aagbi

Staff and Associate Specialist Grades
Storage of Drugs in Anaesthetc rooms
Syringe Labeling Crit care
Management of BP elective surgery
Ultrasound Anaesthesia
Who is the anaesthetist ?
Working arrangements cons Anaesthetists
Workload for Consultant Anaesthetists
Saftey in MRI
MH Crisis
Provision of anesthetic services
Guidelines or obstetric services 2013
OH and the anaesthetist 2014
Out of hours anaesthesia
Perioperative management Obese surgical pt
Perioperative care of elderly
Perioperative fasting
Prehospital anaesthetsia
Role of the anaesthetist
Regional Anaesthesia/abnormal coagulation
Safevascular access
Safe managent anaesthetia Equiment
Skin antiseptic CNB
Controlled Drugs
Core survival Guide
Interhospital Transfer Critically Ill
Day Case ad short stay surgery
Periopertive management diabetes
Drug alcohol abuse anaesthetists
Best management Epidural analgesia
Fatigue and anaesthetics
Management proximal femoral fractures
The good anaesthetist
Good practice guide
Reducing risks hip fractures
Uk national Core competancies PACU
Independant Practice
Infection Control Anaethesia
Interhospital Transfer
Jehovah Witness
Local Toxicity
Anaesthesia Consent
Anaphylaxis
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Blood components and alternatives
Anaesthesia Team
Anaphylaxis management
Arterial blood sampling and hypoglyceamic brain injury
Asistance for the anaesthetist
Age and the anaesthetist
Safe transfer Brain INjury
Care of critically Ill child
Catastrophes in anaesthesia
Blood transfusion
Checking anaesthetic equipement
Private billing
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Staff and Associate
Specialist Grades
2008
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org September 2008
1

MEMBERSHIP OF THE WORKING PARTY
Dr Leslie Gemmell
Dr Ramana Alladi
Dr Michael Wee
Dr Kate Bullen
Dr Andy Lim
Dr Anthea Mowat
Chairman, Honorary Secretary Elect, AAGBI
Chairman of SAS Committee and Council Member, AAGBI
Vice President, AAGBI
Deputy Chairman, BMA
Chairman of SAS Committee and Council Member,
Royal College of Anaesthetists
Member, Staff and Associate Specialists Committee, AAGBI
BMA Staff and Associate Specialists Conference Chair
Ex Officio
Dr David Whitaker
Dr Richard Birks
Dr Iain Wilson
Dr William Harrop-Griffiths
Dr Ian Johnston
Dr David Bogod
President
President Elect
Honorary Treasurer
Honorary Secretary
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia
Acknowledgement
The Working Party is grateful to Dr Christine Robison for her advice and comments.
© Copyright of the Association of Anaesthetists of Great Britain and Ireland.
No part of this book may be reproduced without the written permission of the AAGBI.
2

CONTENTS
Section 1 Introduction 4
Section 2 Recommendations 5
Section 3 The grades 6-10
Section 4 Model SAS charter 11-12
Section 5 AAGBI and the SAS anaesthetist 13-14
Section 6 The SAS contract 15-18
Section 7 References and useful websites 19
Appendix 1 20
Appendix 2 21
3

1. Introduction
The number of Staff and Associate Specialist (SAS) doctors employed in the National Health Service
has grown rapidly in the last few years, during which there have been changes in government policy
that include the introduction of revised terms and conditions of service for both Staff Grades and
Associate Specialists. The Royal College of Anaesthetists (RCoA) has published advice on appointments
procedures for these grades. The number of SAS doctors has increased further since the restructuring
of medical careers within the Modernising Medical Careers (MMC) process, in particular producing a
marked increase in the appointment of Trust Grade doctors.
The 1990 NHS and Community Care Act allowed the establishment of NHS Foundation Trusts with the
freedom to offer new staff, including doctors other than those in the training grades, contracts under
their own terms and conditions of service. The national ceiling on Staff Grade numbers was formally
removed in 1997, and employing authorities and Trusts were made responsible for individual Staff
Grade appointments.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has produced two guideline
documents, the last being published in 1998, offering recommendations and advice to Non-Consultant
Career Grade Doctors (NCCGs). Since then, there have been significant changes to the grades. The
generic name ‘Non-Consultant Career Grade’ (NCCG) has been replaced by ‘Staff and Associate
Specialist’ (SAS) grade. This appears not to include other grades such as Clinical Assistant, Trust Grade
and Hospital Practitioner. However, the Working Party wishes to include all grades considered in
earlier guidance.
The AAGBI established its SAS Committee in 2002 and the RCoA held elections for the first two SAS
council members in the same year.
This edition replaces existing advice contained in the 1992 and 1998 AAGBI publications. The advice is
intended for doctors in the various grades and for Clinical Directors of Departments of Anaesthesia.
4

2. Recommendations
The AAGBI strongly recommends that all appointments are made to the nationally recognised grades
of Staff Grade or Associate Specialist.
The AAGBI does not recommend non-standard grades and other non-training grades with variable
terms and conditions of service.
All grades are clinically responsible to a named consultant and should not be put in the position
of taking ultimate clinical responsibility for the care of patients. There should be an established
mechanism for any eligible Staff Grade doctor to be promoted to the post of Associate Specialist.
Consultants responsible for SAS doctors should ensure that professional support is available. Every
doctor should have a nominated consultant as a mentor.
The AAGBI supports the RCoA in advising that all SAS appointees should have a postgraduate
qualification. The applicant should have undergone suitable training and should have gained sufficient
relevant clinical experience to fulfill the requirements in the job plan.
Suitably experienced SAS doctors who are involved in supervising trainees are encouraged to apply to
be entered in the RCoA’s ‘Approved to Teach’ list, with the support of the College Tutor.
An SAS doctor’s contract should include time for pre-operative and postoperative visits. Provision in
the job plan must be made for activities such as audit, research, appraisal and continuing professional
development (CPD) activities.
The AAGBI recommends a minimum weekly commitment to anaesthesia of three notional half days or
equivalent, including at least two clinical sessions, with adequate time for all supporting professional
activities.
SAS doctors who have job plans involving emergency work must maintain the appropriate skills.
All SAS doctors should have an annual appraisal that should inform job planning.
All SAS doctors should, as a part of their job plan, spend time working with a consultant.
Provision for adequate study and professional leave must be made to all SAS doctors. Funding must
be available for these activities.
All SAS doctors should have representation at departmental level and be allowed to attend departmental
and directorate meetings. There should be representation on the Local Negotiating Committee at Trust/
Board level, and they should be included in the Trust/Board negotiations.
5

3. The grades
Associate Specialist [1-6]
The Associate Specialist grade was introduced in 1981; it was a development of the Medical Assistant
grade. It is a permanent career grade of limited clinical responsibility. Since 1991 an inclusive
professional contract, similar to that of the pre-2003 NHS Consultant Contract, has been in place, with
discretionary points replacing the performance supplement in 1996. Associate Specialists are employed
on contracts based on 11 notional half days per week, in which one notional half day is equivalent
to a minimum of 3.5 hours worked flexibly. Associate Specialists are senior hospital doctors who are
clinically responsible to a named consultant and who should not therefore be put in the position of
taking ultimate responsibility for care of patients. Associate Specialists are subject to the European
Working Time Directive (WTD), which limits time worked to a maximum of 48 hours per week on
average. Associate Specialists are senior hospital doctors and should therefore occupy a senior position
on the on-call rota.
A medical practitioner appointed to the Associate Specialist grade should have served a minimum of four
years in a Specialist Registrar post or Staff Grade post, at least two of which have been in the appropriate
specialty. Equivalent service is acceptable with the agreement of the relevant College Regional Adviser
and Regional Postgraduate Dean. The doctor should have completed 10 years’ medical work, either as
a continuous period or in aggregate, that is acceptable by the General Medical Council (GMC) for full,
limited or temporary - but not provisional - registration. Possession of a higher qualification, e.g. the
FRCA, is desirable but not mandatory.
Associate Specialist posts are often personal appointments established for those doctors committed
to a career in the hospital service who are unable to complete higher professional training or who,
on completion of higher professional training, are unable or do not wish to accept the full clinical
responsibility of a consultant appointment.
In certain circumstances in England and Wales, Trusts may advertise for and recruit Associate Specialists
directly. However, an Associate Specialist post should only be established when it is in the best interests
of the service. A job description for the post should be drawn up with the advice of a representative of
the RCoA. The Central Consultants and Specialists Committee (CCSC) of the British Medical Association
(BMA) has produced a model workload document for Associate Specialists, which was endorsed by
the newly formed Staff and Associate Specialists Committee of the BMA. Associate Specialists have the
option of whole time, maximum part-time or part-time contracts and, although they have the right to
undertake private practice, they may encounter difficulties when claiming reimbursement from private
health care providers.
When job planning, it is worth noting paragraph 26 of the current Terms and Conditions: National Health
Service Hospital Medical and Dental Staff and Doctors in Public Health Medicine and the Community
Health Service (England and Wales), Terms and Conditions of Service September 2002 Version 2 – 1
December 2002, Version 3 – 10 January 2003, Version 4 – 6 February 2004, Version 5 – 17 February
2005, Version 6 – 1 June 2005, Version 7 – 1 March 2007, and Version 8 – 30 July 2007.
6

Associate Specialists should ensure that their workload, including on-call, is reviewed annually.
Consideration should be given not only to the frequency of on-call but also to the intensity of the work.
Particular care should be taken to ensure that the problems previously encountered by trainees are not
merely transferred to the SAS grades.
In any consideration of a career grade appointment, the following factors should be taken into account:
• The need to develop a consultant-based service
• Overall consultant responsibility for patient care
• Consultant cover both in and out of hours in anaesthesia and, where necessary,
in related subspecialties;
• Provision for the teaching of junior doctors and the supervision of both junior
and career grade medical staff
The appointment committee for new Associate Specialist appointments normally comprises, as a
minimum:
• A senior manager
• A consultant from the Trust/Board in the relevant specialty
• An external senior hospital doctor nominated by the RCoA
Guidance for personal regrading from Staff Grade to Associate Specialist is available on the BMA
website: http://www.bma.org.uk/ap.nsf/content/home
Staff Grade [7,8]
The Staff Grade was introduced in 1988 to meet service requirements, and a national ceiling on
numbers that limited the number of Staff Grades to 10% of the total number of consultants was
removed in 1997 when the current Staff Grade contract was introduced (except in Scotland). A
significant number remain on the pre-1997 contract. Whilst Staff Grade doctors are regarded as senior
hospital doctors, it is important to remember that they are in a non-training career grade. As such, they
exercise an intermediate level of clinical responsibility as delegated by the consultant to whom they
are responsible.
A full time Staff Grade contract is for 10 sessions, all of which are superannuable. Staff Grade doctors
are paid at the same sessional rate for work done during working hours or out-of-hours. A session
is four hours, and WTD regulations limit work to an average of 48 hours per week. The duration of
sessions outside normal working hours may vary subject to local Trust negotiation.
It is recommended that doctors (including those in non-standard posts) transfer to the new terms of
service unless it is clearly disadvantageous to do so. Non-standard contracts do not afford the same
protection as nationally agreed terms of service. The BMA has established LNCs in Trusts and Health
Boards to represent doctors of all grades.
7

When drawing up job descriptions for a Staff Grade, employing authorities have complete flexibility,
after consultation with the responsible consultant, with regard to the deployment, location and
rostering of the available sessions. Currently, the RCoA recommends that those SAS doctors without
a postgraduate qualification should not work in isolated areas unsupervised.
A Staff Grade is normally accountable to a named consultant, normally the Clinical Director but,
on a day-to-day basis, to the duty consultant. A model job description is available from the BMA.
The formal requirements for entry to the Staff Grade are:
• full registration with the GMC
• either a minimum of three years’ full time hospital service at Senior House
Officer (SHO) or higher grade, including adequate experience in the relevant specialty;
or equivalent experience
This requirement may be waived if, in the opinion of the College assessor, the applicant has undertaken
suitable training and has gained sufficient relevant experience to fulfil the requirements of the
job plan.
It is recommended that the job plan be approved by the RCoA Regional Education Advisor before the
post is advertised.
The Advisory Appointments Committee in England normally comprises, as a minimum, the following
people:
• A lay Chairman appointed by the Trust/Board
• A consultant anaesthetist from outside the Trust/Board, approved by the Royal College
• A consultant anaesthetist (usually the Clinical Director) from the Trust/Board
The composition of the panel may be different in the devolved nations. After ratification of the
appointment by the Trust, there is normally a probationary period of one year at the end of which
time, subject to approval, the post becomes permanent and subject to standard terms of notice. The
AAGBI strongly disapproves of annually renewable contracts. All Staff Grades should ensure that their
workload, including on-call commitments, is reviewed annually. Consideration should be given not
only to the frequency of on-call but also to the intensity of that work.
Guidance for personal regrading from Staff Grade to Associate Specialist is available on the BMA
website.
Hospital Practitioner [9]
A doctor appointed to this grade has to be a principal in general practice and must have been fully
registered for at least four years. The numbers in this grade are diminishing, probably as a result of
clinical governance considerations, the difficulties of appraisal in dual specialties, the increasing
workload of General Practitioners and the decrease in the number of anaesthetists who have undergone
a substantial period of training before entering general practice.
8

Appointment is limited to those principals who have at least two years’ whole-time (or equivalent parttime)
experience in anaesthesia. Although a postgraduate qualification is not a specific requirement for
the grade, the AAGBI supports the RCoA recommendation that possession of an FRCA or equivalent
is desirable.
Appointment is renewable after one year, subject to confirmation, until the incumbent reaches
retirement age or ceases to be a principal in general practice. This grade is responsible to a named
consultant, and the AAGBI recommends a minimum of two clinical sessions with appropriate time for
pre-operative visits and postoperative care, i.e. three notional half days per week.
Thirty days’ study leave within each three-year period should be included in the contract, and hospital
practitioners would normally be expected to participate in clinical audit and departmental meetings.
Departments of Anaesthesia and College Tutors must encourage Trusts to support applications from
this grade to participate in CPD.
Clinical Assistants (part-time medical officers) [10]
The AAGBI strongly recommends that no further Clinical Assistant appointments be made and that Staff
Grade posts with nationally agreed terms and conditions of service be created in the future when the
need arises. When General Practitioners wish to continue clinical sessions, the Hospital Practitioner
grade would be a more appropriate appointment. It is essential that College Tutors, postgraduate deans
and Trust managers support the need for CPD by clinical assistants, both for the benefit of the individual
and as an intrinsic requirement of good practice, clinical governance and risk management.
Non-standard grades
Many Trusts have created new grades of doctors with non-standard terms and conditions of service to
circumvent manpower planning mechanisms controlling the proportion of SAS doctors within trusts
and also as a result of resource pressures. Such irregular posts are not protected by national terms and
conditions of service, and the BMA has campaigned for many years against their creation. The AAGBI
supports this view.
These non-standard appointments have a number of titles, including Trust Grade doctor, Trust Specialist,
Staff Specialist, Clinical Fellow and Clinical Specialist. The contracts usually incorporate out-of-hours
work at a rate of remuneration defined by the Trust and often permit the use of fixed-term contracts.
The revised terms and conditions of service for Staff Grades and the ability to appoint Associate
Specialists directly have made such posts unnecessary. The AAGBI strongly recommends that
employers use this opportunity to offer existing non-standard grade doctors of the appropriate level
the option to transfer to the new terms and conditions of service. Those doctors who fail to meet the
standards set down in this advice should be offered the opportunity to undergo further training. If, in
exceptional circumstances, a Trust or Department of Anaesthesia deems such a non-standard post to
be necessary, it is recommended that potential applicants obtain advice from the BMA, the AAGBI or
the College tutor.
9

4. Model SAS Charter
The NHS employer should aim to provide a working environment that recognises both the diversity of
SAS doctors and the major contribution that they make to patient care. The NHS employer should realise
that the SAS doctors need both support and resources to develop personally and professionally. The
NHS employer should be committed to ensuring that the role of the SAS doctor is fully acknowledged
and respected by management, colleagues and patients. In order to deliver these aspirations, the
following recommendations are made.
Each Trust should work towards every SAS doctor having the following:
• An appropriate contract of employment incorporating national terms and conditions
• An appropriate agreed job plan. This may only be changed by mutual agreement
between the SAS doctor and the Clinical Director/Lead in accordance with agreed local
procedures for appraisal and job plan review
• An adequate daytime session allocation with separate and identifiable time allocated
for administration, education, audit and teaching commitments, etc. This should not
be any less favourable than the time allotted to consultants undertaking similar
clinical duties
• Access to office accommodation and a computer in each directorate in which
SAS doctors are employed. This should include access to email and suitable storage
facilities for confidential work, related papers, books, etc
• Adequate support and time allocation to allow SAS doctors to participate fully
in the employer’s appraisal process, including access to appraisal training and the
necessary CPD and study leave requirements, which are a natural consequence
of appraisal
• Adequate and fully funded study leave
• All permanent SAS doctors should be members of the Medical Staff Committee/Hospital
Medical Board and should be invited to attend meetings
• There should be SAS representation on the LNC
• The employer should agree a mechanism or adopt BMA recommendations for regrading
from Staff Grade to Associate Specialist
• Access to a fair and appropriate mechanism for the award of optional points for
Staff Grades and discretionary points for Associate Specialists. The BMA recommend
a minimum number of discretionary points/optional points (available at a rate of 0.35
points per year per eligible candidate) that should be awarded. The points should be
awarded for work and contributions over and above that normally expected for a doctor
in the SAS grade. Guidance on completion of the application form is available on the
BMA website
• SAS doctors should have equal access to the benefits of the Improving Working Lives
initiative [12]
• All SAS doctors should be members of the directorate and should be invited to attend
directorate and departmental meetings
10

5. The AAGBI and the SAS anaesthetist
The SAS Committee (SASC) of AAGBI
The AAGBI SASC was established in 2002. The remit of the committee is to:
• Represent the interests of SAS members of the AAGBI
• Advise the AAGBI Council on matters relating to SAS doctors
• Promote the aims and benefits of the AAGBI to SAS doctors
• Encourage the professional development of SAS doctors
• Ensure effective collaboration with the SAS committee of the RCoA,
other Royal Colleges and professional bodies
The Committee is structured as follows:
• Members of the Executive of the AAGBI
• Elected members of the Council as nominated by Council
• A representative of RCoA SAS Committee
• Five SAS representatives co-opted by the Council on the recommendation
of the SAS committee
SAS doctors and teaching
The College, supported by the AAGBI, recognises that SAS anaesthetists have a valuable role to play in
teaching. To be a teacher, possession of an FRCA is not a prerequisite but, like consultants, SAS doctors
must fulfill the RCoA’s CPD requirements. This is essential for those clinical areas in which they have
clinical and on-call responsibilities.
The RCoA encourages College Tutors to identify those SAS anaesthetists with aptitude and to
nominate them to the local School of Anaesthesia, specifying the areas in which they have appropriate
expertise.
SAS doctors who are Fellows or Members of the RCoA and who have been accepted by their School
of Anaesthesia as teachers may, if they wish, ask for their name to be recorded with the College as
‘Approved to Teach’. This list is available on the RCoA website [13].
The specific areas in which SAS doctors teach are best identified at local level, but may include
specialist operating lists in which an individual has expertise.
SAS anaesthetists who teach trainees must have the opportunity to acquire the skills of a competent
teacher.
When being taught by a SAS doctor, trainees must at all times have unimpeded access to consultants
for advice.
11

6. The SAS contract
What is the contract?
A contract is a set of statements governing the agreement between you and your employer. It covers
what work you agree to perform, what facilities your employer agrees to make available for you to
do this work, and what your employer agrees to reward you for your work. It must be both fair and
compatible with the law. Associate Specialists have the option of a whole-time or maximum part-time
contract or may be employed on a part-time basis.
The contract is not a single document. It has several components:
• The statement of particulars (called the contract)
• The terms and conditions of service
• The job plan
The contract
This is usually a document that states your job title, your employing organisation, further details and is
signed by both you and your employer. Standard contracts are negotiated nationally and should not be
varied locally, except when individual circumstances demand changes that are mutually agreed.
The terms and conditions of service
This is a set of rules describing in more detail how the contract operates. The rules are congruent with
the statement of particulars. Employers do not usually circulate these except on request but they can
be found on the web. They are negotiated nationally and should not be varied locally except where
a collective agreement has been reached with the LNC for medical and dental staff in your Trust.
Examples of such agreements might be to vary the provisions of additional programmed activities in
the case of significant private practice, to confirm arrangements for fee-paying services or to agree
appropriate places for supporting professional activities.
The job plan
This is your personal and detailed agreement about your work. The job plan is congruent with the terms
and conditions of service. It will describe the purpose of your job, your work timetable, your objectives
and the supporting resources that should be allocated to help you achieve them. It should include any
other personal agreements about the way you work.
Job plan annual review
The job plan of every SAS doctor (including the work programme) should be subject to an annual
review. This annual review should provide an opportunity for the SAS doctor and the named consultant
to discuss any problems that may have arisen in the preceding year and to agree any changes that need
to be made to meet new circumstances or changed service priorities. It is likely that, in many cases, job
plans will need to be amended only occasionally and even then will be subject to minimal alteration.
12

Where the SAS doctor and the named consultant are unable to reach agreement on the content of
the job plan, either initially or at an annual review, local procedures that provide for the resolution of
grievances or differences relating to an individual practitioner’s duties should be followed.
Preparing for a job plan meeting: keeping a diary and collecting data
It is crucial in preparing for the job planning meeting that you have accurate information about the
job you currently do. This is particularly important if you are going to argue that your work justifies a
revision of the plan. There is no real alternative to collecting this data via a diary of your activity.
For the most part, your work is likely to follow a regular pattern from week to week and should be
relatively easy to assess. There will undoubtedly be exceptions for SAS doctors who do not have such
a regular pattern and, in those circumstances, a more detailed assessment will be necessary. The
assessment will then need to be made over a longer period. Note in particular that your workload is
likely to be higher when you have colleagues on annual leave. Think about this when you complete
your diary.
For many SAS doctors, the most difficult task will be to assess the amount of time spent doing actual
work whilst on-call because this may well vary from night to night or there may be a concerted period
of on-call, for instance during one week in five. There may therefore need to be an assessment of on-call
work over a longer period.
Include in the diary all the work you do, from when you arrive at work each day until the time you
leave. Travelling time is included between sites and where extra time is taken to get to a site different
to your normal one. All work you do when on-call should also be included, such as telephone advice,
travelling to and from work and waiting to begin work. SAS doctors, like most other professionals,
would expect to be contactable during their lunch breaks and to take such breaks flexibly. Where this
happens, it is reasonable to count such breaks as part of working time.
Fixed commitments
For the SAS doctor on a whole-time (or maximum part-time for an Associate Specialist) contract,
between five and seven notional half-days, depending on specialty, should normally be allocated as
fixed commitments in the work programme. For Associate Specialists on other part-time contracts, at
least half of the notional half-days should normally be allocated to fixed commitments. The number
of fixed commitments may be varied with the agreement of the Associate Specialist and their Clinical
Director/Lead. A fixed commitment, e.g. an out-patient clinic or operating list, is a commitment that an
Associate Specialist must fulfill, except by agreement with their named consultant or in an emergency.
Examples of job plans are given in Appendix 1
Waiting List Initiative lists: SAS doctors should be allowed, with the agreement of the department, to
undertake waiting list initiative lists provided appropriate consultant cover is made available.
13

Work diaries should take note of all aspects of work done. This will comprise:-
• Direct clinical care of patients, including all patient-related administration such
as telephone calls, letters, reviewing results, etc.
• Activities to support professional development and CME including audit, training,
research and other similar non-clinical activities
• Agreed additional NHS responsibilities and agreed external duties
Working time is divided into four components:
1. Direct Clinical Care (DCC)
2. Supporting Professional activities (SPA)
3. Additional NHS responsibilities
4. External duties
Examples of DCCs, SPAs, additional NHS responsibilities and external duties can be
found in the AAGBI document giving guidance for the new consultant contract [14] There are example
job plans given in Appendix 1.
Study leave/audit
There should be opportunities for further training and participation in regular CPD in line with the
recommendations of the RCoA.
Appropriate funding and paid time off must be made available by the trust in accordance with national
agreements.
All SAS doctors should take part in regular departmental and hospital-wide audit/clinical governance
and it is recommended that this is formally included in the job plan.
Named consultant
Since the inception of the NHS, it has been a requirement that every patient’s care is undertaken
either by a consultant or by a trainee or SAS doctor under the supervision of a named consultant. All
departments should have an agreed and recognised system in which a ‘named’ consultant is identified
and recorded for every patient. This will be the person to whom SAS doctor should turn to for advice
or help with a case. It should be clear to the SAS doctor how the local system operates and named
individuals should be able to provide or arrange for immediate advice or direct assistance as required.
The exact local implementation of supervision arrangements for individual SAS doctor will depend
upon a number of factors, not the least of which will be the knowledge, skills and experience of the
individual. Clearly, when a senior Associate Specialist is working in an area with which he or she is
very familiar, the requirement for contact and discussion about individual cases will be uncommon.
In contrast, it may be appropriate for a recently appointed Staff Grade doctor to be more closely
supervised. For further details, please refer to the AAGBI SAS Handbook.
14

