reservoir bag may reveal a leak, disconnection, high<br />
pressure or abnormalities of ventilation. Continuous<br />
waveform carbon dioxide concentration monitoring<br />
will detect most of these problems, so this is an essential<br />
part of routine monitoring during anaesthesia. The<br />
2011 AAGBI position statement on capnography outside<br />
the operating theatre recommended that it should<br />
be used for all unconscious anaesthetised patients<br />
regardless of the airway device used or the location of<br />
the patient [18]. There are certain circumstances in<br />
which capnography monitoring is not feasible, for<br />
example during high frequency jet ventilation.<br />
Vapour analyser<br />
The use of a vapour analyser is essential during anaesthesia<br />
whenever a volatile anaesthetic agent or nitrous<br />
oxide is in use. The end-tidal concentration should be<br />
documented on the anaesthetic record.<br />
Infusion devices<br />
When any component of anaesthesia (hypnotic, analgesic,<br />
neuromuscular blockade) is administered by<br />
infusion, the infusion device must be checked before<br />
use. Alarm settings (including infusion pressure alarm<br />
levels) and infusion limits must be verified and set to<br />
appropriate levels before commencing anaesthesia. It is<br />
recommended that the intravenous cannula should be<br />
visible throughout the procedure, when this is practical.<br />
When not practical, increased vigilance is required<br />
and correct functioning of the cannula should be regularly<br />
confirmed. It is recommended that infusion<br />
devices are connected to mains power whenever possible.<br />
When using a total intravenous anaesthesia technique<br />
(TIVA) with neuromuscular blockade, a depth<br />
of anaesthesia monitor is recommended (see below).<br />
Alarms<br />
Anaesthetists must ensure that all alarms are set to<br />
appropriate values. The default alarm settings incorporated<br />
by the manufacturer are often inappropriate.<br />
During the checking procedure, the anaesthetist must<br />
review and reset the upper and lower limits as necessary.<br />
It is recommended that anaesthetic departments<br />
agree consensus-based alarm limits for their monitors<br />
and ask their medical physics technicians to set these<br />
up. Audible alarms must be enabled before anaesthesia<br />
commences.<br />
When intermittent positive pressure ventilation is<br />
used during anaesthesia, airway pressure alarms must<br />
also be used to detect high pressure within the airway<br />
and to give warning of disconnection or leaks.<br />
Provision, maintenance, calibration and renewal of<br />
equipment are the responsibilities of the institution in<br />
which anaesthesia is delivered. Institutions should take<br />
into account (e.g., through suitably constituted equipment<br />
committees) the views of the anaesthetic department<br />
on matters relating to acquisition and<br />
maintenance of equipment.<br />
Monitor displays<br />
Care should be taken to configure the display setup,<br />
with attention to both the size and arrangement of onscreen<br />
data with regular updating of displayed values.<br />
An appropriate automatic non-invasive blood pressure<br />
(NIBP) recording interval should be set; NIBP monitors<br />
should not continue to display readings for longer<br />
than 5 minutes to reduce the risk of an older reading<br />
being mistaken for a recent one.<br />
4 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015<br />
Monitoring the devices<br />
Many devices used in anaesthetic practice need their<br />
own checks and monitoring. This includes monitoring<br />
the cuff pressure of tracheal tubes and cuffed supraglottic<br />
airway devices. Cuff pressure manometers<br />
should be used to avoid exceeding manufacturers’ recommended<br />
intracuff pressures which can be associated<br />
with increased patient morbidity. When using devices<br />
where manufacturers do not specify or recommended<br />
a maximum cuff pressure, there may still be benefit in<br />
avoiding high pressure inflation, as this is associated<br />
with reduced morbidity and improved device performance<br />
[19].<br />
Monitoring the patient<br />
During anaesthesia, the patient’s physiological state<br />
and adequacy of anaesthesia need continual assessment.<br />
Monitoring devices supplement clinical observation<br />
in order to achieve this. Appropriate clinical<br />
observations may include mucosal colour, pupil size,<br />
response to surgical stimuli and movements of the<br />
chest wall and/or the reservoir bag. The anaesthetist<br />
may undertake palpation of the pulse, auscultation of<br />
breath sounds and, where appropriate, measurement of<br />
urine output and blood loss. A stethoscope must<br />
always be available.<br />
Monitoring devices<br />
The monitoring devices described above are essential<br />
to the safe conduct of anaesthesia. If it is necessary to<br />
continue anaesthesia without a particular device, the<br />
anaesthetist must record the reasons for this in the<br />
anaesthetic record and only proceed where the benefits<br />
or clinical urgency outweigh the risks. The following<br />
are considered minimum monitoring for anaesthesia:<br />
• Pulse oximeter<br />
• NIBP<br />
• ECG<br />
•<br />
Inspired and expired oxygen, carbon dioxide,<br />
nitrous oxide and volatile anaesthetic agent if used<br />
(see below)<br />
• Airway pressure<br />
•<br />
Peripheral nerve stimulator if neuromuscular blocking<br />
drugs used (see Appendix 3)<br />
• Temperature for any procedure > 30 min duration<br />
[20].<br />
Monitoring must continue until the patient has<br />
recovered from anaesthesia. Anaesthesia departments<br />
must work towards providing capnography monitoring<br />
throughout the whole period of anaesthesia from<br />
induction to full recovery of consciousness as recommended<br />
by the AAGBI guideline Immediate Postanaesthesia<br />
Recovery 2013 [21].<br />
During induction of anaesthesia in children and in<br />
uncooperative adults, it may not be feasible to attach<br />
all monitoring before induction. In these circumstances,<br />
monitoring must be attached as soon as possible<br />
and the reasons for delay recorded.<br />
Recovery from anaesthesia<br />
Minimum monitoring should be maintained until the<br />
patient has recovered fully from anaesthesia. In this<br />
context, ‘recovered fully’ means that the patient no<br />
longer needs any form of airway support, is breathing<br />
spontaneously, alert, responding to commands and<br />
speaking. Until this point, monitoring must be maintained<br />
to enable rapid detection of airway, ventilatory<br />
and cardiovascular disturbance. The period of transfer<br />
from theatre to recovery can be a time of increased<br />
risk depending on the local geography of the theatre<br />
complex and the status of the patient. Departments<br />
should work towards providing full monitoring,<br />
including capnography, in patients with a tracheal tube<br />
or supraglottic airway in situ, for these transfers and<br />
in the recovery area. Supplemental oxygen should routinely<br />
be given to patients during transfer to the recovery<br />
room and in the recovery room until at least after<br />
full recovery.<br />
In summary, the minimum monitoring for recovery<br />
from anaesthesia [21] includes:<br />
• Pulse oximeter<br />
• NIBP<br />
• ECG<br />
•<br />
Capnography if the patient has a tracheal tube,<br />
supraglottic airway device in situ or is deeply<br />
sedated [17]<br />
• Temperature<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 5
Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015<br />
Additional monitoring<br />
Some patients will require additional monitoring, for<br />
example intravascular pressures, cardiac output<br />
(Appendix 1), or biochemical or haematological variables<br />
depending on patient and surgical factors. The<br />
use of additional monitoring is at the discretion of the<br />
anaesthetist.<br />
Use of depth of anaesthesia monitors, for example<br />
processed EEG monitoring, is recommended when<br />
patients are anaesthetised with total intravenous techniques<br />
and neuromuscular blocking drugs, to reduce<br />
the risk of accidental awareness during general anaesthesia<br />
(see Appendix 2). However, there is no compelling<br />
evidence that routine use of depth of<br />
anaesthesia monitoring for volatile agent-based general<br />
anaesthetics reduces the incidence of accidental awareness<br />
when end-tidal agent monitoring is vigilantly<br />
monitored and appropriate low agent alarms are set<br />
[13, 22].<br />
Regional techniques and sedation for operative<br />
procedures<br />
Patients must have appropriate monitoring, including<br />
[23]: pulse oximeter, NIBP, ECG and end-tidal carbon<br />
dioxide monitor if the patient is sedated.<br />
Monitoring during transfer within the<br />
hospital<br />
It is essential that the standard of care and monitoring<br />
during transfer of patients who are anaesthetised or<br />
sedated is equivalent to that applied in the operating<br />
theatre, and that personnel with adequate knowledge<br />
and experience accompany the patient [24].<br />
The patient should be physiologically as stable as<br />
possible for transfer. Before transfer, appropriate monitoring<br />
must be commenced. Use of a pre-transfer<br />
checklist is recommended [13]. Oxygen saturation,<br />
ECG and NIBP should be monitored in all patients.<br />
Intravascular or other monitoring may be necessary in<br />
special cases. An oxygen supply sufficient to last the<br />
duration of the transfer is essential for all patients. If<br />
the patient has a tracheal tube or supraglottic airway<br />
in situ, end-tidal carbon dioxide should be monitored<br />
continuously. Airway pressure, tidal volume and respiratory<br />
rate must also be monitored when the lungs are<br />
mechanically ventilated.<br />
Monitoring depth of anaesthesia is desirable when<br />
transferring anaesthetised patients who have received<br />
neuromuscular blocking drugs (TIVA is invariably<br />
used in these circumstances), but will remain difficult<br />
to provide until portable, battery-powered depth of<br />
anaesthesia monitors become widely available.<br />
Anaesthesia in locations outside the<br />
operating suite<br />
The standards of monitoring used during general and<br />
regional anaesthesia or sedation administered by an<br />
anaesthetist should be the same in all locations.<br />
When anaesthetists are called to administer general<br />
or regional anaesthesia and/or sedation in locations<br />
outwith the operating theatre (for example<br />
emergency department, cardiac catheter lab, radiology,<br />
department electroconvulsive therapy suite, endoscopy,<br />
pain clinic, community dental clinic critical care, delivery<br />
suite), the same minimum essential standards of<br />
monitoring already outlined in this document should<br />
apply:<br />
• Pulse oximeter<br />
• NIBP<br />
• ECG<br />
• Inspired and expired oxygen, carbon dioxide,<br />
nitrous oxide and volatile anaesthetic agent if used<br />
• Airway pressure<br />
•<br />
Peripheral nerve stimulator when neuromuscular<br />
blocking drugs used (see Appendix 3)<br />
• Temperature in procedures > 30 min duration.<br />
Competing interests<br />
No external funding and no competing interests<br />
declared.<br />
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© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 7
Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015<br />
Appendix 1: Cardiac output monitors<br />
There are a range of cardiac output monitors available<br />
– such as those estimating cardiac output from pulse<br />
pressure, carbon dioxide rebreathing, lithium dilution<br />
or oesophageal Doppler measurements – however,<br />
their routine use is uncommon. Although the literature<br />
base is large, there is little evidence that one type of<br />
monitor is consistently superior to another. Training<br />
in the use of the technique adopted is essential. Invasive<br />
methods, such as those requiring a pulmonary<br />
artery catheter, are more accurate but, because of the<br />
small risk of serious complications associated with the<br />
use of the pulmonary artery catheter, their routine use<br />
outside of cardiac surgical centres cannot be recommended.<br />
There are concerns about accuracy and reliability<br />
with many cardiac output monitors. The percentage<br />
error of pulse contour analysis, oesophageal Doppler,<br />
partial carbon dioxide rebreathing, and transthoracic<br />
bio-impedance has been shown to be greater than<br />
30%, a widely accepted cut-off [25]. The use of cardiac<br />
output monitoring for assessment of fluid responsiveness<br />
has been shown to be more accurate, but interpatient<br />
variability and dynamic changes in stroke volume<br />
may be significant [26].<br />
The cardiac output monitors currently available all<br />
have advantages and disadvantages associated with<br />
their use, and the AAGBI Working Party cannot recommend<br />
one type over another.<br />
In summary:<br />
• the pulmonary artery catheter is the most accurate,<br />
but less invasive monitoring has superseded its routine<br />
use outside of cardiac surgery [27];<br />
• there is conflicting evidence about whether the use<br />
of cardiac output monitoring improves patient outcomes,<br />
and this is an area of ongoing research;<br />
• echocardiography can be used to estimate cardiac<br />
output and allows cardiac function and filling status<br />
to be directly observed - however, training and<br />
experience in its use is required [28, 29];<br />
• there remains doubt about the accuracy of all cardiac<br />
output monitoring devices currently available,<br />
and data are mostly confined to patients whose<br />
lungs are mechanically ventilated;<br />
• the use of cardiac output monitors to assess fluid<br />
responsiveness has some evidence base.<br />
Appendix 2: Depth of anaesthesia<br />
monitors<br />
EEG-based depth of anaesthesia monitors have been<br />
variously recommended as an option in patients at<br />
greater risk of awareness or those likely to suffer the<br />
adverse effects of excessively deep anaesthesia, and also<br />
in patients receiving TIVA [30]. Data on the efficacy<br />
of these devices in correctly predicting accidental<br />
awareness during general anaesthesia (AAGA) or correctly<br />
predicting an adequate level of anaesthesia,<br />
remains inconsistent and debated [31]. However, data<br />
from these monitors may provide an additional source<br />
of information on the patient’s condition.<br />
The NAP5 project published in 2014 made a number<br />
of recommendations on risk factors for AAGA and<br />
the place of depth of anaesthesia monitoring [13],<br />
which can be summarised as:<br />
• the incidence of reports of AAGA was 1 in 8000<br />
when neuromuscular blocking drugs were used (as<br />
high as 1:670 in caesarean section) and 1 in<br />
136 000 when they were not (i.e., implying a focus<br />
should specifically be on paralysed patients);<br />
•<br />
about half of the reports of AAGA occurred<br />
around the time of induction of anaesthesia and<br />
transfer from anaesthetic room to the operating<br />
theatre.<br />
•<br />
almost 20% of AAGA reports occurred at the time<br />
of emergence from general anaesthesia and were<br />
commonly if not universally related to inadequate<br />
reversal of neuromuscular blockade<br />
Building on these recommendations, the AAGBI<br />
Working Party makes the following recommendations:<br />
• Depth of anaesthesia monitoring is recommended<br />
when neuromuscular blockade is used in combination<br />
with TIVA;<br />
• Depth of anaesthesia monitoring should logically<br />
commence from induction of anaesthesia and be<br />
continued at least until the completion of surgical<br />
and anaesthetic interventions (i.e., up to the point<br />
where it is intended to awaken the patient);<br />
8 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015<br />
• Depth of anaesthesia monitoring is recommended<br />
during transfer of patients receiving TIVA and<br />
neuromuscular blockade, but presents difficulties,<br />
because portable battery powered depth of anaesthesia<br />
monitors are not widely available. Such<br />
devices may come to the market in the future and<br />
their efficacy will need to be separately evaluated;<br />
• during inhalational anaesthesia, end-tidal anaesthetic<br />
vapour monitoring with preset low agent<br />
alarms appears a suitable and effective means of<br />
estimating depth of anaesthesia;<br />
• The isolated forearm technique is another technique<br />
to monitor depth of anaesthesia [32]. If used<br />
as a ‘depth of anaesthesia monitor’, care should be<br />
taken to ensure its safe conduct, especially in relation<br />
to avoiding excessive, prolonged cuff inflation.<br />
The interpretation of a positive movement to command<br />
with isolated forearm technique needs careful<br />
interpretation, as does the subsequent management<br />
of a patient who has moved in response to spoken<br />
command [33].<br />
Appendix 3: Monitoring of<br />
neuromuscular blockade during<br />
induction, maintenance and<br />
termination of anaesthesia<br />
A measure of neuromuscular blockade, using a peripheral<br />
nerve stimulator, is essential for all stages of<br />
anaesthesia when neuromuscular blockade drugs are<br />
administered. This is best monitored using an objective,<br />
quantitative peripheral nerve stimulator. Ideally<br />
the adductor pollicis muscle response to ulnar nerve<br />
stimulation at the wrist should be monitored. Where<br />
this is not possible, the facial or posterior tibial nerves<br />
may be monitored [34].<br />
There is variability in the duration of action of<br />
non-depolarising neuromuscular blocking agents.<br />
Residual neuromuscular blockade can be detected in up<br />
to 40% patients for up to two hours after their administration<br />
[35, 36]. Patient harm may result from postoperative<br />
hypoxaemia in the post anaesthesia care unit<br />
[37, 38] and a risk of AAGA at extubation [13].<br />
The NAP5 project on AAGA reported on the role<br />
of neuromuscular blockade in contributing to AAGA,<br />
and how patients interpret unintended paralysis in<br />
extremely distressing ways.<br />
Recommendations:<br />
• a peripheral nerve stimulator is mandatory for all<br />
patients receiving neuromuscular blockade drugs<br />
•<br />
peripheral nerve stimulator monitors should be<br />
applied and used from induction (to confirm adequate<br />
muscle relaxation before endotracheal intubation)<br />
until recovery from blockade and return of<br />
consciousness;<br />
• while a ‘simple’ peripheral nerve stimulator allows<br />
a qualitative assessment of the degree of neuromuscular<br />
blockade; a more reliable guarantee of return<br />
of safe motor function is evidence of a train-of-four<br />
ratio > 0.9.<br />
• a quantitative peripheral nerve stimulator is<br />
required to accurately assess the train of four ratio<br />
[34], but other stimulation modalities (e.g. double<br />
burst or post tetanic count) can also be used for<br />
assessment. Anaesthetic departments are encouraged<br />
to replace existing qualitative nerve stimulators<br />
with quantitative devices.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 9
Anaesthesia 2016, 71, 1503<br />
Correction<br />
doi:10.1111/anae.13691<br />
Following an item of correspondence, the authors of the guidelines [1] agree that the evidence for pH being an<br />
important determinant for suitability for peripheral intravenous administration of fluids is equivocal and limited.<br />
Therefore, the authors would like to correct the following advice given in the section on peripheral cannulation:<br />
Peripheral insertion is inappropriate for infusion of fluid with high osmolality (> 500 mOsm.l<br />
high pH (> 9) or intravenous access for more than 2 weeks.<br />
1 ) or low (< 5) or<br />
This should read:<br />
Peripheral insertion is inappropriate for some fluids and drugs e.g. high osmolality > 500 mOsm.l<br />
vasopressors or intravenous access for more than 2 weeks. Check local or national guidance.<br />
1 , potent<br />
Reference<br />
1. Bodenham A, Babu S, Bennett J, et al. Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016. Anaesthesia<br />
2016; 71: 573–85.<br />
© 2016 The Association of Anaesthetists of Great Britain and Ireland 1503
AAGBI SAFETY GUIDELINE<br />
Safe Management of<br />
Anaesthetic Related Equipment<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
21 Portland Place, London, W1B 1PY<br />
Telephone 020 7631 1650 Fax 020 7631 4352<br />
info@aagbi.org<br />
www.aagbi.org September 2009
Membership of the working party<br />
Dr J A Carter<br />
Dr L W Gemmell<br />
Prof M Y K Wee<br />
Dr C Meadows<br />
Dr T Clutton-Brock<br />
Dr C Waldmann<br />
Dr D Scott<br />
Dr P Bickford-Smith<br />
Dr A Wilkes<br />
Mr C Bray<br />
Mr D McIvor<br />
Mr H Cooke<br />
Ex Officio<br />
Dr R J S Birks<br />
Dr D K Whitaker<br />
Dr A W Harrop-Griffiths<br />
Dr I H Wilson<br />
Dr I G Johnston<br />
Dr E P O’Sullivan<br />
Dr D G Bogod<br />
Chair<br />
AAGBI Honorary Secretary<br />
AAGBI Council Member<br />
Immediate Past GAT Chair<br />
Royal College of Anaesthetists<br />
Intensive Care Society<br />
AAGBI Standards Committee<br />
AAGBI Standards Committee<br />
Medical Device Evaluation Centre<br />
Medicines and Heathcare products<br />
Regulatory Agency<br />
Medicines and Heathcare products<br />
Regulatory Agency<br />
Barema, Trade Association for<br />
Anaesthetic & Respiratory Equipment<br />
President<br />
Immediate Past President<br />
Immediate Past Honorary Secretary<br />
Honorary Treasurer<br />
Honorary Treasurer Elect<br />
Honorary Membership Secretary<br />
Editor-in-Chief, Anaesthesia
Contents<br />
1. Summary 2<br />
2. Introduction 3<br />
3. Responsibility of anaesthetists and Trust or other<br />
healthcare providing organisation 4<br />
4. Standards 8<br />
5. Responsibility of manufacturers and suppliers 10<br />
6. Choosing and trialling equipment 12<br />
7. Public sector procurement regulations and directives<br />
and the process of purchasing 15<br />
8. Commissioning new equipment 19<br />
9. Shared equipment 20<br />
10. Maintenance 21<br />
11. Replacement 24<br />
12. Disposal 25<br />
13. User training 27<br />
14. Incident reporting and investigation 30<br />
15. Audit 33<br />
Glossary of acronyms 33<br />
References 35<br />
Useful numbers and websites 37<br />
To be reviewed by 2015<br />
© Copyright of the Association of Anaesthetists of Great Britain & Ireland. No<br />
part of this book may be reproduced without the written permission of the<br />
AAGBI<br />
1
1. Summary<br />
1.1 Safety, quality and performance considerations must be<br />
included in all equipment acquisition decisions.<br />
1.2 Each directorate should nominate one consultant with<br />
responsibility for equipment management. This Nominated<br />
Consultant should be a member of a Medical Devices<br />
Management Group, which reports directly to the Trust<br />
Board, and he or she should liaise closely with the<br />
Technical Servicing Manager.<br />
1.3 An inventory of all equipment, including donated<br />
equipment, must be held by the technical department for<br />
maintenance and replacement purposes.<br />
1.4 A planned preventative maintenance programme must be<br />
in place.<br />
1.5 There should be a policy to cope with equipment<br />
breakdown.<br />
1.6 A replacement programme which defines equipment life<br />
and correct disposal procedures should be in place.<br />
1.7 Purchase of new equipment should include wide<br />
consultation (especially involving users), and technical<br />
advice to ensure practicality, cost effectiveness and<br />
suitability for purpose.<br />
1.8 There must be a commissioning or acceptance procedure<br />
before any new equipment is put into use.<br />
1.9 All users must be trained in the use of all equipment that<br />
they may use.<br />
1.10 All adverse incidents arising from the use of equipment<br />
must be reported.<br />
2
2. Introduction<br />
The Association of Anaesthetists of Great Britain and Ireland has<br />
long been committed to improving patient safety. The majority<br />
of critical incidents in anaesthesia arise from human error and,<br />
although about 20% of incidents are due to equipment failure,<br />
many incidents that are initially thought to be equipment failure<br />
turn out to be user error or inappropriate use, both of which<br />
indicate a lack of training in the correct use of equipment.<br />
The Association has produced a number of guidelines with<br />
the intention of improving patient safety by reducing human<br />
error and detecting potential equipment failure. These include<br />
Checking Anaesthetic Equipment 3 (2004) and Standards of<br />
Monitoring during Anaesthesia and Recovery Edition 4 (2007)<br />
[1,2]. The Department of Health, through the MHRA, regularly<br />
produces Medical Device Alerts concerning problems with<br />
equipment, and it is essential that all anaesthetists are aware of<br />
relevant publications.<br />
This document gives guidance on choosing, purchasing,<br />
maintaining, replacing and disposing of equipment. It also<br />
emphasises the need to ensure that anaesthetists are trained in<br />
the use of their equipment and that technicians are trained to<br />
maintain the equipment. The MHRA publications, Managing<br />
Medical Devices DB 2006(05) and Devices in Practice – a guide<br />
for health and social care professionals (2008), are written from<br />
a technical point of view and should be used as an adjunct to<br />
the information in this booklet [3,4].<br />
In addition, the MHRA, or their local or national counterpart,<br />
is usually willing and able to give detailed advice on the safe<br />
management of equipment, and their contact details are given<br />
in the appendix.<br />
Throughout this document, the term ‘Trust’ refers to NHS Trusts,<br />
Health Boards, and any other hospital where anaesthetics are<br />
given.<br />
3
3. Responsibility of anaesthetists<br />
and Trust or other healthcare<br />
providing organisation<br />
3.1 The individual anaesthetist<br />
All anaesthetists must be adequately trained in the use of, and<br />
familiar with, all equipment which they use routinely. This<br />
training should be recorded, and individual anaesthetists should<br />
keep their own record of training for appraisal purposes. They<br />
should also be aware of Medical Device Alerts relevant to such<br />
equipment. They should all participate in selection of new<br />
equipment, training in the use of equipment, and reporting<br />
equipment associated incidents.<br />
3.2 The directorate – the nominated consultant or<br />
equipment officer/controller<br />
Anaesthetic directorates should nominate one consultant with<br />
responsibility for equipment (the ‘equipment officer’). The<br />
equipment officer will develop specific expertise with respect to<br />
equipment and be responsible for a co-ordinated approach to its<br />
management (including maintenance and training), replacement<br />
and purchase. He or she may wish to enlist the support of other<br />
colleagues or suitable operating department personnel to assist<br />
with the duties as well as consulting regularly with all members<br />
of the anaesthetic directorate. Identification of the departmental<br />
equipment officer is the responsibility of the clinical director<br />
who should ensure that the individual is identified to the various<br />
heads of the technical department.<br />
Large Trusts will need more than one consultant to fulfil this<br />
role, and an ‘equipment or technical team’, answerable to the<br />
Directorate Management Team, may be required.<br />
4
3.3 Duties of the equipment officer<br />
The equipment officer will represent the directorate on the<br />
Medical Devices Management Group and liaise closely with the<br />
head of the technical department. Their responsibilities include:<br />
• Co-ordinating user input into the choice and procurement<br />
of equipment and ensuring its suitability for the purposes<br />
intended.<br />
• Ensuring that training is available for staff in the use and<br />
care of the equipment and ensuring that appropriate training<br />
records are maintained.<br />
• Acceptance of equipment into service.<br />
• Ensuring that procedures for the use of equipment are<br />
followed.<br />
• Verification of service arrangements and effectiveness.<br />
• Supervision of user servicing tasks.<br />
• Ensuring there are documented contingency arrangements<br />
for patient care in the event of equipment failure.<br />
• Maintaining appropriate records.<br />
• Ensuring that the Trust’s policy applies to all equipment<br />
brought into the Trust irrespective of the source of funding,<br />
e.g. university purchased equipment, loaned and donated<br />
equipment.<br />
• Ensuring that all adverse incidents involving medical<br />
devices are reported in accordance with the instructions<br />
contained in the first Medical Device Alert of each year<br />
(titled ‘All Medical Devices’) issued by the MHRA<br />
and that all MHRA and NPSA safety guidance is distributed<br />
appropriately.<br />
Adequate sessional time to fulfil these duties should be made<br />
available by the Trust.<br />
5
3.4 The Trust - Medical Devices Management Group and<br />
Manager of Technical Servicing<br />
Trusts should establish a Medical Devices Management Group<br />
to develop and implement policies across their organisations.<br />
This group should report directly to the Trust Board, where a<br />
named director should have overall responsibility for medical<br />
equipment.<br />
The responsibility for the technical management of each item of<br />
equipment must be assigned to one department (the ‘technical<br />
department’). Most hospitals have a Manager of Technical<br />
Servicing in post although their title and the department to<br />
which they belong may vary, e.g. department of electronic<br />
and biomedical engineering, department of medical physics or<br />
estates department.<br />
3.5 Inventory of equipment<br />
Technical departments must maintain an ‘inventory of<br />
equipment’ which should include the following information:<br />
• Unique identifier of equipment – item labelled where<br />
possible (if not possible, e.g. endoscope, serial number<br />
recorded).<br />
• Date of purchase and when it was put into service.<br />
• Any specific legal requirements needed and whether they<br />
have been complied with.<br />
• Where it is located, and record of satisfactory<br />
commissioning/installation.<br />
• Recommended service schedule documentation.<br />
• Service arrangements – in-house, supplier, or external<br />
contractor details and service level agreement.<br />
• Service reports.<br />
• Records of incident investigations and product complaints.<br />
• Manual or ‘Instructions For Use’ (IFU) readily available, and<br />
record of where kept.<br />
• End-of-life date.<br />
6
In addition to items for which the technical department has<br />
continuing responsibility, the inventory should also include<br />
items such as laryngoscopes and non-clinical items such as<br />
computers and printers. Although these may not need regular<br />
maintenance they should be included in the replacement<br />
programme.<br />
Every item of equipment, including consumables, must be<br />
identified by a unique number or batch number, and its location<br />
must be recorded. This is particularly important in the case<br />
of equipment recall due to a subsequent fault. All equipment<br />
records should be held on one central record keeping system<br />
where possible, e.g. software database managed by medical<br />
engineering department. If this is not possible, adequate cross<br />
referencing between record systems must be in place. This<br />
is particularly important where equipment may be moved<br />
between sites.<br />
7
4. Standards<br />
4.1 Medical Devices Directive and CE marking<br />
The Medical Devices Directive of the European Union prohibits<br />
the sale of medical devices within the EU that are not CE<br />
(Conformité Européene) marked. A CE mark indicates that<br />
devices meet all essential requirements of the Medical Devices<br />
Directive and are safe and fit for their intended purpose.<br />
However, the CE mark does not indicate clinical efficacy in<br />
all circumstances, therefore user assessment is vital for any<br />
purchase.<br />
4.2 Standards<br />
To ensure suitability for a given task, most devices are<br />
manufactured to one or more verified standards. Standards are<br />
produced by CEN, the Comité Européen de Normalisation,<br />
or European Committee for Standardization, for mechanical<br />
devices, and CENELEC for electrical devices. Many devices<br />
used by anaesthetists use electricity to get mechanical results,<br />
and have to meet standards of both organisations. ISO, the<br />
International Organization for Standardization, and IEC the<br />
International Electrotechnical Commission, produce standards<br />
for the international market. The British Standards Institution<br />
is a national member of the European Organization, and its<br />
standards have gradually been integrated with their European<br />
equivalents.<br />
4.3 CE marking and non-medical equipment<br />
CE marks for medical devices are awarded in four categories<br />
of differing stringency. However, devices intended for nonmedical<br />
use may also bear a CE mark that is indistinguishable<br />
from those on medical devices, but they may not be suitable for<br />
use as medical devices. An example is computer equipment,<br />
including display units and recording devices, which may have<br />
electrical leakage currents which far exceed the safe levels<br />
for use near patients with external pacemakers or central lines<br />
8
that can conduct electricity directly to the heart. A formal risk<br />
assessment by an appropriate expert should be performed,<br />
followed by suitable modification, before such equipment is<br />
used close to patients.<br />
4.4 Non-EU equipment<br />
Equipment purchased outside the European Union may not<br />
carry CE marks. For advice concerning such equipment, see<br />
Medical Devices Regulations 2002 [5]. Use of non-CE marked<br />
medical devices may leave the clinician, and their employer,<br />
open to liability that would otherwise be assumed by the<br />
manufacturer.<br />
4.5 Permissible devices supplied without CE marking<br />
There are three exceptions permissible for a device to be<br />
supplied without a CE mark:<br />
• Custom Made – this is a single device designed and<br />
manufactured specifically for a specific patient as prescribed<br />
by a healthcare professional.<br />
• Device undergoing clinical investigations – the device must<br />
be labelled as such and have the necessary approval<br />
(see CA. ISO 14155).<br />
• Exceptional use on humane grounds.<br />
For both Custom Made and Clinical Trial devices the manufacturer<br />
must adhere to all other requirements for compliance.<br />
9
5. Responsibility of manufacturers<br />
and suppliers<br />
5.1 The Consumer Protection Act, Liability for Defective<br />
Products Act, and the Medical Devices Regulations<br />
The Consumer Protection Act 1988 (CPA) in Britain, the Liability<br />
for Defective Products Act 1991 (LDPA) in Ireland, and the<br />
Medical Devices Regulations in Great Britain and Ireland which<br />
implement the EC Medical Devices Directives into law, embody<br />
the current legislation which describes the manufacturer’s<br />
responsibility with regard to equipment.<br />
5.2 General responsibilities<br />
The CPA, LDPA and Medical Devices Regulations place<br />
absolute responsibility for the safety of products on the manufacturer.<br />
In the event of a defect causing injury, the manufacturer<br />
can be sued by any injured party, i.e. the patient or the<br />
purchaser. This is provided that the device has been used for its<br />
intended purpose, and in accordance with the manufacturer’s<br />
instructions. Negligence need not be proved and it is not<br />
possible for the seller to escape liability by exclusion clauses<br />
in the contract of sale. The manufacturer’s responsibility, as<br />
described in the CPA and LDPA, ends ten years after delivery of<br />
the equipment.<br />
After ten years, the purchaser, but not the patient, could still sue<br />
the manufacturer under the Sale of Goods Act in Britain or the<br />
Sale of Goods and Supply of Services Act in Ireland but it would<br />
probably be difficult to convince the court that the equipment<br />
was still ‘as supplied’.<br />
5.3 Compliance with the regulations and the competent<br />
authority<br />
To place a device on the market a medical device manufacturer<br />
must be in compliance with the applicable European<br />
10
Regulations, including those transposed in each of the member<br />
states, e.g. language requirements. With full compliance a<br />
manufacturer is then able, where applicable, to affix a CE mark<br />
demonstrating compliance with the essential requirements of the<br />
Directive. The Medical Devices Directive and the application of<br />
the CE mark was a legal requirement for all manufacturers with<br />
effect from 14th June 1998, following a 5-year transition period.<br />
Within the United Kingdom and Northern Ireland responsibility<br />
for the enactment and compliance with the Medical Devices<br />
Directives has been assigned to the Medicines and Healthcare<br />
products Regulatory Agency {(MHRA) (Competent Authority<br />
– CA)}, working in conjunction with the respective devolved<br />
administrations of Northern Ireland, Scotland and Wales. The<br />
CA for Ireland is the Irish Medicines Board, Medical Devices<br />
Department.<br />
11
6. Choosing and trialling equipment<br />
6.1 General principles<br />
Choosing anaesthetic equipment should address the<br />
requirements of safety, quality, performance and affordability<br />
(value for money). The selection process should take into<br />
account local and national acquisition policies. The choice of<br />
equipment should incorporate plans for standardisation and<br />
rationalisation to meet existing and future needs. The Medical<br />
Devices Management Group should ensure that acquisition<br />
requirement takes into account the needs and preferences of<br />
all interested parties including the user, the commissioning,<br />
decontamination, maintenance and de-commissioning parties.<br />
6.2 Criteria for choosing<br />
There are many different categories of equipment used in<br />
anaesthesia, ranging from low cost items purchased in large<br />
volumes to high cost items purchased in small numbers.<br />
Purchasers are encouraged to establish a list of available<br />
manufacturers and suppliers. The choice can then be made on<br />
evidence supplied on the following criteria:<br />
• Fitness for intended purpose/application, including ease of<br />
use.<br />
• Safety, quality and performance information from the<br />
manufacturer.<br />
• Rationalising the range of models versus diversity.<br />
• Requirement and availability of training and support<br />
services.<br />
• Single use where appropriate.<br />
• Maintenance, repair support services and availability of<br />
technical support.<br />
• Decontamination and disposal procedures, including<br />
recycling, compatible with local processes.<br />
• Previous performance, reliability and warranty details.<br />
• Lifetime costs.<br />
12
6.3 Assessing equipment and the final choice<br />
Equipment under consideration can be assessed by various<br />
means. A literature review can be carried out to provide the<br />
best evidence. Organisations such as the Centre for Evidencebased<br />
Purchasing (CEP, which was part of the NHS Purchasing<br />
and Supply Agency) and Emergency Care Research Institute (a<br />
US-based organisation) publish reports on various categories<br />
of equipment. For up-to-date information, purchasers should<br />
contact and visit other users, trade exhibitors and sometimes<br />
factories. In particular, previous performance by the<br />
manufacturer in terms of delivery, stock held, training provided<br />
and response to problems are rarely published, but details could<br />
be obtained from users in other Trusts.<br />
The Medical Devices Management Group, including the<br />
anaesthetic equipment officer, should then carefully consider<br />
the options from the information available. Once a choice is<br />
made, a trial should be carried out on the selected equipment<br />
by users. As many users as possible should be encouraged<br />
to participate and to feedback to the equipment officer on an<br />
agreed form. Such forms are often a compulsory part of the<br />
purchasing procedure.<br />
The outcomes from trials of some equipment can be assessed<br />
against the known outcomes from ‘gold standard’ equipment,<br />
for example first time insertion success of laryngeal mask<br />
airways. The manufacturer will usually provide a free loan<br />
of equipment or samples if the products are disposable. It is<br />
important to remember that NHS contract terms impose full<br />
responsibility on the suppliers for equipment on loan. All staff<br />
using loan equipment must be trained by the supplier or an<br />
authorised agent. It is the Trust’s responsibility to ensure that<br />
loan equipment is decontaminated before return to prevent<br />
cross-infection.<br />
To avoid unnecessary duplication of trials, the anaesthetic<br />
13
equipment officer is encouraged to collect all feedback from<br />
the trial and publish the outcome in an appropriate format, for<br />
example at a local or national meeting. The equipment officer<br />
will then recommend the choice of equipment to purchase.<br />
An editorial in Anaesthesia in June 2008 recommended<br />
establishing a Device Evaluation Centre with a panel of experts<br />
to critically appraise available evidence and publish the results<br />
on a website [6]. Individual groups of anaesthetists would be<br />
encouraged to undertake studies with support from the Device<br />
Evaluation Centre in terms of pro formas for ethical approval<br />
and protocols, and statistical help and advice. This would avoid<br />
duplication of trials by individual Trusts and researchers, and<br />
enable rapid removal of inferior products.<br />
6.4 ‘One size suits all’<br />
Having a variety of models for the same purpose can<br />
increase the risk of operator confusion, leading to misuse and<br />
complicating training requirements. In particular, having both<br />
single-use and re-usable equipment intended for the same<br />
purpose could result in re-usable equipment being discarded<br />
and vice versa, resulting in increased costs or potential harm to<br />
the patient and exposing the Trust to risk. Restricting purchase<br />
and stockholding to one type of device reduces these risks and<br />
may reduce maintenance costs. On the other hand, restriction<br />
to one product will increase vulnerability to product faults,<br />
and remove a degree of clinical freedom from individual<br />
practitioners.<br />
6.5 Leasing or purchasing<br />
Consideration should be given whether equipment should be<br />
purchased outright, leased or rented. For example, it may be<br />
more cost effective to rent an expensive item for occasional use<br />
when required.<br />
14
7. Public sector procurement<br />
regulations and directives and the<br />
process of purchasing<br />
7.1 Standing orders and standing financial instructions<br />
(SFIs)<br />
The process of procurement of goods and services in the NHS<br />
is governed by SFIs. There is a financial value for an order or<br />
contract above which a competitive process should be used;<br />
often this is in the region of £15,000 to £30,000.<br />
7.2 Procurement directives<br />
All public sector procurement is subject to the principles of the<br />
Treaty of Rome (transparency and fairness) and the significant<br />
majority (including all medical equipment) is also subject to<br />
the EU Procurement Directives. The Directives were updated<br />
in 2006 to account for the use of eEnablement technologies<br />
in public sector procurement and enable greater flexibility for<br />
complex procurements.<br />
The relevant Directive for medical equipment is the<br />
Procurement Directive 2004/18/EC, 31 March 2004 for Public<br />
Contracts for which the UK Regulation that enforces the<br />
Directive is Public Contracts Regulations SI 2006 No 5 [7,8].<br />
7.3 EU procurement thresholds<br />
The EU Procurement Directives apply to all orders and contracts<br />
for any given organisation (or groups of organisations when<br />
collaborative procurement is undertaken). Splitting lots to avoid<br />
the thresholds contravenes the Directives. A notice of intent<br />
(indicative notice) of known future expenditure should be<br />
placed.<br />
15
EU procurement thresholds<br />
Thresholds applicable from 1 January 2008 are given<br />
below. Thresholds are net of VAT. Public contracts<br />
regulations 2006 - from 1 January 2008<br />
Other public<br />
sector<br />
contracting<br />
authorities<br />
Indicative<br />
notices<br />
SUPPLIES SERVICES WORKS<br />
£139,893<br />
(€206,000)<br />
£509,317<br />
(€750,000)<br />
£139,893<br />
(€206,000)<br />
£509,317<br />
(€750,000)<br />
£3,497,313<br />
(€5,150,000)<br />
£3,497,313<br />
(€5,150,000)<br />
(NB. The Euro values are the reference quantities. The<br />
conversion rate to pounds was based on a exchange rate of 0.68<br />
which may vary).<br />
7.4 Process of purchasing<br />
Most Trusts will use the following process for the purchase<br />
of medical equipment unless it is part of a more complex<br />
procurement. The basic steps involved in this process are:<br />
• Indicative notice (if relevant)<br />
• Advert in the Official Journal of the European Union (OJEU)<br />
• Suppliers express an interest<br />
• Suppliers provide prequalification information (should be<br />
via the NHS supplier information database, SID)<br />
• Short listing and suppliers notified<br />
• Issue of tender<br />
• Presentations by suppliers, visits to suppliers<br />
• Return of completed tender by suppliers<br />
• Evaluation of tenders<br />
• Award notified<br />
• Standstill period (see 7.6)<br />
• Award of contract<br />
16
More guidance on the application can be found on the Office of<br />
Government Commerce and NHS PaSA websites [9,10].<br />
7.5 Purchasing and Supply Agency (PaSA) and ‘Buying<br />
Solutions’<br />
By 2010 the function of PaSA will be taken over by ‘Buying<br />
Solutions’ – the national procurement partner for UK public<br />
services. It is planned that a series of regional support units,<br />
owned by the NHS, will provide a single point of contact for<br />
suppliers in each region.<br />
7.6 Mandatory standstill period<br />
The 2006 UK Regulations also brought into force a<br />
mandatory 10-day standstill period between the notification<br />
of award decision and the date of contract conclusion for all<br />
procurements that are subject to the full scope of the EU public<br />
procurement directives. This is not part of the EU Directives but<br />
follows the Alcatel court case [11].<br />
7.7 Pre-purchase questionnaires<br />
Medical equipment will often be subject to the completion<br />
of a pre-purchase questionnaire (PPQ) by the supplier for the<br />
Trust’s EBME Department. The PPQ is usually completed by the<br />
supplier before or with the order.<br />
7.8 Funding<br />
Major items of equipment (e.g. workstations, monitors) are<br />
funded by the Trust Capital Equipment Committee or similar.<br />
Consumables and items below a threshold figure (usually about<br />
£5000) come out of the directorate or theatre budget.<br />
There should be a planned process of replacement for major<br />
equipment, such as anaesthetic workstations and monitors, so<br />
that each year a proportion of these are replaced in order to<br />
spread the cost. It should be presumed that such equipment<br />
will last about eight years, and the whole life cost taken into<br />
consideration.<br />
17
When negotiating a purchasing agreement for major equipment,<br />
a training package should be included and consideration given<br />
to awarding a servicing agreement. It is often advantageous<br />
to bundle extras into the initial deal rather than pay for<br />
expensive software upgrades at a later date. It is advisable to<br />
compare the complete purchasing agreement from more than<br />
one manufacturer, and in return for notifying the intention to<br />
purchase future equipment from the same company it may<br />
be possible to fix the price for a few years (plus inflation).<br />
This allows the company to plan ahead and the hospital to<br />
standardise equipment.<br />
Advances in technology inevitably give rise to new equipment,<br />
and justification of need through a business case may have to<br />
be submitted to the Trust for approval. In some cases additional<br />
funding has been made available from central sources for<br />
‘essential’ new equipment, such as NICE funding for ultrasound<br />
guided CVC placement. Charitable sources of funding also exist,<br />
e.g. League of Friends, but such organisations prefer not to fund<br />
items which should be bought by the Trust. A personal approach<br />
to such organisations with details of how patient care will be<br />
enhanced is recommended.<br />
18
8. Commissioning new equipment<br />
The MHRA Device Bulletin ‘DB2006(05) Managing Medical<br />
Devices. Guidance for healthcare and social services<br />
organisations’ gives comprehensive advice on commissioning<br />
new equipment [3]. Key major points are summarised below:<br />
• It is important that deliveries of new equipment are<br />
recorded, and go to the right place.<br />
• New anaesthetic equipment, which may not all come at the<br />
same time, has to be unpacked, assembled, recorded on<br />
an inventory, have identifying labels attached, and safety<br />
checks performed. Medical engineering departments will<br />
usually perform these tasks, although sometimes it is the<br />
responsibility of the manufacturer or supplier.<br />
• It should also be noted that Portable Appliance Testing<br />
(PAT) applies to all equipment used in hospitals including,<br />
for example, the coffee machine in the anaesthetic dept.<br />
• Co-ordination between several departments may be<br />
necessary, especially if permanent installation work or<br />
additional services are required.<br />
• Before equipment is used for the first time, full functional<br />
checks must be performed, and staff trained in its use.<br />
• If the equipment uses specialised consumable items,<br />
arrangements to purchase them should be set up well before<br />
the initial stock runs out.<br />
• Loan equipment has to go through a similar process, and<br />
should be subject to a written agreement defining responsibilities<br />
and liabilities.<br />
19
9. Shared equipment<br />
Many types of equipment used by anaesthetists are also used<br />
by other specialties in a variety of locations throughout a<br />
hospital or unit. There are many safety, efficiency and cost<br />
advantages in standardisation. In terms of the patient journey,<br />
for example from admission through accident and emergency,<br />
to radiology, operating theatre, intensive care unit and ward,<br />
the process is considerably simpler and safer if the devices the<br />
patient is attached to all use the same connections to monitoring<br />
devices and infusion systems. It aids staff training and mobility if<br />
similar devices are in use in most areas of a hospital, important<br />
examples being defibrillators and infusion pumps. This may<br />
be facilitated if the equipment officer and the Medical Devices<br />
Management Group liaise closely with the departments using<br />
similar equipment, e.g. intensive care, accident and emergency,<br />
radiology, cardiology and respiratory medicine.<br />
Although departments may wish to compile their own inventory<br />
of equipment for which they have managerial and financial<br />
responsibility, it is a requirement that a database of all such<br />
equipment is maintained by the technical department.<br />
Areas of uncertainty over ownership of equipment should<br />
be clarified. Examples include infusion pumps, patient<br />
controlled analgesia equipment, and blood warmers. It may<br />
be appropriate for some high value items to be shared, and for<br />
commonly used equipment like infusion pumps to be located in<br />
a central store.<br />
The financial implications of asset sharing should be clarified.<br />
Each directorate may have to contribute to the costs of<br />
depreciation, servicing, maintenance and replacement.<br />
Responsibilities for organising and monitoring servicing and<br />
maintenance schedules and for planning replacement must be<br />
defined.<br />
20
10. Maintenance<br />
10.1 Planned preventative maintenance programme<br />
Anaesthetic equipment which is not serviced regularly is liable<br />
to break down with potentially life-threatening consequences.<br />
A planned preventative maintenance programme is essential.<br />
A maintenance log for each device must be kept, linked to the<br />
technical department inventory. A record of all breakdowns<br />
should also be kept. Regular review of each class of item<br />
should reveal the incidence of breakdowns, which could<br />
indicate the need for modification of equipment, frequency<br />
of maintenance or its urgent replacement, or even a need for<br />
further user training.<br />
10.2 Choice of provider<br />
All suppliers must support their equipment, and this includes<br />
maintenance. At the time of purchase, the ‘life time’ cost should<br />
be determined, including the frequency and cost of regular<br />
servicing proposed by the supplier. It is recommended that the<br />
cost of maintenance contracts should be inclusive of emergency<br />
call outs and travel time for engineers, as well as fixed interval<br />
servicing and parts. Cheaper alternatives usually exclude<br />
the cost of emergency call outs and travel time and may be<br />
appropriate for hospitals with sufficient back-up equipment.<br />
Trusts may prefer ‘in-house’ maintenance, as this could have<br />
logistic and cost advantages. The support to be provided by<br />
manufacturers must be defined when equipment is purchased<br />
and should include the provision of service manuals, on-going<br />
technical training and spare parts. If upgrading or modification<br />
of equipment is required at a later date, there are likely to be<br />
additional costs even if the work is to be done in-house. An<br />
annual maintenance budget of at least 10% of the equipment’s<br />
purchase cost is necessary.<br />
Software upgrades must only be undertaken by the supplier.<br />
21
Third party servicing is another option which may be of<br />
particular value for the maintenance of equipment which<br />
requires specialist knowledge and testing, e.g. vaporisers.<br />
Care should be taken to make sure only original equipment<br />
manufacturers (OEM) spare parts are used.<br />
Whichever of these options are chosen, it is essential that they<br />
are fully integrated into the planned maintenance programme.<br />
10.3 Equipment breakdown<br />
The equipment officer should ensure that a complete set of<br />
back-up equipment is available. If it is not, removal of faulty<br />
equipment from service may result in the cancellation of<br />
operating lists with consequent distress to patients and possible<br />
implications for the fulfilment of contracts. The equipment<br />
officer should agree a departmental policy covering the unusual<br />
event that two identical items break down at the same time,<br />
and should support colleagues who invoke this policy. The<br />
policy should be written so that the patient’s best interests are<br />
protected whatever the prevailing circumstances.<br />
In the interests of patient safety, it is essential for all theatres to<br />
keep available manual resuscitation equipment for emergency<br />
use (see Checking Anaesthetic Equipment 3, 2004) [1]. All<br />
theatre staff should be trained in the procedures to be followed<br />
for instances of equipment failure.<br />
10.4 Training in maintenance<br />
Suppliers and their agents are externally audited in all their<br />
procedures, and these include the provision of maintenance.<br />
These standards for quality management systems aid effective<br />
control through the definition and documentation of activities,<br />
the keeping of records to prove that these activities are being<br />
effectively executed and the audit of records by both internal<br />
and external personnel.<br />
22
For ‘in-house’ departments, quality manuals which document<br />
operating policies and procedures need to be verified. These<br />
will cover not only existing activities such as purchasing, repair<br />
and pre-planned maintenance but also other activities such as<br />
document control, corrective action and quality records.<br />
If ‘in-house’ maintenance is chosen, enough time and money<br />
must be allocated for training of technicians to a level<br />
equivalent to that of the supplier so that they are able to provide<br />
a high-quality, safe service. Regular on-going training provided<br />
by the supplier should be the norm.<br />
10.5 Spares<br />
Suppliers have a responsibility to provide spares for seven years<br />
after delivery of the last example of a particular model.<br />
The responsibility for obsolete devices more than seven years<br />
old is that of the Trust, and the need for insurance should be<br />
assessed and acted upon.<br />
10.6 Modifications<br />
If a modification is undertaken on a CE marked device, other<br />
than by the manufacturer, then responsibility for the safety and<br />
liability for the modification changes to the organisation that<br />
has completed the modification. One particular example is if a<br />
device labelled as single-use is reprocessed for further use.<br />
23
11. Replacement<br />
11.1 Planned equipment replacement programme<br />
Equipment must be condemned and replaced before it becomes<br />
unreliable and endangers the patient, and it is recommended a<br />
planned equipment replacement programme, which is phased<br />
over a number of years, is prepared and continuously updated.<br />
This should be planned in conjunction with Trust management<br />
and the finance department. The choice of new equipment<br />
can then be made after appropriate trials, and should take into<br />
account department needs, such as plans for standardisation<br />
and rationalisation (see section 6).<br />
11.2 Timing of equipment replacement<br />
Nationally recognised guidelines on the timing of equipment<br />
replacement do not exist. Therefore it is recommended that<br />
equipment be replaced when it has reached the end of an<br />
agreed time-period, and in consultation with finance officers.<br />
This time period will depend on the type of equipment that<br />
needs replacing.<br />
Replacement of electronic equipment should be considered at<br />
five years and mechanical equipment at eight years. Financial<br />
forecasting should take into account the agreed equipment life<br />
cycle and budgets should be adjusted accordingly to ensure<br />
replacement funding is available, thus avoiding delays and<br />
potential associated patient risks. When delays are inevitable,<br />
clinicians should seek, in writing, an ‘extension of use’ beyond<br />
the agreed time-periods with the relevant medical and financial<br />
officers.<br />
In the past, many items of anaesthetic equipment were<br />
mechanical. Today, most devices contain a high electronic<br />
content, including software. This is placing an increasing burden<br />
on equipment replacement budgets, owing to the increased<br />
pace of obsolescence of electronic equipment.<br />
24
12. Disposal<br />
12.1 General<br />
Unreliable, damaged or worn out equipment should be<br />
removed from service and destroyed. Obsolete but functional<br />
equipment has potential resale value but carries with it liabilities<br />
under the CPA and LDPA. There are companies who can<br />
manage such transactions. The DoH has issued guidelines on<br />
the resale of medical equipment in MHRA DB2006(05) [3].<br />
Alternatively, equipment can be donated to a charity. The donor<br />
has a moral responsibility to ensure that the recipients are given<br />
all relevant information about the equipment.<br />
Full service history, usage, fault log, replacement parts and<br />
decontamination status should be available when equipment is<br />
offered for sale or donation.<br />
Disposed equipment must be removed from the capital asset<br />
register.<br />
12.2 European WEEE Directive<br />
The European WEEE Directive enforces the recovery and<br />
recycling of certain types of electrical and electronic equipment<br />
(EEE) when it is disposed of. The Directive places a requirement<br />
on producers and/or final users to recover and recycle the<br />
equipment in line with specific rules. Producers of electrical and<br />
electronic items are required to register with the Environment<br />
Agency, through organisations referred to as ‘compliance<br />
schemes’, and are required to provide information relating to<br />
material content and recycling [12].<br />
12.3 Re-use of equipment<br />
Equipment that may be used on more than one patient should<br />
be decontaminated or sterilised according to manufacturer’s<br />
instructions and the AAGBI guidelines (see Infection Control<br />
in Anaesthesia 2, 2008) [13]. Some equipment has a limited<br />
25
number of re-uses (e.g. re-usable LMAs) and a record card or<br />
similar device must be used to maintain an accurate record of<br />
the number of re-uses. Any equipment bearing the mark of a<br />
figure 2 with a line crossed through it is for single use only and<br />
must not be re-used.<br />
26
13. User training<br />
13.1 General<br />
Anaesthetists must be trained in the use of all the equipment<br />
that they may use. Training requirements clearly vary widely<br />
between different devices, some requiring little or no additional<br />
training apart from common sense, others being unusable<br />
without complex and specific training. There is little or no<br />
national framework for the standardisation of training in use of<br />
devices in anaesthesia or indeed in any other clinical field, with<br />
the result that currently it is the responsibility of the individual<br />
clinician to ensure that he or she has received the appropriate<br />
training and that it is kept up-to-date. A record of training<br />
received by department members should be kept, and it should<br />
form part of the annual appraisal process.<br />
In more than half of the adverse incidents reported to the<br />
Medicines and Healthcare products Regulatory Agency (MHRA)<br />
there is no readily identifiable equipment fault. Although often<br />
difficult to define precisely, it seems more than reasonable<br />
to assume that many of these have resulted from user related<br />
issues. In some cases it is clear that the user has been the sole<br />
cause of the adverse incident which would not have occurred if<br />
the device had been correctly used.<br />
13.2 Manufacturers’ obligations<br />
Manufacturers of medical devices have a legal obligation to<br />
supply Instructions For Use (IFU) which cover not only how<br />
to use the device but also a description of the intended use of<br />
the device. Using the device outside of the IFU removes much<br />
of the manufacturer’s responsibility and transfers it to the user.<br />
Manufacturers should be encouraged to produce IFUs which<br />
are easy to read and understand; there may be a significant<br />
advantage in producing a summary of the important points or<br />
key instructions. Where practical, these should be available on<br />
the equipment, or held in close proximity.<br />
27
Where new equipment is purchased the amount of training<br />
offered and taken up is very variable. For example, with<br />
complex devices, such as the new generation of anaesthetic<br />
machine workstations, it is usual for manufacturers to supply a<br />
significant amount of user training.<br />
13.3 CCT and CPD<br />
Training in anaesthesia, as described in the CCT documents<br />
published by the Royal College of Anaesthetists, includes<br />
numerous references to anaesthetic related equipment, and both<br />
Primary and Final FRCA examinations cover the basic principles<br />
and more advanced use of a range of medical devices.<br />
Information about new devices and updates on existing ones is<br />
frequently included in Continuing Professional Development<br />
(CPD) programmes, and clinicians should use this as a way of<br />
keeping up-to-date.<br />
13.4 E-learning, simulation and revalidation<br />
E-learning material is now becoming available, in particular<br />
(from the MHRA) on the general principles in using medical<br />
devices safely, e.g. electrosurgery and the anaesthetic machine.<br />
These programmes underline the importance of maintaining<br />
a good understanding of the basic principles behind device<br />
function. For complex devices such as anaesthesia workstations<br />
complementary device-specific educational material is required.<br />
To maintain the necessary independence of bodies with national<br />
regulatory roles means that this type of material will, most<br />
probably, be developed by partnerships between manufacturers,<br />
the Association of Anaesthetists and the Royal College of<br />
Anaesthetists.<br />
There is a coexistent need to develop effective training in the<br />
use of equipment in unanticipated and emergency situations,<br />
particularly in the recognition and management of equipment<br />
failure. These situations fortunately occur infrequently, and<br />
28
anaesthetic simulators already play an important role in<br />
appropriate training.<br />
Users of complex equipment outside of the healthcare setting<br />
(for example in the aviation industry) are subject to much more<br />
clearly defined appropriate training in safety. All responsible<br />
clinicians will use the opportunities provided by CPD to keep<br />
their equipment based skills up-to-date but there are concerns<br />
that the less motivated can still function on a daily basis without<br />
adequate checks on acquisition or retention of skills.<br />
Revalidation of all clinical staff will help to ensure that all<br />
practitioners have up-to-date equipment based skills and have<br />
received appropriate training. Effective training material, with<br />
meaningful assessments, need to be developed. Such material is<br />
already available in some clinical disciplines through e-learning.<br />
29
14. Incident reporting and<br />
investigation<br />
As a profession which emphasises life-long learning, we must<br />
promote an open culture in which all staff will discuss and<br />
report incidents where errors or service failures have occurred.<br />
This encourages the profession to learn from mistakes and<br />
identify any continuing risks.<br />
Each NHS Trust should have risk management systems in place<br />
involving the reporting, analysis, control and prevention of<br />
incidents [14]. It is the responsibility of each anaesthetist to be<br />
aware of the incident reporting procedures of their organisation.<br />
This procedure may include risk managers, medical device<br />
liaison officers and anaesthetic equipment officers.<br />
In addition to the Trust’s local incident reporting system, there<br />
are several organisations, listed below, that may need to be<br />
made aware of adverse incidents associated with anaesthesia.<br />
14.1 Medicines and Healthcare products Regulatory<br />
Agency (MHRA)<br />
The MHRA investigate reports of adverse incidents involving<br />
medical devices or their instructions for use that have led to,<br />
or could lead to, death, life-threatening illness or injury. The<br />
manufacturers of medical devices must report such incidents to<br />
the Competent Authority (the Vigilance System) and investigate<br />
them as part of their post market surveillance responsibilities,<br />
as required by the MDD. Therefore, manufacturers must be<br />
informed of such incidents. However, medical devices (with<br />
any packaging and labelling) which have been involved in an<br />
incident have also to be kept and isolated until MHRA has been<br />
given the opportunity to carry out an investigation.<br />
Where the MHRA investigation concludes there are safety<br />
30
implications for patients or users the Agency will issue a<br />
Medical Device Alert (MDA). MHRA also publish Device<br />
Bulletins and One-Liners to give safety information and<br />
guidance on general safety issues.<br />
There are separate user reporting systems for medical device<br />
incidents which occur within the devolved administrations of<br />
Northern Ireland, Scotland and Wales (see useful numbers and<br />
websites section on page 37).<br />
14.2 National Patient Safety Agency (NPSA)<br />
The NPSA has implemented an anonymised National Reporting<br />
and Learning System across England and Wales. This system<br />
allows reporting of all failures, mistakes, errors and near misses,<br />
with the aim of ensuring that lessons are both learned and<br />
shared throughout the health service. They undertake various<br />
safety initiatives, publish updates on the reports received, and<br />
provide guidance in the form of bulletins and newsletters. The<br />
anonymous reporting allowed under the NPSA system prevents<br />
a full investigation, therefore the NPSA actively encourages<br />
reporting of all medical device incidents directly to the MHRA.<br />
There is an NPSA initiative underway with the Royal College of<br />
Anaesthetists and the AAGBI to institute a specific anaesthetic<br />
reporting system.<br />
14.3 Health and Safety Executive<br />
Incidents involving work-related deaths, major injuries or<br />
injuries resulting in over three days off work, work-related<br />
diseases, and dangerous occurrences (near-miss accidents)<br />
whether involving medical devices or not, should also<br />
be reported under the Reporting of Injuries, Diseases and<br />
Dangerous Occurrences Regulations 1995 (RIDDOR ‘95) to<br />
the relevant enforcing authority for the premises at which the<br />
incident occurred. For healthcare premises, this will usually be<br />
the local office of the Health and Safety Executive (HSE) but<br />
for some it may be the local authority. Further information is<br />
31
available from www.hse.gov.uk<br />
14.4 DoH Estates and Facilities<br />
Incidents involving non-medical equipment, including<br />
engineering plant, parts of the fabric of the building and gas<br />
pipelines should be reported to the Head of Engineering at the<br />
DoH Estates and Facilities in the Department of Health. Further<br />
information is available from www.nhsestates.gov.uk<br />
14.5 Police<br />
The police will investigate where there is the suspicion of<br />
criminal activity, such as malicious tampering with medical<br />
equipment. There is a concordat between the police, HSE and<br />
DoH for the investigation of such incidents; therefore should<br />
the police decide no further action is required the investigation<br />
will pass to the HSE and DoH. Due to the rare and unusual<br />
nature of these investigations there are no established national<br />
guidelines; however advice should be available from your<br />
hospital’s legal department, medical defence organisations,<br />
MHRA and the Association of Anaesthetists.<br />
14.6 Dissemination of safety information to users<br />
Safety information from the MHRA and NPSA is distributed via<br />
the DoH Central Alerting System (CAS) [15]. All internal and<br />
external communications concerning equipment and patient<br />
safety must be cascaded to all the users of equipment through<br />
Trust communication channels.<br />
14.7 Manufacturers<br />
The manufacturer has a legal obligation under the provision<br />
of the European MDD to monitor performance of their devices<br />
in a post production phase, i.e. after placed into clinical<br />
use. Typically this is achieved by a proactive post market<br />
surveillance programme, of which incident reporting may be a<br />
part.<br />
32
15. Audit<br />
15.1 Internal<br />
This is part of the Trust’s clinical governance arrangements and<br />
should consist of regular/annual review of policies and systems<br />
for managing medical equipment.<br />
Healthcare professionals must ensure their own training and<br />
skills remain up-to-date, and this should form part of the annual<br />
staff appraisal.<br />
15.2 External<br />
The Care Quality Commission undertakes audits and inspections<br />
of healthcare organisations regularly to ensure that the MHRA<br />
guidance on safe use of medical devices has been followed.<br />
Strategic Health Authorities audit the performance of Trusts,<br />
including performance against deadlines for action required by<br />
the issue of DoH Safety Alert Broadcast System notices.<br />
Glossary of acronyms<br />
BSI<br />
British Standards Institution<br />
CA<br />
Competent Authority (e.g. in the UK, the MHRA)<br />
CCT Certificate of Completion of Training<br />
CE<br />
Conformité Européene<br />
CEN Comité Européen de Normalisation (For<br />
Mechanical Devices)<br />
CENELEC Comité Européen de Normalisation (For<br />
Electrical Devices)<br />
CEP Centre for Evidence-based Purchasing (part of<br />
PaSA)<br />
CPA Consumer Protection Act 1988<br />
CPD Continuing Professional Development<br />
CVC Central Venous Catheter<br />
33
DB<br />
DoH<br />
EBME<br />
EC<br />
EU<br />
FRCA<br />
HN<br />
HSE<br />
IEC<br />
IFU<br />
ISO<br />
LDPA<br />
LMA<br />
MDA<br />
MDD<br />
MHRA<br />
NICE<br />
OEM<br />
OJEU<br />
PaSA<br />
PAT<br />
PPQ<br />
RIDDOR<br />
SFI<br />
SID<br />
WEEE<br />
Device Bulletin<br />
Department of Health<br />
ElectroBioMedicalEngineering (Hospital<br />
Equipment Technicians)<br />
European Community<br />
European Union<br />
Fellowship of the Royal College of Anaesthetists<br />
Hazard Notice<br />
Health and Safety Executive<br />
International Electrotechnical Commission<br />
Instructions For Use<br />
International Organization for Standardization<br />
Liability for Defective Products Act<br />
Laryngeal Mask Airway<br />
Medical Device Alert<br />
Medical Device Directive<br />
Medicines and Healthcare products Regulatory<br />
Agency<br />
National Institute for Health and Clinical<br />
Excellence<br />
Original Equipment Manufacturer<br />
Official Journal of the European Union<br />
(NHS) Purchasing and Supply Agency<br />
Portable Appliance Testing<br />
Pre-Purchasing Questionnaire<br />
Reporting of Injuries, Diseases and Dangerous<br />
Occurrences Regulations 1995<br />
Standing Orders and Standing Financial<br />
Instructions<br />
Suppliers Information Database<br />
Waste Electrical and Electronic Equipment<br />
34
References<br />
1. Association of Anaesthetists of Great Britain & Ireland.<br />
Checking Anaesthetic Equipment 3, 2004. http://www.<br />
aagbi.org/publications/guidelines/docs/checking04.pdf<br />
2. Association of Anaesthetists of Great Britain & Ireland.<br />
Standards of Monitoring during Anaesthesia and Recovery<br />
4, 2007. http://www.aagbi.org/publications/guidelines/docs/<br />
standardsofmonitoring07.pdf<br />
3. Medicines and Healthcare products Regulatory Agency.<br />
Device Bulletin, Managing Medical Devices DB2006(05)<br />
http://www.mhra.gov.uk/Publications/Safetyguidance/<br />
DeviceBulletins/CON2025142 [accessed 03.08.09]<br />
4. Medicine and Healthcare products Regulatory Agency.<br />
Devices in Practice - a guide for health and social care<br />
professionals, 2008. http://www.mhra.gov.uk/Publications/<br />
Safetyguidance/Otherdevicesafetyguidance/CON007423<br />
[accessed 03.08.09]<br />
5. Office of Public Sector Information. Statutory Instrument<br />
2002 No. 618, The Medical Devices Regulations. http://<br />
www.opsi.gov.uk/SI/si2002/20020618.htm [accessed<br />
03.08.09]<br />
6. Wilkes AR, Hodzovic I, Latto IP. Introducing new<br />
anaesthetic equipment into clinical practice. Anaesthesia<br />
2008; 63: 571-5.<br />
7. Europa Publications Office. Procurement Directive<br />
2004/18/EC, 31 March 2004 for Public Contracts,Official<br />
Journal of the European Union, http://eur-lex.europa.eu/<br />
LexUriServ/site/en/oj/2004/l_134/<br />
l_13420040430en01140240.pdf [accessed 03.08.09]<br />
35
8. OPSI. Statutory Instrument 2006 No 5 Public Contracts<br />
Regulations http://www.opsi.gov.uk/si/si2006/<br />
uksi_20060005_en.pdf [accessed 03.08.09]<br />
9. Office of Government Commerce. European Procurement<br />
Directives, http://www.ogc.gov.uk/procurement_policy_<br />
and_application_of_eu_rules_european_procurement_<br />
directives.asp [accessed 03.08.09]<br />
10. NHS Purchasing and Supply Agency. EU Tenders, http://<br />
www.pasa.nhs.uk/PASAWeb/Guidance/EUtenders.htm<br />
[accessed 03.08.09]<br />
11. Home Office. Procurement Competitions and the Alcatel<br />
Judgement, http://www.homeoffice.gov.uk/about-us/<br />
freedom-of-information/released-information/foi-archiveabout-us/4115-procurement-alcatel?view=Html<br />
[accessed<br />
03.08.09]<br />
12. Department of Health. Sustainable Development - Waste,<br />
http://www.dh.gov.uk/en/Managingyourorganisation/<br />
Estatesandfacilitiesmanagement/Sustainabledevelopment/<br />
DH_4119635 [accessed 03.08.09]<br />
13. Association of Anaesthetists of Great Britain & Ireland.<br />
Infection Control in Anaesthesia 2, 2008. http://www.<br />
aagbi.org/publications/guidelines/docs/infection_control_08.<br />
pdf [accessed 03.08.09]<br />
14. Department of Health. Standards for Better Health, 2004.<br />
http://www.dh.gov.uk/en/publicationsandstatistics/<br />
publications/publicationspolicyandguidance/<br />
dh_4086665 [accessed 03.08.09]<br />
15. Department of Health. Central Alerting System, https://<br />
www.cas.dh.gov.uk/Home.aspx [accessed 03.08.09]<br />
36
Useful numbers and websites<br />
For reporting adverse incidents and further information<br />
MHRA<br />
Tel: 020 7084 3080<br />
Website: www.mhra.gov.uk<br />
Email: aic@mhra.gsi.gov.uk<br />
NPSA<br />
Tel: 020 7927 9500<br />
Website: www.npsa.nhs.uk<br />
Email: enquiries@npsa.nhs.uk<br />
RIDDOR<br />
Tel: 0845 300 9923<br />
Website: www.riddor.gov.uk<br />
Email: riddor@natbrit.com<br />
DoH Estates<br />
Tel: 0113 254 5172<br />
Website: www.nhsestates.gov.uk<br />
Email: nhs.estates@dh.gsi.gov.uk<br />
Northern Ireland<br />
Tel: 028 9052 3704<br />
Website: www.dhsspsni.gov.uk/niaic<br />
Email: niaic@dhsspsni.gov.uk<br />
Scotland<br />
Tel: 0131 275 7575<br />
Website: www.hfs.scot.nhs.uk<br />
Email: enquiries@hfs.scot.nhs.uk<br />
Wales<br />
Tel: 029 2082 3505<br />
Email: health.enquiries@wales.gsi.gov.uk<br />
37
Eire<br />
Tel: 00353 1 676 4971<br />
Website: www.imb.ie<br />
Email: imb@imb.ie<br />
Buying Solutions<br />
Tel: 0345 410 2222<br />
Website: www.buyingsolutions.gov.uk<br />
Email: info@buyingsolutions.gsi.gov.uk<br />
38
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
Peri-operative management<br />
of the obese surgical patient 2015<br />
Published by<br />
The Association of Anaesthetists of Great Britain & Ireland<br />
Society for Obesity and Bariatric Anaesthesia<br />
March 2015
This guideline was originally published in Anaesthesia. If you wish to refer<br />
to this guideline, please use the following reference:<br />
Association of Anaesthetists of Great Britain and Ireland. Peri-operative<br />
management of the obese surgical patient 2015. Anaesthesia 2015, 70,<br />
pages 859–876.<br />
This guideline can be viewed online via the following URL:<br />
http://onlinelibrary.wiley.com/enhanced/doi/10.1111/anae.13101/<br />
© The Association of Anaesthetists of Great Britain & Ireland
Guidelines<br />
Peri-operative management of the obese<br />
surgical patient 2015<br />
Association of Anaesthetists of Great Britain and<br />
Ireland<br />
Society for Obesity and Bariatric Anaesthesia<br />
Members of the Working Party: C. E. Nightingale, 1<br />
M. P. Margarson, 1 E. Shearer, 1 J. W. Redman, 1<br />
D. N. Lucas, 2 J. M. Cousins, 1 W. T. A. Fox, 1 N. J. Kennedy, 1<br />
P. J. Venn, 3 M. Skues, 4 D. Gabbott, 5 U. Misra, 2<br />
J. J. Pandit, 7 M.T. Popat 6 and R. Griffiths (Chair) 7<br />
1 Society for Obesity and Bariatric Anaesthesia, 2 Obstetric Anaesthetists’<br />
Association, 3 Royal College of Anaesthetists, 4 British Association of Day<br />
Surgery, 5 Resuscitation Council (UK), 6 Difficult Airway Society, 7<br />
Association of Anaesthetists of Great Britain & Ireland<br />
Summary<br />
Guidelines are presented for the organisational and clinical peri-operative<br />
management of anaesthesia and surgery for patients who are obese,<br />
along with a summary of the problems that obesity may cause peri-<br />
This is an open access article under the terms of the Creative Commons<br />
Attribution-NonCommercial-NoDerivs License, which permits use and<br />
distribution in any medium, provided the original work is properly<br />
cited, the use is non-commercial and no modifications or adaptations<br />
are made.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
1
operatively. The advice presented is based on previously published<br />
advice, clinical studies and expert opinion.<br />
....................................................................................................<br />
This is a consensus document produced by expert members of a Working<br />
Party established by the Association of Anaesthetists of Great Britain and<br />
Ireland and the Society for Obesity and Bariatric Anaesthesia. It has been<br />
seen and approved by the elected Board/Council of both organisations.<br />
All AAGBI guidelines are reviewed to ensure relevance/accuracy and are<br />
updated or archived when necessary. Date of review: 2020.<br />
Accepted: 10 March 2015<br />
• What other guidelines and statements are available on this topic?<br />
The first Association of Anaesthetists of Great Britain and Ireland<br />
(AAGBI) guidelines on the peri-operative management of the obese<br />
patient were published in 2007 [1]. In 2012, a consensus statement<br />
on anaesthesia for patients with morbid obesity was published by the<br />
Society for Obesity and Bariatric Anaesthesia (SOBA) [2]. The Centre<br />
for Maternal and Child Enquiries (CMACE) and the Royal College<br />
of Obstetricians and Gynaecologists (RCOG) have published joint<br />
guidance on management of women with obesity in pregnancy [3].<br />
•<br />
Why were these guidelines developed?<br />
There is an increased recognition that obese patients present a different<br />
set of challenges and require specific peri-operative care compared<br />
with non-obese patients. These guidelines are intended to<br />
inform anaesthetists about best practice management of obese surgical<br />
patients throughout the peri-operative period, as members of a<br />
multidisciplinary team.<br />
•<br />
How does this statement differ from existing guidelines?<br />
These guidelines include new material on several topics including pharmacology,<br />
positioning and sleep-disordered breathing. The advent of bariatric<br />
(weight treatment) surgery has produced a subgroup of<br />
anaesthetists with more specific experience in the management of obese<br />
patients. The Society for Obesity and Bariatric Anaesthesia was set up in<br />
2009 to share the knowledge gained from bariatric anaesthesia to improve<br />
the anaesthetic care of obese patients in general. This experience forms the<br />
basis of these guidelines.<br />
2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
Recommendations<br />
1 Every hospital should nominate an anaesthetic lead for obesity.<br />
2 Operating lists should include the patients’ weight and body mass<br />
index (BMI).<br />
3 Experienced anaesthetic and surgical staff should manage obese<br />
patients.<br />
4 Additional specialised equipment is necessary.<br />
5 Central obesity and metabolic syndrome should be identified as risk<br />
factors.<br />
6 Sleep-disordered breathing and its consequences should always be<br />
considered in the obese.<br />
7 Anaesthetising the patient in the operating theatre should be considered.<br />
8 Regional anaesthesia is recommended as desirable but is often technically<br />
difficult and may be impossible to achieve.<br />
9 A robust airway strategy must be planned and discussed, as desaturation<br />
occurs quickly in the obese patient and airway management<br />
can be difficult.<br />
10 Use of the ramped or sitting position is recommended as an aid to<br />
induction and recovery.<br />
11 Drug dosing should generally be based upon lean body weight and<br />
titrated to effect, rather than dosed to total body weight.<br />
12 Caution is required with the use of long-acting opioids and sedatives.<br />
13 Neuromuscular monitoring should always be used whenever neuromuscular<br />
blocking drugs are used.<br />
14 Depth of anaesthesia monitoring should be considered, especially<br />
when total intravenous anaesthesia is used in conjunction with neuromuscular<br />
blocking drugs.<br />
15 Appropriate prophylaxis against venous thromboembolism (VTE)<br />
and early mobilisation are recommended since the incidence of<br />
venous thromboembolism is increased in the obese.<br />
16 Postoperative intensive care support should be considered, but is<br />
determined more by co-morbidities and surgery than by obesity per<br />
se.<br />
Introduction<br />
The World Health Organization (WHO) uses a class system to define<br />
obesity (Table 1). Statistics for 2013 from the UK, Health and Social Care<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
3
Table 1 World Health Organization classification of obesity [4].<br />
Body mass index;<br />
kg.m 2<br />
Classification<br />
< 18.5 Underweight<br />
18.5–24.9 Normal<br />
25.0–29.9 Overweight<br />
30.0–34.9 Obese 1<br />
35.0–39.9 Obese 2<br />
> 40.0 Obese 3 (previously ‘morbid obesity’)<br />
Information Centre show that in adults, 24% of men and 25% of women<br />
are classified as obese and over 3% have class-3 obesity [5]. For an average<br />
UK district general hospital serving an adult population of 200 000, this<br />
equates to 52 000 obese and over 6000 class-3 obese patients [6].<br />
Obese patients are more likely to present to hospital because they are<br />
more prone to concomitant disease. Between 2001–2002 and 2011–2012,<br />
there was an eleven-fold increase in the number of patients (from 1019<br />
to 11 736) of all ages admitted to NHS hospitals with a primary diagnosis<br />
of obesity (Fig. 1) [6]. In 2007, the UK Government’s Foresight Report<br />
predicted that 50% of the UK population would be clinically obese by<br />
2050, costing the NHS an extra £45.5 billion (€61.5 billion; $70.1 billion)<br />
per year, but even this may be an underestimate [7].<br />
This consensus guidance is a synthesis of expert opinion, current<br />
practice and literature review, designed to replace the 2007 edition [1]<br />
and act as a guide to the delivery of safe anaesthesia to this clinically<br />
demanding group.<br />
Pathophysiology of obesity<br />
Fat distribution (patient shape)<br />
Not all fat within the body is identical. Unlike peripherally deposited<br />
fat, intra-abdominal fat is highly metabolically active and is known to<br />
be a contributor to several disease states [8]. Patients with centrally distributed<br />
or ‘visceral’ fat are at greater peri-operative risk than those with<br />
peripherally distributed fat, and are far more likely to exhibit the metabolic<br />
syndrome, which consists of central obesity, hypertension, insulin<br />
resistance and hypercholesterolemia [9, 10].<br />
Central obesity can be defined as a waist circumference greater than<br />
88 cm in a woman and 102 cm in a man; or a waist-to-height ratio<br />
greater than 0.55 [10, 11].<br />
4 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
35<br />
30<br />
25<br />
Prevalance (%)<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Figure 1 Adult trends in obesity (BMI ≥ 30 kg.m 2 ) in the UK male (○)<br />
and female (●) population, showing three-yearly averages. Redrawn<br />
from Health Survey England 2013 data (see http://www.hscic.gov.uk/<br />
catalogue/PUB16077) accessed 10/03/2015).<br />
People who exhibit central, or visceral, obesity are often male and<br />
can be described as ‘apple shaped’, while those with a predominantly<br />
peripheral fat distribution are more likely to be female and are described<br />
as ‘pear shaped’.<br />
Respiratory system<br />
Obesity results in reduced functional residual capacity (FRC), significant<br />
atelectasis and shunting in dependent lung regions [12], but resting metabolic<br />
rate, work of breathing and minute oxygen demand are increased.<br />
This combination means that, following the cessation of breathing, arterial<br />
oxygen levels decrease rapidly.<br />
Wheeze in the obese may be due to airway closure rather than<br />
asthma: 50% of patients diagnosed with asthma ‘recover’ with weight<br />
loss [13]. Formal assessment of the effectiveness of bronchodilator therapy<br />
may be useful in differentiating the two conditions [14].<br />
Sleep-disordered breathing<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
5
Sleep-disordered breathing describes the spectrum of conditions ranging<br />
from obstructive sleep apnoea (OSA) through obesity hypoventilation<br />
syndrome (OHS). Each of these conditions has a spectrum of severity,<br />
described according to the number and severity of oxygen desaturations<br />
occurring every hour and their impact upon the patient [15].<br />
Severe OSA occurs in 10–20% of patients with BMI > 35 kg.m 2<br />
and is often undiagnosed. Overall, a diagnosis of OSA is associated with<br />
a greater than doubling of the incidence of postoperative desaturation,<br />
respiratory failure, postoperative cardiac events and ICU admission [16].<br />
The presence of multiple and prolonged oxygen desaturations increases<br />
the sensitivity to opioid-induced respiratory depression [17]. However, if<br />
identified pre-operatively and treated appropriately with continuous<br />
positive airway pressure (CPAP), the risk of complications is much<br />
reduced [18].<br />
Increasing severity of OSA is associated with older age, cardiovascular<br />
disease secondary to heart strain, and the development of left ventricular<br />
dysfunction. It is also associated with a difficult airway and<br />
laryngoscopy. If untreated, OSA may progress to obesity hypoventilation<br />
syndrome, a triad of obesity (BMI > 35 kg.m 2 ), sleep-disordered<br />
breathing (usually OSA) and daytime hypercapnia (pCO 2 > 6 kPa) [19].<br />
The combination of chronic hypoxaemia and hypercapnia make this<br />
subgroup particularly susceptible to the effects of anaesthetic agents and<br />
opioids, which may precipitate acute and chronic hypoventilation and<br />
respiratory arrest in the early postoperative period [20].<br />
Formal diagnosis of sleep-disordered breathing is with polysomnography,<br />
but in the majority of cases, diagnosis can be made by overnight<br />
oximetry testing at home [21]. Nocturnal CPAP is the usual treatment<br />
in patients with significant degrees of OSA, but around 50% of patients<br />
are poorly compliant with CPAP therapy and thus will not obtain benefit,<br />
usually because of problems with the fitting of the mask. Seeking<br />
information on compliance during pre-operative assessment is advised.<br />
Cardiovascular system<br />
Obesity leads to increased blood pressure, cardiac output and cardiac<br />
workload. People with untreated OSA may have associated pulmonary<br />
hypertension and heart failure [15].<br />
There is an increased incidence of arrhythmias, predominantly secondary<br />
to sino-atrial node dysfunction and fatty infiltration of the conducting<br />
system. This results in a relative risk of 1.5 for atrial fibrillation<br />
[22], and a markedly increased risk of sudden cardiac death [23]. There<br />
6 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
is an increased incidence of prolonged QT interval with increasing BMI<br />
[24], and therefore a potential increased risk with drugs such as ondansetron<br />
[25].<br />
Ischaemic heart disease and heart failure are more prevalent in the<br />
obese population, with heart failure the predominant risk factor for<br />
postoperative complications [26].<br />
Thrombosis<br />
Obesity is a prothrombotic state and is associated with increased<br />
morbidity and mortality from thrombotic disorders such as myocardial<br />
infarction, stroke and VTE [27]. The postoperative incidence of<br />
VTE may be 10 times higher in obese women compared with their<br />
healthy-weight counterparts [28]. Previous VTE is an independent<br />
risk factor for patients having gastric bypass surgery [29]. A<br />
hypercoagulable state may extend beyond two weeks, warranting<br />
extended postoperative VTE prophylaxis depending on the type of<br />
surgery and the patient’s BMI [30].<br />
Diabetes<br />
Obesity is strongly associated with increased insulin resistance [31].<br />
Poor glycaemic control in the peri-operative period is associated with<br />
increased morbidity, and good glycaemic control is recommended [32].<br />
Gastric bypass surgery causes a unique neurohumeral response,<br />
resulting in a rapid, dramatic reduction in insulin requirement, starting<br />
immediately after surgery. In this cohort of patients, cautious<br />
postoperative reintroduction of diabetic medication and frequent blood<br />
sugar monitoring are essential [33].<br />
Pharmacology<br />
Body composition<br />
There are a number of terms used to describe the weight of a patient;<br />
the four most useful are shown in Table 2.<br />
Drug dosing<br />
There is limited information on the effect of obesity on the pharmacology<br />
of commonly used anaesthetic drugs. Much of the excess weight is<br />
fat, which has a relatively low blood flow. While lipophilic drugs will<br />
have a larger volume of distribution than hydrophilic ones, the current<br />
evidence indicates that changes in volume of distribution in the obese<br />
are drug-specific, so generalisations are difficult [37]. For most anaes-<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
7
Table 2 The four most useful terms for describing patients’ weight.<br />
Total body<br />
weight (TBW)<br />
Ideal body<br />
weight (IBW)<br />
The actual weight of the patient<br />
What the patient should weigh<br />
with a normal ratio of lean to fat mass.<br />
Varies with age, and is usually<br />
approximated to a function of<br />
height and sex:<br />
IBW (kg) ¼ height (cm) x (where x<br />
¼ 105 in females and 100 in malesÞ<br />
Lean body<br />
weight (LBW)<br />
The patient’s weight excluding fat. Many of the<br />
formulae for calculating lean body weight are<br />
complex but one of the most widely used is that<br />
of Janmahasatian et al. [34]:<br />
LBW (kg) ¼<br />
LBW (kg) ¼<br />
9270 TBW (kg)<br />
6680 þð216 BMI (kg.m 2 ÞÞ ðmenÞ<br />
9270 TBW (kg)<br />
8780 þð244 BMI (kg.m 2 ÞÞ ðwomenÞ<br />
Regardless of total body weight, lean body weight<br />
rarely exceeds 100 kg in men and 70 kg in women<br />
(Fig. 2) [35]<br />
Adjusted body<br />
weight (ABW)<br />
Takes into account the fact that obese individuals<br />
have increased lean body mass and an increased<br />
volume of distribution for drugs. It is calculated<br />
by adding 40% of the excess weight to the IBW [36]:<br />
ABW (kg) = IBW (kg) + 0.4 (TBW (kg) IBW (kg))<br />
thetic agents, dosing to total body weight is rarely appropriate and<br />
increases the risk of relative overdose. Fortunately, most anaesthetic<br />
agents are dosed to affect, e.g. loss of eyelash reflex, nerve stimulator<br />
response or relief of pain. Given the paucity of information, the recommendation,<br />
based on current practice amongst experts in bariatric<br />
8 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
Figure 2 Relationship between total body weight and body mass index<br />
(BMI), showing how lean body mass effectively plateaus despite increasing<br />
BMI. A male of height 190 cm and ideal body weight (IBW) is indicated,<br />
demonstrating how IBW includes a normal 15% fat mass.<br />
anaesthesia, is that lean or adjusted body weight are used as the scalars<br />
for calculating initial anaesthetic drug doses rather than total body<br />
weight (Table 3).<br />
The fifth National Audit (NAP5) into accidental awareness under<br />
anaesthesia (AAGA) included a disproportionate number of obese<br />
patients who suffered AAGA. Half of the incidents of awareness occurred<br />
during the induction of anaesthesia and neuromuscular blocking drugs<br />
were used in 93% of these cases [38]. In the obese patient, after a bolus of<br />
anaesthetic induction agent, anaesthesia will occur before redistribution<br />
from the central compartment, and the induction dose required to produce<br />
unconsciousness correlates well with lean body weight [39]. However,<br />
more rapid redistribution of induction agents into the larger fat mass<br />
means that patients wake up more quickly than non-obese patients after a<br />
single bolus dose. With induction agents, a dose based on total body<br />
weight will last longer than one calculated using lean or adjusted body<br />
weight but is likely to result in significant hypotension. It is likely that in<br />
the cases of AAGA found in NAP5, small doses of induction agent based<br />
on lean or adjusted body weight were not quickly followed by the introduction<br />
of maintenance anaesthesia, thus raising the risk of AAGA. Thio-<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
9
Table 3 Suggested initial dosing scalars for commonly used anaesthetic<br />
drugs for healthy obese adults (notwithstanding the fact that titration to<br />
a suitable endpoint may be necessary).<br />
Lean body weight*<br />
Adjusted body weight*<br />
Propofol (induction)<br />
Propofol (infusion; see text)<br />
Thiopental<br />
Antibiotics<br />
Fentanyl<br />
Low molecular weight heparin<br />
Rocuronium<br />
Alfentanil<br />
Atracurium<br />
Neostigmine (maximum 5 mg)<br />
Vecuronium Sugammadex †<br />
Morphine<br />
Paracetamol<br />
Bupivacaine<br />
Lidocaine<br />
*See Table 1 for definitions/calculations.<br />
† See product literature.<br />
pental is associated with a greater risk of awareness than propofol. It is<br />
strongly recommended that additional induction agent be given if there is<br />
a delay in commencing effective maintenance anaesthesia after induction.<br />
Hydrophilic drugs such as neuromuscular blocking drugs are distributed<br />
primarily in the central compartment and lean body weight<br />
is a suitable dosing scalar. A dose of rocuronium based on total body<br />
weight does not significantly shorten the onset time, but will markedly<br />
increase the duration of action [40]. However, due to increased<br />
plasma cholinesterase activity, total body weight is appropriate for<br />
suxamethonium. Doses of neostigmine and sugammadex are related to<br />
the timing and total dose of neuromuscular blocking drugs to be<br />
reversed and can usually be titrated to effect.<br />
For opioids, the clinical effect is poorly related to the plasma concentration<br />
[41]. Dosing using lean body weight is therefore a sensible<br />
starting point until the patient is awake and titration to effect is possible.<br />
For target controlled infusions (TCI) of propofol, the Marsh and<br />
Schnider formulae become unreliable for patients weighing over 140–<br />
150 kg [40]. Because of this, none of the commercially available pumps<br />
allow input of weights above 150 kg using the Marsh model, or BMI<br />
> 35 kg.m 2 (female) and 42 kg.m 2 (male) using the Schnider model.<br />
There is a lack of evidence as to the best weight scalar to use with TCI<br />
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techniques, and when used with neuromuscular blocking drugs,<br />
awareness is a significant potential risk. In these situations, some form<br />
of depth of anaesthesia monitoring is strongly recommended [42].<br />
Pre-operative preparation<br />
General considerations<br />
The vast majority of obese patients presenting for surgery are relatively<br />
healthy and their peri-operative risk is similar to that of patients of normal<br />
weight. The patients at high risk of peri-operative complications are<br />
those with central obesity and metabolic syndrome, rather than those<br />
with isolated extreme obesity [10].<br />
Particular attention should be focused on screening patients for<br />
sleep-disordered breathing and those at particularly high risk of VTE. A<br />
clear pathway for referral for specialist sleep studies should be identified.<br />
The Obesity Surgery Mortality Risk Stratification score (OS-MRS)<br />
(Table 4) has been validated for patients undergoing gastric bypass surgery<br />
to identify the risk factors associated with mortality [43]. It<br />
includes features of metabolic syndrome and sleep-disordered breathing.<br />
Although only validated for bariatric surgical patients, it may be applicable<br />
to obese patients undergoing non-bariatric operations. Patients who<br />
Table 4 The Obesity Surgery Mortality Risk Stratification score: (a) risk<br />
factors; (b) risk of mortality [43].<br />
Risk factor<br />
Score<br />
(a)<br />
BMI > 50 kg.m 2 1<br />
Male 1<br />
Age > 45 years 1<br />
Hypertension 1<br />
Risk factors for pulmonary embolism: 1<br />
Previous venous thromboembolism<br />
Vena caval filter<br />
Hypoventilation (sleep-disordered breathing)<br />
Pulmonary hypertension<br />
Risk of mortality<br />
(b)<br />
Class A: 0-1 points 0.2–0.3%<br />
Class B: 2–3 points 1.1–1.5%<br />
Class C: 4–5 points 2.4–3.0%<br />
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11
score 4–5 on the OS-MRS are more likely to require closer postoperative<br />
monitoring.<br />
All patients should have their height and weight recorded and BMI<br />
calculated, and these should both be recorded on the operating list to<br />
inform the teams that additional time, equipment and preparation may<br />
be needed. There may be an advantage in estimating lean and adjusted<br />
body weight and recording these in the patient’s records to aid the calculation<br />
of drug doses.<br />
Diagnostic testing should be based on the need to evaluate co-morbidity<br />
and the complexity of surgery, rather than merely as a result of<br />
the presence of obesity.<br />
In bariatric surgery, it is routine to initiate a pre-operative ‘liver<br />
shrinking’ diet to reduce the size of the liver and make access to the<br />
stomach technically easier. There is evidence that 2–6 weeks of intense<br />
pre-operative dieting can improve respiratory function and facilitate laparoscopic<br />
surgery, and may be worth considering in the higher risk<br />
patients [44].<br />
Pre-operative discussion can promote smoking cessation, clarify the<br />
importance of thromboprophylaxis and early mobilisation, plan the<br />
management of medication before admission and remind relevant<br />
patients to bring their own CPAP machine into hospital.<br />
Respiratory assessment<br />
Clinical evaluation of the respiratory system and exercise tolerance<br />
should identify functional limitations and guide further assessment. It is<br />
helpful to assess patients’ arterial saturation in the pre-assessment clinic.<br />
Spirometry is also often useful.<br />
The following features may indicate the presence of significant<br />
underlying respiratory disease and should prompt consideration of preoperative<br />
arterial blood gas analysis [45]:<br />
Arterial saturation < 95% on air<br />
Forced vital capacity < 3 l or forced expiratory volume in 1 s < 1.5 l<br />
• Respiratory wheeze at rest<br />
• Serum bicarbonate concentration > 27 mmol.l 1<br />
An arterial PCO 2 > 6 kPa indicates a degree of respiratory failure<br />
and consequently the likelihood of increased anaesthetic risk.<br />
It is essential to screen for sleep-disordered breathing. Of the several<br />
screening tools available, the STOP-BANG questionnaire (Table 5)<br />
is the best validated in obese patients. It is easy to calculate and has<br />
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Table 5 The STOP-BANG screening questionnaire for obstructive sleep<br />
apnoea (adapted with permission [46, 47]. One point is scored for each<br />
positive feature; a score ≥ 5 is a significant risk.<br />
Snoring<br />
Do you snore loudly (louder than talking or heard<br />
through a closed door?)<br />
Tired<br />
Do you often feel tired, fatigued or sleepy during the<br />
daytime? Do you fall asleep in the daytime?<br />
Observed<br />
Has anyone observed you stop breathing or choking or<br />
gasping during your sleep?<br />
Blood Pressure Do you have, or are you being treated for, high<br />
blood pressure?<br />
BMI BMI > 35 kg.m 2<br />
Age<br />
Age > 50 years<br />
Neck<br />
Circumference (measured around Adam’s apple) > 43 cm<br />
(17 in) for males, > 41 cm (16 in) for females<br />
Gender<br />
Male<br />
shown good correlation with the severity of postoperative apnoeas. A<br />
STOP-BANG score of 5 or greater indicates the possibility of significant<br />
sleep-disordered breathing and should prompt referral to a sleep<br />
physician if time allows [46, 47]. Even in the presence of a low STOP-<br />
BANG score, a history of marked exertional dyspnoea, morning headaches<br />
and ECG evidence of right atrial hypertrophy may indicate the<br />
presence of sleep-disordered breathing and should also prompt referral<br />
for assessment.<br />
Patients with undiagnosed OSA, or those unable to tolerate CPAP,<br />
are at the highest risk of peri-operative respiratory and cardiovascular<br />
morbidity [48], while patients fully compliant with CPAP (usually<br />
indicated by symptomatic benefit) are at lower risk of peri-operative<br />
events. In general, patients with adequately treated sleep-disordered<br />
breathing do not have problems requiring high dependency care and<br />
may even be suitable for day surgery [49] (see below).<br />
Airway assessment<br />
Obesity is associated with a 30% greater chance of difficult/failed intubation,<br />
although predictors for difficult laryngoscopy are the same as for<br />
the non-obese [50]. A large neck circumference is a useful additional<br />
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13
indicator and when greater than 60 cm, is associated with a 35% probability<br />
of difficult laryngoscopy [51].<br />
Bag-mask ventilation is also known to be more difficult in the obese<br />
[52, 53]. Beards in particular can cause problems with bag-mask ventilation<br />
and are quite common in the obese male population. If time allows,<br />
it is recommended that all facial hair should be removed pre-operatively,<br />
or at the very least clipped short.<br />
Cardiovascular assessment<br />
Obese patients should be assessed in the same way as any other patient<br />
group. Features of the metabolic syndrome should be actively identified<br />
as there is a strong association with cardiac morbidity [54]. Assessment<br />
of exercise tolerance can be a valuable tool. The requirement for specific<br />
cardiac investigations should be based on: the degree of exercise tolerance;<br />
the presence of additional co-morbidity; and the site and extent of<br />
the anticipated surgery.<br />
Cardiopulmonary exercise testing (CPET) may predict those at high<br />
risk of postoperative complications and increased length of stay [55, 56].<br />
Standard CPET equipment may not be suitable and recumbent bikes are<br />
available for heavier patients.<br />
Planning postoperative care<br />
The planned postoperative management of most obese patients should<br />
resemble the enhanced recovery programmes of many surgical specialities.<br />
Obesity alone is not a clinical indication for high-dependency postoperative<br />
care. Factors that warrant consideration for a level-2 or -3 setting<br />
include the following:<br />
Pre-existing co-morbidities<br />
Indicated high risk (e.g. OS-MRS 4-5 or limited functional capacity)<br />
Surgical procedure<br />
• Untreated OSA plus a requirement for postoperative parenteral opioids<br />
• Local factors including the skill mix of ward staff<br />
An important consideration for all patients is the degree and site of<br />
surgery. If longer acting opioids (e.g. morphine) are necessary, then<br />
these patients will require closer monitoring, specifically watching for<br />
developing hypercapnia, and level-2 care may be indicated [57].<br />
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Intra-operative care<br />
Preparation of patients<br />
Patients’ dignity is important, so suitably sized theatre gowns and disposable<br />
underwear should be available. Antacid and analgesic premedication<br />
should be considered. As previously mentioned, it may be<br />
appropriate to ask male patients with beards to shave/trim them before<br />
surgery.<br />
Preparation of staff<br />
The specific peri-operative requirements of the obese patient should be<br />
included in the pre-operative team brief of the WHO surgical checklist<br />
to ensure the presence of appropriate equipment, including suitable<br />
operating tables, beds and trolleys (see below).<br />
Extra time should be allowed for positioning the obese patient and<br />
performing anaesthesia. Anaesthetists should recognise when additional<br />
personnel (another trained anaesthetist or additional operating department<br />
practitioners) are needed.<br />
The seniority of both the anaesthetist and the surgeon should be considered.<br />
Patients with an OS-MRS score > 3 should be discussed with a<br />
consultant, and those with a score of 4–5 should be anaesthetised by an<br />
anaesthetist experienced in the management of such patients. An experienced<br />
surgeon will reduce operative time and this will help to limit perioperative<br />
morbidity.<br />
Regional anaesthesia<br />
Where possible, regional anaesthesia is preferred to general anaesthesia,<br />
although a plan for airway management is still mandatory [58]. There is<br />
a higher risk of failure of regional techniques in the obese, and appropriate<br />
patient counselling/consent is advised. [59] If sedation is required<br />
during regional anaesthesia, this should be kept to the minimum. Specific<br />
equipment such as extra-long spinal or epidural needles should be<br />
available and ultrasound might be a useful adjunct [60].<br />
There are advantages to the patient (comfort) and practitioner (success<br />
rates) in using the sitting position for neuraxial techniques, and it<br />
may be helpful to tilt the bed towards the operator so the patient naturally<br />
leans forward [61]. To reduce epidural catheter migration, it is recommended<br />
that at least 5 cm catheter should be left in the epidural<br />
space [62].<br />
It is safer to calculate local anaesthetic drug dose using lean body<br />
weight. Despite the potential reduction in neuraxial volume due to<br />
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15
adipose tissue, standard doses of local anaesthetic are recommended for<br />
central neuraxial blockade [63].<br />
The anaesthetist should be aware that hypotension following neuraxial<br />
anaesthesia may be more problematic in the obese as they are less<br />
tolerant of lying flat or in the Trendelenberg position.<br />
Induction of general anaesthesia<br />
Easily reversible drugs, with fast onset and offset, are the agents of<br />
choice for obese patients.<br />
Anaesthetising the patient in the operating theatre has the advantages<br />
of avoiding the problems associated with transporting an obese anaesthetised<br />
patient, and will also reduce the risk of arterial desaturation<br />
and AAGA associated with disconnection of the breathing system during<br />
transfer [38, 64]. In addition, the patient can position him/herself<br />
on the operating table and can help identify pressure points for protection.<br />
There were a number of learning points from the fourth National<br />
Audit Project (NAP4) which looked at airway complications that are<br />
pertinent to the airway management of the obese patient [65]:<br />
• There was often a lack of recognition and planning for potential airway<br />
problems<br />
• As a result of the reduced safe apnoea time, when airway complications<br />
occurred, they did so rapidly and potentially catastrophically<br />
•<br />
There was evidence that rescue techniques such as supraglottic airway<br />
devices and emergency cricothyroidotomy had an increased failure<br />
rate<br />
•<br />
Adverse events occurred more frequently in obese patients when anaesthetised<br />
by inexperienced staff<br />
Since the work of spontaneous breathing is increased in the obese<br />
patient, tracheal intubation with controlled ventilation is the airway<br />
management technique of choice. Use of supraglottic airway devices as<br />
the primary airway device should be reserved for highly selected patients<br />
undergoing short procedures and, where the patient can be kept headup<br />
during surgery. The upper airway should be accessible at all times<br />
and there must be a plan for tracheal intubation if required.<br />
During induction of anaesthesia, the patient should be positioned in<br />
a ramped position with the tragus of the ear level with the sternum, and<br />
the arms away from the chest (Fig. 3). This will improve lung mechanics,<br />
thereby assisting oxygenation and ventilation and as a result, maxi-<br />
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Figure 3 Ramping position for obese patients. Note the tragus of the<br />
ear level with the sternum.<br />
mising the safe apnoea time. The addition of positive end-expiratory<br />
pressure (PEEP) may further facilitate pre-oxygenation [66]. Minimising<br />
the time from induction to intubation will reduce the risk of oxygen desaturation<br />
should bag-mask ventilation prove difficult. It has been demonstrated<br />
that ramping improves the view at laryngoscopy in the obese<br />
patient and this is therefore the recommended default position during<br />
induction in all obese patients [67]. Any difficulty with/failure of direct<br />
laryngoscopy should be promptly managed in accordance with the Difficult<br />
Airway Society guidelines [68].<br />
Suxamethonium-associated fasciculations increase oxygen consumption<br />
and have been shown to shorten the safe apnoea time [69]; consequently,<br />
it is unlikely to wear off before profound hypoxia occurs, and so<br />
may not be the drug of choice for obese patients [70]. With the advent of<br />
sugammadex, aminosteroids could instead be considered the neuromuscular<br />
blocking drugs of choice. The use of rocuronium can minimise the<br />
apnoea time from cessation of spontaneous ventilation to control of ventilation<br />
via a secure airway if bag-mask ventilation is difficult. The dose of<br />
sugammadex for emergency reversal should be pre-calculated and be<br />
immediately available for preparation if required [71].<br />
Ideal body weight should be used to size tracheal tubes and to calculate<br />
tidal volume during controlled ventilation. Tracheal diameter<br />
reduces slightly with increasing BMI [72]. During controlled ventilation,<br />
no particular mode of controlled ventilation has been proven to be<br />
superior; however, greater tidal volumes for a given peak pressure can<br />
often be achieved using pressure-controlled, rather than volume-con-<br />
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17
trolled, ventilation. The addition of sufficient PEEP and recruitment<br />
manoeuvres will reduce intra- and postoperative atelectasis [73]. For<br />
laparoscopic surgery, flexion of the patient’s trunk, i.e. a slight sitting<br />
position, allows increased abdominal excursion and slightly lower airway<br />
pressures [74].<br />
As intravenous access is often difficult in the obese, it is prudent to<br />
site two intravenous cannulae while in theatre. Ultrasound may prove<br />
useful to help locate peripheral veins but consideration should be given<br />
to unusual sites for intravenous access such as the upper arm and anterior<br />
chest wall. Central venous access should only be used if peripheral<br />
access is impossible, or if specifically indicated.<br />
The ‘SDB-safe’ anaesthetic<br />
A simple and safe principle is to assume that all obese patients have<br />
some degree of sleep-disordered breathing (whether formally tested or<br />
not) and to modify the anaesthetic technique accordingly. Useful<br />
peri-operative strategies therefore include the following:<br />
Avoidance of general anaesthesia and sedatives where possible<br />
Use of short acting agents<br />
•<br />
Use of depth of anaesthesia monitoring techniques to limit anaesthetic<br />
load, particularly when neuromuscular blocking drugs and/or<br />
a total intravenous anaesthetic technique are utilised<br />
•<br />
Use of neuromuscular monitoring to maintain a level of block compatible<br />
with surgery and to ensure complete reversal of block before<br />
waking the patient<br />
• Maximal use of local anaesthetic and multimodal opioid-sparing<br />
analgesia<br />
Maintaining the head–up position throughout recovery<br />
• Monitoring of oxygen saturations until mobile postoperatively<br />
If long-acting opioids are required and the patient is not stabilised<br />
on CPAP pre-operatively, then the use of level-2 care is recommended.<br />
Maintenance of anaesthesia<br />
There is limited evidence at present to favour either TCI of propofol or<br />
volatile agents for maintenance of anaesthesia in the obese. However,<br />
due to the increased risk of AAGA in the obese, it is important that<br />
maintenance is commenced promptly after induction of anaesthesia<br />
[38]. Fat-insoluble volatile agents such as desflurane or sevoflurane have<br />
a faster onset and offset than isoflurane. There is evidence of faster<br />
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eturn of airway reflexes with desflurane compared with sevoflurane in<br />
the obese [75].<br />
Multimodal analgesia techniques, including local anaesthesia, enable<br />
opioid sparing and are strongly recommended.<br />
Emergence from anaesthesia<br />
Both NAP4 and NAP5 showed a high incidence of problems during extubation<br />
in the obese. An extubation plan must therefore be in place in<br />
accordance with the Difficult Airway Society extubation guidelines [76].<br />
Reversal of neuromuscular blockade should be guided by a nerve<br />
stimulator. The aim is to restore motor capacity before waking the<br />
patient [38]. Patients should have return of their airway reflexes and be<br />
breathing with good tidal volumes before tracheal extubation, which<br />
should be performed with the patient awake and in the sitting position.<br />
In those patients with confirmed OSA, the insertion of a nasopharyngeal<br />
airway before waking helps mitigate the partial airway obstruction<br />
that is commonly seen during emergence from anaesthesia.<br />
Postoperative care<br />
Immediate post-anaesthesia care<br />
Full monitoring should be maintained in the post-anaesthesia care unit<br />
(PACU). The patient should be managed in the sitting position or with a<br />
45° head-up tilt.<br />
Oxygen therapy should be applied to maintain pre-operative levels<br />
of arterial oxygen saturation and should be continued until the patient<br />
is mobile postoperatively. If the patient was using CPAP therapy at<br />
home, it should be reinstated on return to the ward or even in the<br />
PACU if oxygen saturation levels cannot be maintained by the use of<br />
inhaled oxygen alone [57]. If supplemental oxygen is necessary, this can<br />
either be given via the patient’s CPAP machine or via nasal specula<br />
under the CPAP mask.<br />
Before discharge from the PACU, all obese patients should be<br />
observed whilst unstimulated for signs of hypoventilation, specifically<br />
episodes of apnoea or hypopnoea with associated oxygen desaturation,<br />
which will warrant an extended period of monitoring in the PACU.<br />
Ongoing hypoventilation will require anaesthetic assessment to establish<br />
the need for further respiratory support and level-2 care.<br />
The patient is safe to return to the ward only when:<br />
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19
Routine discharge criteria are met<br />
•<br />
or apnoea for at least one hour<br />
•<br />
The respiratory rate is normal and there are no periods of hypopnea<br />
The arterial oxygen saturation returns to the pre-operative values<br />
with or without oxygen supplementation<br />
Analgesia and ward care<br />
An enhanced recovery protocol is essential [77]. Early mobilisation is<br />
vital and most patients should be out of bed on the day of surgery. If<br />
possible, restricting the patient with a urinary catheter, intravenous infusions<br />
or other devices should be avoided. Calf compression devices can<br />
be disconnected for mobilisation.<br />
The intramuscular route of drug administration is to be avoided<br />
owing to unpredictable pharmacokinetics.<br />
The use of patient-controlled analgesia (PCA) systems needs careful<br />
consideration because of the increased risk of respiratory depression in<br />
those with undiagnosed sleep-disordered breathing. In those patients<br />
with suspected or poorly treated sleep-disordered breathing, increased<br />
postoperative monitoring in a level-2 unit is recommended if PCA is<br />
required.<br />
Subarachnoid block with an opioid adjunct is a useful technique<br />
resulting in reduced postoperative opioid requirements. Epidural infusions<br />
are associated with reduced postoperative mobility and may be<br />
counterproductive.<br />
In the ward, oxygen therapy should be continued until baseline<br />
arterial oxygen saturations are achieved, and pulse oximetry should continue<br />
until oxygen saturations remain at baseline without supplemental<br />
oxygen and parenteral opioids are no longer required.<br />
Postoperative tachycardia may be the only sign of a postoperative<br />
complication and should not be ignored (see below).<br />
Thromboprophylaxis<br />
Obesity per se is a risk factor for VTE and it is recommended that all<br />
obese patients, undergoing all but minor surgery, should receive VTE<br />
prophylaxis. Guidelines for postsurgical VTE prophylaxis were published<br />
by the National Institute for Health and Care Excellence in 2010<br />
[78]. Strategies to reduce the risk of VTE include: early postoperative<br />
mobilisation; mechanical compression devices; thromboembolic device<br />
(TED) stockings; anticoagulant drugs; and vena caval filters. There is<br />
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Table 6 Dosing schedule for thromboprophylaxis [80].<br />
Enoxaparin<br />
Dalteparin<br />
Tinzaparin<br />
< 50 kg 50–100 kg 100–150 kg > 150 kg<br />
20 mg once 40 mg once 40 mg twice 60 mg twice<br />
daily<br />
daily<br />
daily<br />
daily<br />
2500 units 5000 units 5000 units 7500 units<br />
once daily once daily twice daily twice daily<br />
3500 units 4500 units 4500 units 6750 units<br />
once daily once daily twice daily twice daily<br />
currently limited evidence to support the use of TEDs in obesity, but if<br />
used, it is essential that they be fitted correctly to avoid vascular occlusion.<br />
Current evidence does not support the routine use of venal caval<br />
filters in the obese population [79].<br />
The mainstay of VTE prophylaxis in obesity is pharmacological, with<br />
the criteria for pharmacological prophylaxis including: prolonged immobilisation;<br />
total theatre time > 90 min; age > 60 years; BMI > 30 kg.m 2 ; cancer;<br />
dehydration; and a family history of VTE.<br />
Oral agents such as rivaroxiban and dabigatran are licensed for<br />
VTE prophylaxis following orthopaedic surgery, but there is limited evidence<br />
for their use in obesity. At present, dose adjustment for oral<br />
agents is not recommended for the obese.<br />
There is evidence regarding dose adjustments for low molecular<br />
weight heparins in obesity. The Haemostasis, Anticoagulation and<br />
Thrombosis (HAT) Committee published the dosing schedule reproduced<br />
in Table 6 in April 2010 [80].<br />
Rhabdomyolysis<br />
A rare but serious complication in the obese patient is rhabdomyolysis.<br />
Apart from obesity, pre-disposing risk factors include hypotension,<br />
immobility, prolonged operative procedures and dehydration.<br />
Rhabdomyolysis should be considered if the patient has postoperative<br />
deep tissue pain, classically in the buttocks. Serum creatinine kinase<br />
concentration should be measured promptly, and if rising, aggressive<br />
fluid resuscitation, diuretics and urinary alkalinisation may be required<br />
to prevent further acute kidney injury [81].<br />
Special circumstances<br />
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21
Sedation<br />
Pre-operative evaluation for patients undergoing sedation should be<br />
similar to those having general anaesthesia. Patients with sleep-disordered<br />
breathing are likely to have airway obstruction with even minimal<br />
sedation. Obese patients are not suitable for solo operator-sedator procedures<br />
[82].<br />
Emergency surgery<br />
It is particularly important that obese patients requiring emergency surgery<br />
are managed by an anaesthetist experienced in the care of the<br />
obese, along with an experienced surgeon in order to minimise the<br />
operative time and the risk of complications [83]. Postoperative level-2<br />
nursing care is far more likely to be required owing to the much higher<br />
risk from emergency surgery complications.<br />
Obese patients can look deceptively well and abdominal examination<br />
can be notoriously difficult. Tachycardia, the new onset of abdominal<br />
pain or unexplained fever may be the only signs of intra-abdominal<br />
sepsis and should be an indication for measuring arterial blood gases<br />
and serum lactate.<br />
Day surgery<br />
It is acceptable for obese patients to undergo surgery as a day case if:<br />
the management would not be modified if they were admitted as an<br />
inpatient; and being treated as a day case will not alter the peri-operative<br />
risk.<br />
The exclusion of obese patients from the advantages that day surgery<br />
may offer should not be made on the basis of weight alone. There<br />
is an increased risk of anaesthetic-related complications in obese<br />
patients in the day surgery environment, but these tend to occur on<br />
induction of anaesthesia, intra-operatively or in the early recovery phase<br />
[84]. Obesity has no influence on the rate of unanticipated admission,<br />
postoperative complications, readmission or other unplanned contact<br />
with health professionals after home discharge [85].<br />
Current guidelines advocate automatic acceptance of patients with<br />
BMI < 40 kg.m 2 [86, 87]. A casenote review should be carried out by<br />
an anaesthetist to determine whether individualised discussion and<br />
assessment may be required before the day of surgery for those with comorbidities<br />
or BMI > 40 kg.m 2 .<br />
22 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
A review and meta-analysis by the Society for Ambulatory Anesthesia<br />
provides useful advice on day surgery for patients with sleep-disordered<br />
breathing [49]. Patients with a known diagnosis of OSA can be considered<br />
for day surgery: if they have, and are able to use, a CPAP device after discharge;<br />
if any co-morbid conditions are optimised; and if postoperative<br />
pain relief can be provided predominantly by non-opioid analgesics.<br />
Laparoscopic cholecystectomy and laparoscopic gastric banding are<br />
increasingly being performed as a day-case procedure [88–90].<br />
Obstetrics<br />
Maternal obesity is recognised as one of the most commonly occurring<br />
risk factors seen in obstetrics, with outcomes for both mother and baby<br />
poorer than in the general population [3].<br />
The CMACE report and the Obstetric Anaesthetists’ Association<br />
have made a number of recommendations regarding the care of obese<br />
pregnant women [91, 92]. Obese women have an increased risk of comorbidity<br />
during pregnancy, in particular gestational diabetes and preeclampsia<br />
[93, 94]. Obesity and pregnancy are both significant risk factors<br />
for the development of VTE in pregnancy.<br />
Compared with a non-obese parturient, an obese woman is more<br />
likely to have her labour induced and require instrumental delivery [95,<br />
96]. There is an increased risk of operative and postoperative complications,<br />
including increased rates of postpartum haemorrhage, prolonged<br />
operative times, and infective complications such as endometritis and<br />
wound infection [97].<br />
Fetal outcomes in obese pregnant women are poorer compared with<br />
the general population, with stillbirth rates in women with a BMI<br />
> 35 kg.m 2 twice as high as the national stillbirth rate. There is an<br />
increased risk of preterm delivery in pregnant obese women [98].<br />
In addition, babies born to obese mothers are at increased risk of<br />
shoulder dystocia, brachial plexus lesions, fractured clavicle and congenital<br />
birth defects such as neural tube defects [99].<br />
Specific anaesthetic considerations are similar to those in the nonobstetric<br />
obese patient:<br />
Obese patients are particularly vulnerable to aortocaval compression<br />
• Vascular access may be more difficult and should be established<br />
early in labour in a woman with a BMI > 40 kg.m 2 [3]<br />
•<br />
The provision of general anaesthesia and central neuraxial blockade<br />
is associated with increased difficulties [100–102]. This can lead to<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
23
an increased decision-to-delivery interval in women who require a<br />
category-1 or -2 caesarean section.<br />
The obese obstetric patient is particularly at risk of VTE and conversely,<br />
postpartum haemorrhage. The recommended dosing of anticoagulants<br />
is generally higher for pregnant women; the Royal College of<br />
Obstetricians and Gynaecologists’ Green-top Guideline provides current<br />
recommendations [103].<br />
Critical care<br />
Outcomes of obese patients in critical care remain controversial. In several<br />
recent studies, obesity was not associated with increased mortality;<br />
however, it was associated with a prolonged requirement for mechanical<br />
ventilation, tracheostomy and prolonged length of stay in a critical care<br />
unit [104, 105].<br />
Airway interventions in the obese are associated with an increased<br />
risk of hypoxia and complications and should only be undertaken by<br />
appropriately skilled personnel. Many would advocate an early tracheostomy<br />
if long-term airway management is anticipated. Custom-made tracheostomy<br />
tubes with an adjustable flange may be required to ensure an<br />
adequate length to reach the trachea. Tracheostomies are usually performed<br />
in the intensive care unit using a percutaneous approach, but<br />
surgical placement may be considered, depending on the experience of<br />
the available medical staff.<br />
For mechanical ventilation, ideal body weight is used to calculate<br />
the initial recommended tidal volume of 5–7 ml.kg 1 , ensuring the peak<br />
inspiratory pressure remains < 35 cmH 2 O [106].<br />
Enteral absorption of drugs is not altered in the morbidly obese. However,<br />
owing to the altered pharmacokinetics, monitoring of serum levels is<br />
considered more important in this group of patients to ensure that drug<br />
levels remain within the therapeutic range [37].<br />
Prophylaxis against VTE is vitally important for the morbidly obese<br />
patient in critical care and should follow the guidelines given above.<br />
All critically ill patients are prone to develop protein malnutrition as a<br />
result of metabolic stress and despite having excess fat stores, the morbidly<br />
obese are no different. However, there is some evidence suggesting that<br />
hypocaloric feeding regimens can achieve adequate nitrogen balance with<br />
more favourable outcomes [107].<br />
Early aggressive rehabilitation and physiotherapy should be undertaken<br />
as soon as is possible to encourage early mobilisation. Increased<br />
24 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
numbers of staff are needed to roll these patients to prevent formation<br />
of pressure sores.<br />
Cardiopulmonary resuscitation<br />
Morbid obesity presents additional problems during resuscitation. There<br />
may be delays caused by difficulties in placement of defibrillator pads,<br />
establishment of vascular access or securing an effective airway. Physical<br />
and biological factors related to obesity may affect the quality of chest<br />
compressions delivered, the efficacy of administered vasoactive drugs or<br />
the efficacy of defibrillator shocks applied, because none of these measures<br />
are standardised to a patient’s BMI. The American Heart Association<br />
has concluded that no alterations to resuscitation have been shown<br />
to affect outcome [108].<br />
Inspiratory airway pressures will be higher than normal, and<br />
excessive leak with supraglottic airway devices may mean that chest<br />
compressions will have to be paused to enable ventilation (i.e. a standard<br />
30:2 compression-ventilation ratio). The high airway pressures<br />
that can occur during resuscitation of very obese patients may impair<br />
coronary perfusion pressure and ultimately reduce the chance of survival<br />
[109].<br />
Chest compressions will be difficult to perform in many patients,<br />
simply because of suboptimal positioning of rescuers. A step or platform<br />
may be required, or compressions can be performed from the patients’<br />
head end. Recommended defibrillation energies remain unaltered in the<br />
morbidly obese, though there is evidence that the thoracic impedance is<br />
higher [110]. If defibrillation remains unsuccessful, the defibrillator pads<br />
should be repositioned and the shock energy increased to the maximum<br />
setting.<br />
If intravenous access is difficult, the intraosseous route for drug<br />
delivery is recommended. The upper humerus is a well-established point<br />
of access, and drug delivery during resuscitation is effective via this<br />
route. Standard doses of adrenaline and amiodarone should be used.<br />
Patients with adjustable gastric bands in situ<br />
Laparoscopic adjustable gastric banding is a recognised treatment for<br />
obesity. However, patients with a gastric band in situ are at increased<br />
risk of pulmonary aspiration during general anaesthesia owing to<br />
oesophageal dysmotility and dilatation above the band. The dilatation<br />
may persist following band deflation. There are case reports of regurgitation<br />
of food even after prolonged fasting and a tracheal tube is recom-<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
25
mended in all patients who have a gastric band [111, 112]. Current<br />
advice is not to deflate the band before surgery; however, depending on<br />
the extent and type of surgery, a decision to deflate the band may be<br />
made on an individual basis. Discussion with the bariatric surgical team<br />
is advised.<br />
An important side note is that patients with gastric bands in situ<br />
who present with sudden onset of dysphagia or upper abdominal pain<br />
should be considered as having a band slippage until proved otherwise.<br />
This is a surgical emergency and should be treated by immediate deflation<br />
of the gastric band and referral to a competent general surgeon.<br />
Delay in deflating the band can lead to gastric infarction and perforation.<br />
For the management of other bariatric surgical emergencies, readers<br />
are referred to the American Society for Metabolic and Bariatric Surgery<br />
website (see below).<br />
Resources<br />
Equipment<br />
A 2011 review of incidents related to obesity reported to the National<br />
Patient Safety Agency highlighted that many of these involved inadequate<br />
provision of suitable equipment. This is a clinical governance issue<br />
and hospitals need to invest in appropriate equipment to assist in the<br />
safe management of obese patients. A suggested but not exhaustive list<br />
of equipment to be considered is given in Table 7 [113].<br />
An ‘obesity pack’ is useful; this can include specialised documentation,<br />
the SOBA single-sheet guidelines (see below) and smaller items of<br />
equipment plus a list of where the larger items are located.<br />
Staff<br />
All units managing obese surgical patients must have the ability to escalate<br />
care appropriately in the event of acute deterioration of patients.<br />
It is recommended that a single person in the anaesthetic department<br />
be nominated as the obesity lead. It would be his/her responsibility<br />
to ensure that equipment and training are up to standard and could<br />
act as a point of contact for advice.<br />
Theatre teams should have training in managing obese patients,<br />
which can be provided either internally or externally. In hospitals where<br />
there is a bariatric service, all staff should periodically observe practice<br />
in this area. Specific training on moving the morbidly obese patient<br />
should be provided.<br />
26 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
Table 7 Equipment for managing obese surgical patients.<br />
Ward equipment<br />
Specialised electrically operated beds that can raise a patient to standing<br />
without the need for manual handling with<br />
pressure-relieving mattresses<br />
Suitable bathrooms with floor-mounted toilets, suitable commodes<br />
Large blood pressure measuring cuffs<br />
Extra-large gowns<br />
Suitably sized compression stockings and intermittent compression devices<br />
Larger chairs, wheelchairs and trolleys, all marked with the maximal<br />
recommended weight<br />
Scales capable of weighing up to 300 kg<br />
On-site blood gas analysis<br />
Continuous positive airway pressure or high-flow oxygen delivery device for<br />
the post-anaesthesia care unit<br />
Patient hoist or other moving device (may be shared with other<br />
departments)<br />
Theatre equipment<br />
Bariatric operating table, able to incorporate armboards and table<br />
extensions, attachments for positioning such as leg<br />
supports for the lithotomy position, and shoulder and foot supports<br />
Gel pads and padding for pressure points<br />
Wide Velcro strapping to secure the patient to the operating table<br />
Ramping device/pillows<br />
Raised step for the anaesthetist<br />
Large tourniquets<br />
Readily available difficult airway equipment<br />
Anaesthetic ventilator capable of positive end-expiratory pressure and<br />
pressure modalities<br />
Portable ultrasound machine<br />
Hover-mattress or slide sheet<br />
Long spinal and epidural needles<br />
Long arterial lines if femoral access is necessary<br />
Neuromuscular blockade monitor<br />
Depth of anaesthesia monitoring to minimise residual sedation<br />
In ideal circumstances, all anaesthetic trainees should complete a<br />
module in bariatric anaesthesia to gain insight and hands-on experience<br />
in the management of the morbidly obese surgical patient.<br />
The SOBA single-sheet guide<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland<br />
27
This is designed as an aide memoire to be laminated and left in the<br />
anaesthetic room for reference when required. It is available on the<br />
SOBA website and updated every six months as new evidence becomes<br />
available (see www.sobauk.com).<br />
Useful websites<br />
The Society for Obesity and Bariatric Anaesthesia UK: www.sobauk.com.<br />
British Obesity Surgery Patient Association: www.bospauk.org.<br />
British Obesity and Metabolic Surgery Society: www.bomss.org.uk.<br />
American Society for Metabolic and Bariatric Surgery: www.asmbs.org.<br />
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women. Obstetrics and Gynecology 2004; 104: 943–51.<br />
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101. Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients.<br />
Anesthesiology 1993; 79: 1210–8.<br />
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morbidity. American Journal of Obstetrics and Gynecology 1994; 170: 560–5.<br />
103. Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis<br />
and Embolism During Pregnancy and the Puerperium. 2009. https://<br />
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(accessed 08/01/2015).<br />
104. Kumar G, Majumdar T, Jacobs ER, et al. Outcomes of morbidly obese patients<br />
receiving invasive mechanical ventilation: a nationwide analysis. Chest 2013;<br />
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and mortality: a meta-analysis. Critical Care Medicine 2008; 36: 151–8.<br />
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for acute lung injury and the acute respiratory distress syndrome. The Acute<br />
Respiratory Distress Syndrome Network. New England Journal of Medicine 2000;<br />
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with obesity. Nutrition in Clinical Practice 2014; 29: 786–91.<br />
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2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation<br />
and Emergency Cardiovascular Care. Circulation 2010; 122: S829–61.<br />
34 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd<br />
on behalf of Association of Anaesthetists of Great Britain and Ireland
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Peri-operative management of the<br />
surgical patient with diabetes 2015<br />
Published by<br />
The Association of Anaesthetists of Great Britain & Ireland<br />
Sept 2015
This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please use the following<br />
reference:<br />
Association of Anaesthetists of Great Britain and Ireland. Peri-operative management of the surgical patient with diabetes<br />
2015. Anaesthesia 2015; 70: 1427-1440.<br />
This guideline can be viewed online via the following URL:<br />
http://onlinelibrary.wiley.com/doi/10.1111/anae.13233/full
Anaesthesia 2015<br />
Guidelines<br />
doi:10.1111/anae.13233<br />
Peri-operative management of the surgical patient with diabetes<br />
2015<br />
Association of Anaesthetists of Great Britain and Ireland<br />
Membership of the Working Party: P. Barker, P. E. Creasey, K. Dhatariya, 1 N. Levy, A. Lipp, 2<br />
M. H. Nathanson (Chair), N. Penfold, 3 B. Watson and T. Woodcock<br />
1 Joint British Diabetes Societies Inpatient Care Group<br />
2 British Association of Day Surgery<br />
3 Royal College of Anaesthetists<br />
Summary<br />
Diabetes affects 10–15% of the surgical population and patients with diabetes undergoing surgery have greater complication<br />
rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes<br />
focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c<br />
< 69 mmol.mol<br />
1 ); deciding if the patient can be managed by simple manipulation of pre-existing treatment during<br />
a short starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion;<br />
and safe use of the latter when it is the only option, for example in emergency patients, patients expected not<br />
to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it<br />
is imperative that communication amongst healthcare professionals and between them and the patient is accurate<br />
and well informed at all times. Most patients with diabetes have many years of experience of managing their own<br />
care. The purpose of this guideline is to provide detailed guidance on the peri-operative management of the surgical<br />
patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.<br />
.................................................................................................................................................................<br />
This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists of<br />
Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board of Directors. Date of review: 2020.<br />
Accepted: 12 August 2015<br />
• What other guideline statements are available on this<br />
topic?<br />
The NHS Diabetes Guideline for the Peri-operative<br />
Management of the Adult Patient with Diabetes [1] was<br />
published in 2011 by NHS Diabetes (now part of NHS<br />
Improving Quality), and is due to be updated in 2015.<br />
• Why was this guideline developed?<br />
This guideline was developed to improve both the<br />
safety and the outcome of patients with diabetes<br />
undergoing surgical procedures.<br />
.................................................................................................................................................................<br />
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs<br />
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is<br />
non-commercial and no modifications or adaptations are made.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 1
Anaesthesia 2015<br />
Barker et al. | Guidelines on peri-operative management of diabetes<br />
• How and why does this statement differ from existing<br />
guidelines?<br />
The 2011 guideline [1] deals with the whole patient<br />
pathway, from referral for surgery from primary<br />
care to discharge and follow-up. It is too broad in<br />
scope to be a working document for anaesthetists.<br />
This guideline summarises the existing guideline<br />
and focuses specifically on peri-operative care.<br />
Introduction<br />
The demographics describing the dramatic increase in<br />
the number of patients with diabetes are well known.<br />
Patients with diabetes require surgical procedures more<br />
frequently and have longer hospital stays than those<br />
without the condition [2]. The presence of diabetes or<br />
hyperglycaemia in surgical patients has been shown to<br />
lead to increased morbidity and mortality, with perioperative<br />
mortality rates up to 50% greater than the<br />
non-diabetic population [2]. The reasons for these<br />
adverse outcomes are multifactorial, but include: failure<br />
to identify patients with diabetes or hyperglycaemia [3,<br />
4]; multiple co-morbidities including microvascular and<br />
macrovascular complications [5]; complex polypharmacy<br />
and insulin prescribing errors [6]; increased peri-operative<br />
and postoperative infections [2, 7, 8]; associated<br />
hypoglycaemia and hyperglycaemia [2]; a lack of, or<br />
inadequate, institutional guidelines for management of<br />
inpatient diabetes or hyperglycaemia [2, 9]; and inadequate<br />
knowledge of diabetes and hyperglycaemia management<br />
amongst staff delivering care [10].<br />
Anaesthetists and other peri-operative care providers<br />
should be knowledgeable and skilled in the care<br />
of patients with diabetes. Management of diabetes is a<br />
vital element in the management of surgical patients<br />
with diabetes. It is not good enough for the diabetic<br />
care to be a secondary, or sometimes forgotten, element<br />
of the peri-operative care package.<br />
Previous guidelines<br />
In April 2011 NHS Diabetes (now part of NHS<br />
Improving Quality) published a document: NHS Diabetes<br />
Guideline for the Peri-operative Management of<br />
the Adult Patient with Diabetes, in association with the<br />
Joint British Diabetes Societies (JBDS) [1] (an almost<br />
identical version, Management of Adults with Diabetes<br />
Undergoing Surgery and Elective Procedures: Improving<br />
Standards, is available at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm).<br />
This comprehensive guideline<br />
provided both background information and advice to<br />
clinicians caring for patients with diabetes. Some of<br />
the recommendations in that document were due for<br />
review in the light of new evidence and, in addition, it<br />
was felt that anaesthetists and other practitioners caring<br />
for patients with diabetes in the peri-operative period<br />
needed shorter, practical advice. The Association<br />
of Anaesthetists of Great Britain and Ireland (AAGBI)<br />
offered to co-author this shortened guideline, in collaboration<br />
with colleagues involved with the 2011 document.<br />
The previous 2011 NHS Diabetes guidelines<br />
will also be updated in 2015.<br />
The risks of poor diabetic control<br />
Studies have shown that high pre-operative and perioperative<br />
glucose and glycated haemoglobin (HbA1c)<br />
levels are associated with poor surgical outcomes.<br />
These findings have been seen in both elective and<br />
emergency surgery including spinal [11], vascular [12],<br />
colorectal [13], cardiac [14, 15], trauma [16], breast<br />
[17], orthopaedic [18], neurosurgical, and hepatobiliary<br />
surgery [19, 20]. One study showed that the adverse<br />
outcomes include a greater than 50% increase in mortality,<br />
a 2.4-fold increase in the incidence of postoperative<br />
respiratory infections, a doubling of surgical site<br />
infections, a threefold increase in postoperative urinary<br />
tract infections, a doubling in the incidence of myocardial<br />
infarction, and an almost twofold increase in acute<br />
kidney injury [2]. Paradoxically, there are some data to<br />
show that the outcomes of patients with diabetes may<br />
not be different from, or may indeed be better than,<br />
those without diabetes if the diagnosis is known before<br />
surgery [21]. The reasons for this are unknown, but<br />
may be due to increased vigilance surrounding glucose<br />
control for those with a diagnosis of diabetes.<br />
Referral from primary care and<br />
planning surgery<br />
The aim is to ensure that diabetes is as well controlled as<br />
possible before elective surgery and to avoid delays to<br />
surgery due to poor control. The Working Party supports<br />
the consensus advice published in the 2011 NHS<br />
Diabetes guideline that the HbA1c should be<br />
< 69 mmol.mol<br />
1 (8.5%) for elective cases [1], and<br />
2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland
Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015<br />
that elective surgery should be delayed if it is<br />
≥ 69 mmol.mol<br />
1 , while control is improved. Changes<br />
to diabetes management can be made concurrently with<br />
referral to ensure the patient’s diabetes is as well controlled<br />
as possible at the time of surgery. Elective surgery<br />
in patients with diabetes should be planned with the aim<br />
of minimising disruption to their self-management.<br />
•<br />
Recommendation: Glycaemic control should be<br />
checked at the time of referral for surgery. Information<br />
about duration, type of diabetes, current<br />
treatment and complications should be made available<br />
to the secondary care team.<br />
Surgical outpatient clinic<br />
The adequacy of diabetes control should be assessed<br />
again at the time of listing for surgery, ideally with a<br />
recorded HbA1c < 69 mmol.mol<br />
1 in the previous three<br />
months. If it is ≥ 69 mmol.mol<br />
1 , elective surgery should<br />
be delayed while control is improved. In a small number<br />
of cases it may not be possible to improve diabetic control<br />
pre-operatively, particularly if the reason for surgery,<br />
such as chronic infection, is contributing to poor control,<br />
or if surgery is semi-urgent. In these circumstances, it<br />
may be acceptable to proceed with surgery after explanation<br />
to the patient of the increased risks. Patients should<br />
be managed as a day case if the procedure is suitable<br />
and the patient fulfils the criteria for day-case surgery<br />
management. Well-controlled diabetes should not be a<br />
contra-indication to day-case surgery.<br />
Patients with poorly controlled diabetes at the time<br />
of surgery will need close monitoring and may need to<br />
start a variable-rate intravenous insulin infusion (VRIII).<br />
• Recommendation: Patients with diabetes should be<br />
identified early in the pre-operative pathway.<br />
Pre-operative assessment<br />
Appropriate and early pre-operative assessment should<br />
be arranged. A pre-operative assessment nurse may<br />
undertake the assessment with support from either an<br />
anaesthetist or a diabetes specialist nurse. It should<br />
occur sufficiently in advance of the planned surgery to<br />
ensure optimisation of glycaemic control before the<br />
date of proposed surgery. The aim is to ensure that all<br />
relevant investigations are available and checked in<br />
advance of the planned surgery, that the patient understands<br />
how to manage his/her diabetes in the peri-operative<br />
period, and that the period of pre-operative<br />
fasting is minimised.<br />
• Recommendation: Tests should be ordered to assess<br />
co-morbidities in line with National Institute for<br />
Health and Care Excellence (NICE) guidance on<br />
pre-operative testing [22]. This should include urea<br />
and electrolytes and ECG for all patients with diabetes;<br />
however, a random blood glucose measurement<br />
is not indicated.<br />
Planning admission (including day surgery)<br />
The aim is to minimise the fasting period, ensure<br />
normoglycaemia (capillary blood glucose (CBG) 6–<br />
10 mmol.l<br />
1 ) and minimise as far as possible disruption<br />
to the patient’s usual routine. Ideally, the patient<br />
should be booked first on the operating list to minimise<br />
the period of fasting. If the fasting period is<br />
expected to be limited to one missed meal, the patient<br />
can be managed by modification of his/her usual diabetes<br />
medication (see below). Patients should be provided<br />
with written instructions from the pre-operative<br />
assessment team about management of their diabetes<br />
medication on the day of surgery, the management of<br />
hypo- or hyperglycaemia in the peri-operative period,<br />
and the likely effects of surgery on their diabetes control.<br />
Patients should be advised to carry a form of glucose<br />
that they can take in case of symptoms of<br />
hypoglycaemia that will not cause surgery to be cancelled,<br />
for example a clear, sugar-containing drink<br />
(glucose tablets may be used instead, but some anaesthetists<br />
may feel they should not be taken within 6 h<br />
of the start of anaesthesia). Patients should be warned<br />
that their blood glucose control may be erratic for a<br />
few days after the procedure.<br />
• Recommendation: When possible, admission should<br />
be planned for the day of surgery, with both the<br />
patient and the ward staff aware of the planned<br />
peri-operative diabetes care, including a plan to<br />
manage hypo- and hyperglycaemia. Surgery should<br />
be scheduled at the start of the theatre list to<br />
minimise disruption to the patient’s glycaemic<br />
control.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 3
Anaesthesia 2015<br />
Barker et al. | Guidelines on peri-operative management of diabetes<br />
Management of existing therapy<br />
With appropriate guidance, patients with diabetes<br />
should be allowed to retain control and possession of,<br />
and continue to self-administer, their medication.<br />
Many patients will have several years’ experience and<br />
be expert in self-medication.<br />
The aim is to avoid hypo- or hyperglycaemia<br />
during the period of fasting and the time during and<br />
after the procedure, until the patient is eating and<br />
drinking normally. In people who are likely to miss<br />
one meal only, this can often be achieved by manipulating<br />
the patient’s normal medication using the guidance<br />
provided in Tables 1 and 2.<br />
Glycaemic control in patients with diabetes is a<br />
balance between their carbohydrate intake and utilisation<br />
(for example, exercise). It also depends on what<br />
medication they take and how those medications<br />
work. Some agents (e.g. sulphonylureas, meglitinides,<br />
Table 1 Guideline for peri-operative adjustment of insulin (short starvation period – no more than one missed<br />
meal).<br />
Day of surgery<br />
Insulin<br />
Day before<br />
admission Surgery in the morning<br />
Once daily (e.g. Lantus â , Levemir â , Tresiba â , Insulatard â , Humulin I â , Insuman â )<br />
Evening<br />
Reduce dose Check blood glucose on<br />
by 20% admission<br />
Morning<br />
Reduce dose Reduce dose by 20%; check<br />
by 20% blood glucose on admission<br />
Surgery in the afternoon<br />
Check blood glucose on<br />
admission<br />
Reduce dose by 20%;<br />
check blood glucose on<br />
admission<br />
Whilst a VRIII is<br />
being used*<br />
Continue at 80%<br />
of usual dose<br />
Continue at 80%<br />
of usual dose<br />
Twice daily<br />
Biphasic or ultra-long<br />
acting (e.g. Novomix<br />
30 â , Humulin M3 â ,<br />
Humalog Mix 25 â ,<br />
Humalog Mix 50 â ,<br />
Insuman â Comb 25,<br />
Insuman â Comb 50,<br />
Levemir â , Lantus â )by<br />
single injection, given<br />
twice daily<br />
Short-acting (e.g.<br />
animal neutral,<br />
Novorapid â , Humulin<br />
S â , Apidra â ) and<br />
intermediate-acting<br />
(e.g. animal isophane,<br />
Insulatard â , Humulin I â ,<br />
Insuman â ) by separate<br />
injections, both given<br />
twice daily<br />
No dose<br />
change<br />
No dose<br />
change<br />
Halve the usual morning dose;<br />
check blood glucose on<br />
admission; leave evening meal<br />
dose unchanged<br />
Calculate total dose of morning<br />
insulin(s); give half as<br />
intermediate-acting only in<br />
the morning; check blood<br />
glucose on admission; leave<br />
evening meal dose unchanged<br />
Halve the usual morning<br />
dose; check blood<br />
glucose on admission;<br />
leave the evening meal<br />
dose unchanged<br />
Calculate total dose of<br />
morning insulin(s); give<br />
half as intermediateacting<br />
only in the<br />
morning; check blood<br />
glucose on admission;<br />
leave evening meal<br />
dose unchanged<br />
Stop until eating<br />
and drinking<br />
normally<br />
Stop until eating<br />
and drinking<br />
normally<br />
Three to five injections daily<br />
No dose<br />
change<br />
Basal bolus regimens:<br />
Omit morning and lunchtime<br />
short-acting insulins; keep<br />
basal unchanged*<br />
Premixed morning insulin:<br />
Halve morning dose and omit<br />
lunchtime dose; check blood<br />
glucose on admission<br />
Give usual morning<br />
insulin dose(s); omit<br />
lunchtime dose; check<br />
blood glucose on<br />
admission<br />
Stop until eating<br />
and drinking<br />
normally<br />
* If the patient requires a VRIII then the long-acting background insulin should be continued but at 80% of the dose the patient<br />
usually takes when he/she is well.<br />
VRIII, variable-rate intravenous insulin infusion.<br />
4 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland
Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015<br />
Table 2 Guideline for peri-operative adjustment of oral hypoglycaemic agents (short starvation period – no more<br />
than one missed meal).<br />
Day of surgery<br />
Surgery in the<br />
Agent<br />
Day before admission morning<br />
Drugs that require omission when fasting owing to risk of hypoglycaemia<br />
Meglitinides<br />
Take as normal Omit morning dose if<br />
(e.g. repaglinide,<br />
nil by mouth<br />
nateglinide)<br />
Sulphonylurea<br />
(e.g. glibenclamide,<br />
gliclazide, glipizide)<br />
Take as normal<br />
Omit morning dose<br />
(whether taking<br />
once or twice daily)<br />
Drugs that require omission when fasting owing to risk of ketoacidosis<br />
SGLT-2 inhibitors*<br />
(e.g. dapagliflozin,<br />
canagliflozin)<br />
No dose change Halve the usual<br />
morning dose; check<br />
blood glucose on<br />
admission; leave<br />
evening meal dose<br />
unchanged<br />
Surgery in the<br />
afternoon<br />
Give morning dose if<br />
eating<br />
Omit (whether taking<br />
once or twice daily)<br />
Halve the usual<br />
morning dose; check<br />
blood glucose on<br />
admission; leave the<br />
evening meal dose<br />
unchanged<br />
Whilst a VRIII is<br />
being used<br />
Stop until eating and<br />
drinking normally<br />
Stop until eating and<br />
drinking normally<br />
Stop until eating and<br />
drinking normally<br />
Drugs that may be continued when fasting<br />
Acarbose Take as normal Omit morning dose if<br />
nil by mouth<br />
DPP-IV inhibitors<br />
(e.g. sitagliptin,<br />
vildagliptin, saxagliptin,<br />
alogliptin, linagliptin)<br />
GLP-1 analogues<br />
(e.g. exenatide,<br />
liraglutide, lixisenatide)<br />
Metformin (procedure<br />
not requiring use of<br />
contrast media†)<br />
Give morning dose if<br />
eating<br />
Stop until eating and<br />
drinking normally<br />
Take as normal Take as normal Take as normal Stop until eating and<br />
drinking normally<br />
Take as normal Take as normal Take as normal Take as normal<br />
Take as normal Take as normal Take as normal Stop until eating and<br />
drinking normally<br />
Pioglitazone Take as normal Take as normal Take as normal Stop until eating and<br />
drinking normally<br />
* Also omit the day after surgery.<br />
† If contrast medium is to be used or the estimated glomerular filtration rate is under 60 ml.min 1 .1.73 m 2 , metformin should be<br />
omitted on the day of the procedure and for the following 48 h.<br />
VRIII, variable-rate intravenous insulin infusion; SGLT-2, sodium-glucose co-transporter-2; DPP-IV, dipeptidyl peptidase-IV;<br />
GLP-1, glucagon-like peptide-1.<br />
insulin and to some extent, thiazolidinediones) act by<br />
lowering glucose concentrations, and doses need to<br />
be modified or the agents stopped during periods of<br />
starvation. Others work by preventing glucose levels<br />
from rising (e.g. metformin, glucagon-like peptide-1<br />
analogues, dipeptidyl peptidase-4 inhibitors); these<br />
drugs may be continued without the risk of hypoglycaemia.<br />
The time of day and the expected duration<br />
of the operation need to be considered, as will<br />
whether a VRIII will be needed. Patients with continuous<br />
subcutaneous insulin infusions only missing one<br />
meal should be advised to maintain their CBG at<br />
6–10 mmol.l<br />
1 . If longer periods of starvation are<br />
predicted, a VRIII should be used and specialist<br />
advice sought.<br />
Tables 1 and 2 have been designed to take all of<br />
these factors into consideration. They are a pragmatic<br />
approach to the pre-operative management of all the<br />
available classes of agent used to manage diabetes.<br />
Use of a variable-rate intravenous insulin<br />
infusion<br />
Variable-rate intravenous insulin infusions are preferred<br />
in: patients who will miss more than one meal;<br />
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Barker et al. | Guidelines on peri-operative management of diabetes<br />
those with type-1 diabetes undergoing surgery who<br />
have not received background insulin; those with<br />
poorly controlled diabetes (defined as a HbA1c<br />
> 69 mmol.mol<br />
1 ); and most patients with diabetes<br />
requiring emergency surgery. Variable-rate intravenous<br />
insulin infusions should be administered and monitored<br />
by appropriately experienced and qualified staff.<br />
An example of a VRIII regimen is provided in<br />
Appendix 1.<br />
Intra-operative care and monitoring<br />
The aim of intra-operative care is to maintain good<br />
glycaemic control and normal electrolyte concentrations,<br />
while optimising cardiovascular function and<br />
renal perfusion. If possible, multimodal analgesia<br />
should be used along with appropriate anti-emetic prophylaxis,<br />
to enable an early return to a normal diet<br />
and the patient’s usual diabetes regimen.<br />
• Recommendation: An intra-operative CBG range of<br />
6–10 mmol.l<br />
1 should be aimed for (an upper limit<br />
of 12 mmol.l<br />
1 may be tolerated at times, e.g. if<br />
the patient has poorly controlled diabetes and is<br />
being managed by a modification of his/her normal<br />
medication without a VRIII). It should be understood<br />
by all staff that a CBG within the range of<br />
6–10 mmol.l<br />
1 is acceptable and that there is no<br />
requirment for a CBG of 6 mmol.l<br />
1 to be the target.<br />
The CBG should be checked before induction<br />
of anaesthesia and monitored regularly during the<br />
procedure (at least hourly, or more frequently if<br />
the results are outside the target range). The CBG,<br />
insulin infusion rate and substrate infusion should<br />
be recorded on the anaesthetic record. Some charts<br />
use colour-coded areas to highlight abnormal<br />
results requiring further intervention or a change<br />
of treatment (see Appendix 2).<br />
Management of intra-operative hyperglycaemia<br />
and hypoglycaemia<br />
If the CBG exceeds 12 mmol.l<br />
1 and insulin has been<br />
omitted, capillary blood ketone levels should be measured<br />
if possible (point-of-care devices are available). If<br />
the capillary blood ketones are > 3 mmol.l<br />
1 or there<br />
is significant ketonuria (> 2+ on urine sticks) the<br />
patient should be treated as having diabetic ketoacidosis<br />
(DKA). Diabetic ketoacidosis is a triad of ketonaemia<br />
> 3.0 mmol.l<br />
1 , blood glucose > 11.0 mmol.l<br />
1 ,<br />
and bicarbonate < 15.0 mmol.l<br />
1 or venous pH < 7.3.<br />
Diabetic ketoacidosis is a medical emergency and specialist<br />
help should be obtained from the diabetes team.<br />
If DKA is not present, the high blood glucose<br />
should be corrected using subcutaneous insulin (see<br />
below) or by altering the rate of the VRIII (if in use).<br />
If two subcutaneous insulin doses do not work, a<br />
VRIII should be started.<br />
Treatment of hyperglycaemia in a patient with type-1<br />
diabetes<br />
Subcutaneous rapid-acting insulin (such as Novorapid<br />
â , Humalog â or Apidra â ) should be given (up to<br />
a maximum of 6 IU), using a specific insulin syringe,<br />
assuming that 1 IU will drop the CBG by 3 mmol.l<br />
1 .<br />
Death or severe harm as a result of maladministration<br />
of insulin, including failure to use the specific insulin<br />
syringe, is a ‘Never Event’. If the patient is awake, it is<br />
important to ensure that the patient is content with<br />
proposed dose (patients may react differently to subcutaneous<br />
rapid-acting insulin). The CBG should be<br />
checked hourly and a second dose considered only<br />
after 2 h.<br />
Treatment of hyperglycaemia in a patient with type-2<br />
diabetes<br />
Subcutaneous rapid-acting insulin 0.1 IU.kg 1 should<br />
be given (up to a maximum of 6 IU), using a specific<br />
insulin syringe. The CBG should be checked hourly<br />
and a second dose considered only after 2 h. A VRIII<br />
should be considered if the patient remains hyperglycaemic.<br />
Treatment of intra-operative hypoglycaemia<br />
For a CBG 4.0–6.0 mmol.l<br />
1 , 50 ml glucose 20%<br />
(10 g) should be given intravenously; for hypoglycaemia<br />
< 4.0 mmol.l<br />
1 a dose of 100 ml (20 g) should<br />
be given.<br />
Fluid management<br />
There is a limited evidence base for the recommendation<br />
of optimal fluid management of the adult diabetic<br />
patient undergoing surgery. It is now recognised that<br />
Hartmann’s solution is safe to administer to patients<br />
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with diabetes and does not contribute to clinically significant<br />
hyperglycaemia [23].<br />
Fluid management for patients requiring a VRIII<br />
The aim is to provide glucose as a substrate to prevent<br />
proteolysis, lipolysis and ketogenesis, as well as<br />
to optimise intravascular volume status and maintain<br />
plasma electrolytes within the normal range. It is<br />
important to avoid iatrogenic hyponatraemia from<br />
the administration of hypotonic solutions. Glucose<br />
5% solution should be avoided. Use of glucose 4%<br />
in 0.18% saline can be associated with hyponatraemia.<br />
The substrate solution to be used should be based<br />
on the patient’s current electrolyte concentrations.<br />
While there is no clear evidence that one type of<br />
balanced crystalloid fluid is better than another, halfstrength<br />
‘normal’ saline combined with glucose is, theoretically,<br />
a reasonable compromise to achieve these<br />
aims. Thus, the initial fluid should be glucose 5% in<br />
saline 0.45% pre-mixed with either potassium chloride<br />
0.15% (20 mmol.l<br />
1 ) or potassium chloride 0.3%<br />
(40 mmol.l<br />
1 ), depending on the presence of hypokalaemia<br />
(< 3.5 mmol.l<br />
1 ).<br />
The Working Party recognises that these fluids<br />
may not be available in all institutions. It is our view<br />
that they should be made available in all areas where<br />
patients with diabetes will be managed. (Hospitals caring<br />
for children will usually have these solutions<br />
already available for general paediatric use).<br />
Fluid should be administered at the rate that is<br />
appropriate for the patient’s usual maintenance<br />
requirements – usually 25–50 ml.kg 1 .day 1 (approximately<br />
83 ml.h 1 for a 70-kg patient) [24].<br />
Very occasionally, the patient may develop hyponatraemia<br />
without signs of fluid overload. In these circumstances,<br />
it is acceptable to prescribe one of the following<br />
solutions as the substrate solution: glucose 5% in saline<br />
0.9% with pre-mixed potassium chloride 0.15%<br />
(20 mmol.l<br />
1 ); or glucose 5% in saline 0.9% with premixed<br />
potassium chloride 0.3% (40 mmol.l<br />
1 ). (Again,<br />
hospitals caring for children will usually have these solutions<br />
available).<br />
Additional Hartmann’s solution or another balanced<br />
isotonic crystalloid solution should be used to<br />
optimise intravascular volume status.<br />
Fluid management for patients not requiring a<br />
VRIII<br />
The aim is to avoid glucose-containing solutions unless<br />
the blood glucose is low. It is important to avoid<br />
hyperchloraemic metabolic acidosis; Hartmann’s solution<br />
should be administered to optimise the intravascular<br />
volume status. If the patient requires prolonged<br />
postoperative fluids (> 24 h), a VRIII should be considered<br />
and glucose 5% in saline 0.45% with pre-mixed<br />
potassium chloride given as above.<br />
Returning to ‘normal’ (pre-operative)<br />
medication and diet<br />
The postoperative blood glucose management plan,<br />
and any alterations to existing medications, should be<br />
clearly communicated to ward staff. Patients with diabetes<br />
should be involved in planning their postoperative<br />
care. If subcutaneous insulin is required in<br />
insulin-na€ıve patients, or the type of insulin or the<br />
time it is to be given is to change, the specialist diabetes<br />