Discretionary points and optional points
Performance supplements for Associate Specialists introduced in 1991 have been replaced by
Discretionary Points. Associate Specialists and Staff Grades on the maximum salary scale are eligible for
the award of points: discretionary points for Associate Specialists and optional points for staff grades.
These are consolidated payments made in addition to the maximum salary scale at the discretion of
the employer. They are not seniority payments, nor are they automatic annual increments. They are
superannuable.
The award of points is for work and contributions over and above that normally expected of a doctor
of that grade. Key criteria are clinical expertise and service to patients but account should be taken of
overall workload and its intensity.
It is important that Trusts/Boards set up local award panels in accordance with national guidelines and
that they encourage SAS doctors to apply for these awards. All SAS doctors who are eligible to apply
should make a personal submission each year. The consultants responsible for the work of SAS doctors
may be required to give written recommendations.
There are no absolute requirements to Trusts/Boards to award such discretionary/optional points, but
the BMA recommendation is that a total of 0.35 points be awarded per eligible Associate Specialist per
year and 0.35 points per eligible Staff Grade per year.
15

7. References
1. HSG (91)18: The associate specialist grade: terms and conditions of services. November 1991.
2. DHSS PM (81) 16 recommended form of contract for associate specialists. 1981.
3. NHS Management Executive guidelines relating to terms and conditions of service for doctors in
the associate specialist grade HSG (91) 18. November 1991.
4. Delegation of procedures for appointment to the associate specialist in medical specialties as
announced by the Executive EL (91) 150. November 1991.
5. Arrangements for the payment of Discretionary points to associate specialists AL (MD) 7/95.
1995.
6. NHS executive document on working draft to develop a quality framework for HCHS medical
and dental staffing Annex 2 EL (97) 25. 1995.
7. Advance Letter (MD) 4/97: Terms and Conditions of Service for the Staff Grade. NHS Executive
July 1997.
8. Staff grade DHSS circular giving guidance on arrangements for the employment of hospital
medical and dental staff on the then new staff grade HC (88) 58 and annexes. 1998.
9. In 1979 the Department of Health and Social Security issued guidelines setting out
arrangements for the employment of hospital practitioners HC 7916. The NHS Executive issued
summary guidance amending these arrangements HSG (93) 50. 1993.
10. Guidance relating to conditions of service for clinical assistants was issued by the Department
of Health and Social Security DA (86) 11. 1986.
11. Advance Letter (MD) 05/02 regarding appraisal for NCCGs.
12. http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/
Modelemployer/Improvingworkinglives/index.htm
13. http://www.rcoa.ac.uk/docs/SAS-teach.pdf
14. http://www.aagbi.org/publications/guidelines/docs/jobplanning05.pdf
16

Useful websites
The Association of Anaesthetists of Great Britain and Ireland www.aagbi.org
The Royal College of Anaesthetists www.rcoa.ac.uk
British Medical Association (SAS Contract) www.bma.org.uk/sascontract
Department of Health www.dh.gov.uk
General Medical Council www.gmc-uk.org
NHS www.nhs.uk
Sick Doctors Trust www.sick-doctors-trust.co.uk
17

APPENDIX 1
Job plans
Example of an 11 notional half day Associate Specialist job plan with out of hours emergency cover.
5 clinical sessions, 3 of which are fixed (1 being special interest list)
2 for pre-operative and postoperative visits
1 for CPD/Audit
2 for out of hours cover (1 night per week; and 1 in 5 full weekends or 2 in 5 split weekends)
1 NHD with no clinical work
Example of 12 session Staff Grade post with out of hours cover
3 clinical theatre sessions (one of which is always accompanied)
2 clinical emergency sessions (often ITU cover)
1 session to attend teaching programme (1 week in 3, other week doing emergency cover)
1 session for pre-operative and postoperative visits
1 session for CPD/Audit admin
4 sessions for one night per week of out of hours cover
Example of 10 session Staff Grade post with no out of hours emergency cover and additional
management duties
6 clinical theatre sessions (1 of which is accompanied)
2 sessions for pre-operative and postoperative visits
1 session for CPD/audit
1 session for admin duties (departmental rota/leave co-ordination)
Example of an 11 notional half day Associate Specialist job plan with no out of hours emergency
cover, but with special interest, e.g. chronic pain work
4 clinical theatre sessions
2.5 sessions for chronic pain team (2 clinical and 1 administration)
1 session for admin duties (departmental leave/rota co-ordination)
1 session for CPD/ audit
1.5 sessions for pre-operative and postoperative visits
Example of a 6 session/notional half day (part time) contract
4 clinical theatre sessions
1 session for CPD/Audit/Administration
1 session for pre-operative and postoperative visits
18

APPENDIX 2
Update on the new SAS grade contract
Negotiations on a new national (UK-wide) contract for SAS doctors and dentists began in May 2005.
An agreement was reached with NHS Employers in 2006. The contract was ratified, with some
amendments, by the Government in December 2007, following which SAS grades were balloted, and
voted to accept the contract.
Specialty Doctor
The new contract is offered on an optional basis from 1 April 2008 to doctors / dentists currently in the
following grades:
• Staff Grades
• Associate Specialists
• Senior Clinical Medical Officers
• Clinical Medical Officers
• Non-GP Clinical Assistants
• Non-GP Hospital Practitioners
The new grade of Specialty Doctor will replace the Staff Grade and will be offered by employers from
1 April 2008, so there will be no new appointments to the above grades after that date.
Associate Specialist grade closure
The old Associate Specialist (AS) grade will be closed with effect from 1 April 2008. There is a new
Associate Specialist grade with similar structure to the Specialty Doctor. Current Associate Specialists
will have the option to express an interest in switching to this new Associate Specialist grade. As no
new appointments will be made to Associate Specialist level, the only other route to enter the grade
will be to regrade from eligible Staff Grades, Specialty Doctors or Clinical Assistants, but applications
will only be possible until 31 March 2009, and after that time new applications for regrading will not
be accepted. This will mean that, from 1 April 2009, both the old and new Associate Specialist grades
are closed.
New contract is optional for current SAS grades
Work has begun on implementation and employers will write to all current SAS doctors asking for
expressions of interest in switching to the contract. SAS grades will have 12 weeks from receipt of
the letter from employers to express an interest in the new contract. This does not commit doctors to
accepting the new contract but guarantees back pay to 1 April 2008 once a job plan has been agreed.
Written offers of an agreed job plan need to be accepted within 21 days (28 days in Scotland).
• Current SAS doctors must consider whether they would like to apply for the new contract.
Consideration of individual circumstances will be essential.
• If expressing an interest, it is advisable to begin a diary planning exercise to inform
job planning discussions. This should last for a minimum of six weeks, or one rota cycle,
though a longer period of time would be helpful.
19

• Staff Grades eligible to apply to regrade to the Associate Specialist grade should do so
as soon as possible, as applications will not be accepted after 31 March 2009
• Regrading applications started before 1 April 2008 will be to the old Associate Specialist
contract, with the option then of moving to the new Association Specialist contract.
• Successful applications started on or after 1 April 2008 will be direct to the new Associate
Specialist contract.
• Should it not prove possible to agree a job plan, there is a mediation procedure available.
• If mediation fails, there is an appeals process.
• The BMA SASC is producing further guidance to assist in assimilation.
Programmed Activities (PA)
The new contract for both new Associate Specialist and Specialty Doctor grades are time based, with
each unit of time being a four-hour Programmed Activity (PA). Before signing the contract, you should
have an agreed job plan. The minimum unit of time used in job planning should be 0.5 PA. The contract
for current SAS grades moving to the new contract should be based on a robust diary exercise. Contracts
can be for up to 12 PAs but PAs over 10 are not obligatory, and may not be permanent. Up to 10 PAs
are superannuable.
A full time contract is one with 10 PAs, most of the work being Direct Clinical Care (DCC) with a
minimum of one PA for Supporting Professional Activities (SPA). SAS doctors who currently have more
than one notional half day or session for SPA-type activity should continue to receive this. The minimum
of 1 PA is absolute, and will also apply to part-time staff, i.e. it is not pro-rata. Some SAS grades may
also be eligible to have additional PAs for additional NHS responsibilities or for external duties.
Direct Clinical Care
This is any work to do with care of individual patients, such as:
• Emergency duties: including emergency work carried out during or arising from on-call
(including phone call advice)
• Operating sessions: including pre-and post-operative care
• Ward rounds
• Outpatient clinics
• Clinical diagnostic work
• Other patient treatment, e.g. intensive care work
• Public health duties
• Multi-disciplinary meetings about direct patient care
• Administration related to patient care, e.g. referrals, notes, dictation, correspondence
• Travel: to and from home for on-call work; and between hospitals for elective work
Other areas to be considered are starting work earlier, planning operating list including scheduling
order, prioritising difficult cases, mortality and morbidity meetings if presenting specific patients,
handling complaints.
20

Supporting Professional Activities
There should be a minimum of one SPA in the job plan, though as the SAS doctor becomes more senior
and experienced, it is likely that this will need to be increased, as evidenced by work diary
• Training, e.g. teaching trainees, medical students, paramedical staff or ancillary staff
• Teaching: lectures or seminars whether local, regional or national
• Continuing Professional Development: all activity such as attending professional meetings,
departmental CPD sessions and reading journals
• Audit
• Job planning
• Appraisal
• Research
• Clinical management, including rota co-ordination
• Local clinical governance activity
• Local representational activities
Additional NHS responsibilities
There may be activities that cannot be covered within the time set, which should be recognised as
additional NHS responsibilities. It may be appropriate to replace some DDC PAs to enable this work to
be carried out. Examples include
• Audit lead
• Clinical Governance lead
• Subspecialty or project lead
• Clinical management: Clinical Director, other official Trust management role including
LNC, rota management or Lead Clinician
External duties
This involves activities which are for the greater good of the NHS. The Department of Health recognises
the value of, and has given support for, such activities. If these duties are regular, allowance for them
should be given within the job plan.
Examples include:
• Work for General Medical Council or other national bodies
• College tutor
• NHS disciplinary procedures
• Regional Advisor, deputy, Programme Director
• Trade Union duties, e.g. BMA
• Royal College, Specialist Associations, e.g. AAGBI, Specialist Society work
• University roles
• Work for other NHS bodies, e.g. Healthcare Commission
• Acting as an external member of appointment panels
21

On call supplement
There is a supplement for on-call work, payable as a percentage of the basic salary with the percentage
being dependent on the frequency of the on-call. This will not be payable for a shift pattern. It is payable
for on-call work irrespective of the intensity of the duty.
The supplement is 6% of basic salary for rotas with an on-call frequency equal to or more frequent than
1 in 4, 4% for rotas with frequency less than 1 in 4 or equal to 1 in 8, and 2% for rotas with a frequency
of less than 1 in 8.
This payment is added to basic salary and is superannuable.
Out of Hours work (OOH)
Work actually carried out as Out of Hours work (OOH), as demonstrated by diary exercise, will be
payable at an enhanced rate whereby the rate of pay will be time and a third for a four-hour block of
time actually worked. Alternatively, SAS grades may prefer to consider an OOH PA as a three-hour
block of time of time actually worked, payable as a four-hour PA. OOH work is work done between
19:00 and 07:00 on weeknights and all work at weekends and on public holidays. Where OOH work
is included within the 10-session job plan this will be superannuable. If it forms part of additional PAs
above the basic 10 PAs it will not be superannuable.
Regular OOH worked should be part of the job plan, whether elective or emergency. If the actual
number of OOH hours worked is variable, it can be averaged on a weekly basis for the purposes of job
planning, by using the diary exercise to look at total number of OOH hours actually worked during the
diary period, and dividing by the number of weeks for which the diary was kept. Thus it can then be
designated as a specific amount of DCC time.
It is possible for job plans to include regular elective work to be done in OOH time for specialty doctors,
but this does not apply to associate specialists.
Optional and discretionary points
These awards will no longer exist in the new contract, but will continue to be available for those SAS
doctors who choose to remain in their old contracts.
BMA members can access assistance from the BMA for job planning, for mediation and for appeals.
22

23

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Storage of Drugs in
Anaesthetic Rooms
Guidance on best practice from
the RCoA and AAGBI

Storage of Drugs in Anaesthetic
Rooms
1
Guidance on best practice from the RCoA and AAGBI
The Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) recognise
that secure drug storage makes an important contribution to patient safety, and the safety of the public, but patient safety must
always be the priority. The RCoA and AAGBI support a system of standard operating procedures (SOPs) that makes patient safety
paramount, and recognises that even short delays in accessing drugs may result in an adverse patient outcome. All drugs and
medicines § need to be stored safely. The Royal Pharmaceutical Society (RPS) recognises that there are special requirements for
the storage of drugs in operating theatre departments, and recommends that there should be a system of Standard Operating
Procedures (SOPs) covering each of the activities concerned with medicines use to ensure the safety and security of medicines
stored and used in operating departments. 1
A particular situation not mentioned in the RPS document is that anaesthetic rooms, which function as a form of ‘annexe’ to the
main operating theatre, are usually a place in which drugs and fluids are stored. During the conduct of an anaesthetic and surgery
the anaesthetic room may temporarily and intermittently be unoccupied when the patient is in theatre. Care Quality Commission
(CQC) inspectors have in recent months identified a need for guidance as to whether the storage of drugs and fluids in unlocked
cupboards in temporarily unoccupied anaesthetic rooms is acceptable.
The Health and Social Care Act 2008 2 demands that patients and healthcare staff be protected ‘against the risks associated with
the unsafe use and management of medicines by means of the making of appropriate arrangements for the obtaining, recording,
handling, using, safe keeping, dispensing, safe administration and disposal of medicines’.
There is clear guidance on the storage of Controlled Drugs such as morphine, cocaine, and fentanyl in this setting, 3 but there is
currently no specific advice on best practice for the storage of non-controlled drugs and fluids in anaesthetic rooms. The Royal
College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) convened a working
party to address this issue. This document is the report of the working party.
Guidance
1 Patient safety must be the paramount consideration. Immediate access to a variety of drugs can sometimes be essential, such
that even short delays in drug availability can make a difference to patient outcome.
2 It is not possible to provide a definitive list of ‘emergency drugs’ that should be immediately available at all times, as these
vary depending on patient condition and the surgical procedures being performed. There are few drugs commonly stored in
anaesthetic room drug cupboards that will not be needed urgently on occasion.
3 Local SOPs should exist for the safe storage of drugs (both controlled and non-controlled medicines) and fluids in operating
theatre departments. These should be adequately risk-assessed and agreed by pharmacists, anaesthetists, nurses, operating
department practitioners and ratified by the organisations medicines management committee. The Accountable Officer for
medicines within the organisation should endorse these. 4
4 Decisions about drug security in anaesthetic rooms must reflect a balance between patient safety, staff protection and security.
We understand that this may mean that in defined circumstances, drug cupboards (excluding those containing Controlled
Drugs) may remain unlocked when the anaesthetic room is temporarily unoccupied and the operating theatre is in use.
5 Even if anaesthetic room drug cupboards cannot, in the interests of patient safety, be locked during surgical procedures,
practices can be followed that may minimise medicines security risks, e.g. drugs and fluids prepared in advance for procedures
can be kept in closed cupboards.
6 An unoccupied anaesthetic room should ideally remain visible at all times to those in the operating theatre, usually through
windows in the door.
7 Anaesthetic room drug cupboards must be locked when the operating theatre is unoccupied.
§
For the purposes of this paper the terms drugs, medicines and fluids are used interchangeably.
In this guidance, the term ‘drug cupboard’ includes all forms of drug and fluid storage, including refrigerators.

Storage of Drugs in Anaesthetic
Rooms
2
Guidance on best practice from the RCoA and AAGBI
8 It is common practice to prepare a selection of ‘emergency drugs’ that should be immediately available during the course of
an anaesthetic. These will often accompany the patient from the anaesthetic room into the operating theatre but, if this is not
possible, they should be stored in the anaesthetic room in a manner that maintains their immediate availability. They should be
adequately labelled, and disposed of appropriately if not used.
9 Certain rarely-used emergency drugs may be stored in a central location, serving the entire theatre suite, e.g. dantrolene and
intralipid. Local SOPs should be compliant with relevant legislation and should ensure that the locations of these drugs are
conspicuously signposted.
10 We support the use of effective access control systems for all routes that allow entry into operating departments, limiting access
to only those with legitimate reasons for access.
References
1 The safe and secure handling of medicines: a team approach. RPSGB, London 2005 (http://bit.ly/1R893Hc).
2 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (http://bit.ly/1Zr5Lny).
3 Controlled Drugs (Supervision of management and use) Regulations 2013: Information about the Regulations. DH, London 2013 (http://bit.ly/1R88CNa).
4 Patient Safety Alert (NHS/PSA/D/2014/005). Stage Three: Directive: Improving medication error incident reporting and learning, 20 March 2014.
MHRA and NHSE, London (http://bit.ly/1Zr6h4T).
The RCoA and AAGBI would like to thank the following organisations for providing beneficial comment on this document:
The Royal Pharmaceutical Society (RPS)
The Association for Perioperative Practice (AfPP)
The College of Operating Department Practitioners (CODP)
The Association of Physicians’ Assistants (APA)
The Care Quality Commission (CQC)
Members of the Working Party
Dr Richard Marks, Vice-President, Royal College of Anaesthetists (Chairman)
Dr William Harrop-Griffiths, Council Member, Royal College of Anaesthetists
Mr Mike Zeiderman, National Professional Advisor for Surgical Specialities, CQC
Dr David Selwyn, Chair of Clinical Director Network
Dr Kathleen Ferguson, Council Member AAGBI, Representative of SALG
Ms Katharina Floss, Critical Care Pharmacist, John Radcliffe Hospital
June 2016
Latest review date June 2019
© The Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2016
Churchill House, 35 Red Lion Square, London WC1R 4SG
020 7092 1500 standards@rcoa.ac.uk www.rcoa.ac.uk

SYRINGE LABELLING IN CRITICAL CARE AREAS
REVIEW 2014 (updated November 2016)
Since the new standard for syringe labelling was introduced in May 2003 1 , it has become apparent that a number of changes
need to be made. These changes are to bring the standard in line with the change from British Approved Names (BANs) to
recommended International Non-Propriety Names (rINNs) 2 , and also to bring the standard in line with the Australian/New Zealand
Standard 3 and ISO Standard 4 which have superseded it. The changes are as follows:
• BANs to rINNs
Examples of these affecting anaesthetic drugs are:
• Thiopentone to Thiopental
• Lignocaine to Lidocaine
• Glycopyrrolate to Glycopyrronium
• Drug concentrations
These were all shown on the original document as ‘mg/ml’. Correct concentrations should be used. For example:
• Fentanyl micrograms/ml
• Lidocaine %
• Insulin units/ml
• ‘Adrenaline’ is to be used, not ‘Epinephrine’ (similarly ‘Noradrenaline’, not ‘Norepinephrine’).
• Suxamethonium and Adrenaline
All lettering to be black with the exception of the labels for Suxamethonium and Adrenaline which shall be printed against the
background colour as bold reverse plate letters within a black bar running from edge to edge of the upper half of the label, the
rest of which shall display the coloured background.
• Antagonists
To denote a drug of opposite action, 1mm wide diagonal stripes of the designated colour, alternating with a 1 mm wide white
stripe is used. The stripes should run from lower left to upper right at approximately 45 degrees. The striping should be
omitted behind and below the drug name. Protamine, as an antagonist of Heparin, should be a white label with black stripes.
• Anti-emetics
The syringe label for this group of drugs should have the background colour Salmon 156, which is shared by the major
tranquillisers.
• Combinations of drugs
Drugs which are supplied ready mixed in the ampoule should have a syringe label which denotes the drug name of one of the
two drugs against the appropriate background in the upper half of the label, and the drug name of the second drug against the
appropriate background in the lower half. For example:
• Glycopyrronium and neostigmine
• Lidocaine % and Adrenaline
An exception to this is the label for Propofol with user-addition of Lidocaine. This label should read ‘Propofol/lidocaine’ with
‘mg/ml’ for Propofol against the induction agent background (yellow).
Note to users: The colours are only a guide. All syringes containing drugs must be labelled. It is important to check the drug
ampoule and correctly label the syringe with the correctly texted label. Blank coloured labels are a potential source of confusion
and should not be used.
Dr Tim Meek
Chairman Safety Committee
Association of Anaesthetists of Great Britain and Ireland
1
References
Syringe labelling in critical care areas. RCoA Bulletin 19;May 2003:953.
2
Changes in names of certain medicinal substances. Chief Medical Officer, Chief Nursing Officer and Chief Pharmaceutical Officer.
DoH;17 March 2004:PL/CMO2004/1.
3
User-applied labels for use on syringes containing drugs used during anaesthesia. Australian/New Zealand Standard;4375:1996.
4 Geneva, ISO, 2008. ISO 26825:2008, Anaesthetic and respiratory equipment - User-applied labels for syringes containing drugs
used during anaesthesia - Colours, design and performance.

Propofol
.............................mg/ml.
Induction agents
Ketamine
.............................mg/ml.
Diazepam
..........................mg/ml.
Hypnotics
Midazolam
..........................mg/ml.
.............................mg/ml.
Neuromuscular blocking drugs
Vecuronium
.............................mg/ml.
Neuromuscular blocking drug antagonist
Neostigmine
...............micrograms/ml.
Morphine
.............................mg/ml.
Opioids
Fentanyl
................micrograms/ml.
Opioid antagonist
Naloxone
...............micrograms/ml.
Vasopressors
Hypotensive agent
...............micrograms/ml.
Ephedrine
.............................mg/ml.
Labetalol
..............................mg/ml.
Atropine
..............micrograms/ml.
Anticholinergic agents
Glycopyrronium
.............micrograms/ml.
Lidocaine
...............................%.
Local anaesthetics
Bupivacaine
...............................%.
Anti-emetics
Ondansetron
...................mg/ml.
Heparin
...................units/ml.
Miscellaneous
Protamine
...................mg/ml.
Further information is available from the manufacturer or the following websites: www.astm.org and www.csa.ca
Please note that colours are only a guide and the correct Pantone colour code numbers are listed on the reverse of this sheet. It
is still important to check the drug ampoule and correctly label the syringe containing the drug with the correctly texted label.

STANDARD BACKGROUND COLOURS FOR USER-APPLIED
SYRINGE DRUG LABELS
Drug class Examples Pantone ® colour (uncoated)
Anti-emetics Metoclopramide, Ondansetron Pantone ® 156 (salmon)
Induction agents
Thiopental, etomidate, ketamine,
propofol
Yellow
Hypnotics Diazepam, lorazepam, midazolam Pantone ® 151 (orange)
Hypnotic antagonists
Depolarising neuromuscular
blocking drugs
Non-depolarising neuromuscular
blocking drugs
Neuromuscular blocking drug
antagonists
Flumazenil
Suxamethonium
Atracurium, Vecuronium
Neostigmine
Pantone ® 151 (orange with white
diagonal stripes)
Pantone ® 805 (fluorescent or warm
red lettering out of black above, red
below)
Pantone ® 805 (fluorescent or warm
red)
Pantone ® (fluorescent or warm red)
with white diagonal stripes
Opioids Morphine, fentanyl, remifentanil Pantone ® 297 (blue)
Opioid antagonists
Naloxone
Pantone ® 297 (blue) with white
diagonal stripes
Major tranquilizers Droperidol, chlorpromazine Pantone ® 156 (salmon)
Vasopressors
Hypotensive agents
Adrenaline, ephedrine,
phenylephrine
Nitroprusside, nitroclycerine,
phentolamine
Pantone ® 256 (violet) (Adrenaline
is violet out of black above, violet
below)
Pantone ® 256 (violet) with white
diagonal stripes
Local anaesthetics Lidocaine, bupivacaine Pantone ® 401 (grey)
Anticholinergic agents Atropine, glycopyrronium Pantone ® 367 (green)
Other agents
Oxytocin, heparin, protamine,
antibiotics
Pantone ® transparent white
(Protamine is Pantone ® transparent
white with black diagonal stripes)
The examples shown are representative, not restrictive. See Pantone ® Colour Formula Guide. Pantone ® is
a registered trademark of Pantone, Inc.

The measurement of adult blood pressure
and management of hypertension before
elective surgery 2016
Published by
The Association of Anaesthetists of Great Britain & Ireland
British Hypertension Society
March 2016

This guideline was originally published in Anaesthesia. If you wish to refer to this
guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. The measurement of adult
blood pressure and management of hypertension before elective surgery 2016.
Anaesthesia 2016; 71: 326-337.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13348/full

Anaesthesia 2016, 71, 326–337
Guidelines
doi:10.1111/anae.13348
The measurement of adult blood pressure and management of
hypertension before elective surgery
Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the
British Hypertension Society
A. Hartle, 1 T. McCormack, 2 J. Carlisle, 3 S. Anderson, 4 A. Pichel, 5 N. Beckett, 6 T. Woodcock 7 and
A. Heagerty 8
1 Consultant, Departments of Anaesthesia and Intensive Care, St Mary’s Hospital, London, UK, and co-Chair,
Working Party on behalf of the AAGBI
2 General Practitioner, Whitby Group Practice, Spring Vale Medical Centre, Whitby, UK, Honorary Reader, Hull York
Medical School, UK, and co-Chair, Working Party, on behalf of the British Hypertension Society
3 Consultant, Departments of Anaesthesia, Peri-operative Medicine and Intensive Care, Torbay Hospital, Torquay, UK
4 Clinical Lecturer, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK and British
Hypertension Society
5 Consultant, Department of Anaesthesia, Manchester Royal Infirmary, Manchester, UK
6 Consultant, Department of Ageing and Health, Guys’ and St Thomas’ Hospital, London, UK and British
Hypertension Society
7 Independent Consultant Anaesthetist, Hampshire, UK
8 Professor, Department of Medicine, University of Manchester, Manchester, UK, and British Hypertension Society
Summary
This guideline aims to ensure that patients admitted to hospital for elective surgery are known to have blood pressures
below 160 mmHg systolic and 100 mmHg diastolic in primary care. The objective for primary care is to fulfil this criterion
before referral to secondary care for elective surgery. The objective for secondary care is to avoid spurious hypertensive
measurements. Secondary care should not attempt to diagnose hypertension in patients who are normotensive in
primary care. Patients who present to pre-operative assessment clinics without documented primary care blood pressures
should proceed to elective surgery if clinic blood pressures are below 180 mmHg systolic and 110 mmHg diastolic.
.................................................................................................................................................................
This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists
of Great Britain and Ireland (AAGBI) and the British Hypertension Society (BHS). It has been seen and approved by
the AAGBI Board of Directors and the BHS Executive. It is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives
4.0 International License. Date of review: 2020.
Accepted: 16 November 2015
.................................................................................................................................................................
Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not
permit commercial exploitation.
326 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
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
Recommendations
•
General practitioners should refer patients for elective
surgery with mean blood pressures in primary
care in the past 12 months less than 160 mmHg
systolic and less than 100 mmHg diastolic.
• Secondary care should accept referrals that document
blood pressures below 160 mmHg systolic and
below 100 mmHg diastolic in the past 12 months.
• Pre-operative assessment clinics need not measure
the blood pressure of patients being prepared for
elective surgery whose systolic and diastolic blood
pressures are documented below 160/100 mmHg in
the referral letter from primary care.
• General practitioners should refer hypertensive
patients for elective surgery after the blood pressure
readings are less than 160 mmHg systolic and less
than 100 mmHg diastolic. Patients may be referred
for elective surgery if they remain hypertensive
despite optimal antihypertensive treatment or if
they decline antihypertensive treatment.
• Surgeons should ask general practitioners to supply
primary care blood pressure readings from the last
12 months if they are undocumented in the referral
letter.
• Pre-operative assessment staff should measure the
blood pressure of patients who attend clinic without
evidence of blood pressures less than
160 mmHg systolic and 100 mmHg diastolic being
documented by primary care in the preceding
12 months. (We detail the recommended method
for measuring non-invasive blood pressure accurately,
although the diagnosis of hypertension is
made in primary care.)
• Elective surgery should proceed for patients who
attend the pre-operative assessment clinic without
documentation of normotension in primary care if
their blood pressure is less than 180 mmHg systolic
and 110 mmHg diastolic when measured in clinic.
The disparity between the blood pressure thresholds
for primary care (160/100 mmHg) and secondary
care (180/110 mmHg) allows for a number of factors.
Blood pressure reduction in primary care is based on
good evidence that the rates of cardiovascular morbidity,
in particular stroke, are reduced over years and
decades. There is no evidence that peri-operative blood
pressure reduction affects rates of cardiovascular events
beyond that expected in a month in primary care.
Blood pressure measurements might be more accurate
in primary care than secondary care, due to a less
stressful environment and a more practised technique.
What other guideline statements are available on
this topic?
There is detailed evidence-based guidance on the diagnosis
and treatment of hypertension in the community
from, for example, the National Institute for Health
and Care Excellence [1]. There is little guidance on a
‘safe’ blood pressure for planned anaesthesia and surgery.
Why was this guideline developed?
There is no national guideline for the measurement,
diagnosis or management of raised blood pressure
before planned surgery. There is little evidence that
raised pre-operative blood pressure affects postoperative
outcomes. Local guidelines vary from area to area.
Hypertension is a common reason to cancel or postpone
surgery. In our sprint audit, 1–3% of elective
patients had further investigations precipitated by
blood pressure measurement, of whom half had their
surgery postponed. Across the UK this would equate
to ~100 concerned and inconvenienced patients each
day, with associated costs to the NHS and the national
economy [2, 3].
This guideline is the first collaboration between
the AAGBI and the British Hypertension Society; these
two organisations have very different perspectives.
Members of the British Hypertension Society are concerned
with the long-term reduction in rates of cardiovascular
disease, particularly strokes. Anaesthetists are
more focused on immediate complications, in the perioperative
period. This guideline aims to prevent the
diagnosis of hypertension being the reason that
planned surgery is cancelled or delayed. As such, it
should also be of interest to hospital managers and
commissioners of hospital care.
How does this statement differ from existing
guidelines?
This guideline serves, therefore, not to advise on treatment
of hypertension, but rather to produce a com-
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Management of hypertension before elective surgery guidelines
mon terminology in diagnosis and referral, explaining
the impact of anaesthesia on blood pressure and vice
versa to the wider, non-anaesthetic community. At the
same time, it will review current best practice on the
measurement, diagnosis and treatment of hypertension.
Why does this statement differ from existing
guidelines?
Pre-operative blood pressure management involves
many specialties and professions: primary care, general
medicine, cardiology, endocrinology, pre-operative
assessment clinics and, of course, both anaesthetists
and surgeons. This list is not exhaustive. This guideline
should be a useful summary for all those clinicians
and for patients. The guidance takes into account not
just the best clinical evidence, but the particular pattern
of referral for treatment within the NHS in all
four countries of the UK.
Introduction
The National Institute for Health and Care Excellence
(NICE) has described hypertension as ‘one of the most
important preventable causes of premature morbidity
and mortality in the UK’ [1]. The Association of
Anaesthetists of Great Britain and Ireland (AAGBI),
together with the British Hypertension Society, felt
there was a need for a nationally agreed policy statement
on how to deal with raised blood pressure in the
pre-operative period. We have based this statement on
a consensus view with the backing of graded evidence,
where such evidence is available.
Hypertension is almost always asymptomatic and
it is diagnosed following screening in general practice.
Managing hypertension pre-operatively is a complex
matter of balancing the risks of anaesthesia, treatment
and delay for the individual patient. Most cases of
hypertension are primary, i.e. with no other medical
cause. For the remainder, the cause for hypertension
may be associated with the reason for the proposed
operation.
Cancellations and postponements of planned surgical
procedures have been a major and long-standing
problem for healthcare worldwide. The quantifiable
loss of resource is pitted against unquantifiable and
significant psychological, social and financial implications
of postponement for patients and their families.
Although guidelines exist for the treatment of elevated
blood pressure, there remains a paucity of literature
and accepted guidelines for the peri-operative
evaluation and care of the patient with hypertension
who undergoes non-cardiac surgery [4]. Of particular
importance is defining the patients most vulnerable
to complications and the indications for immediate
and rapid antihypertensive treatment and/or postponement
of surgery to reduce these risks pre-operatively,
intra-operatively and postoperatively. Perioperative
hypertension often occurs in conjunction
with sympathetic nociceptive stimulation during the
induction of anaesthesia, during surgery and with
acute pain in the early postoperative period. Hypertension
may also accompany hypothermia, hypoxia or
intravascular volume overload from excessive intraoperative
fluid therapy, particularly in the ensuing
24–48 h as fluid is mobilised from the extravascular
space [4–6].
There are no nationally agreed guidelines for the
diagnosis or management of raised blood pressure
before elective surgery. The evidence regarding the
effect of raised pre-operative blood pressure is very
limited. Local guidelines do exist but vary from area to
area. Both the AAGBI and the British Hypertension
Society recognised the need for a national guideline
and consensus statement to address the various issues
of concern. We have limited our deliberations to a
specific scope. Only the period before planned surgery
is covered. Blood pressures which may cause an immediate
risk to health are specified, rather than those that
may cause risk over the long-term. The best method of
taking accurate blood pressure measurements is examined.
We considered how long blood pressure should
be controlled before surgery is undertaken. Communication
between different hospital departments, primary
care and the patient are of importance. We hope that
by providing national guidance the chances of a
patient receiving conflicting advice will be minimised.
Scope
This guideline is aimed at adults presenting for
planned surgery. The following groups of patients are
specifically not studied, although many of the general
points covered in the guideline may apply.
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Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337
Emergency/urgent surgery
By definition, these patients have no or very limited
time for investigation, treatment or postponement.
Such surgery must almost always proceed, but all those
involved, including the patient, must be aware of any
associated increased risk.
Obstetrics
Most cases of hypertension in pregnancy will be
directly related to the pregnancy (although with an
ageing obstetric population with higher rates of obesity,
this may be less so). The monitoring and treatment
of blood pressure is a specific and integral part
of obstetric care, regardless of the need for surgery,
and even for ‘elective’ Caesarean section there may be
very limited opportunity for delay.
Paediatrics
Childhood hypertension is relatively uncommon, and
its epidemiology and natural history is relatively
unclear and there are no definitive trials on screening.
Thus, its diagnosis and management, including preoperatively,
is a specialist area beyond the scope of the
general guidance in this publication.
Cardiac surgery
Peri-operative hypertension commonly complicates
surgery for congenital and acquired cardiac disease.
Management will be affected by many other factors
including the planned procedure, the use or not of cardiopulmonary
bypass and the other indications for
vaso- and cardio-active medication. We have thus considered
it to be a specialist area beyond the scope of
the general guidance in this publication.
Surgery for blood pressure management
This includes surgery for phaeochromocytoma and
bariatric surgery; we have excluded this from our guidance
for similar reasons to that of cardiac surgery.
Methods
We formed a Working Party consisting of four members
from each society who were academics and clinicians
with varied interests, including vascular
anaesthesia, cardiology, elderly care medicine and general
practice. We agreed on the scope of the guideline,
and then carried out a systematic review with the quality
of evidence described using the Grading of Recommendations
Assessment, Development and Evaluation
(GRADE) approach [7, 8]. The GRADE approach considers
the quality of a body of evidence as high, moderate,
low or very low. To achieve a full consensus
document was important. Therefore, we consulted 20
general practitioners, including those with a specialist
interest in cardiovascular medicine, as well as senior
academics. A consultation guideline was then made
available to members of both societies for comment.
We specifically asked for and received comments from
the patient group, Blood Pressure UK. The comments
and responses have been made available online. The
Council and Executive of the respective societies were
given the task of final approval.
Blood pressure, hypertension and
anaesthesia
The anaesthetist has two broad considerations in the
hypertensive patient who presents for surgery. One is
to be cognisant of the effect of chronic hypertension
on the individual’s peri-operative and long-term cardiovascular
risk. The other is to consider whether the
blood pressure measured in the primary care setting is
associated with adverse peri-operative events and to
decide whether this should be reduced before surgery.
The association between hypertension and perioperative
harm was first reported in the 1950s [9, 10].
Systolic blood pressures in excess of 170 mmHg and
diastolic blood pressures in excess of 110 mmHg were
associated with complications such as myocardial
ischaemia [11]. Hypertension was the second-most
common factor associated with postoperative morbidity
[12]. In 2003, Weksler et al. published a ‘quasi’-
randomised controlled study of 989 treated hypertensive
patients who had diastolic blood pressures
between 110 and 130 mmHg measured in the anaesthetic
room [13]. In one group, surgery proceeded
after intranasal nifedipine, and in the other group, surgery
was delayed while further antihypertensive treatment
was pursued in hospital. During the first three
postoperative days, the rates of neurological and cardiovascular
complications were similar. One might
conclude that there was no difference in an infrequent
outcome, or that the study had insufficient power to
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Anaesthesia 2016, 71, 326–337
Management of hypertension before elective surgery guidelines
detect a small difference (see section below, treatment
for hypertension: extension of evidence from the community
to the peri-operative period).
The association of hypertension with cardiovascular
disease is established, but there is no clear evidence
that patients with stage 1 or 2 hypertension (Table 1)
without evidence of target organ damage have
increased peri-operative cardiovascular risk [14].
Patients with stage 3 or 4 hypertension, who are more
likely to have target organ damage, have not been subjected
to rigorous randomised controlled trials of perioperative
interventions. There is evidence that hypertension
with target organ damage is associated with a
small increased incidence of peri-operative major
adverse cardiovascular events [4]. It is not known
whether or not reducing blood pressure in these
patients during a postponement of planned surgery
would reduce this rate of events; there is sparse evidence
to guide a decision. Any decision should take
into account factors other than blood pressure, namely:
age; comorbidity; functional capacity (i.e. functional
status and reserve); and the urgency and indication for
surgery (see section below, ‘The treatment of cardiovascular
risk, not hypertension’). The latest guidelines
published by the National Institute for Health and
Care Excellence (NICE), in conjunction with the British
Hypertension Society, recognise the importance of
target organ damage in the management of hypertension
by targeting a lower threshold for further medical
intervention [1]. Whether or not these thresholds and
targets should be rigorously applied in the peri-operative
setting is not clear.
Patients with hypertension (controlled or uncontrolled)
demonstrate a more labile haemodynamic profile
than their non-hypertensive counterparts [5]. The
induction of anaesthesia and airway instrumentation
can lead to a pronounced increase in sympathetic activation,
which may lead to a significant increase in
Table 1 Categorisation of the stages of hypertension.
Category
Systolic blood
pressure; mmHg
Diastolic blood
pressure; mmHg
Stage 1 140–159 90–99
Stage 2 160–179 100–109
Stage 3 180–209 110–119
Stage 4 ≥ 210 ≥ 120
blood pressure and heart rate. A reduction in systemic
vascular resistance soon after the induction of anaesthesia
commonly leads to varying degrees of hypotension.
Reduction in vascular resistance is multifactorial
and may be secondary to loss of the baroreceptor
reflex control, central neuraxial blockade, and direct
effects of anaesthetic agents. The effect on vascular
tone will be exaggerated by ‘deep’ or excessive anaesthesia
and in patients who are fluid-depleted. This,
and the often exaggerated haemodynamic response to
surgery, pain and emergence from anaesthesia, have
also been described as being more common in the
hypertensive population [6]. Some researchers have
demonstrated an association between pre-operative
hypertension and relatively minor physiological
derangements such as intra-operative hypotension,
hypertension and arrhythmia, but studies have not
conclusively demonstrated that fluctuations in haemodynamic
variables cause clinically significant harm
[15]. Larger studies to investigate differences between
untreated hypertensive patients and those treated (successfully
and unsuccessfully) have not demonstrated
increased rates of peri-operative cardiovascular events.
However, these findings may not be applicable to current
practice, as many of these studies were conducted
in the late 1970s [16].
This appreciation of labile haemodynamics in
hypertensive patients has led to a number of anaesthetic
techniques designed to achieve a more stable
haemodynamic profile during surgery. These techniques
include co-induction, invasive arterial monitoring
with titrated or prophylactic vasopressor therapy,
depth-of-anaesthesia monitoring, beta-blockers and the
optimisation of stroke volume with intravascular fluid
therapy. The omission of antihypertensive drugs, such
as angiotensin-converting enzyme inhibitors and
receptor blockers, combined with the careful reintroduction
of these drugs after surgery, is commonplace
and appears to be associated with fewer significant
peri-operative haemodynamic fluctuations [17].
The introduction of peri-operative beta-blockade for
high cardiac-risk patients increases postoperative mortality,
secondary to hypotension and stroke, albeit with
less cardiac injury, as demonstrated in the POISE-1
study [18]. The anaesthetist should be aware that sudden
withdrawal of certain antihypertensive agents such
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Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337
as clonidine, alpha-methyldopa and beta-blockers can
be associated with adverse events. Withdrawal of
beta-blockers may also be associated with myocardial
ischaemia that is often silent in the peri-operative period
and easily missed without continuous ECG monitoring
and serial serum troponin measurements.
Best practice: the measurement of
blood pressure
Blood pressure should be measured in primary care
before non-urgent surgical referral (Fig. 1). Surgical
outpatients should arrange for primary care to supply
blood pressure readings if these have not been
documented in the referral letter. Blood pressure
should be measured by pre-operative assessment
clinics in patients who attend the clinic without documented
blood pressure readings from the last
12 months. The measurement should follow the
principles mandated for primary care (see below)
[1]. Blood pressures less than 180 mmHg systolic
and 110 mmHg diastolic in secondary care should
not preclude elective surgery, although the patient
Elective surgical referral appropriate
No
Measure blood pressure up to
three times
Mean
SBP < 160 mmHg
AND
DBP < 100 mmHg
in past year?
Yes
Refer
Lowest SBP < 140 mmHg
AND the lowest DBP <
90 mmHg?
Yes
Refer
No
Lowest SBP < 160 mmHg
AND the lowest DBP <
100 mmHg?
Yes
Refer*
No
ABPM or HBPM
Mean ‘out of office’
SBP < 150 mmHg AND
the mean DBP < 95
mmHg?
Yes
Refer*
No
Treat until ‘clinic’ SBP < 160 mmHg
AND DBP < 100 mmHg
Refer*
Figure 1 Primary care blood pressure assessment of patients before referral for elective surgery. *Investigations and
treatment should continue to achieve blood pressures < 140/90 mmHg. ABPM and HBPM, ambulatory and home
blood pressure measurement; DBP and SBP, diastolic and systolic blood pressure.
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Anaesthesia 2016, 71, 326–337
Management of hypertension before elective surgery guidelines
should be asked to attend their general practice for
the concurrent determination of whether primary
care hypertension is present.
The setting in which blood pressure is measured
should be relaxed and temperate in a standardised
environment with current calibrated equipment. The
seated patient should have their supported arm outstretched
for at least one minute before the initial
reading. The pulse rate and rhythm should be
recorded before the blood pressure is measured by a
validated device. Automated sphygmomanometers
(www.bhsoc.org/bp-monitors) are inaccurate when the
pulse is irregular, when the blood pressure should be
measured by auscultation over the brachial artery during
manual deflation of an arm cuff.
Blood pressure should be measured in both arms
in patients scheduled for vascular or renal surgery. If
the difference between arms in systolic pressure is
greater than 20 mmHg, repeat the measurements; subsequently,
measure from the arm with the higher
blood pressure.
The patient is normotensive if the blood pressure
measurement is less than 140/90 mmHg. If the first
measurement is equal to or higher than 140/
90 mmHg, the blood pressure should be measured
twice more, with each reading at least one minute
apart. The lower of the last two readings is recorded as
the blood pressure; if it is less than 140/90 mmHg the
patient is normotensive.
If the reading is between 140/90 mmHg and 179/
109 mmHg, the patient may have stage 1 or 2 hypertension.
In primary care, the patient would be offered
ambulatory (ABPM) or home blood pressure monitoring
(HBPM) to establish their true blood pressure
(GRADE 1B). If the reading is equal to or higher than
180/110 mmHg in primary care, the patient may have
severe hypertension and would be considered for
immediate treatment.
Best practice: the diagnosis of
hypertension
General practitioners should establish whether blood
pressure has been measured and managed in all adults
before non-urgent surgical referrals. A blood pressure
measurement taken within the preceding 12 months
should be detailed in the referral letter.
The diagnosis of hypertension in patients
referred for investigation of surgical disease that are
not treated for hypertension and who have not had
a blood pressure measurement in the preceding
12 months follows the same process as any other
primary care patient. We recommend that the practice
instigates ambulatory or home blood pressure
measurements before non-urgent referrals if the standard
blood pressure is equal to or greater than 160/
100 mmHg. If the patient’s ABPM/HBPM blood
pressure is equal to or greater than 150/95 mmHg
(or equal to or greater than 135/85 mmHg with target
organ damage), the patient is diagnosed as having
hypertension; treatment should be discussed and
commenced using the NICE/BHS CG127 algorithm
[19]. This process can take place at the same time
as urgent surgical referral, but a reduction in blood
pressure to less than 160/100 mmHg should precede
non-urgent surgical referral. The referral letter
should document that an informed discussion has
taken place with patients who decline treatment, or
detail that all appropriate attempts have been made
to reduce blood pressure for patients with persistent
hypertension, which might have included specialist
investigations.
Surgical outpatients should request that general
practitioners forward primary care blood pressure
measurements if these have not been documented in
the referral letter. Pre-operative assessment clinics
should measure the blood pressures of patients who
present without documentation of primary care blood
pressures. If the blood pressure is raised above
180 mmHg systolic or 110 mmHg diastolic, the patient
should return to their general practice for primary care
assessment and management of their blood pressure,
as detailed above (Fig. 2). If the blood pressure is
above 140 mmHg systolic or 90 mmHg diastolic, but
below 180 mmHg systolic and below 110 mmHg diastolic,
the GP should be informed, but elective surgery
should not be postponed.
Best practice: the treatment of
hypertension
This section summarises the recommendations for primary
care following the diagnosis of hypertension.
There is good evidence (GRADE 1A) for the treatment
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Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337
Surgeon receives referral
No
Documented
SBP < 160 mmHg
AND
DBP < 100 mmHg
in past year?
Yes
Proceed
Request measurements from GP
Lowest SBP < 160 mmHg
AND the lowest DBP <
100 mmHg?
Yes
Proceed
No
Measure blood pressure up to
three times
Lowest SBP < 180 mmHg
AND the lowest DBP <
110 mmHg?
Yes
Proceed*
No
Refer back to GP*
Figure 2 Secondary care blood pressure assessment of patients after referral for elective surgery. *The GP should be
informed of blood pressure readings in excess of 140 mmHg systolic or 90 mmHg diastolic, so that the diagnosis of
hypertension can be refuted or confirmed and investigated and treated as necessary. DBP and SBP, diastolic and systolic
blood pressure.
of hypertension with one or more of the following:
diuretics (thiazide, chlorthalidone and indapamide);
beta-blockers; calcium channel-blockers (CCB); angiotensin
converting enzyme (ACE) inhibitors, or an
angiotensin-2 receptor blocker (ARB) [1]. In the
future, the threshold for treating high blood pressure
might change to cardiovascular risk (see below, the
treatment of cardiovascular risk, not hypertension).
Step 1 treatment
Patients aged less than 55 years should be offered an
ACE inhibitor, or a low-cost ARB. If an ACE inhibitor
is prescribed but is not tolerated (for example,
because of cough), offer a low-cost ARB. Angiotensin-converting
enzyme inhibitors and ARBs are not
recommended in women of childbearing potential.
An ACE inhibitor should not be combined with
an ARB.
Patients aged over 55 years and Black patients of
African or Caribbean family origin of any age should
be offered a CCB. If a CCB is not suitable, for example
because of oedema or intolerance, or if there is evidence
of heart failure or a high risk of heart failure, a
thiazide-like diuretic should be offered.
If diuretic treatment is to be initiated or changed,
offer a thiazide-like diuretic, such as chlorthalidone
(12.5–25.0 mg once daily), or indapamide (1.5 mg
modified-release once daily or 2.5 mg once daily), in
preference to a conventional thiazide diuretic such as
bendroflumethiazide or hydrochlorothiazide.
For patients who are already having treatment
with bendroflumethiazide or hydrochlorothiazide
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Anaesthesia 2016, 71, 326–337
Management of hypertension before elective surgery guidelines
and whose blood pressure is stable and well controlled,
treatment with the bendroflumethiazide or
hydrochlorothiazide should be continued.
Beta-blockers are not a preferred initial therapy
for hypertension. However, beta-blockers may be
considered in younger patients, particularly those
with an intolerance or contraindication to ACE inhibitors
and ARBs, or women of childbearing potential
or patients with evidence of increased sympathetic
drive. If beta-blockers are started and a second drug
is required, add a CCB rather than a thiazide-like
diuretic to reduce the person’s risk of developing
diabetes.
Step 2 treatment
If blood pressure is not controlled by Step 1 treatment,
use a CCB in combination with either an ACE inhibitor
or an ARB.
If a CCB is not suitable for Step 2 treatment, for
example because of oedema or intolerance, or if there
is evidence of heart failure or a high risk of heart failure,
offer a thiazide-like diuretic.
For Black patients of African or Caribbean family
origin, consider an ARB in preference to an ACE inhibitor,
in combination with a CCB.
Step 3 treatment
Before considering Step 3 treatment, check that drugs
from Step 2 have been prescribed at optimal doses, or
at the maximum tolerated doses. If treatment with
three drugs is required, the combination of ACE inhibitor
or ARB, CCB and thiazide-like diuretic should be
used.
Step 4 treatment
If resistant blood pressure exceeds 140/90 mmHg in
clinic after treatment with the optimal or highest-tolerated
doses of an ACE inhibitor, or an ARB plus a
CCB, with a diuretic; adding a fourth antihypertensive
drug and expert advice should be considered.
Further diuretic therapy with low-dose spironolactone
(25 mg once daily) should be considered if the
serum potassium concentration < 4.6 mmol.l
1 . Caution
is required in patients with reduced estimated
glomerular filtration rates because of an increased risk
of hyperkalaemia. Increasing the dose of thiazide-like
diuretics should be considered if the serum potassium
concentration > 4.5 mmol.l
1 .
Serum sodium and potassium concentrations and
renal function should be checked within 1 month of
increasing diuretic dose, and repeated as required
thereafter. If further diuretic therapy for resistant
hypertension at Step 4 is not tolerated, or is contraindicated
or ineffective, consider an alpha-blocker
or beta-blocker. If blood pressure remains uncontrolled
with the optimal or maximum tolerated doses of four
drugs, expert advice should be sought if it has not yet
been obtained.
As recently as 2008, the HYVET study demonstrated
the clinical benefits of treating hypertension in
people aged ≥ 80 years, while health economic analysis
has confirmed the cost effectiveness of this strategy [1,
20]. As a result, NICE now recommends that patients
aged ≥ 80 years should be offered treatment only if
they have stage 2 hypertension. The 2011 Hypertension
Guideline also recommends that the decision to
treat should be based on standing blood pressure, and
should take into account the presence of co-morbidities
such as dementia. The guideline also makes a distinction
between initiating treatment in the over-80s
and continuing long-term and well-tolerated treatment
when patients reach this age. In other words, patients
who were started on treatment when younger should
not have their current therapy back-titrated when they
celebrate their 80th birthday.
The treatment of cardiovascular risk,
not hypertension
It is likely that treatment for hypertension will no
longer be based upon blood pressure [21]. This is a
surprising statement; the diagnosis of hypertension
that merits treatment has – until recently – been based
on patients’ blood pressure, irrespective of other cardiovascular
risk factors, despite the NICE guidance
recognising their importance [1]. This practice conflicts
with the treatment of hypercholesterolaemia,
which is not based on the cholesterol concentration
alone, but instead on the composite 5- or 10-year risk
of: stroke; myocardial infarction; heart failure; cardiovascular
morbidity; or death, ascribed to these diagnoses.
The magnitude by which cardiovascular disease
is reduced by treatment for both hypercholesterolaemia
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Management of hypertension before elective surgery guidelines Anaesthesia 2016, 71, 326–337
and hypertension is dependent on the composite cardiovascular
risk, not the concentration of cholesterol
or the blood pressure. Anaesthetists should gauge their
concern for a hypertensive patient by the calculated
five-year rate of cardiovascular events, not by the
blood pressure measurement per se.
Hypertension is common; this is responsible for
the well-publicised reduction in population rates of
stroke by antihypertensive treatment. The absolute
effect of treatment for the individual, even over a fiveyear
period, is smaller than many anaesthetists might
realise. Table 2 presents the effect of five-year antihypertensive
treatment for cardiovascular risk in a population
quartered by the five-year rate of any
cardiovascular event. Planned major surgery temporarily
increases mortality. For instance, planned open
repair of abdominal aortic aneurysm increases mortality
in the first postoperative month ten times, whereas
endovascular repair increases mortality four times. If
cardiovascular events are similarly increased by major
planned surgery, one would anticipate that the preoperative
antihypertensive treatment of cardiovascular
risk would have a proportionately greater absolute
effect on the rates of events while their risk remains
elevated. Table 3 illustrates the absolute effect of established
antihypertensive treatment in the month following
a planned operation in patients from Table 2,
assuming two scenarios: that the operation does not
affect the rates of cardiovascular events; and that the
operation increases the rates of cardiovascular events
six times.
This guideline has outlined that blood pressure
before planned non-urgent surgery is measured in primary
care, where the diagnosis of hypertension is
Table 2 The effect of antihypertensive treatment on the five-year rates of events (per 1000) in a population quartered
on the basis of the untreated cardiovascular five-year risk: lowest quartile (< 11% risk); next quartile (11–15%
risk); next quartile (15–21% risk); highest quartile (> 21% risk).
Any event Stroke CHD Heart failure
No
Quartile of risk treatment Treatment No treatment Treatment No treatment Treatment No treatment Treatment
Highest quartile
Event rates 270/1000 232/1000 70/1000 58/1000 63/1000 53/1000 47/1000 34/1000
Event reduction 38/1000 12/1000 10/1000 13/1000
Second quartile
Event rates 180/1000 156/1000 49/1000 40/1000 42/1000 36/1000 27/1000 23/1000
Event reduction 24/1000 9/1000 6/1000 4/1000
Third quartile
Event rates 120/1000 100/1000 36/1000 29/1000 33/1000 28/1000 15/1000 13/1000
Event reduction 20/1000 7/1000 5/1000 2/1000
Lowest quartile
Event rates 60/1000 46/1000 17/1000 11/1000 17/1000 14/1000 6/1000 5/1000
Event reduction 14/1000 6/1000 3/1000 1/1000
CHD, coronary heart disease.
Table 3 The absolute reduction in event rates per 1000 patients per month by antihypertensive treatment, assuming
that the control rate is unaffected by surgery (‘same’) or increased, in this example sixfold (‘9 6’).
Any event Stroke CHD Heart failure
Quartile of risk Same 3 6 Same 3 6 Same 3 6 Same 3 6
Highest quartile 0.6 3.8 0.2 1.2 0.2 1 0.2 1.3
Next quartile 0.4 2.4 0.2 0.9* 0.1 0.6 0.1 0.4
Next quartile 0.3 1.8 0.1 0.7 0.1 0.6 0.0 0.2
Lowest quartile 0.2 1.2 0.1 0.6 0.1 0.3 0.0 0.1
*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.
CHD, coronary heart disease.
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Anaesthesia 2016, 71, 326–337
made, and treatment is managed. The lifelong risk of
mortality and morbidity may be unaffected by postponing
surgery for the assessment of cardiovascular
risk by primary care and possible antihypertensive
treatment [22]. For instance, clinicians might like to
consider the uncertainty in how long it takes for cardiovascular
risk to fall with antihypertensive medication
(as opposed to how long it takes for blood
pressure to fall), and the 1% relative increase in cardiovascular
risk that accompanies each postponed
month, due to the patient ageing. Clinicians might also
consider that patients who smoke or who have hypercholesterolaemia
are not subjected to the summary cancellations
justified by blood pressure readings. A
further consideration is the absence of a scale of
enthusiasm for postponing surgery that matches the
continuum of cardiovascular risk, which would result
in older smoking hypercholesterolaemic normotensive
men having surgery postponed more frequently than
younger hypertensive women who do not have any
other cardiovascular risk factors.
Communication
Pre-operative assessment clinics should inform general
practitioners when they measure raised blood pressures
in patients who have not had readings taken in primary
care in the preceding 12 months. The letter
should request that the general practitioner determine
whether the patient has hypertension in primary care.
The letter should also state whether or not surgery will
proceed without a diagnosis of hypertension being
made or treatment commenced.
Appendix 1 is an example of a letter explaining
that surgery will not proceed until the diagnosis of
hypertension has been excluded or confirmed, and in
the latter case treated with the patient’s consent. It is
important that the patient has a copy and is instructed
to make an appointment at their surgery with a nurse
or a doctor and to take the letter with them. The language
used should seek cooperative management
rather than demand action. In the first instance, the
GP will need to establish that the blood pressure is
high and this is not a white coat effect. It must be
clearly stated how to re-establish the procedural pathway
when the blood pressure has been shown to be
satisfactory, treated or not.
Management of hypertension before elective surgery guidelines
References
1. National Institute for Health and Care Excellence. Hypertension:
Clinical management of primary hypertension in adults.
2011 NICE Clinical Guideline CG127. http://www.nice.org.uk/
guidance/cg127 (accessed 15/01/2015).
2. Cook TM, Woodall N, Frerk C. Fourth National Audit Project.
Major complications of airway management in the UK: results
of the Fourth National Audit Project of the Royal College of
Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.
British Journal of Anaesthesia 2011; 106: 617–31.
3. Cook TM, Andrade J, Bogod DG, et al. The 5th National Audit
Project (NAP5) on accidental awareness during general anaesthesia:
patient experiences, human factors, sedation, consent
and medicolegal issues. Anaesthesia 2014; 69: 1102–16.
4. Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart
disease and perioperative cardiac risk. British Journal of
Anaesthesia 2004; 92: 57–83.
5. Longnecker DE. Alpine anesthesia: can pretreatment with
clonidine decrease the peaks and valleys? Anesthesiology
1987; 67: 1–2.
6. Prys-Roberts C, Greene LT, Meloche R, Foex P. Studies of
anaesthesia in relation to hypertension II. Haemodynamic
consequences of induction and endotracheal intubation.
British Journal of Anaesthesia 1971; 43: 531–47.
7. Guyatt GH, Oxman AD, Kunz R, et al. Going from evidence to
recommendations. British Medical Journal 2008; 336: 1049–
51.
8. Guyatt GH, Oxman AD, Vist G, et al. for the GRADE Working
Group. Rating quality of evidence and strength of recommendations
GRADE: an emerging consensus on rating quality of
evidence and strength of recommendations. British Medical
Journal 2008; 336: 924–6.
9. Smithwick RH, Thompson JE. Splanchnicectomy for essential
hypertension; results in 1,266 cases. Journal of the American
Medical Association 1953; 152: 1501–4.
10. Thompson JE, Smithwick RH. Surgical measures in hypertension.
Geriatrics 1953; 8: 611–9.
11. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial
index of cardiac risk in noncardiac surgical procedures. New
England Journal of Medicine 1977; 297: 845–50.
12. Khuri SF, Daley J, Henderson W, et al. The National Veterans
Administration surgical risk study: risk adjustment for the
comparative assessment of the quality of surgical care. Journal
of the American College of Surgeons 1995; 180: 519–31.
13. Weksler N, Klein M, Szendro G, et al. The dilemma of immediate
preoperative hypertension: to treat and operate, or to
postpone surgery? Journal of Clinical Anesthesia 2003; 15:
179–83.
14. Hanada S, Kawakami H, Goto T, et al. Hypertension and anesthesia.
Current Opinion in Anaesthesiology 2006; 19: 315–9.
15. Chung F, Mezei G, Tong D. Pre-existing medical conditions as
predictors of adverse events in day case surgery. British Journal
of Anaesthesia 1999; 83: 262–70.
16. Goldman L, Caldera DL. Risks of general anesthesia and elective
operation in the hypertensive patient. Anesthesiology
1979; 50: 285–92.
17. Comfere T, Sprung J, Kumar MM, et al. Angiotensin system
inhibitors in a general surgical population. Anesthesia and
Analgesia 2005; 100: 636–44.
18. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended
release metoprolol succinate in patients undergoing non-cardiac
surgery (POISE trial): a randomised controlled trial. Lancet
2008; 371: 1839–47.
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
19. Hypertension Pathyways. http://pathways.nice.org.uk/pathways/
hypertension#path=view%3A/pathways/hypertension/diagnosisand-assessment-of-hypertension.xml&content=view-index
(accessed
16/01/2015).
20. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension
in patients 80 years of age or older. New England
Journal of Medicine 2008; 358: 1958–60.
21. Sundstr€om J, Arima H, Woodward M, et al. on behalf of the
Blood Pressure Lowering Treatment Trialists’ Collaboration.
Blood pressure-lowering treatment based on cardiovascular
risk: a meta-analysis of individual patient data. Lancet 2014;
384: 591–8.
22. Carlisle JB. Too much blood pressure? Anaesthesia 2015; 70:
773–8.
Appendix 1
Example of letter to general practitioner from pre-assessment clinic following measurement of raised blood pressure
in patients who have not had readings taken in primary care in the preceding 12 months.
Dear Doctor
Unfortunately, the procedure for Mr/Ms ...................... has been postponed because their blood pressure was
found to be 182/114 in their pre-operative assessment. It was measured several times following the AAGBI/BHS guidelines.
The guidelines suggest a blood pressure level higher than 180/110 is unsuitable for elective anaesthesia.
We have asked the patient to make an appointment at their surgery for further assessment of their blood pressure. We
would be grateful if you could verify that this is the true blood pressure level and not a white coat effect and treat appropriately
if the patient has hypertension.
We will be pleased to accept the patient back for surgery if their clinical blood pressure is below 160/100. Please
ask the patient to contact ........................... and inform us of their current blood pressure and what medication,
if any, was required to achieve this.
Many thanks in anticipation of your help with this matter
The following GPs were consulted about this letter:
Dr Chris Arden, Dr Ivan Benett, Dr Mark Davis, Dr Richard Falk, Prof David Fitzmaurice, Prof Ahmet Fuat, Dr
Napa Gopi, Dr Kathryn Griffith, Dr Rosie Heath, Prof Richard Hobbs, Dr Paul Johnson Prof Richard McManus, Dr
Jonathan Morrell, Dr Washik Parkar, Dr Neil Paul, Dr Jon Pittard, Dr Peter Savill, Dr Jonathan Shribman, Dr Harjit
Singh, Dr Heather Wetherell.
© 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
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