team should be contacted for advice.<br />
Transferring from a VRIII back to oral<br />
treatment or subcutaneous insulin<br />
If the patient has type-1 diabetes and a VRIII has been<br />
used, it must be continued for 30–60 min after the<br />
patient has had their subcutaneous insulin (see below).<br />
Premature discontinuation is associated with iatrogenic<br />
DKA.<br />
Restarting oral hypoglycaemic medication<br />
Oral hypoglycaemic agents should be recommenced at<br />
pre-operative doses once the patient is ready to eat and<br />
drink; withholding or reduction in sulphonylureas may<br />
be required if the food intake is likely to be reduced. Metformin<br />
should only be restarted if the estimated glomerular<br />
filtration rate exceeds 50 ml.min 1 .1.73 m 2 [25].<br />
Restarting subcutaneous insulin for patients already<br />
established on insulin<br />
Conversion to subcutaneous insulin should commence<br />
once the patient is able to eat and drink without nausea<br />
or vomiting. The pre-surgical regimen should be<br />
restarted, but may require adjustment because the insulin<br />
requirement may change as a result of postoperative<br />
stress, infection or altered food intake. The diabetes spe-<br />
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Barker et al. | Guidelines on peri-operative management of diabetes<br />
cialist team should be consulted if the blood glucose<br />
levels are outside the acceptable range (6–12 mmol.l<br />
1 )<br />
or if a change in diabetes management is required.<br />
The transition from intravenous to subcutaneous<br />
insulin should take place when the next meal-related<br />
subcutaneous insulin dose is due, for example with<br />
breakfast or lunch.<br />
For the patient on basal and bolus insulin<br />
There should be an overlap between the end of the<br />
VRIII and the first injection of subcutaneous insulin,<br />
which should be given with a meal and the intravenous<br />
insulin and fluids discontinued 30-60 min later.<br />
If the patient was previously on a long-acting insulin<br />
analogue such as Lantus â , Levemir â or Tresbia â ,<br />
this should have been continued and thus the only<br />
action should be to restart his/her usual rapid-acting<br />
insulin at the next meal as outlined above. If the basal<br />
insulin was stopped, the insulin infusion should be<br />
continued until a background insulin has been given.<br />
For the patient on a twice-daily, fixed-mix regimen<br />
The insulin should be re-introduced before breakfast<br />
or before the evening meal, and not at any other time.<br />
The VRIII should be maintained for 30-60 min after<br />
the subcutaneous insulin has been given.<br />
For the patient on a continuous subcutaneous insulin<br />
infusion<br />
The subcutaneous insulin infusion should be recommenced<br />
at the patient’s normal basal rate; the VRIII<br />
should be continued until the next meal bolus has<br />
been given. The subcutaneous insulin infusions should<br />
not be re-started at bedtime.<br />
Resumption of normal diet<br />
The key to successful management of the surgical<br />
patient with diabetes is resumption of his/her usual<br />
diet. This allows resumption of normal diabetes medication.<br />
Hospital discharge is only feasible once the<br />
patient has resumed eating and drinking.<br />
Other anaesthetic considerations<br />
Use of dexamethasone<br />
Dexamethasone can lead to hyperglycaemia and should<br />
be used with caution in patients with diabetes [26]. If<br />
it is decided that the possible benefits of earlier<br />
resumption of normal diet outweigh the disadvantages<br />
of hyperglycaemia, it should be ensured that the CBG<br />
is measured hourly for at least 4 h after administration.<br />
Use of regional anaesthesia<br />
Local anaesthetic techniques, when used as the sole<br />
anaesthetic, reduce the risk of postoperative nausea<br />
and vomiting. Furthermore, when used as part of the<br />
multimodal technique in general anaesthesia, they have<br />
opioid-sparing actions, with resultant reduction of opioid-related<br />
side-effects. However, evidence suggests<br />
that patients with diabetes are more prone to epidural<br />
abscesses and haemodynamic instability after central<br />
neuraxial blockade (in patients with an autonomic<br />
neuropathy), and, possibly, increased risk of neuropathy<br />
after peripheral nerve blocks [27–29].<br />
Enhanced recovery after surgery<br />
Enhanced recovery of patients undergoing surgery utilises<br />
several strategies to promote earlier resumption of<br />
normal diet, earlier mobilisation, and reduced length<br />
of stay [30]. This has particular relevance for patients<br />
with diabetes as it promotes eating and drinking<br />
(reducing the risk of iatrogenic harm from a VRIII),<br />
and by promoting earlier discharge.<br />
Use of oral carbohydrate loading drinks<br />
Carbohydrate loading may compromise blood glucose<br />
control and should not be used in patients with insulin-treated<br />
diabetes who are likely to have a short period<br />
of fasting. There is some evidence that oral<br />
carbohydrate loading may be safe in patients with<br />
type-2 diabetes [31], and if a VRIII is to be used in<br />
any case there is no reason to withhold oral carbohydrate<br />
loading drinks in any patient with diabetes.<br />
Patients with diabetes requiring<br />
emergency surgery<br />
There are three ways of managing diabetes in the<br />
patient requiring emergency surgery:<br />
1 Modification of normal medication. This is only<br />
possible if the patient is physiologically well and is<br />
being operated on a scheduled list, for example a<br />
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regular trauma list for minor hand surgery, or<br />
evacuation of retained products of conception on<br />
a regular gynaecology list.<br />
2 Use of a VRIII. This should be the default<br />
technique to manage a patient undergoing emergency<br />
surgery because of the unpredictability of<br />
the starvation period caused by the erratic nature<br />
of emergency lists.<br />
3 Use of a fixed-rate intravenous insulin infusion<br />
(see below). This should only be used if the<br />
patient requires immediate surgery and has concurrent<br />
DKA.<br />
The aim is for the patient to be taken to the<br />
1<br />
operating theatre with a CBG of 6–10 mmol.l<br />
1<br />
(6–12 mmol.l may be acceptable), without overt<br />
DKA, and having been adequately resuscitated.<br />
•<br />
Recommendation: In patients undergoing emergency<br />
surgery, the CBG should be checked regularly<br />
(hourly as a minimum whilst acutely unwell),<br />
and a VRIII established using dextrose 5% in saline<br />
0.45% with pre-mixed potassium chloride as the<br />
substrate.<br />
The patient should be checked for ketonaemia<br />
(> 3.0 mmol.l<br />
1 ) or significant ketonuria (> 2+ on<br />
urine sticks) if the CBG exceeds 12 mmol.l<br />
1 . If the<br />
patient has DKA and requires emergency surgery, the<br />
involvement of senior multidisciplinary input from<br />
intensivists, anaesthetists, surgeons and diabetologists<br />
should be considered to agree optimal peri-operative<br />
management. Operating on a patient with DKA carries<br />
significant mortality and should be avoided if at all possible.<br />
The discussion should include: the requirement<br />
for surgery, because DKA can be associated with<br />
abdominal pain (negative laparotomies have been<br />
reported); the area in which the patient should be resuscitated<br />
before theatre; whether saline 0.9% with premixed<br />
potassium chloride or Hartmann’s solution<br />
should be the main resuscitation fluid; whether a VRIII<br />
or a fixed-rate infusion should be used to treat DKA in<br />
theatre; and the area in which the patient will be recovered<br />
after surgery. Recent guidelines and evidence suggest<br />
that a fixed-rate intravenous insulin infusion is<br />
superior to a VRIII in treating DKA in a ward environment<br />
[32]. However, use of a fixed-rate infusion is associated<br />
with hypoglycaemia and requires administration<br />
of glucose 20% if the CBG is under 14 mmol.l<br />
1 .<br />
Early involvement of the diabetes inpatient specialist<br />
team should be sought.<br />
If possible, long-acting insulins (Levemir, Lantus,<br />
Tresiba) should be continued in all patients at 80% of<br />
the usual dose. This is to avoid rebound hyperglycaemia<br />
when intravenous insulin is stopped.<br />
Safety<br />
Errors in insulin prescribing are common and insulin<br />
has been identified as one of the top five high-risk<br />
medications in the inpatient environment [33]. The<br />
wide range of preparations and devices available for<br />
insulin administration (currently > 60) increases the<br />
potential for error. One third of all inpatient medical<br />
errors leading to death within 48 h of the error involve<br />
insulin administration. Common errors include mistakes<br />
when abbreviating the word ‘units’, failure to use<br />
a specific insulin syringe, and errors when preparing<br />
insulin infusions. Use of pre-filled syringes of insulin<br />
for infusion may reduce the risk and should be considered<br />
by Trusts.<br />
Safe use of VRIIIs<br />
Variable-rate intravenous insulin infusions are overused<br />
in the peri-operative setting. Their use is<br />
associated with hypoglycaemia, hyperglycaemia and<br />
ketosis on cessation, and hyponatraemia. There<br />
seems to be a significant risk of hypoglycaemia in<br />
1<br />
patients with a CBG of 4–6 mmol.l and on a<br />
VRIII. Patients often return to surgical wards from<br />
theatre with an intravenous insulin infusion in place<br />
but no directions for its withdrawal. Hospitals<br />
should have written guidelines for both the safe use<br />
of the VRIII and conversion from the VRIII to the<br />
usual diabetes treatment.<br />
To ensure a steady supply of substrate it is recommended<br />
that glucose 5% in saline 0.45% with potassium<br />
chloride 0.15% or 0.3% should be administered<br />
concurrently with the VRIII, at a rate to meet the<br />
patient’s maintenance fluid requirements. It is imperative<br />
that there is hourly monitoring of the CBG (to<br />
keep the CBG at 6–10 mmol.l<br />
1 ), and that in patients<br />
with type-1 diabetes, the VRIII is not discontinued<br />
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Barker et al. | Guidelines on peri-operative management of diabetes<br />
until alternative subcutaneous insulin has been administered.<br />
Metformin<br />
A number of guidelines available for the use of<br />
metformin recommend withdrawing treatment peri-operatively.<br />
However, evidence for this approach is lacking<br />
and there is some evidence that peri-operative continuation<br />
of metformin is safe. Metformin is renally excreted<br />
and renal failure may lead to high plasma levels which<br />
are associated with an increased risk of lactic acidosis<br />
[34]. Metformin should be withheld if there is pre-existing<br />
renal impairment or significant risk of the patient<br />
developing acute kidney injury. Anaesthetists should be<br />
vigilant about the dangers of the use of nephrotoxic<br />
agents, including contract media [35].<br />
Non-steroidal anti-inflammatory drugs (NSAIDs)<br />
There are several additional considerations to the use<br />
of NSAIDs in patients with diabetes, including the<br />
redistribution of renal blood flow in the presence of<br />
hypovolaemia and the risk of oedema, especially if<br />
given concurrently with metformin and glitazones.<br />
Quality control and audit<br />
A number of bodies have published quality standards<br />
pertinent to the peri-operative care of patients with diabetes.<br />
These include NICE, the Royal College of Anaesthetists<br />
(RCoA) and NHS Diabetes (the latter no longer<br />
exists and the Joint British Diabetes Societies Inpatient<br />
Care Group has taken over some of its roles).<br />
National Institute for Health and Care<br />
Excellence<br />
Quality Standard 6, Diabetes in Adults, includes an<br />
auditable standard relating to inpatient care: “People<br />
with diabetes admitted to hospital are cared for by<br />
appropriately trained staff, provided with access to a<br />
specialist diabetes team, and given the choice of selfmonitoring<br />
and managing their own insulin” [36].<br />
Royal College of Anaesthetists<br />
The RCoA’s Guidelines for the Provision of Anaesthetic<br />
Services [37] contains much advice relating to the perioperative<br />
care of patients, including those with diabetes.<br />
In addition, the RCoA publication Raising the<br />
Standard – a Compendium of Audit Recipes contains<br />
details on audit and quality improvement topics pertinent<br />
to patients with diabetes [38]. These focus on<br />
peri-operative care and are suitable for use by anaesthetists<br />
wishing to assess the quality of local provision.<br />
For example, topics include availability of guidelines<br />
for, and management of, chronic medication during<br />
the peri-operative period, and peri-operative fasting.<br />
NHS Diabetes<br />
The NHS Diabetes guideline contains a number of<br />
suggested audit standards covering medication, safety,<br />
training and institutional issues [1].<br />
National Diabetes Inpatient Audit<br />
Whilst the audit standards suggested above may be<br />
used within an organisation, national audit projects<br />
provide a broader picture and allow benchmarking.<br />
The National Diabetes Inpatient Audit (NaDIA) is an<br />
annual snapshot audit of surgical and medical inpatients<br />
with diabetes. The majority of Trusts in<br />
England and Wales are now taking part. The audit is<br />
commissioned by the Healthcare Quality Improvement<br />
Partnership as part of the National Clinical Audit and<br />
Patient Outcomes Programme. The results are available<br />
online in the spring of each year and enable<br />
organisations to assess their performance in caring for<br />
inpatients with diabetes [39].<br />
Included in the audit are questions relating to<br />
whether diabetes management minimises the risk of<br />
avoidable complications, harm resulting from the<br />
inpatient stay, patient experience and the change in<br />
patient feedback on the quality of care since<br />
NaDIA began. Of particular relevance to anaesthetists,<br />
NaDIA includes comparative data on the prevalence of<br />
medication errors, intravenous insulin infusions, glycaemic<br />
control and patient harm. In addition, there<br />
are considerable data from patients’ feedback questionnaires<br />
concerning their experience and involvement in<br />
their own care.<br />
• Recommendation: Anaesthetists interested in perioperative<br />
diabetes management should access the<br />
National Diabetes Inpatient Audit and look up the<br />
results for their own organisation.<br />
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Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015<br />
Acknowledgements<br />
This guideline and the text are based in large part on<br />
the guidelines available from the JBDS [1]. The Working<br />
Party and AAGBI are grateful to the JBDS Inpatient<br />
Care Group for permission to use its document<br />
as the basis for this guideline.<br />
Competing interests<br />
No external funding and no competing interests<br />
declared.<br />
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1. Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline<br />
for the perioperative management of the adult patient with<br />
diabetes. Diabetic Medicine 2012; 29: 420–33.<br />
2. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical<br />
outcome of hyperglycemia in the perioperative period in noncardiac<br />
surgery. Diabetes Care 2010; 33: 1783–8.<br />
3. Rayman G. Inpatient audit. Diabetes Update. https://www.diabetes.org.uk/upload/Professionals/publications/Comment_Inpatient%20audit_new.pdf<br />
(accessed 11/08/2015).<br />
4. Hamblin PS, Topliss DJ, Chosich N, Lording DW, Stockigt JR.<br />
Deaths associated with diabetic ketoacidosis and hyperosmolar<br />
coma, 1973-1988. Medical Journal of Australia 1989; 151:<br />
441–2.<br />
5. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other<br />
risk factors, and 12-yr cardiovascular mortality for men<br />
screened in the Multiple Risk Factor Intervention Trial. Diabetes<br />
Care 1993; 16: 434–44.<br />
6. National Patient Safety Agency. Insulin safety. Reducing harm<br />
associated with the unsafe use of insulin products. http://<br />
www.nrls.npsa.nhs.uk/resources/collections/10-for-2010/insulin/?entryid45=74287<br />
(accessed 11/08/2015).<br />
7. Jhanji S, Thomas B, Ely A, Watson D, Hinds CJ, Pearce RM. Mortality<br />
and utilisation of critical care resources amongst highrisk<br />
surgical patients in a large NHS trust. Anaesthesia 2008;<br />
63: 695–700.<br />
8. Pearce RM, Harrison DA, James P, et al. Identification and<br />
characterisation of the high-risk surgical population in the United<br />
Kingdom. Critical Care 2006; 10: R10.<br />
9. Sampson MJ, Brennan C, Dhatariya K, Jones C, Walden E. A<br />
national survey of in-patient diabetes services in the United<br />
Kingdom. Diabetic Medicine 2007; 24: 643–9.<br />
10. George JT, Warriner D, McGrane DJ, et al. Lack of confidence<br />
among trainee doctors in the management of diabetes: the<br />
Trainees Own Perception of Delivery of Care (TOPDOC) Diabetes<br />
Study. Quarterly Journal of Medicine 2011; 104: 761–6.<br />
11. Walid MS, Newman BF, Yelverton JC, et al. Prevalence of previously<br />
unknown elevation of glycosylated hemoglobin in<br />
spine surgery patients and impact on length of stay and total<br />
cost. Journal of Hospital Medicine 2010; 5: E10–4.<br />
12. O’Sullivan CJ, Hynes N, Mahendran B, et al. Haemoglobin A1c<br />
(HbA1C) in non-diabetic and diabetic vascular patients. Is<br />
HbA1C an independent risk factor and predictor of adverse<br />
outcome? European Journal of Vascular and Endovascular Surgery<br />
2006; 32: 188–97.<br />
13. Gustafsson UO, Thorell A, Soop M, Ljungqvist O, Nygren J.<br />
Haemoglobin A1c as a predictor of postoperative hyperglycaemia<br />
and complications after major colorectal surgery. British<br />
Journal of Surgery 2009; 96: 1358–64.<br />
14. Halkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative<br />
hemoglobin A1c level is associated with reduced long-term<br />
survival after coronary artery bypass surgery. Annals of Thoracic<br />
Surgery 2008; 86: 1431–7.<br />
15. Alserius T, Anderson RE, Hammar N, Nordqvist T, Ivert T. Elevated<br />
glycosylated haemoglobin (HbA1c) is a risk marker in<br />
coronary artery bypass surgery. Scandinavian Cardiovascular<br />
Journal 2008; 42: 392–8.<br />
16. Kreutziger J, Schlaepfer J, Wenzel V, Constantinescu MA. The<br />
role of admission blood glucose in outcome prediction of surviving<br />
patients with multiple injuries. Journal of Trauma –<br />
Injury, Infection and Critical Care 2009; 67: 704–8.<br />
17. Vilar-Compte D, Alvarez de Iturbe I, Martin-Onraet A, et al.<br />
Hyperglycemia as a risk factor for surgical site infections in<br />
patients undergoing mastectomy. American Journal of Infection<br />
Control 2008; 36: 192–8.<br />
18. Shibuya N, Humphers JM, Fluhman BL, Jupiter DC. Factors<br />
associated with nonunion, delayed union, and malunion in<br />
foot and ankle surgery in diabetic patients. Journal of Foot<br />
and Ankle Surgery 2013; 52: 207–11.<br />
19. Chuang SC, Lee KT, Chang WT, et al. Risk factors for wound<br />
infection after cholecystectomy. Journal of the Formosan Medical<br />
Association 2004; 103: 607–12.<br />
20. Ambiru S, Kato A, Kimura F, et al. Poor postoperative blood<br />
glucose control increases surgical site infections after surgery<br />
for hepato-biliary-pancreatic cancer: a prospective study in a<br />
high-volume institute in Japan. Journal of Hospital Infection<br />
2008; 68: 230–3.<br />
21. Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D.<br />
Importance of perioperative glycemic control in general surgery:<br />
a report from the surgical care and outcomes assessment<br />
program. Annals of Surgery 2013; 257: 8–14.<br />
22. National Institute for Health and Care Excellence. Preoperative<br />
Tests: the Use of Routine Preoperative Tests for Elective Surgery.<br />
NICE Guideline CG3, June 2003 www.nice.org.uk/guidance/cg3<br />
(accessed 11/08/2015).<br />
23. Simpson AK, Levy N, Hall GM. Peri-operative i.v. fluids in diabetic<br />
patients – don’t forget the salt. Anaesthesia 2008; 63:<br />
1043–5.<br />
24. National Institute for Health and Care Excellence. Intravenous<br />
fluid therapy in adults in hospital. NICE guideline CG174,<br />
December 2013. www.nice.org.uk/guidance/cg174/evidence<br />
(accessed 11/08/2015).<br />
25. Lipska KJ, Bailey CJ, Inzucchi SE. Use of metformin in the setting<br />
of mild-to-moderate renal insufficiency. Diabetes Care<br />
2011; 34: 1431–7.<br />
26. Geer EB, Islam J, Buettner C. Mechanisms of glucocorticoid-induced<br />
insulin resistance. Endocrinology and Metabolism Clinics<br />
of North America 2014; 43: 75–102.<br />
27. Royal College of Anaesthetists. Major complications of central<br />
neuraxial block in the UK. Third National Audit of The Royal<br />
College of Anaesthetists, January 2009. www.rcoa.ac.uk/nap3<br />
(accessed 11/08/2015).<br />
28. Hebl JR, Kopp SL, Schroeder DR, Horlocker TT. Neurologic complications<br />
after neuraxial anesthesia or analgesia in patients<br />
with pre-existing peripheral sensorimotor neuropathy or diabetic<br />
polyneuropathy. Anesthesia and Analgesia 2006; 103:<br />
1294–9.<br />
29. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a<br />
meta-analysis of 915 patients. Neurosurgical Review 2000;<br />
23: 175–204.<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 11
Anaesthesia 2015<br />
Barker et al. | Guidelines on peri-operative management of diabetes<br />
30. Varadhan KK, Neal KR, Dejong CH, et al. The enhanced recovery<br />
after surgery (ERAS) pathway for patients undergoing<br />
major elective open colorectal surgery: a meta-analysis of<br />
randomized controlled trials. Clinical Nutrition 2010; 29:<br />
434–40.<br />
31. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate<br />
loading may be used in type 2 diabetes patients.<br />
Acta Anaesthesiologica Scandinavica 2008; 52: 946–51.<br />
32. Joint British Diabetes Societies Inpatient Care Group. The management<br />
of diabetic ketoacidosis in adults, September 2013.<br />
http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_DKA_Adu<br />
lts_Revised.pdf) (accessed 11/08/2015).<br />
33. National Patient Safety Agency. The fourth report of the Patient<br />
Safety Observatory. Safety in doses: medication safety incidents<br />
in the NHS, January 2007. www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-safety/?entryid45=59822&q=0%<br />
c2%acsafety+in+doses%c2%ac (accessed 11/08/2015).<br />
34. Duncan AI, Koch CG, Xu M, et al. Recent metformin ingestion<br />
does not increase in-hospital morbidity or mortality<br />
after cardiac surgery. Anesthesia and Analgesia 2007; 104:<br />
42–50.<br />
35. Royal College of Radiologists. Standards for Intravascular Contrast<br />
Agent Administration to Adult Patients, 2nd edn. London:<br />
RCR, 2010.<br />
36. National Institute for Health and Care Excellence. Diabetes in<br />
Adults. Quality Standard 6, March 2011. www.nice.org.uk/<br />
guidance/qs6 (accessed 11/08/2015).<br />
37. Royal College of Anaesthetists. Guidelines for the Provision of<br />
Anaesthetic Services 2015. www.rcoa.ac.uk/GPAS2015 (accessed<br />
11/08/2015).<br />
38. Royal College of Anaesthetists. Raising the Standard: A Compendium<br />
of Audit Recipes for Continuous Quality Improvement<br />
in Anaesthesia, 3rd edn, 2012. www.rcoa.ac.uk/<br />
system/files/CSQ-ARB-2012_1.pdf (accessed 11/08/2015).<br />
39. Health and Social Care Information Centre. National Diabetes<br />
Inpatient Audit. www.hscic.gov.uk/diabetesinpatientaudit (accessed<br />
11/08/2015).<br />
12 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland
Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015<br />
Appendix 1<br />
Example of a variable-rate intravenous insulin infusion prescription. Glucose concentration is usually measured in capillary blood.<br />
Glucose<br />
concentration;<br />
1<br />
mmol.l<br />
Standard rate (use unless otherwise indicated)<br />
No basal insulin<br />
< 4 0.5 IU.h 1 + give<br />
100 ml glucose 20%<br />
intravenously<br />
4.1–6.0 0.5 IU.h 1 + consider<br />
50 ml glucose 20%<br />
intravenously<br />
Basal insulin<br />
continued No basal insulin<br />
STOP + give 100 ml<br />
glucose 20%<br />
intravenously<br />
STOP + consider<br />
50 ml glucose 20%<br />
intravenously<br />
Reduced rate (e.g. insulin-sensitive patients<br />
(i.e. < 24 IU.day 1 ))<br />
0.2 IU.h 1 + give<br />
100 ml glucose 20%<br />
intravenously<br />
0.2 IU.h 1 + give<br />
50 ml glucose 20%<br />
intravenously<br />
Basal insulin<br />
continued No basal insulin<br />
STOP + give 100 ml<br />
glucose 20%<br />
intravenously<br />
STOP + consider<br />
50 ml glucose 20%<br />
intravenously<br />
Increased rate (e.g. insulin-resistant patients<br />
(i.e. > 100 IU.day 1 ))<br />
0.5 IU.h 1 + give<br />
100 ml glucose 20%<br />
intravenously<br />
0.5 IU.h 1 + give<br />
50 ml glucose 20%<br />
intravenously<br />
Basal insulin<br />
continued<br />
STOP + give 100 ml<br />
glucose 20%<br />
intravenously<br />
STOP + consider<br />
6.1–8.0 1 IU.h 1 1 IU.h 1 0.5 IU.h 1 0.5 IU.h 1 2 IU.h 1 2 IU.h 1<br />
8.1–12.0 2 IU.h 1 2 IU.h 1 1 IU.h 1 1 IU.h 1 4 IU.h 1 4 IU.h 1<br />
12.1–16.0 4 IU.h 1 4 IU.h 1 2 IU.h 1 2 IU.h 1 6 IU.h 1 6 IU.h 1<br />
16.1–20.0 5 IU.h 1 5 IU.h 1 3 IU.h 1 3 IU.h 1 7 IU.h 1 7 IU.h 1<br />
20.1–24.0 6 IU.h 1 6 IU.h 1 4 IU.h 1 4 IU.h 1 8 IU.h 1 8 IU.h 1<br />
> 24.1 8 IU.h 1 8 IU.h 1 6 IU.h 1 6 IU.h 1 10 IU.h 1 10 IU.h 1<br />
> 24.1 Ensure insulin is running and that the measured blood glucose concentration is not artefactual<br />
50 ml glucose 20%<br />
intravenously<br />
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 13
Anaesthesia 2015<br />
Barker et al. | Guidelines on peri-operative management of diabetes<br />
Appendix 2<br />
Example of a variable-rate intravenous insulin infusion regimen observation chart. Reproduced by kind<br />
permission of the Norfolk and Norwich University Hospitals NHS Foundation Trust.<br />
BLOOD GLUCOSE MONITORING CHART (adults, not pregnant)<br />
B<br />
Paent Name:<br />
Hospital Number:<br />
Date of birth:<br />
Consultant:<br />
Date<br />
(dd/mm/yyyy):<br />
Time:<br />
Blood glucose<br />
reading (mmol/L)<br />
OR PATIENT LABEL<br />
A SINGLE reading in a RED area requires acon<br />
TWO consecuve readings in the AMBER areas<br />
require acon<br />
This is the ACCEPTABLE glucose range<br />
This is the IDEAL glucose target range<br />
Ward:<br />
Blood glucose readings (mmol/L)<br />
Ketone levels<br />
Diabetes Inpatient Specialist Nurse bleep - 0407 - available Monday to Friday 9am to 5pm<br />
Urine<br />
Blood<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
++++<br />
+++<br />
++<br />
+<br />
Nil<br />
ALL ACTION TAKEN MUST BE DOCUMENTED IN THE HOSPITAL NOTES<br />
Inials<br />
14 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
Out of Hours Activity<br />
(Anaesthesia)<br />
Guiding Principles and Recommendations<br />
JOINT POSITION STATEMENT<br />
Association of Anaesthetists of Great Britain and Ireland<br />
and<br />
Royal College of Anaesthetists<br />
October 2014<br />
1
Definitions<br />
The times that can be considered to be “out of hours” (OOH) may be defined contractually or by reference to<br />
published national standards. In the current Consultant Contracts for England and Wales, OOH is defined by<br />
the concept of “premium time”, i.e. that which is outside of 07.00 h – 19.00 h on non-Bank Holiday weekdays.<br />
Current and future contract negotiations may change the periods covered by “premium time”. The National<br />
Confidential Enquiry into Patient Outcome and Death (NCEPOD) defines OOH as: “any time outside 08.00 to<br />
17.59 on weekdays, and any time on a Saturday or Sunday”. We will simply define OOH work as that done<br />
outside of the normal working week.<br />
Emergency work<br />
Anaesthetic services delivered OOH are key to the provision of emergency care. Anaesthetists will<br />
reasonably be expected to provide OOH cover for cases that come under the NCEPOD Classification of<br />
Intervention as being “Immediate” or “Urgent”. Following clinical assessment, those cases classified as being<br />
“Expedited” or “Elective” need not be done OOH. Immediate or urgent cases should be prioritised over<br />
routine / elective care at all times.<br />
Drivers for increased OOH activity<br />
The NHS has always operated a 7 day service for patients requiring emergency admissions and surgery.<br />
There is current pressure towards a “7-day NHS” based on the information that some patients admitted to<br />
hospitals at the weekend have worse outcomes compared with those admitted during the working week. It<br />
seems likely that more consultants will be required to be present in hospitals at the weekend, along with<br />
support services. In some units it may be inevitable that the increased workload combined with sicker<br />
patients with increased co-morbidity will require Consultant Anaesthetists to be in-hospital providing resident<br />
shifts during part of the OOH period. The AAGBI and RCOA support measures to improve patient safety and<br />
quality of care but note that this will have a significant impact on Anaesthesia workforce. It has been<br />
suggested that with increased support services, it would be safe to perform elective operating lists at the<br />
weekend, and the principle of elective work OOH in the form of ‘Waiting List Initiatives’ is well established.<br />
Standards and operating procedures developed to make patient care as safe as possible during normal<br />
working hours would be maintained for any elective care taking place out of hours. This should not be seen<br />
as a solution to the failure to carry out this work successfully in normal hours during the week. An increasing<br />
emergency workload and pressure on beds will increase the demand for daily trauma and emergency lists to<br />
expedite surgery and speed patient throughput. Extending planned surgery throughout the week could<br />
enable existing operating theatres to be used for more hours than at present, although it must be noted that<br />
over 70% of theatre running costs relate to staff, drugs and disposables (information available on line from<br />
Information Services Division, NHS Scotland).<br />
The risks of OOH working<br />
Different risks are posed by OOH working in the evening and overnight to working daytimes at weekends.<br />
There are physiological differences between working during the day, and in the evenings or at night and<br />
these differences cannot be fully mitigated. This must be taken into consideration when OOH working is<br />
considered 1 . Studies have shown that human beings do not adapt despite prolonged exposure to night<br />
work 2 . Working in the evening or night especially after having worked during the day may lead to significant<br />
fatigue, as may work at weekends after a full working week 3 . A further factor in fatigue experienced by<br />
anaesthetists is sleep disturbance caused by shifts and irregular patterns of work. Fatigue is associated with<br />
an increased incidence of critical incidents and thus has a direct impact on patient safety 4 . There are<br />
significant additional risks in OOH working that should be mitigated by limiting night-time work to that which<br />
is clinically necessary and adjusting working patterns and arrangements to minimise fatigue. Onsite facilities<br />
that help mitigate the effects of fatigue, such as the timely availability of healthy foods and appropriate areas<br />
for rest, are important to the delivery of safe OOH care.<br />
Patient considerations<br />
Patients should receive appropriate treatment to national standards of care from competent and fit–for-work<br />
clinicians in a timely fashion. However, there must be a balance between the need for speed with which<br />
urgent and expedited surgery is performed in order to minimise the pain and anxiety, and the need to<br />
maintain standards of safety if the provision of OOH is increased. Patient safety must always be prioritised<br />
over patient convenience.<br />
2
Considerations for anaesthetists<br />
The implementation of the Working Time Regulations (WTR) means that trainees no longer work excessive<br />
hours, although the shift patterns worked by the substantial majority do lead to fatigue 2 . Decreases in trainee<br />
hours and overall numbers as well as an increasingly elderly population with greater co-morbidities mean<br />
that career grade doctors, i.e. Consultants and Specialty Doctors, are doing an increasing proportion of OOH<br />
work. As career grade doctors can derogate from WTR, there is a risk that pressure may be exerted to<br />
increase both the amount of work performed and the proportion of work that is done OOH, and the current<br />
government has signalled its intention to look again at the application of WTR to trainees 5 . The ability to<br />
recover from sleep deprivation deteriorates with age, and particular attention should be paid to the impact of<br />
excessive or irregular working hours on the older anaesthetist. It is essential that all anaesthetists are aware<br />
of the potential impact of fatigue on their cognitive ability and ensure they are well rested before treating<br />
patients 3 . Careful planning is required so that patient risk is not increased as a result of fatigue. Specialties<br />
that conduct larger proportions of their clinical activity OOH may experience problems in recruitment and<br />
retention.<br />
Principles and recommendations<br />
Emergency OOH work has always been a fundamental part of the work of anaesthetists. OOH services<br />
should be planned carefully in order to deliver high quality patient care. The extension of planned and<br />
elective clinical activities into periods outside of the normal working week carries with it patient safety risks<br />
and must only happen with careful planning. The provision, capacity and quality of support services must be<br />
provided to the same degree as those in normal working hours, making due allowance for human factors.<br />
Extended work should not drain resources from other clinical areas<br />
The conduct of planned OOH operating sessions is a matter for local discussion and agreement. The AAGBI<br />
and RCoA are agreed that the following issues must be considered:<br />
• Planned OOH sessions during which expedited or elective cases are performed must have the same<br />
levels of pre and post-operative ward staffing, consultant supervision and training, diagnostic and<br />
laboratory services, support services and critical care facilities as sessions done during working<br />
hours.<br />
• Start and finish times of elective operating sessions that extend into OOH periods must take into<br />
account human performance factors.<br />
• In the interests of providing the highest quality service to patients, appropriate compensatory rest<br />
must be taken particularly after a prolonged duty period and rest should be taken at the earliest<br />
possible opportunity.<br />
• Theatre sessions should be fully staffed with cover for contracted breaks. If sessions extend beyond<br />
normal working hours, there should be provision for additional support and breaks.<br />
• Anaesthetists should only provide cover for elective surgery for more than 12 hours in any 24-hour<br />
period in exceptional circumstances. Travel times should be taken into consideration.<br />
• Only immediate or urgent procedures should be conducted at night (after 21.00hrs).<br />
• Special consideration should be given to the very young, the very old and the clinically unstable<br />
patient who should be operated on during the day where possible.<br />
• There must always be sufficient backup and additional facilities to deal with any life or limb<br />
threatening emergency without delay.<br />
• Recovery units should be scheduled to be sufficiently staffed so that all elective cases admitted may<br />
be fully recovered and transferred to the ward without interfering with the urgent/emergency<br />
workload.<br />
• Anaesthesia and surgery should not commence unless all the necessary arrangements are in place<br />
for the complete perioperative patient care pathway.<br />
• Audit of the outcome and productivity of OOH operating sessions must be conducted and compared<br />
with comparable sessions done within normal working hours.<br />
• Extending elective/expedited surgery into OOH periods will demand more financial and human<br />
resources if patient safety is to be maintained. Clinical Directors of Departments of Anaesthesia must<br />
work with clinical governance systems within hospitals to ensure that patient safety is put first and is<br />
not compromised.<br />
3
Members of the working party:<br />
Dr Kathleen Ferguson (Chair), Dr Ramana Alladi, Dr Les Gemmell, Dr William Harrop-Griffiths, Dr Richard<br />
Griffiths, Dr Barry Nichols, Dr Anna-Maria Rollin,Dr Caroline Wilson, Dr David Whitaker<br />
Contributions were received from:<br />
Dr Andrew Hartle, Dr Peter McGuire, Dr Felicity Plaat, Dr Samantha Shinde, Dr Sean Tighe, Dr Isabeau<br />
Walker<br />
The Joint Position Statement was reviewed by the Council of AAGBI and RCoA prior to publication.<br />
References<br />
1. Folkard S,Tucker P. Shift work, safety and productivity Occupational Medicine 2003; 53; 95‐101.<br />
2. Howard SK, Rosekind MR et al. Fatigue in anaesthesia. Anesthesiology 2002; 97; 1281‐1294.<br />
3. Fatigue and Anaesthetists 2014.<br />
http://www.aagbi.org/sites/default/files/Fatigue%20Guideline%20web.pdf<br />
4. Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP. Effects of health care<br />
provider work hours and sleep deprivation on safety and performance. Joint Commission Journal on<br />
Quality and Patient Safety 2007; 33: 7-18.<br />
5. https://www.gov.uk/government/news/more-flexibility-for-nhs-doctors-under-european-working-timedirective<br />
accessed September 2014<br />
4
OAA / AAGBI Guidelines for<br />
Obstetric Anaesthetic Services 2013<br />
3<br />
Published by<br />
Association of Anaesthetists of Great Britain & Ireland<br />
Obstetric Anaesthetists’ Association<br />
June 2013
Membership of the working party<br />
Dr Felicity Plaat<br />
Dr David Bogod<br />
Dr Valerie Bythell<br />
Dr Mary Mushambi<br />
Dr Paul Clyburn<br />
Dr Nuala Lucas<br />
Dr Ian Johnston<br />
Dr Sarah Gibb<br />
Dr Iftikhar Parvez<br />
Dr Anne Thornberry<br />
AAGBI, Chair of working party<br />
OAA, President<br />
AAGBI<br />
OAA<br />
AAGBI<br />
OAA<br />
AAGBI<br />
AAGBI, GAT representative<br />
AAGBI, SAS representative<br />
RCoA representative<br />
Association of Anaesthetists of Great Britain & Ireland<br />
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
Website: www.aagbi.org<br />
Obstetric Anaesthetists’ Association<br />
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 8883<br />
Fax: 020 7631 4352<br />
Email: secretariat@oaa-anaes.ac.uk<br />
Website: www.oaa-anaes.ac.uk<br />
© The Association of Anaesthetists of Great Britain & Ireland and the Obstetric Anaesthetists’ Association 2013.
Contents<br />
1. Key recommendations 2<br />
2. Introduction 3<br />
3. Staffing 4<br />
4. Services and standards 8<br />
5. Training and education 17<br />
6. The labour ward team 20<br />
7. Support services, equipment, facilities and accommodation 23<br />
8. The future 27<br />
9. List of recommended guidelines 28<br />
10. References 30<br />
This is a consensus document produced by expert members of a Working Party established by the<br />
Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Obstetric Anaesthetists’<br />
Association (OAA). It updates and replaces previous guidance published in May 2005. It has been<br />
seen and approved by the AAGBI Council and the OAA Committee.<br />
• What other guideline statements are available on this topic?<br />
The Royal College of Obstetricians & Gynaecologists have produced guidelines on the provision<br />
of maternity services:<br />
1. High quality women’s health care: A proposal for change. RCOG press, London, 2011.<br />
2. Safer childbirth: Minimum standards for the organization and delivery of care in labour. RCOG<br />
press, London, 2007.<br />
• Why was this guideline developed?<br />
The original guideline published in 1998 was developed to ensure that obstetric patients received<br />
the same standards of anaesthetic care as those recommended for the general surgical<br />
population.<br />
• How and why does this statement differ from existing guidelines?<br />
This guideline concentrates on the roles and activities of the obstetric anaesthetist within the<br />
multidisciplinary team required to deliver safe maternity care. The major changes compared with<br />
the 2005 version include a section on maternity critical care and the recommendation for<br />
increased dedicated consultant anaesthetic sessions.<br />
The need to define anaesthetic services in maternity in 2013 reflect the expanding role of the<br />
anaesthetist as peri-partum physician in caring for an increasingly challenging patient population<br />
in a rapidly changing health service.<br />
Date of review: 2018<br />
1
1. Key recommendations<br />
1. A duty anaesthetist must be immediately available for emergency work on the delivery suite<br />
24 hours a day.<br />
2. There must be a nominated consultant in charge of obstetric anaesthesia with time allocated<br />
for this role.<br />
3. There should be a clear line of communication from the duty anaesthetist to the supervising<br />
consultant at all times.<br />
4. The workload of the obstetric anaesthetist continues to increase. As a basic minimum there<br />
must be 12 consultant sessions per week to cover emergency work on delivery suite.<br />
5. Scheduled obstetric anaesthetic activities (e.g. elective caesarean section lists, clinic) require<br />
additional consultant sessions over and above the 12 for emergency cover.<br />
6. Women should have antenatal access to evidence based information about the availability<br />
and provision of all types of analgesia and anaesthesia. This information should be provided<br />
or at least ratified by the department of obstetric anaesthesia.<br />
7. There should be an agreed system whereby the anaesthetist is given sufficient advance<br />
notice of all potentially high-risk patients.<br />
8. When a 24-hour epidural service is offered, the time from the anaesthetist’s being informed<br />
that a woman is requesting an epidural and ready to receive one until attending the mother<br />
should not normally exceed 30 minutes. This period should only exceed one hour in<br />
exceptional circumstances. Responses times should be regularly audited and if the above<br />
standards are missed frequently, consideration should be given to alteration of staffing<br />
arrangements.<br />
9. Provision should be made for those who cover the delivery suite on-call, but do not have<br />
regular sessions there, to spend time on the delivery suite in a supernumerary capacity with<br />
one of the regular obstetric anaesthetic consultants.<br />
10. There must be separate provision of staffing and resources to enable elective work to run<br />
independently of emergency work, in particular to prevent delays to both emergency and<br />
elective procedures and provision of analgesia in labour.<br />
11. The person assisting the anaesthetist must have no other conflicting duties, must be trained<br />
to a nationally recognised standard and must work regularly and frequently in the obstetric<br />
unit.<br />
12. The training undergone by staff and the facilities provided in the maternity recovery unit must<br />
be of the same standard as for general recovery, as defined in current, published guidelines.<br />
13. Appropriate facilities should be available for the antenatal and peripartum management of the<br />
sick obstetric patient as defined in the document Providing Equity of Critical and Maternity<br />
Care for the Critically Ill Pregnant or Recently Pregnant Patient.<br />
2
2. Introduction<br />
This is the third version of the joint Association of Great Britain and Ireland/Obstetric Anaesthetists’<br />
Association (AAGBI/OAA) guidelines [1, 2]. A major change from the last revision in 2005 is the<br />
inclusion of a section on critical care in maternity. This reflects the belated recognition of this<br />
increasingly important area of obstetrics [3]. The number of women requiring advanced levels of care<br />
is set to increase as the trend towards an older obstetric population with increasing morbidities and<br />
levels of obesity shows no sign of abating. As a result, obstetric anaesthetists will continue to be<br />
required to take on the role of peripartum physician (paralleling a growing enthusiasm for that of perioperative<br />
physician in non-obstetric practice [4]). This will inevitably mean involvement in training of<br />
staff caring for high-risk parturients and adoption of management roles to develop and maintain<br />
critical care facilities.<br />
These guidelines recommend a further increase in the minimum number of weekly anaesthetic<br />
consultant sessions to 12 in order to provide delivery suite cover plus further sessions for scheduled<br />
work (caesarean section lists/clinic, etc). This arises from three developments. Firstly, recent surveys<br />
have confirmed that the workload of obstetric anaesthetists is increasingly onerous and complex [5,<br />
6]. Secondly, the presence of the obstetric consultant on the delivery suite is now mandatory, with the<br />
number of hours per week determined by the number of deliveries [7]; this must be reflected in<br />
anaesthetic input. Thirdly, the Clinical Negligence Scheme for Trusts has circulated a draft standard<br />
that elective work should be independently staffed in order that it can run uninterrupted by<br />
emergencies. This is expected to be adopted as a full standard in due course.<br />
On-call rooms are disappearing from many maternity units despite the well-described benefits of<br />
enabling periods of proper rest during night-time working [8]. Even when working to a shift-based rota,<br />
the most common pattern for trainees, fatigue is more likely to affect performance and thus patient<br />
safety at night. Even short periods of sleep can help mitigate these effects and we have therefore<br />
recommended that appropriate facilities be made available.<br />
Effective teamworking is crucial to maternity care as highlighted in a recent report on safety in<br />
maternity services [9]. Obstetric anaesthetists play a pivotal role in the team itself and in delivering<br />
training in teamworking. This is reflected in our recommendations for anaesthetic representation on all<br />
maternity committees.<br />
As noted in the previous version of these guidelines, we realise that our recommendations potentially<br />
have major financial and organisational implications. However, they are based on consideration of the<br />
safety of the women who deliver in our units and their babies. We have therefore stressed yet again<br />
that consideration should be given to amalgamating units that are too small to support the costs of<br />
providing these services.<br />
3
3. Staffing<br />
Anaesthetists are involved in the care of over 60% of pregnant women. The Audit Commission found<br />
a wide variability of anaesthetic staffing on labour wards [10] and a recent survey confirms this [6].<br />
Previous recommendations concerning anaesthetic staffing were based on delivery rates. Busy units<br />
were defined somewhat arbitrarily as those with > 5000 deliveries per year, an epidural rate > 35%<br />
and a caesarean section rate > 25%, tertiary referral centres and/or centres with a high proportion of<br />
high-risk cases. It was proposed that there should one consultant session per 500 deliveries with at<br />
least 10 sessions for units with over 3000 deliveries [2]. However, there are several problems with the<br />
use of such definitions [11]. The use of crude delivery rates:<br />
• Does not take into account the huge variation in casemix that exists between units<br />
• Does not take into account the impact of changing obstetric demographics (increased maternal<br />
co-morbidities such as obesity, increased maternal age, increased assisted conception,<br />
increasing immigrant population)<br />
• Does not take account of the impact of the changes to training in anaesthesia (in particular the<br />
effect of the European Working Time Regulations on training, associated paperwork and reduced<br />
trainee numbers)<br />
• Does not reflect the increased demand for the delivery of additional anaesthetic services such as<br />
anaesthetic clinics, maternity high dependency units (HDUs) and support for interventional<br />
radiology, etc<br />
• Does not take into account changes in obstetric practice, such as increasing rates of caesarean<br />
section, trial of instrumental delivery, cervical cerclage and repair of complex tears, all of which<br />
increase theatre workload<br />
The calculation of consultant sessions will need to take into account the volume of clinical work, the<br />
contribution by consultants towards administration and other non-clinical activities, and the numbers<br />
and experience of trainees. It is essential that the contribution made by non-consultant career-grade<br />
anaesthetists is included.<br />
It is the unanimous opinion of this Working Party that a move towards obstetric anaesthetic services’<br />
being fully consultant delivered is both desirable and inevitable. Obstetricians have already set this<br />
as an objective and are in the process of working towards it [12]. Ultimately, obstetric consultant<br />
sessions devoted to emergency and elective obstetric activities should be matched by anaesthetic<br />
consultant sessions.<br />
4
Recommendations<br />
Medical staff<br />
The term ‘duty anaesthetist’ denotes an anaesthetist who has been assessed as competent to<br />
undertake duties on the delivery suite under a specified degree of supervision.<br />
The duty anaesthetist should be immediately* available to attend the obstetric unit 24 hours per day,<br />
and must therefore have no other responsibilities outside obstetrics. In all units offering a 24-hour<br />
epidural service, the duty anaesthetist must be resident on site.<br />
If the duty anaesthetist is not a consultant, consultant support and on-call availability is essential 24<br />
hours per day and a clear line of communication from the duty anaesthetist to the on-call consultant is<br />
essential at all times. If the duty anaesthetist is a consultant, the workload of the unit may dictate a<br />
need for additional manpower in order to deliver a safe service, and contact details of a back-up<br />
anaesthetist should be immediately available at all times.<br />
The name of the on-call consultant must be prominently displayed at all times. The names of all<br />
consultants who cover labour ward, and their contact numbers, should be readily available.<br />
The duty anaesthetist should not be responsible for planned maternity work such as elective<br />
caesarean section lists, anaesthetic antenatal clinics, etc. Such activities should be able to continue<br />
uninterrupted in the face of non-elective activities (e.g. emergency caesarean section, requests for<br />
regional analgesia in labour).<br />
In consultant-led obstetric units where anaesthetic care is not primarily consultant-delivered, there<br />
should be a minimum of 12 consultant anaesthetic sessions (direct clinical care) per week to cover<br />
non-elective activity (i.e. a minimum of two sessions per working day, taking account of leave). Where<br />
there is a high turnover of trainees (i.e. a three-month interval or more frequent), a third evening<br />
session may be necessary in order to train and supervise trainees adequately.<br />
In addition, there must be further consultant sessions for direct clinical care, to cover elective<br />
caesarean section lists and anaesthetic clinics.<br />
There must be a nominated lead obstetric anaesthetist who has an active role in leading and<br />
managing services, with this adequately recognised in their job plan.<br />
*Immediately available – able to attend within 5 min or less of being summoned, except in exceptional circumstances.<br />
5
Induction<br />
All trainee and non-trainee anaesthetists, regardless of prior experience in obstetric anaesthesia,<br />
should receive a formal induction to the obstetric anaesthetic unit before commencing duties. This<br />
ideally should include:<br />
• Information regarding the obstetric anaesthetic clinical supervisor and, if relevant, the educational<br />
supervisor for their attachment<br />
• A physical tour of the delivery suite, obstetric theatres, learning environment and any other<br />
relevant areas<br />
• Equipment:<br />
o A demonstration of relevant equipment, e.g. anaesthetic machine, epidural infusion devices<br />
o Location of the difficult airway trolley and its contents, including subglottic airway equipment<br />
o Depending on the stage of training/prior experience, location of other equipment such as<br />
blood storage fridge, rapid infusor device, cell salvage<br />
• Resuscitation:<br />
o Location of the cardiac arrest trolley with demonstration of the defibrillator and any other<br />
equipment if unfamiliar<br />
o Location of lipid emulsion<br />
o Use of the resuscitaire and location of equipment required for neonatal resuscitation<br />
• A clear description of:<br />
o Local arrangements for handover and contacting senior staff<br />
o Local arrangements for contacting the obstetric anaesthetist in an emergency and for a<br />
category-1 emergency caesarean section<br />
o The trainee/non-trainees’ responsibilities whilst covering the delivery suite<br />
• The location of local guidelines for obstetric anaesthesia.<br />
Handover<br />
Time for formal handover between shifts must be built into the timetable. The shift pattern of different<br />
professional groups should be compatible, e.g. anaesthetic and obstetric shifts should start/finish at<br />
the same times to allow multidisciplinary handover.<br />
Anaesthetists not in training<br />
A survey has shown that associate specialist/staff grade/specialty doctors contribute to the provision<br />
of obstetric anaesthetic services in 61% of units in the UK [6].<br />
All non-trainee anaesthetists who undertake anaesthetic duties on the delivery suite should have<br />
successfully completed the Initial Assessment of Competence in Obstetric Anaesthesia (IACOA) and<br />
have been deemed by the consultant in charge of obstetric services to be competent to perform their<br />
duties in accordance with OAA and Royal College of Anaesthetists (RCoA) guidelines. The doctors<br />
must work regularly on the delivery suite and must also regularly undertake non-obstetric anaesthetic<br />
work to ensure maintenance of a broad range of anaesthetic skills. Non-trainee anaesthetists who are<br />
6
appointed directly from other countries may not be familiar with the protocols in the UK. The following<br />
recommendations are to ensure that they are safe and are supported in the new working<br />
environment:<br />
1. There should be a defined period of directly supervised obstetric sessions. The duration of<br />
supervision will depend on individual circumstances and should be mutually agreed<br />
2. The anaesthetist must have successfully completed the IACOA before being allowed to work<br />
unsupervised.<br />
Theatre staffing<br />
Many units still use midwifery staff to assist in the operating theatre and this has an impact on<br />
midwifery staff on the labour ward. Strategic Health Authorities and Health Boards have been urged to<br />
make significant progress in replacing midwifery staff in the scrub/instrument role [13].<br />
Staffing for theatre recovery and anaesthetic assistance<br />
Parturients requiring anaesthesia have the right to the same standards of peri-operative care as any<br />
other surgical patient, including anaesthetic assistance. Training must be to the standards defined for<br />
the care of the general surgical patient [14].<br />
If the person assisting the anaesthetist is a nurse or midwife, they must have current and effective<br />
registration, and must have been appropriately trained and been assessed as having achieved the<br />
required core competencies [15]. They must be experienced and should assist the anaesthetist on<br />
labour ward on a regular basis in order to maintain competence. The team providing care for women<br />
undergoing obstetric operations must include a dedicated anaesthetic assistant for each patient in an<br />
operating theatre. The assistant should have no other duties in the operating suite concurrently.<br />
Newly recruited assistants should undergo a period of induction before working on the maternity unit.<br />
The training undergone by staff in recovery, whether they are midwives, nurses or Operating<br />
Department Practitioners, must also be of the same standard as that required for general recovery<br />
facilities [16]. Midwives with no additional training are not equipped to recover patients following<br />
anaesthesia. Staff should work in a general theatre recovery unit on a regular basis to ensure<br />
competence is maintained.<br />
All staff must be given regular access to continuing professional development and complete all<br />
mandatory training as frequently as required.<br />
7
4. Services and standards<br />
In consultant-led, as opposed to midwifery-led, units, anaesthetic services should be available to all<br />
women. The exact nature and availability of the services offered should be clear both to women<br />
choosing to book in a particular unit and to commissioning bodies.<br />
Antenatal services<br />
Information for mothers<br />
Up-to-date, locally relevant information about the services offered should be available for mothers in a<br />
range of formats appropriate to their needs (e.g. written, electronic, audio with translations), including<br />
as a minimum:<br />
• Analgesia for labour: benefits (including efficacy); risks; and availability of all options offered<br />
• Anaesthesia for caesarean section: benefits; risks; relative merits of all options offered<br />
• All women should be asked if they would be prepared to receive blood in the case of<br />
haemorrhage and this should be documented in the notes.<br />
Information should be given to mothers in a timely way – usually antenatally – that is relevant to them.<br />
Anaesthetists must have central role in the development of all information about pain relief and<br />
anaesthesia. All mothers should be given and encouraged to read information about analgesia for<br />
labour and anaesthesia for caesarean section, as the need for these choices is unpredictable and<br />
may arise in an emergency.<br />
Antenatal assessment and multidisciplinary planning<br />
Timely antenatal anaesthetic assessment services should be provided for women who:<br />
• Might present difficulties should anaesthesia or regional analgesia be required<br />
• Are at high risk of obstetric complications<br />
• Have a body mass index (BMI) greater than 40 kg.m -2 at booking [17]<br />
• Have had previous difficulties with, or complications of, regional or general anaesthesia<br />
• Have significant medical conditions.<br />
Locally agreed referral criteria should be in place. Sample guidelines regarding referral to anaesthetic<br />
services and supporting information are available from the OAA [18].<br />
Reviewing women antenatally allows for communication between obstetric anaesthetists,<br />
obstetricians and other specialists as required, and enables planning for the safe provision of<br />
anaesthesia for high-risk women.<br />
8
Peripartum care<br />
Pre-operative assessment of women scheduled to deliver by caesarean section<br />
Before admission, women should receive information about anaesthesia, relevant investigations<br />
should be undertaken and arrangements made for pre-operative preparation (fasting, antacid therapy<br />
and any other medication that should be given or withheld). This pre-operative assessment and<br />
preparation may be led by midwifery or other appropriate staff, but an anaesthetist must be available<br />
to provide advice and, if necessary, to review patients during this process. The process for such preassessment<br />
services must include anaesthetic input and review.<br />
Women should be assessed by an anaesthetist before their operation, and the plan for the<br />
anaesthetic and informed consent to the anaesthetic confirmed (this may be done verbally – see<br />
below).<br />
Fasting guidelines are discussed below.<br />
Informed consent<br />
Information for mothers about labour analgesia and obstetric anaesthesia is available in a variety of<br />
languages and formats to aid the process of informed consent [19]. The principles of consent for<br />
anaesthesia or analgesia are set out in national guidelines [20]; it is not usually considered necessary<br />
to obtain written consent. Brief details of the discussion that has taken place, and of risks that the<br />
patient has been informed about should be recorded.<br />
Regional analgesia for labour<br />
Regional analgesia is the most effective form of labour analgesia [21]. Regional analgesia should be<br />
available 24 hours per day, seven days per week, to all women delivering in consultant-led obstetric<br />
units. Local guidelines should be developed covering the initiation, maintenance and management of<br />
complications of regional analgesia for labour, based on current national guidelines and/or best<br />
evidence [22].<br />
Time to attend a request for analgesia<br />
Requests for analgesia should be met as soon as possible. The time taken for the anaesthetist to<br />
attend requests for analgesia, and from request for analgesia to achieving analgesia, should be<br />
audited regularly: at least once a year in smaller units and more frequently in larger units. The time<br />
from request for analgesia to the anaesthetist’s attending should not exceed 30 minutes. The RCoA<br />
suggests unit audit standards for the proportion of women attended by anaesthetist within 30 minutes<br />
of requesting epidural analgesia in labour [23].<br />
9
Aseptic technique<br />
It is mandatory to prepare the skin before performing central neuraxial block, and to use full aseptic<br />
precautions to reduce the risk of infective complications. Antiseptic solutions are neurotoxic, hence it<br />
is necessary to develop a systematic process for avoiding accidental injection or contamination of<br />
neuraxial injectate with antiseptic solution. A local policy should be in place taking into account these<br />
factors. Antiseptic solution should not be poured into receptacles on the sterile field that is to be used<br />
for regional blockade [24, 25].<br />
Initiation and maintenance of analgesia<br />
The anaesthetist should be immediately available for review of women and management of initial<br />
complications such as hypotension for at least 20 minutes after administration of the initial dose of<br />
regional analgesic. Local guidelines should address the management of initial complications.<br />
Continuing availability of an anaesthetist for review of women receiving regional analgesia is required<br />
throughout its duration.<br />
Monitoring and care of women receiving regional analgesia in labour<br />
Midwives caring for women receiving regional analgesia for labour should have been trained and<br />
deemed competent to do so by a local mechanism. Competence to care for women with epidural<br />
analgesia should be re-certified annually as a minimum. The specific recommendations set out in<br />
current national guidance should be followed [22].<br />
The workload of the midwife assigned to a woman with a epidural in labour should be such that care<br />
of that woman is not compromised as specified by local guidelines. The anaesthetist must be satisfied<br />
with the level of care available.<br />
Ambulation of mothers following initiation of epidural analgesia<br />
Many delivery units encourage mothers who choose regional analgesia to ambulate. If ambulation is<br />
facilitated, a specific guideline should exist outlining the process in place for assessing whether<br />
women are able to ambulate safely. Falls, slips and trips occurring in women mobilising during<br />
epidural analgesia should be reported via local incident reporting systems and audited.<br />
Post-delivery care following regional analgesia in labour<br />
Removal of the epidural catheter and its integrity should be documented. Return of motor power<br />
should be monitored by continuing observations of motor power until full recovery is present. Women<br />
should be advised not to get out of bed unaccompanied in the first instance. Postnatal falls in women<br />
who have had epidural or regional analgesia for labour should be reported via local incident<br />
monitoring systems, and monitored.<br />
10
Intravenous patient-controlled opioid analgesia in labour<br />
Intravenous patient-controlled analgesia (PCA) may be offered as an alternative to regional analgesia.<br />
Recently, the use of remifentanil PCA has increased [26]. There have been serious safety incidents<br />
associated with the use of remifentanil PCA in labour [27]. Strict adherence to locally developed<br />
guidelines [28], careful monitoring of the mother and baby, and the constant presence of a member of<br />
staff who is trained and competent to monitor maternal respiration are the minimum that is necessary<br />
to ensure that this technique is safe.<br />
Caesarean section<br />
Many aspects of preparation and anaesthesia for caesarean section have been comprehensively<br />
reviewed in the clinical guidelines on caesarean section produced by the National Institute for Health<br />
and Clinical Excellence (NICE) [29]. Some of the more important standards or aspects not covered<br />
are dealt with in this section.<br />
Classification of urgency of caesarean section<br />
Existing national guidelines should be followed regarding classification of urgency of caesarean<br />
section:<br />
1. Immediate threat to the life of the woman or fetus<br />
2. Maternal or fetal compromise which is not immediately life-threatening<br />
3. No maternal or fetal compromise but needs early delivery<br />
4. Delivery timed to suit woman or staff.<br />
The following audit categories have been suggested:<br />
• ≥ 90% category-1 caesarean sections should have a decision-to-delivery interval ≤ 30 min<br />
• ≥ 90% category-2 caesarean sections should have a decision-to-delivery interval ≤ 75 min [23].<br />
However, regardless of the classification, each case must be judged and managed on its own merits<br />
with delivery achieved as quickly as it is safely possible to do.<br />
Pre- operative preparation<br />
Before elective surgery, standard adult fasting guidelines should be adhered to [30]. Women waiting<br />
for planned surgery should not be subjected to long periods of starvation and/or fluid deprivation (they<br />
should be encouraged to drink clear fluids up until two hours pre-operatively). This should be audited<br />
and monitored.<br />
Choice of anaesthesia<br />
The choice of anaesthesia for caesarean section rests with the competent mother. Information for<br />
mothers is available in a variety of formats via the OAA website and should be used to help women<br />
choose. Units should audit the type of anaesthesia used continuously, and monitor the results<br />
annually against the RCoA’s proposed audit standards (Table 1) [23].<br />
11
Table 1 Suggested audit standards for use of regional anaesthesia for caesarean section (CS) [23].<br />
Category 1 2-3 4<br />
Proportion of CS* under regional anaesthesia > 50% > 85% > 95%<br />
Presence of birth partners<br />
Obstetrics stands alone in permitting members of the public (usually the birth partner) to accompany<br />
patients during an operation. Inviting members of the public into the operating theatre environment<br />
carries risks. These should be managed by ensuring that the purpose of the birth partner’s presence<br />
is clear to all concerned, and that the birth partner agrees to follow certain codes of behaviour, which<br />
should be set out in a local guideline and ideally clarified in a written information leaflet. The local<br />
guideline should identify the member of staff responsible for looking after birth partners if they require<br />
care or assistance unexpectedly during the operation.<br />
Any particular needs that the birth partner has should be considered, and organised (if necessary)<br />
antenatally. For example, partners with a raised BMI may require special seating.<br />
Whilst most obstetric units encourage birth partners to support women during operations under<br />
regional anaesthesia, few encourage their presence during general anaesthesia. This may be<br />
distressing for both women and their partners, and policies should be clear. Safety of the woman and<br />
her baby must be paramount. Development of antenatal information for birth partners would help to<br />
address this issue and is encouraged.<br />
Elective caesarean section lists<br />
Women delivering by planned caesarean section should have their operations performed as part of a<br />
scheduled list, resourced separately from the general workload of the delivery unit. A separately run<br />
list requires a full theatre team and should include a consultant obstetrician and a consultant<br />
anaesthetist. The list should be managed in the same way and to the same standards as other<br />
elective surgery lists. This may not be cost effective in units with a low elective workload (e.g. one or<br />
fewer elective caesareans per weekday or approximately 250 planned operations per year) but for all<br />
other units, separate resources should be allocated.<br />
Elective caesarean sections should neither interfere with delivery unit work nor be interrupted by<br />
emergencies. Such interruptions and delays (to both the scheduled and the emergency workload)<br />
should be audited and monitored, and any necessary action taken to correct recurrence.<br />
Postoperative analgesia<br />
Intrathecal or epidural diamorphine or morphine can provide adequate analgesia after caesarean<br />
section without the addition of intravenous PCA opioid. The administration of parenteral opioids to<br />
women who have received neuraxial opioids is discouraged as it increases the risk of respiratory<br />
12
depression. In the absence of contra-indications, women should be prescribed regular oral analgesia<br />
postoperatively. Pain scores on movement and sedation scores should be kept for all women<br />
postoperatively, and additional analgesia should be offered without delay when required.<br />
Recovery care<br />
Local guidelines (based on relevant national standards) for standards of care in recovery should be<br />
regularly updated, audited and monitored.<br />
The following are recommendations of the AAGBI [16]:<br />
• No fewer than two members of staff (of whom at least one must be a registered practitioner)<br />
should be present when there is a patient in recovery who does not fulfil the criteria for discharge<br />
to the ward<br />
• All registered practitioners should be appropriately trained in accordance with the standards and<br />
competencies detailed in the UK National Core Competencies for Post-anaesthesia Care [31].<br />
All women leaving obstetric recovery areas should continue to receive appropriate post-operative<br />
care. Staff caring for post-operative patients on post-natal wards must be trained to do so, and should<br />
carry out post-surgical care as set out in local guidelines.<br />
There should be a ratio of two recovery beds to one operating theatre [31]. It should be noted that<br />
more space is required per bed area for obstetric theatre recovery, compared with general postoperative<br />
recovery areas. This is because there is a need to accommodate birth partners, cots etc as<br />
well as the patient in the same area.<br />
To ensure privacy and dignity are maintained and that infection risk is reduced there should be<br />
adequate space between beds, and the facility to have private conversations with mothers and to<br />
conduct physical examinations (for example to check vaginal blood loss) [29].<br />
Postnatal care<br />
Following operative delivery, women need continuing care [29]. Any woman who has received<br />
neuraxial opioids should have respiratory rate, pain and sedation scores monitored for a period<br />
appropriate to the clinical situation.<br />
Women who have received anaesthetic care (whether analgesia for labour or anaesthesia) should be<br />
followed up routinely to obtain feedback and exclude complications. With early discharge following<br />
delivery, it may be logistically impossible to achieve this, and significant complications may not<br />
become manifest until after women have been discharged. Therefore, all women who have received<br />
regional analgesia or anaesthesia should receive written information about when and how to seek<br />
help if complications should arise; this is particularly important for women who are discharged within<br />
13
24 hours of their procedure. Patients who have suffered significant complications (for example<br />
awareness under general anaesthesia, accidental dural puncture) should be offered follow-up<br />
outpatient review with a consultant anaesthetist in the postnatal period [23].<br />
Resuscitation team<br />
A team trained in advanced resuscitation of the pregnant woman should be available to all women in<br />
obstetric units, and their skills should include the ability to carry out a peri-mortem caesarean section.<br />
A system for calling and admitting the team urgently to the delivery unit should be in place. Regular<br />
team training drills should be held.<br />
Risk management<br />
Units are expected to participate in relevant national audits, e.g. the Confidential Enquiries into<br />
Maternal Deaths, the OAA’s National Obstetric Anaesthetic Database (NOAD), the UK Obstetric<br />
Surveillance System (UKOSS), national incident reporting to the Medicines and Healthcare products<br />
Regulatory Agency (MHRA) and other relevant bodies, local incident reporting and risk management.<br />
Quality improvement, involving continuous monitoring of activity and outcomes to facilitate continuous<br />
quality improvement, using appropriate formats, should be practised. The RCoA publishes a list of<br />
relevant audits of obstetric anaesthesia services, which should be used to audit these standards [23].<br />
Local safety procedures such as syringe labelling, double checking or both should be developed to<br />
reduce the risk of wrong-route and other drug and infusion errors – and there should be adherence to<br />
national standards in all locations, including in delivery rooms.<br />
Local anaesthetic solutions intended for epidural infusion should be stored separately from<br />
intravenous infusion solutions, in a locked cupboard or other safe area, to minimise the risk of<br />
accidental intravenous administration of such drugs [32].<br />
Maternal critical care<br />
Maternity critical care is an important emerging area for obstetric anaesthetists that poses significant<br />
organisational and clinical challenges. Compared with other areas of acute medicine, there is a<br />
paucity of published evidence on which to base guidance.<br />
Timely recognition of the sick parturient is key to ensuring a good outcome and reducing maternal<br />
morbidity and mortality. Maternity services should implement NICE guidance on the recognition and<br />
response to acute illness in adults in hospital [33]. Although these guidelines do not specifically<br />
include the sick parturient, they provide a clear strategy for the delivery of care in this area.<br />
Physiological observations should be recorded on admission for all women admitted to maternity<br />
units, including midwifery-led units. A graded response strategy for patients identified as being at risk<br />
14
of clinical deterioration, as recommended by the Maternity Critical Care Working Party [3], should be<br />
agreed and delivered locally.<br />
It is widely recognised that the quality of evidence for track-and-trigger systems in any area of<br />
medicine is limited. Such systems allowing a graded medical response can be based on aggregate<br />
scoring of physiological parameters (where points are allocated according to the degree of<br />
derangement of physiological variables, and then combined into a composite score). Alternatively,<br />
multiple parameter systems can be used (in which constituent criteria are not assigned a score but<br />
instead trigger when combinations of criteria are met). Both systems have inherent advantages and<br />
disadvantages. The recently published National Early Warning Score is an aggregate system but<br />
specifically excludes the obstetric population [34].<br />
Whether an aggregate or multiple parameter system is used, the response should consist of the<br />
following three levels:<br />
• Low-score group: increased frequency of observations and the midwife in charge alerted<br />
• Medium-score group: urgent call to team with primary medical responsibility for the patient, plus a<br />
simultaneous call to personnel with core competences for acute illness<br />
• High-score group: emergency call to a team with critical care competences and a maternity team.<br />
There should be an immediate response.<br />
The Department of Health has defined a chain of response for the hospital team involved in the care<br />
of the acutely ill patient in hospital (Fig. 1) [34]. This can be adapted for use in the maternity setting.<br />
Non-clinical<br />
Staff<br />
→ Recorder → Recogniser →<br />
Primary<br />
Responder<br />
→<br />
Secondary<br />
Responder<br />
→<br />
Tertiary<br />
Responder<br />
(Critical Care)<br />
Communication and handover<br />
Figure 1 Chain of response for acutely ill patients in hospital. Redrawn from [34].<br />
Staffing<br />
Where level-2 care (see below) is provided in the maternity unit, staff appropriately trained to provide<br />
HDU care should be available 24 hours a day. The midwife/nurse-to-patient ratio must be at least one<br />
midwife/nurse to two patients or one-to-one if care is provided in individual rooms. Midwives working<br />
in this setting should have additional training that equips them with the necessary critical care<br />
competences that have been clearly set out [3].<br />
There should be a named consultant anaesthetist and obstetrician responsible for all level-2 patients,<br />
24 hours a day.<br />
15
High dependency care (level-2 adult critical care)<br />
Since 2007, the obstetric population has been included in the Intensive Care Society (ICS) definitions<br />
of levels of care in the adult population (Table 2) [35].<br />
Table 2 Levels of care as defined by the ICS [35].<br />
Level 0 Patients whose needs can be met by normal ward care<br />
Level 1<br />
Patients at risk of deterioration, needing a higher level of observation or those recently<br />
relocated from higher levels of care<br />
Level 2<br />
Patients requiring invasive monitoring/intervention that includes support for a single<br />
failing organ (excluding advanced respiratory support i.e. mechanical ventilation)<br />
Level 3<br />
Patients requiring advanced respiratory support alone or basic respiratory support in<br />
addition to support of one or more additional organs<br />
All units that care for high-risk patients must be able to access level-2 (HDU care) on site. Level-2<br />
care may be provided within the maternity unit or within a hospital’s general adult critical care unit.<br />
Level-2 care should be delivered to the same standard regardless of the setting.<br />
Larger obstetric units should have a designated consultant (usually an anaesthetist) with relevant<br />
skills who is responsible for delivery of obstetric HDU care. This lead person should ensure that local<br />
standards are developed for identifying women who require critical care, based on existing national<br />
standards [35].<br />
In smaller units, the lead obstetric anaesthetist should ensure that local standards exist.<br />
Intensive care (level-3 adult critical care)<br />
Some patients on the maternity HDU (level 2) may progress to requiring level-3 critical care (ICU).<br />
Delays in the transfer of critically ill obstetric patients to the ICU can significantly increase the mortality<br />
rate. Therefore it is essential that every unit has clear pathways in place to facilitate transfer. There<br />
should be close co-operation between the maternity HDU and the ICU teams at an early stage, with<br />
consultant-to-consultant referral and early involvement of the ICU consultant. Formal, documented<br />
local arrangements should exist for support and input from other disciplines (cardiology, respiratory<br />
medicine and allied professionals) when required.<br />
Escalation protocols should be in place for women requiring level-3 critical care.<br />
All patients must be able to access level-3 critical care if required; units without such provision on site<br />
must have an arrangement with a nominated level-3 ICU and an agreed policy for the stabilisation<br />
and safe transfer of patients to this unit when required.<br />
16
5. Training and education<br />
Each obstetric anaesthetic unit should have a consultant with overall responsibility for the training and<br />
education of trainee and non-trainee anaesthetists. They should be supported locally by trainers,<br />
educational supervisors, College Tutors and Regional Advisors, and programmed activity time should<br />
be allocated for work relating to this responsibility. Trainers must fulfil the RCoA [36] and General<br />
Medical Council (GMC) criteria [37] and can include consultants, SAS doctors and senior trainees.<br />
It is expected that in the future, the service is likely to be consultant-delivered; however, in the interim,<br />
rotas should be designed to maximise training opportunities including, for example, an extended<br />
working day for consultants [38].<br />
Although a 24-hour obstetric anaesthetic consultant presence is the ideal, trainees also need to learn<br />
to work without direct supervision and should develop their skills and confidence accordingly, without<br />
compromising patient safety.<br />
Induction<br />
All trainee and non-trainee anaesthetists, regardless of prior experience in obstetric anaesthesia,<br />
should receive a formal induction to the obstetric anaesthetic unit before commencing duties there<br />
(see Section 3).<br />
Levels of training<br />
• A training programme appropriate to the educational opportunities offered by the unit should be in<br />
place as documented in the RCoA 2010 Curriculum [36]<br />
• Basic training for core trainees: this should consist of an absolute minimum of 20 directly<br />
supervised sessions within a four-month period, during which time the trainee should achieve the<br />
core clinical learning outcomes. It is recommended that at least half of these sessions are<br />
supervised by a consultant obstetric anaesthetist<br />
• Intermediate training for ST3/4 trainees: obstetric anaesthesia is one of the essential units of<br />
intermediate level training. There should be a dedicated block of training over a 4-12 week period<br />
and this should include 20 sessions as a minimum in order that all core clinical learning outcomes<br />
can be completed. It would be anticipated that for most trainees, this would require several more<br />
sessions than the 20 recommended<br />
• Higher training: the majority of ST5/6/7 trainees will be expected to complete this level which is<br />
required for any consultant covering delivery suite out of hours. It can be delivered in nonspecialist<br />
units. Local arrangements should be in place to ensure that all the required learning<br />
outcomes can be completed<br />
• Advanced training for ST6/7 trainees: this should be undertaken by those trainees wishing to<br />
develop a sub-specialty interest in obstetric anaesthesia and/or undertake daytime sessions in<br />
obstetric anaesthesia, and those who are likely to go on to work in an obstetric tertiary referral<br />
17
centre. This level of training can only be delivered in centres that allow the trainee the opportunity<br />
to develop the skills required to manage the delivery suite and undertake complex obstetric cases<br />
whilst building and consolidating knowledge of obstetric anaesthesia, obstetrics and neonatology<br />
• Less than full-time (LTFT) trainees: at each level of training, LTFT trainees should be given an<br />
appropriate period of training in obstetric anaesthesia, proportionate to the percentage of whole<br />
time equivalent worked.<br />
Assessment<br />
Completion of the IACOA is mandatory for all core trainees before being allowed to work in an<br />
obstetric unit without direct supervision. Achieving the IACOA, however, does not signal the<br />
completion of the basic level unit of training in obstetric anaesthesia.<br />
Supervision<br />
All trainees should be supervised directly by a trainer present on delivery suite until the IACOA is<br />
completed. In addition, a joint OAA/ RCoA survey in 2010 [5] recommended that:<br />
• The IACOA should be used in conjunction with a local system of review that satisfies local clinical<br />
governance arrangements before a trainee works without immediate supervision<br />
• No trainee who feels unprepared to start obstetric on-call (regardless of completion of IACOA)<br />
should be expected to join the on-call rota unless directly supervised. Departments should make<br />
provision for this eventuality where rotas are written a long time in advance<br />
• All trainees who have completed their basic obstetric training should have some opportunity to<br />
cover the labour ward without immediate supervision, so that they are confident to take on this<br />
responsibility once they are appointed to an ST3 post.<br />
The first two of the above recommendations should also apply to non-trainee anaesthetists. All trainee<br />
and non-trainee anaesthetists working without direct supervision on delivery suite must have a named<br />
supervising consultant and both parties must be happy with the level of supervision available. In<br />
addition, they must know how to contact the supervising consultant in the event of an emergency.<br />
Simulation<br />
Simulation-based educational techniques can be used to assist all anaesthetists to develop the skills<br />
and attributes required to work safely and efficiently within the multidisciplinary obstetric team,<br />
including:<br />
• Technical skill development using part-task simulators e.g. epidural, cricothyroidotomy [39]<br />
• Reinforcement of emergency drills e.g. failed intubation [40]<br />
• Teaching and assessing clinical skills when clinical opportunities are limited e.g. general<br />
anaesthesia for caesarean section<br />
• Maternal and neonatal resuscitation [40]<br />
• Teamwork training emphasising non-technical skills [9]<br />
18
• Skills and drills training: anaesthetists should help organise and participate in regular<br />
multidisciplinary drills covering delivery suite emergencies such as major obstetric haemorrhage,<br />
maternal collapse and failed intubation [41]. These drills should be followed by debriefing and<br />
feedback so that lessons can be learned at both an individual and a systems level.<br />
Continuing professional development<br />
All anaesthetists involved in the delivery of obstetric anaesthetic services should undertake<br />
appropriate continuing professional development activities in line with revalidation guidelines.<br />
19
6. The labour ward team<br />
Maternity care is delivered by teams rather than individuals. Effective teamwork can increase safety;<br />
poor teamwork can have the opposite effect [9]. A report on safety standards in the maternity services<br />
identified the following problems:<br />
• Differing goals of midwives and doctors with regard to the care of women<br />
• Poor leadership and management<br />
• Difficulties with communication between healthcare professionals during emergencies and shift<br />
changes<br />
It is essential that obstetric anaesthetists should establish clear lines of communication with other<br />
professionals such as intensivists, neurologists, cardiologists, haematologists, other physicians,<br />
surgeons, radiologists, outreach nurses, physiotherapists and pharmacists.<br />
Team briefing and a safety checklist should be used routinely to facilitate good communication and<br />
teamworking and reduce adverse incidents [42].<br />
Checklists and team briefing<br />
Pre-operative checklists and team briefing procedures should be used, both for elective and<br />
emergency obstetric operations. Nationally-developed obstetric modifications of the standard format<br />
exist and should be used or adapted for local use. In extreme emergencies, the procedure may be<br />
truncated, but it must be borne in mind that these are the most error-prone situations. Use of the<br />
checklist should be audited.<br />
Anaesthetists and midwives<br />
‘Midwifery-led care’ refers to all cases in which the lead professional for the case is a midwife rather<br />
than an obstetrician. This type of care may be delivered in a variety of units. If regional analgesia is<br />
required, the anaesthetist may be the only medically-qualified person involved with the<br />
labour/delivery.<br />
It is recommended that the following criteria should be met whenever a hospital or maternity unit is<br />
proposing that anaesthetists should work directly with midwives who are acting as lead providers of<br />
obstetric care:<br />
• There should be a consultant-led obstetric service on site<br />
• There must be guidelines in place for the management of regional analgesia that have been<br />
agreed by anaesthetists, midwives and obstetricians. Midwives practising independently but<br />
intending to make use of a regional analgesia service must agree to follow the guidelines of the<br />
unit where they deliver their clients<br />
20
• The midwife caring for a woman with an epidural must be trained in its management to a standard<br />
acceptable to the anaesthetist responsible for the service, must undergo regular refresher<br />
training, and must be managing regional analgesia on a regular basis<br />
• The midwife must allow the anaesthetist access to any woman considering regional analgesia<br />
who wishes to discuss pain relief options<br />
• If the anaesthetist feels that an obstetric opinion is necessary, he/she should consult the midwife<br />
in the first instance. However, if necessary, the anaesthetist may consult directly with the<br />
obstetricians, but should inform the midwife that this is his/her intention<br />
• All decisions regarding regional analgesia must rest with the anaesthetist.<br />
Anaesthetists and obstetricians<br />
• Anaesthetists should encourage and facilitate consultation in the antepartum period by making<br />
themselves available when antenatal clinics are in progress and by ensuring clear lines of referral.<br />
A system for the antenatal assessment of high-risk mothers should be in place with 24-hour<br />
access to the information on the delivery suite<br />
• Good communication on the delivery suite is vital in order to minimise last-minute referral and the<br />
hasty decision-making that often ensues. Anaesthetists should make themselves known to<br />
obstetricians who should, in turn, keep them informed of developing problems. Anaesthetists’<br />
attendance at obstetric ward rounds is to be encouraged in order to be kept well informed of the<br />
labour ward caseloads and casemix<br />
• There should be formal arrangements in place and protected time for multidisciplinary handover<br />
at the beginning and end of each shift<br />
• Anaesthetists should be involved in planning decisions that affect the delivery of maternity<br />
services. Anaesthesia should be represented on any committee that has relevance to anaesthetic<br />
services on the labour ward such as the labour suite working party, obstetric directorate and risk<br />
management forum.<br />
Communication and classification of urgency<br />
Whilst this section applies primarily to delivery by caesarean section, many of the items also apply in<br />
principle to trial of operative vaginal delivery in the operating theatre. Standard classification of the<br />
urgency of caesarean section as described in Section 4.6 should be used for caesarean section and<br />
this classification should be considered for operative vaginal delivery. It is recognised that this grading<br />
artificially categorises cases when in reality there is a continuum of risk, and that within a grade, some<br />
cases may require delivery more urgently than others. Each case must be graded and managed<br />
individually.<br />
The situation may change after the decision to deliver has been made, and the classification should<br />
be re-assessed following transfer to theatre by the responsible obstetrician, and kept under review<br />
whilst anaesthesia is established.<br />
21
Communicating both the planned procedure and its grade of urgency with the entire theatre team, as<br />
soon as the decision to deliver is taken, is vital, and a process for doing this should be covered by<br />
local guidelines. In addition, the anaesthetist responsible for the anaesthetic should be informed of<br />
both the indication for the procedure and its urgency by the operating obstetrician in person whenever<br />
possible.<br />
Transferring patients to theatre may lead to delays, and measures to reduce such delays should be<br />
covered by local guidelines.<br />
Other professionals and roles<br />
Neonatal resuscitation<br />
Units differ as to their policies about the involvement of the anaesthetist in neonatal resuscitation.<br />
Where they are given a role, anaesthetists should work with the neonatal team to ensure that<br />
appropriate training is delivered and maintained.<br />
Maternity care assistants<br />
The role of maternity care assistants (MCAs) is to complement and not to substitute for midwives. In<br />
some units they may be involved in monitoring and recording routine observations, or in assisting with<br />
epidural placement or in theatre. Appropriate training must be provided if they are to adopt these<br />
roles.<br />
Support personnel<br />
Increasing activity on the labour ward that requires information input, admissions and clerical duties<br />
demonstrate the need for a ward clerk or receptionist to be available at all times. Housekeeping,<br />
portering and maintenance teams need to be accessible on site because of the high turnover bed<br />
occupancy, high technology environment and emergency service provision.<br />
22
7. Support services, equipment, facilities and accommodation<br />
For the efficient functioning of the obstetric anaesthetic service, the following support services,<br />
equipment, facilities and accommodation are essential. The standards of equipment and monitoring<br />
must be the same as that of non-obstetric anaesthetic service.<br />
Support services<br />
A supply of O rhesus-negative blood should be immediately (within five minutes) available to the<br />
delivery suite at all times for emergency use. Grouping can be performed in about 10 minutes [42]<br />
and group-specific blood should be delivered within 20 minutes of request. Standard issue of crossmatched<br />
blood may take approximately 45 minutes [43] although some patients without antibodies<br />
may be eligible for electronic issue which can be much quicker: if the laboratory is in receipt of two<br />
‘group & save’ samples taken on separate occasions they may be able to issue cross-matched blood<br />
as rapidly as group-specific [44].<br />
In order to ensure that blood can be made available within the time frames stipulated, the transfusion<br />
laboratory should ideally be situated on the same site as the maternity unit.<br />
Due to changes in transfusion practice, apart from packed red cells, blood products such as fresh<br />
frozen plasma (FFP), cryoprecipitate and platelets are now required earlier in the management of<br />
haemorrhage. As part of the response to a major obstetric haemorrhage call, the laboratory should<br />
make FFP available as rapidly as possible, enabling an approximate 1:1 ratio of red cells:FFP if<br />
deemed appropriate [44]. Platelets are not stored by all laboratories. If a significant delay is<br />
anticipated, the delivery suite should be notified in advance. The use of fibrinogen and prothrombin<br />
complex concentrates should be considered early [45].<br />
Haematology and biochemistry services must be able to provide rapid analysis of blood and other<br />
body fluids. However, near-patient testing (see below) will guide blood and product replacement far<br />
more quickly than standard laboratory tests and should be utilised whenever possible.<br />
There must be rapid availability of diagnostic radiological services. In tertiary referral centres, 24-hour<br />
access to interventional radiology services is highly recommended.<br />
Medical physics technicians are required to maintain, repair and calibrate anaesthetic machines,<br />
monitoring and infusion equipment.<br />
Physiotherapy services should be available 24 hours a day, 365 days a year for patients requiring<br />
critical care.<br />
23
Hotel services must provide suitable on-call facilities including housekeeping for resident and nonresident<br />
anaesthetic staff. Refreshments must be available throughout the 24-hour period.<br />
There must be adequate secretarial support for the antenatal anaesthetic assessment clinic and other<br />
duties of the consultant obstetric anaesthetist: teaching; research; audit; study; appraisal activities;<br />
and other administrative work.<br />
Equipment<br />
Units should purchase appropriate equipment to enable safe delivery of neuraxial analgesia and<br />
anaesthesia with regard to any relevant national or international safety guidance. It is mandatory that<br />
local obstetric anaesthetists are involved in purchasing decisions involving equipment for neuraxial<br />
analgesia and anaesthesia. Epidural infusion sets should conform to standards for colour-coding and<br />
should be labelled.<br />
A blood warmer allowing the transfusion of blood and fluids as well as warm air blankets must be<br />
available. A Level 1® or equivalent rapid infusion device should be available for the management of<br />
major haemorrhage.<br />
A difficult intubation trolley with a variety of laryngoscopes, laryngeal mask airways and tracheal tubes<br />
should be available. Second generation supraglottic airway devices that give some protection from<br />
gastric contents [45] and other aids for airway management must be available in theatre. There<br />
should be 24-hour access to a fibreoptic ’scope [46].<br />
The maximum weight that the operating table can support must be known and alternative provision<br />
made for women who exceed this. The operating table should be able to support a weight of at least<br />
160 kg. Other equipment to facilitate the care of obese parturients such as weighing scales,<br />
wheelchairs, equipment to assist with the transfer of patients between beds, equipment to assist with<br />
ramping in order to optimise head and neck position for laryngoscopy, and appropriate ward beds<br />
should be readily available [47].<br />
Cell salvage equipment (and personnel trained it its use) should be available at all times for<br />
emergency and elective caesarean sections in units that deliver women who decline to have blood<br />
transfusion [48].<br />
There must be equipment such as HemoCue® or blood gas analyser to enable bedside estimation of<br />
haemoglobin concentration.<br />
It is strongly recommended that there should be equipment to enable bedside estimation of<br />
coagulation such as thromboelastography (TEG) or thromboelastometry (ROTEM) [43].<br />
24
Equipment for PCA must be available for postoperative pain relief. Ultrasound machines should be<br />
available for the use of ultrasound-guided central venous pressure lines insertion and transversus<br />
abdominis plane (TAP) blocks, and to assist with central neuraxial blocks in obese patients.<br />
Accurate clocks should be available in all delivery rooms and theatres.<br />
Resuscitation equipment including a defibrillator should be readily available on the delivery suite and<br />
should be checked regularly.<br />
Facilities<br />
The delivery suite rooms must be equipped with monitoring equipment for the measurement of noninvasive<br />
blood pressure. There should also be readily available equipment for monitoring ECG,<br />
oxygen saturation, temperature and invasive haemodynamic monitoring if required. All delivery rooms<br />
must have oxygen, suction equipment and access to resuscitation equipment. Delivery suite rooms<br />
must have active scavenging of inhalational analgesics to comply with Control of Substances<br />
Hazardous to Health (COSHH) guidelines on anaesthetic gas pollution [49].<br />
There must be easy and safe access to the delivery suite from the main hospital at all times of the<br />
day.<br />
There should be at least one fully-equipped obstetric theatre within the delivery suite. Where this is<br />
not possible, a lift that can be commandeered for the rapid transfer of women to theatre must be<br />
available. The number of operating theatres required should depend on the number of deliveries and<br />
operative risk profile of the women delivering in the unit.<br />
Obstetric theatres should be equipped and staffed to the same standards as other operating theatres.<br />
[13, 49]. The standard of monitoring in the obstetric theatre must allow the conduct of safe<br />
anaesthesia for surgery. The same standards of monitoring apply whenever an anaesthetist is<br />
responsible for anaesthesia, whether general, regional or local [50].<br />
Adequate post-anaesthesia care facilities, including the ability to monitor systemic blood pressure,<br />
ECG, oxygen saturation and capnography, must be available within the delivery suite theatre<br />
complex. The layout/lighting should conform to established standards; however, it must be<br />
appreciated that obstetric recovery spaces need to be much larger than required for standard adult<br />
recovery [16, 51].<br />
There should be readily available ‘eclampsia boxes’ containing all necessary equipment and a<br />
protocol for eclampsia [52].<br />
25
Lipid emulsion, dantrolene and sugammadex may all be useful in anaesthetic emergencies. These<br />
should be immediately available on the delivery suite and location of these drugs should be clearly<br />
identified. Local anaesthetic and opioid solutions intended for epidural use should be available and<br />
stored separately from intravenous fluids to minimise the risk of accidental intravenous administration<br />
of such fluids.<br />
All units that care for high-risk patients should be able to access level-2 HDU care on site (see<br />
Section 4).<br />
Accommodation<br />
All consultant obstetric units should include dedicated office space for the sole use of the anaesthesia<br />
team on the delivery suite, or close enough for the resident anaesthetist to be able to work there<br />
between cases. This space should have adequate information technology facilities for both trainee<br />
and trained staff to be able to deal with emails, complete mandatory online training, access journals<br />
and search engines via the internet, complete portfolios and enter audit-related data. Local<br />
multidisciplinary evidence-based guidelines must be available in the office. The office space, facilities<br />
and furniture should comply with the standards recommended by AAGBI guidelines [53].<br />
A library of specialist reference books/journals should be available. There should be a separate<br />
anaesthetic consultants’ office available to allow teaching, assessment and appraisal, that complies<br />
with AAGBI guidelines [53].<br />
A communal rest-room in the delivery suite should be provided to enable staff of all specialities to<br />
meet. A seminar room(s) must be available for training, teaching and multidisciplinary meetings.<br />
We strongly support the provision of an on-call room containing a bed as there is good evidence that<br />
even short periods of sleep improve performance during nightshift work (regardless of the length of<br />
the shift) [8, 54].<br />
Where a consultant is required to be resident, appropriate on-call accommodation should be provided<br />
[55].<br />
26
8. The future<br />
The delivery of healthcare constantly needs to evolve to meet the challenges of a changing population<br />
and deliver high-quality care; obstetric anaesthesia is no exception to this.<br />
Changes in healthcare encompass both organisational and clinical aspects. Developments that the<br />
Working Party supports include:<br />
• An aspiration to develop a 24-hour consultant-delivered anaesthesia service in the maternity unit,<br />
with the instigation of twilight and weekend sessions as an initial step<br />
• An expanded role of the obstetric anaesthetist as a ‘peripartum physician’ – in particular, more<br />
antenatal involvement in the management of women with high-risk/complicated pregnancies<br />
• Developing relationships between the maternity team and other specialities in the hospital setting,<br />
e.g. medical specialities such as cardiology, with maternity units receiving support from a named<br />
cardiologist<br />
• More extensive use of near-patient testing in the maternity unit<br />
• Development of safe and effective alternatives to regional analgesia in labour<br />
• Outcome-based research on the impact of intrapartum analgesia and anaesthesia on mother and<br />
baby<br />
• Further research into increased levels of anaesthetic safety<br />
• Development of enhanced recovery programmes in obstetrics<br />
• Confirmation at Department of Health level of the uninterrupted continuation of the Confidential<br />
Enquiries into maternal death and morbidity with more timely and frequent reports<br />
• Promoting equitable provision of anaesthetic services by ensuring anaesthetic representation on<br />
commissioning bodies.<br />
27
9. List of recommended guidelines<br />
Departments should have written guidelines, setting out local standards of care (based on national<br />
standards where these exist), including as a minimum the following (listed alphabetically):<br />
• Analgesia post-caesarean section (including TAP blocks)<br />
• Antacid prophylaxis for labour and delivery<br />
• Antibiotic and thromboprophylaxis for caesarean section<br />
• Awareness under general anaesthesia<br />
• Cell salvage<br />
• Conditions requiring antenatal referral to the anaesthetist<br />
• Fasting before elective and emergency obstetric procedures<br />
• General anaesthesia for caesarean section<br />
• Guideline development<br />
• HDU admission and discharge criteria<br />
• High BMI (> 40 kg.m -2 )<br />
• Intrauterine fetal resuscitation<br />
• Intravenous opioid PCA (Including remifentanil PCA if available locally)<br />
• Management of major haemorrhage (including trigger phrase to activate major haemorrhage<br />
transfusion protocol)<br />
• Management of pre-eclampsia and eclampsia<br />
• Modified Obstetric Early Warning Score use<br />
• Oral intake during labour<br />
• Provision of information to patients including:<br />
o Anaesthesia for caesarean section (general and regional)<br />
o Pain management in labour<br />
• Regional anaesthesia including:<br />
o Hypotension during regional block<br />
o Management of failed or inadequate regional block<br />
o Management of high regional block<br />
o Management of accidental dural puncture<br />
o Management of epidural haematoma<br />
o Management of post-dural puncture headache<br />
o Management of regional techniques in patients receiving thromboprophylaxis<br />
o Regional blocks for labour analgesia<br />
o Regional blocks for surgery<br />
• Recovery following general and regional anaesthesia<br />
• Resuscitation of the pregnant patient<br />
• Staffing levels<br />
• Skills and drills training.<br />
28
The following national guidelines should be displayed or be immediately available in all locations<br />
where obstetric anaesthesia is delivered:<br />
• Adult resuscitation guidelines [Resuscitation Council (UK)]<br />
• Anaesthetic machine checklist [AAGBI]<br />
• Management of:<br />
o Anaphylaxis [AAGBI and/or Resuscitation Council (UK)]<br />
o Failed intubation [to be produced by Dififcult Airway Society/OAA]<br />
o Malignant hyperthermia [AAGBI]<br />
o Neonatal life support [Resuscitation Council (UK)]<br />
o Peri-arrest arrhythmias [Resuscitation Council (UK)]<br />
o Severe local anaesthetic toxicity [AAGBI]<br />
29
10. References<br />
1. Association of Anaesthetists of Great Britain & Ireland and Obstetric Anaesthetists’ Association.<br />
Guidelines for Obstetric Anaesthesia Services. London: AAGBI, 1998.<br />
2. Association of Anaesthetists of Great Britain & Ireland and Obstetric Anaesthetists’ Association.<br />
Guidelines for Obstetric Anaesthetic Services 2. London: AAGBI, 2005.<br />
3. Maternity Critical Care Working Group. Providing Equity of Critical and Maternity Care for the<br />
Critically Ill Pregnant or Recently Pregnant Woman. London: Royal College of Anaesthetists, 2011.<br />
4. Grocott MPW, Pearce RM. Perioperative medicine: the future of anaesthesia? British Journal of<br />
Anaesthesia 2012; 108: 723-6.<br />
5. Obstetric Anaesthetists’ Association. Joint RCoA-OAA obstetric anaesthetic training survey 2010.<br />
http://www.oaa-anaes.ac.uk/content.asp?ContentID=452 (accessed 26/04/2013).<br />
6. Obstetric Anaesthetists’ Association. OAA-AAGBI workload survey. http://www.oaaanaes.ac.uk/content.asp?ContentID=467<br />
(accessed 19/03/2013).<br />
7. Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College<br />
of midwives, Royal College Paediatrics and Child Health. Safer Childbirth: Minimum Standards for<br />
the Organization and Delivery of Care in Labour. London: RCOG Press, 2007.<br />
8. Association of Anaesthetists of Great Britain & Ireland. Fatigue and Anaesthetists. London: AAGBI,<br />
2004.<br />
9. The King’s Fund. Safe Births: Everybody’s Business. London: The King’s Fund, 2008.<br />
10. Audit Commission. Anaesthesia under Examination: the Efficiency and Effectiveness of<br />
Anaesthesia and Pain Relief Services in England and Wales. Oxford: Audit Commission, 1997.<br />
11. Yentis SM, Robinson PN. Definitions in obstetric anaesthesia: how should we measure anaesthetic<br />
workload and what is ‘epidural rate’? Anaesthesia 1999; 54: 958–62.<br />
12. Royal College of Obstetricians and Gynaecologists. High Quality Women’s Health Care: a Proposal<br />
for Change. London: RCOG Press, 2011.<br />
13. College of Operating Department Practitioners. Staffing of obstetric theatres – a consensus<br />
statement. http://www.codp.org.uk/documents/Staffing%20of%20Obstetric%20Theatres.pdf<br />
(accessed 19/03/2013).<br />
14. Association of Anaesthetists of Great Britain & Ireland. The Anaesthesia Team 3. London: AAGBI,<br />
2010.<br />
15. NHS Education for Scotland. Core competencies for anaesthetic assistants 2011<br />
www.nes.scotland.nhs.uk/media/4239/anaesthetic_core_competencies_2011.pdf (accessed<br />
19/03/2013).<br />
16. Association of Anaesthetists of Great Britain & Ireland. Immediate Post-anaesthesia Recovery<br />
2013. Anaesthesia 2013; 68: 288-97.<br />
17. RCOG/CMACE. Joint Guideline Management of women with obesity in pregnancy. London:<br />
RCOG/CMACE, 2010.<br />
18. Obstetric Anaesthetists’ Association. Referral to anaesthetists. http://www.oaaanaes.ac.uk/content.asp?ContentID=339<br />
(accessed 19/03/2013).<br />
30
19. Obstetric Anaesthetists’ Association. Information for mothers. http://www.oaaanaes.ac.uk/content.asp?ContentID=83<br />
(accessed 19/03/2013).<br />
20. Association of Anaesthetists of Great Britain & Ireland. Consent for Anaesthesia 2. London: AAGBI,<br />
2006.<br />
21. Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of<br />
systematic reviews. http://www.thecochranelibrary.com/details/file/1598141/CD009234.html<br />
(accessed 19/03/2013).<br />
22. National Institute for Health and Clinical Excellence. NICE Clinical Guideline 55. Intrapartum Care.<br />
London: NICE, 2007. [being updated]<br />
23. Royal College of Anaesthetists. Raising the Standard: a Compendium of Audit Recipes. 3 rd Edition<br />
2012. London: RCoA, 2012.<br />
24. Royal College of Anaesthetists. NAP3 National Audit of Major Complications of Central Neuraxial<br />
Block in the United Kingdom, p75. London: RCoA, 2009.<br />
25. Scott M, Stones J, Pane N. Antiseptic solutions for central neuraxial blockade: which concentration<br />
of chlorhexidine in alcohol should we use? British Journal of Anaesthesia 2009; 103: 456-57.<br />
26. Hinova A, Fernando R. Remifentanil for labor analgesia. Anesthesia and Analgesia 2009; 109:<br />
1925-29.<br />
27. Muchatula NA, Kinsella SM. Remifentanil for labour analgesia: time to draw breath? Anaesthesia<br />
2013; 68: 227- 35.<br />
28. Obstetric Anaesthetists’ Association. Remifentanil. http://www.oaaanaes.ac.uk/content.asp?ContentID=333<br />
(accessed 26/03/13).<br />
29. National Institute for Health and Clinical Excellence. Caesarean section clinical guidelines CG132.<br />
http://www.nice.org.uk/CG132 (accessed 26/03/2013).<br />
30. Association of Anaesthetists of Great Britain & Ireland. Preoperative Assessment and Patient<br />
Preparation. The Role of the Anaesthetist 2. London: AAGBI, 2010.<br />
31. Association of Anaesthetists of Great Britain & Ireland. UK National Core Competencies for Post-<br />
Anaesthesia Care. London: AAGBI, 2013.<br />
32. The Royal College of Anaesthetists. NAP3 full report. www.rcoa.ac.uk/document-store/nap3-fullreport<br />
(accessed 26/03/2013).<br />
33. National Institute for Health and Clinical Excellence. Acutely ill patients in hospital clinical<br />
guidelines CG50. http://guidance.nice.org.uk/CG50 (accessed 26/03/2013).<br />
34. Royal College of Physicians. National Early Warning Scores (NEWS).<br />
http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warning-scorestandardising-assessment-acute-illness-severity-nhs.pdf<br />
(accessed 26/03/2013).<br />
35. Intensive Care Society. Levels of Critical care for Adult Patients. London: ICS, 2009.<br />
36. Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics, 2 nd edn, London: RCoA,<br />
2010.<br />
37. General Medical Council. The Trainee Doctor. London: GMC, 2011.<br />
31
38. Royal College of Anaesthetists. Working Time Directive 2009 and shift working: ways forward for<br />
anaesthetic services, training, doctor and patient safety. https://www.rcoa.ac.uk/system/files/TRG-<br />
WTR-Shift-Working.pdf (accessed 10/04/2013).<br />
39. Uppal V, Kearns RJ, McGrady EM. Evaluation of the M43B Lumbar Puncture Simulator II as a<br />
training tool for identification of the epidural space and lumbar puncture. Anaesthesia 2011; 66:<br />
493-6.<br />
40. Pratt S. Simulation in obstetric anaesthesia, Anesthesia and Analgesia 2012; 114: 186-90.<br />
41. NHS Litigation Authority. Clinical Negligence Scheme for Trusts, maternity clinical risk<br />
management standards.<br />
http://www.nhsla.com/safety/Documents/Central%20Manchester%20University%20Hospitlas%20N<br />
HS%20Foundation%20Trust%20-%20February%202012%20-%20Maternity.pdf (accessed<br />
10/04/2013).<br />
42. Haynes AB, Weiser TG, Berry WR, et al. The safe surgery saves lives study group. A surgical<br />
safety checklist to reduce morbidity and mortality in a global population. New England Journal of<br />
Medicine 2009; 360:491-9.<br />
43. Association of Anaesthetists of Great Britain &Ireland. Blood Transfusion and the Anaesthetist.<br />
Management of Massive Haemorrhage. London: AAGBI, 2010.<br />
44. Medicines and Healthcare Products Regulatory Agency. MHRA guidance on electronic issue.<br />
http://www.mhra.gov.uk/home/groups/is-insp/documents/websiteresources/con081801.pdf<br />
(accessed 10/04/2013).<br />
45. Sambasivan CN, Schreiber MA. Emerging therapies in traumatic haemorrhage control. Current<br />
Opinion in Critical Care 2009; 15: 560–8.<br />
46. The Royal College of Anaesthetists. NAP4 full report. http://www.rcoa.ac.uk/system/files/CSQ-<br />
NAP4-Full.pdf (accessed 10/04/2013).<br />
47. Association of Anaesthetists of Great Britain & Ireland. Peri-Operative Management of the Morbidly<br />
Obese Patient. London: AAGBI, 2007.<br />
48. Catling SJ, Freites O, Krishnan S, Gibbs R. Clinical experience with cell salvage in obstetrics: 4<br />
cases from one UK centre. International Journal of Obstetric Anesthesia 2002; 11: 128-34.<br />
49. Health and Safety Executive. EH40/96. Occupational exposure limits 1996. London: HMSO, 1996.<br />
50. Association of Anaesthetists of Great Britain & Ireland. Recommendations for Standards of<br />
Monitoring During Anaesthesia and Recovery. London: AAGBI, 2007.<br />
51. NHS Estates. Revised schedules of accommodation. London: NHS, 2002.<br />
52. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. Quality and<br />
Safety in Health Care 2004; 13:127–129.<br />
53. Association of Anaesthetists of Great Britain & Ireland. Department of Anaesthesia – secretariat<br />
and accommodation guidelines. London: AAGBI, 1992.<br />
54. Department of Health and Social Security. Anaesthetic Service Accommodation in District General<br />
Hospitals. A Design Guide. London: DHSS, 1971.<br />
55. Department of Health and Social Security. Secretarial and Support Services for Hospital Medical<br />
and Dental Staff. Report of a Departmental Working Party. London: DHSS, 1987.<br />
32
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
Association of Anaesthetists of Great Britain & Ireland<br />
Needlestick Working Party Report<br />
Council of the Association of Anaesthetists of Great Britain & Ireland (AAGBI) established a<br />
Working Party on Needlestick Injuries in December 2007. Its initial membership was:<br />
Dr Andrew Hartle (Chair)<br />
Dr Steve Yentis<br />
Dr Stuart White<br />
Dr Mark Hearn<br />
Dr Dominic Bell<br />
Dr Daniel Sokol<br />
Ms Kim Sunley<br />
Dr Andy Lim<br />
Ms Janette Roberts<br />
AAGBI Council<br />
AAGBI Council<br />
Consultant Anaesthetist, Brighton<br />
GAT Representative<br />
Intensive Care Society<br />
Lecturer in Medical Ethics & Law<br />
Royal College of Nursing<br />
Royal College of Anaesthetists<br />
Patient Liaison Group<br />
The Working Party was to consider the testing of patients for Blood Borne Viruses (BBV) after<br />
needlestick and other occupational injuries, especially in the light of recent legislative change<br />
(Human Tissue Act 2004 [HTA] and Mental Capacity Act 2005 [MCA]), and the withdrawal of<br />
previous guidance from the General Medical Council (GMC).<br />
The legal ‘limbo’ surrounding the testing of patients who lacked capacity, and who had been<br />
the source of a needlestick or other occupational injury had been described in detail in Stuart<br />
White’s editorial in Anaesthesia (Needlestuck. Anaesthesia 2007; 62: 1199-201). Initial<br />
guidance from the GMC had been that testing of such patients could take place in exceptional<br />
circumstances. The introduction of HTA and MCA had led to that guidance being withdrawn,<br />
and advice from Medical Indemnity organisations was now that such testing without the<br />
patient’s consent was unlawful. This now meant that Healthcare professionals who sustained<br />
occupational exposure were unable to know the viral status of the source when making<br />
decisions about the initiation or discontinuation of post exposure prophylaxis (PEP).
At the first meeting held on 9 th May 2008 it was agreed that there were three strands to the<br />
WP’s remit:<br />
• Establish what changes were possible to the current legal situation and make<br />
recommendations.<br />
• Identify mechanisms by which change could be effected.<br />
• Identify ways by which public support for such change could be achieved, including<br />
identifying other stakeholders.<br />
The WP discussed the apparent variability of response to the current situation. In some units<br />
patients were never tested after occupational injury, but in others testing may still be<br />
performed, either with or without the agreement of next of kin. This creates a ‘postcode<br />
lottery’ in the management of occupational injuries, and also places healthcare workers at risk<br />
of legal, disciplinary or regulatory action. Such inconsistency in management is not<br />
acceptable.<br />
After some discussion, the following possible changes were agreed, roughly in order of most to<br />
least restrictive, and possibly in ascending order of likely public acceptability:<br />
• Blanket testing of all patients.<br />
• Testing of all patients who become the source of a needlestick/infective injury.<br />
• ‘Presumed Consent’ for testing unless prior evidence of objection.<br />
• The previous status quo, i.e. testing only after an individual risk/benefit analysis (to<br />
include psychological as well as physical risk).<br />
• Testing with the consent of next of kin.<br />
• No testing without specific consent from the patient.<br />
Members of the WP agreed to analyse each of these options, before making recommendations<br />
to Council. Those analyses are attached.<br />
The WP agreed that, before the situation of testing arose, first priorities for all stakeholders<br />
should be:<br />
• Prevention/preventative technology<br />
• Improved (confidential) reporting<br />
• De-stigmatisation
Three principle methods of achieving a change in the law were identified:<br />
1. A change in the law (Statutory Instrument, amendment, primary legislation)<br />
2. An elaboration of existing law<br />
3. A test case<br />
In order to establish public support, which will be vital for any change, the following themes<br />
were explored:<br />
• Exploring broader benefits and harms to -<br />
o Individual patients<br />
o Individual healthcare staff<br />
o Employers<br />
o Society<br />
• The virtuous/responsible patient<br />
• Comparisons with zero tolerance to violence<br />
• Reciprocity<br />
Other stakeholders included:<br />
• British Association of Operating Department Practitioners<br />
• Unison<br />
• Unite<br />
• Chartered Society of Physiotherapists<br />
• Association of Occupational Health<br />
• NHSE (including medical Directors)<br />
• Patients Association<br />
• Terrence Higgins Trust<br />
• GMC<br />
• NHSLA<br />
• MPS/MDU/MDDUS<br />
• BMA<br />
• Court of Protection<br />
• Office of Official Solicitor<br />
• Health and Safety Executive<br />
• Department of Health<br />
• Human Tissue Authority
Methods to estimate/establish public support included:<br />
• Properly conducted patient/lay person research<br />
• Public opinion poll<br />
• Letters/editorial in other journals<br />
• Parliamentary spokesmen (especially for Trade Unions)<br />
• BBC Online Poll<br />
• Online Downing Street petition<br />
• The general and medical press<br />
The Working Party met again in June 2008, when initial drafts of the analyses were considered.<br />
At a subsequent meeting in February 2009, the WP was joined by Veronica English of the BMA<br />
Ethics Department. The RCN was represented on that occasion by Janice Gabriel, and David<br />
Whitaker (Immediate Past President, AAGBI) was also present.<br />
VE explained that the BMA had met with Lord Warner at the Department of Health.<br />
Amendment(s) of the Human Tissue Act would probably not help clarify the current legal<br />
limbo, as serum (ie not containing cells) was stored and tested for blood borne viruses (BBV),<br />
so the HTA was not engaged.<br />
The BMA would prefer not to stretch a best interests argument, although this might be possible<br />
by changes to the Mental Capacity Act’s code of conduct.<br />
After much discussion the WP narrowed its recommended options to Council as being:<br />
1. All patients who were the source of an occupational injury should be tested for BBV.<br />
This would be the greatest infringement of Human Rights and would need primary<br />
legislation, but would be fair as all patients would be treated the same. An analogy<br />
might be drawn with compulsory testing for alcohol and drugs following a Road Traffic<br />
Accident. There was an impression that this was what lay people thought happened<br />
anyway.<br />
2. The restoration of the previous position whereby the merits of a particular case were<br />
assessed and the decision to test or not could then be justified. This was the BMA’s<br />
preferred option. Trusts could produce policies to ensure fairness, transparency and<br />
accountability.
3. Testing could take place with the consent of next-of-kin or other delegated decision<br />
makers.<br />
Recommendations as to how the necessary legal change could be effected would depend on<br />
meetings between the BMA and the DoH.<br />
AH met with officials from the Department of Health on 15 th May 2009. They were very<br />
interested in the WP’s work, particularly the bringing together of a ‘coalition’ involving such a<br />
wide range of Health Care Workers, and the ethical analyses done by the WP. The<br />
designation of an affected Health Care Worker as ‘patient 2’ was particularly compelling.<br />
There was no doubt that DoH supports some change in the legal position, but was similarly<br />
unsure of which proposal to advocate, or how best to bring this about. Legislation runs serious<br />
risks of having unforeseen consequences, and is dependent on the political cycle.<br />
AH was invited to join the DoH Stakeholder Group, which met in July 2009. DoH legal<br />
advice was Option 1 would be unlikely to be helpful, as individuals who had had blood taken<br />
without consent after road traffic accidents could still withhold consent for its testing, although<br />
they would then be guilty of the offence of “refusing to give a sample”.<br />
In November 2009 the Department of Health published Legal issues relevant to nonheartbeating<br />
organ donation, which clearly endorses an expanded interpretation of best<br />
interests with specific regard to virological testing using the assent of the next of kin. This<br />
interpretation of legislation may be a basis on which to move forward.<br />
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan<br />
ce/DH_108825]<br />
Current position<br />
The WP has now fulfilled its first two objectives (determining whether the legal situation<br />
should be changed, recommending what that change should be). The legal position remains<br />
complicated and will need amendments to the Mental Capacity Act and/or its Code of<br />
Conduct. This will require parliamentary time and political will.
Recommendations<br />
The WP recommends:<br />
1. That AAGBI Council should adopt as policy that the necessary legislative<br />
change is effected at least to restore the previous position to allow individual<br />
cases to be judged on their merits and testing of patients for Blood Borne<br />
Viruses performed after occupational exposure when justified.<br />
2. Council should consider whether to pursue legislative change that would allow<br />
a. Processing of a blood sample taken for any other purpose in the event of<br />
a patient refusal, and<br />
b. presumed consent for testing where the patient lacks capacity and is<br />
unlikely to regain this within a set timeframe, (e.g. 6-12 hours)<br />
3. Pending such legislative change, Council should support the model of next of<br />
kin assent pending the above resolution and for presumed consent where no<br />
next of kin have been identified within the above timeframe of 6-12 hours.<br />
4. Any legislative/policy change should accommodate the principle of reciprocity.<br />
The decision to test should be based on defined, objective principles and avoid<br />
arbitrary or varying decision-making. Logical and defensible solutions already<br />
exist and are currently being applied in some units.<br />
5. Council should approve a revision of its current guidance on ‘Blood Borne<br />
Viruses and the Anaesthetist’. In particular this should focus on the<br />
implications of an occupational injury, post exposure prophylaxis and follow<br />
and the subsequent employment. [Note: a WP on ‘Occupational Health and the<br />
Anaesthetist’ has been established with Dr Paul Clyburn as chair.]<br />
6. Council should consider a survey of members to establish the frequency of<br />
occupational exposure, particularly when the source patient is unable or refuses<br />
to consent to testing [Note: a paper has been accepted for the September 2010<br />
edition of Anaesthesia which describes an anonymised postal survey of current<br />
practice in ICUs in England. This has an accompanying editorial by AH]<br />
June 2010
Appendices:<br />
1. Needlestuck<br />
2. Analysis of benefits and harms of blanket testing<br />
3. Analysis of Presumed Consent<br />
4. Analysis of non-consensual testing<br />
5. Analysis of Status Quo<br />
6. Analysis of Next of Kin Assent/Consent<br />
7. Patient perspectives
Anaesthesia, 2007, 62, pages 1199–1201<br />
.....................................................................................................................................................................................................................<br />
Editorial<br />
Needlestuck<br />
Enacted on the 15th November, 2004,<br />
and fully enforced on the 1st September,<br />
2006, the Human Tissue Act 2004<br />
(HTA) [1] is the UK government’s<br />
woefully impenetrable attempt to clarify<br />
the statutory law in England and Wales<br />
with regard to the use and storage of<br />
human tissue, organs and bodies. The<br />
HTA repeals the Human Tissue Act<br />
1961, the Anatomy Act 1984, and the<br />
Human Organ Transplants Act 1989.<br />
In response to public concern over<br />
the organ retention scandals at Alder<br />
Hey Hospital [2] and the Bristol Royal<br />
Infirmary [3], and the findings of the<br />
Isaacs Inquiry [4], the government hurriedly<br />
introduced a consultation document,<br />
Human Bodies, Human Voices [5],<br />
in July 2002, leading to the introduction<br />
of the Human Tissue Bill, in December<br />
2003.<br />
In line with much recent legislation,<br />
consent was proposed as a fundamental<br />
protection for patients, such that virtually<br />
all tissue taken from humans could<br />
only be used or stored having obtained<br />
appropriate consent (from the patient<br />
if alive, from the parents of children,<br />
or premortem if the patient was now<br />
dead), under penalty of fine or imprisonment.<br />
Some ramifications of the Bill<br />
were immediately apparent, and elicited<br />
considerable debate among, and opposition<br />
from, the research, legal [6–8]<br />
and transplant communities, especially<br />
pertaining to anatomy demonstration,<br />
research using human tissue [9, 10],<br />
tissue databanking [11], genetic research<br />
[12] and organ transplantation [13, 14].<br />
Less apparent, unfortunately, were<br />
some of the ramifications relating to<br />
everyday clinical practice. One scenario<br />
in particular has given rise to concern<br />
about the protection of healthcare professionals<br />
in the event of a needlestick<br />
injury.<br />
Accidental blood and body fluid<br />
exposure is a daily risk for health care<br />
workers, with an incidence of approximately<br />
1–5 per 100 person-years [15].<br />
Up to 40% of patients with HIV are<br />
unaware of their status when they<br />
are admitted to intensive care [16].<br />
Needlestick injuries account for<br />
approximately 80% of exposures, are<br />
more common with more complex<br />
procedures, and can lead to infection<br />
with HIV, and hepatitis B, C and ⁄ or D<br />
[17]. Seroconversion rates are low for<br />
HIV (0.3%) and HCV (0.5%), but much<br />
higher for HBV (18–30%) [18]. A<br />
number of postexposure prophylaxis<br />
(PEP) guidelines are available for HIV<br />
[19], HBV and HCV [20]. In the case of<br />
HIV, PEP should ideally be commenced<br />
within an hour of exposure,<br />
and continued at least until the HIV<br />
status of the source patient is confirmed.<br />
Delays in source patient HIV testing can<br />
expose health care workers to inappropriate<br />
continuation of PEP administration<br />
of drugs with significant side-effect<br />
profiles.<br />
However, there is considerable confusion<br />
surrounding the issue of consent<br />
when testing a source patient for HIV<br />
(or other blood-borne viruses). No<br />
specific statute exists, and so the legality<br />
of testing lies in the common law.<br />
Testing involves physical contact with a<br />
patient, and therefore the patient’s<br />
consent is required. Their consent is<br />
legally valid if they are appropriately<br />
informed (about the nature and purpose<br />
of the test, and the risks and consequences<br />
of testing), competent to<br />
decide (that is, they understand the<br />
information presented to them, remember<br />
it, and use it to decide whether or<br />
not to have the test), and give consent<br />
voluntarily [21]. Competent adult patients<br />
can consent to, or refuse, testing for<br />
any reason, or for no reason at all. At<br />
present, no-one may give consent on<br />
behalf of an incompetent patient (for<br />
example, an unconscious patient in the<br />
intensive care unit). Under the common<br />
law in England and Wales, the<br />
HIV testing of an unconscious patient is<br />
legal if it is necessary and in the patient’s<br />
best interests (for example, to establish<br />
their HIV status for the purposes of<br />
treatment).<br />
Therefore, in theory at least, a doctor<br />
may not test a source patient for HIV<br />
for the benefit of an injured healthcare<br />
worker either if the patient refuses a<br />
test, or if the patient is incompetent<br />
⁄ unconscious.<br />
However, this is not the advice<br />
offered in professional guidelines,<br />
namely the General Medical Council’s<br />
Serious Communicable Diseases guidelines<br />
of 1997 [22] (the British Medical Association<br />
and Department of Health defer<br />
to the GMC in their own advice). The<br />
GMC advises that ‘You must obtain<br />
consent from patients before testing for<br />
a serious communicable disease’ (s.4),<br />
and ‘you may test unconscious patients<br />
for serious communicable diseases,<br />
without their prior consent, where<br />
testing would be in their immediate<br />
clinical interests’ (s.7), in line with the<br />
common law. However, the GMC then<br />
advise that ‘you may test an existing<br />
blood sample, taken for other purposes’<br />
if the patient has refused testing or is<br />
unable to consent, and the doctor has<br />
good reason to believe the patient may<br />
have a communicable disease for which<br />
prophylaxis is available, and an experienced<br />
colleague has been consulted, and<br />
the patient is unlikely to regain capacity<br />
within 48 h (s.8 + s.9), which course of<br />
action may not be in line with the<br />
common law, even if the patient is<br />
informed of the non-consensual test at<br />
the earliest opportunity (s.10).<br />
The advice states that ‘you must<br />
therefore be prepared to justify your<br />
decision (to test non-consensually)’ if a<br />
complaint is made to the doctor’s<br />
employer or the GMC, or if challenged<br />
in court, but justification could prove<br />
difficult. Several arguments might be<br />
used. Firstly, the ‘best interests’ argument:<br />
the patient was tested because<br />
his ⁄ her symptoms were unexplained<br />
and possibly attributable to HIV ⁄<br />
HBV ⁄ HCV, requiring diagnosis and<br />
Ó 2007 The Author<br />
Journal compilation Ó 2007 The Association of Anaesthetists of Great Britain and Ireland 1199
Editorial Anaesthesia, 2007, 62, pages 1199–1201<br />
.....................................................................................................................................................................................................................<br />
treatment. This would require a high<br />
standard of circumstantial medical evidence<br />
suggesting this to be the case.<br />
Second, the ‘good egg’ argument: the<br />
unconscious patient is assumed to be a<br />
kind person, who would consent to<br />
testing if s ⁄ he were competent, and<br />
therefore, have his best interests served<br />
through not subjecting the injured<br />
healthcare worker to either the anxiety<br />
of not knowing the patient’s HIV status,<br />
or the side-effects of PEP. Finally, the<br />
‘rights’ argument: that the healthcare<br />
worker’s right to discover the patient’s<br />
HIV status (possibly with reference to<br />
Articles 2 and 3 of the Human Rights<br />
Act 1998 (HRA) [23]) is more pressing<br />
than the patient’s right to not be tested<br />
(possibly protected by Articles 2, 3 and<br />
8 of the HRA).<br />
In practice, such justification is yet to<br />
be tested in a UK court [24], and is now<br />
unlikely to be, as the GMC has recently<br />
rescinded paragraphs 8–11 of Serious<br />
communicable diseases, in light of the<br />
Human Tissue Act 2004 and the Mental<br />
Capacity Act 2005.<br />
According to the HTA, appropriate<br />
consent from living patients is legally<br />
required [1(1)(d) + (f)] for storage and<br />
use of human tissue (which includes<br />
blood for HIV testing) for the purpose<br />
inter alia of obtaining scientific or<br />
medical information about a living or<br />
deceased person which may be relevant<br />
to any other person [Schedule 1, s.1(4)].<br />
Storage and use of tissue from patients<br />
who lack capacity (i.e. many intensive<br />
care patients) is unlawful (s.6), unless<br />
allowed by the Secretary of State, in this<br />
instance according to the Human Tissue<br />
Act 2004 (Persons Who Lack Capacity<br />
to Consent and Transplants) Regulations<br />
2006 [25]. The Regulations allow<br />
for non-consensual storage and use of<br />
tissue to ‘obtain scientific or medical<br />
information about a living … person<br />
which may be relevant to another’ (i.e.<br />
an HIV test after needlestick injury),<br />
provided inter alia that the nominated<br />
doctor taking the blood does so in ‘what<br />
s ⁄ he reasonably believes to be in the<br />
best interests of the person lacking<br />
capacity from whose body the material<br />
came’. So again, blood may only be<br />
taken if the intent is to benefit the<br />
patient, and not the healthcare worker.<br />
The Mental Capacity Act 2005 [26]<br />
(MCA) is no more helpful in terms of<br />
the non-consensual testing of patients<br />
who lack legal capacity. From October<br />
2007, patients over 16 years of age must<br />
be assumed to have capacity unless they<br />
are found to lack capacity. Any decision<br />
to test a patient without capacity for<br />
HIV must continue to be made in the<br />
patient’s best interests, if there is no<br />
other way to establish his ⁄ her HIV<br />
status. Although it will remain the case<br />
that the doctor will usually decide (s ⁄ he<br />
must be able to justify that decision in<br />
court), any decision must be made in<br />
the patient’s best interests (i.e. not the<br />
interests of the healthcare worker sustaining<br />
a needlestick injury). Interestingly,<br />
a properly appointed donee of an<br />
Lasting Power of Attorney, or a courtappointed<br />
deputy, may give proxy<br />
consent for blood testing, but again<br />
they must do so in the patient’s best<br />
interests. In addition, a patient may, in<br />
theory, consent to or refuse HIV testing<br />
by means of an advanced directive.<br />
Effectively, therefore, the combined<br />
effects of the HTA and MCA have<br />
firmly closed the backdoor to testing<br />
afforded by the GMC’s previous guidelines,<br />
and threatened doctors with<br />
imprisonment if they test patients for<br />
HIV non-consensually.<br />
This problem was foreseen during<br />
the passage of the Mental Capacity Bill,<br />
but an attempt by the British Medical<br />
Association to amend the Bill to allow<br />
non-consensual HIV testing to ‘avert<br />
the death of, or serious illness in,<br />
another person’ was withdrawn, after<br />
assurances from the government that<br />
this circumstance would be clarified in<br />
the Code of Practice accompanying the<br />
Act [27]. Predictably it wasn’t – there is<br />
no reference to HIV testing in all 302<br />
pages of the Code of Practice [28].<br />
Section 6 of the Code deals with the<br />
protections that the Act offers for<br />
healthcare workers (amongst others),<br />
but repeats the maxim that any intervention<br />
must be in the patient’s best<br />
interests.<br />
In an attempt to clarify the law in<br />
relation to HIV testing, I contacted<br />
both the HTA and the Court of<br />
Protection (the latter via the Public<br />
Guardianship Office). Both agencies<br />
were very helpful. After consultation,<br />
the HTA sent me the following statement<br />
for publication:<br />
‘The HTA are aware of the complex<br />
issues this situation generates. The HTA<br />
are currently part of discussions on this<br />
issue being led by the Department of<br />
Health, BMA and other organisations in<br />
relevant sectors. The general status of<br />
the situation is that this issue is still<br />
under discussion and the regulations are<br />
still being drafted. Therefore, at present<br />
it is difficult for the HTA to comment<br />
further on this area. We are waiting<br />
further clarification from the Department<br />
of Health at which point we will<br />
be in a position to move forward on this<br />
area of work. Please keep checking the<br />
HTA and relevant websites in the sector<br />
for any news on this issue’.<br />
The Public Guardianship Office referred<br />
me to the Human Tissue Branch<br />
of the Department of Health, who<br />
concurred with the above analysis of<br />
the problem, and stated by letter: ‘We<br />
are actively considering this complex<br />
issue and have – as the HTA advised<br />
you – been in discussion with a number<br />
of interested bodies. We hope to be in a<br />
position during the summer to consult<br />
on new proposals for addressing some of<br />
the concerns expressed’.<br />
To summarise, anaesthetists must<br />
beware: in the event of a needlestick<br />
injury to a healthworker, blood may<br />
only be drawn from an unconscious<br />
patient for the purposes of communicable<br />
virus detection, provided that to<br />
do so would be in the best interests of<br />
the patient.<br />
The medical and nursing professions,<br />
in partnership with the Department of<br />
Health and the Courts, would be well<br />
advised to strenuously seek an expeditious<br />
solution to this impasse to optimise<br />
the postexposure treatment of<br />
healthcare workers after needlestick<br />
injuries.<br />
Acknowledgements<br />
I would like to thank the Human Tissue<br />
Authority, Public Guardianship Office<br />
and Department of Health for their<br />
prompt assistance, as well as Dr Steve<br />
Yentis for initially raising the issue. An<br />
interesting discussion of the ethics surrounding<br />
these issues can be found on<br />
Ó 2007 The Author<br />
1200 Journal compilation Ó 2007 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2007, 62, pages 1199–1201<br />
Editorial<br />
.....................................................................................................................................................................................................................<br />
Radio 4’s Inside the Ethics Committee,<br />
broadcast 12th September, 2007 [29].<br />
Stuart M. White<br />
Consultant in Anaesthesia<br />
Brighton Anaesthesia Research Forum,<br />
Brighton and Sussex University<br />
Healthcare NHS Trust<br />
Eastern Road<br />
Brighton, East Sussex, BN2 5BE,<br />
UK<br />
E-mail: igasbest@hotmail.com<br />
References<br />
1 HMSO. The Human Tissue Act,<br />
2004. http://www.opsi.gov.uk/acts/<br />
acts2004/20040030.htm [accessed 10<br />
October 2007].<br />
2 Redfern M. The Royal Liverpool<br />
Children’s Enquiry. January 2001.<br />
http://www.rlcinquiry.org.uk/<br />
download/index.htm [accessed 10<br />
October 2007].<br />
3 Kennedy I. The Bristol Royal Infirmary<br />
Inquiry. Final Report. July 2001.<br />
http://www.bristol-inquiry.org.uk/<br />
final_report/index.htm [accessed 10<br />
October 2007].<br />
4 HM Inspector of Anatomy. The<br />
Investigation of events that followed<br />
the death of Cyril Mark Isaacs. May<br />
2003. http://www.doh.gov.uk/cmo/<br />
isaacsreport/ [accessed 10 October<br />
2007].<br />
5 Department of Health. Human Bodies,<br />
Human Choices. The Law on<br />
Human Organs and Tissue in England<br />
and Wales. A Consultation Report.<br />
July, 2002. http://www.doh.gov.uk/<br />
tissue/humanbodieschoices.pdf<br />
[accessed 10 October 2007].<br />
6 Liddell K, Hall A. Beyond Bristol and<br />
Alder Hey: the future regulation of<br />
human tissue. Medical Law Review<br />
2005; 13: 170–223.<br />
7 McHale J. The Human Tissue Act<br />
2004: innovative legislation – fundamentally<br />
flawed or missed opportunity?<br />
Liverpool Law Review 2005; 26:<br />
169–88.<br />
8 Mavroforou A, Giannoukas A, Michalodimitrakis<br />
E. Consent for organ<br />
and tissue retention in British law in<br />
the light of the Human Tissue Act<br />
2004. Medicine and Law 2006; 25: 427–<br />
34.<br />
9 Furness PN. The Human Tissue Act.<br />
British Medical Journal 2006; 333: 512.<br />
10 Editorial. Effective implementation of<br />
the Human Tissue Act. Lancet 2006;<br />
368: 891.<br />
11 Underwood JC. The impact on<br />
histopathology practice of new human<br />
tissue regulation in the UK. Histopathology<br />
2006; 49: 221–8.<br />
12 Lucassen A, Kaye J. Genetic testing<br />
without consent: the implications of<br />
the new Human Tissue Act 2004.<br />
Journal of Medical Ethics 2006; 32: 690–<br />
2.<br />
13 Bell MD. The UK Human Tissue Act<br />
and consent: surrendering a fundamental<br />
principle to transplantation<br />
needs? Journal of Medical Ethics 2006;<br />
32: 283–6.<br />
14 Bell MD. Emergency medicine, organ<br />
donation and the Human Tissue Act.<br />
Emergency Medicine Journal 2006; 23:<br />
824–7.<br />
15 Elder A, Paterson C. Sharps injuries in<br />
UK health care: a review of injury<br />
rates, viral transmission and potential<br />
efficacy of safety devices. Occupational<br />
Medicine 2006; 56: 566–74.<br />
16 Huang L, Quartin A, Jones D, Havlir<br />
DV. Current concepts: intensive care<br />
of patients with HIV Infection. New<br />
England Journal of Medicine 2006; 355:<br />
173–81.<br />
17 Health Protection Agency. Eye of the<br />
Needle. Surveillance of significant<br />
occupational exposure to bloodborne<br />
viruses in healthcare workers. January<br />
2005. http://www.hpa.org.uk/<br />
infections/topics_az/bbv/pdf/eye_<br />
of_the_needle.pdf [accessed 10<br />
October 2007].<br />
18 Rapiti E, Prüss-Üstün A, Hutin Y.<br />
Assessing the Burden of Disease from<br />
Sharps Injuries to Health-Care Workers at<br />
National and Local Levels. Geneva:<br />
World Health Organization, 2005.<br />
http://www.who.int/quantifying_<br />
ehimpacts/global/7sharps.pdf<br />
[accessed 10 October 2007].<br />
19 UK Chief Medical Officer’s Expert<br />
Advisory Group on AIDS. HIV postexposure<br />
prophylaxis. http://<br />
www.dh.gov.uk/assetRoot/04/08/<br />
36/40/04083640.pdf [accessed 10<br />
October 2007].<br />
20 Puro V, Cicalini S, De Carli G, et al.<br />
European recommendations for the<br />
management of healthcare workers<br />
occupationally exposed to hepatitis B<br />
virus and hepatitis C virus. Euro<br />
Surveillance 2005; 10: 260–4.<br />
21 Consent. In: White SM, Baldwin TJ.<br />
Legal and Ethical Issues in Critical Care<br />
and Perioperative Medicine. Cambridge:<br />
Cambridge University Press, 2004:<br />
49–71.<br />
22 General Medical Council. Serious<br />
communicable diseases. October<br />
1997. http://www.gmc-uk.org/<br />
guidance/current/library/serious_<br />
communicable_diseases.asp [accessed<br />
10 October 2007].<br />
23 White SM, Baldwin TJ. The Human<br />
Rights Act, 1998: implications for<br />
anaesthesia and intensive care. Anaesthesia<br />
2002; 57: 882–8.<br />
24 Halpern SD. HIV testing without<br />
consent in critically ill patients. Journal<br />
of the American Medical Association 2005;<br />
294: 734–7.<br />
25 Human Tissue Act 2004 (Persons<br />
Who Lack Capacity to Consent and<br />
Transplants) Regulations : SI no.<br />
1659. 1. http://www.opsi.gov.uk/<br />
SI/si2006/20061659.htm [accessed 10<br />
October 2007].<br />
26 White SM, Baldwin TJ. The Mental<br />
Capacity Act, 2005. Implications for<br />
anaesthesia and intensive care. Anaesthesia<br />
2006; 61: 381–9.<br />
27 Mental Capacity Bill. Hansard,<br />
1st February 2005, 194. http://www.<br />
publications.parliament.uk/pa/<br />
ld200405/ldhansrd/vo050201/text/<br />
50201-27.htm#50201–27_spnew1<br />
[accessed 10 October 2007].<br />
28 Department for Constitutional Affairs.<br />
Mental Capacity Act 2005. Code of<br />
Practice. http://www.dca.gov.uk/<br />
legal-policy/mental-capacity/mca-cp.<br />
pdf [accessed 10 October 2007].<br />
29 British Broadcasting Corporation.<br />
Inside the Ethics Committee. Can an<br />
unconscious patient be tested for<br />
HIV without his consent? Broadcast<br />
12th September 2007. http://<br />
www.bbc.co.uk/radio4/science/<br />
ethicscommittee_s3_tr3.shtml<br />
[accessed 10 October 2007].<br />
Ó 2007 The Author<br />
Journal compilation Ó 2007 The Association of Anaesthetists of Great Britain and Ireland 1201
Analysis of Benefits and Harms of Compulsory testing<br />
Patient Practitioner Team Trust Public<br />
Benefits<br />
Harms<br />
Fair – all patients<br />
treated the same<br />
Possible early<br />
diagnosis and Rx<br />
Autonomy overridden<br />
- coercion<br />
Small risk from<br />
procedure<br />
False<br />
positives/negatives<br />
Certainty of need<br />
for Rx<br />
Better informed<br />
decision<br />
Feels “valued”<br />
More likely to<br />
report?<br />
Uncertainty of –ve<br />
result<br />
False -ve<br />
Team morale<br />
Feel “valued”<br />
Les likely to have<br />
absence due to stress<br />
May be less risk<br />
averse<br />
More likely to report<br />
Additional procedure -<br />
> additional exposure<br />
May become less<br />
careful<br />
Practicality Additional storage of samples<br />
Cost of testing, staff time<br />
How to deal with results – confidentiality for patient and practitioner<br />
Simplified Process<br />
Primary medical/dental care?<br />
Better Staff Morale<br />
More focused Rx may reduce<br />
costs<br />
Reduced absence<br />
Senior Mgt do not have to<br />
spend time on individual<br />
cases<br />
Legal clarity<br />
Improved Occupational<br />
Health<br />
Resistance from<br />
GUM/Virology<br />
Happier valued workforce<br />
Enhance Recruitment<br />
retention<br />
Better prevalence<br />
information<br />
“right Thing to do”<br />
HCPs may less risk averse<br />
Potential Distrust of<br />
doctors/NHS<br />
Costs of testing/treatment<br />
Potential Compensation to<br />
patient/practitioner
OPTION 3 – PRESUMED CONSENT.<br />
‘Presumed consent’, in the context of blood borne virus testing, assumes that consent has<br />
been given for blood testing unless the patient has specifically refused testing. There is no legal<br />
precedent for presumed consent in the United Kingdom.<br />
Several commentators have decried the very notion of presumption, declaring that<br />
‘presumed consent’ is equivalent to ‘no consent at all’ and that the presumption of consent<br />
affords the patient little protection against what would otherwise be legally considered a battery.<br />
Presumption places no duty on the doctor to ascertain whether the patient might indeed be<br />
capable of giving consent (as should happen according to the Mental Capacity Act 2005), or to<br />
provide information to the patient about the risks and benefits of BBV testing, or to assess<br />
whether there is any voluntariness on the part of the patient to agree to what is proposed. In<br />
addition, vulnerable groups (children, mentally incompetent adults) may not be in a position to<br />
raise an objection. As such, presumed consent is contrary to the increasing emphasis placed on<br />
patient autonomy by UK legislators, through consent.<br />
Nevertheless, 4 arguments might be used to support the introduction of presumed consent<br />
for BBV testing:<br />
1) Public support. Overwhelming public support, through informed public debate, could<br />
consolidate an ethical mandate for presumed consent in this specific instance.<br />
2) Social contract. Doctors and nurses will continue to provide healthcare for patients, on the<br />
understanding that consent will be presumed for BBV testing should a needlestick injury<br />
occur and there is a genuine risk of inoculation (with safeguards similar to the GMC’s<br />
withdrawn advice).<br />
3) ‘Soft’ presumed consent ie presumed consent only with the confirmative assent of relatives or<br />
close acquaintances.<br />
4) Organ donation. The government have recently indicated at least an interest in presumed<br />
consent with regards organ donation. Applied to BBV testing, this would mean that<br />
individuals would have to specifically ‘opt out’ of testing, probably by indicating in written<br />
form that they would not want to be tested. There is a danger that by setting a new legal<br />
context in the case of BBVs, that a precedent of presumed consent could be extended to<br />
organ donation.
AAGBI Needlestick Injuries Working Party<br />
Daniel K. Sokol<br />
Option: non-consensual testing of patients (on an existing or specifically taken sample) in<br />
the event of a needlestick injury for the benefit of the injured healthcare professional.<br />
This option is currently unlawful in England and Wales if the testing is not in the<br />
patient’s best interests.<br />
Several arguments can be presented in favour of the option:<br />
1. The clinical, social and psychological benefits to the healthcare professional outweigh<br />
the relatively minor infringement of autonomy associated with testing a sample.<br />
2. In the case of unconscious patients, it is probable that the vast majority would not<br />
object to the test, given the absence of pain, the virtually non-existent clinical risks of<br />
the testing and the obvious benefits to the healthcare professional.<br />
3. The injured worker’s colleagues who form part of the medical team may be reassured<br />
by a) knowing their colleague’s state of infection, b) knowing that their colleague is<br />
aware of his or her state of infection and c) knowing that testing is a lawful option in<br />
the eventuality of sustaining a needlestick injury themselves.<br />
4. In light of the incidence of needlestick injuries and the distress potentially caused by<br />
ignorance of one’s disease status, allowing such testing is likely to boost staff morale,<br />
reduce ‘burnout’ in the profession generally and may help retain staff. This should<br />
benefit patients generally.<br />
5. This option, which emphasises the autonomy and welfare of the healthcare<br />
professional, may aid recruitment into high-risk specialties or, at least, will not<br />
contribute to a fall in recruitment.<br />
6. Reciprocity – one may argue that patients have certain duties towards the healthcare<br />
professionals who are putting themselves at risk to help them (e.g. the duty not to be<br />
physically or verbally abusive), as long as these duties are not too onerous. Allowing<br />
oneself to be tested for HIV and hepatitis, even if only for the benefit of the<br />
healthcare workers, may constitute a patient’s duty and should be enforced.<br />
There are also arguments against the option:<br />
1. Non-consensual testing may violate the autonomy of those who either explicitly refuse<br />
to be tested or, if unconscious, who would have refused to be tested.<br />
2. Is it really practicable or indeed desirable to obtain a sample from a conscious patient<br />
who does not wish to be tested? One less coercive option, then, would be to permit nonconsensual<br />
testing on unconscious patients only (except when it is known that the patient<br />
would not have wanted to be tested, e.g. in an advance directive or through a Lasting
Power of Attorney) while requiring some form of consent for conscious patients. If the<br />
patient is conscious but incapacitous, we could suggest that testing is permitted on an<br />
existing sample only.<br />
3. If testing is compulsory, patients in need of medical treatment may be reluctant to seek<br />
treatment for fear of being tested against their will (albeit only in the rare eventuality of a<br />
needlestick injury). This could have adverse effects on the patients’ health and have<br />
negative cost implications to the National Health Service. This represents another reason<br />
for preferring the non-mandatory option mentioned above.<br />
A number of questions remain. If the test is performed against a competent patient’s will,<br />
should the information obtained be offered to the patient? Should it be recorded in the<br />
patient’s notes? If the patient was unconscious when the test was performed, when, how<br />
and what should he or she be told?
AAGBI NEEDLESTICK INJURIES WORKING PARTY<br />
OPTIONS FOR CHANGE<br />
OPTION 5 – MAINTAIN STATUS QUO.<br />
A competently made refusal of BBV testing by a patient prohibits a doctor from testing that<br />
patient’s blood for BBVs in the event of a needlestick injury to a third party.<br />
The effect of Mental Capacity Act 2005 and the Human Tissue Act 2004 on the non-consensual<br />
testing for BBVs after needlestick injuries involving patients without capacity has been to countermand<br />
the advice (now withdrawn) of the GMC (Serious Communicable Diseases guidelines, 1997) with<br />
regard to this eventuality. Statute now demands that in the event of a needlestick injury to a<br />
healthworker, blood may only be drawn from a patient who lacks legal capacity for the purposes of<br />
BBV detection, provided that to do so would be in the best interests of the patient.<br />
If BBV testing is prohibited, the injured third party must wait for 3-6 months before secondary<br />
testing to confirm seroconversion, taking appropriate post-exposure prophylaxis (PEP) in the interim<br />
exposing themselves to both the side-effects of PEP drugs, and associated psychological stress.<br />
The prevention of needlestick injuries remains of primary importance. Nevertheless, injuries are<br />
likely to still occur. Pragmatically, such injuries are rare; furthermore, needlestick injuries from a<br />
known patient who is permanently unable to consent are likely to be extremely rare. Nevertheless, a<br />
situation involving an untestable patient is likely to arise, and it is morally untenable that the ‘right’ to<br />
treatment of the injured party should defer to any ‘right’ of an incompetent patient not to have a BBV<br />
test, particularly if a more minimally invasive test can be used and appropriate safeguards regarding<br />
confidentiality are observed.<br />
Possible solutions include:<br />
1) Covert, non-consensual testing – which is against the law;<br />
2) Testing secondary to reassessment of a patient’s BBV risk, in which case testing would (probably)<br />
be in the patient’s best interests<br />
3) Non-consensual testing to provoke a legal test case. This is a high-risk strategy that could lead to<br />
imprisonment, but could stimulate a thus far intransigent government into introducing secondary<br />
legislation<br />
4) Lobbying government to introduce secondary legislation, or MPs to introduce a Private Member’s<br />
Bill<br />
5) Increasing awareness among patients of how to assert their choice under existing legislation, for<br />
example, via a Lasting Power of Attorney or Advance Decision.
Needle-stick injury and HIV testing of the incompetent adult<br />
– the status of assent of the next-of-kin<br />
MD Dominic Bell<br />
The precise status of the next-of-kin in the healthcare management of the incompetent<br />
adult remains ill-defined within the UK or indeed any jurisdiction. The Mental<br />
Health Act 1959 removed any authority under English law and although the Mental<br />
Capacity Act has extended ‘power-of-attorney’ to medical and personal welfare<br />
matters, this will predictably be limited numerically and in the nature of the<br />
undertakings. Responsibility continues to rest therefore with medical staff acting in<br />
the ‘best interests’ of the patient, 1 but directives from both government and the<br />
professional bodies specify the involvement of the next-of-kin in decision-making. 2 3<br />
Furthermore, since ‘best interests’ are not limited to ‘best medical interests’, but<br />
incorporate ‘the patient’s wishes and beliefs when competent, their general well-being<br />
and their spiritual and religious welfare’, 2 3 it appears essential to consult the next-ofkin<br />
to determine their interpretation of these factors.<br />
Despite this somewhat ambivalent position and additional conflict with the duty of<br />
confidentiality, it is routine practice therefore within critical care to engage the next of<br />
kin not only to update them on condition, prognosis and plans, but to ensure their<br />
understanding of and assent to interventions such as surgery, tracheostomy, or blood<br />
transfusion, using Consent Form 4 in certain circumstances.<br />
The responsibility of the next of kin is particularly increased in decision-making on<br />
maintenance, escalation, or withdrawal of life-sustaining medical treatment [LSMT]<br />
when the prognosis and longer-term benefits are doubtful, and the next of kin are<br />
asked to express a view on what they believe the patient would have wanted in such<br />
circumstances, knowing their values and beliefs. This principle is extended further<br />
Appendix6 1
when asking for the family’s position as to whether the patient would have favoured<br />
organ donation when active support is to be withdrawn following a consensus on<br />
futility. The overwhelming benefit of organ donation falls to a third party and it can<br />
be seen that with reference to non heart beating donation, further undertakings are<br />
necessary to ensure that the transplanted organs are at optimal viability and safety,<br />
including serological testing for HIV and other transmissible diseases prior to death,<br />
an intervention endorsed by the Intensive Care Society. 4<br />
The arguments for this<br />
approach are that it is in no one’s interests to embark on the process of retrieval and to<br />
subsequently discover the presence of transmissible disease, or to delay the<br />
transplantation of vulnerable organs whilst awaiting the results of such tests or indeed<br />
tissue typing, taken after death. 5<br />
In this scenario the next of kin are provided with full information as to all the facets of<br />
organ donation, including the above aspects, in line with previous government<br />
directives on provision of information for valid consent, 6 and give assent on that<br />
basis.<br />
The proposal to adopt this approach for serological testing after needlestick injury is<br />
not therefore radical. The historical stigmata associated either with testing or a<br />
positive result have been largely eliminated through legislation and government<br />
directives, as well as the advances in medical therapy such as HAART. The key<br />
principles essential to make this approach ethically defensible would be provision of<br />
full information on what the test involves and the implications of a positive result, full<br />
information on the physical and mental health implications for the relevant healthcare<br />
practitioner of either knowing or not knowing a test result, choice as to how the test<br />
result is recorded and ultimately provided to the patient if and when they should<br />
Appendix6 2
egain capacity, and the absence of coercion. By considering standards in other<br />
settings, it would appear essential to provide a written booklet on the above aspects<br />
and for the interview to be carried out jointly by senior practitioners from intensive<br />
care and genitourinary medicine. [This strategy has been defined and carried out<br />
within the critical care environment of the General Infirmary at Leeds over the last 18<br />
months].<br />
Legal, political and professional implications of these proposals<br />
The above strategy would arguably not require any change in legislation since the<br />
Human Tissue Act does not specifically prohibit serological testing but simply<br />
dictates that any intervention be in the patient’s ‘best interests’. For the protection of<br />
the involved health care practitioners, it would however clearly be helpful for<br />
government to endorse an expanded interpretation of ‘best interests’ to include<br />
‘values and beliefs’ as well as purely medical best interests, and the role of the next of<br />
kin in determining those best interests for the individual patient. If such endorsement<br />
were not to be forthcoming, it should be apparent that non heart beating organ<br />
donation could no longer be considered viable, since the process is critically<br />
dependent on a parallel expanded interpretation of best interests and the assent of the<br />
next of kin. With such endorsement however, it would then fall to the health-care<br />
professions to explicitly define process as above to ensure provision of all essential<br />
information and avoid any consideration of coercion.<br />
1<br />
2<br />
3<br />
4<br />
5<br />
6<br />
Re F (Mental Patient: Sterilisation) [1990] 2 AC 1 (HL)<br />
Department of Health. Good Practice in Consent. HSC 2001/023<br />
GMC. Seeking patients' consent: the ethical considerations. GMC November 1998<br />
Ridley S, Bonner S, Bray K, et al. UK guidance for non-heart beating donation. Br J Anaesth<br />
2005; 95:592-595<br />
Bell MDD. Non-heartbeating organ donation – clinical process and fundamental issues Br J<br />
Anaesth 2005; 94: 474-78<br />
Isaacs Report. Department of Health. London May 2003<br />
Appendix6 3
Needle-stick Injuries from a Patients Perspective<br />
The options considered at the meeting of /May 9 th with regard to the testing of<br />
patients who have been the source of needle stick injuries were discussed with a broad<br />
range of people i.e.: Yorkshire Cancer Network, Members of the Membership Council<br />
of the local Trust, Members of Cancer Connections, general members of the public<br />
with the ages ranging from late teens to 70s.<br />
There was a general concern that NHS staff (considered in the widest terms) could be<br />
left in a vulnerable situation, emotionally and psychologically should there be a<br />
needle stick injury, with no recourse to testing if there is no permission given by the<br />
source of the possible infection. They did not believe that it should be an occupational<br />
hazard that should be accepted. The general opinion was that all staff had the right to<br />
work in a safe environment and that their rights were every bit as important as the<br />
patients.<br />
There was an overwhelming belief that there should be effective training in place for<br />
all staff on how to deal with equipment that could cause a needle-stick injury and how<br />
to dispose of it correctly; also that the correct equipment for disposal should be a top<br />
priority for all Trusts regardless of costs. There was also a belief that the training<br />
should be updated regularly so that standards of care were maintained. It was also felt<br />
that all Trust should be aware of the safest equipment on the market and encourage<br />
staff to use it, thereby having an environment of good practice. There was a wish<br />
expresses that an environment of openness operates within the NHS so that staff felt<br />
that they would be well supported if a needle-stick injury occurred.<br />
All six options were presented to the individuals questioned. There was a range of<br />
responses as to how the case for needle stick testing should take place,<br />
A) Probably most felt that there should that there should be blanket testing, that a<br />
form should be signed when admitted to hospital for any procedure. Even<br />
when it was pointed out that certain patients might not present them-selves for
treatment if it was understood that a sample of body fluids needed to be taken<br />
(for fear of needles). The question was asked if a mouth swab would allow the<br />
range of tests needed to confirm a blood borne disease thereby circumventing<br />
the need to take blood.<br />
B) The next most made response was, all patients should sign a form that should<br />
they be the source of a needle-stick injury they would be prepared to be tested.<br />
It was stressed in both response a / b that the consent forms should be<br />
explained very clearly to all. Not one person spoken to said that they would<br />
refuse consent for testing for them selves or for a relative should that relative<br />
be unable to give permission due to their medical condition.<br />
C) When asked what should happen if an accident occurred when a patient was<br />
unconscious with no person present to give permission for testing to take<br />
place, the general response was that a test should go ahead with a full<br />
explanation given, either to the relatives when they arrive or the patient when<br />
conscious again. Should the relatives be present then they should have a clear<br />
picture drawn of the situation and be asked for permission to test.<br />
D) There was a general resistance to the idea of presumed consent for both<br />
competent and incompetent patients. What was strongly expressed was the<br />
feeling that the treatment throughout a needle-stick injury incident should be<br />
sensitively managed for patient and professional so that it would have the best<br />
outcome for all concerned.<br />
It should be appreciated the general public do not have the detailed knowledge of the<br />
medical ethics that are being considered by the committee. The responses recorded<br />
are their reactions to the six changes to be considered.<br />
Everyone without exception was concerned for the safety of NHS staff, they were<br />
concerned for the cost implications if staff were off sick and if other NHS personnel<br />
did not declare a possible infection and go on to infect other colleagues or patients.<br />
It was recognised by all that there will always be unreasonable people what ever<br />
changes take place and some felt that if they did not co-operate with NHS personnel<br />
then treatment could be refused.