in
s
ca
Ultrasound in Anaesthesia and Intensive Care:
A Guide to Training
Published by
The Association of Anaesthetists of Great Britain & Ireland
The Royal College of Anaesthetists
The Intensive Care Society
July 2011

Membership of the working party
(Details correct at the start of the working party process)
Dr N M Denny
Dr K Fox
Dr C Gillbe
Dr A W Harrop-Griffiths
Dr M Jones
Dr N Love
Dr P MacNaughton
Dr R McWilliams
Dr B Nicholls
Dr P Nightingale
Dr J Pilcher
Dr S Price
Mr J Sloan
Dr S Ward
AAGBI (Chair)
British Society of Echocardiography
AAGBI
AAGBI
Society for Acute Medicine
Group of Anaesthetists in Training
Intensive Care Society
Royal College of Radiologists
Regional Anaesthesia (UK)
Royal College of Anaesthetists
British Medical Ultrasound Society
Intensive Care Society and British Society of
Echocardiography
College of Emergency Medicine
British Pain Society
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
Website: www.aagbi.org
The Royal College of Anaesthetists
Churchill House, 35 Red Lion Square, London, WC1R 4SG
Tel: 020 7092 1500
Fax: 020 7092 1730
Email: info@rcoa.ac.uk
Website: www.rcoa.ac.uk
The Intensive Care Society
Churchill House, 35 Red Lion Square, London, WC1R 4SG
Tel: 020 7280 4350
Fax: 020 7280 4369
Email: info@ics.ac.uk
Website: www.ics.ac.uk
1

Contents
1. Introduction 3
2. Clinical governance and ultrasound 10
3. Recommended essential ultrasound knowledge and skills 11
4. Regional anaesthesia and pain medicine 15
5. Vascular procedures 21
6. Thoracic ultrasound 25
7. Abdominal ultrasound 30
8. Echocardiography 34
9. References 40
Appendix 1 – RCoA DOPS form 43
To be reviewed in 2016
© The Association of Anaesthetists of Great Britain & Ireland, The Royal College of
Anaesthetists and The Intensive Care Society 2011
2

1. Introduction
This document presents a goal for the delivery of training of procedures using
ultrasound in anaesthesia and critical care. The document not only sets out a
practice-based curriculum for those who already hold a Certificate of Completion of
Training (CCT) but also describes how the trainee might organise their own training
within the Royal College of Anaesthetists’ (RCoA’s) CCT curriculum or Out-of-
Programme Training (OOPT) to match these aspirations.
Over the last 10 years, ultrasound has developed into an indispensable tool in
anaesthesia and intensive care. The combination of National Institute of Health
and Clinical Excellence (NICE) guidance for central venous access [1] and the
availability of small, portable, ‘point of care’ machines has led to the introduction
and increasingly widespread use of ultrasound in clinical practice. More recently,
further NICE guidance on the use of ultrasound for epidurals [2] and regional
anaesthesia [3] has ensured that ultrasound is now deeply embedded within
anaesthetic practice. Other uses now include: thoracic scanning for diagnosis and
treatment of pleural effusions and pneumothoraces; abdominal scanning (Focused
Assessment with Sonography in Trauma - FAST) looking for intra-abdominal
fluid; and focused transthoracic echocardiography in non-traumatic resuscitation
(Focused Echocardiography in Emergency Life support – FEEL).
The widespread introduction of ultrasound has brought with it many concerns
relating to competency and training. Ultrasound is not new to medicine but its
use in anaesthesia is. With the greater availability of machines and an increasing
number of clinical indications, it is important to remember that there is a
requirement for employing hospitals to ensure that clinicians are competent in
the use of any equipment used by an employee [4]. Ultrasound has a distinct
learning curve and trainee usage is characterised by common novice behaviour and
mistakes [5,6].
The aim of this document is to produce a set of broad guidelines for current trainees
and those who completed their formal training programmes before the introduction
of ultrasound. Whilst the core knowledge and skills required to perform ultrasound
are identical in both groups, it is recognised that the competencies will be gained
in different ways. These can be termed the ‘trainee-based College programme
pathway’ and the ‘practice pathway’ for non-trainees.
Recommendations for the use of ultrasound for non–radiologists have been
published by the Royal College of Radiologists (2005) [7], the European Federation
of Societies for Ultrasound in Medicine and Biology (EFSUMB) [8] and the College
of Emergency Medicine (CEM) [9]. The importance of these recommendations is
that they specify both a training syllabus and requirements that should be met by an
individual using ultrasound.
3

Training should consist of both theoretical and practical aspects, and be modular
in nature, allowing trainees to acquire different levels of competency depending
upon the practical skills needed, with competency assessment and multidisciplinary
training. The levels of training have been broadly divided into three (Levels 1, 2
and 3), the boundaries of which are not precise and are difficult to define and, as
such, should be seen as a guide to different levels of competence and experience.
It is important to realise that an appropriate level of training in ultrasound is one
that allows for the provision of a safe and effective ultrasound service. This may be
purely diagnostic, predominately interventional or a clinically-focused service.
Equivalent training and experience: the ‘Grandfather Clause’
This working party recognises that many practitioners have received ad hoc
training and have learned ultrasound techniques ‘on the job’. While this pathway
is not prospectively supported, it is recognised that for many such individuals their
knowledge and experience makes them entirely appropriate practitioners and
teachers of others. Furthermore, clinicians from specialties other than anaesthesia
or intensive care medicine may hold equivalent qualifications or training. The
recognition and awarding of an equivalent qualification to one achievable by
a structured training programme is termed a ‘Grandfather Clause’. Failure to
recognise such individuals is likely to lead to a loss of training opportunities for
others, and loss of enthusiasm by the individual. In general, the working party
therefore encourages individuals to seek recognition rather than making this process
obstructive.
The following should be included in any application for recognition under these
circumstances:
• A description of the approximate number of scans performed and any
relevant training experience obtained, e.g. sabbatical or work
placements.
• A description of the current job plan outlining the role ultrasound
plays and the typical range of scanning techniques used with
representative frequencies.
• Confirmation that the individual is in a permanent UK NHS non-training
post of Staff Grade, Associate Specialist, Specialty Doctor or Consultant,
including any UK recognised qualifications of training, e.g. FRCA.
• A declaration from the Service Director, Governance Lead or Ultrasound
Lead confirming substantial experience in ultrasound and ongoing use in
clinical practice.
• Any equivalent training or recognition awarded by other specialties, e.g.
CEM Level 1 and 2 ultrasound, British Society of Echocardiography (BSE)
certification, or similar.
• Any further information demonstrating experience and knowledge of
ultrasound, e.g. developing a service.
4

There is at present no specific body to award such ‘Grandfather’ status, but with the
increased development of ultrasound groups within hospitals to monitor the use and
training of non-radiology ultrasound, these groups may fulfil this role. In awarding
equivalence of training, clinicians need to ensure they keep up to date with
developments in ultrasound and, where feasible, obtain appropriate qualifications
in their sphere of practice. The status of ‘Grandfather’ will need to be agreed by
the head of that individual’s department and the head of Clinical Governance.
This ‘Grandfather Clause’ should be withdrawn in the future when robust training
capacity exists.
Training levels
The concept of levels of training is a way of standardising training requirements
across specialties. These levels are a guide to training and do not necessarily
correspond to individual College recommendations and curriculum needs, e.g. CEM
Level 1 is the standard of knowledge and practice that Emergency Medicine doctors
should have in the future. This is also the case in anaesthesia and intensive care,
where the use of ultrasound is not routinely practised or taught in all departments.
Currently, it is likely that only a few trainees in anaesthesia or intensive care will
be trained to be a Level 1 practitioner in all the aspects of ultrasound applicable to
their clinical practice. Therefore, although Level 1 is the desired level of training for
all trainees, it is at present too comprehensive to be achievable within the current
RCoA curriculum.
Level 1 – core training
This is the expected standard of knowledge and practice that anaesthetic and
intensive care consultants should have in the future and that should be achievable
during normal postgraduate specialist training.
Level 1 practice may be defined by the following generic competencies:
• Ability to perform common examinations and interventions safely and
accurately.
• Ability to recognise normal and abnormal anatomy and pathology.
• Ability to use ultrasound in real time to guide common invasive
procedures (Level 1 specific to anaesthesia and intensive care).
• Ability to recognise when referral for a second opinion is indicated.
• Ability to understand the benefits of ultrasound imaging and its value and
relationship to other imaging modalities used in anaesthesia and
intensive care, e.g. x-ray.
In the future, Level 1 will be considered to be core and fundamental to the practice
of anaesthesia and intensive care, and the components therefore considered
essential parts of a specialist training programme. At present there is no restriction
on the training that can be achieved within an anaesthetic and intensive care
training programme, and it may be common to find individuals who have Level 1
5

training in certain areas and Level 2 training in others at the time of completion of
training and award of a CCT.
Level 2 – extended training
This is a more advanced level of practice and can be considered extended.
This would be the expected level of practice for those with a special interest in
ultrasound. A Level 2 practitioner would have the following abilities:
• Significant experience of Level 1 practice, e.g. >12 months.
• Ability to perform the complete range of examinations in the area of practice.
• Ability to recognise significant pathology within the relevant organ system.
• Ability to use ultrasound to guide the full range of procedures in the particular
area of practice.
• Ability to act as mentor and trainer for Level 1 practitioners.
• Ability to accept referrals from Level 1 practitioners.
Level 2 practice is likely to require a period of additional training and experience
beyond that obtained during normal postgraduate specialist training and the RCoA’s
requirements for a CCT. A modular nature of practice is proposed such that an
individual may be a Level 2 practitioner in one area of ultrasound practice, e.g.
vascular access, and Level 1 in another, e.g. regional anaesthesia.
Level 3 – advanced training
This is an advanced level of practice and is equivalent to a consultant
radiologist with a special interest in ultrasound or a cardiologist specialising in
echocardiography. A Level 3 practitioner will be able to accept referrals from Level
2 practitioners and perform specialised examinations. They are involved in all areas
of ultrasound training and may undertake research within the field of ultrasound.
This level of practice is unlikely to be relevant to the majority of those practising
anaesthesia and intensive care.
Training
Although the training pathway may differ between established specialists and
trainees, the core content of the programme will be the same. The outcomes should
also be the same for anaesthetists and others undertaking similar procedures.
Theoretical training
Preliminary theoretical training should cover relevant anatomy, the physics of
ultrasound, levels and sophistication of equipment, image recording and reporting,
artefacts and the relevance of other imaging. This element of training may be
delivered by existing national courses, local ‘in-house’ courses or by the use of
e-learning modules.
Practical training
Practical training should include both training with phantoms and models before
6

using ultrasound in a clinical situation. Practical experience should be gained
under the guidance of a named supervisor trained in ultrasound. Practical training
should focus on demonstrating competence rather than performance of an arbitrary
number of procedures undertaken. However, to ensure optimal training and timely
acquisition of the required competencies, practical training should involve frequent
supervised examinations. In all cases involving a patient, an explanation of the
technique and consent must be obtained before initiating a practical procedure; this
is even more important in a training situation. A logbook of all training cases should
be kept and ideally should include a number of more detailed case studies. The
ability to store ultrasound images (still and video) for later review is an invaluable
part of training and is essential in certain areas such as echocardiography. The
trainee should ensure that all examinations performed during training are logged.
Examinations should concentrate on the core areas of practice. A competency
assessment sheet should be completed for each area of practice during the course
of training, as it will help to determine in which area(s) the trainee can practise
independently.
Generic training
Training pathways
The training pathway will differ between those who are established anaesthetists
with no previous ultrasound experience, those who have been practising ultrasound
without formal competency assessment, those who have achieved formal
competency in other modules, and specialist trainees in anaesthetics.
Clinical practice pathway
For established anaesthetists, with no previous experience of ultrasound, practical
training will depend upon exposure to it and should be based on a combination
of in-house and external courses. A basic skills and knowledge course (outlined
below) is mandatory before practising on patients. All departments need to develop
a training programme that is appropriate for them, but the following strategies are
useful.
1. Complete basic knowledge and skills course; consider e-learning
modules or web-based courses.
2. Attendance at a dedicated ‘hands-on’ ultrasound course.
3. Practise of normal scanning on colleagues or volunteers.
4. Use of web-based courses and textbooks.
5. Use ultrasound on patients, with their consent, under supervision by a
recognised trainer.
6. Use of commercially available or ‘home-made’ phantoms or meat
products to practise ultrasound-guided needle co-ordination.
7. Clinical practice should be supervised by a Level 2 practitioner or a
Level 1 practitioner with at least 12 months’ experience.
In addition to the suggested competency assessments described below, clinicians
7

should keep a logbook of cases that may include some key images. This could
form part of an overall ultrasound portfolio that would include documentation
of theoretical and practical training and assessments, any related self-audit and
relevant Continuous Professional Development (CPD) teaching. Ideally, those
clinicians already practising without formal competency review should, for the
purposes of appraisal and good clinical governance, seek some form of recognition,
e.g. a letter from a recognised Level 2 practitioner or radiologist confirming their
competency.
Trainee pathway
Although ultrasound is yet to be formally incorporated into the RCoA curriculum, it
is being increasingly taught by ultrasound enthusiasts during trainees’ subspecialty
attachments. Much of the core learning can be self-driven through a variety of
educational media, or possibly by linking to one of the university courses with
Consortium for the Approval of Sonographic Education (CASE) approval [10].
Practical training should ideally be on a weekly basis and overseen by a named
supervisor. A logbook of all training cases should be kept and ideally should include
a number of more detailed case studies.
1. Basic knowledge/skills course (vide supra).
2. Practical training should be overseen by a clinical supervisor at least Level 1.
3. If practical training is not possible in the current training scheme, the trainee
should consider applying through the Deanery for OOPT or Out-of-Programme
Experience (OOPE) [11].
It is envisaged that all anaesthetists using ultrasound need to know and have the
basic skills and competencies outlined in this section. Thereafter, trainees will
follow the training curriculum, and everyone else will follow a clinically based
pathway.
Trainers
Level 1 training should be delivered by a Level 2 practitioner or a Level 1
practitioner with at least 12 months’ experience. The modular nature of training
allows trainers to be competent to train in a focused area of practice, e.g. vascular
access, without needing to be proficient in all areas of ultrasound practice. To
become a Level 2 practitioner, the appropriate level of experience and competence
must be demonstrated by completion of a logbook. A Level 2 practitioner will need
to undertake frequent examinations commensurate with their area of practice. In
addition, an existing Level 2 practitioner will need to confirm that they have the
required competencies. Although there is no formal recognition or certification of
‘level of training’, it is beholden upon the individual clinician to act responsibly and
meet the competencies necessary for the level of personal practice and revalidation
in the area of expertise. These can be enhanced by personal CPD and completion
and maintenance of a current log book. For trainees, assessment will be under the
auspices of their respective Colleges and approved trainers. For all others, it will be
8

up to individual departments to train and assess competencies using this document
as a guide, the use of either individual hospitals’ assessment tools or College-based
assessment tools are to be encouraged. Overall training will be achieved by a
combination of CPD recognised external courses as well as ‘in-house’ training.
Basic skills and knowledge training
All clinicians should be familiar with some basic concepts and practicalities before
placing an ultrasound probe on a patient with the intention of either making a
diagnosis or performing a practical procedure. Ultrasound is different to other
commonly used imaging modalities and as such an understanding of the basic
physics is mandatory. The production of sound waves and their interaction with
tissues is determined and limited by the laws of physics. Knowledge of these
principles enables a clinician to optimise the image with respect to the ultrasound
frequency, probe design, focus and gain. The resulting image is formed from
reflection of the ultrasound waves from multiple tissue interfaces. This reflection
is dependent on the angle of the ultrasound beam, the ultrasound frequency used
and tissue characteristics, which will be weaker at increasing depths. Accurate
interpretation of the image is made with a knowledge of the ultrasound appearances
of the different tissue seen, e.g. veins and arteries, nerves, muscle, bone and pleura,
and the common artefacts encountered. Interpretation of any ultrasound image is
dependent on a thorough and detailed knowledge of the anatomy of the area of
interest. It is important to understand that when using ultrasound, you ‘only see
what you know’: the structures are not labelled and may appear different from
individual to individual.
A variety of ultrasound machines is now available to clinicians, including small
hand-held (pocket-size) devices, laptops and cart-based machines. These machines
will have a variety of probes (hockey stick, linear, curvilinear and phased array)
and preset imaging modalities (harmonic imaging, multibeam function, trapezoid
display and 3D volume rendering). All this can lead to total confusion for an
ultrasound novice; familiarity with the machine and its capabilities before use is
vital.
Theoretical training
Theoretical training and assessment should be undertaken before using ultrasound
in clinical situations, but sometimes this may go hand in hand with supervised
clinical training. Preliminary theoretical training should cover relevant anatomy,
the physics of ultrasound, machine familiarisation, image recording and reporting,
artefacts and the relevance of other imaging modalities to ultrasound. This element
of training may be delivered ‘in-house’ (using ‘Level 1 plus 12 months’ and Level
2 practitioners: anaesthetists, radiologists, ultrasonographers, cardiac physiologists,
cardiologists or medical physicists), and by distance learning or web-based
packages. The identity of who delivers this training is not as important as the
assessment of the individuals to ensure that they have understood and can apply
this knowledge to clinical practice.
9

2. Clinical governance and ultrasound
Keeping records
Logbook data of patients treated during training should be recorded in accordance
with RCoA standards. It is recommended that electronic recordings of ultrasound
examinations and anaesthetic or therapeutic interventions are made and
retained during training. It is recommended that hospitals develop the routine
electronic recording of all ultrasound examinations and anaesthetic or therapeutic
interventions. Even after completing training in ultrasound-based skills, it is
recommended that logbook data are continually recorded.
Audit
The success or failure of ultrasound-based interventions and complications of
these interventions should be recorded to inform audit, appraisal and revalidation
processes. When learning a new skill, cumulative sum control chart (CUSUM)
analysis of success has been shown to be useful in the evaluation of ability and
the need for supervision [12-14]. Even after training, a failure rate in excess of
commonly accepted norms should cause the practitioner to seek advice and, if
appropriate, remedial training.
Maintenance of skills
All manual skills need to be maintained, and it is recommended that after a break
in the performance of an ultrasound-based intervention, the practitioner should
be aware that their practical skills may have deteriorated. The individual has the
responsibility to ensure that their skills are adequately maintained and should seek
supervision where necessary. Having reached Level 1 competency, clinicians will
need to maintain their ultrasound skills, minimising the time between successive
examinations. The number of scans preformed should be commensurate with their
area and level of practice. It is recommended that CPD time is directed towards
ultrasound, either through educational meetings, self audit, or case reviews with a
mentor.
Clinical governance standards [15]
It is the responsibility of individual hospitals to establish clinical governance
processes that will determine the experience and training appropriate for the
unsupervised performance of ultrasound-based examinations or interventions.
Practitioners should make themselves aware of these processes and should only
practise within local clinical governance guidelines. It is recommended that within
each department a designated consultant or permanent member of staff competent
at Level 2 or 3 should oversee ultrasound training and be responsible for basic
training and competency assessment. These activities should form part of their job
plan, and time should be allocated within the job plan for the proper fulfilment of
these duties.
10

3. Recommended essential ultrasound
knowledge and skills
Basics of ultrasound
Basic components of an ultrasound machine.
Types of transducers and production of ultrasound with an emphasis on operator
controlled variables.
Use of ultrasound controls – ‘knobology’.
An understanding of the frequencies used in medical ultrasound and the effect
on image quality and penetration.
The interaction of ultrasound with tissue including biological effects.
Understanding of hyperechoic, hypo-echoic and anechoic and how it relates to
tissues, structures and formation of the image.
Sonographic appearance of tissues, muscle, blood vessels, nerves, tendons, etc.
The safety of ultrasound and of ultrasound contrast agents.
The basic principles of real time and Doppler ultrasound including colour flow
and power Doppler.
The recognition and explanation of common artefacts.
The storage and recording of still and video images, and integration with Picture
Archiving and Communication Systems (PACS).
Administration
Image recording, storing and filing.
Reporting of images.
Medicolegal aspects – outlining the responsibility to practise within specific
levels of competence and the requirement for training.
Understanding of sterility, health and safety, and machine cleaning.
Value and role of departmental and hospital protocols and guidelines.
Resource implication of ultrasound use.
Interpersonal and communications skills
Patient preparation and information.
Sensitive and effective communication with patient and family regarding
ultrasound findings.
Explanation of findings and the complexities of ultrasound techniques in terms
that the patient can understand.
Development of team leadership and management skills in developing and
maintaining an ultrasound service.
Needling techniques
Understanding of terminology of planes of view, e.g. transverse, longitudinal.
Understanding of terminology of needle insertion: in-plane and out-of-plane.
Relationship of needle gauge, angle of insertion, depth and needle visibility.
Limitation of out-of-plane needle insertion with regard to visibility of needle tip.
11

Limitation of in-plane technique: beam width, parallelism.
The use and limitations of needle guides and ultrasound visible needles.
Knowledge of common causes of failure to see the needle during placement.
Practical
Demonstration of knowledge of equipment selection (probe) and settings.
Ergonomic position of patient and equipment.
Pre-scan technique or understanding of benefits.
Correct application of gel and probe contact with skin.
Applications of probe cover, sheath or condom.
Correct orientation of probe with screen image.
Successful identification of the target within phantom or patient.
Adjustment of resolution to improve image of structures.
Correct use of depth and sector width controls to optimise structures being
observed.
Understanding of how to adjust the gain to optimise image quality and
consistency.
Demonstration of knowledge of the relevance of the angle of insonation to
visibility of relevant structures (anisotropy).
Correct use of focus or multiple focal zones to optimise image.
Use of Doppler, including continuous wave and pulsed wave Doppler.
Demonstration of the understanding of the longitudinal (long axis) and transverse
(short axis) planes of view.
Ability to store images.
Cleaning the probe and machine before storing or use on another patient.
Needling
Demonstration of understanding of the term ‘in-plane’ approach by placing
needle under the long axis of the ultrasound probe.
Demonstration of understanding of the term ‘out-of-plane’ approach by placing
needle at 90°to the long axis of the ultrasound probe.
Precise control of the probe and needle with minimal unintentional movement.
Demonstration of techniques to maximise the visibility of the needle,
parallelism, rotation, tissue movement and hydro-dissection.
Positioning of the needle within a vascular structure using both in-plane and outof-plane
technique in a phantom or clinical situation.
Demonstration of correct and appropriate spread of fluid or local anaesthetic
around a nerve in either a phantom model or clinical situation.
Following completion of basic theoretical and practical training, some form of
assessment of knowledge and practical skills should be completed. This can be
achieved by either multiple-choice questions (MCQs) for the theoretical knowledge
and formal Direct Observation of Procedural Skills (DOPS) or other ‘in house’
(individual hospital) assessment. In any case, some form of documentation should
be filed within an individual’s appraisal record or logbook. In an ideal situation, this
12

initial assessment of practical skills should be performed on a phantom or model,
but clinical needs will dictate whether this is the case or if the initial assessment
should be done in a clinical situation. The following table of competencies, and
all others provided in this document, should be assessed using some form of
assessment such as DOPS. The current RCoA DOPS form is provided in Appendix
1.
13

Basic ultrasound competencies
1 Demonstration of knowledge of the equipment and probe selection
2 Ergonomic positioning of self, patient, ultrasound machine and equipment
3 Correct use of gel and probe contact
4 Application of probe cover, sheath or condom to protect probe from
contamination
5 Correct orientation of probe with screen image
6 Ergonomic probe handling and movement
7 Successful identification of target structure within phantom, model or
patient
8 Adjustment of resolution to improve image of structures being imaged
9 Correct use of depth control to optimise structures being visualised
10 Understanding of how to adjust the gain to optimise image quality and
consistency
11 Demonstration of knowledge of the relevance of the angle of insonation to
visibility of relevant structures (anisotropy)
12 Correct use of focus or multiple focal zones to optimise image
13 Demonstration of use of Doppler for identification of vessels and the use
of M mode, continuous wave Doppler and pulsed wave Doppler where
appropriate
13 Demonstration of the understanding of the longitudinal (long axis) and
transverse (short axis) planes of view
14 Demonstration of understanding of the term ‘in-plane’ approach by
placing needle under the long axis of the ultrasound probe
15 Demonstration of understanding of the term ‘out-of-plane’ approach by
placing the needle under middle of the probe at right angles to the long
axis of the probe
16 Precise control of the probe and needle with minimal unintentional
movement
17 Ability to save and store images transfer to PACS or transfer to encrypted
memory stick
18 Cleaning of probe and machine after use to minimise transfer of infection;
storage of probe and machine to minimise damage
14

4. Regional anaesthesia and pain medicine
Over the last five years, ultrasound has revitalised and rejuvenated interest in
regional anaesthesia amongst anaesthetists in general and trainees in particular. The
availability of portable, high-resolution machines driven by NICE guidance on the
insertion of central venous catheters [1] has made it possible for most anaesthetists
to have easy access to a machine. Ultrasound allows direct observation of target
nerves and their surrounding structures, recognition of anatomical variance,
real-time guidance of the needle and direct observation of the spread of local
anaesthetic around the nerve. This is something that established techniques
(peripheral nerve stimulation or paraesthesia) cannot achieve, and improved
success rates, decreased volumes of local anaesthetic solutions, decreased
incidence of side effects and improved patient comfort have all been demonstrated
when using ultrasound.
Ultrasound-guided regional anaesthesia (UGRA) as a technique is rapidly gaining
momentum as shown by the increasing numbers of publications and advertised
workshops. A recent NICE interventional procedure guidance [3] supports the use
of ultrasound guidance in regional anaesthesia, stating “that clinicians wishing to
perform this procedure should be experienced in regional nerve blocks and trained
in ultrasound guided techniques”. This has been supported by American Society
of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of
Regional Anaesthesia and Pain Therapy (ESRA) Joint Committee recommendations
for education and training in ultrasound guided regional anaesthesia [16]. NICE has
also produced guidance on the use of ultrasound and epidural catheterisation [2].
The natural progression from regional anaesthesia to pain medicine has seen the
growing popularity of the use of ultrasound in modern pain management [17-19].
Ultimately, it will be up to practitioners themselves to satisfy not only clinical
governance directives but also the rigours of appraisal and revalidation. This will
almost certainly require the keeping of logbooks and competency curves. As time
passes, more people will have completed their ultrasound training as part of basic
anaesthetic training and the prospect of a more robust certification process can be
realised as part of accreditation.
15

Curriculum for regional anaesthesia
Basic knowledge and skills
See pages 12-15.
Practice
Level 1 practice
Superficial cervical plexus block
Interscalene brachial plexus block
Supraclavicular block
Infraclavicular block
Suprascapular block
Axillary brachial plexus block
Blockade of the terminal peripheral nerves of the arm
Rectus sheath block
Ilio-inguinal / iliohypogastric block
Transversus abdominis plane (TAP) block
Fascia iliaca block
Femoral nerve block
Obturator nerve block
Saphenous nerve block
Lateral cutaneous nerve of thigh block
Sciatic (trans-gluteal, sub-gluteal, anterior or mid-thigh) nerve block
Popliteal sciatic nerve block
Ankle block
Blockade of the terminal peripheral nerves of the leg
Epidural – assessment of spinal level, epidural depth and direction
Caudal
Catheter techniques
Level 2 practice
Lumbar plexus block
Deep cervical plexus block (cervical nerve root)
Paravertebral block / intercostal nerve block
Real-time ultrasound-guided epidural puncture and spinal anaesthesia
Anatomy
Level 1 anatomy
Detailed knowledge of relevant sectional anatomy:
Brachial plexus
Lumbosacral plexus
Terminal peripheral nerves of the arm and hand
16

Terminal peripheral nerves of the abdomen
Terminal peripheral nerves of the leg and foot
Level 2 anatomy
Additional knowledge of sectional anatomy:
Brachial plexus
Interscalene region
Supraclavicular region
Axillary region
Lumbosacral plexus
Posterior abdominal wall, lumbar plexus and psoas muscle
Femoral triangle and anterior thigh, including obturator nerve and
saphenous nerve
Buttock and upper thigh
Popliteal fossa
Ankle and foot
Chest and anterior abdominal wall
Rib and intercostal space
Anterior abdominal wall: rectus sheath; internal and external oblique; and
transversus abdominis
Inguinal region
Spine
Cervical spine, facet joints, cervical roots
Thoracic spine, facet joints and paravertebral space
Lumbar spine, facet joints, spinous process, intraspinous space and
intralaminar space
Cervical, thoracic , lumbar and caudal epidural space
Sacrum and sacral hiatus
Pathology
Regional anaesthesia is primarily the practical performance of standard techniques
with the sole purpose of anaesthesia and analgesia for surgery and postoperative
pain control. Specific associated pathologies, e.g. venous thrombosis and thyroid
cysts, are not deliberately sought but may be noticed or detected by some
clinicians.
Level 1 pathology
Understanding of the common anatomical variations of the brachial and
lumbosacral plexuses.
Level 2 pathology
Knowledge of the common associated pathologies that may be seen with respect to
peripheral nerves and the surrounding structures.
17

Pain
Specific and additional knowledge will be needed for the practice of pain medicine.
Competencies
The technical skills needed to perform any form of UGRA and pain medicine
technique are the same independent of the overall level of training. The ability
to see the nerve, control needle passage and observe the needle/nerve interface
whilst injecting local anaesthetic are core to performing any block. The level of
training is dependent on the technique used: some of these are easily learned with
few complications (Level 1: axillary); others require improved scanning skills and
knowledge (Level 2: paravertebral). The individual levels are arbitrary distinctions
between those that will be required for CCT and those that can be achieved within
a comprehensive training programme, and the distinctions should be viewed as
guidance only. Level 1 training is deliberately minimalistic so that all trainees
can achieve this level of training irrespective of the hospitals visited within their
rotations.
Level 1 competencies
Patient
Performance of gentle ultrasound examinations, provide appropriate sedation.
Demonstration of proper patient selection.
Use of appropriate monitoring to Association of Anaesthetists of Great Britain &
Ireland (AAGBI) standards.
Demonstration of proper nerve location techniques.
Performance of effective and safe nerve block techniques.
Ultrasound knowledge
Understanding of general principles of ultrasound physics.
Understanding of benefits and limitations of UGRA techniques.
Understanding of the differences between in-plane and out-of-plane needling
techniques and their indications and limitations
Understanding of key artefacts and pitfalls of UGRA.
Development of an intimate knowledge of the 2D ultrasound anatomy of the
major neurovascular structures of the upper and lower extremities.
Understanding of common anatomical variations associated with the
neurovascular and musculoskeletal structures of the upper and lower
extremities.
Understanding of the clinical applications and uses of colour Doppler in UGRA.
Understanding of and be able to use ultrasound equipment.
Demonstration of knowledge of sterility, infection control and equipment
cleaning.
Establishment of familiarity with the scientific literature pertaining to UGRA.
Demonstration of knowledge and learning of commonly used UGRA techniques.
18

Interpersonal and communications skills
Sensitive and effective communication with patients and families.
Providing explanation of the procedure in terms that the patient can understand,
outlining the benefits, risks and complications.
Demonstration of effective communication with anaesthetic colleagues,
operating departmental practitioners (ODPs) and supporting nursing and
ancillary staff.
Level 2
Professionalism and learning
Development of the skill to manage a regional anaesthetic service effectively.
Understanding of the costs relating to ultrasound regional anaesthetic service.
Remaining open to constructive criticism.
Awareness of the increasing literature relating to UGRA and its value.
Partaking in research and audit of UGRA practice.
19

Assessment checklist – regional anaesthesia
Demonstration of appropriate attitude and professional manner
Explanation of procedure, risks and complications to patient as appropriate
Checking patient’s details and entering them into record and machine as
appropriate
Confirmation of indication and checking of any supportive imaging
Positioning of patient and machine ergonomically
Selection of appropriate probe and optimisation of machine settings
Identification of nerve or plexus using a preliminary scan
Optimisation of the image by adjustment of gain, depth and focus
Demonstration of good needling technique with maintenance of the needle tip
within the scan plane at all times
Confirmation of position of needle with respect to nerve
Identification of spread of local anaesthetic perineurally, NOT intravascular
Demonstration of spread of local anaesthetic around the nerve or nerves
Performance of technique safely and effectively
Attention to sterility with respect to procedure, patient and machine
Adequate documentation and storage of images and scans as appropriate
Provision of information to patient and reporting of findings where appropriate
Identification of whether a further scan or alternative imaging is indicated
Cleaning of equipment and storage to minimise damage
20

5. Vascular procedures
The use of ultrasound to guide vascular access is associated with a higher firstpass
success and a reduced rate of complications. This led NICE to recommend
that ultrasound guidance be the preferred method for insertion of central venous
catheters (CVC) into the internal jugular vein and that ultrasound should be
considered in most clinical circumstance where CVC insertion is necessary, either
electively or in an emergency [1]. Following this guidance, the use of ultrasound
to guide CVC placement has increased markedly in recent years as clinicians have
realised its benefits in terms of ensuring the success of placement while minimising
the risk of complications [20]. Many experienced clinicians now use ultrasound
successfully to guide all CVC placements regardless of site or urgency such that it
is becoming a standard of care. However, the safe use of ultrasound to guide CVC
placement requires appropriate training and experience to achieve competence.
Some clinicians limit the use of ultrasound to confirm anatomy while they continue
to perform a standard landmark technique when inserting the CVC. This approach
is not recommended, as it does not allow the full benefits of ultrasound guidance
to be realised. It is recommended that when ultrasound is used to assist CVC
placement, it should be used to guide needle placement into the vein in real time.
There is a number of other areas of practice relevant to anaesthesia and intensive
care in which vascular ultrasound may have a useful clinical role. These include the
use of ultrasound to diagnose venous thrombosis, dynamic imaging of the inferior
vena cava to assess circulating volume status and specialist applications such as
transcranial Doppler. These are considered advanced areas of practice within
anaesthesia and intensive care medicine in which clinicians with a special interest
in ultrasound may wish to gain the necessary competencies.
21

Curriculum for vascular procedures
Basic knowledge and skills
See pages 12-15.
Practice
Level 1 practice
Cannulation of internal jugular vein
Cannulation of femoral vessels: vein and artery
Cannulation of peripheral veins and arteries
Insertion of peripheral inserted central catheter
Level 2 practice
Cannulation of axillary and subclavian vein
Assessment and diagnosis of venous thrombosis (upper and lower limb)
Assessment of volume status from dynamic ultrasound imaging of inferior
vena cava (see section on abdominal ultrasound)
Level 3 practice
Specialist vascular examinations, e.g. transcranial Doppler, renal artery
Doppler
Anatomy
Level 1 anatomy
Vascular access
Cross-sectional and ultrasonographic anatomy of:
• Neck (carotid artery and jugular vein)
• Femoral vessels
• Upper limb vessels
• Common anatomical variations
Level 2 anatomy
Axillary and subclavian vessels
Venous thrombosis
Vascular sectional and ultrasound anatomy of the arms and legs including
common anatomical variants
Pathology
Level 1 pathology
Recognition of thrombosis and haematoma in major vessels, e.g. internal jugular
and femoral veins.
22

Level 2 pathology
Ultrasonic appearance of peripheral venous thrombosis.
Competencies
Level 1 competencies
Identification of vein and artery in transverse and longitudinal scan.
Differentiation of the appearance of arteries and veins with 2D ultrasound.
Use of colour flow Doppler.
Identification of common anatomical variations.
Preparation of equipment to maintain sterility during ultrasound-guided
cannulation.
Undertaking of ultrasound-guided cannulation in real time maintaining
sterility.
Identification of needle tip with transverse and longitudinal views.
Identification of guide wire within vessel.
Insertion of appropriate sized cannula into vessel to correct length and secure
fixation.
Level 2 competencies
Identification of deep veins in leg: common femoral, femoral and popliteal
veins.
Assessment of lumen of veins in terms of diameter, echogenicity and
compressibility.
Use of continuous wave Doppler to demonstrate arterial and venous
waveforms.
Use of colour flow and pulsed wave Doppler to demonstrate patency of flow
with phasic variation with respiration and augmentation of flow following
distal compression.
Sequential scanning to demonstrate patency of common femoral, femoral
into lower thigh and popliteal veins.
Identification of common pathology: venous thrombosis, haematoma.
Identification and assessment of external iliac veins.
Identification and assessment of upper limb veins.
23

Assessment checklist – vascular procedures
Demonstration of appropriate attitude and professional manner
Explanation of procedure, risks and complications to patient as appropriate
Checking patient’s details/entry into machine as appropriate
Confirmation of indication and checking of any supportive imaging
Positioning of patient and machine ergonomically
Selection of appropriate probe and optimisation of machine settings
Identification of the vein and artery in transverse and longitudinal scan
Confirmation of patency and absence of thrombus or haematoma by compression,
Doppler
Undertaking of ultrasound guided cannulation in real time maintaining sterility
Identification of needle tip using in-plane or out-of-plane technique
Identification of guide wire within vein
Insertion of appropriate sized cannula into vessel to correct length and secure
Performance of technique safely and effectively
Attention to sterility with respect to procedure, patient and machine
Adequate documentation and storage of images and scans as appropriate
Provision of information to patient and reporting of findings where appropriate
Identification of whether a further scan or alternative imaging is indicated
Cleaning of equipment and storage to minimise damage
24