The measurement of adult blood pressure<br />
and management of hypertension before<br />
elective surgery 2016<br />
Published by<br />
The Association of Anaesthetists of Great Britain & Ireland<br />
British Hypertension Society<br />
March 2016
This guideline was originally published in Anaesthesia. If you wish to refer to this<br />
guideline, please use the following reference:<br />
Association of Anaesthetists of Great Britain and Ireland. The measurement of adult<br />
blood pressure and management of hypertension before elective surgery 2016.<br />
Anaesthesia 2016; 71: 326-337.<br />
This guideline can be viewed online via the following URL:<br />
http://onlinelibrary.wiley.com/doi/10.1111/anae.13348/full
Anaesthesia 2016, 71, 326–337<br />
Guidelines<br />
doi:10.1111/anae.13348<br />
The measurement of adult blood pressure and management of<br />
hypertension before elective surgery<br />
Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the<br />
British Hypertension Society<br />
A. Hartle, 1 T. McCormack, 2 J. Carlisle, 3 S. Anderson, 4 A. Pichel, 5 N. Beckett, 6 T. Woodcock 7 and<br />
A. Heagerty 8<br />
1 Consultant, Departments of Anaesthesia and Intensive Care, St Mary’s Hospital, London, UK, and co-Chair,<br />
Working Party on behalf of the AAGBI<br />
2 General Practitioner, Whitby Group Practice, Spring Vale Medical Centre, Whitby, UK, Honorary Reader, Hull York<br />
Medical School, UK, and co-Chair, Working Party, on behalf of the British Hypertension Society<br />
3 Consultant, Departments of Anaesthesia, Peri-operative Medicine and Intensive Care, Torbay Hospital, Torquay, UK<br />
4 Clinical Lecturer, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK and British<br />
Hypertension Society<br />
5 Consultant, Department of Anaesthesia, Manchester Royal Infirmary, Manchester, UK<br />
6 Consultant, Department of Ageing and Health, Guys’ and St Thomas’ Hospital, London, UK and British<br />
Hypertension Society<br />
7 Independent Consultant Anaesthetist, Hampshire, UK<br />
8 Professor, Department of Medicine, University of Manchester, Manchester, UK, and British Hypertension Society<br />
Summary<br />
This guideline aims to ensure that patients admitted to hospital for elective surgery are known to have blood pressures<br />
below 160 mmHg systolic and 100 mmHg diastolic in primary care. The objective for primary care is to fulfil this criterion<br />
before referral to secondary care for elective surgery. The objective for secondary care is to avoid spurious hypertensive<br />
measurements. Secondary care should not attempt to diagnose hypertension in patients who are normotensive in<br />
primary care. Patients who present to pre-operative assessment clinics without documented primary care blood pressures<br />
should proceed to elective surgery if clinic blood pressures are below 180 mmHg systolic and 110 mmHg diastolic.<br />
.................................................................................................................................................................<br />
This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists<br />
of Great Britain and Ireland (AAGBI) and the British Hypertension Society (BHS). It has been seen and approved by<br />
the AAGBI Board of Directors and the BHS Executive. It is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives<br />
4.0 International License. Date of review: 2020.<br />
Accepted: 16 November 2015<br />
.................................................................................................................................................................<br />
Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not<br />
permit commercial exploitation.<br />
326 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.<br />
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and<br />
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337<br />
Recommendations<br />
•<br />
General practitioners should refer patients for elective<br />
surgery with mean blood pressures in primary<br />
care in the past 12 months less than 160 mmHg<br />
systolic and less than 100 mmHg diastolic.<br />
• Secondary care should accept referrals that document<br />
blood pressures below 160 mmHg systolic and<br />
below 100 mmHg diastolic in the past 12 months.<br />
• Pre-operative assessment clinics need not measure<br />
the blood pressure of patients being prepared for<br />
elective surgery whose systolic and diastolic blood<br />
pressures are documented below 160/100 mmHg in<br />
the referral letter from primary care.<br />
• General practitioners should refer hypertensive<br />
patients for elective surgery after the blood pressure<br />
readings are less than 160 mmHg systolic and less<br />
than 100 mmHg diastolic. Patients may be referred<br />
for elective surgery if they remain hypertensive<br />
despite optimal antihypertensive treatment or if<br />
they decline antihypertensive treatment.<br />
• Surgeons should ask general practitioners to supply<br />
primary care blood pressure readings from the last<br />
12 months if they are undocumented in the referral<br />
letter.<br />
• Pre-operative assessment staff should measure the<br />
blood pressure of patients who attend clinic without<br />
evidence of blood pressures less than<br />
160 mmHg systolic and 100 mmHg diastolic being<br />
documented by primary care in the preceding<br />
12 months. (We detail the recommended method<br />
for measuring non-invasive blood pressure accurately,<br />
although the diagnosis of hypertension is<br />
made in primary care.)<br />
• Elective surgery should proceed for patients who<br />
attend the pre-operative assessment clinic without<br />
documentation of normotension in primary care if<br />
their blood pressure is less than 180 mmHg systolic<br />
and 110 mmHg diastolic when measured in clinic.<br />
The disparity between the blood pressure thresholds<br />
for primary care (160/100 mmHg) and secondary<br />
care (180/110 mmHg) allows for a number of factors.<br />
Blood pressure reduction in primary care is based on<br />
good evidence that the rates of cardiovascular morbidity,<br />
in particular stroke, are reduced over years and<br />
decades. There is no evidence that peri-operative blood<br />
pressure reduction affects rates of cardiovascular events<br />
beyond that expected in a month in primary care.<br />
Blood pressure measurements might be more accurate<br />
in primary care than secondary care, due to a less<br />
stressful environment and a more practised technique.<br />
What other guideline statements are available on<br />
this topic?<br />
There is detailed evidence-based guidance on the diagnosis<br />
and treatment of hypertension in the community<br />
from, for example, the National Institute for Health<br />
and Care Excellence [1]. There is little guidance on a<br />
‘safe’ blood pressure for planned anaesthesia and surgery.<br />
Why was this guideline developed?<br />
There is no national guideline for the measurement,<br />
diagnosis or management of raised blood pressure<br />
before planned surgery. There is little evidence that<br />
raised pre-operative blood pressure affects postoperative<br />
outcomes. Local guidelines vary from area to area.<br />
Hypertension is a common reason to cancel or postpone<br />
surgery. In our sprint audit, 1–3% of elective<br />
patients had further investigations precipitated by<br />
blood pressure measurement, of whom half had their<br />
surgery postponed. Across the UK this would equate<br />
to ~100 concerned and inconvenienced patients each<br />
day, with associated costs to the NHS and the national<br />
economy [2, 3].<br />
This guideline is the first collaboration between<br />
the AAGBI and the British Hypertension Society; these<br />
two organisations have very different perspectives.<br />
Members of the British Hypertension Society are concerned<br />
with the long-term reduction in rates of cardiovascular<br />
disease, particularly strokes. Anaesthetists are<br />
more focused on immediate complications, in the perioperative<br />
period. This guideline aims to prevent the<br />
diagnosis of hypertension being the reason that<br />
planned surgery is cancelled or delayed. As such, it<br />
should also be of interest to hospital managers and<br />
commissioners of hospital care.<br />
How does this statement differ from existing<br />
guidelines?<br />
This guideline serves, therefore, not to advise on treatment<br />
of hypertension, but rather to produce a com-<br />
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 327
Anaesthesia 2016, 71, 326–337<br />
Management of hypertension before elective surgery guidelines<br />
mon terminology in diagnosis and referral, explaining<br />
the impact of anaesthesia on blood pressure and vice<br />
versa to the wider, non-anaesthetic community. At the<br />
same time, it will review current best practice on the<br />
measurement, diagnosis and treatment of hypertension.<br />
Why does this statement differ from existing<br />
guidelines?<br />
Pre-operative blood pressure management involves<br />
many specialties and professions: primary care, general<br />
medicine, cardiology, endocrinology, pre-operative<br />
assessment clinics and, of course, both anaesthetists<br />
and surgeons. This list is not exhaustive. This guideline<br />
should be a useful summary for all those clinicians<br />
and for patients. The guidance takes into account not<br />
just the best clinical evidence, but the particular pattern<br />
of referral for treatment within the NHS in all<br />
four countries of the UK.<br />
Introduction<br />
The National Institute for Health and Care Excellence<br />
(NICE) has described hypertension as ‘one of the most<br />
important preventable causes of premature morbidity<br />
and mortality in the UK’ [1]. The Association of<br />
Anaesthetists of Great Britain and Ireland (AAGBI),<br />
together with the British Hypertension Society, felt<br />
there was a need for a nationally agreed policy statement<br />
on how to deal with raised blood pressure in the<br />
pre-operative period. We have based this statement on<br />
a consensus view with the backing of graded evidence,<br />
where such evidence is available.<br />
Hypertension is almost always asymptomatic and<br />
it is diagnosed following screening in general practice.<br />
Managing hypertension pre-operatively is a complex<br />
matter of balancing the risks of anaesthesia, treatment<br />
and delay for the individual patient. Most cases of<br />
hypertension are primary, i.e. with no other medical<br />
cause. For the remainder, the cause for hypertension<br />
may be associated with the reason for the proposed<br />
operation.<br />
Cancellations and postponements of planned surgical<br />
procedures have been a major and long-standing<br />
problem for healthcare worldwide. The quantifiable<br />
loss of resource is pitted against unquantifiable and<br />
significant psychological, social and financial implications<br />
of postponement for patients and their families.<br />
Although guidelines exist for the treatment of elevated<br />
blood pressure, there remains a paucity of literature<br />
and accepted guidelines for the peri-operative<br />
evaluation and care of the patient with hypertension<br />
who undergoes non-cardiac surgery [4]. Of particular<br />
importance is defining the patients most vulnerable<br />
to complications and the indications for immediate<br />
and rapid antihypertensive treatment and/or postponement<br />
of surgery to reduce these risks pre-operatively,<br />
intra-operatively and postoperatively. Perioperative<br />
hypertension often occurs in conjunction<br />
with sympathetic nociceptive stimulation during the<br />
induction of anaesthesia, during surgery and with<br />
acute pain in the early postoperative period. Hypertension<br />
may also accompany hypothermia, hypoxia or<br />
intravascular volume overload from excessive intraoperative<br />
fluid therapy, particularly in the ensuing<br />
24–48 h as fluid is mobilised from the extravascular<br />
space [4–6].<br />
There are no nationally agreed guidelines for the<br />
diagnosis or management of raised blood pressure<br />
before elective surgery. The evidence regarding the<br />
effect of raised pre-operative blood pressure is very<br />
limited. Local guidelines do exist but vary from area to<br />
area. Both the AAGBI and the British Hypertension<br />
Society recognised the need for a national guideline<br />
and consensus statement to address the various issues<br />
of concern. We have limited our deliberations to a<br />
specific scope. Only the period before planned surgery<br />
is covered. Blood pressures which may cause an immediate<br />
risk to health are specified, rather than those that<br />
may cause risk over the long-term. The best method of<br />
taking accurate blood pressure measurements is examined.<br />
We considered how long blood pressure should<br />
be controlled before surgery is undertaken. Communication<br />
between different hospital departments, primary<br />
care and the patient are of importance. We hope that<br />
by providing national guidance the chances of a<br />
patient receiving conflicting advice will be minimised.<br />
Scope<br />
This guideline is aimed at adults presenting for<br />
planned surgery. The following groups of patients are<br />
specifically not studied, although many of the general<br />
points covered in the guideline may apply.<br />
328 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337<br />
Emergency/urgent surgery<br />
By definition, these patients have no or very limited<br />
time for investigation, treatment or postponement.<br />
Such surgery must almost always proceed, but all those<br />
involved, including the patient, must be aware of any<br />
associated increased risk.<br />
Obstetrics<br />
Most cases of hypertension in pregnancy will be<br />
directly related to the pregnancy (although with an<br />
ageing obstetric population with higher rates of obesity,<br />
this may be less so). The monitoring and treatment<br />
of blood pressure is a specific and integral part<br />
of obstetric care, regardless of the need for surgery,<br />
and even for ‘elective’ Caesarean section there may be<br />
very limited opportunity for delay.<br />
Paediatrics<br />
Childhood hypertension is relatively uncommon, and<br />
its epidemiology and natural history is relatively<br />
unclear and there are no definitive trials on screening.<br />
Thus, its diagnosis and management, including preoperatively,<br />
is a specialist area beyond the scope of the<br />
general guidance in this publication.<br />
Cardiac surgery<br />
Peri-operative hypertension commonly complicates<br />
surgery for congenital and acquired cardiac disease.<br />
Management will be affected by many other factors<br />
including the planned procedure, the use or not of cardiopulmonary<br />
bypass and the other indications for<br />
vaso- and cardio-active medication. We have thus considered<br />
it to be a specialist area beyond the scope of<br />
the general guidance in this publication.<br />
Surgery for blood pressure management<br />
This includes surgery for phaeochromocytoma and<br />
bariatric surgery; we have excluded this from our guidance<br />
for similar reasons to that of cardiac surgery.<br />
Methods<br />
We formed a Working Party consisting of four members<br />
from each society who were academics and clinicians<br />
with varied interests, including vascular<br />
anaesthesia, cardiology, elderly care medicine and general<br />
practice. We agreed on the scope of the guideline,<br />
and then carried out a systematic review with the quality<br />
of evidence described using the Grading of Recommendations<br />
Assessment, Development and Evaluation<br />
(GRADE) approach [7, 8]. The GRADE approach considers<br />
the quality of a body of evidence as high, moderate,<br />
low or very low. To achieve a full consensus<br />
document was important. Therefore, we consulted 20<br />
general practitioners, including those with a specialist<br />
interest in cardiovascular medicine, as well as senior<br />
academics. A consultation guideline was then made<br />
available to members of both societies for comment.<br />
We specifically asked for and received comments from<br />
the patient group, Blood Pressure UK. The comments<br />
and responses have been made available online. The<br />
Council and Executive of the respective societies were<br />
given the task of final approval.<br />
Blood pressure, hypertension and<br />
anaesthesia<br />
The anaesthetist has two broad considerations in the<br />
hypertensive patient who presents for surgery. One is<br />
to be cognisant of the effect of chronic hypertension<br />
on the individual’s peri-operative and long-term cardiovascular<br />
risk. The other is to consider whether the<br />
blood pressure measured in the primary care setting is<br />
associated with adverse peri-operative events and to<br />
decide whether this should be reduced before surgery.<br />
The association between hypertension and perioperative<br />
harm was first reported in the 1950s [9, 10].<br />
Systolic blood pressures in excess of 170 mmHg and<br />
diastolic blood pressures in excess of 110 mmHg were<br />
associated with complications such as myocardial<br />
ischaemia [11]. Hypertension was the second-most<br />
common factor associated with postoperative morbidity<br />
[12]. In 2003, Weksler et al. published a ‘quasi’-<br />
randomised controlled study of 989 treated hypertensive<br />
patients who had diastolic blood pressures<br />
between 110 and 130 mmHg measured in the anaesthetic<br />
room [13]. In one group, surgery proceeded<br />
after intranasal nifedipine, and in the other group, surgery<br />
was delayed while further antihypertensive treatment<br />
was pursued in hospital. During the first three<br />
postoperative days, the rates of neurological and cardiovascular<br />
complications were similar. One might<br />
conclude that there was no difference in an infrequent<br />
outcome, or that the study had insufficient power to<br />
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 329
Anaesthesia 2016, 71, 326–337<br />
Management of hypertension before elective surgery guidelines<br />
detect a small difference (see section below, treatment<br />
for hypertension: extension of evidence from the community<br />
to the peri-operative period).<br />
The association of hypertension with cardiovascular<br />
disease is established, but there is no clear evidence<br />
that patients with stage 1 or 2 hypertension (Table 1)<br />
without evidence of target organ damage have<br />
increased peri-operative cardiovascular risk [14].<br />
Patients with stage 3 or 4 hypertension, who are more<br />
likely to have target organ damage, have not been subjected<br />
to rigorous randomised controlled trials of perioperative<br />
interventions. There is evidence that hypertension<br />
with target organ damage is associated with a<br />
small increased incidence of peri-operative major<br />
adverse cardiovascular events [4]. It is not known<br />
whether or not reducing blood pressure in these<br />
patients during a postponement of planned surgery<br />
would reduce this rate of events; there is sparse evidence<br />
to guide a decision. Any decision should take<br />
into account factors other than blood pressure, namely:<br />
age; comorbidity; functional capacity (i.e. functional<br />
status and reserve); and the urgency and indication for<br />
surgery (see section below, ‘The treatment of cardiovascular<br />
risk, not hypertension’). The latest guidelines<br />
published by the National Institute for Health and<br />
Care Excellence (NICE), in conjunction with the British<br />
Hypertension Society, recognise the importance of<br />
target organ damage in the management of hypertension<br />
by targeting a lower threshold for further medical<br />
intervention [1]. Whether or not these thresholds and<br />
targets should be rigorously applied in the peri-operative<br />
setting is not clear.<br />
Patients with hypertension (controlled or uncontrolled)<br />
demonstrate a more labile haemodynamic profile<br />
than their non-hypertensive counterparts [5]. The<br />
induction of anaesthesia and airway instrumentation<br />
can lead to a pronounced increase in sympathetic activation,<br />
which may lead to a significant increase in<br />
Table 1 Categorisation of the stages of hypertension.<br />
Category<br />
Systolic blood<br />
pressure; mmHg<br />
Diastolic blood<br />
pressure; mmHg<br />
Stage 1 140–159 90–99<br />
Stage 2 160–179 100–109<br />
Stage 3 180–209 110–119<br />
Stage 4 ≥ 210 ≥ 120<br />
blood pressure and heart rate. A reduction in systemic<br />
vascular resistance soon after the induction of anaesthesia<br />
commonly leads to varying degrees of hypotension.<br />
Reduction in vascular resistance is multifactorial<br />
and may be secondary to loss of the baroreceptor<br />
reflex control, central neuraxial blockade, and direct<br />
effects of anaesthetic agents. The effect on vascular<br />
tone will be exaggerated by ‘deep’ or excessive anaesthesia<br />
and in patients who are fluid-depleted. This,<br />
and the often exaggerated haemodynamic response to<br />
surgery, pain and emergence from anaesthesia, have<br />
also been described as being more common in the<br />
hypertensive population [6]. Some researchers have<br />
demonstrated an association between pre-operative<br />
hypertension and relatively minor physiological<br />
derangements such as intra-operative hypotension,<br />
hypertension and arrhythmia, but studies have not<br />
conclusively demonstrated that fluctuations in haemodynamic<br />
variables cause clinically significant harm<br />
[15]. Larger studies to investigate differences between<br />
untreated hypertensive patients and those treated (successfully<br />
and unsuccessfully) have not demonstrated<br />
increased rates of peri-operative cardiovascular events.<br />
However, these findings may not be applicable to current<br />
practice, as many of these studies were conducted<br />
in the late 1970s [16].<br />
This appreciation of labile haemodynamics in<br />
hypertensive patients has led to a number of anaesthetic<br />
techniques designed to achieve a more stable<br />
haemodynamic profile during surgery. These techniques<br />
include co-induction, invasive arterial monitoring<br />
with titrated or prophylactic vasopressor therapy,<br />
depth-of-anaesthesia monitoring, beta-blockers and the<br />
optimisation of stroke volume with intravascular fluid<br />
therapy. The omission of antihypertensive drugs, such<br />
as angiotensin-converting enzyme inhibitors and<br />
receptor blockers, combined with the careful reintroduction<br />
of these drugs after surgery, is commonplace<br />
and appears to be associated with fewer significant<br />
peri-operative haemodynamic fluctuations [17].<br />
The introduction of peri-operative beta-blockade for<br />
high cardiac-risk patients increases postoperative mortality,<br />
secondary to hypotension and stroke, albeit with<br />
less cardiac injury, as demonstrated in the POISE-1<br />
study [18]. The anaesthetist should be aware that sudden<br />
withdrawal of certain antihypertensive agents such<br />
330 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337<br />
as clonidine, alpha-methyldopa and beta-blockers can<br />
be associated with adverse events. Withdrawal of<br />
beta-blockers may also be associated with myocardial<br />
ischaemia that is often silent in the peri-operative period<br />
and easily missed without continuous ECG monitoring<br />
and serial serum troponin measurements.<br />
Best practice: the measurement of<br />
blood pressure<br />
Blood pressure should be measured in primary care<br />
before non-urgent surgical referral (Fig. 1). Surgical<br />
outpatients should arrange for primary care to supply<br />
blood pressure readings if these have not been<br />
documented in the referral letter. Blood pressure<br />
should be measured by pre-operative assessment<br />
clinics in patients who attend the clinic without documented<br />
blood pressure readings from the last<br />
12 months. The measurement should follow the<br />
principles mandated for primary care (see below)<br />
[1]. Blood pressures less than 180 mmHg systolic<br />
and 110 mmHg diastolic in secondary care should<br />
not preclude elective surgery, although the patient<br />
Elective surgical referral appropriate<br />
No<br />
Measure blood pressure up to<br />
three times<br />
Mean<br />
SBP < 160 mmHg<br />
AND<br />
DBP < 100 mmHg<br />
in past year?<br />
Yes<br />
Refer<br />
Lowest SBP < 140 mmHg<br />
AND the lowest DBP <<br />
90 mmHg?<br />
Yes<br />
Refer<br />
No<br />
Lowest SBP < 160 mmHg<br />
AND the lowest DBP <<br />
100 mmHg?<br />
Yes<br />
Refer*<br />
No<br />
ABPM or HBPM<br />
Mean ‘out of office’<br />
SBP < 150 mmHg AND<br />
the mean DBP < 95<br />
mmHg?<br />
Yes<br />
Refer*<br />
No<br />
Treat until ‘clinic’ SBP < 160 mmHg<br />
AND DBP < 100 mmHg<br />
Refer*<br />
Figure 1 Primary care blood pressure assessment of patients before referral for elective surgery. *Investigations and<br />
treatment should continue to achieve blood pressures < 140/90 mmHg. ABPM and HBPM, ambulatory and home<br />
blood pressure measurement; DBP and SBP, diastolic and systolic blood pressure.<br />
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 331
Anaesthesia 2016, 71, 326–337<br />
Management of hypertension before elective surgery guidelines<br />
should be asked to attend their general practice for<br />
the concurrent determination of whether primary<br />
care hypertension is present.<br />
The setting in which blood pressure is measured<br />
should be relaxed and temperate in a standardised<br />
environment with current calibrated equipment. The<br />
seated patient should have their supported arm outstretched<br />
for at least one minute before the initial<br />
reading. The pulse rate and rhythm should be<br />
recorded before the blood pressure is measured by a<br />
validated device. Automated sphygmomanometers<br />
(www.bhsoc.org/bp-monitors) are inaccurate when the<br />
pulse is irregular, when the blood pressure should be<br />
measured by auscultation over the brachial artery during<br />
manual deflation of an arm cuff.<br />
Blood pressure should be measured in both arms<br />
in patients scheduled for vascular or renal surgery. If<br />
the difference between arms in systolic pressure is<br />
greater than 20 mmHg, repeat the measurements; subsequently,<br />
measure from the arm with the higher<br />
blood pressure.<br />
The patient is normotensive if the blood pressure<br />
measurement is less than 140/90 mmHg. If the first<br />
measurement is equal to or higher than 140/<br />
90 mmHg, the blood pressure should be measured<br />
twice more, with each reading at least one minute<br />
apart. The lower of the last two readings is recorded as<br />
the blood pressure; if it is less than 140/90 mmHg the<br />
patient is normotensive.<br />
If the reading is between 140/90 mmHg and 179/<br />
109 mmHg, the patient may have stage 1 or 2 hypertension.<br />
In primary care, the patient would be offered<br />
ambulatory (ABPM) or home blood pressure monitoring<br />
(HBPM) to establish their true blood pressure<br />
(GRADE 1B). If the reading is equal to or higher than<br />
180/110 mmHg in primary care, the patient may have<br />
severe hypertension and would be considered for<br />
immediate treatment.<br />
Best practice: the diagnosis of<br />
hypertension<br />
General practitioners should establish whether blood<br />
pressure has been measured and managed in all adults<br />
before non-urgent surgical referrals. A blood pressure<br />
measurement taken within the preceding 12 months<br />
should be detailed in the referral letter.<br />
The diagnosis of hypertension in patients<br />
referred for investigation of surgical disease that are<br />
not treated for hypertension and who have not had<br />
a blood pressure measurement in the preceding<br />
12 months follows the same process as any other<br />
primary care patient. We recommend that the practice<br />
instigates ambulatory or home blood pressure<br />
measurements before non-urgent referrals if the standard<br />
blood pressure is equal to or greater than 160/<br />
100 mmHg. If the patient’s ABPM/HBPM blood<br />
pressure is equal to or greater than 150/95 mmHg<br />
(or equal to or greater than 135/85 mmHg with target<br />
organ damage), the patient is diagnosed as having<br />
hypertension; treatment should be discussed and<br />
commenced using the NICE/BHS CG127 algorithm<br />
[19]. This process can take place at the same time<br />
as urgent surgical referral, but a reduction in blood<br />
pressure to less than 160/100 mmHg should precede<br />
non-urgent surgical referral. The referral letter<br />
should document that an informed discussion has<br />
taken place with patients who decline treatment, or<br />
detail that all appropriate attempts have been made<br />
to reduce blood pressure for patients with persistent<br />
hypertension, which might have included specialist<br />
investigations.<br />
Surgical outpatients should request that general<br />
practitioners forward primary care blood pressure<br />
measurements if these have not been documented in<br />
the referral letter. Pre-operative assessment clinics<br />
should measure the blood pressures of patients who<br />
present without documentation of primary care blood<br />
pressures. If the blood pressure is raised above<br />
180 mmHg systolic or 110 mmHg diastolic, the patient<br />
should return to their general practice for primary care<br />
assessment and management of their blood pressure,<br />
as detailed above (Fig. 2). If the blood pressure is<br />
above 140 mmHg systolic or 90 mmHg diastolic, but<br />
below 180 mmHg systolic and below 110 mmHg diastolic,<br />
the GP should be informed, but elective surgery<br />
should not be postponed.<br />
Best practice: the treatment of<br />
hypertension<br />
This section summarises the recommendations for primary<br />
care following the diagnosis of hypertension.<br />
There is good evidence (GRADE 1A) for the treatment<br />
332 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337<br />
Surgeon receives referral<br />
No<br />
Documented<br />
SBP < 160 mmHg<br />
AND<br />
DBP < 100 mmHg<br />
in past year?<br />
Yes<br />
Proceed<br />
Request measurements from GP<br />
Lowest SBP < 160 mmHg<br />
AND the lowest DBP <<br />
100 mmHg?<br />
Yes<br />
Proceed<br />
No<br />
Measure blood pressure up to<br />
three times<br />
Lowest SBP < 180 mmHg<br />
AND the lowest DBP <<br />
110 mmHg?<br />
Yes<br />
Proceed*<br />
No<br />
Refer back to GP*<br />
Figure 2 Secondary care blood pressure assessment of patients after referral for elective surgery. *The GP should be<br />
informed of blood pressure readings in excess of 140 mmHg systolic or 90 mmHg diastolic, so that the diagnosis of<br />
hypertension can be refuted or confirmed and investigated and treated as necessary. DBP and SBP, diastolic and systolic<br />
blood pressure.<br />
of hypertension with one or more of the following:<br />
diuretics (thiazide, chlorthalidone and indapamide);<br />
beta-blockers; calcium channel-blockers (CCB); angiotensin<br />
converting enzyme (ACE) inhibitors, or an<br />
angiotensin-2 receptor blocker (ARB) [1]. In the<br />
future, the threshold for treating high blood pressure<br />
might change to cardiovascular risk (see below, the<br />
treatment of cardiovascular risk, not hypertension).<br />
Step 1 treatment<br />
Patients aged less than 55 years should be offered an<br />
ACE inhibitor, or a low-cost ARB. If an ACE inhibitor<br />
is prescribed but is not tolerated (for example,<br />
because of cough), offer a low-cost ARB. Angiotensin-converting<br />
enzyme inhibitors and ARBs are not<br />
recommended in women of childbearing potential.<br />
An ACE inhibitor should not be combined with<br />
an ARB.<br />
Patients aged over 55 years and Black patients of<br />
African or Caribbean family origin of any age should<br />
be offered a CCB. If a CCB is not suitable, for example<br />
because of oedema or intolerance, or if there is evidence<br />
of heart failure or a high risk of heart failure, a<br />
thiazide-like diuretic should be offered.<br />
If diuretic treatment is to be initiated or changed,<br />
offer a thiazide-like diuretic, such as chlorthalidone<br />
(12.5–25.0 mg once daily), or indapamide (1.5 mg<br />
modified-release once daily or 2.5 mg once daily), in<br />
preference to a conventional thiazide diuretic such as<br />
bendroflumethiazide or hydrochlorothiazide.<br />
For patients who are already having treatment<br />
with bendroflumethiazide or hydrochlorothiazide<br />
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 333
Anaesthesia 2016, 71, 326–337<br />
Management of hypertension before elective surgery guidelines<br />
and whose blood pressure is stable and well controlled,<br />
treatment with the bendroflumethiazide or<br />
hydrochlorothiazide should be continued.<br />
Beta-blockers are not a preferred initial therapy<br />
for hypertension. However, beta-blockers may be<br />
considered in younger patients, particularly those<br />
with an intolerance or contraindication to ACE inhibitors<br />
and ARBs, or women of childbearing potential<br />
or patients with evidence of increased sympathetic<br />
drive. If beta-blockers are started and a second drug<br />
is required, add a CCB rather than a thiazide-like<br />
diuretic to reduce the person’s risk of developing<br />
diabetes.<br />
Step 2 treatment<br />
If blood pressure is not controlled by Step 1 treatment,<br />
use a CCB in combination with either an ACE inhibitor<br />
or an ARB.<br />
If a CCB is not suitable for Step 2 treatment, for<br />
example because of oedema or intolerance, or if there<br />
is evidence of heart failure or a high risk of heart failure,<br />
offer a thiazide-like diuretic.<br />
For Black patients of African or Caribbean family<br />
origin, consider an ARB in preference to an ACE inhibitor,<br />
in combination with a CCB.<br />
Step 3 treatment<br />
Before considering Step 3 treatment, check that drugs<br />
from Step 2 have been prescribed at optimal doses, or<br />
at the maximum tolerated doses. If treatment with<br />
three drugs is required, the combination of ACE inhibitor<br />
or ARB, CCB and thiazide-like diuretic should be<br />
used.<br />
Step 4 treatment<br />
If resistant blood pressure exceeds 140/90 mmHg in<br />
clinic after treatment with the optimal or highest-tolerated<br />
doses of an ACE inhibitor, or an ARB plus a<br />
CCB, with a diuretic; adding a fourth antihypertensive<br />
drug and expert advice should be considered.<br />
Further diuretic therapy with low-dose spironolactone<br />
(25 mg once daily) should be considered if the<br />
serum potassium concentration < 4.6 mmol.l<br />
1 . Caution<br />
is required in patients with reduced estimated<br />
glomerular filtration rates because of an increased risk<br />
of hyperkalaemia. Increasing the dose of thiazide-like<br />
diuretics should be considered if the serum potassium<br />
concentration > 4.5 mmol.l<br />
1 .<br />
Serum sodium and potassium concentrations and<br />
renal function should be checked within 1 month of<br />
increasing diuretic dose, and repeated as required<br />
thereafter. If further diuretic therapy for resistant<br />
hypertension at Step 4 is not tolerated, or is contraindicated<br />
or ineffective, consider an alpha-blocker<br />
or beta-blocker. If blood pressure remains uncontrolled<br />
with the optimal or maximum tolerated doses of four<br />
drugs, expert advice should be sought if it has not yet<br />
been obtained.<br />
As recently as 2008, the HYVET study demonstrated<br />
the clinical benefits of treating hypertension in<br />
people aged ≥ 80 years, while health economic analysis<br />
has confirmed the cost effectiveness of this strategy [1,<br />
20]. As a result, NICE now recommends that patients<br />
aged ≥ 80 years should be offered treatment only if<br />
they have stage 2 hypertension. The 2011 Hypertension<br />
Guideline also recommends that the decision to<br />
treat should be based on standing blood pressure, and<br />
should take into account the presence of co-morbidities<br />
such as dementia. The guideline also makes a distinction<br />
between initiating treatment in the over-80s<br />
and continuing long-term and well-tolerated treatment<br />
when patients reach this age. In other words, patients<br />
who were started on treatment when younger should<br />
not have their current therapy back-titrated when they<br />
celebrate their 80th birthday.<br />
The treatment of cardiovascular risk,<br />
not hypertension<br />
It is likely that treatment for hypertension will no<br />
longer be based upon blood pressure [21]. This is a<br />
surprising statement; the diagnosis of hypertension<br />
that merits treatment has – until recently – been based<br />
on patients’ blood pressure, irrespective of other cardiovascular<br />
risk factors, despite the NICE guidance<br />
recognising their importance [1]. This practice conflicts<br />
with the treatment of hypercholesterolaemia,<br />
which is not based on the cholesterol concentration<br />
alone, but instead on the composite 5- or 10-year risk<br />
of: stroke; myocardial infarction; heart failure; cardiovascular<br />
morbidity; or death, ascribed to these diagnoses.<br />
The magnitude by which cardiovascular disease<br />
is reduced by treatment for both hypercholesterolaemia<br />
334 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337<br />
and hypertension is dependent on the composite cardiovascular<br />
risk, not the concentration of cholesterol<br />
or the blood pressure. Anaesthetists should gauge their<br />
concern for a hypertensive patient by the calculated<br />
five-year rate of cardiovascular events, not by the<br />
blood pressure measurement per se.<br />
Hypertension is common; this is responsible for<br />
the well-publicised reduction in population rates of<br />
stroke by antihypertensive treatment. The absolute<br />
effect of treatment for the individual, even over a fiveyear<br />
period, is smaller than many anaesthetists might<br />
realise. Table 2 presents the effect of five-year antihypertensive<br />
treatment for cardiovascular risk in a population<br />
quartered by the five-year rate of any<br />
cardiovascular event. Planned major surgery temporarily<br />
increases mortality. For instance, planned open<br />
repair of abdominal aortic aneurysm increases mortality<br />
in the first postoperative month ten times, whereas<br />
endovascular repair increases mortality four times. If<br />
cardiovascular events are similarly increased by major<br />
planned surgery, one would anticipate that the preoperative<br />
antihypertensive treatment of cardiovascular<br />
risk would have a proportionately greater absolute<br />
effect on the rates of events while their risk remains<br />
elevated. Table 3 illustrates the absolute effect of established<br />
antihypertensive treatment in the month following<br />
a planned operation in patients from Table 2,<br />
assuming two scenarios: that the operation does not<br />
affect the rates of cardiovascular events; and that the<br />
operation increases the rates of cardiovascular events<br />
six times.<br />
This guideline has outlined that blood pressure<br />
before planned non-urgent surgery is measured in primary<br />
care, where the diagnosis of hypertension is<br />
Table 2 The effect of antihypertensive treatment on the five-year rates of events (per 1000) in a population quartered<br />
on the basis of the untreated cardiovascular five-year risk: lowest quartile (< 11% risk); next quartile (11–15%<br />
risk); next quartile (15–21% risk); highest quartile (> 21% risk).<br />
Any event Stroke CHD Heart failure<br />
No<br />
Quartile of risk treatment Treatment No treatment Treatment No treatment Treatment No treatment Treatment<br />
Highest quartile<br />
Event rates 270/1000 232/1000 70/1000 58/1000 63/1000 53/1000 47/1000 34/1000<br />
Event reduction 38/1000 12/1000 10/1000 13/1000<br />
Second quartile<br />
Event rates 180/1000 156/1000 49/1000 40/1000 42/1000 36/1000 27/1000 23/1000<br />
Event reduction 24/1000 9/1000 6/1000 4/1000<br />
Third quartile<br />
Event rates 120/1000 100/1000 36/1000 29/1000 33/1000 28/1000 15/1000 13/1000<br />
Event reduction 20/1000 7/1000 5/1000 2/1000<br />
Lowest quartile<br />
Event rates 60/1000 46/1000 17/1000 11/1000 17/1000 14/1000 6/1000 5/1000<br />
Event reduction 14/1000 6/1000 3/1000 1/1000<br />
CHD, coronary heart disease.<br />
Table 3 The absolute reduction in event rates per 1000 patients per month by antihypertensive treatment, assuming<br />
that the control rate is unaffected by surgery (‘same’) or increased, in this example sixfold (‘9 6’).<br />
Any event Stroke CHD Heart failure<br />
Quartile of risk Same 3 6 Same 3 6 Same 3 6 Same 3 6<br />
Highest quartile 0.6 3.8 0.2 1.2 0.2 1 0.2 1.3<br />
Next quartile 0.4 2.4 0.2 0.9* 0.1 0.6 0.1 0.4<br />
Next quartile 0.3 1.8 0.1 0.7 0.1 0.6 0.0 0.2<br />
Lowest quartile 0.2 1.2 0.1 0.6 0.1 0.3 0.0 0.1<br />
*The ‘0.2’ was rounded up from a value near 0.15, which is why this value 9 6 is 0.9, not 1.2.<br />
CHD, coronary heart disease.<br />
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 335
Anaesthesia 2016, 71, 326–337<br />
made, and treatment is managed. The lifelong risk of<br />
mortality and morbidity may be unaffected by postponing<br />
surgery for the assessment of cardiovascular<br />
risk by primary care and possible antihypertensive<br />
treatment [22]. For instance, clinicians might like to<br />
consider the uncertainty in how long it takes for cardiovascular<br />
risk to fall with antihypertensive medication<br />
(as opposed to how long it takes for blood<br />
pressure to fall), and the 1% relative increase in cardiovascular<br />
risk that accompanies each postponed<br />
month, due to the patient ageing. Clinicians might also<br />
consider that patients who smoke or who have hypercholesterolaemia<br />
are not subjected to the summary cancellations<br />
justified by blood pressure readings. A<br />
further consideration is the absence of a scale of<br />
enthusiasm for postponing surgery that matches the<br />
continuum of cardiovascular risk, which would result<br />
in older smoking hypercholesterolaemic normotensive<br />
men having surgery postponed more frequently than<br />
younger hypertensive women who do not have any<br />
other cardiovascular risk factors.<br />
Communication<br />
Pre-operative assessment clinics should inform general<br />
practitioners when they measure raised blood pressures<br />
in patients who have not had readings taken in primary<br />
care in the preceding 12 months. The letter<br />
should request that the general practitioner determine<br />
whether the patient has hypertension in primary care.<br />
The letter should also state whether or not surgery will<br />
proceed without a diagnosis of hypertension being<br />
made or treatment commenced.<br />
Appendix 1 is an example of a letter explaining<br />
that surgery will not proceed until the diagnosis of<br />
hypertension has been excluded or confirmed, and in<br />
the latter case treated with the patient’s consent. It is<br />
important that the patient has a copy and is instructed<br />
to make an appointment at their surgery with a nurse<br />
or a doctor and to take the letter with them. The language<br />
used should seek cooperative management<br />
rather than demand action. In the first instance, the<br />
GP will need to establish that the blood pressure is<br />
high and this is not a white coat effect. It must be<br />
clearly stated how to re-establish the procedural pathway<br />
when the blood pressure has been shown to be<br />
satisfactory, treated or not.<br />
Management of hypertension before elective surgery guidelines<br />
References<br />
1. National Institute for Health and Care Excellence. Hypertension:<br />
Clinical management of primary hypertension in adults.<br />
2011 NICE Clinical Guideline CG127. http://www.nice.org.uk/<br />
guidance/cg127 (accessed 15/01/2015).<br />
2. Cook TM, Woodall N, Frerk C. Fourth National Audit Project.<br />
Major complications of airway management in the UK: results<br />
of the Fourth National Audit Project of the Royal College of<br />
Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.<br />
British Journal of Anaesthesia 2011; 106: 617–31.<br />
3. Cook TM, Andrade J, Bogod DG, et al. The 5th National Audit<br />
Project (NAP5) on accidental awareness during general anaesthesia:<br />
patient experiences, human factors, sedation, consent<br />
and medicolegal issues. Anaesthesia 2014; 69: 1102–16.<br />
4. Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart<br />
disease and perioperative cardiac risk. British Journal of<br />
Anaesthesia 2004; 92: 57–83.<br />
5. Longnecker DE. Alpine anesthesia: can pretreatment with<br />
clonidine decrease the peaks and valleys? Anesthesiology<br />
1987; 67: 1–2.<br />
6. Prys-Roberts C, Greene LT, Meloche R, Foex P. Studies of<br />
anaesthesia in relation to hypertension II. Haemodynamic<br />
consequences of induction and endotracheal intubation.<br />
British Journal of Anaesthesia 1971; 43: 531–47.<br />
7. Guyatt GH, Oxman AD, Kunz R, et al. Going from evidence to<br />
recommendations. British Medical Journal 2008; 336: 1049–<br />
51.<br />
8. Guyatt GH, Oxman AD, Vist G, et al. for the GRADE Working<br />
Group. Rating quality of evidence and strength of recommendations<br />
GRADE: an emerging consensus on rating quality of<br />
evidence and strength of recommendations. British Medical<br />
Journal 2008; 336: 924–6.<br />
9. Smithwick RH, Thompson JE. Splanchnicectomy for essential<br />
hypertension; results in 1,266 cases. Journal of the American<br />
Medical Association 1953; 152: 1501–4.<br />
10. Thompson JE, Smithwick RH. Surgical measures in hypertension.<br />
Geriatrics 1953; 8: 611–9.<br />
11. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial<br />
index of cardiac risk in noncardiac surgical procedures. New<br />
England Journal of Medicine 1977; 297: 845–50.<br />
12. Khuri SF, Daley J, Henderson W, et al. The National Veterans<br />
Administration surgical risk study: risk adjustment for the<br />
comparative assessment of the quality of surgical care. Journal<br />
of the American College of Surgeons 1995; 180: 519–31.<br />
13. Weksler N, Klein M, Szendro G, et al. The dilemma of immediate<br />
preoperative hypertension: to treat and operate, or to<br />
postpone surgery? Journal of Clinical Anesthesia 2003; 15:<br />
179–83.<br />
14. Hanada S, Kawakami H, Goto T, et al. Hypertension and anesthesia.<br />
Current Opinion in Anaesthesiology 2006; 19: 315–9.<br />
15. Chung F, Mezei G, Tong D. Pre-existing medical conditions as<br />
predictors of adverse events in day case surgery. British Journal<br />
of Anaesthesia 1999; 83: 262–70.<br />
16. Goldman L, Caldera DL. Risks of general anesthesia and elective<br />
operation in the hypertensive patient. Anesthesiology<br />
1979; 50: 285–92.<br />
17. Comfere T, Sprung J, Kumar MM, et al. Angiotensin system<br />
inhibitors in a general surgical population. Anesthesia and<br />
Analgesia 2005; 100: 636–44.<br />
18. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended<br />
release metoprolol succinate in patients undergoing non-cardiac<br />
surgery (POISE trial): a randomised controlled trial. Lancet<br />
2008; 371: 1839–47.<br />
336 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337<br />
19. Hypertension Pathyways. http://pathways.nice.org.uk/pathways/<br />
hypertension#path=view%3A/pathways/hypertension/diagnosisand-assessment-of-hypertension.xml&content=view-index<br />
(accessed<br />
16/01/2015).<br />
20. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension<br />
in patients 80 years of age or older. New England<br />
Journal of Medicine 2008; 358: 1958–60.<br />
21. Sundstr€om J, Arima H, Woodward M, et al. on behalf of the<br />
Blood Pressure Lowering Treatment Trialists’ Collaboration.<br />
Blood pressure-lowering treatment based on cardiovascular<br />
risk: a meta-analysis of individual patient data. Lancet 2014;<br />
384: 591–8.<br />
22. Carlisle JB. Too much blood pressure? Anaesthesia 2015; 70:<br />
773–8.<br />
Appendix 1<br />
Example of letter to general practitioner from pre-assessment clinic following measurement of raised blood pressure<br />
in patients who have not had readings taken in primary care in the preceding 12 months.<br />
Dear Doctor<br />
Unfortunately, the procedure for Mr/Ms ...................... has been postponed because their blood pressure was<br />
found to be 182/114 in their pre-operative assessment. It was measured several times following the AAGBI/BHS guidelines.<br />
The guidelines suggest a blood pressure level higher than 180/110 is unsuitable for elective anaesthesia.<br />
We have asked the patient to make an appointment at their surgery for further assessment of their blood pressure. We<br />
would be grateful if you could verify that this is the true blood pressure level and not a white coat effect and treat appropriately<br />
if the patient has hypertension.<br />
We will be pleased to accept the patient back for surgery if their clinical blood pressure is below 160/100. Please<br />
ask the patient to contact ........................... and inform us of their current blood pressure and what medication,<br />
if any, was required to achieve this.<br />
Many thanks in anticipation of your help with this matter<br />
The following GPs were consulted about this letter:<br />
Dr Chris Arden, Dr Ivan Benett, Dr Mark Davis, Dr Richard Falk, Prof David Fitzmaurice, Prof Ahmet Fuat, Dr<br />
Napa Gopi, Dr Kathryn Griffith, Dr Rosie Heath, Prof Richard Hobbs, Dr Paul Johnson Prof Richard McManus, Dr<br />
Jonathan Morrell, Dr Washik Parkar, Dr Neil Paul, Dr Jon Pittard, Dr Peter Savill, Dr Jonathan Shribman, Dr Harjit<br />
Singh, Dr Heather Wetherell.<br />
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 337
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
AAGBI Safety Guideline<br />
Management of Severe Local Anaesthetic Toxicity<br />
1<br />
Recognition<br />
2<br />
Immediate<br />
management<br />
3<br />
Treatment<br />
Signs of severe toxicity:<br />
• Sudden alteration in mental status, severe agitation or loss of consciousness,<br />
with or without tonic-clonic convulsions<br />
• Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and<br />
ventricular tachyarrhythmias may all occur<br />
• Local anaesthetic (LA) toxicity may occur some time after an initial injection<br />
• Stop injecting the LA<br />
• Call for help<br />
• Maintain the airway and, if necessary, secure it with a tracheal tube<br />
• Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may<br />
help by increasing plasma pH in the presence of metabolic acidosis)<br />
• Confirm or establish intravenous access<br />
• Control seizures: give a benzodiazepine, thiopental or propofol in small<br />
incremental doses<br />
• Assess cardiovascular status throughout<br />
• Consider drawing blood for analysis, but do not delay definitive treatment to do<br />
this<br />
In circulatory arrest<br />
• Start cardiopulmonary resuscitation<br />
(CPR) using standard protocols<br />
• Manage arrhythmias using the<br />
same protocols, recognising that<br />
arrhythmias may be very refractory to<br />
treatment<br />
• Consider the use of cardiopulmonary<br />
bypass if available<br />
Without circulatory arrest<br />
Use conventional therapies to treat:<br />
• hypotension,<br />
• bradycardia,<br />
• tachyarrhythmia<br />
Give intravenous<br />
lipid emulsion<br />
(following the regimen overleaf)<br />
• Continue CPR throughout treatment<br />
with lipid emulsion<br />
• Recovery from LA-induced cardiac<br />
arrest may take >1 h<br />
• Propofol is not a suitable substitute<br />
for lipid emulsion<br />
• Lidocaine should not be used as an<br />
anti-arrhythmic therapy<br />
Consider intravenous<br />
lipid emulsion<br />
(following the regimen overleaf)<br />
• Propofol is not a suitable substitute<br />
for lipid emulsion<br />
• Lidocaine should not be used as an<br />
anti-arrhythmic therapy<br />
4<br />
Follow-up<br />
• Arrange safe transfer to a clinical area with appropriate equipment and suitable<br />
staff until sustained recovery is achieved<br />
• Exclude pancreatitis by regular clinical review, including daily amylase or lipase<br />
assays for two days<br />
• Report cases as follows:<br />
in the United Kingdom to the National Patient Safety Agency<br />
(via www.npsa.nhs.uk)<br />
in the Republic of Ireland to the Irish Medicines Board (via www.imb.ie)<br />
If Lipid has been given, please also report its use to the international registry at<br />
www.lipidregistry.org. Details may also be posted at www.lipidrescue.org<br />
Your nearest bag of Lipid Emulsion is kept<br />
This guideline is not a standard of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan<br />
must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options available.<br />
© The Association of Anaesthetists of Great Britain & Ireland 2010
Immediately<br />
Give an initial intravenous bolus<br />
injection of 20% lipid emulsion<br />
1.5 ml.kg –1 over 1 min<br />
and<br />
Start an intravenous infusion of 20%<br />
lipid emulsion at 15 ml.kg –1 .h –1<br />
after 5 min<br />
Give a maximum of two repeat<br />
boluses (same dose) if:<br />
• cardiovascular stability has not<br />
been restored or<br />
• an adequate circulation<br />
deteriorates<br />
Leave 5 min between boluses<br />
A maximum of three boluses can be<br />
given (including the initial bolus)<br />
and<br />
Continue infusion at same rate, but:<br />
Double the rate to 30 ml.kg –1 .h –1 at<br />
any time after 5 min, if:<br />
• cardiovascular stability has not been<br />
restored or<br />
• an adequate circulation deteriorates<br />
Continue infusion until stable and<br />
adequate circulation restored or<br />
maximum dose of lipid emulsion given<br />
Do not exceed a maximum cumulative dose of 12 ml.kg –1<br />
An approximate dose regimen for a 70-kg patient would be as follows:<br />
Immediately<br />
Give an initial intravenous bolus<br />
injection of 20% lipid emulsion<br />
100 ml over 1 min<br />
and<br />
Start an intravenous infusion of 20%<br />
lipid emulsion at 1000 ml.h –1<br />
after 5 min<br />
Give a maximum of two repeat<br />
boluses of 100 ml<br />
and<br />
Continue infusion at same rate<br />
but double rate to 2000 ml.h –1 if<br />
indicated at any time<br />
Do not exceed a maximum cumulative dose of 840 ml<br />
This AAGBI Safety Guideline was produced by a Working Party that comprised:<br />
Grant Cave, Will Harrop-Griffiths (Chair), Martyn Harvey, Tim Meek, John Picard, Tim Short and Guy Weinberg.<br />
This Safety Guideline is endorsed by the Australian and New Zealand College of Anaesthetists (ANZCA).<br />
© The Association of Anaesthetists of Great Britain & Ireland 2010
Malignant Hyperthermia Crisis Task Allocations<br />
AAGBI Safety Guideline<br />
The successful management of a malignant hyperthermia crisis requires multiple simultaneous<br />
treatment actions. This is made far easier through effective teamwork and specific task allocation.<br />
1 st anaesthetist - commence immediate management (on guideline sheet)<br />
The anaesthetist diagnosing MH or the most senior anaesthetist responding should assume the role of<br />
clinical leader once immediate management actions have been undertaken and avoid becoming focused<br />
on a single task.<br />
2 nd anaesthetist - resuscitation<br />
• Ensure dantrolene is given in correct dose (2.5mg/kg initially then 1mg/kg every 10-15min)<br />
• Commence TIVA<br />
• Management of hyperkalaemia<br />
• Management of arrhythmias<br />
• Management of acidosis<br />
• Renal protection (forced alkaline diuresis)<br />
1 st anaesthetic nurse/ODP<br />
• Collect MH kit<br />
• Collect cold saline & insulin<br />
• Set up lines (arterial/CVC)<br />
• Runner for resuscitation drugs/equipment<br />
2 nd anaesthetic nurse/ODP (ideally two people)<br />
• Draw up dantrolene as requested by anaesthetist in charge of resuscitation<br />
3 rd anaesthetist - lines/investigations<br />
• Site arterial line<br />
• Send bloods for<br />
o ABG – repeated (approx every 30 min initially)<br />
o U&Es<br />
o CK<br />
o FBC<br />
o Coagulation screen<br />
o Cross match<br />
• Central venous access<br />
• Urinary myoglobin<br />
• Monitor core and peripheral temperatures<br />
Surgical team<br />
• Catheterise<br />
• Complete/abandon surgery as soon as feasible<br />
• Undertake cooling manoeuvres<br />
Adapted from the Malignant Hyperthermia Australia and New Zealand (MHANZ) MH Resource Kit with permission
AAGBI SAFETY GUIDELINE<br />
Interhospital Transfer<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland,<br />
21 Portland Place, London W1B 1PY<br />
Telephone 020 7631 1650 Fax 020 7631 4352<br />
info@aagbi.org<br />
www.aagbi.org<br />
February 2009
MEMBERSHIP OF THE WORKING PARTY<br />
Dr D Goldhill<br />
Dr L Gemmell<br />
Dr D Lutman<br />
Dr S McDevitt<br />
Dr M Parris<br />
Dr C Waldmann<br />
Dr C Dodds<br />
Chairman, Consultant Anaesthetist,<br />
Royal National Orthopaedic Hospital<br />
Honorary Secretary Elect, AAGBI<br />
Consultant Anaesthetist, Great<br />
Ormond St Hospital<br />
Council Member, AAGBI<br />
Group of Anaesthetists in Training<br />
Consultant Anaesthetist, Royal<br />
Berkshire Hospital<br />
Royal College of Anaesthetists<br />
Ex-Officio<br />
Dr D K Whitaker<br />
Dr R J S Birks<br />
Dr I H Wilson<br />
Dr A W Harrop-Griffiths<br />
Dr I G Johnston<br />
Dr D G Bogod<br />
President<br />
President Elect<br />
Honorary Treasurer<br />
Honorary Secretary<br />
Honorary Membership Secretary<br />
Editor-in-Chief, Anaesthesia<br />
© Copyright of the Association of Anaesthetists of Great Britain and Ireland.<br />
No part of this book may be reproduced without the written permission of the AAGBI.