6. Thoracic ultrasound
The use of point of care ultrasound for assessing and treating thoracic pathology
in the intensive care environment has increased significantly in the last decade.
Not only can it answer queries arising from standard chest radiographs, e.g.
distinguishing effusion from consolidation from collapse, it can also be used to
make primary diagnoses such as pneumothorax and pulmonary oedema or the
interstitial syndrome. As well as a diagnostic tool, ultrasound is increasingly used to
guide invasive procedures relating to the thorax, namely diagnostic thoracocentesis,
chest drain insertion, pleural biopsy and percutaneous tracheostomy [21]. There
is now an increased focus on the use of ultrasound to guide chest drain insertion
for pleural fluid as a result of a rapid response report by the National Patient Safety
Agency in 2008 [22], with subsequent guidelines issued by the British Thoracic
Society [23-27].
As a technique, thoracic ultrasound is relatively straightforward to perform.
However, it fosters a large number of acoustic artefacts. Some of these can aid and
some can hinder diagnosis. Appropriate training is therefore mandatory in order
to avoid serious interpretation errors. Level 1 training in thoracic ultrasound is not
mandatory for the CCT in Anaesthetics and is not part of the RCoA curriculum.
25

Curriculum for thoracic ultrasound
Basic knowledge and skills
See pages 12–15.
Practice
Level 1 practice
Systematic examination of the normal thorax
Assessment and diagnosis of pleural effusions
Ultrasound guided thoracocentesis and chest drain insertion
Use of ultrasound to diagnose pneumothorax
Level 2 practice
Assessment and diagnosis of pleural pathology
Assessment and diagnosis of lung pathology
Assessment of diaphragmatic function
Ultrasound guided pleural and lung biopsy
Ultrasound guided percutaneous tracheostomy and cricthyroidotomy
Identification of the cricoid cartilage and extrathoracic tracheal rings
Knowledge of the appearance of normal thyroid versus goitre and Doppler
assessment of vascularity
Anatomy
Level 1 anatomy
Detailed knowledge of relevant sectional anatomy
Right and left hemidiaphragm
Chest wall layers
Ribs and intercostal spaces
Surface anatomy of pleural reflections
Heart
Liver, spleen and kidneys
Thyroid
Level 2 anatomy
Additional knowledge of sectional anatomy
Supraclavicular region
Anterior and superior mediastinum
Laryngeal cartilages and extrathoracic trachea
Thyroid
26

Pathology
Level 1 pathology
Pleural effusion
Pleural thickening
Pneumothorax
Consolidated lung
Atelectasis
Level 2 pathology
Interstitial thickening
Pulmonary mass/abscess
Paralysed diaphragm
Mediastinal and pleural masses
Multinodular goitre
Competencies
Level 1 competencies
Performance of systematic examination of thorax identifying normal structures
including diaphragm, liver and spleen.
Identification of ultrasound appearances of normal aerated lung including:
• Diaphragmatic movement
• Pleural line and gliding sign
• Normal aerated lung (including A-lines and B-lines artefacts).
Recognition of pleural fluid:
• Appearances suggesting transudate, exudate and loculation
• Assessment of size of effusion
• Differentiation between pleural thickening and effusion
• Distinguishing small or loculated pleural fluid from pleural thickening.
Recognition of consolidated lung:
• Distinguishing atelectasis from consolidation: with and without air
bronchograms
• Recognition of signs of pneumothorax including lung point sign and
appearance on M-mode.
Recognition of heart, liver and spleen.
Performance of ultrasound-guided (direct and indirect) thoracocentesis.
Performance of ultrasound-guided chest drain insertion and identification of
when to use a direct or indirect approach.
Level 2 competencies
Differentiation between consolidated lung, abscess and pulmonary mass.
Differentiation of types of pleural thickening, e.g. pleural masses and plaques.
Use of colour/power Doppler to help distinguish between pleural and
lung pathologies.
27

Familiarity with the altered artefact patterns seen with pulmonary oedema
and interstitial syndrome.
Identification of the cricoid cartilage and extrathoracic tracheal rings.
Knowledge of the appearance of normal thyroid versus goitre and Doppler
assessment of vascularity.
Performance of ultrasound-guided percutaneous tracheostomy or
cricothyrotomy.
28

Assessment checklist – thoracic ultrasound
Demonstration of appropriate attitude and professional manner
Explanation of procedure, risks and complications to patient as appropriate
Checking patient’s details/entry into machine as appropriate
Confirmation of indication and check any supportive imaging
Positioning of patient and machine ergonomically
Selection of appropriate probe and optimisation of machine settings
Correct identification of normal lung, pleural line and movement
Demonstration of pleural sliding in 2D and M mode
Identification of normal diaphragm, liver and spleen
Identification of pleural effusion
Differentiation of pleural effusion from intra-abdominal fluid (ascites)
Description of appearances of transudate and exudate
Demonstration of how volume of effusion may be estimated
Use of ultrasound to identify appropriate site for drainage of effusion
Demonstration of ultrasound guided thoracocentesis
Identification of consolidation
Identification of atelectasis
Recognition of signs of pneumothorax including lung point sign, appearance in M
mode
Demonstration of ultrasound guided chest drain insertion
Performance of technique safely and effectively
Attention to sterility with respect to procedure, patient and machine
Adequate documentation and storage of images and scans as appropriate
Informing patient and reporting findings where appropriate
Identification of whether a further scan or alternative imaging is indicated
Cleaning of equipment and storage to minimise damage
29

7. Abdominal ultrasound
The ability to detect free intraperitoneal fluid, assess the aortic diameter, assess
the inferior vena cava (IVC), and measure bladder volume is extremely valuable.
The finding of free fluid may have significance for patient management, especially
following trauma. The purpose of ultrasound in the initial assessment of abdominal
trauma is solely to document the presence of free intra-peritoneal fluid. In the
context of abdominal trauma this is assumed to be blood. There is no attempt
to identify specific organ injuries as ultrasound is not accurate in the early
assessment of solid or hollow viscus injury. When abdominal scanning techniques
are combined with basic cardiac scanning, the combination is known as ACES
(Abdominal and Cardiac Evaluation with Sonography in shock). Fluid assessment
is also known as FAST (Focused Assessment with Sonography in Trauma) if in a
trauma setting. If one adds assessment of the upper pleura for pneumothorax, this is
known as EFAST (Extended FAST) [28,29]. Level 1 training in abdominal ultrasound
is not mandatory for a CCT in Anaesthetics and is not part of the RCoA curriculum.
30

Curriculum for abdominal ultrasound
Basic knowledge and skills
See pages 12–15.
Practice
Level 1 practice
Detection of free intraperitoneal fluid
Assessment of the abdominal aorta
Assessment of the IVC including filling pressures
Bladder volume assessment
Level 2 practice
Assessment of the gall bladder
Assessment of the kidneys
Level 3 practice
Comprehensive abdominal scanning
Anatomy
Level 1 anatomy
Aorta and IVC
Liver
Morrison pouch and right costophrenic pleural recess / splenorenal recess
and left costophrenic pleural recess
Rectovesical, vesico-uterine and recto-uterine pouches
Bladder
Level 2 anatomy
Kidney
Liver (detailed)
Spleen
Pathology
Level 1 pathology
Intraperitoneal and pleural fluid
Aortic aneurysm and rupture
IVC collapse greater than 50%
Pneumothorax
31

Level 2 pathology
Biliary disease including common bile duct obstruction, gallstones,
gallbladder wall thickening and oedema, common bile duct dilatation.
Mesenteric ischaemia.
Renal parenchymal disease, hydronephrosis, renal stones, renal tract
obstruction.
Competencies
Level 1 competencies
Recognition of what is normal and abnormal in standard abdominal views.
Identification of the aorta and IVC in transverse and longitudinal sections.
Recognition of the main features of the aorta, and know how to measure it, i.e.
antero-posterior diameter, outer anterior to outer posterior layer, distinction from
the IVC.
Ability to carry out scanning in three planes.
Ability to use the machine to determine bladder volume.
Recognition of a catheter balloon within the bladder.
Knowledge of when to repeat the scan, and the value of repeat scans.
Level 2 competencies
Ability to assess the kidneys and recognise hydronephrosis.
Knowledge of how to image the gall bladder and measure wall thickness.
Assessment of the common bile duct for dilatation.
Assessment of the superior mesenteric artery for patency and flow.
Application of these findings to the clinical context appropriately.
32

Assessment checklist – abdominal ultrasound
Demonstration of appropriate attitude and professional manner
Explanation of procedure, risks and complications to patient as appropriate
Checking patient’s details/entry into machine as appropriate
Confirmation of indication and checking any supportive imaging
Positioning of patient and machine ergonomically
Selection of appropriate probe and optimising machine settings: gain, depth and
focus
Demonstration of Morrison’s pouch and right costo-phrenic pleural recess
Demonstration of the spleno-renal interface and left costo-phrenic pleural recess
Identification of the bladder
Demonstration of potential fluid in the pelvis
Demonstration of pericardial views and cardiac motion
Application of examination in an Advanced Life Support (ALS) setting
Demonstration of the pleural space and can identify fluid
Performance of technique safely and effectively
Attention to sterility with respect to procedure, patient and machine
Adequate documentation and storage of images and scans as appropriate
Informing patient and reporting of findings where appropriate
Identification of whether a further scan or alternative imaging is indicated
Cleaning of equipment and storage to minimise damage
33

8. Echocardiography
The application of echocardiography (transthoracic and transoesophageal
echocardiography – TTE and TOE) in the critical care arena has been well
recognised for some time, expanding beyond cardiothoracic critical care to include
diagnosis and monitoring on the general intensive care unit (ICU) [30]. When
dealing with critically ill patients, two clinical scenarios need to be considered,
which may be regarded as corresponding to Level 1 and Level 2 proficiency.
Level 1
In the peri-resuscitation setting, relatively simple information obtained using TTE
may profoundly affect patient management. Here, a basic focused scan may be
appropriate, which when performed during active resuscitation must be strictly
ALS-compliant [31]. There is accumulating evidence in the literature that this can
be achieved with appropriate training of novice practitioners [32, 33]. Several
courses exist to train the novice practitioner to this level, including FEEL-UK, which
is endorsed by the British Society of Echocardiography (BSE) and supported by the
Resuscitation Council (UK) [34, 35]. Beyond peri-resuscitation echocardiography,
the requirements for practitioners in different specialties begin to diverge.
Practitioners already proficient in peri-resuscitation echocardiography may wish
to develop their skills for use in trauma, emergency medicine or critical care,
depending upon their base specialty [36], may do additional training to achieve
accreditation in echocardiography (Level 2 – see below). For these and others
keen to extend their skills, courses and training programmes such as FAST, FATE
(Focused Assessment by Transthoracic Echo), CAUSE (Cardiac Arrest Ultra-Sound
Examination) and FUSE (Focused Ultrasound and Echocardiography) provide a
framework within which to achieve this in the UK [37- 40].
Level 2
As defined elsewhere, Level 2 training includes the ability to perform the
complete range of echocardiographic examinations, recognise almost all cardiac
pathology and to use echocardiography to guide interventional procedures. In
the critically ill patient, Level 2 echocardiography can provide information about
cardiac function and the causes of inadequate cardiac output, guide therapeutic
interventions and monitor the effects of any treatment instigated [41- 43]. This
may be focused or comprehensive, and require TTE or TOE depending upon the
clinical question being asked. This level of practice is equivalent to accreditation in
echocardiography, i.e. the most basic level at which a practitioner is judged to be
capable of independent practice [35]. Echocardiography training is not mandatory
for a CCT in Anaesthetics or General Internal Medicine, and is not part of the RCoA
or Royal College of Physicians (RCP) curriculum.
34

Curriculum for echocardiography
Basic knowledge and skills
See pages 12-15.
Practice
Level 1 practice
Performance of a basic echocardiography examination of a normal heart.
Assessment and diagnosis of significant cardiac pathology including severe left
ventricular dysfunction, right ventricular dysfunction (massive pulmonary
embolus), pericardial effusion and tamponade, and hypovolaemia.
Performance of an ALS compliant examination when indicated.
Level 2 practice
Performance of focused or comprehensive echocardiography examinations in all
relevant situations (emergency care, peri-operative and intensive care, high
dependency unit and coronary care unit) as appropriate for the patient and
clinical scenario.
Recognition of almost all cardiac pathologies.
Use of echocardiography to guide interventional procedures and monitor and
assess the effects of interventions and therapies.
Anatomy
Level 1 anatomy
Basic anatomy of the heart, coronary arteries and great vessels.
Coronary anatomy and correlation with myocardial territories supplied (2D
views).
Left and right ventricular anatomy and correlation with 2D views.
Basic heart valve anatomy and correlation with 2D views.
IVC anatomy and correlation with 2D views.
Normal changes in IVC dimensions in response to spontaneous respiration and
ventilation.
Basic anatomy of the pericardium and normal pericardial space, including
differentiation from pleural space.
Pathology
Level 1 pathology
Dilated left ventricle
Grossly underfilled left ventricle
Significantly impaired left ventricular systolic function
Severe wall motion abnormalities
35

Significant right ventricular dilatation
Features of pulmonary hypertension and massive acute pulmonary
embolism
Features of significant hypovolaemia
Fixed, dilated IVC and its causes
Differentiation of pericardial collection and tamponade
Competencies
Level 1 competencies
Demonstration of the four basic echocardiography scan planes:
• Parasternal long axis view
• Parasternal short axis view including aortic valve, mitral valve and papillary
muscles
• Apical 4-chamber view
• Subcostal view
Recognition of normal cardiac structures and important landmarks in all four
scan plane: left atrium, right atrium, inter-atrial septum, left ventricle, right
ventricle, inter-ventricular septum, aortic valve, ascending aorta, mitral valve,
tricuspid valve, inferior vena cava, descending aorta, pericardium.
Understanding of and performance of measurements of global systolic function:
eyeballing, MAPSE (mitral annular plane systolic excursion), TAPSE (tricuspid
annular plane systolic excursion), fractional shortening and ejection fraction
using Simpson’s rule.
Recognition of a dilated left ventricle.
Recognition of a severely underfilled left ventricle, and differentiate from severe
left ventricular hypertrophy.
Differentiation of normal from significantly impaired left ventricular systolic
function and severe wall motion abnormalities.
Differentiation of normal from significantly impaired left ventricular systolic
function.
Recognition of features of pulmonary hypertension.
Recognition of a significantly dilated right ventricle.
Recognition of significant right ventricular dysfunction.
Recognition of features of acute, massive pulmonary embolism.
Recognition of features of pulmonary hypertension.
Recognition of features of significant hypovolaemia.
Recognition of a fixed, dilated IVC.
Identification of a pericardial collection.
Differentiation of between pleural and pericardial collection.
Identification of right ventricular diastolic collapse.
Identification of swinging heart.
36

Technique of pericardiocentesis, including echo-guidance.
Ability to differentiate asystole from fine ventricular fibrillation.
Ability to differentiate pulseless electrical activity (PEA) from pseudo-PEA.
ALS peri-resuscitation competencies
Knowledge of current ALS algorithm and when to apply FEEL.
Ability to follow the steps required to perform FEEL during cardiopulmonary
resuscitation in an ALS complaint manner.
Ability to follow the steps required if an inadequate echocardiography window
is not obtained.
Ability to obtain cardiac images within 10 s.
Ability to interpret images in the context of a cardiac arrest scenario.
Ability to communicate findings clearly to resuscitation team leader.
37

Assessment checklist – echocardiography
Demonstration of appropriate attitude and professional manner
Explanation of procedure, risks and complications to patient as appropriate
Checking patient’s details/entry into record as appropriate
Confirmation of indication and check any supportive imaging
Positioning of patient and machine ergonomically
Selection of appropriate probe and optimising machine settings
Demonstration of all four standard views:
• Parasternal long axis
• Parasternal short axis
• Apical four chamber
• Sub-costal
Recognition of normal cardiac structures and landmarks in all four major scan
planes
Left ventricle – recognition of dilated or grossly under filled left ventricle and
normal from significantly impaired function
Right ventricle – recognition of significant right ventricular dilatation and features
of acute pulmonary hypertension
Inferior vena cava (IVC) – recognition of signs of significant hypovolaemia and
detection of a fixed dilated IVC
Pericardium – recognition of a pericardial collection, distinguishing this from
pleural effusion, recognition of right ventricular collapse and a ‘swinging heart’
Performance of trans-thoracic ECHO in compliance with an ALS-algorithm
Performance of technique safely and effectively
Attention to sterility with respect to procedure, patient and machine
Adequate documentation and storage of images and scans as appropriate
Informing patient and reporting findings where appropriate
Identification of whether a further scan or alternative imaging is indicated
Cleaning of equipment and storage to minimise damage
38

Level 2 accreditation
A proportion of trainees may wish to extend their echocardiographic skills further
to be competent to perform a comprehensive or focused study either on the ICU, or
during general anaesthesia of the high-risk patient. Before 2010 the only accredited
examination for transthoracic echocardiography in the UK was the ‘Accreditation
in Adult Echocardiography’, administered and awarded by the BSE and for
transoesophageal echocardiography, the ‘ACTA/BSE TOE accreditation’. However,
the BSE has been working together with key stakeholders and has now introduced
an accreditation specifically for critical care. The development of this accreditation
is analogous to those that were developed for cardiothoracic anaesthetists wishing
to obtain TOE accreditation. As with other areas outlined in this document, Level
2 practice in echocardiography is likely to require a period of additional training
and experience beyond that obtained during normal postgraduate specialist training
[44].
39

9. References
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Ceccon MS. Learning curves and mathematical models for interventional
ultrasound basic skills. Anesthesia and Analgesia 2008; 106: 568-73.
14. Ali D, Rhodes S. Cusum Charts: A tool for assessing competency. Anaesthesia
2009; 64: 1385-6.
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15. The British Medical Ultrasound Society. Ultrasound Clinical Governance.
www.bmus.org/ policies-guides/ClinicalGovernanceInUltrasound-061108.pdf
(accessed 17/11/10).
16. Sites BD, Chan VW, Neal JM, et al. The American Society of Regional
Anesthesia and Pain Medicine and the European Society of Regional
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and training in ultrasound-guided regional anesthesia. Regional Anesthesia and
Pain Medicine 2009; 34: 40-6.
17. Curatolo M, Eichenberger U. Ultrasound-guided blocks for the treatment of
chronic pain. Techniques in Regional Anesthesia & Pain Management 2007;
11: 95-102.
18. Gofeld M. Ultrasonography in pain medicine: a critical review. Pain Practitioner
2008; 8: 226-40.
19. Peng PWH, Narouze S. Ultrasound-guided interventional procedures in pain
medicine: a review of anatomy, sonoanatomy and procedures. Regional
Anesthesia and Pain Medicine 2009; 34: 458-78.
20. Karakistos D, Labropoulous N, De Groot E, et al. Real-time ultrasound guided
catheterization of the internal jugular vein: a prospective comparison with the
landmark technique in critical care patients. Critical Care 2006; 10: R162.
21. Lichtenstein A. Whole body Ultrasonography in the Critically Ill, 1 st edition.
Heidelberg: Springer, 2010: 99-209.
22. National Patient Safety Agency. Chest drains: risks associated with the insertion
of chest drains. http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/risksof-chest-drain-insertion
(accessed 17/11/10).
23. Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic
ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax
2010; 65: i61-76.
24. Bouhemad B, Zhang M, Lu Q, Rouby J-J. Clinical review: bedside ultrasound in
critical care practice. Critical Care 2007; 11: 205.
25. Koh D-M, Burke S, Davies N, Padley S. Transthoracic US of the chest: clinical
uses and application. Radiographics 2002; 22: e1.
26. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax
in the critically ill. Lung sliding. Chest 1995; 108: 1345-8.
27. Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O. The comet-tail
artifact: an ultrasound sign of alveolar-interstitial syndrome. American Journal of
Respiratory Critical Care Medicine. 1997; 156: 1640-1646.
28. Yoshii H, Sato M, Yamamoto S, et al. Usefulness and limitations of
ultrasonography in the intial evaluation of blunt abdominal trauma. Journal of
Trauma 1998; 45: 45-50.
29. Branney SW, Wolfe RE, Moore FE, et al. Quantitative sensitivity of ultrasound in
detecting free intraperitoneal fluid. Journal of Trauma 1995; 39: 375-80.
30. Cholley BP, Viellard-Baron A, Mebazza A. Echocardiography in the ICU: time
for widespread use! Intensive Care Medicine 2006; 32: 9-10.
31. Resuscitation Council (UK). Resuscitation guidelines 2010 p67. http://www.
resus.org.uk/pages/guide.htm (accessed 17/11/10).
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32. Niendorff D, Rassias A, Palac R, et al. Rapid cardiac ultrasound of inpatients
suffering PEA arrest performed by non expert sonographers. Resuscitation 2005;
67: 81-7.
33. Breitkreutz R, Walcher F, Seegar F. Focused echocardiographic evaluation in
resuscitation management: concept of an advanced life support-conformed
algorithm. Critical Care Medicine 2007; 35: S150-161.
34. Breitkreutz R, Uddin S, Steiger H, et al. Focused echocardiography entry level:
new concept of a 1-day training course. Minerva Anestesiologica 2009; 75:
285-92.
35. Price S, Ilper H, Uddin S, et al., Peri-resuscitation echocardiography: Training
the novice practitioner. Resuscitation 2010; 81: 1534-9.
36. Neri L, Storti E, Lichtenstein D. Toward an ultrasound curriculum for critical
care medicine. Critical Care Medicine 2007; 35: S290-304.
37. Rose JS. Ultrasound in abdominal trauma. Emergency Medicine Clinics North
America 2004; 22: 581-99, vii.
38. Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiography
for cardiopulmonary monitoring in intensive care. European Journal of
Anaesthesiology 2004; 21: 700-7.
39. Hernandez C, Shuler K, Hannan H, et al. C.A.U.S.E.: Cardiac arrest ultra-sound
exam – a better approach to managing patients in primary non-arrhythmogenic
cardiac arrest. Resuscitation 2008; 76: 198-206.
40. Morris C, Bennett S, Burn S , Russell C, Jarman R, Swanevelder J.
Echocardiography in the intensive care unit: current position, future directions.
Journal of Intensive Care Society 2010; 11: 90-7.
41. Orme RM, Oram MP, McKinstry CE. Impact of echocardiology on patient
management in the intensive care unit: an audit of district general hospital
practice. British Journal of Anaesthesia 2009; 102: 340-4.
42. Price S, Via G, Sloth E, et al. Echocardiography practice, training and
accreditation in the intensive care: document for the World Interactive Network
Focused on Critical Ultrasound (WINFOCUS). Cardiovascular Ultrasound 2008;
6: 49.
43. ACC/AHA ASE 2003 guideline update for the clinical application of
echocardiography: summary article. Circulation 2003; 108: 1146.
44. British Society of Echocardiography. Accreditation in Adult Critical Care. http://
www.bsecho.org/index.php?option=content&task=category&sectionid=13&id=
31&Itemid=57 chocardiography [Information Pack] (accessed 17/11/10).
42

Appendix 1 RCoA Direct Observation of Procedural Skills [DOPS]
Assessment Form
Please complete the question using a cross (x). Please use black ink and CAPITAL LETTERS
Trainee’s surname
Trainee’s forename(s)
GMC number
GMC NUMBER MUST BE COMPLETED
Observation
Code number
Observed by
GMC number
Date
GMC NUMBER MUST BE COMPLETED
Assessment:
Practice was satisfactory
Assessor’s Signature
Practice was unsatisfactory
Assessors Signature
If the performance was judged to be unsatisfactory, you must tick the boxes on the reverse of
this form to indicate which areas of performance you judged to be unsatisfactory.
Example of good practice were:
Areas of practice requiring improvement were:
Further learning and experience should focus on:
43

If you have rated the performance unsatisfactory please indicate which elements were unsatisfactory:
Did not understand the indications and contraindications to the
procedure.
Did not properly explain the procedure to the patient.
Does not understand the relevant anatomy.
Failed to prepare properly for the procedure.
Did not communicate appropriately with the patient or staff.
Aseptic precautions were inadequate.
Did not perform the technical aspects of the procedure correctly.
Failed to adapt to unexpected problems in the procedure.
Failed to demonstrate adequate skill and practical fluency.
Was unable to properly complete the procedure.
Did not properly complete relevant documentation.
Did not issue clear post-procedure instructions to patient and/or
staff.
Did not maintain an appropriate professional demeanor.
44

intensive care
society
care when it matters

DITION
WHO IS THE
ANAESTHETIST?
FIFTH EDITION 2013
www.aagbi.org/
professionals/trainees

GROUP OF ANAESTHETISTS IN TRAINING
GAT (Group of Anaesthetists in Training) is the trainee body of the Association of
Anaesthetists of Great Britain and Ireland (AAGBI) through which anaesthetists are
represented at a national level. All trainee members of the Association are automatically
members of GAT and currently account for about a third of the membership of the AAGBI.
Approximately 70% of all anaesthetic trainees in the UK are members of GAT.
The elected GAT Committee has representatives at all levels of training from within
the UK and Ireland. The committee aims to represent the views and perspectives of
anaesthetic trainees throughout the UK and Ireland. The GAT Committee also has links
with anaesthesia training bodies around the world. We strive to maintain transparency and
accuracy, allowing trainees to make their own informed opinions on issues that will affect
them as professionals both at the current time and in their future career.
Information is relayed back through the GAT website (www.aagbi.org/professionals/
trainees) and Trainee Network Leads who are in all schools of anaesthesia nationwide.
A comprehensive list of current Trainee Network Leads is available on the GAT website.
ASSOCIATION OF ANAESTHETISTS
OF GREAT BRITAIN AND IRELAND
The Association of Anaesthetists of Great Britain and Ireland (AAGBI) represents the
medical and political views of over 10,000 anaesthetists in the UK and the Republic of
Ireland. Through its overseas membership it has close contact with anaesthetists in many
other countries. The AAGBI is run by the Council who are elected from the membership for
a term of four years. The Executive Officers are elected from within the Council.
The AAGBI has a broad constitution that enables it to promote and advance education,
safety and research in anaesthesia, as well as the professional aspects of the specialty
and the welfare of individual anaesthetists. The AAGBI has been responsible for initiating
or promoting many major developments in British and Irish anaesthesia, and continues to
thrive. It issues and revises guidelines and advice, and encourages and supports specialist
societies. The AAGBI continues to raise the profile and enhance the image of anaesthetists
to the public.
2 WHO IS THE ANAESTHETIST?

THE ROYAL COLLEGE OF ANAESTHETISTS
The Royal College of Anaesthetists (RCoA) is the professional body responsible for the
specialty of anaesthesia throughout the United Kingdom. Its principal responsibility is to
ensure the quality of patient care through the maintenance of standards in anaesthesia,
pain medicine and critical care. The College’s activities include:
• Setting standards of clinical care
• Establishing standards for the training of anaesthetists and those practicing critical
care and/or acute and chronic pain medicine
• Setting and running examinations
• Continued medical education of all anaesthetists.
Every hospital with anaesthetists in training has a College Tutor who can give advice on
training. Information is relayed to members via the RCoA website (www.rcoa.ac.uk) and in
the bi-monthly College Bulletin.
THE COLLEGE OF ANAESTHETISTS OF IRELAND
The College of Anaesthetists of Ireland exists to promote best practice in the fields of
anaesthesia, intensive care and pain medicine through its training, examination and
educational programmes. The College is responsible for setting training standards and for
the organisation, supervision and counselling of doctors in training in Ireland.
WHO IS THE ANAESTHETIST? 3

CONTENTS
Who should read this? 05
Introduction 05
Where can you find an anaesthetist? 05
Operating theatre work 06
Anaesthetic subspecialties 07
Academia and research 09
Training and exams 10
Less than full time training 12
How can I find out more? 13
Useful contacts 14
ACKNOWLEDGEMENTS
The GAT Committee wishes to thank Dr Jonathan Price, Dr Nicholas Love
and Dr Richard Paul for revising and editing this fifth edition.
© Copyright of the Association of Anaesthetists of Great Britain & Ireland.
4 WHO IS THE ANAESTHETIST?

WHO SHOULD READ THIS?
This guide is designed for medical students and foundation
doctors who are considering a career in anaesthesia. Historically,
junior doctors were able to spend several years sampling different
specialties before making their career choices but this is now
increasingly difficult. Foundation doctors have to make tough
decisions about their future careers, sometimes with limited
knowledge and experience of the possibilities.
We hope to explain what a career in anaesthesia entails and explore some of the aptitudes
and skills required. We hope that this will allow you to make a more informed choice and
so start on a successful, enjoyable and rewarding career.
INTRODUCTION
Anaesthetists encounter a wide range of patients and specialties. We are one of
the largest hospital departments and work in a variety of settings. Our core activity is
providing anaesthesia for surgery but this straddles ages and pathologies. It is a very
different challenge to anaesthetise a healthy two-year old for day surgery compared with
a frail elderly patient for an emergency laparotomy. We are evolving into peri-operative
physicians, responsible for assessment and optimisation pre-operatively, ensuring optimal
operative conditions and providing peri-operative support to surgical teams.
Our training programme encourages anaesthetists to generate an in-depth understanding
of basic science, physiology and pharmacology. We learn how to apply these principles to
the broad landscape of clinical practice within the hospital, spanning medical and surgical
specialities. This knowledge is married to the development of expert practical skills and a
patient centred approach, allowing us to manage the large spectrum of patients requiring
anaesthetic services. In one day you may go from seeing outpatients in a chronic pain
clinic to performing an awake fibreoptic intubation for impending airway compromise, or
resuscitating patients with polytrauma in the emergency department.
WHERE CAN YOU FIND AN ANAESTHETIST?
Anaesthetists work in nearly all departments of the hospital and some even work outside of
the hospital too. Our natural habitat is the operating theatre but you will also find us on the
wards, in pre-assessment or chronic pain clinics, on the labour ward, in radiology suites
and in critical care. Anaesthetists work in a wide variety of roles ranging from pre-hospital
care to teaching and research. Broad clinical exposure and strong interest in patient safety
often leads consultant anaesthetists to develop leadership roles within the hospital. It is
not uncommon to find anaesthetists in the senior management team of a hospital or trust.
As multifaceted professionals with a wide range of transferrable skills, no two anaesthetists
are quite the same. A career in anaesthesia enables you to mould yourself to fit a plethora
of different jobs. You may wish to work in a teaching or district general hospital, you may
wish to pursue a particular clinical subspecialty or research interest – all of these options
are available.
WHO IS THE ANAESTHETIST? 5

OPERATING THEATRE WORK
Safe care of patients in theatre starts with a thorough pre-operative assessment, either
in the clinic or on the ward. This allows the operating team to make decisions on the
appropriateness of the proposed procedure and if any additional resources may be
required, such as a postoperative intensive care bed.
Pre-assessment enables the anaesthetist to establish a rapport with the patient and to
identify any potential anaesthetic difficulties or pre-existing medical conditions. Some
patients will require further investigation and optimisation pre-operatively and this may
involve anaesthetic-led advanced physiology testing or expert advice from other medical
specialties.
Having ascertained the necessary information, it is possible to quantify the risks of surgery
and therefore formulate an appropriate management plan to provide the safest possible
care. This may be very straightforward for healthy individuals having minor operations but
can be extremely complex for unwell patients undergoing major surgery. Anaesthetists are
responsible for explaining such risks to a patient and outlining the proposed management
plan.
The choice of anaesthetic management for a particular case is often not clear cut and there
may be a number of possible options available to safely facilitate surgery. For example,
repairing a broken ankle can be appropriately performed under general anaesthesia,
targeted nerve blocks, a spinal injection or a combination of these. The final choice of
technique is determined by patient factors, surgical factors and anaesthetic factors but is
an agreement between the patient, their anaesthetist and the surgical team.
6 WHO IS THE ANAESTHETIST?

In theatre, the anaesthetist becomes the patient’s carer and safety is paramount.
Control of the patient’s airway, breathing and circulation are of particular importance.
Close attention is paid to the patient’s condition during surgery and the anaesthetic
tailored to each individual. Complex operations may require invasive monitoring such
as transoesophageal echocardiography to monitor real time cardiac function, invasive
arterial blood pressures or whole blood clotting effectiveness with thromboelastography.
At the end of the procedure, the anaesthetist is responsible for ensuring full recovery from
anaesthesia in a safe environment and ensuring adequate analgesia.
Not all patients need to be asleep for their surgery and anaesthetists are skilled at using
regional nerve block techniques to anaesthetise discrete regions of the body. Local
anaesthetic is deposited around major nerves or plexuses with the aid of ultrasound or
nerve stimulators to produce numbness or analgesia. Regional techniques are commonly
used for day-stay patients or those considered high risk for general anaesthesia. Some
patients may have surgery performed under local anaesthesia alone.
Anaesthetists are responsible for planning and facilitating effective and safe postoperative
care. This may require postoperative ventilation on the intensive care unit, topping up an
epidural or planning discharge medications for a day case patient.
ANAESTHETIC SUBSPECIALTIES
The majority of anaesthetists are responsible for a wide variety of theatre cases so their
working week may range from quick turnover day cases for fit people to major complex
vascular surgery in sick elderly patients. Along with this, many anaesthetists have one or
more subspecialty interests, which further enhances the breadth of their clinical work.
Intensive care medicine
Intensive care medicine (ICM) treats the most critically ill patients in the hospital. An ICM
doctor can provide advanced organ support and is responsible for coordinating the care
of patients on the intensive care unit. ICM is high-tech, lifesaving care that interacts with
all other areas of the hospital. At present most UK intensive care doctors come from an
anaesthetic background, although some are physicians or surgeons.
Intensivists are experts at recognising and managing organ system failures. Anaesthetists
have a detailed knowledge of physiology and a comprehensive understanding of
pharmacology and monitoring techniques so are perfectly suited to work in a critical care
environment. A good intensive care doctor also needs excellent communication skills, a
firm grasp of ethical principles and an ability to manage people and resources. Effective
and sensitive communication with families is essential in times of extreme stress associated
with critical illness.
Training to become an intensive care doctor has changed recently with the foundation of
the Faculty of Intensive Care Medicine in 2012. It is now possible to train purely in ICM (from
ST3 onwards) or ‘dual train’ in conjunction with another speciality, such as anaesthesia,
although this takes longer. More details are available on the Faculty of Intensive Care
Medicine website (www.ficm.ac.uk). Anaesthetic skills will always remain essential and the
WHO IS THE ANAESTHETIST? 7

majority of currently advertised consultant posts in the UK are for anaesthetists with allied
intensive care qualifications.
Resuscitation and trauma
Anaesthetists are core members of the hospital trauma team, involved in the initial
resuscitation of trauma victims in the emergency department and their ongoing care in
the operating theatre. Some work outside the hospital in pre-hospital emergency teams
to treat trauma victims on the roadside. Specific training programmes for anaesthetists or
emergency medicine trainees interested in a career in pre-hospital medicine are currently
being introduced. More information can be found on the Intercollegiate Board for Training
in Pre-hospital Emergency Medicine website (www.ibtphem.org.uk).
Obstetrics
Two thirds of women giving birth in the UK will come across an anaesthetist in some
capacity and most delivery suites have dedicated anaesthetic cover. We assess women in
antenatal clinics to discuss methods of pain relief, anticipated anaesthetic problems or any
other special requirements. Anaesthetists are responsible for performing labour epidurals
to provide pain relief, as well as anaesthesia for surgical procedures such as caesarean
section. The presence of anaesthetists in the delivery suite has been accompanied by
a marked reduction in morbidity and mortality for both mother and baby. Obstetric
anaesthetists are integral to obstetric high dependency units for mothers with significant
co-morbid disease or for those who have experienced serious complications around
childbirth.
Paediatric anaesthesia
Paediatric anaesthetists do not need to have trained as paediatricians or passed exams
set by the Royal College of Paediatrics and Child Health. Paediatric anaesthetists gather
their skills and knowledge through specific placements during their generic anaesthetic
training, alongside at least one additional year of anaesthesia for children. Most hospitals
will provide anaesthetic services for children to some extent but those under the age of one
are normally treated in a specialist centre.
Cardiac and thoracic anaesthesia
Much like a paediatric anaesthetist, a cardiac anaesthetist is not first required to train as
a cardiac surgeon or cardiologist. All trainees are exposed to cardiothoracic anaesthesia
but to pursue a career it may be necessary to do additional years of specialist training
in the UK or abroad. Many cardiothoracic anaesthetists in the UK practise mainly adult
cardiac anaesthesia but some combine this with thoracic anaesthesia or paediatric cardiac
anaesthesia.
8 WHO IS THE ANAESTHETIST?

Pain medicine
Pain medicine describes the management of patients with acute, chronic and cancer
pain using physical, pharmacological, interventional and psychological techniques in a
multidisciplinary setting. The Faculty of Pain Medicine comes under the umbrella of the
Royal College of Anaesthetists. All anaesthetic trainees complete basic and intermediate
training in pain medicine but to become a pain specialist requires additional units to be
completed.
Acute pain management is a core skill of all anaesthetists. Techniques ranging from simple
oral analgesics to epidurals and infusions of peri-neural local anaesthetic may be utilised
to manage pain. Anaesthetist-led pain teams conduct ward rounds to identify and aid
treatment of complex acute pain problems.
Pain medicine is a distinct and very different specialty to anything else in anaesthesia.
Chronic pain conditions affect a large number of people and there is a great demand for
pain management services. Pain specialists are experts in invasive treatment techniques
such as nerve blocks, injection procedures and implantation of pain-relieving devices. They
play a central role in multidisciplinary pain management programmes, working closely with
psychologists and physiotherapists.
Regional anaesthesia
This involves anaesthetising parts of the body using targeted injections of local anaesthetic
drugs. Regional anaesthesia may be used in conjunction with a general anaesthetic (for
example, in shoulder surgery) or as a sole technique, particularly in sick patients where a
general anaesthetic may be very risky. Regional anaesthesia is common in day surgery
because it allows patients to walk as soon as possible after their operation. Recent
advances in ultrasound technology have encouraged the utilisation of such techniques
and are drawing more anaesthetists to specialise in this area.
ACADEMIA AND RESEARCH
Anaesthetists already have deep roots in scientific knowledge through studying for the
Fellowship of the Royal College of Anaesthetists (FRCA) and their clinical application of
science. Building on these foundations, anaesthetic trainees are well positioned to be
involved in research focused on the improvement of patient care.
Opportunities exist for anaesthetists who wish to make a career of primarily academic work.
A limited number of Academic Clinical Fellow (ACF) in Anaesthesia posts are available at
ST3 level or it is possible to take time out of training to study for a higher degree such as an
MD or PhD. The National Institute of Academic Anaesthesia was established in 2008 and
is committed to the academic advancement of trainees whether they are purely clinically
orientated or future physician-scientists.
WHO IS THE ANAESTHETIST? 9

TRAINING AND EXAMS
Entry to basic training requires graduation from medical school and successful completion
of two years of foundation training (or the equivalent). The training programme consists
of four phases:
Basic level
Intermediate level
Higher level
Advanced level
Core training (2 or 3 years) or ACCS (3 years)
(2 years)
(2 years)
(1 year)
There are two routes into anaesthesia - the direct route through Core Training or the
Acute Care Common Stem (ACCS) route. Core Training is two years in duration (in Wales
this is extended to three years) and is focused purely on anaesthesia and intensive care
medicine. ACCS is a three-year training programme to enable a broader exposure to acute
hospital specialties. The first two years of ACCS are spent rotating through emergency
medicine, general medicine, anaesthesia and intensive care. The third year is spent
providing training that will ensure the trainee meets the minimum requirements for entry
into specialty training in their parent specialty. So for anaesthetic ACCS trainees this third
year will be the equivalent of the second Core Training year. More information is available
on the ACCS National Training website (www.accsuk.org.uk).
The whole anaesthesia programme is normally seven years for trainees taking the Core
anaesthesia route, or eight years for those following the ACCS route. On completion of
the training programme, the GMC awards a Certificate of Completion of Training (CCT) or
Certificate of Eligibility for Specialist Registration [Combined Programmes] (CESR[CP])
which then allows the holder to apply for a consultant post. More information is available at
http://www.rcoa.ac.uk/careers-training/training-anaesthesia/the-cct-vs-cesrcp.
Basic level training (CT1-2)
This is normally two years in duration and concentrates on foundations of anaesthetic
practice and basic anaesthesia. Before a novice anaesthetic trainee can work without
direct supervision they must pass the structured Initial Assessment of Competency which
normally happens after about three months. Basic training includes three months of ICM
and exposure to obstetric anaesthesia but the remainder is dedicated towards general
anaesthesia and passing the Primary FRCA exam. Trainees who enter through the ACCS
route complete their basic level training in three years.
Satisfactory annual assessment, appropriate workplace-based assessments and success
in the Primary FRCA are required to progress to ST3. Application for ST3 posts is a
competitive process.
Intermediate level training (ST3-4)
Intermediate training lasts two years and introduces specialist areas of anaesthesia
including cardiothoracic and neuroanaesthesia. Trainees must pass the Final FRCA
examination to be allowed to progress on to higher training.
10 WHO IS THE ANAESTHETIST?

Higher level training (ST5-6)
Higher level training lasts two years, of which least one year is spent on general duties.
Some flexibility is possible to incorporate the special interests of an individual. Trainees
must complete the essential units of training and may also choose to do one or more
of the optional units. Higher level and advanced level training can be delivered flexibly
depending on individual schools of anaesthesia. For example, a trainee could begin
higher level training in ST5, undertake advanced level in ST6 and finish higher training in
ST7. It is possible to arrange out-of-programme experience or training (OOPE or OOPT)
at this stage. This may include studying for a PhD, anaesthesia in the third world or a
specialist fellowship.
Advanced level training (ST7)
Advanced level training is aimed at preparing you for being a consultant. Trainees may
choose to specialise in paediatric, cardiothoracic or neuroanaesthesia if they aspire to
work in a tertiary referral centre. In preparation for becoming a consultant, learning is
focussed on building expertise in specific areas of practice and greater exposure to the
professional competencies such as leadership, team working and management.
Training in Ireland
The structure and nomenclature of anaesthetic training in Ireland changed in 2012.
Specialist Anaesthesia Training (SAT) in Ireland now takes six years and is based in
hospitals accredited by the College of Anaesthetists of Ireland.
The structure of training is similar to that in the UK; two years of basic training are followed
by three years of sub-speciality training with a final advanced year to finish. At present both
old and new schemes are running in tandem and we would recommend consulting the
College of Anaesthetists of Ireland website for detailed information (www.anaesthesia.ie).
The Committee of Anaesthetic Trainees (CAT) provide trainee representation and support
(cat@coa.ie).
WHO IS THE ANAESTHETIST? 11

LESS THAN FULL TIME TRAINING
If you are considering training less than full time (LTFT) it is likely that you have other
commitments or areas of your life to which you need to devote time, whilst also trying to
get the most out of your training. Anaesthesia has a long tradition of supporting doctors
who wish to train LTFT and of all hospital specialities is second only to paediatrics for
numbers of part-time trainees. LTFT training programmes in anaesthesia have dedicated
programme directors and are usually well organised, and most departments will have had
experience of LTFT trainees. The sessional nature of anaesthesia facilitates a satisfying
career without too much family disruption, compared with working LTFT in other specialties
which may require dropping clinics and cross-cover of inpatients by colleagues in your
absence. There is a comprehensive guide to LTFT available to download from the AAGBI
website.
12 WHO IS THE ANAESTHETIST?

HOW CAN I FIND OUT MORE?
If you have been inspired to join us on the exciting and rewarding career path of anaesthesia
then it is time to do some homework!
Exposure to anaesthesia can be limited as a medical student and most people will want
to know more about the speciality before applying for a job. How best to go about doing
this depends on what stage you are at in your medical career. Undergraduates can
consider doing a special study module or elective in anaesthesia to gain more exposure.
Departments around the world are usually very willing to take students.
Limited numbers of four-month anaesthesia or intensive care posts are available on
foundation programmes. These are often highly sought after as they offer great experience
and learning opportunities with close consultant supervision. If you are applying for
foundation jobs and considering a career in anaesthesia then these offer a brilliant
opportunity to gain exposure to anaesthetists and their work. Current foundation doctors
can organise ‘taster weeks’ in specialties in which they may be interested, so why not
consider anaesthesia or critical care?
Anaesthetists are involved all over the hospital so whether you are a student or a foundation
doctor you are sure to come across them, wherever you are working. We are a friendly
profession so will not mind being approached by an inquisitive and interested potential
colleague! Talk to anaesthetic trainees as well the consultants, as they will tell you what
training is really like and how they secured their training rotation.
Information about a career in anaesthesia, the training and exams involved is available
online. We have included a list of useful contacts towards the end of this document. If
you want to discuss your aspirations then find out who the College Tutor for anaesthesia
is in your hospital and arrange to meet them. These are consultants who also represent
the Royal College of Anaesthetists and will have up-to-date advice on training and how to
apply for jobs.
Regional and national careers fairs offer the opportunity to talk to doctors from a wide
range of specialties in one room and offer advice from clinicians based beyond your local
hospital.
Anaesthesia is a great career. Entry to training is competitive and the exams do require
hard work but it is worth it in the end. The more experience you can get and the more you
can find out before you apply, the better choice you will be making for yourself and the
more likely you will be to secure a job.
WHO IS THE ANAESTHETIST? 13

USEFUL CONTACTS
Group of Anaesthetists in Training (GAT)
c/o The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Email: gat@aagbi.org
www.aagbi.org/professionals/trainees
Association of Anaesthetists of Great Britain and Ireland (AAGBI)
21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Email: info@aagbi.org
www.aagbi.org
The Royal College of Anaesthetists (RCoA)
Churchill House, 35 Red Lion Square, London WC1R 4SG
Email: training@rcoa.ac.uk
www.rcoa.ac.uk
The College of Anaesthetists of Ireland
22 Merrion Square North, Dublin 2, Ireland
Tel: +353 1 2650600
Email: info@coa.ie
www.anaesthesia.ie
Committee of Anaesthesia Trainees (CAT)
c/o The College of Anaesthetists of Ireland
22 Merrion Square North, Dublin 2, Ireland
Email: cat@coa.ie
www.anaesthesia.ie/index.php/training/committee-of-annaesthetist-trainees
The Faculty of Intensive Care Medicine
Churchill House, 35 Red Lion Square, London WC1R 4SG
Email: ficm@rcoa.ac.uk
www.ficm.ac.uk
Faculty of Pain Medicine of The Royal College of Anaesthetists
Churchill House, 35 Red Lion Square, London WC1R 4SG
Email: fpm@rcoa.ac.uk
www.fpm.ac.uk
NHS Careers
www.nhscareers.nhs.uk
14 WHO IS THE ANAESTHETIST?