CONTENTS<br />
Section 1 Recommendations ..............................................................2<br />
Section 2<br />
Section 3<br />
Section 4<br />
Section 5<br />
Section 6<br />
Section 7<br />
Section 8<br />
Section 9<br />
Background..........................................................................3<br />
Introduction.........................................................................4<br />
The decision to transfer........................................................5<br />
Stabilisation before transfer..................................................7<br />
Accompanying the patient...................................................8<br />
Monitoring, drugs and equipment......................................10<br />
The ambulance..................................................................11<br />
Documentation and handover............................................13<br />
Appendix ..........................................................................................14<br />
References ..........................................................................................15<br />
1
Section 1<br />
Recommendations<br />
1. Transfer can be safely accomplished even in extremely ill patients.<br />
Those involved in transfers have the responsibility for ensuring that<br />
everything necessary is done to achieve this.<br />
2. The need for transfers between hospitals is likely to increase. Transfers<br />
for non-clinical reasons should only take place in exceptional<br />
circumstances and ideally only during daylight hours.<br />
3. The decision to transfer must involve a senior and experienced<br />
clinician.<br />
4. Hospitals should form transfer networks to coordinate and manage<br />
clinically indicated transfers.<br />
5. Networks should take responsibility for ensuring that arrangements can<br />
be made for accepting transfers to an agreed protocol with minimal<br />
administrative delays.<br />
6. Protocols, documentation and equipment for transfers should be<br />
standardised within networks.<br />
7. All doctors and other personnel undertaking transfers should have the<br />
appropriate competencies, qualifications and experience. It is highly<br />
desirable that this should include attendance at a suitable transfer<br />
course.<br />
8. A professional, dedicated transfer service has many advantages and is<br />
the preferred method of transferring suitable patients.<br />
9. Hospitals must ensure that suitable transfer equipment is provided.<br />
10. Hospitals must ensure that they have robust arrangements to ensure that<br />
sending personnel on a transfer does not jeopardise other work within<br />
the hospital.<br />
11. Hospitals must ensure that employees sent on transfers have adequate<br />
insurance cover and are made aware of the terms and limitations of this<br />
cover.<br />
12. Arrangements must be in place to ensure that personnel and equipment<br />
can safely and promptly return to base after the transfer.<br />
13. Details of every transfer must be recorded and subject to regular audit<br />
and review.<br />
2
Section 2<br />
Background<br />
The AAGBI Council decided to commission a Working Party to produce<br />
guidelines in the usual format of the Association to provide instruction and<br />
help to those arranging transfers and those involved with the actual transfer of<br />
the patients between hospitals.<br />
A large number of interhospital transfers already take place and the number<br />
is likely to increase. Anaesthetists are commonly involved in transferring<br />
the sickest of these patients. This has the potential to affect an Anaesthetic<br />
Department’s budget and ability to maintain a service and on-call rotas.<br />
This document addresses transfers between hospitals, not within a hospital.<br />
However, the principles for the safe movement of patients are also applicable<br />
to transport within a hospital.<br />
3
Section 3<br />
Introduction<br />
In 1997 it was estimated that over 11,000 critically ill patients were transferred<br />
between intensive care units in the UK [1]. The majority of transfers are for<br />
appropriate clinical reasons for patients requiring care not available in the<br />
referring hospital. Such specialist care includes neuroscience, paediatrics,<br />
burns, spinal injury, etc. There is a limited number of paediatric and neonatal<br />
centres with high-level critical care support. Transfer of critically ill children<br />
must be a consideration in any hospital with an emergency department. Many<br />
transfers are undertaken for non-clinical reasons commonly related to the<br />
relative lack of critical care beds. It is government policy that these transfers<br />
should be as few as possible and contained within critical care transfer<br />
groups [2]. A relatively small percentage of patients transferred between<br />
hospitals involve repatriations of patients previously transferred. Patients may<br />
be transferred from the emergency department, critical care units, operating<br />
theatres, wards or other areas of the hospital. Transfers often occur outside of<br />
normal working hours and take place at short notice [3]. During the transfer<br />
the patient is in a noisy, difficult and potentially dangerous environment and<br />
the transferring medical team is operating independently. All hospitals that<br />
may be involved in transfers must ensure that the appropriate personnel,<br />
equipment, training and support are available. In the past, inexperienced<br />
doctors with inadequate training, supervision and equipment carried out<br />
many of the transfers [1,3-5]. Although the situation has improved, in many<br />
regions of the country there are still significant limitations in the process of<br />
arranging and carrying out a transfer.<br />
This booklet should be read in conjunction with ‘Recommendations for the<br />
Safe Transfer of Patients with Brain Injury’ published by the Association of<br />
Anaesthetists in 2006 (http://www.aagbi.org/publications/guidelines/docs/<br />
braininjury.pdf). Other guidelines have been published including those from<br />
the Intensive Care Society ([6] available from www.ics.ac.uk). This booklet<br />
is not intended to be an in-depth document on transfer but should be read in<br />
conjunction with these and other guidelines.<br />
4
Section 4<br />
The decision to transfer<br />
It is essential that a systematic approach is taken to the process of patient<br />
transfer; starting with the decision to transfer, through the pre-transfer<br />
stabilisation, and then the management of the transfer itself. This will<br />
encompass all the stages including skilled evaluation, communication,<br />
documentation, monitoring and treatment, handover and return to base.<br />
Education and preparation are central to any safe transfer.<br />
The decision to transfer must not be taken lightly. It has the potential to expose<br />
the patient and transferring staff to additional risk, requires trained personnel,<br />
specialised equipment and a vehicle, and may result in additional expense<br />
and worry for carers and relatives. A senior doctor, normally a consultant,<br />
should therefore be involved in making this decision. Documentation of the<br />
decision should include the name of the doctor making the decision with their<br />
grade and contact details, and the date and time at which the decision was<br />
made. Reasons for the decision should be given including whether it is for<br />
clinical or non-clinical reasons.<br />
Once the decision is made a hospital and medical team must agree to take<br />
the patient. In much of the United Kingdom critical care transfer groups have<br />
been established with a role of co-ordinating and facilitating transfers within<br />
a network. If a critical care bed is required, direct consultant-to-consultant<br />
contact is often the best way to make arrangements. In the appropriate<br />
circumstances and for the right patient many intensive care units are able<br />
to accommodate patients at short notice. However, the further away the<br />
referring hospital and the more tenuous the links, the less responsibility the<br />
accepting hospital is likely to feel. We would therefore strongly advise groups<br />
of hospitals to form networks to facilitate and organise transfers.<br />
Most of the country is covered by bed bureaux such as the Emergency<br />
Bed Service (EBS). They contact critical care units on a regular basis and<br />
are able to provide some indication of the availability of beds. They do<br />
not take responsibility for arranging the transfer and it is still necessary to<br />
negotiate directly with individual units. Once a critical care unit has agreed<br />
to accept a patient it is necessary for the patient’s medical team to arrange<br />
for the appropriate medical speciality in the receiving hospital to take overall<br />
responsibility for the patient during their admission to that hospital.<br />
5
This process may require many telephone calls and take several hours [7].<br />
Streamlining this process should be a responsibility for a transfer network.<br />
The process of arranging the transfer must be documented including the<br />
name, grade and contact details of those making the arrangements both at the<br />
referring and receiving centres, the date and time of calls made and details of<br />
any advice received.<br />
A limited number of retrieval services able to perform transfers exist in the UK,<br />
mainly covering paediatric patients. A professional, dedicated transfer service<br />
has many advantages and is the preferred method of transferring suitable<br />
patients. Networks should aim to fund and develop such teams. Members of<br />
these teams have the training and competencies to undertake transfers; such<br />
teams have appropriate equipment and can work with the ambulance service,<br />
hospitals and other interested parties on protocols and guidelines. They also<br />
ensure that transfers can be safely achieved without compromising the work<br />
of the transferring hospital.<br />
Although these services are extremely welcome they cannot be relied upon<br />
to provide a service at short notice and at all times [8-10]. Every hospital that<br />
may transfer patients must have suitable arrangements in place for providing<br />
transfers. Most transfers are in an ambulance by road. There is an increasing<br />
number of transfers in rotary and fixed wing aircraft. Air transfers confer<br />
additional hazards and expense and require further training [11,12].<br />
6
Section 5<br />
Stabilisation before transfer<br />
Although transfers are potentially associated with additional risk to patients<br />
[13-15], they can be safely accomplished even in extremely ill patients [16-<br />
18]. Generally, a transfer should not be undertaken until the patient has<br />
been resuscitated and stabilised. All hospitals involved in transfers must<br />
ensure that they have appropriate arrangements in place for this. It may be<br />
several hours after the decision to transfer before the transfer can take place.<br />
It may be necessary to secure the airway, and many patients will require<br />
a tracheal tube or tracheostomy with appropriate end-tidal carbon dioxide<br />
monitoring. Appropriate venous access must be in place and monitoring<br />
instituted. Continuous invasive blood pressure measurement is the best<br />
technique for monitoring blood pressure during the transfer of ill patients.<br />
Treatment should not be delayed while waiting for the transfer. The accepting<br />
hospital may be able to provide advice on the immediate management in<br />
specialised situations. A ‘scoop and run’ philosophy is only appropriate on<br />
rare occasions when the urgency of the situation and the need for definitive<br />
treatment will limit the time available for stabilisation before transfer. For<br />
example, transfer of a patient with a leaking aortic aneurysm to a vascular<br />
centre may be time-critical. Even in these situations the transfer should not<br />
begin until essential management and monitoring has been undertaken. It<br />
is good practice to establish the patient on the transport ventilator and other<br />
equipment for a period of time before they are moved.<br />
7
Section 6<br />
Accompanying the patient<br />
A critically ill patient should be accompanied by a minimum of two<br />
attendants. The precise requirement for accompanying personnel will depend<br />
upon the clinical circumstances in each case. The level of a patient’s critical<br />
care dependency provides a guide to the personnel who should accompany<br />
them [19]. A senior doctor, normally a consultant, should take the decision<br />
on who should accompany the patient. Before departure the senior individual<br />
undertaking the transfer should be satisfied with the state of the patient and<br />
all other aspects associated with the transfer. Many patients do not need<br />
anaesthetic support during interhospital transfer.<br />
These patients include:<br />
• patients who are not likely to need airway or ventilatory support<br />
• patients for whom attempting cardiopulmonary resuscitation would<br />
be inappropriate<br />
• patients being transferred for acute definitive management for whom<br />
anaesthesia support will not affect their outcome<br />
Levels of patients’ critical care needs as a guide to transfer requirements.<br />
The decision should be made by a senior doctor [19]<br />
Level 0:<br />
Patients whose needs can be met through normal ward care in an acute<br />
hospital should not usually need to be accompanied by a doctor, nurse or<br />
paramedic.<br />
Level 1:<br />
At risk of their condition deteriorating, or those recently relocated from higher<br />
levels of care and whose needs can be met on an acute ward with additional<br />
advice and support from the critical care team will require a paramedic<br />
ambulance crew and may require a nurse, paramedic and/or medical escort.<br />
Level 2:<br />
Requiring more detailed observation or intervention including support for a<br />
single failing organ system or post-operative care and those stepping down<br />
from higher levels of care must be escorted by competent, trained and<br />
experienced personnel, usually a doctor and a nurse or paramedic.<br />
8
Level 3:<br />
Patients requiring advanced respiratory support alone or basic respiratory<br />
support together with support of at least two organ systems. This level<br />
includes all complex patients requiring support for multi-organ failure. These<br />
patients must be escorted by competent, trained and experienced personnel,<br />
usually a doctor and a nurse or paramedic.<br />
When the request for anaesthetic care during transfer exceeds the Department<br />
of Anaesthesia’s ability to do this safely, decisions about priority and relative<br />
risk may have to be taken. Although the patient would benefit from anaesthesia<br />
management, the issue may be one of either delaying transfer until resources<br />
are available or sending the patient without an accompanying anaesthetist<br />
but with another doctor. Anaesthetic Departments should use interhospital<br />
transfers to provide doctors with training and experience under the direct<br />
supervision of an experienced transfer team.<br />
All individuals involved in the transport of critically ill patients should be<br />
suitably competent, trained and experienced. A competency-based training<br />
curriculum is being developed by the Royal College of Anaesthetists. There<br />
are generic training courses available but consideration should be given to the<br />
development of local Trust and Network training and simulation programmes.<br />
Good communication skills are essential. Each Trust should have a designated<br />
consultant who is responsible for secondary transfers, guideline production<br />
and training and audit.<br />
While safety is of paramount importance during transfer, there is always a<br />
remote possibility of an ambulance being involved in an accident resulting in<br />
death or serious injury to staff. The insurance situation in these circumstances<br />
is complex. It is essential that all members of staff who might be involved<br />
in transporting patients and their employers ensure that adequate financial<br />
arrangements are in place for themselves and their dependents in the event of<br />
an accident and that they are made aware of the terms and limitations of this<br />
cover. In addition, the AAGBI has negotiated insurance for all their members<br />
involved in the transport of critically ill patients. Details of the appropriate<br />
insurance schemes and the cover benefit of membership are available from<br />
the AAGBI (www.aagbi.org). The AAGBI also recommends that doctors<br />
involved with the transfer of patients are members of a medical defence<br />
organisation.<br />
9
Section 7<br />
Monitoring, drugs and equipment<br />
Patients with level 1, 2 or 3 critical care needs will require monitoring during<br />
the transfer. Monitoring needs to be established and secure before the transfer<br />
is started. This may require the insertion of central venous lines, arterial lines<br />
and equipment for measuring cardiac output, as well as end-tidal carbon<br />
dioxide monitoring.<br />
The personnel involved in the transfer should ensure that they have adequate<br />
supplies of the necessary drugs. These may include sedatives, analgesics,<br />
muscle relaxants, and inotropes. Many of these drugs are best prepared<br />
beforehand in pre-filled syringes. The patient should be established on the<br />
medication to be used during the transfer before the transfer commences.<br />
As much of the equipment as possible should be mounted at or below the<br />
level of the patient. In particular, large arrays of vertical drip stands should be<br />
avoided. This allows unhindered access to the patient and improves stability of<br />
the patient trolley. All equipment should be robust, durable and lightweight.<br />
Electrical equipment must be designed to function on battery when not<br />
plugged into the mains. Additional batteries should be carried in case of<br />
power failure. Portable monitors should have a clear illuminated display and<br />
be capable of displaying ECG, arterial oxygen saturation, non-invasive blood<br />
pressure, two invasive pressures, capnography and temperature. Non-invasive<br />
blood pressure may rapidly deplete battery power and is unreliable when<br />
there is external movement and vibration. Alarms should be visible as well<br />
as audible in view of the loud background noise levels.<br />
Portable mechanical ventilators should have, as a minimum, disconnection<br />
and high pressure alarms, the ability to supply positive end expiratory pressure<br />
and variable inspired oxygen concentration, inspiratory : expiratory ratio,<br />
respiratory rate and tidal volume. In addition, the ability to provide pressurecontrolled<br />
ventilation, pressure support and continuous positive airway<br />
pressure is desirable. Additional equipment for maintaining and securing the<br />
airway, intravenous access, etc should also be available.<br />
Ideally, all equipment within a Critical Care Network should be standardised<br />
to enable the seamless transfer of patients without, for example, interruption of<br />
drug therapy or monitoring due to incompatibility of leads and transducers.<br />
10
Section 8<br />
The ambulance<br />
The European Committee for Standardisation has published specifications for<br />
ambulances. Private transport services may use Type C mobile ICU vehicles.<br />
These will have 240V AC power, a secure critical care trolley and carry a<br />
ventilator and syringe drivers. It is more usual to request an ambulance from<br />
the local ambulance service to perform the transfer. This is a likely to be a<br />
Type B or equivalent vehicle that has 12V electric sockets, oxygen supply and<br />
limited monitoring and other equipment.<br />
Before transfer it is essential to ascertain what needs to be taken with the<br />
patient to support the transfer. The oxygen supply and battery operated<br />
equipment must be more than sufficient for the anticipated duration of the<br />
transfer. Unless a transfer service is used, everything except the oxygen<br />
supply usually has to be supplied by the transferring hospital. Hospitals<br />
involved in transfers must ensure that the appropriate equipment is available<br />
for likely transfers at all times.<br />
The standard ambulance trolley is ill-suited to patient transfers. Ideally, it<br />
should be able to carry all the equipment including oxygen supply, a ventilator,<br />
syringe drivers, suction and backup batteries. These items should be placed<br />
below the patient, and the trolley should be secured within the ambulance to<br />
allow free access to all sides with a fixation capable of withstanding up to 10<br />
G in all directions. It is not acceptable to place items on the patient’s trolley<br />
or on shelves within the vehicle. Gravity feed drips are unreliable in moving<br />
vehicles. Sufficient syringe or infusion pumps are required to enable essential<br />
fluids and drugs to be delivered. Pumps should preferably be mounted below<br />
the level of the patient and infusion sets fitted with anti-siphon devices.<br />
Portable warm-air devices for maintaining the patient’s temperature can be<br />
useful and can also be mounted on the patient’s trolley.<br />
A major issue relating to safety during transport is the speed of travel. For<br />
the majority of cases high-speed travel is not necessary and the safety of all<br />
passengers and other road users is paramount. Medical personnel present<br />
may offer advice as to the patient’s clinical condition and the speed of travel<br />
but they should be aware of the requirements of the Road Traffic Act in such<br />
cases. The decision to use blue lights and sirens rests with the ambulance<br />
driver. The goal is to facilitate a smooth and rapid transfer with the minimum<br />
acceleration and deceleration. A police escort may be required through<br />
11
heavily congested areas, but not all police authorities provide this service.<br />
Staff should remain seated at all times and wear the seat belts provided. If,<br />
despite meticulous preparation, unforeseen clinical emergencies arise and<br />
the patient requires intervention, this should not be attempted in a moving<br />
ambulance. The vehicle should be stopped appropriately in a safe place and<br />
the patient attended to. Where staff may be required to move outside the<br />
vehicle, high visibility clothing must be worn. On safety issues all staff in the<br />
vehicle must obey the instructions of the crew.<br />
Air transport should be considered for longer journeys where road access is<br />
difficult or when, for other reasons, it may be quicker. Perceived speed of<br />
air transport must be balanced against organisational delays and inter-vehicle<br />
transfers at either end of the journey. Helicopters vary in size, capacity and<br />
range. They generally provide a less comfortable, more cramped environment<br />
than a road ambulance or pressurised fixed wing aircraft. In addition, they are<br />
expensive and have a poorer safety record.<br />
The transport of patients by air presents medical escorts with many problems<br />
unique to this mode of travel. Staff involved in aeromedical transport must<br />
have both a high level of expertise, specialist knowledge and practical training.<br />
Staff without appropriate training should not undertake aeromedical transfers.<br />
Minimum requirements include safety training, evacuation procedures for the<br />
aircraft and basic on-board communication skills (particularly for helicopters).<br />
However, more advanced training in aeromedical transport medicine is<br />
desirable. Training should also address the special physical, physiological<br />
and psychological stresses that are important when flying as well as provide<br />
a detailed knowledge of how medical conditions can be affected by this<br />
environment and the necessary precautions needed to facilitate safe transfer.<br />
12
Section 9<br />
Documentation and handover<br />
Clear records should be maintained at all stages. This is a legal requirement<br />
and should include details of the patient’s condition, reason for transfer,<br />
names of referring and accepting consultants, clinical status prior to transfer<br />
and details of vital signs, clinical events and therapy given during transport.<br />
Standard documentation should be developed across networks and be<br />
used for both intra-hospital and interhospital transport. The clinical record<br />
should briefly summarise the patient’s clinical status before, during and after<br />
transport, including relevant medical conditions, environmental factors and<br />
therapy given. This should include a core data set for audit purposes and the<br />
transport team should be able to retain a duplicate. There should be a process<br />
to investigate specific problems, including delays in transportation.<br />
Clear information should be given to the transport team before departure about<br />
the location of the receiving area for the formal handover of the patient. On<br />
arrival at the receiving hospital, there should be a formal handover between<br />
the transport team and the receiving medical and nursing staff who will<br />
assume responsibility for the patient’s care. Handover should include a verbal<br />
and written account of the patient’s history, vital signs, therapy and significant<br />
clinical events during transport. X-rays, scans and other investigation results<br />
should be described and handed over to receiving staff.<br />
After handover, the transport team is relieved of the duty of care to the patient,<br />
who is now in the medical care of the receiving hospital. This is an important<br />
part of the transfer of care and the status of the patient should be formally<br />
noted by the receiving team. It should be noted that the ambulance crew<br />
or air crew may not always be able to return the transfer team whence they<br />
came. The transfer team should be prepared to return home by taxi or other<br />
appropriate means and therefore thought should be given to clothing, the<br />
amount of equipment to be carried and the means of payment for the return<br />
journey.<br />
13
APPENDIX<br />
1 Departure checklist<br />
Do attendants have adequate competencies, experience, knowledge<br />
of case, clothing, insurance?<br />
Appropriate equipment and drugs?<br />
Batteries checked?<br />
Sufficient oxygen?<br />
Trolley available?<br />
Ambulance service aware or ready?<br />
Bed confirmed? Exact location?<br />
Case notes, X ray films, results, blood collected?<br />
Transfer chart prepared?<br />
Portable phone charged?<br />
Contact numbers known?<br />
Money or cards for emergencies?<br />
Estimated time of arrival notified?<br />
Return arrangements checked?<br />
Relatives informed?<br />
Patient stable, fully investigated?<br />
Monitoring attached and working?<br />
Drugs, pumps, lines rationalised and secured?<br />
Adequate sedation?<br />
Still stable after transfer to mobile equipment?<br />
Anything missed?<br />
14
References<br />
1. Mackenzie PA, Smith EA, Wallace PG. Transfer of adults between<br />
intensive care units in the United Kingdom: postal survey. British<br />
Medical Journal 1997; 314: 1455-6.<br />
2. Department of Health. Comprehensive Critical Care. a review of adult<br />
critical care services. 2000. London, Department of Health.<br />
3. Gray A, Gill S, Airey M, Williams R. Descriptive epidemiology of adult<br />
critical care transfers from the emergency department. Emergency<br />
Medicine Journal 2003; 20: 242-6.<br />
4. Jameson PP, Lawler PG. Transfer of critically ill patients in the Northern<br />
region. Anaesthesia 2000; 55: 489.<br />
5. Spencer C, Watkinson P, McCluskey A. Training and assessment<br />
of competency of trainees in the transfer of critically ill patients.<br />
Anaesthesia 2004; 59: 1248-9.<br />
6. Guidelines for the transport of the critically ill adult. 2002. London,<br />
The Intensive Care Society.<br />
7. Duke GJ, Green JV. Outcome of critically ill patients undergoing<br />
interhospital transfer. The Medical Journal of Australia 2001; 174: 122-<br />
5.<br />
8. Vos GD, Nissen AC, Nieman FH et al. Comparison of interhospital<br />
pediatric intensive care transport accompanied by a referring<br />
specialist or a specialist retrieval team. Intensive Care Medicine 2004;<br />
30: 302-8.<br />
9. Bellingan G, Olivier T, Batson S, Webb A. Comparison of a specialist<br />
retrieval team with current United Kingdom practice for the transport<br />
of critically ill patients. Intensive Care Medicine 2000; 26: 740-4.<br />
10. Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do<br />
specialist transport personnel improve hospital outcome in critically ill<br />
patients transferred to higher centers? A systematic review. Journal of<br />
Critical Care 2006; 21: 8-17.<br />
11. Diaz MA, Hendey GW, Bivins HG. When is the helicopter faster? A<br />
comparison of helicopter and ground ambulance transport times. The<br />
Journal of Trauma 2005; 58: 148-53.<br />
12. Dewhurst AT, Farrar D, Walker C, Mason P, Beven P, Goldstone JC.<br />
Medical repatriation via fixed-wing air ambulance: a review of patient<br />
characteristics and adverse events. Anaesthesia 2001; 56: 882-7.<br />
15
13. Bercault N, Wolf M, Runge I, Fleury JC, Boulain T. Intrahospital<br />
transport of critically ill ventilated patients: a risk factor for ventilatorassociated<br />
pneumonia--a matched cohort study. Critical Care Medicine<br />
2005; 33: 2471-8.<br />
14. Fan E, Macdonald RD, Adhikari NK et al. Outcomes of interfacility<br />
critical care adult patient transport: a systematic review. Critical Care<br />
2005; 10: R6.<br />
15. Waydhas C. Intrahospital transport of critically ill patients. Critical Care<br />
1999; 3: R83-R89.<br />
16. Gebremichael M, Borg U, Habashi NM et al. Interhospital transport of<br />
the extremely ill patient: the mobile intensive care unit. Critical Care<br />
Medicine 2000; 28: 79-85.<br />
17. Penner GE, Brabson TA, Bunk C. Are interfacility ground transports<br />
of patients utilizing intra-aortic balloon pumps safe? Prehospital<br />
Emergency Care 2001; 5: 395-8.<br />
18. Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe long-distance<br />
interhospital ground transfer of critically ill patients with acute severe<br />
unstable respiratory and circulatory failure. Intensive Care Medicine<br />
2002; 28: 1122-5.<br />
19. The Intensive Care Society. Levels of critical care for adult patients.<br />
2002. London, The Intensive Care Society.<br />
16
17
21 Portland Place, London W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
AAGBI SAFETY GUIDELINE<br />
Infection Control in Anaesthesia<br />
2<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland,<br />
21 Portland Place, London W1B 1PY<br />
Telephone: 020 7631 1650<br />
E-mail: info@aagbi.org Website: www.aagbi.org<br />
October 2008
Membership of the Working Party<br />
Dr Leslie Gemmell<br />
Dr Richard Birks<br />
Dr Patrick Radford<br />
Professor Don Jeffries CBE<br />
Dr Geoffrey Ridgway<br />
Mr Douglas McIvor<br />
Chairman, Honorary Secretary Elect<br />
President Elect<br />
Royal College of Anaesthetists<br />
Emeritus Professor of Virology, University of London<br />
Consultant Microbiologist<br />
Medicines and Healthcare Products Regulatory Authority<br />
Ex officio<br />
Dr David Whitaker<br />
Dr William Harrop-Griffiths<br />
Dr Iain Wilson<br />
Dr Ian Johnston<br />
Dr David Bogod<br />
President<br />
Honorary Secretary<br />
Honorary Treasurer<br />
Honorary Membership Secretary<br />
Editor-in-Chief, Anaesthesia<br />
This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please<br />
use the following reference:<br />
Anaesthesia 2008, 63; 1027-36
Anaesthesia, 2008, 63, pages 1027–1036<br />
doi:10.1111/j.1365-2044.2008.05657.x<br />
.....................................................................................................................................................................................................................<br />
GUIDELINES<br />
Infection Control in Anaesthesia<br />
Association of Anaesthetists of Great Britain and Ireland<br />
Membership of the Working Party: Gemmell L, Chair; Birks R, President Elect; Radford P, Royal<br />
College of Anaesthetists representative; Jeffries D, National Institute for Health and Clinical<br />
Excellence; Ridgway G, consultant microbiologist; McIvor D, Medicines and Healthcare Products<br />
Regulatory Authority; Executive Officers of AAGBI, ex officio<br />
This is a consensus document produced by expert members of a Working Party established by the Association of<br />
Anaesthetists of Great Britain and Ireland (AAGBI). It updates and replaces previous guidance published in<br />
2002.<br />
1.0. Summary<br />
(1) A named consultant in each department of anaesthesia<br />
should liaise with Trust Infection Control<br />
Teams and Occupational Health Departments to<br />
ensure that relevant specialist standards are established<br />
and monitored in all areas of anaesthetic<br />
practice.<br />
(2) Precautions against the transmission of infection<br />
between patient and anaesthetist or between patients<br />
should be a routine part of anaesthetic practice.<br />
In particular, anaesthetists must ensure that hand<br />
hygiene becomes an indispensable part of their<br />
clinical culture.<br />
(3) Anaesthetists must comply with local theatre infection<br />
control policies including the safe use and disposal of<br />
sharps.<br />
(4) Anaesthetic equipment is a potential vector for<br />
transmission of disease. Policies should be documented<br />
to ensure that nationally recommended<br />
decontamination practices are followed and audited<br />
for all reusable anaesthetic equipment.<br />
(5) Single use equipment should be utilised where<br />
appropriate but a sterile supplies department (SSD)<br />
should process reusable items.<br />
(6) An effective, new bacterial ⁄ viral breathing circuit<br />
filter should be used for every patient and a local<br />
policy developed for the re-use of breathing circuits<br />
in line with manufacturer’s instructions. The AAGBI<br />
recommends that anaesthetic departments should<br />
consider changing anaesthetic circuits on a daily basis<br />
in line with daily cleaning protocols.<br />
(7) Appropriate infection control precautions should be<br />
established for each anaesthetic procedure, to include<br />
maximal barrier precautions for the insertion of central<br />
venous catheters, spinal and epidural procedures and<br />
any invasive procedures in high risk patients.<br />
2.0. Introduction<br />
The Association of Anaesthetists of Great Britain and<br />
Ireland (AAGBI) published guidelines in 2002 on problems<br />
relating to infection control in anaesthetic practice.<br />
In addition to AAGBI Officers and Council members,<br />
representation included the Royal College of Anaesthetists<br />
and the Medicines and Healthcare Products Regulatory<br />
Authority (MHRA). This is an updated version of<br />
that guidance document.<br />
Healthcare organisations now have a legal responsibility<br />
to implement changes to reduce healthcare associated<br />
infections (HCAIs). The Health Act 2006 provided the<br />
Healthcare Commission with statutory powers to enforce<br />
compliance with the Code of Practice for the Prevention<br />
and Control of Healthcare Associated Infection (The<br />
Code). The Code provides a framework for NHS Bodies<br />
to plan and implement structures and systems aimed at<br />
prevention of HCAIs. The Code sets out criteria that<br />
mandate NHS bodies, including Acute Trusts, and which<br />
ensure that patients are cared for in a clean environment.<br />
Anaesthetists should be in the forefront of ensuring<br />
that their patients are cared for in the safest possible<br />
environment. Further advice can be obtained from the<br />
Department of Health (DOH) website http://www.<br />
clean-safe-care.nhs.uk.<br />
Ó 2008 The Authors<br />
Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 1027
Infection control in anaesthesia Anaesthesia, 2008, 63, pages 1027–1036<br />
.....................................................................................................................................................................................................................<br />
3.0. General principles<br />
Healthcare providers have responsibilities under the<br />
Health and Safety at Work Act 1974; offences against<br />
the Act are covered by Criminal Law. The Control of<br />
Substances Hazardous to Health (COSHH) Regulations 1999<br />
have been considered part of the Health and Safety at Work<br />
Act; the Act ensures that Trusts are responsible for the<br />
health and safety of their employees and others (including<br />
visitors and patients), and the control and management of<br />
the risk of infection. As part of the Health Act 2006, the<br />
Department of Health (DOH) released the Code of Practice<br />
for the Prevention and Control of Healthcare Associated<br />
Infections [1].<br />
Trust Chief Executives are accountable for ensuring<br />
that care delivered within each Trust meets relevant<br />
standards. Trusts should have Infection Control Committees<br />
and Infection Control Teams responsible for<br />
preparing policies and monitoring compliance with<br />
appropriate standards. A microbiologist should be designated<br />
to provide advice on microbiological aspects of<br />
decontamination and sterilisation. The AAGBI Working<br />
Party recommends that a named consultant in each<br />
Department of Anaesthesia should liaise with the Infection<br />
Control Team and the Occupational Health Department<br />
to ensure that relevant standards are established and<br />
monitored in all areas of anaesthetic practice.<br />
The environment<br />
Hospital environmental hygiene encompasses a wide<br />
range of routine activities that are important in the<br />
prevention of HCAI. The hospital must be visibly clean<br />
and acceptable to patients, visitors and staff. Statutory<br />
requirements must be met in relation to safe disposal of<br />
clinical waste, laundry and linen. Bed occupancy should<br />
ensure enough time between patient admissions to ensure<br />
adequate cleaning and decontamination of the patient<br />
area.<br />
The Code of Practice enshrines in law the duty of<br />
Trusts to maintain a clean and appropriate environment<br />
for patients including the fabric of the building and related<br />
structures. Operating theatres and associated areas should<br />
be designed and maintained to the standards defined<br />
in Health Building Note 26, Facilities for Surgical Procedures<br />
published in 2004. Microbiological commissioning and<br />
monitoring of operating theatre suites should adhere to<br />
national recommendations.<br />
Standard precautions<br />
Anaesthetists will be involved in the care of patients who<br />
may harbour potentially pathogenic organisms, which<br />
may not be obvious or readily identifiable. Precautions<br />
aimed at preventing the transmission of organisms<br />
between patient and anaesthetist or between patients<br />
must be a routine part of anaesthetic practice.<br />
The AAGBI recommends the use of Standard Precautions,<br />
which incorporate additional safeguards for specific<br />
procedures and patients, including single-use gloves, fluid<br />
resistant masks with a transparent face shield and gowns<br />
[2]. Precautions are recommended for all patients regardless<br />
of their diagnosis or presumed infectious status and<br />
must be implemented when there is a possibility of<br />
contact with:<br />
1 Blood.<br />
2 All other body fluids.<br />
3 Non-intact skin.<br />
4 Mucous membranes.<br />
Preventative measures should be based on the likelihood<br />
of an infectious agent being present, the nature of<br />
the agent and the possibility of dispersion, e.g. splashing.<br />
A standard set of precautions should be established for<br />
every invasive procedure (see below) with additional risk<br />
assessment of each patient to determine extra and specific<br />
precautions that may be appropriate.<br />
Hand hygiene<br />
Anaesthetists must ensure that good hand hygiene becomes<br />
an indispensable part of their clinical culture<br />
Hand-mediated transmission is the major contributing<br />
factor to infection associated with healthcare [3]. Effective<br />
hand decontamination immediately before every episode<br />
of direct patient contact will result in a significant<br />
reduction in the transfer of potential pathogens and a<br />
decrease in the incidence of preventable HCAI [4].<br />
Despite consistent advice, staff often neglect hand hygiene<br />
when caring for patients.<br />
At the start of every session, and when visibly soiled or<br />
potentially contaminated, hands must be washed with<br />
liquid soap and water. When there is no soiling, the<br />
Hand Hygiene Liaison Group advocates that staff should<br />
use an antimicrobial hand rub between patients or<br />
activities [5] as this is effective and quicker. It is vital to<br />
ensure that the whole hand and fingers (particularly the<br />
tips), are exposed to the hand rub. Antimicrobial hand<br />
rub is not effective in preventing cross infection with<br />
Clostridium difficile.<br />
Trusts must ensure that sinks, soap and antimicrobial<br />
hand rubs are conveniently placed to encourage regular<br />
use. Watches and jewellery (including dress rings<br />
and wrist adornments) must be removed at the beginning<br />
of each clinical session, before regular hand decontamination<br />
begins. Cuts and abrasions must be covered with<br />
waterproof dressings, which must be changed as appropriate.<br />
Staff with dermatitis, psoriasis or other skin<br />
conditions should consult with the Occupational Health<br />
Department for further advice.<br />
Ó 2008 The Authors<br />
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Anaesthesia, 2008, 63, pages 1027–1036<br />
Infection control in anaesthesia<br />
.....................................................................................................................................................................................................................<br />
The Code of Practice states that policies should be<br />
directly tied to the clinical governance framework and<br />
regularly reviewed under a system of audit, revision and<br />
update.<br />
Gloves<br />
It is important to undertake a risk assessment regarding<br />
the safe use of gloves. Although they may offer some<br />
protection against inoculation with blood-borne viruses,<br />
incorrect use of gloves could actually spread infection<br />
between patients.<br />
Sterile gloves must be worn for invasive procedures and<br />
contact with sterile sites. Non-sterile examination gloves<br />
must be worn for contact with mucous membranes, nonintact<br />
skin and all activities that carry a risk of exposure to<br />
blood, body fluids, secretions and excretions. All blood<br />
and body fluids, substances, secretions and excretions may<br />
be considered to be potentially infective regardless of the<br />
perceived risk of the source.<br />
Gloves must be worn as single-use items. They should<br />
be put on immediately before an episode of patient<br />
contact and removed as soon as the activity is completed,<br />
and before contact with fomites, including curtains, pens,<br />
clinical notes, keyboards and telephones. Gloves should<br />
be changed between patients and between different<br />
procedures on the same patient. Gloves must be disposed<br />
of as clinical waste and hands should be washed or<br />
decontaminated following the removal of gloves. It has<br />
been demonstrated that 98% of anaesthetists’ contact with<br />
patients’ blood could be prevented by routine use of<br />
gloves [6].<br />
Gloves of an acceptable quality must be available in all<br />
clinical areas. Latex-free gloves must be available for use<br />
for staff or patients who have an allergy or sensitivity to<br />
rubber gloves.<br />
Facemasks<br />
The use of facemasks to decrease the incidence of<br />
postoperative wound infection has been questioned<br />
[7, 8]. However, masks with a face shield should be<br />
worn when there is a risk of blood, body fluids, secretions<br />
and excretions splashing into the face and eyes. Masks<br />
must also be worn by anaesthetists when carrying out a<br />
sterile procedure under full aseptic conditions (see later).<br />
If worn, masks should not be taken down to speak and<br />
should be changed if they become damp or contaminated.<br />
Masks must only be handled by the ties. Correctly fitting<br />
facemasks may also give some protection to the anaesthetist<br />
against inhaling infected droplets from the respiratory<br />
tracts of patients with infectious respiratory<br />
diseases.<br />
The Working Party is aware that the wearing of masks<br />
remains an area of contention in many Trusts and<br />
conflicting evidence may be cited [9, 10]. In view of<br />
the continuing controversy about the wearing of masks,<br />
the Working Party suggests that local protocols should be<br />
agreed about their use in hospitals.<br />
Theatre caps<br />
Theatre personnel in most UK operating theatres wear<br />
disposable headgear although there is little evidence for<br />
the effectiveness of this practice except for scrub staff in<br />
close proximity to the operating field [11]. However,<br />
theatre caps should be worn in laminar flow theatres<br />
during prosthetic implant operations, and it is the<br />
Working Party’s view that their general use should<br />
continue.<br />
Theatre suits and gowns<br />
The skin of staff working in the operating theatre is a<br />
major source of bacteria that have the potential for being<br />
dispersed into the air. Clean theatre suits should be<br />
available for all staff in theatre. Full body, fluid-repellent<br />
gowns should be worn where there is a risk of extensive<br />
splashing of blood, body fluids, secretions and excretions.<br />
Sterile gowns should be worn when invasive procedures<br />
are undertaken. Disposable plastic aprons are often worn<br />
on wards in situations where there is a risk of physical<br />
soiling of clothing in order to prevent transmission of<br />
infection between patients.<br />
Contaminated clothing should be changed and safely<br />
discarded into an appropriate receptacle at the earliest<br />
opportunity.<br />
There is little evidence to show that wearing surgical<br />
attire outside the theatre and returning to the theatre<br />
without changing increases surgical wound infection<br />
rates. With the widespread move to admission on the<br />
day of surgery, the times when anaesthetists will have to<br />
leave theatre have increased and repeated changing will<br />
impact on theatre efficiency. Local policies must be<br />
developed and reflect the necessity for ‘theatre discipline’<br />
and allay perceived concerns of patients and visitors. Local<br />
policies should be agreed between all theatre users and<br />
Trusts must ensure adequate provision of appropriate<br />
clothing. The DoH guidance on Uniforms and Workwear<br />
[12] also recognises that there is little evidence that<br />
work clothes pose a significant hazard in terms of<br />
increased infection rates.<br />
Shoes and overshoes<br />
Special footwear should be worn in the operating<br />
department and cleaned if contaminated or after every<br />
use. Trusts should ensure that a system for cleaning<br />
theatre footwear is in place in each theatre suite. Plastic<br />
overshoes may increase bacterial contamination of floors<br />
[13] and, in addition, hands become contaminated when<br />
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.....................................................................................................................................................................................................................<br />
overshoes are put on or removed. Their use is not<br />
recommended.<br />
Movement within the theatre complex<br />
To reduce airborne contamination, general traffic in and<br />
out of the operating theatre itself should be kept to a<br />
minimum. Doors should be kept closed to ensure the<br />
efficiency of the ventilation system.<br />
Moving patients on their beds into the operating<br />
theatre may increase the bacterial count on floors, but it is<br />
claimed that this is of little significance if bed linen is<br />
changed before transfer [14]. All used linen must be<br />
handled safely to minimise the risk of contamination of<br />
the environment and staff. Used bed linen must be<br />
handled with care to reduce the release of small fomite<br />
particles into the air – bed linen should be ‘bagged’ by the<br />
bed or patient trolley. The use of separate trolleys from<br />
ward to transfer area and transfer area to table has not<br />
been shown to have benefit [15] although this practice<br />
continues in many operating areas.<br />
If entering the operating theatre itself, visitors should<br />
change into theatre suits and wear designated footwear.<br />
Order of patients<br />
There should be a written hospital policy requiring<br />
accurate printed theatre lists to be available prior to the<br />
scheduled date. ‘Dirty cases’, i.e. patients likely to disperse<br />
microbes of particular risk to other patients, should be<br />
identified before surgery and theatre staff should be<br />
notified. These patients should be scheduled last on an<br />
operating list to minimise risk. Where this is not possible,<br />
the Hospital Infection Society (HIS) advises that a<br />
plenum-ventilated operating theatre should require a<br />
minimum of 15 min before proceeding to the next case<br />
after a ‘dirty’ operation [16].<br />
The most probable routes for transmission of infection<br />
between successive patients are airborne or on items and<br />
surfaces that have been in contact with the patient.<br />
Appropriate cleaning of the operating theatres between<br />
all patients should be undertaken. Whenever there is<br />
visible contamination with blood or other body materials,<br />
the area must be disinfected with sodium hypochlorite<br />
(according to local protocols) and then cleaned with<br />
detergent and water. Floors of the operating room should<br />
be disinfected at the end of each session.<br />
Safe use and disposal of sharps<br />
Accidental injury has long been recognised as an occupational<br />
hazard in the healthcare setting. Accidental<br />
inoculation with infected blood, however small in<br />
amount, presents a significant risk to anaesthetists.<br />
In the UK, 16% of occupational injuries occurring<br />
in hospitals are attributed to sharps injuries. These are<br />
predominantly caused by needles and are associated<br />
mainly with venepuncture, administration of intravenous<br />
drugs and recapping of needles. These should be<br />
preventable by adhering to national guidelines and agreed<br />
standards [17]:<br />
• Sharps must not be transferred between personnel and<br />
handling should be kept to a minimum.<br />
• Needles must not be bent or broken prior to use or<br />
disposal.<br />
• Needles and syringes must not be disassembled by hand<br />
prior to disposal.<br />
• Needles should not be recapped or resheathed.<br />
• Used sharps must be discarded into an approved sharps<br />
container at the point of use.<br />
• The sharps container should be sealed and disposed of<br />
safely by incineration when about two-thirds full or in<br />
use for more than four weeks, whichever is sooner.<br />
Sharps containers must comply with BS 7320:1990 –<br />
‘Specification for sharps’.<br />
• Blunt aspirating needles should be used for drawing up<br />
drugs.<br />
• Needle protection devices may reduce needlestick<br />
injuries but require further evaluation before widespread<br />
use can be advised.<br />
Preventing contamination of drugs<br />
Drugs and fluids require safe handling by anaesthetists,<br />
who should follow local protocols for preparation and<br />
administration to prevent contamination.<br />
Syringes and needles are sterile, single-use items and,<br />
after entry or connection to a patient’s vascular system<br />
or attachment to infusions, a syringe and needle should<br />
be considered contaminated and used only for that<br />
patient. A syringe must not be used for multiple<br />
patients even if the needle is changed. Before use,<br />
prepared syringes and needles should be stored in a<br />
clean container and syringes capped to avoid contamination.<br />
After use or at the end of the anaesthetic, all<br />
used syringes with needles should be discarded into an<br />
approved sharps container.<br />
Care must be taken when drawing up drugs. Single use<br />
ampoules should be discarded after the required amount<br />
of drug is drawn up and not re-used for subsequent<br />
patients. Ampoules can be kept for identification purposes<br />
and discarded at the end of the list. Multiple-use ampoules<br />
are not recommended.<br />
All infusions, administration sets or items in contact<br />
with the vascular system or other sterile body compartments<br />
are for single-patient use. An aseptic technique<br />
should be used when preparing infusions and breaks ⁄ taps<br />
in lines should be kept to a minimum. Injection ports<br />
should be maintained with a sterile technique, kept free<br />
of blood and covered with a cap when not in use.<br />
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.....................................................................................................................................................................................................................<br />
Connections and injection ports in intravenous lines<br />
should be kept to a minimum. Three-way taps should be<br />
avoided if practicable. Needle-free Luer injection devices<br />
should be used to cover exposed female Luer injection<br />
ports. These are easily cleaned before and after drug<br />
administration, do not harbour blood in crevices and also<br />
reduce the need for needles, resulting in a reduction of<br />
needlestick injuries.<br />
infection. ‘Guidance on Decontamination’ prepared by<br />
the MHRA and DoH provides guidelines for the safe<br />
reprocessing of medical devices [19, 20]. It is recommended<br />
that each department identifies a designated<br />
consultant who, in conjunction with the appropriate<br />
bodies in their Trust, will develop specific guidelines for<br />
anaesthetic practice which satisfy national recommendations<br />
and that these practices are audited on a regular basis.<br />
4.0. Anaesthetic equipment and infection<br />
control<br />
Items of anaesthetic equipment may become contaminated<br />
either by direct contact with patients, indirectly via<br />
splashing, by secretions or from handling by staff.<br />
Contamination is not always visible and all used pieces<br />
of equipment must be assumed to be contaminated and<br />
disposed of or, if reusable, undergo a process of decontamination.<br />
The Code of Practice has specific requirements<br />
for the decontamination of surgical equipment<br />
and other equipment used in patient care. There is a need<br />
to designate a person who is responsible for ensuring<br />
equipment cleanliness.<br />
Single-use equipment<br />
Where appropriate, single-use disposable equipment will<br />
remove the difficulties of re-use and decontamination<br />
procedures. The use of such equipment is to be encouraged.<br />
However, there are problems of cost, storage and<br />
disposal of single-patient use devices, and for some<br />
equipment there is no feasible disposable alternative.<br />
The balance between single-use items and re-usable<br />
equipment will require local determination based on an<br />
assessment of patient safety, the available facilities and cost.<br />
Packaging should not be removed until the point of use for<br />
infection control, identification, traceability in the case of<br />
a manufacturer’s recall, and safety.<br />
A multidisciplinary research team at the University of<br />
Nottingham has carried out a study investigating the use<br />
and re-use of single-use devices in English NHS operating<br />
theatres. The published paper clarified some of the issues<br />
around single-use devices such as single-use equipment<br />
that must be immediately discarded after use, e.g. suction<br />
catheters, and some that may be re-used in the same<br />
patient in the same episode, e.g. disposable laryngoscope<br />
blades [18].<br />
Decontamination<br />
Decontamination is a combination of processes including<br />
cleaning, disinfection and ⁄ or sterilisation used to make a<br />
re-usable item safe to be handled by staff and safe for<br />
further use on patients. Effective decontamination of<br />
re-usable devices is essential in reducing the risk of<br />
Decontamination processes<br />
Cleaning – removal of foreign material from an item.<br />
This usually involves washing with a detergent to remove<br />
contamination followed by rinsing and drying. All<br />
organic debris, e.g. blood, tissue or body fluids, must be<br />
removed before disinfection or sterilisation, as its presence<br />
will inhibit disinfectant or sterilant from contacting<br />
microbial cells. Cleaning before sterilisation is of the<br />
utmost importance in the effectiveness of decontamination<br />
procedures in reducing the risk of transmission of<br />
prions.<br />
Low Level Disinfection – kills most vegetative bacteria<br />
(except TB and endospores), some fungi and some viruses<br />
using disinfectants such as sodium hypochlorite, 70%<br />
alcohol and chlorhexidine.<br />
High Level Disinfection – kills vegetative bacteria (not<br />
all endospores), fungi and viruses. With sufficient contact<br />
time (often several hours), these high level disinfectants<br />
may produce sterilisation, e.g. the use of aldehydes,<br />
peracetic acid and chlorine dioxide.<br />
Sterilisation – A process used to render an object free<br />
from viable micro-organisms, including all bacteria,<br />
spores, fungi and viruses, with techniques such as<br />
autoclaving (but see prions later).<br />
Risk assessment<br />
The choice of equipment and ⁄ or the level of cleanliness<br />
⁄ disinfection ⁄ sterility required of re-usable items may<br />
be assessed against the risk posed to patients of transmission<br />
of infection during any procedure in which the<br />
equipment is employed. It has been proposed by the<br />
MHRA Microbiology Advisory Committee that three<br />
levels should be considered:<br />
1 High Risk – the device will penetrate skin or<br />
mucous membranes, enter the vascular system or a<br />
sterile space – these devices require sterilisation.<br />
2 Intermediate Risk – the device will be in contact<br />
with intact mucous membranes or may become<br />
contaminated with readily transmissible organisms –<br />
these devices require high level disinfection or<br />
sterilisation.<br />
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3 Low Risk – the device contacts intact skin or does not<br />
contact patient directly – these devices require low<br />
level disinfection or cleaning.<br />
Infection control policy<br />
Anaesthetic face masks<br />
Although normally in contact with intact skin, these<br />
items are frequently contaminated by secretions from<br />
patients and have been implicated in causing crossinfection<br />
[21]; local disinfection is not normally effective<br />
. These items should be single-use items or should<br />
be sterilised between patients by an audited Sterile<br />
Supplies Department in accordance with the manufacturer’s<br />
instructions.<br />
Airways and tubes<br />
Oral airways, nasal airways and tracheal tubes should be<br />
of single-use type since they readily become contaminated<br />
with transmissible organisms [22] and blood [23].<br />
Ideally, supraglottic airways should be of the singlepatient<br />
use type but the re-usable design is in common<br />
use and many anaesthetists perceive it as being less<br />
traumatic. Therefore, a supraglottic airway designed for<br />
repeated use should be sterilised (in an audited SSD) no<br />
more often than the manufacturer recommends. A<br />
supraglottic airway used for tonsillectomy or adenoidectomy<br />
should not be used again (see section on Prion<br />
Diseases). The AAGBI recommends single-use supraglottic<br />
airways.<br />
Catheter mounts – angle pieces<br />
It is recommended that these items are single-patient use<br />
type.<br />
Anaesthetic breathing systems<br />
The AAGBI has previously recommended that ‘an<br />
appropriate filter should be placed between the patient<br />
and the breathing circuit (a new filter for each patient)’.<br />
Although it appears that pleated hydrophobic filters<br />
have a better filtration performance than most electrostatic<br />
filters, the clinical relevance of this has yet to be<br />
established [24, 25]. The MHRA have also warned of the<br />
difficulty in assessing the performance of breathing filters<br />
in MDA ⁄ 2004 ⁄ 013.<br />
Until 2001 manufacturers of disposable anaesthetic<br />
breathing circuits supplied these as non-reusable items. In<br />
practice, most UK departments of anaesthesia used these<br />
circuits for more than one patient or for more than one<br />
operating session in conjunction with the use of a new<br />
filter for each patient. In 2006, the MHRA re-emphasised<br />
in Devices Bulletin DB 2006(04) the clinical and legal<br />
implications of re-use of devices labelled for single use and<br />
the AAGBI firmly supports their recommendations.<br />
Therefore, departments may follow the manufacturer’s<br />
recommendations for use for up to 7 days. However, to<br />
ensure consistency in the infection control process, the<br />
Working Party recommends that circuits are disposed of<br />
when the anaesthetic machine and monitors are cleaned<br />
(see below). The AAGBI recommends that anaesthetic<br />
circuits are routinely changed on a daily basis. If<br />
visibly contaminated or used for highly infectious cases,<br />
e.g. tuberculosis, the circuits should be changed between<br />
patients and safely discarded. No attempt should be made<br />
to reprocess these items.<br />
Anaesthetic machines<br />
Routine daily sterilisation or disinfection of internal<br />
components of the anaesthetic machine is not necessary if<br />
a bacterial ⁄ viral filter is used between patient and circuit.<br />
However, manufacturers’ cleaning and maintenance policies<br />
should be followed, and bellows, unidirectional<br />
valves and carbon dioxide absorbers should be cleaned<br />
and disinfected periodically. All the surfaces of anaesthetic<br />
machines and monitors should be cleaned on a daily basis<br />
with an appropriate disinfectant or immediately if visibly<br />
contaminated.<br />
Laryngoscopes<br />
As with anaesthetic facemasks, laryngoscopes are known<br />
to become contaminated during use. Current practices<br />
for decontamination and disinfection between<br />
patients are frequently ineffective, leaving residual<br />
contamination that has been implicated as a source of<br />
cross-infection [26, 27]. Blades are also regularly<br />
contaminated with blood [28], indicating penetration<br />
of mucous membranes, which places these items into a<br />
high-risk category. Proper cleaning of laryngoscope<br />
blades is of great importance before decontamination<br />
⁄ sterilisation, particularly of residue around light<br />
sources or articulated sections. New purchases should<br />
be of a design that is easy to clean. Although repeated<br />
autoclaving may affect the function of laryngoscopes<br />
[29], the Working Party recommends that re-usable<br />
laryngoscope blades should be sterilised by an audited<br />
SSD between patients, following the manufacturers’<br />
instructions. Plastic sheaths may be used to cover blades<br />
and handles to reduce contamination but it has been<br />
noted, especially with blade covers, that these have<br />
created difficulties during tracheal intubation.<br />
There are an increasing number of inexpensive, singleuse<br />
laryngoscope blades and handles of improving design<br />
available, and their use is to be encouraged. The choice of<br />
blade must be dictated by Departments of Anaesthesia.<br />
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Traditional blades should be available at all times in case<br />
difficulty is encountered.<br />
Laryngoscope handles also become contaminated with<br />
micro-organisms and blood during use, and they should<br />
be washed ⁄ disinfected and, if suitable, sterilised by SSDs<br />
after every use. The knurled handles of laryngoscopes<br />
cannot be cleaned reliably manually if covered in blood or<br />
body fluids.<br />
Anaesthetists should show great care when handling<br />
laryngoscopes: wear gloves during intubation and place<br />
used instruments in a designated receptacle to prevent<br />
contamination of surfaces, pillows and drapes.<br />
Fibreoptic bronchoscopes<br />
These are expensive items which cannot be autoclaved.<br />
Decontamination is dependent on sufficient contact time<br />
with high level disinfectants and it is particularly important<br />
that the washing and cleaning process removes all<br />
tissue residues from the lumens. Decontamination is best<br />
achieved with an automated system. National guidelines<br />
for care of these instruments have been provided by the<br />
MDA, now the MHRA, DoH and NHS Estates [18, 30,<br />
31, and 32].<br />
With the uncertainty of the future implications of<br />
variant Creutzfeld Jakob Disease (CJD), these items<br />
should have a unique identifier which should be recorded<br />
at every use to permit future tracing.<br />
Bougies<br />
Re-use of these items has been associated with crossinfection<br />
[33]. Manufacturers recommend that a gum<br />
elastic bougie may be disinfected up to five times between<br />
patients and stored in a sealed packet. It is preferable that<br />
alternative single-use intubation aids are employed when<br />
possible.<br />
Surfaces<br />
The surfaces of anaesthetic machines and monitoring<br />
equipment, especially those areas which are likely to<br />
have been touched by the gloved hand that has been in<br />
contact with blood or secretions, should be regarded as<br />
contaminated and should be cleaned at the earliest<br />
opportunity, probably between patients. Local policies<br />
should be in place to ensure that all equipment that<br />
touches intact skin, or does not ordinarily touch the<br />
patient at all, is cleaned with a detergent at the end<br />
of the day or whenever visibly contaminated. This<br />
includes non-invasive blood pressure cuffs and tubing,<br />
pulse oximeter probes and cables, stethoscopes,<br />
electrocardiographic cables, blood warmers etc., and<br />
the exterior of anaesthetic machines and monitors.<br />
Items such as temperature probes should be for single<br />
patient use.<br />
Oxygen masks and tubing<br />
Single-patient use products should be used.<br />
Resuscitation equipment<br />
Single-patient use equipment should be kept in a sealed<br />
package or should be resterilised between patients<br />
according to the manufacturer’s instructions. All training<br />
equipment should be handled similarly.<br />
5.0. Prion diseases<br />
Transmissible Spongiform Encephalopathies (TSEs) are a<br />
group of illnesses in which there is progressive neurological<br />
degeneration associated with characteristic pathological<br />
changes. TSEs are caused by abnormal prions,<br />
which are infectious proteins. Microscopic traces of<br />
tissue often remain on surgical instruments after washing<br />
and autoclaving or disinfecting and any prion protein in<br />
these traces could still transmit the disease if inoculated<br />
into another patient. However, successive washing after<br />
use reduces the concentration so that, after about 10<br />
decontamination cycles, infectivity becomes negligible<br />
[34].<br />
Variant Creutzfeldt-Jakob disease (vCJD) is a TSE<br />
caused by the same prion protein that causes Bovine<br />
Spongiform Encephalopathy (BSE) in cattle. After an<br />
incubation period of several years, the disease shows itself<br />
as a progressive degeneration of the brain leading to<br />
death. It is similar to sporadic CJD, which has been spread<br />
by neurosurgical instruments, dura mater grafts and<br />
pituitary extracts. However, while sporadic CJD prion<br />
protein is to be found only in brain, spinal cord and<br />
posterior eye, the prion protein of vCJD can also be<br />
found in lymph nodes, appendix and tonsils. Prion<br />
protein becomes detectable in tissues in the later period<br />
of incubation and is present in higher concentrations once<br />
the disease becomes manifest [34]. Advice on the<br />
detection and prevention of prion diseases is available<br />
from the Advisory Committee on Dangerous Pathogens<br />
(ACDP), the Spongiform Encephalopathy Advisory<br />
Committee (SEAC) and the National Institute for Health<br />
and Clinical Excellence [35]. The CJD Incidents Panel<br />
Advice advises on the prevention of transmission of CJD<br />
in specific cases [36, 37].<br />
Tonsillectomy and adenoidectomy<br />
Lymphoid tissue, including that of the adenoid and tonsil,<br />
is of ‘medium infectivity’ for vCJD and it is possible that a<br />
patient undergoing surgery could be incubating this<br />
disease. Surgeons routinely operate with traceable reusable<br />
instruments in accord with latest national advice,<br />
since single-use instruments were associated with excessive<br />
bleeding and risks of CJD transfer are low [38].<br />
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Tracheal tubes, supraglottic airways and oral airways<br />
should be destroyed after use for these operations as they<br />
can be contaminated by infectious tissue and batch<br />
cleaning may cause transfer of protein from one device<br />
to another [39].<br />
Theoretically, a laryngoscope blade used at the end of<br />
surgery or for emergency re-intubation could become<br />
contaminated. However, the Working Party’s estimate is<br />
that the risk is extremely small and probably less than<br />
those posed by the use of a disposable laryngoscope for<br />
what could be a difficult laryngoscopy. Therefore, the<br />
recommendation is that single-use laryngoscopes are<br />
not mandatory in anaesthesia for tonsil and adenoid<br />
surgery. Those purchasing laryngoscopes with single-use<br />
blades (and other single-use devices) have a responsibility<br />
to ensure that the performance of the instruments is at<br />
least as good as that of the standard reusable alternatives.<br />
Anaesthetic management of cases of CJD<br />
This advice covers known cases, suspected cases and those<br />
who are at risk of developing CJD. Isolation is not<br />
needed. Standard (‘universal’) precautions are essential.<br />
Blood and other samples should be labelled ‘Biohazard’.<br />
Invasive procedures such as central venous cannulation<br />
and spinal anaesthesia mandate the use of full aseptic<br />
procedures, including mask and eye protection. The area<br />
around where invasive procedures are performed should<br />
be clear enough to allow easy mopping of spillages. High<br />
infectivity tissues are those in the brain, spinal cord and<br />
posterior eye; medium risk tissues for CJD are those in the<br />
anterior eye and olfactory epithelium – any needles or<br />
probes used by anaesthetists near these tissues will be<br />
disposable. In vCJD, lymphoid tissue is also classed as<br />
having medium infectivity. In these circumstances, it is<br />
advisable that any laryngoscope used after the tonsil has<br />
been operated on or any bronchoscope used for biopsy on<br />
patients in this group should be treated as potentially<br />
contaminated. These instruments should either be<br />
destroyed (easily done with single-use laryngoscopes) or<br />
should be quarantined pending advice. Such advice can<br />
be obtained from the CJD Incidents Panel.<br />
Transmission of vCJD by transfusion of blood<br />
and blood products<br />
Although only three cases have been discovered, this is<br />
the only route of transfer of vCJD as yet shown to be<br />
from medical interventions. The National Blood Transfusion<br />
Service repeatedly updates its procedures so as to<br />
reduce the tiny risk of transfer of prions, viruses and<br />
bacteria [40]. Procedures include leucodepletion and<br />
sourcing most plasma products from outside the UK.<br />
Anaesthetists can further decrease the risk by minimising<br />
the use of blood and blood products.<br />
Summary: how to reduce the risk of transmission<br />
of prion disease<br />
1 Adherence to the same universal precautions as for<br />
other potential infections.<br />
2 Minimising the use of transfusion of blood and blood<br />
products.<br />
3 Use of SSD decontamination and sterilisation with<br />
tracing for all reusable equipment.<br />
4 Ensuring that any instrument that contacts the brain,<br />
spinal cord or dura is destroyed afterwards.<br />
5 The employment of single-use equipment when this is<br />
as reliable and safe as the re-usable alternatives.<br />
6 Destroying or quarantining instruments used on cases<br />
who may have CJD and for those known to be at risk.<br />
7 Ensuring that all airway devices used during tonsillectomy<br />
and adenoidectomy are discarded after use.<br />
6.0. Infection control precautions for<br />
anaesthetic procedures<br />
Carrying out procedures in an operating theatre does not<br />
pose a lower risk of infection than other hospital locations<br />
and the risk of infection depends on the procedure and on<br />
the level of barrier protection rather than the surrounding<br />
environment [41].<br />
Maximal barrier precautions<br />
Maximal barrier precautions involve full hand washing,<br />
the wearing of sterile gloves and gown, a cap, mask and<br />
the use of a large sterile drape [42]. The skin entry site<br />
should be cleaned with an alcoholic chlorhexidine<br />
gluconate solution or alcoholic povidone-iodine solution<br />
[43]. The antiseptic should be allowed to dry before<br />
proceeding.<br />
Certain invasive anaesthetic procedures require this<br />
optimum aseptic technique:<br />
• Insertion of central venous catheters.<br />
• Spinal, epidural and caudal procedures.<br />
The Working Party is aware that many anaesthetists do<br />
not employ this level of asepsis for ‘one-shot’ spinals or<br />
epidurals but believes that, when central neural spaces are<br />
penetrated, full aseptic precautions are required.<br />
Comprehensive guidelines have been prepared for<br />
insertion and maintenance of central venous catheters<br />
[44] and are commended to all anaesthetists. The use of<br />
care bundles has been advocated by IHI (Institute of<br />
Health Improvement) to reduce catheter related bacteraemias.<br />
Originally developed in the USA, Care Bundles<br />
is an approach that systematically appraises clinical<br />
processes. It is based on measuring the actual provision<br />
of therapeutic interventions according to standards,<br />
informed by evidence, which local clinicians set themselves<br />
[45].<br />
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Other barrier precautions<br />
Certain invasive procedures do not require full barrier<br />
precautions as above but nevertheless demand appropriate<br />
aseptic techniques. Such precautions involve the wearing<br />
of sterile gloves and use of small drapes, although similar<br />
attention is required to hand washing and skin preparation.<br />
These procedures include:<br />
• Peripheral regional blocks.<br />
• Arterial line insertion.<br />
Peripheral venepuncture or intramuscular injection in<br />
low-risk patients will involve handwashing, non-sterile<br />
gloves and skin preparation with propyl alcohol. Peripheral<br />
intravenous catheters are a significant source of<br />
nosocomial bacteraemias and care is required.<br />
High-risk patients<br />
Certain patients may be especially vulnerable to infection,<br />
e.g. the immunocompromised, or offer particularly high<br />
risk of transmitting infection, e.g. tuberculosis and HIV.<br />
For the immunocompromised, maximal barrier precautions<br />
are required for all invasive procedures and similarly,<br />
where there is a high infection risk, staff should concentrate<br />
not only on preventing cross-infection between<br />
patients but in protecting themselves by ensuring compliance<br />
with all precautions.<br />
7.0. References<br />
1 DoH The Health Act 2006. Code of Practice for the Prevention<br />
and Control of Health Care Associated Infections.<br />
2 National Association of Theatre Nurses. Universal Precautions<br />
and Infection Control in the Peri-Operative Setting. Harrogate:<br />
NATN, 1997.<br />
3 Stone SP, Teare L, Cookson BD. The evidence for hand<br />
hygiene. Lancet 2001; 357: 479–80.<br />
4 Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a<br />
hospital wide programme to improve compliance with hand<br />
hygiene. Lancet 2000; 356: 1307–12.<br />
5 Teare L, Cookson B, Stone S. Hand hygiene. British Medical<br />
Journal 2001; 323: 411–12.<br />
6 Kristensen M, Sloth E, Jensen TK. Relationship<br />
between anaesthetiprocedure and contact of anesthesia<br />
personnel with patient body fluids. Anesthesiology 1990; 73:<br />
619–24.<br />
7 Orr NW. Is a mask necessary in the operating theatre? Annals<br />
of the Royal College of Surgeons of England 1981; 63: 390–2.<br />
8 Mitchell NJ, Hunt S. Surgical face masks in modern<br />
operating rooms – a costly and unnecessary ritual? Journal of<br />
Hospital Infection 1991; 18: 239–42.<br />
9 McLure HA, Tallboys CA, Yentis SM, Azadian BS. Surgical<br />
face masks and downward disposal of bacteria. Anaesthesia<br />
1998; 53: 624–6.<br />
10 Philips BJ, Ferguson S, Armstrong P, Anderson P, Anderson<br />
FM, Wildsmith JAW. Surgical face masks are effective in<br />
reducing bacterial contamination caused by dispersal from<br />
the upper airway. British Journal of Anaesthesia 1992; 69:<br />
407–8.<br />
11 Humphreys H, Russell AJ, Marshall RJ, Ricketts VE, Reeves<br />
DS. The effect of surgical theatre headgear on bacterial counts.<br />
Journal of Hospital Infection 1991; 19: 175–80.<br />
12 DoH Uniforms and Workwear. An Evidence Base for<br />
Developing Local Policy, Department of Health, 2007.<br />
13 Humphreys H, Marshall RJ, Ricketts UE, Russell AJ,<br />
Reeves DG. Theatre overshoes do not reduce operating<br />
theatre floor bacterial counts. Journal of Hospital Infection 1991;<br />
17: 117–23.<br />
14 Litsky BY, Litksy W. Bacterial shedding during bedstripping<br />
of reusable and disposable linens as detected by the<br />
high volume air sampler. Health Laboratory Science 1971; 8:<br />
29–34.<br />
15 Lewis DA, Weymond G, Nokes CM, et al. A bacteriological<br />
study of the effect on the environment of using a one or two<br />
trolley system in theatre. Journal of Hospital Infection 1990; 15:<br />
35–53.<br />
16 Hospital Infection Society: Behaviours and Rituals in the<br />
Operating Theatre – A Report from the Hospital Infection Society<br />
Working Group on Infection Control in Operating Theatres.<br />
Hospital Infection Society, 2002.<br />
17 Health Service Advisory Committee. Safe disposal of clinical<br />
waste. Sheffield HSE, 1999; 68.<br />
18 Rowley E, Dingwall R. The use of single-use devices in<br />
anaesthesia: balancing the risks to patient safety. Anaesthesia<br />
2007; 62: 569–74.<br />
19 Sterilisation, disinfection and cleaning of medical equipment.<br />
Guidance on decontamination from the Microbiology<br />
Advisory Committee to Department of Health Medical<br />
Devices Agency MDA. London 2002, 2005, 2006.<br />
20 NHS Decontamination Programme. Department of Health<br />
(UK). http://www.dh.gov.uk/en/Managingyourorganisation/<br />
Leadershipandmanagement/Healthcareenvironment/<br />
NHSDecontaminationProgramme/index.htm (accessed 15<br />
July 2008).<br />
21 MacCallum FO, Noble WC. Disinfection of anaesthetic face<br />
masks. Anaesthesia 1960; 15: 307.<br />
22 Miller DH, Youkhana I, Karunaratne WU, Pearce A. Presence<br />
of protein deposits on cleaned re-usable anaesthetic equipment.<br />
Anaesthesia 2001; 56: 1069–72.<br />
23 Chrisco JA, Devane G. A descriptive study of blood in the<br />
mouth following routine oral endotracheal intubation.<br />
Journal of American Association of Nurse Anesthetists 1992; 60:<br />
379–83.<br />
24 Wilkes AR. Breathing system filters. British Journal of<br />
Anaesthesia. CEPD Review. 2002; 2: 151–4.<br />
25 Wilkes AR, Benbough JE, Speight SE, Harmer M.<br />
The bacterial and viral filtration performance of breathing<br />
system filters. Anaesthesia 2002; 55: 458–65.<br />
26 Ballin MS, McCluskey A, Maxwell S, Spilsbury S.<br />
Contamination of laryngoscopes. Anaesthesia 1999; 54:<br />
1115–6.<br />
27 Esler MD, Baines LC, Wilkinson DJ, Langford RM.<br />
Decontamination of laryngoscopes: a survey of national<br />
practice. Anaesthesia 1999; 54: 587–92.<br />
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28 Phillips RA, Monaghan WP. Incidence of visible and<br />
occult blood on laryngoscope blades and handles. Journal<br />
of American Association of Nurse Anesthetists 1997; 65: 241–6.<br />
29 Bucx MJ, Veldman DJ, Beenhakker MM, Koster R. The<br />
effect of steam sterilisation at 134°C on light intensity<br />
provided by fibrelight Macintosh laryngoscopes. Anaesthesia<br />
1999; 54: 875–8.<br />
30 Device Bulletin DB2002 (05) Decontamination of<br />
Endoscopes. London: MDA, 2002.<br />
31 Transmissible spongiform encephalopathy agents: safe<br />
working and the prevention of infection, annex F<br />
(Decontamination of endoscopes, amended 2005). Advisory<br />
Committee of Dangerous Pathogens and Spongiform<br />
Encephalopathy Advisory Committee. http://www.<br />
advisorybodies.doh.gov.uk/acdp/tseguidance/index.htm<br />
(accessed 15 July 2008).<br />
32 HTM 2030, Washer Disinfectors. London: NHS Estates, 1997.<br />
The Stationary Office.<br />
33 Jerwood DC, Mortiboy D. Disinfection of gum elastic<br />
bougies. Anaesthesia 1995; 50: 376.<br />
34 Transmissible spongiform encephalopathy agents. safe<br />
working and the prevention of infection. Guidance from the<br />
(updated website): http://www.advisorybodies.doh.gov.uk/<br />
acdp/tseguidance/index.htm (accessed 15 July 2008).<br />
35 Patient safety and the reduction of risk of transmission of<br />
Creutzfeldt-Jakob disease (CJD) via interventional procedures.<br />
National Institute for Health and Clinical Excellence<br />
interventional procedure guidance 196, available via the<br />
NICE website: http://www.nice.org.uk (accessed 15 July<br />
2008).<br />
36 Health Protection Agency CJD Panel: information and<br />
advice. http://www.hpa.org.uk/infections/topics_az/cjd/<br />
incidents_panel.htm (accessed 15 July 2008).<br />
37 CJD Incidents Panel Fifth Annual Report to the<br />
Advisory Committee on Dangerous Pathogens on Transmissible<br />
Spongiform Encephalopathies (2006): website as<br />
above.<br />
38 Re-introduction of Re-usable instruments for tonsil surgery.<br />
Press release from the UK Department of Health, 14<br />
December 2001.<br />
39 Richards E, Brimacombe J, Laupau W, Keller C. Protein<br />
cross-contamination during batch cleaning and autoclaving<br />
of the ProSeal TM laryngeal mask airway. Anaesthesia 2006;<br />
61: 431–3.<br />
40 Current information from the UK and Scottish blood<br />
transfusion services. http://www.blood.co.uk/hospitals/<br />
library and http://www.scotblood.co.uk (accessed 15 July<br />
2008).<br />
41 Pearson ML Hospital Infection Control Practices Advisory<br />
Committee. Guidelines for prevention of intravascular<br />
device related infections. Infection Control and Hospital<br />
Epidemiology 1994; 15, 227–30.<br />
42 Fletcher SJ, Bodenham AR. Catheter-related sepsis:<br />
an overview. British Journal of Intensive Care 1999; 9: 74–80.<br />
43 Maki DG, Ringer M, Alvacado CJ. Prospective<br />
randomised trial of providone-iodine, alcohol, and<br />
chlorhexidine for prevention of infection associated with<br />
central venous and arterial catheters. Lancet 1991; 338:<br />
339–43.<br />
44 Pratt RJ, Pellowe C, Loveday HP, et al. The Epic Project –<br />
Guidelines for preventing infections associated with the<br />
insertion and maintenance of central venous catheters. Journal<br />
of Hospital Infection 2001; 47: (Suppl) S47–67.<br />
45 Implement the central line bundle. http://www.ihi.org/<br />
IHI/Topics/CriticalCare/IntensiveCare/Changes/<br />
ImplementtheCentralLineBundle (accessed 15 July 2008).<br />
Ó 2008 The Authors<br />
1036 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY<br />
Telephone: 020 7631 1650<br />
Fax: 020 76314352<br />
E-mail: info@aagbi.org<br />
Website: www.aagbi.org
AAGBI SAFETY GUIDELINE<br />
Immediate Post-anaesthesia Recovery 2013<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
21 Portland Place, London, W1B 1PY<br />
Telephone 020 7631 1650 Fax 020 7631 4352<br />
info@aagbi.org<br />
www.aagbi.org March 2013
This guideline was originally published in Anaesthesia.<br />
If you wish to refer to this guideline, please use the following<br />
reference:<br />
Association of Anaesthetists of Great Britain and Ireland.<br />
Immediate Post-anaesthesia Recovery 2013. Anaesthesia<br />
2013; 68: pages 288-97.<br />
This guideline can be viewed online via the following URL:<br />
http://onlinelibrary.wiley.com/doi/10.1111/anae.12146/abstract
Guidelines<br />
Immediate post-anaesthesia recovery 2013<br />
Association of Anaesthetists of Great Britain and<br />
Ireland<br />
Membership of the Working Party: D. K. Whitaker (Chair),<br />
H. Booth, 3 P. Clyburn, W. Harrop-Griffiths, H. Hosie, 1<br />
B. Kilvington, 3 M. MacMahon, P. Smedley 2 and R. Verma 4<br />
1 Scottish Multiprofessional Anaesthetic Assistants Development Group<br />
2 British Anaesthetic and Recovery Nurses Association<br />
3 College of Operating Department Practitioners<br />
4 Royal College of Anaesthetists<br />
Summary<br />
1 After general, epidural or spinal anaesthesia, all patients should be<br />
recovered in a specially designated area (henceforth ‘post-anaesthesia<br />
care unit’, PACU) that complies with the standards and recommendations<br />
described in this document.<br />
2 The anaesthetist must formally hand over the care of a patient to<br />
an appropriately trained and registered PACU practitioner.<br />
3 Agreed, written criteria for discharge of patients from the PACU to<br />
the ward should be in place in all units.<br />
4 An effective emergency call system must be in place in every PACU<br />
and tested regularly.<br />
Re-use of this article is permitted in accordance with the Creative Commons Deed,<br />
Attribution 2.5, which does not permit commercial exploitation.<br />
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5 No fewer than two staff (of whom at least one must be a registered<br />
practitioner) should be present when there is a patient in a PACU<br />
who does not fulfil the criteria for discharge to the ward.<br />
6 All registered practitioners should be appropriately trained in accordance<br />
with the standards and competencies detailed in the UK<br />
National Core Competencies for Post Anaesthesia Care.<br />
7 All patients must be observed on a one-to-one basis by an anaesthetist<br />
or registered PACU practitioner until they have regained control<br />
of their airway, have stable cardiovascular and respiratory systems<br />
and are awake and able to communicate.<br />
8 All patients with tracheal tubes in place in a PACU should be monitored<br />
with continuous capnography. The removal of tracheal tubes<br />
is the responsibility of the anaesthetist.<br />
9 There should be a specially designated area for the recovery of children<br />
that is appropriately equipped and staffed.<br />
10 All standards and recommendations described in this document<br />
should be applied to all areas in which patients recover after anaesthesia,<br />
to include those anaesthetics given for obstetric, cardiology,<br />
imaging and dental procedures, and in psychiatric units and community<br />
hospitals. Only registered PACU practitioners who are<br />
familiar with these areas should be allocated to recover patients in<br />
them as and when required.<br />
11 Patients’ dignity and privacy should be respected at all times but<br />
patients’ safety must always be the primary concern.<br />
12 When critically ill patients are managed in a PACU because of bed<br />
shortages, the primary responsibility for the patient lies with the<br />
hospital’s critical care team. The standard of nursing and medical<br />
care should be equal to that in the hospital’s critical care units.<br />
13 Audit and critical incident reporting systems should be in place in<br />
all PACUs.<br />
....................................................................................................<br />
This is a consensus document produced by expert members of a Working<br />
Party established by the Association of Anaesthetists of Great Britain and<br />
Ireland (AAGBI). It has been seen and approved by the AAGBI Council.<br />
Accepted: 7 December 2012<br />
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• What other guideline statements are available on this topic?<br />
This guidance replaces previous guidelines issued by the Association<br />
of Anaesthetists of Great Britain and Ireland (AAGBI) published in<br />
2002 [1]. European guidance was published in 2009 [2].<br />
•<br />
Why was this guideline developed?<br />
The AAGBI Council decided to update its previous guidance as part<br />
of the AAGBI’s process of regular review of its guidelines, in the<br />
light of recent developments and advances.<br />
•<br />
How and why does this statement differ from existing guidelines?<br />
The guideline uses the widely used term ‘post-anaesthesia care unit’<br />
(PACU) to refer to all areas that would formerly have been called<br />
‘recovery rooms’. The guideline recommends that all PACU staff<br />
should be trained to nationally recognised standards and be familiar<br />
with relevant safeguarding/child protection procedures as appropriate,<br />
and that all patients with tracheal tubes in place in PACUs<br />
should be monitored with continuous capnography. These recommendations<br />
align this guideline with other recent guidance on these<br />
and related topics.<br />
In 1985, the AAGBI published recommendations for the improvement<br />
and management of recovery facilities in hospitals. These were<br />
updated in 1993 and 2002 [1]. However, many changes in practice,<br />
workload, expectations and staff training have occurred in the last<br />
10 years, and the recommendations in this new document reflect these<br />
changes.<br />
Another change that has taken place in this time is the use of the<br />
term PACU in some hospitals as an abbreviation for ‘post-anaesthesia<br />
care unit’ and in others, post-anaesthesia recovery unit (PARU). This<br />
document primarily considers care delivered in the immediate postoperative<br />
period and will use the term PACU to refer to all areas that<br />
would formerly have been called ‘recovery rooms’.<br />
Every patient undergoing general anaesthesia or central neuraxial<br />
blockade for surgery should be recovered in a designated area as<br />
described in this document. These recommendations are not concerned<br />
with those patients recovering from sedation, as guidelines with respect<br />
to this area of practice have been published separately [3].<br />
The PACU facility<br />
As the number and complexity of surgical procedures have increased,<br />
immediate postoperative care has developed from a brief period of<br />
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observation in a convenient area near the operating theatre suite to a<br />
more prolonged and active period of monitoring and intervention in a<br />
specifically designed clinical environment.<br />
The NHS Estates Agency of the Department of Health issues regulations<br />
and guidelines with respect to the design and building of hospitals<br />
and their facilities. Health Building Note (HBN) 26 refers to operating<br />
departments, and includes advice on the design of PACUs [4]. Other<br />
factors involved in design include guidance on fire precautions (Health<br />
Technical Memoranda, Fire Practice Notes), operational management<br />
(Health Guidance Notes), specialised building systems (Health Technical<br />
Memoranda), engineering services (Model Engineering Specifications),<br />
contracts and commissioning (Concode) and recommendations on<br />
energy, water and waste [4, 5].<br />
The PACU should be in a central position within the theatre complex<br />
enabling ease of access from the operating theatre but with a separate<br />
outside access for transfer of patients to the ward. Health Building<br />
Note 26 relates the size of a PACU to the number of operating theatres<br />
served, e.g. a recovery area for a typical department of eight theatres<br />
would have 16 bays, 12 of 13.5 m 2 and four larger ones of 26 m 2 [4].<br />
However, it recognises that the size and number of beds should also<br />
reflect the number of cases per session and the average time spent in<br />
the PACU. The ratio of PACU beds to operating theatres should not be<br />
less than two. The bed spaces should allow unobstructed access for trolleys,<br />
x-ray equipment, resuscitation carts and clinical staff. The facility<br />
should be open-plan, allowing each recovery bay to be observed but<br />
with the provision of curtains for patient privacy. The PACU should be<br />
mechanically ventilated, as the environment is potentially polluted by<br />
anaesthetic gases. Other facilities should include storage areas for equipment,<br />
a dirty utility room, a secure supply of drugs, easy access to sinks<br />
and space for information technology equipment and clerical activities.<br />
All PACU bed spaces should have 12 electrical socket outlets (six<br />
each side of the bed), one oxygen pipeline outlet, one medical air outlet,<br />
two vacuum outlets, an adjustable examination light, a push-button<br />
emergency call system, and physiological monitors with a display screen<br />
and recording system for patient data [6]. An exhaled gas scavenging<br />
system must be available for the occasional use of an anaesthetic<br />
machine. The dećor should provide an attractive ambiance and, if possible,<br />
windows should be present. Lighting should not be harsh and<br />
should comply with recommended standards [4]. Local lighting to assist<br />
clinical examination must also be available. Noise levels should be kept<br />
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as low as possible and the ceiling should be sound absorbent. Good<br />
communication systems linking PACU staff with the operating theatres,<br />
wards and other clinical facilities are essential. An effective emergency<br />
call system must be in place, with alarm and telephone or intercom<br />
links to operating theatres and rest areas. All members of staff must be<br />
aware of this system and it should be tested at least weekly. At least two<br />
separate landline telephones are recommended to facilitate both incoming<br />
and outgoing calls during incidents, as in all important clinical<br />
areas.<br />
There should be access to a staff rest area near to, but outside, the<br />
immediate recovery area. Other facilities should include toilets, showers,<br />
clean duty clothes and secure storage for personal possessions. Patient<br />
and staff safety should be assured by appropriate security systems, especially<br />
at night.<br />
Monitoring, equipment and drugs<br />
An appropriate standard of monitoring should be maintained until the<br />
patient is fully recovered from anaesthesia [6]. Clinical observation<br />
should therefore be supplemented as in the operating theatre by a minimum<br />
of pulse oximetry, non-invasive blood pressure monitoring, ECG<br />
and, if patients’ tracheas remain intubated or they have their airways<br />
maintained with a supraglottic or other similar airway device, continuous<br />
capnography [7, 8]. Difficult airway equipment [9], a nerve stimulator<br />
for assessing neuromuscular blockade, a thermometer and patient<br />
warming devices should be immediately available. It is recommended<br />
that there should be full compatibility between operating theatre, PACU<br />
and ward monitoring equipment.<br />
All drugs, equipment, fluids and algorithms required for resuscitation<br />
and management of anaesthetic and surgical complications should<br />
be immediately available. Consideration should be given to providing<br />
dedicated trolleys or carts for this purpose.<br />
PACU staff<br />
No fewer than two staff (of whom at least one must be a registered<br />
practitioner) should be present when there is a patient in the PACU<br />
who does not fulfil the criteria for discharge to the ward. Staffing numbers<br />
should allow one-to-one observation of every patient by an anaesthetist,<br />
registered PACU practitioner or other properly trained member<br />
of staff until they have regained airway control, respiratory and cardiovascular<br />
stability, and are able to communicate. In addition, there<br />
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should be an anaesthetist who is supernumerary to requirements in the<br />
operating theatres immediately available for patients in PACU. There<br />
should be a consultant anaesthetist lead for the PACU appointed, with<br />
appropriate time allocated in his/her job plan [10], and dedicated anaesthetic<br />
sessions in the PACU should be considered in large, busy units.<br />
The provision of a satisfactory quality of care during recovery from<br />
anaesthesia and surgery relies heavily on investment in the education<br />
and training of PACU staff. Maintenance of standards requires continuous<br />
updating, e.g. resuscitation skills, new airway techniques and<br />
advances in pain management. Regular team rehearsal of emergency<br />
scenarios should be considered. PACU staff are specialist and often play<br />
a key role in the education of others, including theatre staff, ward-based<br />
nurses, midwives and trainee doctors.<br />
All specialist staff should have received appropriate training to<br />
nationally recognised standards such as the UK National Core Competencies<br />
for Post-anaesthesia Care [11]. Training should be tailored to<br />
meet the needs of the individual staff member and the PACU, but practical<br />
training and maintenance of skills must supplement theoretical<br />
knowledge. At all times, at least one member of staff present should be<br />
a certified Acute Life Support (ALS) provider and, for children, hold an<br />
appropriate paediatric life support qualification. All staff should be<br />
encouraged to attain and maintain at least one such life support qualification,<br />
e.g. ALS, APLS, PLS, PILS.<br />
Continued professional development and the training of other staff<br />
is facilitated by activities such as the establishment of lead practitioners<br />
in certain areas, e.g. pain relief, life support, infection control, paediatrics,<br />
liaison with ward staff, health and safety matters, and training cocoordination.<br />
PACUs should consider rotation of duties with the local<br />
high dependency units (HDUs) and intensive care units (ICUs), an<br />
audit programme, educational posters, journal clubs and tutorials.<br />
Specialist PACU staff normally work as part of a team in large<br />
PACUs attached to main operating theatre suites, but many hospitals<br />
have isolated PACUs, e.g. for obstetrics, cardiac catheter laboratories<br />
and facilities for electroconvulsive therapy, which may only be used<br />
intermittently, although sometimes for high-risk patients. Patient safety<br />
considerations dictate that patients recovering in these environments<br />
should only be cared for by registered PACU practitioners who are<br />
members of the hospital’s core PACU team and who are familiar with<br />
these areas and allocated to work in them as and when required.<br />
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Transfer and handover of care to the PACU team<br />
The transfer of patients from the operating theatre to the PACU and<br />
elsewhere has been considered in two publications by the AAGBI [6,<br />
12]. Before transfer, the anaesthetist should be satisfied that the PACU<br />
staff are competent and able to take responsibility for the patient. If this<br />
cannot be assured, the anaesthetist should stay with the patient, either<br />
in the operating theatre or the PACU, until the patient is fit to return<br />
to the ward. It is essential that the anaesthetist formally hands over care<br />
of the patient to an appropriately trained and registered PACU practitioner.<br />
Formal handover checklists can improve the safety of handovers<br />
and should be developed for local use.<br />
The patient should be physiologically stable on departure from the<br />
operating theatre, and the anaesthetist must decide on the extent of<br />
monitoring during transfer. This will depend on factors such as proximity<br />
to the PACU, the patient’s level of consciousness and both respiratory<br />
and cardiovascular status. If the PACU is not immediately adjacent<br />
to the operating theatre, or if the patient’s condition is poor, adequate<br />
mobile monitoring is required, i.e. a minimum of pulse oximetry and<br />
non-invasive blood pressure, ECG and capnography if the trachea is intubated,<br />
with the immediate availability of a nerve stimulator, and a<br />
means of measuring body temperature [6]. The anaesthetist is responsible<br />
for ensuring that this transfer is accomplished safely. Supplemental<br />
oxygen should be administered to all patients during transfer unless the<br />
patient did not receive supplemental oxygen during surgery. All lines<br />
should be flushed to remove any residual anaesthetic drugs if necessary<br />
and checked to be patent, adequately secured and protected. Details of<br />
any difficulties experienced during intubation or other relevant procedures<br />
should be included in the handover [9].<br />
Management of patients in the PACU<br />
Patients must be observed on a one-to-one basis by an anaesthetist, registered<br />
PACU practitioner or other properly trained member of staff<br />
until they have regained airway control, respiratory and cardiovascular<br />
stability, and are able to communicate. This recommendation is paramount<br />
and must be observed, even if it causes delay in the throughput<br />
of patients. All PACUs must be staffed to a level that allows this to be<br />
routine practice, even at times of peak activity. Life-threatening complications<br />
may occur during this period [13], and failure to provide adequate<br />
care may prove catastrophic for patients, their relatives and the<br />
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Table 1 Minimum information to be recorded for patients in the postanaesthesia<br />
care unit.<br />
• Level of consciousness<br />
• Patency of the airway<br />
• Respiratory rate and adequacy<br />
• Oxygen saturation<br />
• Oxygen administration<br />
• Blood pressure<br />
• Heart rate and rhythm<br />
• Pain intensity on an agreed scale<br />
• Nausea and vomiting<br />
• Intravenous infusions<br />
• Drugs administered<br />
• Core temperature<br />
• Other parameters depending on circumstances, e.g. urinary output, central<br />
venous pressure, expired CO 2 , surgical drainage volume.<br />
staff involved, and may have serious medicolegal consequences. Patients<br />
must be kept under clinical observation at all times, and all measurements<br />
should be recorded, preferably by an automatic recording system<br />
networked with theatre systems. The frequency of observations will<br />
depend upon the stage of recovery, the nature of the surgery and clinical<br />
condition of the patient. The frequency of the observations and the<br />
quality of record keeping should not be influenced by staffing levels.<br />
Certain information should be recorded as a minimum (Table 1).<br />
For all patients, the National Patient Safety Agency (NPSA) recommended<br />
dataset of their last name, first name, date of birth and NHS<br />
number [14] should be recorded in that order, together with their time<br />
of admission, time of fitness for discharge, time of discharge and destination<br />
in a central register.<br />
Pain, nausea and vomiting<br />
No patient should be returned to the ward until control of postoperative<br />
nausea and vomiting and pain is satisfactory. All PACU staff should be<br />
specifically trained in the management of patients with patient-controlled<br />
analgesia, epidurals, spinals and peripheral nerve blockade. Nurse administration<br />
of intravenous analgesics, e.g. paracetamol, non-steroidal<br />
anti-inflammatory drugs (NSAIDs) and opioids prescribed by the anaesthetists<br />
as part of a specific protocol, facilitates rapid and flexible pain<br />
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control. Such protocols should incorporate precise instructions on the<br />
administration of the drugs and the recognition and management of their<br />
side-effects. Nurse administration of intravenous opioids should not occur<br />
unless there is the immediate availability of an anaesthetist. All syringes<br />
containing drugs should be clearly labelled.<br />
Tracheal tubes and other airway devices<br />
On many occasions, patients will be handed over to the PACU nurse with<br />
a laryngeal mask airway or other supraglottic airway device in place. The<br />
nurse must be specifically trained in the management of these patients<br />
and in the removal of the airway device. An anaesthetist should be immediately<br />
available to assist if problems occur while the airway device is in<br />
place or when it is removed by a qualified member of the PACU staff.<br />
The incidence of upper airway obstruction that may lead to postobstructive<br />
pulmonary oedema and severe hypoxia can be minimised by<br />
the use of oropharyngeal airways, bite blocks, airway devices incorporating<br />
them or similar devices [9].<br />
The removal of tracheal tubes from patients in the PACU is the<br />
responsibility of the anaesthetist, who may delegate the removal to an<br />
appropriately trained member of the PACU team who is prepared to<br />
accept this responsibility.<br />
Discharge from the PACU<br />
Every PACU should have well-defined minimum criteria for fitness for<br />
the discharge of patients to the general ward or other clinical areas<br />
(Table 2).<br />
Discharge from the PACU is the responsibility of the anaesthetist<br />
but the adoption of strict discharge criteria allows this to be delegated<br />
to PACU staff. If the discharge criteria are not met, the patient should<br />
remain in the PACU and the anaesthetist should be informed. An<br />
anaesthetist must be available at all times when a patient who has not<br />
reached the criteria for discharge is present in the PACU. Patients who<br />
have potential airway problems or complications should be reassessed<br />
by the responsible anaesthetist before discharge from the PACU [9].<br />
If there is any doubt as to whether a patient fulfils the criteria, or if<br />
there has been a problem during the recovery period, the anaesthetist<br />
who gave the anaesthetic (or another anaesthetist with special duties in<br />
the PACU) must assess the patient. After medical assessment, patients<br />
who do not fulfil the discharge criteria may be transferred to an appropriate<br />
HDU or ICU.<br />
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Table 2 Minimum criteria for discharge of patients from the postanaesthesia<br />
care unit.<br />
• The patient is fully conscious, able to maintain a clear airway and has protective<br />
airway reflexes<br />
• Breathing and oxygenation are satisfactory<br />
• The cardiovascular system is stable, with no unexplained cardiac irregularity<br />
or persistent bleeding. The specific values of pulse and blood pressure<br />
should approximate to normal pre-operative values or be at an acceptable<br />
level, ideally within parameters set by the anaesthetist, and peripheral perfusion<br />
should be adequate<br />
• Pain and postoperative nausea and vomiting should be adequately controlled,<br />
and suitable analgesic and anti-emetic regimens prescribed<br />
• Temperature should be within acceptable limits [15]. Patients should not<br />
be returned to the ward if significantly hypothermic<br />
• Oxygen therapy should be prescribed if appropriate<br />
• Intravenous cannulae should be patent, flushed if necessary to ensure<br />
removal of any residual anaesthetic drugs and intravenous fluids should be<br />
prescribed if appropriate<br />
• All surgical drains and catheters should be checked<br />
• All health records should be complete and medical notes present.<br />
Handing over to ward staff<br />
Patients should be transferred to the ward accompanied by two members<br />
of staff, at least one of whom should be suitably trained. The anaesthetic<br />
record, together with the recovery and prescription charts, must<br />
accompany the patient and clearly indicate to the ward staff the details<br />
of relevant drugs administered in theatre and PACU, e.g. analgesics and<br />
antibiotics. The PACU nurse must ensure that full clinical details are<br />
relayed to the ward nurse, with particular emphasis on ongoing problems<br />
and the management of infusions. Local policies should be developed<br />
for the safe handover of infusion devices and syringe pumps, e.g.<br />
the collecting ward nurse checking and signing for the pump settings.<br />
Formal handover checklists can improve the safety of handovers and<br />
should be developed for local use.<br />
Local anaesthesia and regional anaesthesia<br />
The principles of management of any patient undergoing local anaesthesia,<br />
either alone or in addition to general anaesthesia, are the same as<br />
for any other patient. Information given on handover to PACU staff<br />
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should include the site and type of local block, drug, dosage, time of<br />
administration and anticipated duration of action. Instructions for ward<br />
staff should include further pain relief and any particular positional<br />
requirements for the patient. Information for the patient includes the<br />
anticipation of return of sensation and motor function, care with hot<br />
and cold items and weight-bearing.<br />
Considerations after spinal and epidural anaesthesia include noting<br />
the level of analgesia achieved, the time and dose of drug administered,<br />
cardiovascular status, bladder care, details of any continuous infusions,<br />
degree of motor block and the time of anticipated motor and sensory<br />
recovery. Many of these considerations apply also to plexus blocks and<br />
major nerve trunk blocks. All PACU staff should be trained in the recognition<br />
and management of local anaesthetic toxicity and have immediate<br />
access to a supply of Intralipid [16].<br />
Children<br />
Children have special needs reflecting fundamental psychological, anatomical<br />
and physiological differences from adults. These needs are best<br />
met by having a designated, separate paediatric recovery area that is<br />
child-friendly and staffed by nurses trained in the recovery of babies,<br />
children and young people. The area should be kept warm to prevent<br />
hypothermia and provision should be made for a parent or carer to<br />
rejoin the child in the recovery area as soon as they are awake [17].<br />
All staff working in PACU should be familiar with the relevant procedures<br />
and personnel if there are Safeguarding or Child Protection<br />
concerns that arise whilst the child is in theatre [18, 19].<br />
Equipment must include a full range of sizes of facemasks, breathing<br />
systems, airways, nasal prongs and tracheal tubes. Essential monitoring<br />
equipment includes a full range of paediatric non-invasive blood<br />
pressure cuffs and small pulse oximeter probes. Capnography should<br />
also be available.<br />
All drugs, equipment, fluids required for paediatric resuscitation<br />
and other emergencies should be immediately available. Consideration<br />
should be given to providing a separate dedicated paediatric<br />
trolley for this purpose. Guidelines and commonly used algorithms<br />
for paediatric emergencies should be readily available and regularly<br />
rehearsed.<br />
Children are more likely to become restless or disorientated after<br />
surgery and require one-to-one supervision throughout their PACU<br />
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stay. Provision should be made to protect a child from injury in this situation<br />
by supplying washable cot or bed protectors. Postoperative vomiting,<br />
bradycardia and laryngeal spasm are more common. The latter<br />
can result in major life-threatening desaturation, as infants and small<br />
children become hypoxaemic 2–3 times more quickly than adults.<br />
Children should not be denied adequate pain relief because of a fear<br />
of side-effects. It can be difficult to assess pain, especially in the pre-verbal<br />
child. However, suitable techniques are available and protocols for<br />
pain management in children should be readily available [20, 21]. When<br />
intravenous and epidural analgesic drugs are given to babies and children,<br />
systems must be in place to double-check doses, which may be<br />
less familiar if used infrequently.<br />
Before discharge from the PACU, the need to ensure that the dead<br />
space of all intravenous cannulae is flushed and patent is particularly<br />
important in children [22].<br />
Patients’ perspective<br />
The written information given to patients before their admission to hospital<br />
should explain the purpose and nature of the PACU. Anaesthesia<br />
and Anaesthetists: Information for Patients and their Relatives published<br />
by the Royal College of Anaesthetists and the AAGBI is an example of<br />
this [23]. Information for children and young people of all ages about<br />
anaesthesia is also available [24].<br />
Although the design of recovery facilities is, by necessity, open-plan, there<br />
should be provision for patients’ privacy and dignity, e.g. curtains. However,<br />
safety considerations override their use during resuscitation and the management<br />
of other crises. If other awake patients are also present in the PACU,<br />
curtains should only be closed around the awake patients and not the patient<br />
who is being resuscitated. Most patients find PACUs unpleasant, and they<br />
should be transferred out as soon as discharge criteria are met.<br />
Staff in some hospitals may require access to interpreters and translators<br />
to facilitate communication with non-English speaking patients.<br />
Anaesthesia and recovery in special areas<br />
Anaesthesia is often administered in areas such as obstetric, x-ray, cardiology,<br />
dental and psychiatric units, and in community hospitals. All<br />
standards and guidelines described in this document must be completely<br />
fulfilled at any site in which anaesthesia is administered and immediate<br />
postanaesthesia recovery planned.<br />
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Critically ill patients<br />
The primary goal of a PACU is to provide postoperative patients with<br />
the optimum standard of care during the initial period of their recovery<br />
from anaesthesia and surgery. During times of bed or staff shortages in<br />
critical care areas, and because of the resources available, PACUs are<br />
occasionally used for the contingency management of and delivery of<br />
care to critically ill patients [25]. During such times, it must be recognised<br />
that the primary responsibility for the patient lies with the consultant<br />
in charge of the ICU and his/her team. An ICU-trained nurse must<br />
care for the patient on a one-to-one basis, with immediate access to<br />
senior ICU nursing assistance. The standard of medical and nursing<br />
care should be equal to that within the ICU, and a specific action plan<br />
should be formulated by the critical care team to facilitate discharge to<br />
a more appropriate area as soon as possible. The delivery of critical care<br />
in a PACU for longer than 4 h should trigger the collection of a Critical<br />
Care Minimum Data Set (CCMDS) [25]. There should be a mechanism<br />
in place for PACU personnel either to collect this data set or to request<br />
its collection.<br />
End of life care in the PACU<br />
Occasionally, a patient who is expected to die imminently will be taken<br />
to the PACU. The patient should be managed according to an endof-life<br />
care pathway, in isolation from others who should ideally be<br />
unaware of the situation. Relatives must be able to be present and a<br />
dedicated nurse should be available [26].<br />
Audit and quality control in the PACU<br />
The recording of key quality and outcome data from all patients passing<br />
through the PACU should be routine for all hospitals [27]. The data<br />
recorded from PACU patients should be compared with national and<br />
local benchmarks with the express aim of improving and maintaining<br />
the quality of pre-, intra- and postoperative care, and measuring compliance<br />
with national standards. The AAGBI recommends that a minimum<br />
dataset should be recorded for all patients admitted to a PACU<br />
(Table 3). In addition to these, some PACUs may wish to record data<br />
relating to patients’ satisfaction with their care in the PACU.<br />
Some of these data should be available from Trust and Health<br />
Board IT systems, and resources should be made available to integrate<br />
these systems with recording of PACU data to facilitate PACU data<br />
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Table 3 Minimum dataset to be recorded for all patients admitted to a<br />
post-anaesthesia care unit.<br />
• Last name, first name, date of birth and NHS number<br />
• Gender<br />
• ASA physical status<br />
• Surgical procedure performed<br />
• Names of anaesthetist and surgeon<br />
• Type of anaesthesia<br />
• Time of admission<br />
• Core temperature on admission to the PACU<br />
• Incidence and severity of postoperative nausea and vomiting<br />
• Severity of pain experienced in the PACU<br />
• Analgesia given in the PACU<br />
• Time of fitness for discharge from the PACU<br />
• Time of discharge from the PACU<br />
• Complications<br />
entry, storage and interpretation. Information derived from this data collection<br />
should be analysed and fed back to anaesthetists and theatre teams<br />
in a way that will allow individuals and teams to compare their performance<br />
with others. Interpretation of these data by experienced anaesthetists<br />
is important, and both patients’ characteristics and the nature of the<br />
surgery should be taken into account before conclusions are drawn. Local<br />
clinical governance arrangements will usually require discussion of any<br />
incidents at regular multidisciplinary PACU team meetings.<br />
In addition to these data, there should be a list of adverse incidents<br />
that should be recorded and fed into a clinical governance programme<br />
that records and disseminates the incidence of adverse incidents, and<br />
can investigate individual incidents if appropriate. These might include:<br />
Cardiopulmonary arrest<br />
Major airway complications<br />
Death<br />
Severe pain that is difficult to treat<br />
Prolonged stay (> 2h)<br />
Significant hypothermia (< 35 °C)<br />
Need to call an anaesthetist to review a patient<br />
•<br />
Need for ventilatory support (CPAP, tracheal intubation, lung ventilation)<br />
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• Need for cardiovascular support (inotropes, vasoconstrictors, anti-arrhythmics)<br />
Return to the operating theatre before discharge from PACU<br />
• Inadequate reversal of neuromuscular blocking drugs.<br />
Reports of such incidents should be accompanied by clinical information<br />
that will allow further analysis.<br />
The PACU is also a useful area in which to monitor compliance<br />
with Trust initiatives that seek to improve patient care and safety. These<br />
might include:<br />
Compliance with WHO checklist performance<br />
Administration of antibiotics<br />
Thrombo-embolic prophylaxis<br />
Compliance with analgesic and anti-emetic protocols<br />
•<br />
Completion of postoperative instructions relating to oxygen therapy,<br />
pain therapy, fluid management, wound and drain management,<br />
restarting of oral intake and other elements of early postoperative care.<br />
Competing interests<br />
DKW is a Past President of the AAGBI and is currently Chairman of<br />
the European Board of Anaesthesiology Safety Committee, and a member<br />
of the European Board of Anaesthesiology/European Society of Anaesthesiology<br />
Patient Safety Task Force. No external funding or<br />
competing interests declared.<br />
Acknowledgement<br />
The Working Party is very grateful to Dr K. Wilkinson for providing<br />
help and advice, particularly on the care of children.<br />
References<br />
1. Association of Anaesthetists of Great Britain & Ireland. Immediate Postanaesthetic<br />
Recovery. London: AAGBI, 2002.<br />
2. Vimlatia L, Gilsanzb F, Goldikc Z. Quality and safety guidelines of postanaesthesia<br />
care Working Party on Post Anaesthesia Care (approved by the European Board and<br />
Section of Anaesthesiology, Union Europeénne des Médecins Spećialistes). European<br />
Journal of Anaesthesiology 2009; 26: 715–21.<br />
3. Royal College of Anaesthetists. Implementing and Ensuring Safe Sedation Practice<br />
for Healthcare Procedures in Adults. http://www.rcoa.ac.uk/system/files/PUB-<br />
SafeSedPrac.pdf (accessed 03/12/2012).<br />
4. NHS Estates. Health Building Note 26, Facilities for Surgical Procedures: volume 1.<br />
London: The Stationery Office, 2004.<br />
© 2013 The Association of Anaesthetists of Great Britain and Ireland 15
Anaesthesia 2013<br />
Whitaker et al. | Guidelines: Immediate post-anaesthesia recovery<br />
5. Health Facilities Scotland. Scottish Health Planning Note 00-07: Resilience Planning<br />
for the Healthcare Estate. http://www.hfs.scot.nhs.uk/publications/1253180726-<br />
SHPN%2000-07%20Final.pdf (accessed 03/12/2012).<br />
6. Association of Anaesthetists of Great Britain and Ireland. Recommendations for<br />
Standards of Monitoring During Anaesthesia and Recovery. http://www.aagbi.org/<br />
sites/default/files/standardsofmonitoring07.pdf (accessed 03/12/2012).<br />
7. Association of Anaesthetists of Great Britain and Ireland. AAGBI safety statement:<br />
the use of capnography outside the operating theatre. http://www.aagbi.org/<br />
sites/default/files/Safety%20Statement%20-%20The%20use%20of%20capnography%20outside%20the%20operating%20theatre%20May%202011_0.pdf<br />
(accessed<br />
03/12/2012).<br />
8. European Section and Board of Anaesthesiology UEMS. EBA Recommendation for<br />
the Use of Capnography. http://www.eba-uems.eu/resources/PDFS/EBA-UEMS-recommendation-for-use-of-Capnography.pdf<br />
(accessed 03/12/2012).<br />
9. Royal College of Anaesthetists. Major Complications of Airway Management in the<br />
UK, 4th National Audit Project. http://www.rcoa.ac.uk/system/files/CSQ-NAP4-<br />
Full.pdf (accessed 03/12/2012).<br />
10. Association of Anaesthetists of Great Britain and Ireland. Guidance on the 2003<br />
(New) Contract and Job Planning for Consultant Anaesthetists. http://www.aagbi.<br />
org/sites/default/files/jobplanning05.pdf (accessed 03/12/2012).<br />
11. Association of Anaesthetists of Great Britain and Ireland. UK National Core Competencies<br />
for Post-anaesthesia Care. http://www.aagbi.org/sites/default/files/corecompetencies2013.pdf<br />
(in press).<br />
12. Association of Anaesthetists of Great Britain and Ireland. The Anaesthesia Team 3.<br />
London: AAGBI, 2010 http://www.aagbi.org/sites/default/files/anaesthesia_<br />
team_2010_0.pdf (accessed 03/12/2012).<br />
13. Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from<br />
the anaesthetic incident monitoring study (AIMS). Anaesthesia 2002; 57: 1060–6.<br />
14. NHS. Guidance on the Standard for Patient Identifiers for Identity Bands. http://<br />
www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60136&type=full&-<br />
servicetype=Attachment (accessed 03/12/2012).<br />
15. National Institute for Health and Clinical Excellence. Management of Inadvertent<br />
Perioperative Hypothermia in Adults. http://www.nice.org.uk/CG065 (accessed<br />
03/12/2012).<br />
16. Association of Anaesthetists of Great Britain and Ireland. Management of Severe<br />
Local Anaesthetic Toxicity. http://www.aagbi.org/sites/default/files/la_toxicity_<br />
2010_0.pdf (accessed 03/12/2012).<br />
17. Royal College of Anaesthetists. Guidance on the Provision of Paediatric Anaesthetic<br />
Services. http://www.rcoa.ac.uk/system/files/CSQ-GPAS8-Paeds_0.pdf (accessed<br />
03/12/2012).<br />
18. Royal College of Anaesthetists. Child Protection and the Anaesthetist: Safeguarding<br />
Children in the Operating Theatre. http://www.rcoa.ac.uk/system/files/PUB-Child-<br />
Protection.pdf (accessed 03/12/2012).<br />
19. Royal College of Anaesthetists. Safeguarding Children and Young People: Roles and<br />
Competencies for Health Care Staff. http://www.rcoa.ac.uk/system/files/PUB-Safeguarding-Children_0.pdf<br />
(accessed 03/12/2012).<br />
16 © 2013 The Association of Anaesthetists of Great Britain and Ireland
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20. Royal College of Nursing. The Recognition and Assessment of Acute Pain in Childhood.<br />
http://www.rcn.org.uk/__data/assets/pdf_file/0004/269185/003542.pdf<br />
(accessed 03/12/2012).<br />
21. Association of Paediatric Anaesthetists. Good Practice in Post-operative and Procedural<br />
Pain. http://www.apagbi.org.uk/sites/default/files/APA%20Guideline%<br />
20part%201.pdf (accessed 03/12/2012).<br />
22. NHS. Residual anaesthetic drugs in cannulae. http://www.nrls.npsa.nhs.uk/<br />
resources/type/signals/?entryid45 = 65333 (accessed 03/12/2012).<br />
23. Royal College of Anaesthetists. Anaesthesia Explained: Information for Patients and<br />
their Relatives. http://www.rcoa.ac.uk/system/files/PI-AE-2008.pdf (accessed 03/<br />
12/2012).<br />
24. Royal College of Anaesthetists. Information for Children and Parents. http://<br />
www.rcoa.ac.uk/node/429 (accessed 03/12/2012).<br />
25. Royal College of Nursing. Standards for Contingency Management and Delivery of<br />
Critical Care in a Post Anaesthesia Care Unit (PACU). http://www.rcn.org.uk/<br />
__data/assets/pdf_file/0010/351784/003842.pdf (accessed 03/12/2012).<br />
26. Marie Curie Palliative Care Institute. Liverpool Care Pathway for the Dying Patient.<br />
http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/ (accessed 03/12/2012).<br />
27. Royal College of Anaesthetists. Audit Recipe Book, Section 3: Post-operative Care.<br />
https://www.rcoa.ac.uk/system/files/CSQ-ARB2012-SEC3.pdf (accessed 03/12/<br />
2012).<br />
© 2013 The Association of Anaesthetists of Great Britain and Ireland 17
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
www.aagbi.org
The Royal College of<br />
Anaesthetists<br />
The Association of<br />
Anaesthetists of Great<br />
Britain and Ireland<br />
The Good Anaesthetist<br />
Standards of Practice for Career Grade Anaesthetists<br />
February 2010
The Royal College<br />
of Anaesthetists<br />
The Association of<br />
Anaesthetists of<br />
Great Britain and<br />
Ireland<br />
The Good Anaesthetist<br />
Standards of Practice for Career Grade Anaesthetists<br />
Prepared by the Joint Committee on Good Practice<br />
ISBN: 978-1-900936-00-2<br />
Published February 2010 by the Royal College of Anaesthetists.<br />
Design and layout by the Royal College of Anaesthetists.<br />
This publication will be reviewed in 2011.<br />
© The Royal College of Anaesthetists 2010<br />
All rights reserved. No part of this framework may be reproduced or transmitted in any<br />
form or by any means, electronic or mechanical, including photocopying, recording or any<br />
information storage or retrieval system without prior permission of the Royal College of<br />
Anaesthetists.<br />
Whilst the Royal College of Anaesthetists has endeavoured to ensure that the document is<br />
as current as possible at the time it was published, it can take no responsibility for matters<br />
arising from circumstances which may have changed, or information which may become<br />
available subsequently.<br />
All enquiries in regard to this document should be addressed to:<br />
Professional Standards Directorate<br />
The Royal College of Anaesthetists<br />
Churchill House<br />
35 Red Lion Square<br />
London WC1R 4SG<br />
email: standards@rcoa.ac.uk<br />
Page 1
Contents ❚<br />
Foreword 4<br />
Introduction 5<br />
Notes on terminology 6<br />
Related guidelines and sources of information 7<br />
Domain A: knowledge, skills and performance<br />
Attribute 1: maintain your professional performance 8<br />
Attribute 2: apply knowledge and experience to practice 10<br />
Attribute 3: keep clear, accurate and legible records 12<br />
Domain B: safety and quality<br />
Attribute 4: put into effect systems to protect patients and improve care 14<br />
Attribute 5: respond to risks to safety 16<br />
Attribute 6: protect patients and colleagues from any risk posed by your health 18<br />
Domain C: communication, partnership and teamwork<br />
Attribute 7: communicate effectively 20<br />
Attribute 8: work constructively with colleagues and delegate effectively 22<br />
Attribute 9: establish and maintain partnerships with patients 24<br />
Domain D: maintaining trust<br />
Attribute 10: show respect for patients 26<br />
Attribute 11: treat patients and colleagues fairly and without discrimination 28<br />
Attribute 12: act with honesty and integrity 30<br />
Prepared by the Joint Committee on Good Practice | Page 3
Foreword ❚<br />
This document represents the distillation of many previous publications related to the standards<br />
of practice expected of clinicians delivering anaesthesia. These standards have been mapped<br />
to the generic standards in the Framework for Appraisal and Assessment published by the<br />
General Medical Council (GMC) in 2008. In this document they defined four domains and three<br />
attributes in each domain. There are then standards within each attribute, 75 in all, which every<br />
doctor with a licence to practise must meet.<br />
Our specialty standards must, and indeed do, map to all of these 75 generic standards but<br />
also include those that effectively define the current practice of anaesthesia. They have been<br />
ratified by the Joint Committee on Good Practice (JCGP) of the Royal College of Anaesthetists<br />
(RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) and will be regularly<br />
reviewed and updated as necessary.<br />
It is these specialty specific standards that we have submitted to the GMC and which will<br />
underpin all aspects of revalidation for anaesthetists. At first glance they appear daunting, but<br />
in practice they simply describe activities we all do, and which are usually reviewed in annual<br />
appraisal. It is worth taking some time to compare what information we each have to support<br />
our claim to meet these standards (usually in our appraisal documents) and therefore identify<br />
where we might be sensible to gather more supporting information (or ‘evidence’) before our<br />
next appraisal.<br />
Acknowledgements<br />
We are extremely grateful to the many individuals who have contributed their time in preparing<br />
the original document and those who assisted in the revisions for this new document. In<br />
particular, we wish to thank Professor David Hatch and Dr Maria Rollin in their role as primary<br />
authors; Mr Charlie McLaughlan (Director of Professional Standards), Mr Don Liu (Revalidation<br />
Project Manager), Dr Judith Hulf CBE (Revalidation Lead, Academy of Medical Royal Colleges),<br />
Dr Kirstyn Shaw (Revalidation Manager, Academy of Medical Royal Colleges) for their input; and,<br />
finally, Councils for both the RCoA and AAGBI, the JCGP and the RCoA Patient Liaison Group for<br />
their help in assisting with the revisions.<br />
Professor C Dodds<br />
RCoA Revalidation Lead<br />
February 2010<br />
Page 4 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Introduction ❚<br />
The Good Anaesthetist has been compiled to set standards for career grade anaesthetists working<br />
in hospital settings within and/or outside of the NHS. It provides a structured framework detailing<br />
the minimum standards that anaesthetists are expected to meet. In particular, the framework can<br />
be used to reflect on practice and identify knowledge areas, skills and attitudes for professional<br />
development. The Good Anaesthetist also underpins the revalidation process for the specialty. It<br />
maps a number of generic and specialty standards to the 12 attributes, as set out in the GMC<br />
Framework for Appraisal and Assessment (2008), which anaesthetists are required to demonstrate<br />
they are continuing to meet through supporting information and during annual appraisal.<br />
The Good Anaesthetist is also intended for use by patients, to provide an informed understanding<br />
of the standards that can be reasonably expected from a competent career grade anaesthetist.<br />
The list of standards is not intended to be exhaustive, but to indicate the range of knowledge,<br />
skills and attitudes in the pattern of practice expected of a career grade anaesthetist. The<br />
standards that are generic to all doctors are drawn principally from Good Medical Practice (2006)<br />
and can be found in the GMC Framework for Appraisal and Assessment. These generic standards<br />
have been incorporated into The Good Anaesthetist and have been supplemented by standards<br />
agreed by the JCGP of the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists<br />
of Great Britain and Ireland (AAGBI). The vast majority listed have been defined as the essential<br />
minimum standards. Anaesthetists who repeatedly fail to conform to the minimum standards<br />
without good and sufficient reason may place their licence to practise at risk during the<br />
revalidation process.<br />
Within each attribute we have grouped the standards according to a shared identifiable<br />
characteristic, i.e. a knowledge, skill, attitude or function area. No one individual standard<br />
should be given a greater degree of importance, including the standard at the beginning of<br />
each group. The groups are a practical way to help anaesthetists approach revalidation in an<br />
organised and focused manner. Anaesthetists will be required to collect supporting information<br />
in each attribute and consideration of standards, when grouped together according to a shared<br />
characteristic, will provide focus for this activity.<br />
Good practice in anaesthesia is dependent not only on the knowledge levels, skills and attitudes<br />
of the individual but also on co-operation from organisations – in particular, in the provision of<br />
adequate resources and time. All anaesthetists should bring to the attention of their employing<br />
organisations any deficiency in resources which impacts on meeting the standards listed in The<br />
Good Anaesthetist and which subsequently influence the quality of medical care and patient safety.<br />
Prepared by the Joint Committee on Good Practice | Page 5
Notes on terminology ❚<br />
The standards listed in The Good Anaesthetist are derived from Good Medical Practice (2006) and<br />
from the work carried out by the JCGP. In Good Medical Practice the terms ‘you must’ and ‘you<br />
should’ are used and the same convention is applied throughout The Good Anaesthetist.<br />
■ ■<br />
■ ■<br />
■ ■<br />
‘An anaesthetist must’ – is used for an overriding duty or principle.<br />
‘An anaesthetist should’ – is used when providing an explanation of how that overriding duty<br />
is to be met.<br />
‘An anaesthetist should’ – is also used where a duty or principle will not apply in all situations<br />
or circumstances, or where there are factors outside your control that affect whether you can<br />
comply with the guidance.<br />
‘Ensure’ is used where anaesthetists must do all that is within their control to make sure that the<br />
event takes place.<br />
Page 6 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Related guidelines and sources of information ❚<br />
We have provided references to other guidance to illustrate how the standards in The Good<br />
Anaesthetist can be interpreted and applied in practice. References are placed within the<br />
appropriate attribute, although many of the guidelines cited cover a number of issues and are<br />
applicable to several attributes.<br />
For the sake of brevity we have not cited the following high level good practice guidelines<br />
because they are applicable to all 12 attributes. It is therefore worth referring to the following:<br />
The General Medical Council<br />
››<br />
Good medical practice, 2006.<br />
The Royal College of Anaesthetists and The Association of Anaesthetists of<br />
Great Britain and Ireland<br />
››<br />
Good practice: a guide for departments of anaesthesia, critical care and pain<br />
management (3rd edition), 2006.<br />
The Royal College of Anaesthetists<br />
››<br />
Guidelines for the provision of anaesthetic services (3rd edition), 2009.<br />
The Royal College of Anaesthetists and The Pain Society<br />
››<br />
Pain management services: good practice, 2003.<br />
The guidelines referenced in The Good Anaesthetist have been developed by the GMC, RCoA<br />
or AAGBI. We have only listed those which are currently active. There are a number of other<br />
guidance documents produced by professional bodies including the specialist societies, which<br />
may be relevant to your job plan and professional practice. These guidelines should be referred<br />
to as they may also illustrate how the standards in The Good Anaesthetist can be applied. The Good<br />
Anaesthetist will be made available online as a web based resource. As we develop this area of<br />
work we will include links to the full text of all relevant guidance documents as they are published.<br />
Prepared by the Joint Committee on Good Practice | Page 7
Domain A: knowledge, skills and performance<br />
Attribute 1: maintain your professional performance<br />
Standards<br />
➣➣<br />
An anaesthetist must maintain knowledge of the law and other regulation relevant to<br />
their practice.<br />
❏❏<br />
An anaesthetist must adhere to the laws and codes of practice relevant to their work.<br />
➣➣<br />
An anaesthetist must keep knowledge and skills up to date.<br />
❏❏<br />
An anaesthetist should regularly update relevant knowledge and skills in relation<br />
to clinical practice to comply with core, higher and advanced level requirements of<br />
continuing professional development (CPD).<br />
❏❏<br />
An anaesthetist should regularly update relevant knowledge and skills in relation to<br />
wider clinical practice.<br />
❏❏<br />
An anaesthetist should learn and practise new improved techniques for patient<br />
wellbeing and safety.<br />
➣➣<br />
An anaesthetist must participate in professional development and educational<br />
activities.<br />
❏❏<br />
An anaesthetist should formulate a personal development plan.<br />
❏❏<br />
An anaesthetist should attend hospital and departmental educational meetings.<br />
❏❏<br />
An anaesthetist should seek opportunities to learn from colleagues locally and<br />
elsewhere.<br />
❏❏<br />
An anaesthetist should retain records of CPD activities to support the revalidation<br />
process.<br />
❏❏<br />
An anaesthetist must be truthful in recording CPD activities.<br />
➣➣<br />
An anaesthetist must take part in regular and systematic audit.<br />
❏❏<br />
An anaesthetist should participate actively in departmental or hospital audit meetings<br />
on a regular basis.<br />
❏❏<br />
An anaesthetist should reflect upon and evaluate personal practice at regular intervals.<br />
Page 8 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain A: knowledge, skills and performance<br />
Attribute 1: maintain your professional performance<br />
Explanatory notes<br />
Maintaining professional performance is both a necessary and continuous process due to medical,<br />
scientific and technological advances and changes in patient expectations. Realisation of these<br />
advances and meeting of those expectations by the profession as a whole, in the day to day practice of<br />
anaesthesia, pain medicine and intensive care, are dependent on individual doctors keeping up to date<br />
with new knowledge and skills and applying them locally and nationally. Individual commitment to<br />
this process requires planned and regular participation in the core, higher and advanced level areas of<br />
continuing professional development (CPD), and also regular review of clinical practice against current<br />
best practice and defined evaluation criteria.<br />
An important aspect of keeping up to date is knowledge of current legal, regulatory and professional<br />
codes which influence clinical and professional practice, e.g. controlled drug provision.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Guidance on CPD online (accessed 23 November 2009) www.gmc-uk.org/education.<br />
The Royal College of Anaesthetists<br />
››<br />
Continuing professional development guidelines (2nd edition), 2010 (in press).<br />
››<br />
Raising the standard: a compendium of audit recipes (2nd edition), 2006.<br />
Prepared by the Joint Committee on Good Practice | Page 9
Domain A: knowledge, skills and performance<br />
Attribute 2: apply knowledge and experience to practice<br />
Standards<br />
➣➣<br />
In providing care an anaesthetist must recognise and work within the limits of their<br />
competence.<br />
❏❏<br />
When a problem arises outside their area of competence an anaesthetist must seek help<br />
from a suitable colleague.<br />
❏❏<br />
An anaesthetist must act promptly and appropriately when anaesthetic complications<br />
arise and be familiar with the operation of resuscitation equipment and current<br />
resuscitation guidelines.<br />
❏❏<br />
An anaesthetist must take urgent appropriate action if a patient has suffered harm<br />
through misadventure or for any other reason.<br />
❏❏<br />
An anaesthetist must use safe, regularly maintained equipment which has been checked<br />
before use, and use equipment and techniques with which he or she is familiar.<br />
➣➣<br />
An anaesthetist must adequately assess the patient’s condition.<br />
❏❏<br />
An anaesthetist must assess the patient before anaesthesia and devise an appropriate<br />
plan of anaesthetic management.<br />
➣➣<br />
An anaesthetist must provide or arrange advice, investigations or treatment where<br />
necessary.<br />
❏❏<br />
An anaesthetist must prescribe drugs or treatment, including repeat prescriptions, safely<br />
and appropriately.<br />
❏❏<br />
An anaesthetist must take steps to alleviate pain and distress whether or not a cure may<br />
be possible.<br />
❏❏<br />
An anaesthetist must provide effective treatments based on the best available evidence.<br />
❏❏<br />
An anaesthetist should consider appropriate local or nationally agreed guidelines when<br />
planning an anaesthetic.<br />
❏❏<br />
An anaesthetist must consult colleagues, or refer patients to colleagues, when this is in<br />
the patient’s best interest.<br />
➣➣<br />
If they are involved in teaching, an anaesthetist must apply the skills, attitudes and<br />
practice of a competent teacher/trainer.<br />
❏❏<br />
An anaesthetist should support the College Tutor in the teaching and clinical supervision<br />
of anaesthetic trainees.<br />
❏❏<br />
An anaesthetist should participate actively in the professional development of trainees.<br />
❏❏<br />
An anaesthetist should participate in the assessment of trainees, having undertaken the<br />
necessary training.<br />
❏❏<br />
An anaesthetist should contribute to the teaching of medical and other students.<br />
❏❏<br />
An anaesthetist should adopt a multidisciplinary approach to learning and teaching.<br />
❏❏<br />
An anaesthetist should help to foster a culture of lifelong learning.<br />
Page 10 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain A: knowledge, skills and performance<br />
Attribute 2: apply knowledge and experience to practice<br />
Explanatory notes<br />
Patients rely on anaesthetists to utilise and apply their expert knowledge and experience when making<br />
professional judgements, dealing with complex situations and solving clinical problems. However, on<br />
the other hand, given the rate of scientific and technological advances in medicine the majority of<br />
patients do not expect anaesthetists to be the fountain of all knowledge. In return for this recognition,<br />
anaesthetists must work within the limits of their competence; and where appropriate consult or seek<br />
advice from other sources or refer patients to colleagues, including those from other specialties, who<br />
do have the necessary experience and expertise.<br />
An environment where patient care prospers is one where all members of the healthcare team can<br />
learn from one another. Anaesthetists must therefore share their knowledge, skills and expertise by<br />
engaging in the education, training and professional development of colleagues. This educational role<br />
also includes undertaking reliable and honest formative assessment of students and trainees; providing<br />
constructive feedback to them as appropriate.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Good practice in prescribing medicines: supplementary guidance, 2008.<br />
››<br />
Withholding and withdrawing life-prolonging treatments: good practice in decision making, 2006.<br />
The Royal College of Anaesthetists<br />
››<br />
Cardiopulmonary resuscitation: standards for clinical practice and training, 2004.<br />
››<br />
Good practice in the management of continuous epidural analgesia in the hospital setting, 2004.<br />
››<br />
Local anaesthesia for intraocular surgery, 2001.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Checking anaesthetic equipment (3rd edition), 2004.<br />
››<br />
Day surgery (2nd edition), 2005.<br />
››<br />
Do not attempt resuscitation (DNAR) decisions in the peri-operative period, 2009.<br />
››<br />
Guidelines for the management of a malignant hyperthermia crisis, 2007.<br />
››<br />
Peri-operative management of the morbidly obese patient, 2007.<br />
››<br />
Pre-hospital anaesthesia. AAGBI safety guideline, 2009.<br />
››<br />
Pre-operative assessment: the role of the anaesthetist, 2001.<br />
››<br />
Safe management of anaesthetic related equipment, 2009.<br />
››<br />
Suspected anaphylactic reactions associated with anaesthesia (4th edition). AAGBI safety guideline, 2009.<br />
Prepared by the Joint Committee on Good Practice | Page 11
Domain A: knowledge, skills and performance<br />
Attribute 3: keep clear, accurate and legible records<br />
Standards<br />
➣➣<br />
In providing care an anaesthetist must keep clear, accurate and legible records.<br />
❏❏<br />
An anaesthetist should enter their name and GMC number on the anaesthetic record<br />
sheet, in addition to the name of the patient and their details; non-consultants should<br />
record the name of their consultant supervisor.<br />
❏❏<br />
An anaesthetist should only use recognised abbreviations in keeping clear and legible<br />
records.<br />
➣➣<br />
In providing care an anaesthetist must make records at the same time as the events<br />
they are recording or as soon as possible afterwards.<br />
❏❏<br />
An anaesthetist should ensure that the anaesthetic record sheet or hospital notes are up<br />
to date as soon as practicable after the management of complications which have arisen<br />
unexpectedly.<br />
❏❏<br />
An anaesthetist should make an accurate, legible, contemporaneous record of the timing<br />
and doses of drugs and fluids administered such that a colleague could take over the<br />
administration of the anaesthetic if necessary.<br />
❏❏<br />
An anaesthetist should ensure that the results of physiological monitoring of the patient<br />
are recorded at appropriate intervals.<br />
➣➣<br />
An anaesthetist must record clinical findings, decisions, information given to patients,<br />
drugs prescribed and other information or treatment.<br />
❏❏<br />
An anaesthetist should make a written record of the pre-operative assessment and<br />
discussion, including any specific consent for regional anaesthesia or other procedures<br />
when necessary.<br />
❏❏<br />
An anaesthetist should complete an entry in the hospital incident reporting system<br />
following a critical incident.<br />
Page 12 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain A: knowledge, skills and performance<br />
Attribute 3: keep clear, accurate and legible records<br />
Explanatory notes<br />
The basic premise for keeping good quality medical records in anaesthesia, pain medicine and intensive<br />
care is to facilitate communication amongst colleagues, and ensure the effective and safe continuation<br />
of care of patients at different times and by different team members. It is therefore particularly<br />
important that critical incidents, complications and unexpected events are accurately documented.<br />
A secondary, but important, premise is that records (provided patients have been informed and they<br />
do not object) are an important resource when it comes to auditing areas of anaesthesia care and<br />
reviewing cases for educational purposes.<br />
Related guidelines and sources of information<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Information management: guidance for anaesthetists, 2008.<br />
Prepared by the Joint Committee on Good Practice | Page 13
Domain B: safety and quality<br />
Attribute 4: put into effect systems to protect patients and improve care<br />
Standards<br />
➣➣<br />
An anaesthetist must respond constructively to the outcome of audit, appraisals and<br />
performance reviews or assessments.<br />
❏❏<br />
An anaesthetist must participate in the annual appraisal process.<br />
➣➣<br />
An anaesthetist must take part in systems of quality assurance and quality<br />
improvement.<br />
❏❏<br />
An anaesthetist should co-operate with internal and external reviews.<br />
➣➣<br />
An anaesthetist must comply with risk management and clinical governance<br />
procedures.<br />
❏❏<br />
An anaesthetist should participate in relevant national reporting schemes.<br />
❏❏<br />
An anaesthetist must cooperate with legitimate requests for information from<br />
organisations monitoring public health.<br />
➣➣<br />
An anaesthetist must provide information for confidential enquiries and significant<br />
event reporting.<br />
❏❏<br />
An anaesthetist must report suspected adverse drug reactions.<br />
➣➣<br />
An anaesthetist must ensure arrangements are made for the continuing care of the<br />
patient where necessary.<br />
❏❏<br />
An anaesthetist should ensure that on-call teams have a range of skills sufficient to<br />
manage any reasonable predictable clinical eventuality.<br />
❏❏<br />
An anaesthetist must write clear instructions for post-operative care including pain relief,<br />
oxygen therapy and fluid management as necessary.<br />
❏❏<br />
An anaesthetist must ensure that there is continuous supervision of a patient receiving<br />
anaesthesia. If in exceptional circumstances you are required to leave the theatre, you<br />
must ensure that the patient is supervised by another anaesthetist or appropriately<br />
trained assistant following a handover in accordance with AAGBI guidelines.*<br />
❏❏<br />
An anaesthetist must ensure that recovering patients are observed on a one-to-one<br />
basis by an anaesthetist, recovery nurse or other properly trained member of staff<br />
in accordance with AAGBI guidelines** until they have regained airway control and<br />
cardiovascular stability and are able to communicate.<br />
Page 14 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain B: safety and quality<br />
Attribute 4: put into effect systems to protect patients and improve care<br />
Explanatory notes<br />
Anaesthetists have a duty of care in ensuring patient safety at all times. This duty applies at both<br />
systems and individual patient care levels. Taking part in data collection exercises and reporting<br />
significant events and complications are vital in developing an organisational culture whereby issues<br />
that could potentially affect patient safety can be systematically identified. The duty of care extends,<br />
whether you are on or off duty, to making sure that competent members of staff are involved in the<br />
provision of safe and continuous care of patients. Patient safety, including measures to foresee and<br />
prevent any adverse incidents that may arise, should be given due consideration in any service or<br />
performance review, including the annual appraisal.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Raising concerns about patient safety, 2008.<br />
The Royal College of Anaesthetists<br />
››<br />
Syringe labelling in critical care areas, 2004.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Controlled drugs in perioperative care, 2006.<br />
››<br />
Immediate postanaesthetic recovery, 2002.**<br />
››<br />
Interhospital transfer. AAGBI safety guideline, 2009.<br />
››<br />
Provision of anaesthetic services in magnetic resonance units, 2002.<br />
››<br />
Recommendations for standards of monitoring during anaesthesia and recovery (4th edition), 2007.*<br />
››<br />
Recommendations for the safe transfer of patients with brain injury, 2006.<br />
››<br />
Theatre efficiency: safety, quality of care and optimal use of resources, 2003.<br />
Prepared by the Joint Committee on Good Practice | Page 15
Domain B: safety and quality<br />
Attribute 5: respond to risks to safety<br />
Standards<br />
➣➣<br />
An anaesthetist must report risks in the healthcare environment to their employing or<br />
contracting bodies.<br />
❏❏<br />
An anaesthetist should respond promptly to risks posed by patients.<br />
❏❏<br />
An anaesthetist must follow infection control procedures and regulations.<br />
❏❏<br />
An anaesthetist must safeguard and protect the health and well being of vulnerable<br />
people, including children and the elderly and those with learning disabilities.<br />
➣➣<br />
An anaesthetist must take action where there is evidence that a colleague’s conduct,<br />
performance or health may be putting patients at risk.<br />
❏❏<br />
An anaesthetist should be able to recognise when a colleague may be putting patients<br />
at risk because of poor performance, misconduct or health reasons.<br />
❏❏<br />
An anaesthetist should listen impartially to medical, nursing and other colleagues when<br />
they express concerns about a fellow anaesthetist, and discuss such concerns only in an<br />
appropriate forum.<br />
❏❏<br />
An anaesthetist must take action and inform the clinical director or other responsible<br />
person if necessary when a colleague may be putting patients at risk, and keep a written<br />
record of the action taken.<br />
Page 16 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain B: safety and quality<br />
Attribute 5: respond to risks to safety<br />
Explanatory notes<br />
Risks to patient safety can come from several, sometimes unexpected, sources. Responsibilities in<br />
regard to occupational health and safety laws apply to all employees in an organisation. However, there<br />
are some risks that only a doctor, with their expertise and experience, will be able to recognise. Risk to<br />
patient safety may stem from a poorly performing doctor in your team. If this risk could potentially or<br />
does already affect patient safety, depending on seriousness, appropriate action must be taken in line<br />
with local Trust and national procedures. The poorly performing doctor may be a close colleague or a<br />
senior member of the clinical team, but your overriding duty is to take appropriate steps if there is a risk<br />
to patient safety. Poor performance may be due to ill health; another reason to take appropriate action,<br />
in helping a fellow colleague.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
0–18 years: guidance for all doctors, 2007.<br />
››<br />
Raising concerns about patient safety, 2008.<br />
The Royal College of Anaesthetists<br />
››<br />
Child protection and the anaesthetist: safeguarding children in the operating theatre –<br />
intercollegiate document, 2007.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Anaesthesia and peri-operative care of the elderly, 2001.<br />
››<br />
Infection control in anaesthesia (2nd edition). AAGBI safety guideline, 2008.<br />
Prepared by the Joint Committee on Good Practice | Page 17
Domain B: safety and quality<br />
Attribute 6: protect patients and colleagues from any risk posed by your health<br />
Standards<br />
➣➣<br />
An anaesthetist should make arrangements for accessing independent medical advice<br />
when necessary.<br />
❏❏<br />
An anaesthetist must seek advice and help from a suitably qualified professional in<br />
accordance with GMC guidance if you know that you may have a serious condition<br />
which either could affect your performance or is transmissible to patients.<br />
❏❏<br />
An anaesthetist should access professional counselling, advice, support and help services<br />
if they are suffering from any mental health problem, including addiction, which could<br />
potentially affect their professional judgement or performance.<br />
➣➣<br />
An anaesthetist must make arrangements to protect patients and colleagues from their<br />
own health or other problem.<br />
❏❏<br />
An anaesthetist should be immunised against common serious communicable diseases<br />
where vaccines are available.<br />
❏❏<br />
An anaesthetist should hand over duties to a colleague if judgement or ability is<br />
temporarily impaired due to stress, tiredness or illness.<br />
❏❏<br />
An anaesthetist must not work under the influence of alcohol or drugs.<br />
❏❏<br />
An anaesthetist should take reasonable steps to stay healthy.<br />
Page 18 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain B: safety and quality<br />
Attribute 6: protect patients and colleagues from any risk posed by your health<br />
Explanatory notes<br />
Looking after patients should not distract an anaesthetist from looking after their own physical and<br />
mental health. A healthy anaesthetist is one who can contribute fully to a team and, in turn, the<br />
effective provision of medical care. Patients have a right to expect safe treatment. This expectation<br />
extends to doctors whose health poses no risk in their professional relationships with patients. You<br />
must seek formal advice if you think your own health is putting patients at risk or you feel it is limiting<br />
your ability as a doctor to function effectively. Dependence on alcohol or drugs falls into this category,<br />
as do stress and fatigue.<br />
Related guidelines and sources of information<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Fatigue and anaesthetists, 2004.<br />
››<br />
Welfare resource pack, 2008.<br />
Prepared by the Joint Committee on Good Practice | Page 19
Domain C: communication, partnership and teamwork<br />
Attribute 7: communicate effectively<br />
Standards<br />
➣➣<br />
An anaesthetist must communicate clearly and effectively with colleagues within and<br />
outside the team.<br />
❏❏<br />
An anaesthetist must pass on information to colleagues involved in, or taking over, the<br />
care of your patient.<br />
❏❏<br />
An anaesthetist should communicate directly with senior and specialist medical<br />
colleagues when appropriate.<br />
❏❏<br />
An anaesthetist should communicate effectively with all members of the team to ensure<br />
resources are used to best effect for the delivery of patient care.<br />
❏❏<br />
An anaesthetist should explain to assistants and other staff what your requirements are<br />
likely to be in advance of inducing anaesthesia.<br />
➣➣<br />
An anaesthetist must visit and explain to patients and/or involved parties after surgery<br />
when something has gone wrong.<br />
❏❏<br />
An anaesthetist should meet with close relatives by appointment when asked to do so to<br />
discuss when things have gone wrong.<br />
❏❏<br />
An anaesthetist must be considerate to those close to the patient.<br />
❏❏<br />
An anaesthetist should ensure that a witness is present when explaining what went<br />
wrong with a patient and/or involved parties, and that the incident and patient visit are<br />
both adequately documented in the clinical records.<br />
➣➣<br />
An anaesthetist must keep patients informed about the progress of their care.<br />
❏❏<br />
An anaesthetist must listen to patients and respect their views about their health.<br />
❏❏<br />
An anaesthetist must give patients the information they need in order to make decisions<br />
about their care in a way they can understand.<br />
❏❏<br />
An anaesthetist should encourage questions when possible and allow time to listen<br />
to the concerns of patients, guardians or parents before and, where possible, after an<br />
anaesthetic or therapeutic procedure.<br />
❏❏<br />
An anaesthetist must respond to patients’ questions.<br />
❏❏<br />
An anaesthetist must answer questions openly and honestly.<br />
Page 20 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain C: communication, partnership and teamwork<br />
Attribute 7: communicate effectively<br />
Explanatory notes<br />
Effective provision of care in anaesthesia, pain medicine and intensive care requires anaesthetists<br />
to utilise a number of communication skills. Listening, questioning and providing instructions to<br />
colleagues are just some of the skills that are necessary within a functioning multidisciplinary setting.<br />
Non-verbal forms of communication are just as important as verbal ones.<br />
Patients are very much seen as partners and contributors in the provision of their own healthcare.<br />
Whether they can effectively contribute to this partnership is dependent on information provided by<br />
their doctor in ways that can be easily understood. Again, this is very much dependent on a doctor’s<br />
communication skills. Mistakes, as in any other area of life, can occur in medical practice. When a<br />
mistake has been made, whether a complaint has followed or not, an informed and appropriate<br />
explanation must be given to the patient or a close family member.<br />
Related guidelines and sources of information<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Catastrophes in anaesthetic practice: dealing with the aftermath, 2005.<br />
Prepared by the Joint Committee on Good Practice | Page 21
Domain C: communication, partnership and teamwork<br />
Attribute 8: work constructively with colleagues and delegate effectively<br />
Standards<br />
➣➣<br />
An anaesthetist must treat colleagues fairly and with respect.<br />
❏❏<br />
An anaesthetist should respect the skills and contributions of other members of the<br />
anaesthetic, medical and nursing team.<br />
❏❏<br />
An anaesthetist should encourage multidisciplinary team working.<br />
❏❏<br />
An anaesthetist should ensure that the work content of job plans and on-call rotas is<br />
fairly distributed among colleagues.<br />
➣➣<br />
An anaesthetist must support colleagues who have problems with their performance,<br />
conduct or health.<br />
❏❏<br />
An anaesthetist should always be willing to advise and help colleagues.<br />
❏❏<br />
An anaesthetist should support colleagues undergoing rehabilitation after their illness or<br />
returning to work after a period of absence for any reason.<br />
➣➣<br />
An anaesthetist should act as a positive role model for colleagues.<br />
❏❏<br />
An anaesthetist should provide appropriate professional support and encouragement for<br />
trainees, staff and associate specialist grade (SAS) doctors and other anaesthetists under<br />
their supervision.<br />
❏❏<br />
An anaesthetist should attend hospital promptly when requested and only leave when<br />
appropriate to do so.<br />
❏❏<br />
An anaesthetist should be prepared to work flexibly within the department.<br />
❏❏<br />
An anaesthetist should ensure that they are aware of being placed on a roster to cover<br />
emergency operating lists and on-call duties.<br />
❏❏<br />
An anaesthetist must make sure that when on-call they can easily be contacted.<br />
❏❏<br />
An anaesthetist should arrange annual, professional and study leave in advance in<br />
accordance with local departmental policy.<br />
➣➣<br />
An anaesthetist must ensure that colleagues to whom they delegate have appropriate<br />
qualifications and experience.<br />
❏ ❏ An anaesthetist with a management role should confirm that the on-call staff work<br />
within their competencies.<br />
Page 22 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain C: communication, partnership and teamwork<br />
Attribute 8: work constructively with colleagues and delegate effectively<br />
Explanatory notes<br />
Anaesthetists usually function as members of departments and multidisciplinary teams in order to<br />
provide safe and effective care to patients. Developing good relationships with colleagues is important,<br />
as well as understanding and respecting their professionalism, roles and views. Anaesthetists are<br />
commonly leaders of clinical teams and should therefore ensure that ineffective team working does not<br />
compromise patient care. Displaying the behaviours and attitudes of a positive role model is often the<br />
first step in achieving this.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Management for doctors, 2006.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
The anaesthesia team (2nd edition), 2005.<br />
››<br />
Consultant trainee relationships – a guide for consultants, 2001.<br />
››<br />
Guidance on the 2003 (new) contract and job planning for consultant anaesthetists, 2005.<br />
››<br />
Guidance on the supervision of non-consultant anaesthetists, 2008.<br />
Prepared by the Joint Committee on Good Practice | Page 23
Domain C: communication, partnership and teamwork<br />
Attribute 9: establish and maintain partnerships with patients<br />
Standards<br />
➣➣<br />
An anaesthetist should encourage patients to take an interest in their health and take<br />
action to improve and maintain it.<br />
❏❏<br />
An anaesthetist must support patients in caring for themselves.<br />
❏❏<br />
An anaesthetist should engage in the education of patients and the wider public.<br />
❏❏<br />
An anaesthetist should promote the specialty of anaesthesia in the wider public interest.<br />
➣➣<br />
An anaesthetist must be satisfied that they have consent or other valid authority before<br />
they undertake any examination or investigation, provide treatment or involve patients<br />
in teaching or research.<br />
❏❏<br />
An anaesthetist should ensure that patients have understood the nature and purpose of<br />
any proposed treatment or investigation and any significant risk or side effects associated<br />
with it, enabling them to make an informed choice of anaesthetic technique by giving<br />
clear explanation of the advantages and disadvantages of the options available, using<br />
terms that a patient can understand and relate to when giving consent.<br />
❏❏<br />
An anaesthetist must abide with local research ethics committee and multicentre<br />
research ethics committee guidelines when carrying out research.<br />
Page 24 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain C: communication, partnership and teamwork<br />
Attribute 9: establish and maintain partnerships with patients<br />
Explanatory notes<br />
It has been recognised that good professional relationships with patients is fundamental to the practice<br />
of medicine. Establishing a partnership, which is built on trust, will allow an anaesthetist to influence<br />
the patient’s approach and attitude to their treatment and care over time. Trust is gained through an<br />
anaesthetist’s professionalism, which covers not only their knowledge and clinical skills but also their<br />
ability to empathise with, understand and respect the views and feelings of patients. This is a process<br />
and the same consideration must also be given when obtaining patient consent. It is not just a signing<br />
of an appropriate consent form but involves listening to a patient’s concerns and anxieties, answering<br />
their questions and providing information in a way they can understand. Having an anaesthetic, an<br />
admission to critical care or the requirement for pain medicine are often parts of medical care about<br />
which patients are most anxious.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Consent: patients and doctors making decisions together, 2008.<br />
››<br />
Maintaining boundaries: supplementary guidance, 2006.<br />
››<br />
Making and using visual and audio recordings of patients: guidance for doctors, 2002.<br />
››<br />
Research: the role and responsibility of doctors, 2002.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Consent for anaesthesia (2nd edition), 2004.<br />
Prepared by the Joint Committee on Good Practice | Page 25
Domain D: maintaining trust<br />
Attribute 10: show respect for patients<br />
Standards<br />
➣➣<br />
An anaesthetist must implement and comply with systems to protect patient<br />
confidentiality.<br />
❏❏<br />
An anaesthetist must maintain patient confidentiality at all times.<br />
➣➣<br />
An anaesthetist must be polite, considerate and honest and respect patients’ dignity<br />
and privacy.<br />
❏❏<br />
An anaesthetist should promote trust with patients through courteous behaviour,<br />
honest discussions and respect for their right to privacy and dignity, whether conscious<br />
or unconscious.<br />
❏❏<br />
An anaesthetist must treat each patient fairly and as an individual.<br />
Page 26 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain D: maintaining trust<br />
Attribute 10: show respect for patients<br />
Explanatory notes<br />
Politeness, consideration, honesty and respect are recognised social norms in any professional working<br />
environment. Showing respect to patients includes respecting their privacy. Without assurances about<br />
privacy, patients may be reluctant to seek help from doctors or part with the necessary information so that<br />
doctors can provide safe and effective care. Patient confidentiality is therefore a duty for all doctors but it<br />
is not an absolute. Information can or should be disclosed in certain circumstances, e.g. to satisfy a legal<br />
requirement, and under certain conditions, as stipulated by the latest GMC guidance on confidentiality.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Confidentiality, 2009.<br />
››<br />
Maintaining boundaries: supplementary guidance, 2006.<br />
››<br />
Personal beliefs and medical practice: supplementary guidance, 2008.<br />
Prepared by the Joint Committee on Good Practice | Page 27
Domain D: maintaining trust<br />
Attribute 11: treat patients and colleagues fairly and without discrimination<br />
Standards<br />
➣➣<br />
An anaesthetist must be honest and objective when appraising or assessing colleagues<br />
and when writing references.<br />
❏❏<br />
An anaesthetist must not exaggerate competence or fail to mention significant<br />
weaknesses in a reference.<br />
❏❏<br />
An anaesthetist should be honest and open in relations with colleagues.<br />
❏❏<br />
An anaesthetist should provide references, reports or signed documents within a<br />
reasonable time.<br />
❏❏<br />
An anaesthetist should ensure that an applicant is aware that a reservation would be<br />
expressed when writing a reference for him or her.<br />
➣➣<br />
An anaesthetist must respond promptly and fully to complaints.<br />
❏❏<br />
An anaesthetist should, if appropriate, give an apology to the patient and their relatives<br />
and explain in understandable terms what occurred when an untoward incident took<br />
place.<br />
❏❏<br />
An anaesthetist should respond constructively to any complaints received and cooperate<br />
with any relevant complaints procedures or formal inquiry into the treatment of<br />
a patient.<br />
➣➣<br />
An anaesthetist must provide care on the basis of the patient’s needs and the likely<br />
effect of treatment.<br />
❏❏<br />
An anaesthetist must act in the patient’s interest at all times.<br />
❏❏<br />
An anaesthetist must not allow their personal prejudice to affect the treatment or<br />
management of a patient under their care.<br />
❏❏<br />
An anaesthetist should consider the clinical needs of the patient and the professional<br />
needs of colleagues when planning a clinical session.<br />
Page 28 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain D: maintaining trust<br />
Attribute 11: treat patients and colleagues fairly and without discrimination<br />
Explanatory notes<br />
Engaging with your colleagues fairly and without discrimination, irrespective of their gender, age, race,<br />
sexuality, economic status, lifestyle, culture and religious or political belief, is essential when working<br />
as part of a team. The reverse of this is your right to work without being subject to discrimination.<br />
Consideration of a colleague’s competence and performance must be based on honest and objective<br />
decisions and judgements. Honesty and objectivity must also be applied in your professional<br />
relationships with patients. Best practice involves the recognition and acknowledgement of different<br />
needs in helping patients access medical care on an equal basis.<br />
Complaints must also be managed fairly and without discrimination. Not all complaints by patients<br />
are a result of a mistake; but complaints have risen in recent years due in part to general expectations<br />
increasing and tolerances decreasing. If justified, an anaesthetist should respond promptly and<br />
appropriately to any complaint.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Personal beliefs and medical practice: supplementary guidance, 2008.<br />
››<br />
Withholding and withdrawing life-prolonging treatments: good practice in decision making, 2006.<br />
››<br />
Writing references: supplementary guidance, 2007.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Consultant trainee relationships – a guide for consultants, 2001.<br />
››<br />
Management of anaesthesia for Jehovah’s Witnesses (2nd edition), 2005.<br />
Prepared by the Joint Committee on Good Practice | Page 29
Domain D: maintaining trust<br />
Attribute 12: act with honesty and integrity<br />
Standards<br />
➣➣<br />
An anaesthetist must ensure that they have adequate indemnity or insurance cover for<br />
their practice.<br />
➣➣<br />
An anaesthetist must be honest in financial and commercial dealings.<br />
❏❏<br />
An anaesthetist must inform patients about any fees and charges before starting<br />
treatment.<br />
❏❏<br />
An anaesthetist must ensure any published information about their services is factual<br />
and verifiable.<br />
❏❏<br />
An anaesthetist should not undertake private practice or any other commitment which<br />
would prevent them from fulfilling rostered clinical NHS duties.<br />
➣➣<br />
An anaesthetist must be honest in any formal statement or report, whether written or<br />
oral, making clear the limits of your knowledge or competence.<br />
Page 30 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists
Domain D: maintaining trust<br />
Attribute 12: act with honesty and integrity<br />
Explanatory notes<br />
Honesty and integrity form the cornerstone of medical professionalism. Divergence away from these<br />
virtues, regardless of where an anaesthetist may be working (e.g. the NHS or private healthcare sector),<br />
risks diminishing the trust placed in anaesthetists and the profession by patients, colleagues and the<br />
public. In providing information about yourself, your services and others, honesty is reflected by the<br />
accuracy and verifiability of that information. Fulfilling contractual and professional obligations to their<br />
employer and patients will demonstrate the integrity of an anaesthetist.<br />
Related guidelines and sources of information<br />
The General Medical Council<br />
››<br />
Acting as an expert witness: supplementary guidance, 2008.<br />
››<br />
Conflicts of interest: supplementary guidance, 2008.<br />
››<br />
Reporting criminal and regulatory proceedings within and outside the UK:<br />
supplementary guidance, 2008.<br />
››<br />
Taking up and ending appointments: supplementary guidance for doctors, 2008.<br />
››<br />
Writing references: supplementary guidance, 2007.<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
››<br />
Guidance on the 2003 (new) contract and job planning for consultant anaesthetists, 2005.<br />
››<br />
Independent practice, 2008.<br />
››<br />
Voluntary code of practice for billing private patients, 2008.<br />
Prepared by the Joint Committee on Good Practice | Page 31
The Royal College of Anaesthetists<br />
Churchill House | 35 Red Lion Square | London WC1R 4SG<br />
020 7092 1500 www.rcoa.ac.uk info@rcoa.ac.uk<br />
Design and layout by The Royal College of Anaesthetists<br />
The Association of Anaesthetists of Great<br />
Britain and Ireland<br />
21 Portland Place | London W1B 1PY<br />
020 7631 1650 www.aagbi.org info@aagbi.org
Day Case and Short Stay Surgery<br />
2<br />
Published by<br />
The Association of Anaesthetists of Great Britain & Ireland<br />
The British Association of Day Surgery<br />
May 2011
This guideline was originally published in Anaesthesia. If you wish to refer to<br />
this guideline, please use the following reference:<br />
Verma R, Alladi R, Jackson I, et al. Day case and short stay surgery: 2,<br />
Anaesthesia 2011; 66: pages 417-434<br />
This guideline can be viewed online via the following URL:<br />
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06651.x/pdf<br />
This guideline has been endorsed by the Association of Surgeons of<br />
Great Britain and Ireland and the Association for Perioperative Practice.<br />
© The Association of Anaesthetists of Great Britain & Ireland and the British Association of Day<br />
Surgery 2011
GUIDELINES<br />
Day case and short stay surgery: 2<br />
Association of Anaesthetists of Great Britain and Ireland<br />
British Association of Day Surgery<br />
Membership of the Working Party: R. Verma (Chairman), R. Alladi,<br />
I. Jackson, I. Johnston, C. Kumar, R. Page, I. Smith, M. Stocker,<br />
C. Tickner, S. Williams and R. Young<br />
This is a consensus document produced by expert members of a Working Party<br />
established by the Association of Anaesthetists of Great Britain and Ireland<br />
(AAGBI) and British Association of Day Surgery (BADS). It has been seen and<br />
approved by the Councils of the AAGBI and BADS.<br />
Summary<br />
1 Day surgery is a continually evolving speciality performed in a range of<br />
ways across different units.<br />
2 In recent years, the complexity of procedures has increased with a wider<br />
range of patients now considered suitable for day surgery.<br />
3 Effective pre-operative preparation and protocol-driven, nurse-led<br />
discharge are fundamental to safe and effective day and short stay surgery.<br />
4 Fitness for a procedure should relate to the patient’s health as<br />
determined at pre-operative preparation and not limited by arbitrary<br />
limits such as ASA status, age or body mass index.<br />
5 Patients presenting with acute conditions requiring urgent surgery can be<br />
efficiently and effectively treated as day cases via a semi-elective pathway.<br />
6 Central neuraxial blockade and a range of regional anaesthetic<br />
techniques, including brachial plexus and paravertebral blocks, can be<br />
used effectively for day surgery.<br />
Re-use of this article is permitted in accordance with the Creative Commons Deed,<br />
Attribution 2.5, which does not permit commercial exploitation.<br />
Ó 2011 The Authors<br />
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Guidelines: Day case and short stay surgery<br />
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7 Each anaesthetist should develop techniques that permit the patient to<br />
undergo the surgical procedure with minimum stress and maximum<br />
comfort, and optimise his ⁄ her chance of early discharge.<br />
8 Every day surgery unit must have a Clinical Lead with specific interest<br />
in day surgery and whose remit includes the development of local<br />
policies, guidelines and clinical governance.<br />
9 Good quality advice leaflets, assessment forms and protocols are in use<br />
in many centres and are available to other units.<br />
10 Effective audit is an essential component of good care in all aspects of<br />
day and short stay surgery.<br />
11 Enhanced recovery is based on established day surgery principles and<br />
is aimed at improving the quality of recovery after inpatient surgery<br />
such that the patient is well enough to go home earlier and<br />
healthier.<br />
The definition of day surgery in the UK and Ireland is clear: the patient<br />
must be admitted and discharged on the same day, with day surgery as the<br />
intended management. Although still counted as inpatient treatment<br />
(except in the US), 23-h and short stay surgery apply the same principles of<br />
care outlined in this document and can improve the quality of patient care<br />
whilst reducing length of stay.<br />
Since the previous guideline was published in 2005, the complexity of<br />
procedures has increased with a wider range of patients now considered<br />
suitable for day surgery. Despite these advances, the overall rates of day<br />
surgery remain variable across the UK. Whereas the target of 75% of<br />
elective surgery to be performed as day cases from the NHS plan<br />
remains [1], the true picture is difficult to determine, since the only<br />
nationally reported data are limited to 25 procedures [2]. Ten years on,<br />
the advancement of minimally invasive surgery is allowing more<br />
procedures to be performed as day surgery and even higher rates should<br />
be possible.<br />
There was a major drive to promote day surgery around the turn of<br />
this century, but the political focus moved on before all of the lessons<br />
learned were fully implemented [3]. Nevertheless, the recent drive to<br />
reduce length of stay and improve the quality of postoperative recovery<br />
has ensured that day surgery principles are fundamental to modern<br />
patient care. Shortened hospital stays and earlier mobilisation also reduce<br />
the risk of hospital-acquired infections and venous thromboembolism<br />
(VTE).<br />
Ó 2011 The Authors<br />
2 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
Guidelines: Day case and short stay surgery<br />
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Recent reports<br />
The NHS Modernisation Agency produced an operational guide detailing the<br />
facilities available in, and the management of, day units [4]. This was further<br />
refined in the Ten High Impact Changes document in which the principle of<br />
treating day surgery as the default option for elective surgery was set out [3].<br />
The NHS Institute for Innovation and Improvement has also produced a<br />
document focusing on day case laparoscopic cholecystectomy [5]. Whereas<br />
this document is specific to one procedure, many aspects of the ideal patient<br />
pathway are equally applicable to a wide range of day surgery procedures.<br />
Effective pre-operative assessment and preparation with protocol-driven,<br />
nurse-led discharge are fundamental to safe and effective day and short stay<br />
surgery. Several recent publications provide useful advice on the establishment<br />
and running of both services [6–10].<br />
The British Association of Day Surgery has produced a directory of<br />
procedures that provides targets for day and short stay surgery rates for over<br />
200 different procedures [11]. These procedure-specific targets serve as a<br />
focus for clinicians and managers in the planning and provision of short stay<br />
elective surgery and illustrate the high quality of service achievable in<br />
appropriate circumstances.<br />
In March 2010, the Department of Health published the enhanced<br />
recovery guide that extends day surgery principles to inpatient surgery [12].<br />
Selection of patients<br />
Patients may be referred for day surgery from outpatient clinics, accident<br />
and emergency departments or primary care.<br />
Recent advances in surgical and anaesthetic techniques, as well as the<br />
publication of successful outcomes in patients with multiple comorbidities,<br />
have changed the emphasis in day surgery patient selection. It is now<br />
accepted that the majority of patients are appropriate for day surgery unless<br />
there is a valid reason why an overnight stay would be to their benefit. If<br />
inpatient surgery is being considered it is important to question whether any<br />
strategies could be employed to enable the patient to be treated as a day case.<br />
Full-term infants over 1 month are usually appropriate to undergo day<br />
surgery. A higher age limit is advisable for ex-premature infants (60 weeks<br />
post-conceptional age). The significant risk posed by postoperative apnoea<br />
must be considered and infants with recent apnoea episodes, cardiac or<br />
respiratory disease, family history of sudden infant death syndrome and<br />
Ó 2011 The Authors<br />
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Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
adverse social circumstances should be considered for overnight admission<br />
and close monitoring. Day surgery units should not perform surgery on<br />
children unless they have suitable staff and facilities.<br />
It is recommended that a multidisciplinary approach, with agreed<br />
protocols for patient assessment including inclusion and exclusion criteria<br />
for day surgery, should be agreed locally with the anaesthetic department.<br />
Patient assessment for day surgery falls into three main categories:<br />
Social factors<br />
(a) The patient must understand the planned procedure and postoperative<br />
care and consent to day surgery.<br />
(b) Following most procedures under general anaesthesia, a responsible<br />
adult should escort the patient home and provide support for the first<br />
24 h.<br />
(c) The patient’s domestic circumstances should be appropriate for<br />
postoperative care.<br />
Medical factors<br />
(a) Fitness for a procedure should relate to the patient’s health as<br />
determined at pre-operative assessment and not limited by arbitrary<br />
limits such as ASA status, age or BMI [13–15].<br />
(b) Patients with stable chronic disease such as diabetes, asthma or epilepsy<br />
are often better managed as day cases because of minimal disruption to<br />
their daily routine.<br />
(c) Obesity per se is not a contraindication to day surgery as even morbidly<br />
obese patients can be safely managed in expert hands, with appropriate<br />
resources. The incidence of complications during the operation or in<br />
the early recovery phase increases with increasing BMI. However,<br />
these problems would still occur with inpatient care and have usually<br />
resolved or been successfully treated by the time a day case patient<br />
would be discharged. In addition, obese patients benefit from the<br />
short-duration anaesthetic techniques and early mobilisation associated<br />
with day surgery [16].<br />
Surgical factors<br />
(a) The procedure should not carry a significant risk of serious complications<br />
requiring immediate medical attention (haemorrhage, cardiovascular<br />
instability).<br />
Ó 2011 The Authors<br />
4 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
Guidelines: Day case and short stay surgery<br />
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(b) Postoperative symptoms must be controllable by the use of a<br />
combination of oral medication and local anaesthetic techniques.<br />
(c) The procedure should not prohibit the patient from resuming oral<br />
intake within a few hours.<br />
(d) Patients should usually be able to mobilise before discharge although<br />
full mobilisation is not always essential.<br />
Pre-operative preparation<br />
Pre-operative preparation (formerly known as pre-operative assessment) has<br />
three essential components:<br />
1 To educate patients and carers about day surgery pathways.<br />
2 To impart information regarding planned procedures and postoperative<br />
care to help patients make informed decisions – important information<br />
should be provided in writing.<br />
3 To identify medical risk factors, promote health and optimise the<br />
patient’s condition.<br />
All patients must be assessed by a member of the multidisciplinary team<br />
trained in pre-operative assessment for day surgery. Consultant-led and<br />
nurse-run clinics have proved very successful.<br />
Pre-operative preparation is best performed within a self-contained day<br />
surgery facility, where available. This allows patients and their relatives the<br />
opportunity to familiarise themselves with the environment and to meet<br />
staff who will provide their peri-operative care [17]. One-stop clinics,<br />
where pre-operative preparation is performed on the same day as decision<br />
for surgery, offer significant advantages.<br />
Screening questionnaires (Appendix 1), in conjunction with pre-set<br />
protocols, can offer guidance on appropriate investigations, as routine<br />
pre-operative investigations have no relevance in modern anaesthesia.<br />
Although the National Institute of Health and Clinical Excellence<br />
(NICE) guidance on pre-operative investigations [18] is widely<br />
used, one recent study showed no difference in the outcomes of day<br />
surgery patients even when all pre-operative investigations were omitted<br />
[19].<br />
Pre-operative preparation clinics can improve efficiency by enabling<br />
early review of the notes of complex cases, ensuring appropriate<br />
investigations are carried out and that patients are referred for specialist<br />
opinion if deemed necessary.<br />
Ó 2011 The Authors<br />
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Guidelines: Day case and short stay surgery<br />
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Day surgery for urgent procedures<br />
Patients presenting with acute conditions requiring urgent surgery can be<br />
efficiently and effectively treated as day cases via a semi-elective pathway<br />
[20]. After initial assessment many patients can be discharged home and<br />
return for surgery at an appropriate time, either on a day case list or as a<br />
scheduled patient on an emergency list, whereas others can be immediately<br />
transferred to the day surgery service. This reduces the likelihood of<br />
repeated postponement of surgery due to prioritisation of other cases. A<br />
robust day surgery process is key to the success of this service. Some of the<br />
procedures successfully managed in this manner are shown in Table 1<br />
[21–25]. Essential components of an emergency day surgery pathway are:<br />
1 Identification of appropriate procedures.<br />
2 Identification of a theatre list that can reliably accommodate the<br />
procedure (e.g. a dedicated day surgery list or a flexibly run emergency<br />
theatre list).<br />
3 There should be clear pathways for day surgery in place.<br />
4 The condition must be safe to be left untreated for a day or two and<br />
manageable at home with oral analgesia (standardised analgesic pack for<br />
the patient to take home).<br />
5 There should be provision of clear pre-operative patient information,<br />
ideally in writing.<br />
Documentation<br />
Detailed documentation is important within the day surgery environment<br />
as the patient’s experience is often condensed into a few hours. All aspects<br />
Table 1 Types of urgent surgery suitable for day case procedures.<br />
General surgery Gynaecology Trauma Maxillofacial<br />
Incision and drainage<br />
of abscess<br />
Laparoscopic<br />
cholecystectomy<br />
Laparoscopic<br />
appendicectomy<br />
Temporal artery<br />
biopsy<br />
Evacuation of retained<br />
products of conception<br />
Laparoscopic ectopic<br />
pregnancy<br />
Tendon repair<br />
Manipulation<br />
of fractures<br />
Plating of<br />
fractured<br />
clavicle<br />
Manipulation of<br />
fractured nose<br />
Repair of fractured<br />
mandible ⁄ zygoma<br />
Ó 2011 The Authors<br />
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Guidelines: Day case and short stay surgery<br />
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of treatment and care must be recorded accurately to ensure that each<br />
patient follows an effective and safe pathway.<br />
Documentation should be a continuum from pre-operative preparation<br />
to discharge and subsequent follow-up. Single care plans reflecting a<br />
multidisciplinary approach are favoured in many units. Variations for<br />
specific groups including children and patients undergoing procedures<br />
under local anaesthesia should be available. Procedure-specific care plans<br />
reflecting integrated care pathways may be used for more complex and<br />
challenging cases [26]. Such care plans are also useful for audit and<br />
evaluating outcome.<br />
Patients should be provided with general as well as procedure-specific<br />
information. This should be given in advance of admission to allow time for<br />
questioning and preparation for same day surgery. Verbal comments should<br />
be reinforced with written material. General information should include<br />
practical details about attending the day surgery unit whereas procedurespecific<br />
information should include clinical information about the patient’s<br />
condition and surgical procedure (Appendix 2). The anaesthetic information<br />
leaflets developed jointly between the AAGBI and the Royal College<br />
of Anaesthetists (RCoA) may also be used [27]. Information for children is<br />
also available [28].<br />
Management and staffing<br />
Every day surgery unit must have a Clinical Lead with specific interest in<br />
day surgery and whose remit includes the development of local policies,<br />
guidelines and clinical governance. A consultant anaesthetist with<br />
management experience is ideally suited to such a role and job plans must<br />
reflect this responsibility [4]. Day surgery must be represented at Board<br />
level [4].<br />
The Clinical Lead should be supported by a day surgery manager who<br />
has responsibility for the day-to-day running of the unit. The manager will<br />
often have a nursing background and should have the knowledge and skills<br />
to make informed decisions and lead on all aspects of day surgery<br />
development.<br />
Nurses, operating department practitioners, physicians’ assistants<br />
(anaesthesia) (PA(A)s), and other ancillary staffing levels will depend<br />
on the design of the facility, casemix, workload and local preferences<br />
and ability to conform to national guidelines. Staff working in these<br />
Ó 2011 The Authors<br />
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Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
units should be specifically trained in day surgery care. Many units<br />
favour multiskilled staff who have the knowledge and skills to work<br />
within several different areas of the day surgery unit. Efficient use of<br />
resources is best achieved by a well-trained, flexible and multiskilled<br />
workforce [29].<br />
Extended roles facilitate job satisfaction and encourage personal development<br />
and staff retention. Many health care assistants in the day surgery<br />
unit are now able to perform duties traditionally only undertaken by<br />
qualified nurses [30–32]. Individual units should formulate a staffing<br />
structure that takes into consideration local needs.<br />
Each unit should have a multidisciplinary operational group that oversees<br />
the day-to-day running of the unit, agrees policies and timetables, reviews<br />
operational problems and organises audit strategies.<br />
Facilities<br />
Day surgery should ideally be provided in a self-contained unit that is<br />
functionally and structurally separate from inpatient wards and theatres<br />
[33]. It should have its own reception, consulting rooms, ward, theatre<br />
and recovery areas, together with administrative facilities. The operating<br />
theatre and first stage recovery areas should be equipped and staffed to<br />
the same standards as an inpatient facility, with the exception of the<br />
use of trolleys rather than beds. Several patients per day can occupy the<br />
same trolley space, providing far greater efficiency than on wards where<br />
one day case may occupy a bed for a whole day. Car parking or<br />
short stay drop-off and pick-up areas should be provided adjacent to the<br />
unit.<br />
An alternative to a purpose-built unit is the use of a day case ward with<br />
patients transferred to the main operating theatre. This model allows a more<br />
straightforward transition from overnight stay to day case for complex<br />
procedures as there is little impact on theatre equipment or staffing.<br />
However, day case beds dispersed around many wards do not achieve these<br />
efficiencies, nor do they provide the targeted service that is required to<br />
achieve good outcomes.<br />
Typical day unit opening hours would be 07:00–20:00 Monday to<br />
Friday, but with the increasing complexity of surgery many units now open<br />
until about 22:00.<br />
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Guidelines: Day case and short stay surgery<br />
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Many hospitals provide care for day surgery patients who require<br />
anaesthesia in specialised units, e.g. ophthalmology or dentistry. It may not<br />
be possible or appropriate to centralise these services; however, all such<br />
patients should receive the same high standards of selection, preparation,<br />
peri-operative care, discharge and follow-up as those attending dedicated<br />
day surgery facilities.<br />
Facilities should ensure the maintenance of patients’ privacy and<br />
dignity at all times. Side rooms are particularly useful when caring for<br />
patients requiring an increased level of sensitivity, or for those with<br />
special needs.<br />
Children should be cared for in a facility that reflects their emotional<br />
and physical needs, separate from adult patients and conforming to the<br />
standards required by paediatric units. Nursing staff should be skilled in<br />
paediatric day surgical care. Parents and carers, wherever possible, should<br />
be involved in all aspects of care and appropriate facilities provided for<br />
them.<br />
Anaesthetic management<br />
Day surgery anaesthesia should be a consultant-led service. However, as<br />
day surgery becomes the norm for elective surgery, consideration should<br />
be given to education of trainees as recommended by the RCoA. This<br />
requires appropriate training and provision of senior cover, especially in<br />
stand-alone units. Staff grade and associate specialist anaesthetists who<br />
have an interest in day surgery should be encouraged to develop this as a<br />
specialist interest and take an important role in the management of the<br />
unit.<br />
Appropriate selection and patient preparation is crucial for day surgery.<br />
National guidelines for patient monitoring and assistance for the anaesthetist<br />
should be followed [34, 35].<br />
Anaesthetic techniques should ensure minimum stress and maximum<br />
comfort for the patients and should take into consideration the risks and<br />
benefits of the individual techniques. Analgesia is paramount and must be<br />
long acting but, as morbidity such as nausea and vomiting must be<br />
minimised, the indiscriminate use of opioids is discouraged (particularly<br />
morphine). Prophylactic oral analgesics with long-acting non-steroidal antiinflammatory<br />
drugs (NSAIDs) should be given to all patients if not<br />
contraindicated. For certain procedures (e.g. laparoscopic cholecystectomy)<br />
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there is evidence that standardised anaesthesia protocols or techniques<br />
improve outcome. Anaesthetists should adhere to such clinical guidelines<br />
where they exist.<br />
Although early mobilisation should be beneficial, extending the range<br />
and complexity of day surgery procedures may increase the risk of VTE.<br />
National guidelines for VTE risk assessment and prophylaxis should be<br />
followed.<br />
Policies should exist for the management of postoperative nausea and<br />
vomiting (PONV) and discharge analgesia. Prophylactic antiemetics are<br />
only recommended in patients with a strong history of PONV, motion<br />
sickness and those undergoing certain procedures such as laparoscopic<br />
sterilisation ⁄ cholecystectomy or tonsillectomy. However, it is important<br />
that PONV is treated seriously once it occurs. Routine use of intravenous<br />
fluids can enhance the patients’ feeling of wellbeing and further reduce<br />
PONV [36].<br />
Regional anaesthesia<br />
Local infiltration and nerve blocks can provide excellent anaesthesia and<br />
pain relief after day surgery. Patients may safely be discharged home with<br />
residual sensory or motor blockade, provided the limb is protected and<br />
appropriate support is available for the patient at home. The expected<br />
duration of the blockade must be explained and the patient must receive<br />
written instructions as to their conduct until normal power and sensation<br />
returns. Infusions of local anaesthesia may also have a place [37]. The use of<br />
ultrasound is increasingly gaining popularity, particularly in upper limb<br />
surgery, and is recognised as a useful tool in several areas of regional<br />
anaesthesia.<br />
Central neuraxial blockade (spinal or caudal) can be useful in day<br />
surgery and is increasing in popularity, although residual blockade may<br />
cause postural hypotension or urinary retention despite the return of<br />
adequate motor and sensory function. These problems can be minimised<br />
by choosing an appropriate local anaesthetic agent or by the use of lowdose<br />
local anaesthetic ⁄ opioid mixtures [38]. Suggested criteria before<br />
attempting ambulation after neuraxial block include the return of<br />
sensation in the perianal area (S4-5), plantar flexion of the foot at preoperative<br />
levels of strength and return of proprioception in the big toe<br />
[39].<br />
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Sedation is seldom needed but, if used, suggested discharge criteria<br />
should be met and the patient must receive an appropriate<br />
explanation.<br />
Oral analgesics should be started before the local anaesthesia begins to<br />
wear off and also given subsequently on a regular basis.<br />
The patient’s hydration should be checked. Concerns about post-dural<br />
puncture headache (PDPH) have limited the use of spinals in day surgery<br />
patients in the past, but the use of smaller gauge (‡ 25-G) and pencil-point<br />
needles has reduced the incidence to < 1%. Information about PDPH and<br />
what to do if this occurs should be included in the patient’s discharge<br />
instructions as well as the provision of alternative analgesics. Further<br />
information on the use of spinal anaesthesia in day surgery and examples of<br />
patient information leaflets can be found on the BADS website (http://<br />
www.bads.co.uk).<br />
The current nationally agreed curriculum limits the scope of PA (A)s. On<br />
completion of training they are not qualified to undertake regional<br />
anaesthesia or regional blocks [40].<br />
Postoperative recovery and discharge<br />
Recovery from anaesthesia and surgery can be divided into three phases:<br />
1 First stage recovery lasts until the patient is awake, protective reflexes<br />
have returned and pain is controlled. This should be undertaken in a<br />
recovery area with appropriate facilities and staffing [41]. Use of<br />
modern drugs and techniques may allow early recovery to be complete<br />
by the time the patient leaves the operating theatre, allowing some<br />
patients to bypass the first stage recovery area [42]. Most patients who<br />
undergo surgery with a local anaesthetic block can be fast-tracked in<br />
this manner.<br />
2 Second stage recovery ends when the patient is ready for discharge from<br />
hospital. This should ideally be in an area adjacent to the day surgery<br />
theatre. It should be equipped and staffed to deal with common<br />
postoperative problems (PONV, pain) as well as emergencies (haemorrhage,<br />
cardiovascular events). The anaesthetist and surgeon (or a deputy)<br />
must be contactable to help deal with problems. Nurse-led discharge<br />
using agreed protocols is appropriate (Appendix 3). Some of the<br />
traditional discharge criteria such as tolerating fluids and passing urine are<br />
no longer enforced. Mandatory oral intake is not necessary and may<br />
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provoke nausea and vomiting and delay discharge. Voiding is also not<br />
always required, although it is important to identify and retain patients<br />
who are at particular risk of developing later problems, such as those who<br />
have experienced prolonged instrumentation or manipulation of the<br />
bladder [43]. Protocols may be adapted to allow low-risk patients to be<br />
discharged without fulfilling traditional criteria. Mild postoperative<br />
confusion in the elderly after surgery is common. This is usually<br />
insignificant and should not influence discharge provided social circumstances<br />
permit; in fact, the avoidance of hospitalisation after minor<br />
surgery is preferred [15, 44]. Patients and their carers should be provided<br />
with written information that includes warning signs of possible<br />
complications and where to seek help. Protocols should exist for the<br />
management of patients who require unscheduled admission, especially<br />
in a stand-alone unit.<br />
3 Late recovery ends when the patient has made a full physiological and<br />
psychological recovery from the procedure. This may take several weeks<br />
or months and is beyond the scope of this document.<br />
Postoperative instructions and discharge<br />
All patients should receive verbal and written instructions on discharge and<br />
be warned of any symptoms that might be experienced. Wherever possible,<br />
these instructions should be given in the presence of the responsible person<br />
who is to escort and care for the patient at home.<br />
Advice should be given not to drink alcohol, operate machinery or drive<br />
for 24 h after a general anaesthetic [45]. More importantly, patients should<br />
not drive until the pain or immobility from their operation allows them to<br />
control their car safely and perform an emergency stop. Procedure-specific<br />
recommendations regarding driving should be available.<br />
All patients should be discharged with a supply of appropriate analgesics<br />
and instructions in their use. Analgesia protocols (Appendix 4) relating<br />
to day surgery case mix should be agreed with the pharmacy. Free<br />
pre-packaged take-home medications should be provided as they are<br />
convenient and prevent delays and unnecessary visits to the hospital<br />
pharmacy.<br />
Discharge summary<br />
It is essential to inform the patient’s general practitioner promptly of<br />
the type of anaesthetic given, the surgical procedure performed and<br />
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postoperative instructions given. Patients should be given a copy of this<br />
discharge summary to have available should they require medical assistance<br />
overnight.<br />
Day surgery units must agree with their local primary care teams how<br />
support is to be provided for patients in the event of postoperative<br />
problems. Best practice is a helpline for the first 24 h after discharge<br />
and to telephone the patient the next day. Telephone follow-up is<br />
highly rated by patients, provides support for any immediate complications,<br />
and is useful for auditing postoperative symptoms and patient<br />
satisfaction.<br />
Audit<br />
Effective audit is an essential component of assessing, monitoring and<br />
maintaining the efficiency and quality of patient care in day surgery units.<br />
Systems should be in place to ensure the routine collection of data regarding<br />
patient throughput and outcomes. There have been a variety of tools<br />
developed to determine patient outcomes. Questionnaires, which rely on<br />
the patients’ completing documentation and returning them to the day<br />
unit, are notoriously inaccurate and response rates are often very low. The<br />
most successful units collect data electronically at all stages of the day<br />
surgery process.<br />
The RCoA’s compendium of audit recipes devotes a section to possible<br />
audits relevant to day surgery [46]. It must be stressed that the most<br />
reliable way of improving service is continuous audit and review of<br />
outcomes rather than one-off snapshots. Information regarding trends in<br />
the patients’ outcomes should be widely distributed amongst the members<br />
of the team.<br />
Audit of day surgery services relate primarily to quality of care and<br />
efficiency. Examples of day surgery processes amenable to audit that have<br />
some measurable outcomes are shown in Table 2.<br />
Audit of patients’ satisfaction should be carried out routinely. A robust<br />
database is helpful; however, the best databases fail to effect change unless<br />
the information is clearly displayed and freely disseminated to the day<br />
surgery users. Monthly graphs and figures detailing all outcomes and trends<br />
should be disseminated to everyone, particularly to key individuals<br />
empowered to influence change.<br />
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Table 2 Day surgery processes amenable to audit.<br />
Component of process<br />
Outcome measure<br />
Booking process<br />
Patients failing to attend for surgery ⁄ theatre utilisation<br />
Pre-operative preparation Patients cancelled on the day of surgery ⁄ patients failing to<br />
attend<br />
Admission process<br />
Theatre start times<br />
Anaesthesia quality<br />
Unplanned admission rates ⁄ postoperative symptoms<br />
Surgery quality<br />
Unplanned admission rates ⁄ postoperative symptoms<br />
Recovery Discharge times ⁄ unplanned admission rates ⁄<br />
postoperative symptoms<br />
Discharge process<br />
Episodes of unplanned contact with primary care ⁄ out of<br />
hours health services<br />
Postoperative follow-up Episodes of unplanned contact with primary care ⁄ out of<br />
hours health services<br />
Audit<br />
Quality and efficiency improvements<br />
Teaching and training<br />
The RCoA has placed Day Surgery as a core module in all three<br />
components of anaesthetic training: Basic (year 1 ⁄ 2) [47], Intermediate<br />
(year 3 ⁄ 4) [48] and Higher (year 5 ⁄ 6 ⁄ 7) [49]. It also recommends day<br />
surgery as a specialty for advanced level training [50]. However, formal<br />
day surgery training programmes for anaesthetic (and surgical) trainees are<br />
rare.<br />
The competencies required by the RCoA cover the entire day surgery<br />
process, not simply the anaesthetic component. It is essential to design a<br />
well-structured module that provides training in anaesthesia for all<br />
aspects of day surgery and exposure to the organisational challenges of<br />
running a day surgery unit. To facilitate this, it is recommended that<br />
advanced training should take place in a dedicated day surgery unit [50],<br />
yet few such units exist. It is important to remember that high quality<br />
day surgery requires the experience of senior anaesthetists (and surgeons)<br />
and that although the day surgery unit is an ideal environment for<br />
training junior medical staff, relying on them to deliver the service<br />
results in poorer quality patient outcomes and reduced efficiency<br />
[51, 52].<br />
A list of topics that might be included in a day surgery module is shown<br />
in Appendix 5.<br />
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The training delivery should be audited; some suggestions for this are<br />
given in the RCoA audit compendium [46].<br />
The day surgery unit is an excellent environment for surgical and nursing<br />
training and many of the aspects covered above are equally applicable to<br />
surgical and nursing colleagues.<br />
Day surgery in special environments<br />
A number of complex and highly specialist procedures are beginning to<br />
enter the day surgery arena. Awake craniotomy for tumour resection has<br />
been performed as a day case in the UK [53]. In the interventional X-ray<br />
suite, uterine artery embolisation is a day case procedure, whereas<br />
endovascular aneurysm stents and several other procedures are appropriate<br />
for a short stay approach. Optimal care for these procedures should be<br />
developed by those with expertise in day and short stay surgery, working in<br />
collaboration with specialists in the management of the specific procedure.<br />
Many of these procedures are undertaken in challenging environments,<br />
such as X-ray departments. All the accepted standards for delivery of<br />
anaesthesia, assistance for the anaesthetist, minimal monitoring and the<br />
availability of appropriate recovery (post-anaesthesia care unit (PACU))<br />
facilities should be achieved.<br />
Introducing new procedures to day surgery<br />
The successful introduction of new procedures to day surgery depends on<br />
many factors, including the procedure itself and surgical, nursing and<br />
anaesthetic colleagues. It is important to evaluate the procedure while still<br />
performing it as an overnight stay and identify any steps in the process<br />
that require modification to enable it to be performed as a day case, e.g.<br />
timing of postoperative X-rays, modification of intravenous antibiotic<br />
regimens, physiotherapy input and analgesia protocols [54]. A multidisciplinary<br />
visit to another unit where the procedure is performed<br />
successfully as a day case can be very helpful. Initially limiting the<br />
procedure to a few colleagues (surgeons and anaesthetists) allows an<br />
opportunity to evaluate and optimise techniques and to implement step<br />
changes so that the patient can be discharged safely and with good<br />
analgesia. Support from community nursing can be helpful, especially in<br />
these early stages. Once the procedure has been successfully moved to the<br />
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day surgery setting it can be expanded to include other surgeons and<br />
anaesthetists as appropriate. Clear clinical protocols help to ensure that all<br />
the lessons learned during the evaluation phase are clearly passed on to<br />
colleagues.<br />
Isolated day surgery units<br />
Many day surgery facilities in the UK and Ireland are isolated and the<br />
number of these is increasing. Currently, there is no set absolute<br />
minimum distance between any stand-alone unit and the nearest acute<br />
or associated hospital, although large distances are uncommon. The<br />
commissioning of any new isolated stand-alone unit requires analysis of<br />
its suitability for the provision of intended services. These facilities may<br />
or may not be purpose-built and the Clinical Lead must be aware of this<br />
in managing any risk. Any association with a nearby acute unit should<br />
be reviewed regularly.<br />
Remoteness is a factor to be considered in the delivery of a safe and<br />
efficient service. A minimum of two anaesthetists on site should be<br />
considered at any one time. Prolonged travel time may be an issue for<br />
visiting staff. On-call commitments must be taken into account so as to<br />
avoid accidents and fatigue either in theatre or when travelling.<br />
The operational policy must agree clear management of certain key<br />
issues. These include:<br />
• Management of patients who cannot be discharged home.<br />
• Management of patients with problems after discharge.<br />
• Appropriate cover for the service and patients until they are<br />
discharged.<br />
• Appropriate patient screening and selection with availability of medical<br />
records.<br />
• Management of medical emergencies, e.g. cardiac arrest and major<br />
haemorrhage, and the availability of materials and skilled personnel to<br />
deal with complications when the anaesthetist is in theatre.<br />
• Transfer agreements with local hospitals and intensive care facilities<br />
• Robust, tested communications between the stand-alone unit, the<br />
nearest acute hospital and the ambulance services.<br />
• Teaching, training and supervision and opportunities for research.<br />
This list is not meant to be exhaustive but gives guidance to some of the<br />
important areas that require consideration.<br />
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Short stay surgery and enhanced recovery<br />
New approaches to the assessment and management of patients undergoing<br />
more complex surgery are being used to improve the quality of recovery,<br />
reduce the incidence of postoperative complications and reduce lengths of<br />
stay. Many of these techniques are based on the wider application of wellestablished<br />
day surgery principles and are aimed at improving the quality of<br />
recovery so that the patient is well enough to go home sooner. These<br />
strategies are variously called enhanced recovery, fast-track [55], accelerated<br />
or rapid recovery. For any surgical operation there is a large variation in<br />
average lengths of stay in hospitals across the UK and Ireland. Increasing<br />
numbers of hospitals are focusing on the short stay pathway and plan to<br />
manage the majority of their elective patients with stays of fewer than 72 h.<br />
To achieve the maximum benefit from this, hospitals are developing 24-h<br />
stay facilities (some as part of their existing day units) and are embracing<br />
these principles.<br />
Principles of enhanced recovery<br />
Enhanced recovery is the outcome of applying a range of multimodal<br />
strategies that are designed to prepare and optimise patients before, during<br />
and after surgery, ensuring prompt recovery and discharge [12]. Most of<br />
these principles are already well established in day surgery, which can be<br />
considered the ultimate example of enhanced recovery. Anaesthetic<br />
departments should play a major role in this as they can contribute<br />
extensively to all phases of the patients’ management. Many of these<br />
interventions are derived from day surgery.<br />
Pre-operative factors<br />
Pre-operative preparation of the patient plays a crucial role and identifies<br />
additional risk factors and ensures that their medical condition is<br />
optimised. Cardiopulmonary exercise testing provides further information<br />
to enable anaesthetists to discuss these risks with their patients and ensure<br />
that high-risk patients are counselled appropriately. An appropriate level<br />
of intensive or high dependency care can also be put in place if<br />
necessary. Patients and their carers should receive a careful explanation<br />
about the procedure and what will happen to them at every stage of the<br />
peri-operative pathway. This includes resumption of food, drink,<br />
mobilisation and information about discharge and when this is likely<br />
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to take place. As with day surgery, the provision of written information<br />
is vital.<br />
Patients should usually be admitted on the day of surgery with minimal<br />
starvation times (i.e. 3 h for fluids) and consideration given to the use of<br />
oral carbohydrate loading. Analgesia with paracetamol and NSAIDs<br />
should be started pre-operatively if not contraindicated, and hypothermia<br />
avoided.<br />
Intra-operative factors<br />
Minimally invasive surgery should be combined with use of regional<br />
anaesthesia where possible. Thoracic epidurals or other regional anaesthetic<br />
techniques should normally be used for abdominal surgery in patients likely<br />
to require more than oral analgesia postoperatively. Long acting opioids,<br />
nasogastric tubes and surgical drains should be avoided. Intra-operative fluid<br />
therapy should be goal directed to avoid sodium ⁄ fluid overload and<br />
attention should be paid to maintaining normothermia. Anaesthetic<br />
techniques are otherwise similar to day surgery with the expectation that<br />
patients will mobilise and eat ⁄ drink later in the day.<br />
Postoperative factors<br />
Effective analgesia that minimises the risk of PONV and allows early<br />
mobilisation plays a vital role in enhanced recovery. Systemic opioids<br />
should be avoided where possible and regular oral (or intravenous) analgesia<br />
with simple analgesics (paracetamol and NSAIDs) should be used. For more<br />
invasive procedures, epidural analgesia should be maintained in the<br />
postoperative period. Hydration should be maintained with intravenous<br />
fluids but discontinued as soon as the patient returns to oral fluids, and<br />
PONV should be treated aggressively using a multimodal approach to<br />
therapy.<br />
The patient should be mobilised within 24 h. They should be aware and<br />
encouraged to meet milestones for mobilisation, drinking and eating. This<br />
requires active involvement from both the medical and nursing teams in the<br />
immediate postoperative period. The provision of a specified dining room,<br />
with access to high calorie drinks and where meals can be taken, encourages<br />
the patient to mobilise.<br />
There should be a target discharge date set for which the staff, patients<br />
and relatives should aim, and as in day surgery the discharge should be a<br />
nurse-led process and not dependent on consultant review.<br />
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The patient’s perspective<br />
A Mayo Clinic study in 2006 showed that patients want their doctors to be<br />
confident, empathetic, humane, personal, forthright, respectful and thorough<br />
[56]. Interestingly, there was no mention of competence, implying<br />
that patients inherently believe their doctors to be competent. A survey<br />
carried out by MORI on behalf of the RCoA in May 2000 found that 35%<br />
of the general public did not believe that anaesthetists were medically<br />
qualified doctors [57]. Hence, there is a credibility gap that anaesthetists<br />
need to address. It is important to ensure that patients are made aware that<br />
anaesthetists are highly qualified professional doctors. The patient information<br />
leaflets produced by the AAGBI and the RCoA can be useful in this<br />
regard.<br />
It is important to realise that to most patients, anaesthesia means general<br />
anaesthesia with loss of consciousness during the procedure, and the patient<br />
sees this as ceding total control to someone else. Nobody is really<br />
completely comfortable with this. The psychology of surrendering control<br />
can result in patient attitudes that may not be explicitly communicated to<br />
the anaesthetist. This can cause a lot of stress and anxiety. Patients are<br />
therefore worried about:<br />
• Never waking up.<br />
• Dying during an operation.<br />
• Waking up during surgery.<br />
• Feeling pain and possibly not being able to make anyone else aware.<br />
In a recent study [58], the top three were identified as being of most<br />
concern to day case patients. The same study highlighted that the factor that<br />
alleviated most anxiety was the presence of a partner or friend, especially<br />
during recovery. Importantly, patients were more receptive to anaesthetists’<br />
visiting and giving information about the procedure than to information<br />
provided by the nursing staff.<br />
Other concerns that are relatively common to patients having a general<br />
anaesthetic are also associated with loss of control:<br />
• Embarrassment about perceived loss of control of bodily functions e.g.<br />
wetting the bed, or saying something inappropriate while still drowsy.<br />
• Nausea and vomiting.<br />
It is important for the anaesthetist to offer reassurances, as this has the<br />
greatest impact compared with delegating this responsibility to the nursing<br />
staff. Apprehensive patients don’t easily absorb big words. Explanations<br />
should be given in simple terms, avoiding jargon and not using emotive<br />
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language. This is particularly important in helping children understand the<br />
planned procedure and what is to follow. Information provided in writing<br />
before the day of surgery also helps.<br />
A patient about to undergo elective surgery often has contradicting<br />
feelings. On the one hand they are glad that the surgery will cure their<br />
medical problem and provide a life enhancing experience. On the other<br />
hand they are riddled with innumerable anxieties and although it might<br />
seem routine and straightforward to the doctor, the patient will inevitably<br />
view it all very differently. No patient expects surgery to be actually<br />
enjoyable, but what is most appreciated is information delivered by a<br />
respected, highly trained professional, who is empathetic and regards the<br />
patient as a person and not merely as a statistic.<br />
An information leaflet designed to help patients prepare themselves for<br />
day surgery is available on the BADS website [59].<br />
References<br />
1 Department of Health. The NHS Plan. A Plan for Investment. A Plan for Reform.<br />
London: DoH, 2000.<br />
2 NHS Institute for Innovation and Improvement. Better Care, Better Value<br />
Indicators. http://www.productivity.nhs.uk (accessed 03 ⁄ 01 ⁄ 2011).<br />
3 Department of Health NHS Modernisation Agency. 10 High Impact Changes for<br />
Service Improvement and Delivery, 2004. http://www.ogc.gov.uk/documents/<br />
Health_High_Impact_Changes.pdf (accessed 03 ⁄ 01 ⁄ 2011).<br />
4 Department of Health. Day surgery: Operational Guide. Waiting, Booking and<br />
Choice, 2002. http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/<br />
@dh/@en/documents/digitalasset/dh_4060341.pdf (accessed 03 ⁄ 01 ⁄ 2011).<br />
5 NHS Institute for Innovation and Improvement. Focus On: Cholecystectomy.<br />
Coventry: NHS Institute for Innovation and Improvement, 2006.<br />
6 Association of Anaesthetists of Great Britain and Ireland. Pre-operative Assessment<br />
and Patient Preparation – The Role of the Anaesthetist 2. London: AAGBI, 2010.<br />
7 British Association of Day Surgery. Ten Dilemmas in Preoperative Assessment for<br />
Day Surgery. London: BADS, 2009.<br />
8 British Association of Day Surgery. Organisational Issues in Pre Operative Assessment<br />
for Day Surgery. London: BADS, 2010.<br />
9 British Association of Day Surgery. Ten More Dilemmas in Day Surgery. London:<br />
BADS, 2008.<br />
10 British Association of Day Surgery. Nurse Led Discharge. London: BADS, 2009.<br />
11 British Association of Day Surgery. BADS Directory of Procedures, 3rd edn.<br />
London: BADS, 2009.<br />
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12 NHS Enhanced Recovery Partnership Programme. Delivering Enhanced recovery.<br />
Helping Patients to Get Better Sooner After Surgery, 2010. http://www.dh.gov.uk/<br />
dr_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/<br />
dh_115156.pdf (accessed 03 ⁄ 01 ⁄ 2011).<br />
13 Ansell GL, Montgomery JE. Outcome of ASA III patients undergoing day case<br />
surgery. British Journal of Anaesthesia 2004; 92: 71–4.<br />
14 Aldwinckle RJ, Montgomery JE. Unplanned admission rates and post discharge<br />
complications in patients over the age of 70 following day case surgery.<br />
Anaesthesia 2004; 59: 57–9.<br />
15 Canet J, Raeder J, Rasmussen LS, et al. Cognitive dysfunction after minor<br />
surgery in the elderly. Acta Anaesthesiologica Scandinavica 2003; 47: 1204–10.<br />
16 Davies KE, Houghton K, Montgomery JE. Obesity and day-case surgery.<br />
Anaesthesia 2001; 56: 1112–5.<br />
17 Lewis S, Stocker M, Houghton K, Montgomery JE. A patient survey to<br />
determine how day surgery patients would like preoperative assessment to be<br />
conducted. Journal of One-day Surgery 2009; 19: 32–6.<br />
18 National Institute for Health and Clinical Excellence. NICE Clinical Guideline<br />
3 — Pre-operative tests. The Use of Routine Preoperative Tests for<br />
Elective Surgery, 2003. http://www.nice.org.uk/CG003 (accessed<br />
03 ⁄ 01 ⁄ 2011).<br />
19 Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT. Elimination of<br />
preoperative testing in ambulatory surgery. Anesthesia and Analgesia 2009; 108:<br />
467–75.<br />
20 Smith I. Emergency day surgery. Journal of One-day Surgery 2009; 19: 2–3.<br />
21 Bhattacharyya M, Gerber B. Minimally-invasive surgical repair of ruptured<br />
Achilles tendon as a day case procedure with early full weight bearing. Journal of<br />
One-day Surgery 2007; 17: 70–5.<br />
22 Howells N, Tompsett E, Moore A, Hughes A, Livingstone J. Day surgery for<br />
trauma patients. Journal of One-day Surgery 2009; 19: 23–6.<br />
23 Mayell AC, Barnes SJ, Stocker ME. Introducing emergency surgery to the day<br />
case setting. Journal of One-day Surgery 2009; 19: 10–3.<br />
24 Miyagi K, Yao C, Lazenby K, Himpson R, Ingham Clark CL. Use of the day<br />
surgery unit for emergency surgical cases. Journal of One-day Surgery 2009; 19:<br />
5–8.<br />
25 Curtis MJ, Samsoon G, Parmar N. Fixation of clavicle fractures: the role of day<br />
surgery? Journal of One-day Surgery 2004; 14: 89–90.<br />
26 British Association of Day Surgery. Examples of Useful Patient Documentation.<br />
http://www.bads.co.uk/bads/joomla/index.php?option=com_content&view=<br />
article&id=60&Itemid=95 (accessed 09 ⁄ 10 ⁄ 2010).<br />
27 Royal College of Anaesthetists and Association of Anaesthetists of Great Britain<br />
and Ireland. You and Your Anaesthetic. Information to Help Patients Prepare<br />
Ó 2011 The Authors<br />
Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 21
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
for an Anaesthetic, 3rd edn. London: RCoA ⁄ AAGBI, 2008 http://www.rcoa.<br />
ac.uk/docs/PI_yaya.pdf (accessed 03 ⁄ 01 ⁄ 2011).<br />
28 The Royal College of Anaesthetists. Anaesthesia Information for Children and<br />
Young People, 2010. http://www.rcoa.ac.uk/index.asp?PageID=1520 (accessed<br />
03 ⁄ 01 ⁄ 2011).<br />
29 British Association of Day Surgery. Skill Mix and Nursing Establishment for Day<br />
Surgery. London: BADS, 2009.<br />
30 Tickner C. Health care assistant enabled discharge. Journal of One-day Surgery<br />
2009; 17: 106–9.<br />
31 Perioperative Care Collaborative. Delegation: The Support Worker in the Scrub<br />
Role, 2007. http://www.proprius.org.uk/documents/Delegation.pdf (accessed<br />
03 ⁄ 01 ⁄ 2011).<br />
32 Perioperative Care Collaborative. Optimising the Contribution of the Perioperative<br />
Support Worker, 2007. http://www.proprius.org.uk/documents/Perioperative-<br />
Support.pdf (accessed 03 ⁄ 01 ⁄ 2011).<br />
33 Castero C, Bertinato L, Baccaglini U, Drace C, McKee M. Perioperative Care<br />
Collaborative. Copenhagen: WHO European Centre for Health, 2007.<br />
34 Association of Anaesthetists of Great Britain and Ireland. Standards of Monitoring<br />
During Anaesthesia and Recovery 4. London: AAGBI, 2007.<br />
35 Association of Anaesthetists of Great Britain and Ireland. The Anaesthesia Team 3.<br />
London: AAGBI, 2010.<br />
36 Yogendran S, Asokumar B, Cheng DCH, Chung F. A prospective<br />
randomized double-blind study of the effect of intravenous fluid therapy on<br />
adverse outcomes on outpatient surgery. Anesthesia and Analgesia 1995; 80:<br />
682–6.<br />
37 Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-controlled<br />
local anesthetic administration at home. Anesthesia and Analgesia 1998; 86:<br />
86–9.<br />
38 British Association of Day Surgery. Spinal Anaesthesia for Day Surgery Patients.<br />
London: BADS, 2010.<br />
39 Pflug AE, Aasheim GM, Foster C. Sequence of return of neurological function<br />
and criteria for safe ambulation following subarachnoid block. Canadian<br />
Anaesthetists’ Society Journal 1978; 25: 133–9.<br />
40 Joint statement from the Association of Anaesthetists of Great Britain & Ireland<br />
and the Royal College of Anaesthetists. Physicians’ Assistants (Anaesthesia) –<br />
PA(A)s, 2008. http://www.rcoa.ac.uk/docs/PA(A)_JointStatement.pdf<br />
(accessed 03 ⁄ 01 ⁄ 2011).<br />
41 Association of Anaesthetists of Great Britain and Ireland. Immediate Postanaesthetic<br />
Recovery. London: AAGBI, 2002.<br />
42 Lubarsky DA. Fast track in the post-anesthesia care unit: unlimited possibilities?<br />
Journal of Clinical Anesthesia 1996; 8: 70S–2S.<br />
Ó 2011 The Authors<br />
22 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
43 Pavlin DJ, Pavlin EG, Fitzgibbon DR, Koerschgen ME, Plitt TM. Management<br />
of bladder function after outpatient surgery. Anesthesiology 1999; 91:<br />
42–50.<br />
44 Ward B, Imarengiaye C, Peirovy J, Chung F. Cognitive function is minimally<br />
impaired after ambulatory surgery. Canadian Journal of Anesthesia 2005; 52:<br />
1017–21.<br />
45 Chung F, Kayumov L, Sinclair DR, Edward R, Moller HJ, Shapiro CM. What<br />
is the driving performance of ambulatory surgical patients after general<br />
anesthesia? Anesthesiology 2005; 103: 951–6.<br />
46 Royal College of Anaesthetists. Raising the Standard: A Compendium of Audit<br />
Recipes. London: RCoA, 2006.<br />
47 The Royal College of Anaesthetists. CCT in Anaesthetics. Annex B. Basic Level<br />
Training, 2nd edn. London: RCoA, 2010.<br />
48 The Royal College of Anaesthetists. CCT in Anaesthetics. Annex C. Intermediate<br />
Level Training, 2nd edn. London: RCoA, 2010.<br />
49 The Royal College of Anaesthetists. CCT in Anaesthetics. Annex D. Higher Level<br />
Training, 2nd edn. London: RCoA, 2010.<br />
50 The Royal College of Anaesthetists. CCT in Anaesthetics. Annex E. Advanced<br />
Level Training, 2nd edn. London: RCoA, 2010.<br />
51 Royal College of Surgeons of England. Commission on the Provision of Surgical<br />
Services. Guidelines for Day Case Surgery. London: HMSO, 1992.<br />
52 Hanousek J, Stocker ME, Montgomery JE. The effect of grade of anaesthetist on<br />
outcome after day surgery. Anaesthesia 2009; 64: 150–5.<br />
53 Weidmann C, Grundy P. Day-case awake craniotomy for tumour resection.<br />
Journal of One-day Surgery 2008; 18: 45–7.<br />
54 Hamer C, Holmes K, Stocker M. A generic process for transferring procedures<br />
to the day case setting: the Torbay hospital proposal. Journal of One-day Surgery<br />
2008; 18: 9–12.<br />
55 Wilmore DW, Kehlet H. Recent advances: management of patients in fast track<br />
surgery. British Medical Journal 2001; 322: 473–6.<br />
56 Li JT. The quality of caring. Mayo Clinic Proceedings 2006; 81: 294–6.<br />
57 Corrado M, Carluccio A. Perceptions of anaesthetists – a survey of the general<br />
public research study conducted for the Royal College of Anaesthetists for<br />
National Anaesthesia Day. Royal College of Anaesthetists Newsletter 2000; 51:<br />
319–21 http://www.rcoa.ac.uk/docs/newsletter2000-51.pdf (accessed 03 ⁄ 01 ⁄<br />
2011).<br />
58 Mitchell M. General anaesthesia and day-case patient anxiety. Journal of Advanced<br />
Nursing 2010; 66: 1059–71.<br />
59 Advice for Patients. http://www.bads.co.uk/bads/joomla/images/stories/<br />
downloads/generaladvice.pdf, 2010 (accessed 03 ⁄ 01 ⁄ 2011).<br />
Ó 2011 The Authors<br />
Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 23
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Further reading<br />
1 Association for Perioperative Practice. Staffing for Patients in the<br />
Perioperative setting. Harrogate: AfPP, 2008.<br />
2 Department of Health. Getting the right start. National Service Framework<br />
for Children – Standard for Hospital Services. London: DoH, 2003.<br />
3 Department of Health and Children. Children First: National Guidelines<br />
for the Protection and Welfare of Children. London: DoH, 1999.<br />
4 Health Service Executive. HSE National Service Plan 2010. Dublin:<br />
HSE, 2010.<br />
5 Jakobson J. Anaesthesia for Day Case Surgery. New York: Oxford<br />
University Press, 2009.<br />
6 Lemos P, Jarrett P, Philip B eds. Day Surgery Development and Practice.<br />
Porto: International Association for Ambulatory Surgery, 2006.<br />
7 National Association for the Welfare of Children in Hospital. Caring for<br />
children in the Health Services. Just for the Day. London: The Stationery<br />
Office, 1991.<br />
8 National Leadership and Innovation Agency for Healthcare. Day<br />
Surgery in Wales: a guide to good practice. Cardiff: The Welsh Assembly<br />
Government, 2004.<br />
9 NHS Estates. HBN 26 Facilities for Surgical Procedures. Volume 1.<br />
London: The Stationery Office, 2004.<br />
10 NHS Management Executive Value for Money Unit. Day Surgery.<br />
Making it happen. London: HMSO, 1991.<br />
11 NHS Modernisation Agency. National Good Practice Guidelines on<br />
Pre-operative Assessment for Day Surgery. The Stationery Office,<br />
2002.<br />
12 Raeder J. Clinical Ambulatory Anesthesia. New York: Cambridge<br />
University Press, 2010.<br />
13 Scottish Health Planning Note 52: Accommodation for Day Care: Part<br />
1: Day surgery unit. Glasgow: Health Facilities Scotland, 2001.<br />
14 Smith I, ed. Day Care Anaesthesia. Fundamentals of Anaesthesia & Acute<br />
Medicine Series. London: BMJ Books, 2000.<br />
15 The Office of the Comptroller and Auditor General. Accounts of<br />
Public Services 2008. Dublin, Government of Ireland, 2009. http://<br />
www.audgen.gov.ie/documents/annualreports/2008/Appropriation_<br />
Account_2008Rev1.pdf (accessed 11 ⁄ 01 ⁄ 2011).<br />
Ó 2011 The Authors<br />
24 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Appendix 1<br />
Sample screening questionnaire for use in day surgery. University Hospital of<br />
North Staffordshire, with permission.<br />
Ó 2011 The Authors<br />
Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 25
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Ó 2011 The Authors<br />
26 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Appendix 2<br />
Sample patient information sheet for use in day surgery. Royal Surrey County<br />
Hospital NHS Foundation Trust, with permission.<br />
Ó 2011 The Authors<br />
Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 27
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Appendix 3<br />
Discharge checklist for day surgery. Reproduced from: British Association<br />
of Day Surgery. Nurse Led Discharge. London: BADS, 2009, with<br />
permission.<br />
Criteria Yes No N ⁄ A Initials Details<br />
Vital signs stable<br />
Orientated to time, place & person<br />
Passed urine (if applicable)<br />
Able to dress & walk (where appropriate)<br />
Oral fluids tolerated (if applicable)<br />
Minimal pain<br />
Minimal bleeding<br />
Minimal nausea ⁄ vomiting<br />
Cannula removed<br />
Responsible escort present<br />
Has carer for 24-h post op<br />
Written & verbal post op instructions<br />
Knows who to contact in an emergency<br />
Follow up appointment<br />
Removal of sutures required?<br />
Referrals made<br />
Dressings supplied<br />
Patient copy of GP letter<br />
Carbon copy of consent<br />
Sick certificate<br />
Has take home medication<br />
Next Dose:<br />
Information leaflet for tablets<br />
Post op phone call required<br />
Discharged by: Nurse’s Signature<br />
___________________________________________________<br />
Date ⁄ Time ____________ Print Name<br />
___________________________________________________<br />
Ó 2011 The Authors<br />
28 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Appendix 4a<br />
Acute pain protocol for adult surgery.<br />
Pain intensity<br />
Discharge medication<br />
Doctor’s signature<br />
(sign one box only)<br />
A None None<br />
B Mild Paracetamol 1 g qds<br />
C Moderate Paracetamol 1 g qds<br />
Plus<br />
Ibuprofen 600 mg qds<br />
C* Moderate<br />
(NSAID intolerant)<br />
Paracetamol 500 mg ⁄ codeine<br />
30 mg 1–2 tabs qds<br />
D Severe Paracetamol 500 mg ⁄ codeine<br />
30 mg 1–2 tabs qds<br />
Plus<br />
Ibuprofen 600 mg qds<br />
D* Severe<br />
(NSAID intolerant)<br />
Paracetamol 1 g qds<br />
Plus<br />
Oral morphine 20 mg qds<br />
Appendix 4b<br />
Pain categories for common procedures in the day surgery unit, to be used<br />
in conjunction with the above.<br />
A B C D<br />
EUA ears<br />
Cystoscopy<br />
Restorative<br />
dentistry<br />
Cataract surgery<br />
Grommets ⁄<br />
T-tube removal ⁄<br />
insertion<br />
Prostate biopsy<br />
Sebaceous cyst surgery<br />
Sigmoidoscopy<br />
Skin lesion surgery<br />
Urethral surgery<br />
Anal surgery<br />
Apicectomy<br />
Arthroscopy<br />
Axillary clearance<br />
Breast lumps<br />
Dupuytren’s contracture<br />
Carpal tunnel<br />
decompression<br />
Cervical ⁄ vulval surgery<br />
Hysteroscopy ⁄ D&C<br />
Middle ear surgery<br />
MUA ± steroid injection<br />
Vaginal sling<br />
Varicose vein surgery<br />
Vasectomy<br />
Non-wisdom tooth<br />
extraction<br />
ACL reconstruction<br />
Circumcision<br />
Endometrial ablation<br />
Laparoscopy<br />
Haemorrhoidectomy<br />
Hernia repair<br />
Joint fusions ⁄ osteotomy<br />
Shoulder surgery<br />
Squint surgery<br />
Testicular surgery<br />
Tonsillectomy<br />
Wisdom tooth extraction<br />
Dental clearance<br />
EUA ⁄ MUA, examination ⁄ manipulation under anaesthesia; ACL, anterior cruciate ligament<br />
Ó 2011 The Authors<br />
Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 29
Guidelines: Day case and short stay surgery<br />
.....................................................................................................................................<br />
Appendix 5<br />
Suitable topics for a training module in day case anaesthesia.<br />
1 Patient selection and preparation:<br />
• The role of patient selection in day surgery<br />
• Medical, social and surgical factors<br />
• Unit protocols for patient selection<br />
• The role of pre-operative preparation in day surgery<br />
• Instructions for ⁄ preparation of patients for day surgery<br />
• Management of patients with complex medical conditions<br />
• Recognition of patients who are unsuitable for day surgery<br />
2 Anaesthetic techniques for day surgery:<br />
• General anaesthetic techniques<br />
• Antiemetic therapy<br />
• Analgesia including the role of nerve blockade<br />
• Fluid therapy<br />
• Airway management<br />
3 Surgical techniques appropriate for day surgery:<br />
• Surgical advances enabling procedures to transfer to day surgery<br />
• Limitations of day surgery<br />
• Risks ⁄ concerns<br />
4 Recovery assessment and discharge criteria:<br />
• Adequacy of analgesia<br />
• Fitness for discharge<br />
• Role of early intervention in prevention of unplanned admissions<br />
• Instructions for patients<br />
• Discharge medication<br />
5 Postoperative follow up and audit:<br />
• Value of postoperative follow-up to patients and the unit<br />
• Use of information technology for audit of outcomes and service development<br />
6 Team working:<br />
• The day unit as a multidisciplinary team<br />
7 Children in the day surgery unit:<br />
• National Service Framework for Children’s requirements for provision of children’s services<br />
• Preparation of children for surgery<br />
8 Management of a day surgery unit:<br />
• Role of day surgery managers<br />
• Role of day surgery within the trust<br />
• Government’s agenda for day surgery<br />
• Booking processes for day surgery<br />
• Knowledge of local and national day surgery performance<br />
• Advances and controversies in day surgery<br />
Ó 2011 The Authors<br />
30 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland
The Association of Anaesthetists of Great Britain & Ireland<br />
21 Portland Place, London, W1B 1PY<br />
Tel: 020 7631 1650<br />
Fax: 020 7631 4352<br />
Email: info@aagbi.org<br />
Website: www.aagbi.org<br />
The British Association of Day Surgery<br />
35-43 Lincoln’s Inn Fields, London, WC2A 3PE<br />
Tel: 020 7973 0308<br />
Fax: 020 7973 0314<br />
Email: bads@bads.co.uk<br />
Website: www.bads.co.uk
AAGBI SAFETY GUIDELINE<br />
Checking Anaesthetic Equipment 2012<br />
Published by<br />
The Association of Anaesthetists of Great Britain and Ireland<br />
21 Portland Place, London, W1B 1PY<br />
Telephone 020 7631 1650 Fax 020 7631 4352<br />
info@aagbi.org<br />
www.aagbi.org June 2012
This guideline was originally published in Anaesthesia. If you wish to refer to<br />
this guideline, please use the following reference:<br />
Association of Anaesthetists of Great Britain and Ireland. Checking<br />
Anaesthetic Equipment 2012. Anaesthesia 2012; 67: pages 660-68. This<br />
guideline can be viewed online via the following URL: http://onlinelibrary.<br />
wiley.com/doi/10.1111/j.1365-2044.2012.07163.x/abstract<br />
© The Association of Anaesthetists of Great Britain 2012
Guidelines<br />
Checking Anaesthetic Equipment 2012<br />
Association of Anaesthetists of Great Britain and<br />
Ireland<br />
Membership of the Working Party: A. Hartle (Chair), E. Anderson,<br />
V. Bythell, L. Gemmell, H. Jones 1 , D. McIvor 2 , A. Pattinson 3 ,<br />
P. Sim 3 and I. Walker<br />
1 Royal College of Anaesthetists<br />
2 Medicines and Healthcare products Regulatory Agency<br />
3 British Association of Anaesthetic and Respiratory Equipment<br />
Manufacturers Association<br />
Summary<br />
A pre-use check to ensure the correct functioning of anaesthetic<br />
equipment is essential to patient safety. The anaesthetist has a primary<br />
responsibility to understand the function of the anaesthetic equipment and<br />
to check it before use. Anaesthetists must not use equipment unless they<br />
have been trained to use it and are competent to do so. A self-inflating bag<br />
must be immediately available in any location where anaesthesia may be<br />
given. A two-bag test should be performed after the breathing system,<br />
vaporisers and ventilator have been checked individually. A record should<br />
be kept with the anaesthetic machine that these checks have been done.<br />
The ‘first user’ check after servicing is especially important and must be<br />
recorded.<br />
Reuse of this article is permitted in accordance with the Creative Commons Deed, Attribution<br />
2.5, which does not permit commercial exploitation.<br />
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 1
Anaesthesia 2012<br />
Hartle et al. | Checking anaesthetic equipment<br />
..................................................................................................<br />
This is a consensus document produced by expert members of a Working<br />
Party established by the Association of Anaesthetists of Great Britain and<br />
Ireland (AAGBI). It has been seen and approved by the AAGBI Council.<br />
This article is accompanied by an Editorial. See page 571 of this issue.<br />
You can respond to this article at http://www.anaesthesiacorrespondence.com<br />
Accepted: 18 March 2012<br />
• What other guideline statements are available on this topic?<br />
Guidelines on checking anaesthetic equipment have been published by<br />
the Association of Anaesthetists of Great Britain and Ireland (AAGBI),<br />
and amongst others, the American Society of Anesthesiologists, the<br />
Australian and New Zealand College of Anaesthetists and the World<br />
Federation of Societies of Anesthesiologists.<br />
• Why was this guideline developed?<br />
The increasing sophistication and diversity of anaesthesia workstations<br />
made the AAGBI’s existing guideline less universally applicable.<br />
Incidents reported to the Medicines and Healthcare products<br />
Regulatory Agency (MHRA), National Patient Safety Agency (NPSA)<br />
and AAGBI also highlighted priority checks that would avoid harm.<br />
• How does this statement differ from existing guidelines?<br />
The checklist specifies outcomes rather than processes and covers all the<br />
equipment necessary to conduct safe anaesthesia, not just the<br />
anaesthesia workstation. It has been written by Officers and Council<br />
members of the AAGBI in conjunction with representatives of the Royal<br />
College of Anaesthetists (RCoA), MHRA, NPSA and manufacturers. It<br />
was modified after a consultation with the membership of the AAGBI<br />
and industry. It has been trialled and modified in simulator settings on<br />
different machines. It has been endorsed by the Chief Medical Officers<br />
of England, Scotland, Wales and Northern Ireland.<br />
• Why does this statement differ from existing guidelines?<br />
The guideline reflects anaesthetic practice and staffing in the UK and<br />
Ireland and is applicable to any anaesthetic machine, including those yet<br />
to be developed.<br />
The pre-use check to ensure the correct functioning of anaesthetic<br />
equipment is essential to patient safety. The importance of this pre-use<br />
check is recognised worldwide and the check has been included in the<br />
2 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Hartle et al. | Checking anaesthetic equipment Anaesthesia 2012<br />
World Health Organization’s Surgical Safety Checklist [1]. The AAGBI<br />
published the third edition of Checking Anaesthetic Equipment in 2004,<br />
and this has gained widespread acceptance in the profession. Changes in<br />
anaesthetic equipment and introduction of microprocessor-controlled<br />
technology necessitate continued revision of this document.<br />
This new edition of the safety guideline updates the procedures<br />
recommended in 2004 and places greater emphasis on checking all of the<br />
equipment required. A Working Party was established in 2009 comprising<br />
Officers and Council Members of the AAGBI and representatives of the<br />
Group of Anaesthetists in Training (GAT), RCoA, MHRA and the British<br />
Association of Anaesthetic and Respiratory Equipment Manufacturers<br />
Association (BAREMA). The Working Party reviewed the 2004 guideline,<br />
together with guidelines published by other organisations, and in addition<br />
reviewed incidents reported to the MHRA and the National Reporting and<br />
Learning Service (NRLS) of the NPSA [2]. The accompanying Checklist for<br />
Anaesthetic Equipment 2012 has been completely reformatted (Fig. 1).<br />
There are two new checklists – the first to be completed at the start of<br />
every operating session, the second a short set of checks before each case.<br />
The detail of how to perform these checks is given in this safety guideline.<br />
The first draft was circulated to the membership of the AAGBI and to<br />
manufacturers for comments, and the guideline amended in the light of<br />
these. Several versions of the checklist were trialled in simulators using<br />
different machines. The final version of the checklist was then submitted<br />
for further usability tests in simulators. The guideline and checklists have<br />
been endorsed by the Chief Medical Officers of England, Scotland, Wales<br />
and Northern Ireland.<br />
The principles set out in previous guidelines have governed<br />
amendments in this new edition. It must be emphasised that failure to<br />
check the anaesthetic machine and ⁄ or the breathing system features as a<br />
major contributory factor in many anaesthetic misadventures, including<br />
some that have resulted in hypoxic brain damage or death. The RCoA<br />
recognises the importance of these safety checks, and knowledge of them<br />
may be tested as part of the FRCA examination [3].<br />
The anaesthetist has a primary responsibility to understand the<br />
function of the anaesthetic equipment and to check it before use<br />
Anaesthetists must not use equipment unless they have been trained to use<br />
it and are competent to do so [4]. The NHS Clinical Negligence Scheme<br />
for Trusts and NHS Quality Improvement Scotland require that hospitals<br />
ensure all personnel are trained to use and to check relevant equipment<br />
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 3
Anaesthesia 2012<br />
Hartle et al. | Checking anaesthetic equipment<br />
Figure 1 Checklist for Anaesthetic Equipment 2012.<br />
[5, 6]. This may take place at induction for new staff or at the introduction<br />
of new equipment. This responsibility may be devolved to the department<br />
of anaesthesia, but where such a department does not exist other<br />
4 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Hartle et al. | Checking anaesthetic equipment Anaesthesia 2012<br />
This checklist is an abbreviated version of the publication by the Association of Anaesthetists of Great Britain and<br />
Ireland 'Checking Anaesthesia Equipment 2012'.<br />
Figure 1 (Continued).<br />
arrangements must be made. A record of training must be kept. The use of<br />
routine checks and associated checklists is an important part of training in<br />
anaesthesia, and is part of the RCoA’s Competency Based Training.<br />
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 5
Anaesthesia 2012<br />
Hartle et al. | Checking anaesthetic equipment<br />
Modern anaesthetic workstations<br />
The AAGBI checklist for anaesthetic equipment is applicable to all<br />
anaesthetic workstations and should take only a few minutes to perform. It<br />
represents an important part of safe patient care. It is not intended to<br />
replace the manufacturer’s pre-anaesthetic checks, and should be used in<br />
conjunction with them. For example, some modern anaesthetic workstations<br />
will enter a self-testing cycle when the machine is switched on, in<br />
which case those functions tested by the machine need not be retested by<br />
the user. The intention is to strike the right balance so that the AAGBI<br />
checklist for anaesthetic equipment is not so superficial that its value is<br />
doubtful or so detailed that it is impractical to use. Manufacturers may<br />
also produce checklists specific to their device; these should be used in<br />
conjunction with the AAGBI checklist for anaesthetic equipment.<br />
The checking procedure described covers all aspects of the anaesthetic<br />
delivery system from the gas supply pipelines, the machine and breathing<br />
systems, including filters, connectors and airway devices. It includes an<br />
outline check for ventilators, suction, monitoring and ancillary equipment.<br />
The anaesthetic equipment must be checked by trained staff on a<br />
routine basis using the checklist and according to the manufacturer’s<br />
instructions, in every environment where an anaesthetic is given. A record<br />
should be kept with the anaesthetic machine that these checks have<br />
been done.<br />
Each hospital must ensure that all machines are fully serviced at the<br />
regular intervals designated by the manufacturer and that a service record<br />
is maintained. As it is possible for errors to occur when reassembling an<br />
anaesthetic machine, it is essential to confirm that the machine is correctly<br />
configured for use after each service. The ‘first user’ check after servicing<br />
is especially important and must be recorded.<br />
Equipment faults may develop during anaesthesia that were either not<br />
present or not apparent on the pre-operative check. This may be caused by<br />
pipeline failure, electrical failure, circuit disconnection or incorrect<br />
configuration, etc. An immediate and brief check of equipment should<br />
be made if there is a critical incident involving a patient, even if the<br />
equipment was checked before the start of the case, as the incident may be<br />
caused by a primary problem with the equipment.<br />
The checking procedure described in this publication is reproduced in<br />
an abbreviated form, as a sheet entitled Checklist for Anaesthetic<br />
Equipment 2012 (Fig. 1). This laminated sheet should be attached to each<br />
anaesthetic machine and used to assist in the routine checking of<br />
anaesthetic equipment.<br />
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Procedures for checking anaesthetic equipment<br />
The following checks should be carried out at the beginning of each<br />
operating theatre session. In addition, specific checks should be carried out<br />
before each new patient during a session or when there is any alteration or<br />
addition to the breathing system, monitoring or ancillary equipment.<br />
It is the responsibility of the anaesthetist to make sure that these checks<br />
have been performed, and the anaesthetist must be satisfied that they have<br />
been carried out correctly. In the event of a change of anaesthetist during an<br />
operating session, the status of the anaesthetic equipment must be<br />
confirmed, including that a formal check has been performed.<br />
Before using any anaesthetic equipment, ventilator, breathing system<br />
or monitor, it is essential to be fully familiar with it. Modern anaesthetic<br />
workstations are complex devices. It is essential that anaesthetists have full<br />
training and formal induction for any machines they may use. A quick<br />
‘run-through’ before the start of an operating session is not acceptable.<br />
Careful note should be taken of any information or labelling on the<br />
anaesthetic machine that might refer to its current status.<br />
Alternative means of ventilation<br />
The early use of an alternative means of ventilation (a self-inflating bag<br />
that does not rely on a source of oxygen to function) may be life-saving. A<br />
self-inflating bag must be immediately available in any location where<br />
anaesthesia may be given [7, 8]. An alternative source of oxygen should be<br />
readily available.<br />
Perform manufacturer’s machine check<br />
Modern anaesthesia workstations may perform many of the following<br />
checks automatically during start-up. Users must know which are included<br />
and ensure that the automated check has been performed.<br />
Power supply<br />
Check that the anaesthetic workstation and relevant ancillary equipment<br />
are connected to the mains electrical supply (where appropriate) and<br />
switched on. The anaesthetic workstation should be connected directly to<br />
the mains electrical supply, and only correctly rated equipment connected<br />
to its electrical outlets. Multisocket extension leads must not be plugged<br />
into the anaesthetic machine outlets or used to connect the anaesthetic<br />
machine to the mains supply.<br />
Hospitals should have back-up generators, and many operating<br />
theatres will have their own back-up system. Anaesthetists should know<br />
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what is available where they are working. Back-up batteries for anaesthetic<br />
machines and other equipment should be charged.<br />
Switch on the gas supply master switch (if one is fitted).<br />
Check that the system clock (if fitted) is set correctly.<br />
Gas supplies and suction<br />
To check the correct function of the oxygen failure alarm involves<br />
disconnecting the oxygen pipeline on some machines, whilst on machines<br />
with a gas supply master switch, the alarm may be operated by turning the<br />
master switch off. As repeated disconnection of gas hoses may lead to<br />
premature failure of the Schrader socket and probe, these guidelines<br />
recommend that the regular pre-session check of equipment includes a ‘tug<br />
test’ to confirm correct insertion of each pipeline into the appropriate socket.<br />
It is therefore recommended that, in addition to these checks, the<br />
oxygen failure alarm must be checked on a weekly basis by disconnecting<br />
the oxygen hose whilst the oxygen flowmeter is turned on, and a written<br />
record kept. In addition to sounding an alarm, which must sound for at<br />
least 7 s, oxygen failure warning devices are also linked to a gas shut-off<br />
device. Anaesthetists must be aware of both the tone of the alarm and also<br />
which gases will continue to flow on the particular model of anaesthetic<br />
machine in use.<br />
Medical gas supplies<br />
Identify and take note of the gases that are being supplied by pipeline,<br />
confirming with a ‘tug test’ that each pipeline is correctly inserted into the<br />
appropriate gas supply terminal. Note that excessive force during a ‘tug<br />
test’ may damage the pipeline and ⁄ or gas supply terminal.<br />
1 Check that the anaesthetic apparatus is connected to a supply of oxygen<br />
and that an adequate reserve supply of oxygen is available from a spare<br />
cylinder.<br />
2 Check that adequate supplies of any other gases intended for use are<br />
available and connected as appropriate. All cylinders should be securely<br />
seated and turned off after checking their contents.<br />
3 Carbon dioxide cylinders should not be present on the anaesthetic<br />
machine. Where a blanking plug is supplied this should be fitted to any<br />
empty cylinder yoke.<br />
4 Check that all pressure gauges for pipelines connected to the anaesthetic<br />
machine indicate 400–500 kPa.<br />
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5 Check the operation of flowmeters, where these are present, ensuring that<br />
each control valve operates smoothly and that the bobbin moves freely<br />
throughout its range without sticking. If nitrous oxide is to be used, the<br />
anti-hypoxia device should be tested by first turning on the nitrous oxide<br />
flow and ensuring that at least 25% oxygen also flows. Then turn the<br />
oxygen flow off and check that the nitrous oxide flow also stops. Turn on<br />
the oxygen flow and check that the oxygen analyser display approaches<br />
100%. Turn off all flow control valves. (Machines fitted with a gas supply<br />
master switch will continue to deliver a basal flow of oxygen).<br />
6 Operate the emergency oxygen bypass control and ensure that flow<br />
occurs from the gas outlet without significant decrease in the pipeline<br />
supply pressure. Ensure that the emergency oxygen bypass control<br />
ceases to operate when released.<br />
Suction<br />
Check that the suction apparatus is functioning and all connections are<br />
secure; test for the rapid development of an adequate negative pressure.<br />
Breathing system and vaporisers<br />
Whole breathing system<br />
Check all breathing systems that are to be used and perform a ‘two-bag<br />
test’ before use, as described below [9]. Breathing systems should be<br />
inspected visually and inspected for correct configuration and assembly.<br />
Check that all connections within the system and to the anaesthetic<br />
machine are secured by ‘push and twist’. Ensure that there are no leaks or<br />
obstructions in the reservoir bags or breathing system and that they are<br />
not obstructed by foreign material. Perform a pressure leak test (between<br />
20 and 60 cmH 2 O on the breathing system by occluding the patient-end<br />
and compressing the reservoir bag.<br />
Vaporisers<br />
Manual leak testing of vaporisers was previously recommended routinely.<br />
It should only be performed on basic ‘Boyle’s’ machines and it may be<br />
harmful to many modern anaesthetic workstations. Refer to the<br />
manufacturer’s recommendation before performing a manual test.<br />
Check that the vaporiser(s) for the required volatile agent(s) are fitted<br />
correctly to the anaesthetic machine, that any locking mechanism is fully<br />
engaged and that the control knobs rotate fully through the full range(s).<br />
Ensure that the vaporiser is not tilted. Turn off the vaporisers.<br />
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Check that the vaporiser(s) are adequately filled but not overfilled, and<br />
that the filling port is tightly closed.<br />
Manual leak test of vaporiser<br />
1 Set a flow of oxygen of 5 l.min )1 and with the vaporiser turned off,<br />
temporarily occlude the common gas outlet. There should be no leak<br />
from any part of the vaporiser and the flowmeter bobbin (if present)<br />
should dip.<br />
2 Where more than one vaporiser is present, turn each vaporiser on in<br />
turn and repeat this test. After this test, ensure that the vaporisers and<br />
flowmeters are turned off.<br />
Changing and filling vaporisers during use. It may be necessary to<br />
change a vaporiser during use. Where possible, repeat the leak test; failure<br />
to do so is a common cause of critical incidents [10]. Some anaesthetic<br />
workstations will automatically test vaporiser integrity.<br />
It is only necessary to remove a vaporiser from a machine to refill it if<br />
the manufacturer recommends this. Vaporisers must always be kept<br />
upright. Tilting a vaporiser can result in delivery of dangerously high<br />
concentrations of vapour [11].<br />
Carbon dioxide absorber<br />
Inspect the contents and connections and ensure there is adequate supply<br />
of carbon dioxide absorbent. Check the colour of the absorbent.<br />
Alternative breathing systems<br />
For Bain-type and circle co-axial systems, perform an occlusion test on the<br />
inner tube and check that the adjustable pressure limiting (APL) valve,<br />
where fitted, can be fully opened and closed.<br />
Correct gas outlet<br />
Particular care must be exercised in machines with an auxiliary common<br />
gas outlet (ACGO). Incidents of patient harm have resulted from<br />
misconnection of a breathing system to an ACGO or misselection of the<br />
ACGO [12].<br />
Whenever a breathing system is changed, either during a case or a list,<br />
its integrity and correct configuration must be confirmed. This is<br />
particularly important for paediatric lists when breathing systems may<br />
be changed frequently during a list.<br />
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Ventilator<br />
Check that the ventilator is configured correctly for its intended use. Ensure<br />
that the ventilator tubing is securely attached. Set the controls for use and<br />
ensure that adequate pressure is generated during the inspiratory phase.<br />
Check that alarms are working and correctly configured.<br />
Check that the pressure relief valve functions correctly at the set pressure.<br />
Two-bag test<br />
A two-bag test should be performed after the breathing system, vaporisers<br />
and ventilator have been checked individually [9].<br />
1 Attach the patient-end of the breathing system (including angle piece<br />
and filter) to a test lung or bag.<br />
2 Set the fresh gas flow to 5 l.min )1 and ventilate manually. Check the<br />
whole breathing system is patent and the unidirectional valves are<br />
moving (if present).<br />
3 Check the function of the APL valve by squeezing both bags.<br />
4 Turn on the ventilator to ventilate the test lung. Turn off the fresh gas<br />
flow or reduce to a minimum. Open and close each vaporiser in turn.<br />
There should be no loss of volume in the system.<br />
Breathing systems should be protected with a test lung or bag when<br />
not in use to prevent intrusion of foreign bodies.<br />
Scavenging<br />
Check that the anaesthetic gas scavenging system is switched on and<br />
functioning. Ensure that the tubing is attached to the appropriate exhaust<br />
port of the breathing system, ventilator or anaesthetic workstation [13].<br />
Monitoring equipment<br />
Check that all monitoring devices, especially those referred to in the<br />
AAGBI’s Standards of Monitoring during Anaesthesia and Recovery<br />
guidelines [14], are functioning and that appropriate parameters and<br />
alarms have been set before using the anaesthetic machine. This includes<br />
the cycling times, or frequency of recordings, of automatic non-invasive<br />
blood pressure monitors. Check that gas sampling lines are properly<br />
attached and free from obstruction or kinks. In particular, check that the<br />
oxygen analyser, pulse oximeter and capnograph are functioning correctly<br />
and that appropriate alarm limits for all monitors are set. Be aware of the<br />
‘default’ alarm settings if using these.<br />
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Gas monitoring lines are often the cause of a significant leak; check that<br />
they are properly attached and any sampling ports not in use have been<br />
blanked off. To eliminate the need to change the sampling line repeatedly,<br />
the gas monitoring line should be assembled as an integral part of the<br />
breathing circuit by attaching it proximal to the patient breathing filter.<br />
Airway equipment<br />
These include bacterial filters, catheter mounts, connectors and tracheal<br />
tubes, laryngeal mask airways, etc.; check that these are all available in the<br />
appropriate sizes, at the point of use, and that they have been checked for<br />
patency.<br />
A new, single-use bacterial filter and angle piece ⁄ catheter mount must<br />
be used for each patient. It is important that these are checked for patency<br />
and flow, both visually and by ensuring gas flow through the whole<br />
assembly when connected to the breathing system, as described below.<br />
Check that the appropriate laryngoscopes are available and function<br />
reliably. Equipment for the management of the anticipated or unexpected<br />
difficult airway must be available and checked regularly in accordance with<br />
departmental policies [15]. A named consultant anaesthetist must be<br />
responsible for difficult airway equipment and the location of this<br />
equipment should be known.<br />
Total intravenous anaesthesia (TIVA)<br />
When TIVA is used there must be a continuous intravenous infusion of<br />
anaesthetic agent or agents; interruption from whatever cause may result<br />
in awareness. A thorough equipment check is therefore the most<br />
important step in reducing the incidence of awareness. Anaesthetists<br />
using TIVA must be familiar with the drugs, the technique and all<br />
equipment and disposables being used.<br />
The Safe Anaesthesia Liaison Group (SALG) has produced safety<br />
guidance on guaranteeing drug delivery during TIVA [16]; SALG made<br />
the following recommendations:<br />
1 An anti-reflux ⁄ non-return valve should always be used on the<br />
intravenous fluid infusion line when administering TIVA.<br />
2 Sites of intravenous infusions should be visible so that they may be<br />
monitored for disconnection, leaks or infusions into subcutaneous<br />
tissues.<br />
3 Clinical staff should know how to use, and to check, the equipment<br />
before use.<br />
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4 Organisations should give preference to purchasing intravenous<br />
connectors and valves that are clearly labelled.<br />
Ancillary and resuscitation equipment<br />
Check that the patient’s trolley, bed or operating table can be tilted headdown<br />
rapidly. A resuscitation trolley and defibrillator must be available in<br />
all locations where anaesthesia is given and checked regularly in<br />
accordance with local policies.<br />
Equipment and drugs for rarely encountered emergencies, such as<br />
malignant hyperthermia and local anaesthetic toxicity must be available<br />
and checked regularly in accordance with local policies. The location of<br />
these must be clearly signed [17, 18].<br />
Single-use devices<br />
Any part of the breathing system, ancillary equipment or other apparatus<br />
that is designated ‘single-use’ must be used for one patient only, and not<br />
reused. Packaging should not be removed until the point of use, for<br />
infection control, identification and safety. (For details of decontamination<br />
of reusable equipment, see the AAGBI safety guideline Infection Control in<br />
Anaesthesia [19].)<br />
Machine failure<br />
In the event of failure, some modern anaesthetic workstations may default<br />
to little or no flow, or oxygen only with no vapour. Users must know the<br />
default setting for the machine in use. Alternative means of oxygenation,<br />
ventilation and anaesthesia must be available.<br />
‘Shared responsibility’ equipment<br />
As a member of the theatre team, the anaesthetist will share responsibility<br />
for the use of other equipment, e.g. diathermy, intermittent compression<br />
stockings, warming devices, cell salvage and tourniquets, but should have<br />
received appropriate training. Involvement with this equipment, especially<br />
‘trouble shooting’ problems that arise intra-operatively, must not be<br />
allowed to distract anaesthetists from their primary role.<br />
Recording and audit<br />
A clear note must be made in the patient’s anaesthetic record that the<br />
anaesthetic machine check has been performed, that appropriate<br />
monitoring is in place and functional, and that the integrity, patency<br />
and safety of the whole breathing system has been assured. A logbook<br />
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should also be kept with each anaesthetic machine to record the daily presession<br />
check and weekly check of the oxygen failure alarm. Modern<br />
anaesthesia workstations may record electronic self tests internally. Such<br />
records should be retained for an appropriate time. Documentation of the<br />
routine checking and regular servicing of anaesthetic machines and patient<br />
breathing systems should be sufficient to permit audit on a regular basis.<br />
Recovery<br />
There must be clear departmental procedures for the daily and other<br />
checks of equipment that is used in recovery. This may also include preuse<br />
checks of patient-controlled analgesia and epidural pumps, etc. [20].<br />
Disclaimer<br />
The AAGBI cannot be held responsible for failure of any anaesthetic<br />
equipment as a result of a defect not revealed by these procedures.<br />
References<br />
1. National Patient Safety Agency. WHO Surgical Safety Checklist NPSA ⁄ 2009 ⁄<br />
PSA002 ⁄ U1, January 2009, NPSA. http://www.nrls.npsa.nhs.uk/resources/<br />
?entryid45=59860 (accessed 09 ⁄ 04 ⁄ 12).<br />
2. Cassidy CJ, Smith A, Arnot-Smith J. Critical incident reports concerning anaesthetic<br />
equipment: analysis of the UK National Reporting and Learning System (NRLS) data<br />
from 2006–2008. Anaesthesia 2011; 66: 879–88.<br />
3. Royal College of Anaesthetists. CCT in Anaesthetics Annex B Basic Level Training<br />
Edition 2 Version 1.2, August 2010. http://www.rcoa.ac.uk/index.asp?PageID=1479<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
4. Association of Anaesthetists of Great Britain & Ireland. Safe Management of<br />
Anaesthetic Related Equipment, 2009. http://www.aagbi.org/publications/guidelines/docs/safe_management_2009.pdf<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
5. NHS Litigation Authority. NHSLA Risk Management Standards for Acute Trusts Primary<br />
Care Trusts and Independent Sector Providers of NHS Care, January 2010. London:<br />
NHSLA, 2010.<br />
6. NHS Quality Improvement Scotland. Clinical Standards for Anaesthesia July 2003.<br />
http://www.nhshealthquality.org/nhsqis/files/ANAES_STND_JUL03.pdf (accessed<br />
29 ⁄ 01 ⁄ 2012).<br />
7. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2005 ⁄ 062 07<br />
November 2004 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON2022493<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
8. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2010 ⁄ 036 06 May 2010<br />
http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/<br />
CON081785 (accessed 29 ⁄ 01 ⁄ 2012).<br />
9. Australian and New Zealand College of Anaesthetists. Recommendations on Checking<br />
Anaesthesia Delivery Systems, 4.2.3.4.2, 2003. http://www.anzca.edu.au/<br />
resources/professional-documents/ps31.html (accessed 29 ⁄ 01 ⁄ 2012).<br />
14 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
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10. Medicines and Healthcare products Healthcare Regulatory Agency. MDA ⁄ 2010 ⁄ 052<br />
02 June 2010 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON085024<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
11. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2003 ⁄ 039 06<br />
November 2003 http://www.mhra.gov.uk/Publications/Safetywarnings/Medical<br />
DeviceAlerts/CON008613 (accessed 29 ⁄ 01 ⁄ 2012).<br />
12. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2011 ⁄ 108 01 December<br />
2011 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/<br />
CON137664 (accessed 29 ⁄ 01 ⁄ 2012).<br />
13. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2010 ⁄ 21, 10 March<br />
2010. http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/<br />
CON076104 (accessed 29 ⁄ 01 ⁄ 2012).<br />
14. Association of Anaesthetists of Great Britain & Ireland. Standards of Monitoring during<br />
Anaesthesia and Recovery 4, 2007. http://www.aagbi.org/publications/guidelines/<br />
docs/standardsofmonitoring07.pdf (accessed 29 ⁄ 01 ⁄ 2012).<br />
15. Difficult Airway Society. Recommended Equipment for Management of Unanticipated<br />
Difficult Intubation, July 2005. http://www.das.uk.com/equipmentlistjuly2005.htm<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
16. Safe Anaesthesia Liaison Group. Guaranteeing Drug Delivery in Total Intravenous<br />
Anaesthesia, September 2009. http://www.aagbi.org/news/docs/tiva_infonov09.pdf<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
17. Association of Anaesthetists of Great Britain & Ireland. Management of a Malignant<br />
Hyperthermia Crisis, 2007. http://www.aagbi.org/publications/guidelines/docs/<br />
malignanthyp07amended.pdf (accessed 29 ⁄ 01 ⁄ 2012).<br />
18. Association of Anaesthetist of Great Britain & Ireland. Management of Severe Local<br />
Anaesthetic Toxicity 2, 2010. http://www.aagbi.org/publications/guidelines/docs/<br />
standardsofmonitoring07.pdf (accessed 29 ⁄ 01 ⁄ 2012).<br />
19. Association of Anaesthetists of Great Britain & Ireland. Infection Control in<br />
Anaesthesia 2, 2008. http://www.aagbi.org/publications/guidelines/docs/infection_control_08.pdf<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
20. Association of Anaesthetists of Great Britain & Ireland. Immediate Post anaesthetic<br />
Recovery, 2002. http://www.aagbi.org/publications/guidelines/docs/postanaes02.pdf<br />
(accessed 29 ⁄ 01 ⁄ 2012).<br />
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 15
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