WHO IS THE ANAESTHETIST? 15

Group of Anaesthetists in Training (GAT)
c/o The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Tel: 020 7631 1650 Fax: 020 7631 4352 Email: gat@aagbi.org
www.aagbi.org/professionals/trainees

Working Arrangements for Consultant Anaesthetists
in the United Kingdom
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org March 2011

Membership of the working party
Contents
Dr Paul Clyburn
Dr Kathleen Ferguson
Dr Ian Geraghty
Dr William Harrop-Griffiths
Dr Robert Harwood
Dr Peter Maguire
Dr Mark Porter
Dr Elizabeth Shewry
Professor Robert Sneyd
AAGBI Council Member
AAGBI Council Member
RCoA Representative
Chair, AAGBI Council Member
BMA Representative
BMA Representative
BMA Representative
GAT Representative
AAGBI Council Member
1. Introduction 4
2. Principles of the 2003 consultant contract 5
3. DCC PAs and their calculation 7
4. SPAs and their justification 11
5. WTR – rest and work patterns 15
6. Leave of all sorts 18
7. On-call 23
8. Part-time and flexible working 28
9. Job planning 31
This guideline has been seen and approved by the Council of the AAGBI.
10. Changes to job plans when services are reconfigured 35
11. Academic contracts 37
12. Differences in the devolved nations 41
13. The pre-2003 contract 45
14. Starting out as a consultant 47
15. References 50
© The Association of Anaesthetists of Great Britain & Ireland 2011
2 3

1. Introduction
The Association of Anaesthetists of Great Britain & Ireland (AAGBI) receives
a number of queries every year from members that relate specifically
to working arrangements. Although not a trade union, the AAGBI has a
responsibility to support and advise its members and it therefore responds to
the majority of these queries. Although we refer some more detailed queries
to the trade unions that represent doctors in the UK (the British Medical
Association – BMA – and Hospital Consultants and Specialists Association
– HCSA), many questions about working arrangements have common
themes. Council of the AAGBI established a working party to consider
questions and problems relating to working arrangements for consultants, and
charged it with producing a concise guide for AAGBI members. Including
representatives from the BMA, the Royal College of Anaesthetists (RCoA) and
the Group of Anaesthetists in Training (GAT), the working party has produced
this report. We plan to update the guidance as necessary, and we would
welcome comments and suggestions from members about future editions of
this document.
It is important to note that the AAGBI cannot arbitrate on or resolve disputes
between consultants and their employers. This guidance is not a definitive
document; it offers the opinion of the AAGBI on some common contractual
issues. Consultants who fail to reach agreement with their clinical managers
on the details of contracts, job plans, working arrangements, terms and
conditions should follow mediation and appeals processes within their
hospitals and should consider seeking the support of their Local Negotiating
Committee (LNC). The AAGBI advises those anaesthetists who are not
members of the armed forces to become members of a trade union that
can offer them formal support in resolving disagreements about contractual
matters.
2. Principles of the 2003 consultant contract
A contract is nothing more than an enforceable agreement that regulates
the relationship between two parties. In this case, the two parties are the
employer and employee, or consultant and their employing health authority,
NHS Trust or Board. In short, it describes what one agrees to do, what one
gets paid for doing it, and a mechanism for enforcing the agreement at law.
The contract thus comprises the agreement between a consultant and
his/her employer, and is described through the national model contract,
the statement of particulars (the letter sent on appointment), the terms and
conditions of service and the consultant’s individual job plan.
The new consultant contracts were negotiated in order to address changes
in the way the NHS and consultants had been working over the preceding
few years and to prepare for future developments. Consultant job planning
had been introduced in 1991 but too often remained just a discussion about
the weekly timetable rather than developing into the intended conversations
about a consultant’s duties, objectives and responsibilities, and the allocation
of time and other supporting resources to achieve these. From a consultant’s
point of view, job planning did not provide tools that were successfully able
to control the growing workload of consultants due to both patient demand
and the increasing burden of out-of-hours work.
The overall principle was that of accountability and mutual respect for both
parties. The profession accepted a time-sensitive contract, in which there is a
simple and direct relationship between the amount of time spent working and
the payment for this work. The relationship did not go so far as to introduce
‘clocking in and clocking out’ – it is accepted that the assessment of time
spent working should be brought to job planning meetings to discuss the
prospective allocations of time, rather than consultants’ being paid by the
hour like many other grades of staff in the NHS. However, it did allow a
consultant to control his/her workload by demonstrating the time spent on
it, and where this workload was excessive, expect either a reduction in the
workload or extra payments.
In return, the contract contained better tools to co-ordinate consultants’ work
with that of his/her hospital or employer, and the needs of his/her local health
economy, through the use of job planning and objective setting. Consultants
would now be expected to be able to account for the time spent on activities
and objectives, whether clinical or other, and the outcomes achieved during
that time, at the job planning meeting and in the appraisal meeting.
4 5

The practical changes were that a closer time-sensitivity came in through
organising work into PAs (programmed activities); payments for work done
while on-call were introduced, along with availability allowances for being
on-call. An ‘overtime rate’ was introduced, with PAs being four hours in
length except during premium time when they are three hours. Overall
salary levels increased and new higher levels were introduced, along with
a threshold system to require the consultant to fulfill basic engagement with
the contract in order to access these higher levels. The ‘10% rule’ reducing
salary when one did significant amounts of private practice was replaced by
a requirement to offer an extra paid PA to the NHS before engaging in private
practice if one wished to progress through the pay thresholds, a requirement
that most anaesthetists found was fulfilled through the new recognition of the
excessive work they had undertaken under the old contract.
Working time was divided for all into direct clinical care – DCC (and patientrelated
administration was recognised for the first time in this category)
- and supporting professional activities (SPA), with some consultants also
undertaking additional NHS responsibilities or external duties. The contract
defined a typical balance – so doctors employed in the consultant grade
should, unless otherwise agreed, spend the 10 programmed activities
of a whole time contract balanced between 7.5 DCC PAs and 2.5 SPAs.
This balance was designed to emphasise the importance of consultants’
undertaking quality assurance and quality improvement.
The consultant’s job plan should contain objectives, and describe the
supporting resources that the employer will provide in order to achieve these
objectives. The contractual commitment is to do one’s best to achieve the
objectives, and discussion on this point should form a central part of the job
plan review.
A new system of mediation and appeal was introduced in order to deal
with those circumstances in which there was a failure to agree the job plan
between the consultant and their employer.
Consultants who did not wish to transfer to the new contracts were able to
remain on the old contract (except in Wales – see section 12), accepting
lower salaries but keeping what was seen as less managerial control over
their working lives.
3. DCC PAs and their calculation
Direct clinical care programmed activities describe the portion of a
consultant’s working week devoted to the delivery of patient care; for an
anaesthetist this is usually individual patient care. Employers are keen to
maximise the proportion of a consultant’s work week devoted to patient
care, sometimes believing such PAs to be of greater worth; it should be
remembered that the 2003 consultant contract rightly places equal value on
both DCC and SPA PAs. The terms and conditions of service for the 2003
consultant contract defines direct clinical care activities as:
• Emergency duties, including emergency work carried out during or arising
from on-call
• Operating sessions, including pre-operative and postoperative care
• Ward rounds
• Outpatient clinic work
• Clinical diagnostic work
• Other patient treatment
• Multidisciplinary meetings about direct patient care
• Administration directly related to the above (including but not limited to
referrals and notes)
• Assessing patients in pre-assessment clinics and as ward referrals
• Checking equipment before use
• Drawing up and checking drugs before use
• Transfer of patient within and between hospitals
• WHO checklists
• Time spent checking/searching for beds for patients
• Time spent at end of list waiting/ensuring full and stable recovery from
anaesthesia
• Clinic letters
• Telephone contact regarding patient care (outside of DCC period of duty)
• Travel time between hospital sites
• Travel time to and from hospital when on-call (from the time of first contact to
arrival back at home)
It may be that other work may reasonably be included as DCC time. Such work
might include:
• Planning, discussing or reviewing the management of complex cases
• Planning surgical lists, managing list throughput
• Theatre floor troubleshooting or postoperative recovery unit based work or
supervision
• Special request pre-operative patient assessment
• The entire period spent within the hospital, whether actively working or not,
while providing resident on-call cover
Finally, the whole approach was supported by the introduction of a new
clinical excellence award (CEA) scheme, extending the scope of the old
distinction award and discretionary points schemes so that the majority of
consultants should be able to progress to an award through application.
6 7

Direct clinical care time may be made up of time worked in standard time
and time worked in premium time. Standard time is defined as the period
from 07:00 h – 19:00 h Monday to Friday, excluding Bank Holidays. Premium
time is any work outside of that period, including weekend and Bank Holiday
working at any time of day. A standard time PA is 4 h in duration; a PA
worked in premium time is 3 h in duration.
Traditional methods of calculating the number of DCCs in an individual
job plan, such as allocating a PA tariff based on the number of half-day lists
worked, are useful rules of thumb but may not properly represent the total
number of PAs worked. Changes to anaesthetist’s working patterns – sameday
patient admission with corresponding earlier start times, all-day and
long-day operating sessions together with decreased trainee presence for outof-hours
work – may have substantially altered the time associated with each
clinical commitment. In financially straitened times it is particularly important
that anaesthetists can demonstrate to employers the full extent of their clinical
activity.
First, record time spent on predictable emergency work during the reference
period, note when the work was done (to note standard or premium time PAs).
Add up the total time spent on predictable emergency work for both standard
and premium time during the reference period. Divide each by the number
of weeks in the reference period to create weekly averages (values W and Y
below). Divide each value again by 4 or 3, as appropriate, to convert to PAs to
reflect work undertaken in standard or premium time (values X and Z, below).
Add together both the PA values (X and Z, below); call the sum value ‘A’.
However, notwithstanding these caveats, many departments do find tariff
systems convenient, allowing changes to sessions and work patterns without
extensive recalculations of the hours worked. A commonly used tariff might
be for an inpatient operating list (a standard ‘session’ of 4 h anaesthesia
and operating time) to represent a standard 1.25 DCC PAs, including preoperative
and postoperative visits, machine and equipment checks, and
drawing up drugs. Extending this value to other sessions such as a day surgery
list, critical care session, obstetric anaesthetic session or outpatient session
such as chronic pain or pre-assessment should be undertaken with caution.
When using tariffs, care should be taken to ensure that the PA tariff allocated
to a particular session is an accurate reflection of the total time spent.
A diary record of some sort is invaluable in demonstrating to an employer
the range and duration of work that an individual consultant undertakes. An
ongoing diary of work activity is accurate, is individually specific and can
accommodate the normal workload variation between working weeks for a
consultant anaesthetist. There are several electronic diary systems available,
both commercial and freely available. An appropriate diary system must be
capable of recording the time spent on different work activities and should
deliver information acceptable to both parties in a job plan discussion.
Alternatively, paper based diaries may be preferred. In this case, consultants
should decide on a reference period of several weeks reflective of their
normal working pattern.
Figure 1: Calculating the PAs spent on predictable emergency work – for
explanation see text.
Repeat the process for unpredictable emergency work; call that sum value ‘B’.
Record the time spent on patient administration (clinic letters, results,
multidisciplinary team meetings) during the reference period; note when the
work was done (to note standard or premium time PAs). Add up the total time
spent on patient administration for both standard and premium time during the
reference period. Divide each by the number of weeks in the reference period
as before to create weekly averages (values S and U, overleaf). Divide each
value again by 4 or 3, as appropriate, to convert to PAs to reflect whether work
8 9

was undertaken in standard or premium time (values T and V, below). Add
together both the PA values (T and V, below); call the sum value ‘C’.
4. SPAs and their justification
Supporting professional activities are the activities that underpin direct
clinical care in one’s own practice and in that of other consultants. They
can be defined for example as participation in training, medical education,
continuing professional development, formal teaching, audit, job planning,
appraisal, research, clinical management and local clinical governance
activities, but it may be more helpful to think of them as activities that are
essential to quality assurance and quality improvement. Clinical practice
is the largest part of the need for employing consultants but all practice,
whether individual or in a team, will atrophy or fail to develop if not
examined in a rigorous manner and the need for change and development
considered.
Figure 2: Calculating the PAs spent on patient administration – for
explanation see text.
Repeat once more for non-emergency clinical work in the reference period
(clinics, rounds, patient assessment, anaesthesia and operating etc). Call this
value ‘D’.
Add A + B + C + D; this gives a value for average DCC PAs worked over the
reference period. Please note: unpredictable emergency work averaging over
2 PAs per week should trigger a job plan review with a view to decreasing the
requirement for such work. It is useful to agree the method and standard of
diary evidence that may be required before any job planning meeting.
Accurate diary monitoring is important in job planning (see page 31)
and is particularly useful if agreement between a consultant and his/her
clinical manager cannot be reached, and a mediation and appeal process is
embarked upon. In fact, experience has suggested that if no diary data are
presented, an appeal is likely to fail.
The model contract states that [1]:
“Subject to the provisions for recognising emergency work arising from
on-call rotas below, the schedule in your Job Plan will typically include an
average of 7.5 Programmed Activities for Direct Clinical Care duties and
2.5 Programmed Activities for Supporting Professional Activities. Where
your agreed level of duties in relation to supporting professional activities,
additional responsibilities and other duties is significantly greater or lower
than 2.5 programmed activities there will be local agreement as to the
appropriate balance between activities. Part-time consultants need to devote
proportionately more of their time to Supporting Professional Activities. This
should be agreed on an individual basis. Refer to the guidance on part time
and flexible working for further information.
“The precise balance will be agreed as part of Job Plan reviews and may
vary to take account of circumstances where the agreed level of duties in
relation to Supporting Professional Activities, Additional NHS Responsibilities
and External Duties is significantly greater or lower than 2.5 Programmed
Activities.”
The meaning of this is clear. The consultant grade is characterised by a
consultant agreeing this balance in his/her job plan, although there is scope
to accept something different where appropriate – and agreed. You are
strongly advised not to accept fewer SPAs in your job plan unless you are
content with the reduced ability to work on quality assurance and quality
improvement, and you should discuss it with a colleague or mentor if you
are considering this. If your employer is not persuaded by your arguments on
this, collect evidence and consider delaying agreement on your job plan until
10 11

further discussion and negotiation have been exhausted before going towards
mediation and appeal.
It appears that some NHS employers do not understand the value of SPAs
and believe that different specialties require different amounts of SPA time
to underpin safe and effective performance. In particular, there seems to
be a belief that the time of consultant anaesthetists is better spent giving
anaesthetics and that anaesthetists have little need for SPAs. The AAGBI
refutes these suggestions and supports the 2003 contract in recommending
that the job plans of consultant anaesthetists should typically include
2.5 SPAs. Although SPAs might not be seen by some Trusts to be directly
productive, this argument ignores the need for quality assurance and
quality improvement through all the listed SPA activities. Not only is it
a strict requirement for Trusts to undertake these activities, e.g. Clinical
Negligence Scheme for Trusts (CNST) compliance, compliance with the
recommendations of national audits, and clinical audit of innovative
techniques, it is also essential for services to change and develop with time.
Consultants hold the prime responsibility for doing this, and the link through
learning about a new technique, planning its introduction and auditing the
results is as valid for consultant anaesthetists as for anyone else. Productivity
is about the efficient and effective generation of desired outcomes, with
services continually improving, not simply carrying on doing what we did last
year and the year before. Continuous improvement requires consultants to
undertake continual reflection and change management.
Supporting professional activities are not as easy to count as patients on
a theatre list, but they can and should be accounted for. The commitment
for someone with 2.5 SPAs in their job plan is to undertake this amount
on average over a representative period, not to do exactly that, no more
and no less, each week. You should expect to undertake some SPAs in a
fixed fashion, e.g. clinical audit meetings, committee meetings, weekly
Continuing Professional Development (CPD) and journal clubs, and some
in a more flexible fashion, e.g. writing a new clinical guideline, undertaking
an audit, reviewing a proposed policy, mandatory training, dealing with
correspondence and teaching at undergraduate and postgraduate level. It is
reasonable for your clinical manager to expect some record of the time spent
on these activities in aggregate so as to ensure that the prescribed balance of
activities is being delivered. After all, a typical consultant anaesthetist is paid
about 20% of his/her pay slip income for these 2.5 SPAs in his/her job plan.
This is also where job planning objectives come in. By agreeing objectives
and working towards them, one can take to the job plan review or the
appraisal meeting a record of the outcomes achieved during SPA time. This
is not only valuable to keep track of one’s own professional development but
also to demonstrate effective use of this time.
It cannot be over-emphasised how important it is to place yourself in a
position to be able to answer cogently when asked what you spend your SPA
time on and what you have achieved during that time.
It is sometimes argued that consultant anaesthetists need less SPA time
than consultants in other specialties. This is wrong. Even though consultant
anaesthetists tend to work in larger teams and departments than many other
consultants, the breadth of scope of anaesthesia practice means that there
need to be lead clinicians with specific responsibilities in a wider range of
areas. A clinical director should maintain a list of departmental leads and
responsibilities [2] and consultants could not only ensure that their name
appears on that list in several places but also that they are active in those
areas and can demonstrate what they have achieved over the past year.
Box 2 (below) contains some suggestions for important roles and activities
within a typical department of anaesthesia.
• Clinical Director
• Chairman of the Department
• SAS Mentor
• Revalidation Advisor and Coordinator
• Appraisal Lead
• Rota-writer
• Job Planning Lead
• Productive Operating Theatre Lead
• On-call Rota-writer and Trouble-
Shooter
• College Tutor and Deputy
• Trainee Rota-writer
• Local Induction Lead
• Clinical Governance Lead
• Risk Management Lead
• Clinical Governance Links for
Subspecialty Areas
• Audit Coordinator
• Safety Lead
• NICE Guideline Lead
• Complaints Lead
• Guideline Development and
Monitoring
• Critical Incident and Serious
Untoward Incident Investigator
• Blood Transfusion Lead
• Infection Lead
• Pharmacy Link
• Equipment Lead
• Medical Devices Training Lead
• Health Informatics Lead
• Procurement Lead
• Airway Lead
• Cell Salvage Lead
• Resuscitation Lead
• Sedation Lead
• Pre-assessment Lead
• Subspecialty Area Leads
• Educational Supervisors
• Programme Directors
• Trainee Mentors
• Acute Pain Lead
• Library Monitor
• Student Work Experience Lead
• Research Lead
• CPD Lead
• Allergy Testing Lead
12 13

For most consultants, the majority of SPA time is not spent on service
objectives in pursuit of the employer’s goals, but is spent on personal
development objectives and other activities that contribute to appraisal
and revalidation. A heavy managerial responsibility should be agreed as
an additional NHS duty, not as SPA time. The Academy of Medical Royal
Colleges has stated that consultants need a minimum of 1.5 SPAs per week
on average to undertake the activities that will lead to personal revalidation,
and more to undertake any duties or responsibilities in management, any
teaching or training or research, and they emphasise that all consultants must
engage in service development and clinical governance activities [3]. All this
applies to consultant anaesthetists as much as anyone else.
Time and place is important when thinking about SPAs. The spectrum might
run from a Trust in which complete freedom exists to undertake SPA work
whenever and wherever one likes, to a Trust in which one is expected to sit
at a specific desk for 10 h every Wednesday. Neither is particularly supported
by the terms and conditions of service, and neither is necessarily appropriate,
but some principles are important:
• If you undertake clinical work during SPA time, which may be
appropriate from time to time, then you have a right to have that SPA
time returned to you.
• If you agree to be in a specific place at a specific time, then your
employer must provide proper supporting resources. A chair might
be sufficient for attending a clinical audit meeting, but for individual
governance work then a desk, computer, office and solitude are
as likely to be important.
• If you take time back one week, put it in the next.
• Be reasonable and repay the trust that someone places in you.
Supporting professional activities are a vital part of consultant practice.
Think as carefully about planning and delivering your SPAs as you do about
your clinical work and all is likely to be well. The AAGBI believes that the
outcome of the time spent on SPA is more important than the number of
minutes spent per week, but consultants should be prepared to deliver – and
to show that they deliver – on the time agreed within their job plans.
5. WTR – rest and work patterns
The Working Time Regulations (WTR) is British and Irish health and safety
legislation that has applied to consultants and other career grade doctors
since 1998 – often incorrectly called the Eurpoean Working Time Directive
(EWTD). The application of WTR to junior doctors has been on a phased
basis, but applied in full – a 48-h maximum average working week – from
August 2009. A very small number of specific junior doctor rotas have
received derogation to have a 52-h working week until 2011. The reason
that WTR impacts so significantly on healthcare services is as a result of two
European Court of Justice (ECJ – Europe’s highest court) rulings (SiMAP and
Jaeger) on working time while on healthcare premises. These rulings have
effectively ended the longstanding practice of on-call duties and made shift
working the norm for doctors resident in hospitals. Box 3 (below) illustrates
these rulings.
SiMAP ruling (2000)
This defined all time when a doctor is required to be present on site as
actual working hours for the purposes of work and rest calculations.
Jaeger ruling (2003)
This confirmed that this was the case even if the doctor is allowed to sleep
when their services are not required.
In April 2010 the European Commission announced its work plans during
the European Parliamentary Session, which would include collation of data
in relation to the actual implementation of the WTR across EU member
states, its actual impact on health services and, most importantly, plans to
renegotiate the Directive by the end of 2010. However, in practice, even
if a new EWTD is agreed at the end of 2010, there will be at least a 2 – 3
year period before any change to employment law is actually enshrined in
individual member state law.
The elected membership of the current European Parliament has moved
significantly towards the right politically following elections during 2009. This
is likely to alter the views of Parliament as a whole on many social issues,
including WTR.
14 15

The European Commission, after consulting European social partners, has
issued opinions on the WTR derogations for the UK underlining that the
average weekly working time for doctors in training may not exceed 52h,
including on-call at the work place, and that the temporary extension will last
until 31 July 2011 [4].
The European Trade Union Confederation recently called upon the European
Commission to pursue infringement proceedings against member states not
adhering to the current WTR rules, including the ECJ rulings. The Commission
has signalled its intention to delay any infringement proceedings for most
countries in order to give individual member states further time to comply
with the rulings but has commenced proceedings against Greece and Ireland,
which on paper have poor track records of implementing WTR within their
healthcare sectors.
‘Hot’ weeks in ICU
Over recent years, especially in intensive care units (ICUs), it has become
customary for consultants to have ‘hot’ or very busy weeks on duty. These
hot weeks allow improved continuity of patient care. This is acceptable
under WTR since guidance specifies that the average 48-h working week is
calculated over a 26-week reference period. The single area that may not be
averaged is the rest period; therefore, ICUs should be staffed to ensure that
all doctors working there have an 11-h rest period in a given 24-h period.
Although consultants can derogate from many aspects of the WTR, they may
not derogate from the requirement to have an 11-h rest period (see Box 4,
below). Those with responsibility for agreeing the job plans of consultant
intensivists should be aware of this. Some ICU rotas provide for a ‘warm
week’ in which a consultant acts as a backup to allow the first-on consultant
to take the rest period if necessary.
Indemnity
The three main UK Medical Defence Organisations (MDOs) and the NHS
Litigation Authority (NHSLA) have confirmed that doctors are indemnified
when working in excess of a 48-h working week. The main exclusion from
this indemnity cover would be wilful neglect or negligence by any doctor
working in contravention of the General Medical Council guidance – ‘Good
Medical Practice’ [5]. A doctor working as a locum (even via an agency)
solely within the NHS will remain covered by the NHS Litigation Authority
(NHSLA). The AAGBI advises that all doctors work responsibly, be mindful of
not working excessive hours or treating patients when tired, and recommends
that AAGBI members should be members of one of the MDOs. While not
mandatory, it is prudent to notify your MDO if you voluntarily opt out of
the WTR maximal working week, advising them of the actual hours you are
working. This should be done in advance of working prolonged hours.
Members should note that NHSLA cover applies to work in the NHS but does
not include all matters that can include representation at coroner’s courts,
disciplinary cover and professional guidance on an individual basis – thus the
recommendation to be an MDO member.
Private practice and the WTR
Question:
Answer:
Question:
Do the WTR apply to private practice?
The WTR only apply to employed work. However, there is
a legal requirement for doctors not to present for work in an
unfit condition.
Can I do private work during my compensatory rest period?
May consultants derogate from the average weekly working hours rules in
the WTR?
The answer is yes – but with two provisos:
1) That they should not be obliged to do so by their employers
2) That they may not derogate from the requirement for 11-h continuous
rest period within any 24-h period
Answer:
This is not recommended, as problems with patient care
might be ascribed to your being unfit for work because of
fatigue.
16 17

6. Leave of all sorts
Annual leave
Consultants are entitled to six weeks’ annual leave. In England, consultants
are allowed an additional two days called statutory days (‘stat’ days).
Consultants in Northern Ireland have an additional two Bank Holidays
(St Patrick’s Day and Orangemen’s Day). Consultants in Scotland and Wales
have to make do with only the six weeks. In England and Northern Ireland,
consultants on the 2003 contract and in post for seven years or more have
an addition two days’ annual leave. While there is no standard definition
of a leave week, it is sensible and fair that this is commensurate with an
individual’s working week. Thus, someone who works three days per week
should expect to calculate leave entitlement on the basis of 6 x 3 (plus any
additional) days, i.e. 18 (plus any additional) days and take leave of 18 (plus
any additional) working days only. This should be defined in local leave
policies and be fairly and equitably applied.
Calculating annual leave
Six weeks’ leave can be 42 days, 30 working days or six weeks’ worth of
clinical sessions. Departments have different ways of calculating leave, but
leave calculations can still be the source of much unhappiness. Consultants
should agree a mechanism for ensuring fairness in leave taking. The AAGBI
thinks that it may sometimes be unfair to employers to take leave primarily
on days that would otherwise include NHS clinical activity. In an extreme
example, a consultant’s working week could be compressed into two long
clinical activity days. If the consultant were to take just these two days off
in each of 21 weeks, they would have taken 42 days’ leave but would have
avoided clinical work for five months. This is evidently unfair. The AAGBI
suggests that leave periods should in general contain the same proportion of
DCC and SPA time as is in the consultant’s job plan.
Another way of achieving fairness to employee and employer is to calculate
consultant leave in terms of clinical sessions missed. Calculated in this way,
a consultant who has six weeks’ annual leave and who does six operating
lists per week would be allowed to miss 36 lists per year. Additional
days’ leave can be calculated as proportions of a week. For instance, if a
consultant is entitled to six weeks and four days’ leave, this equals 6.8 weeks
in decimal notation. If they do six lists per week, this comes to 6 x 6.8 =
40.8 sessions. The kind Leave Monitor will round this up to 41 sessions. The
punctilious Leave Monitor will allow 41 sessions’ leave in four out of every
five years but only 40 sessions in the fifth year.
It is worth noting that some employers are taking an increasingly
unsympathetic view of consultants who seek special leave (see page 21) to
perform duties for the wider NHS, such as work for the AAGBI, RCoA or
BMA. As a result, some consultants are being forced to take annual leave to
fulfil these valuable duties. If this is the case, and if such dates tend to fall
on days when a consultant would normally be committed to direct clinical
care, it is hoped that the Leave Monitor and Clinical Director will take a
lenient approach and relax the approach suggested in the box above. It is
also worth noting that consultants who maintain a meticulous and continuous
year-round work diary will have a record of how many DCC PAs they have
delivered for their Trusts. This may inform discussions and negotiations about
leave, as it will provide an accurate record of what work has actually been
done rather than a calculation of what should have been done.
The annual leave year usually begins at the anniversary of commencement
of the consultant contract but some employers have a standard leave year
for all employers, e.g. 1st April, which should be specified in the contract.
Consultants on a substantive contract may carry over up to five days of
untaken annual leave, although more may be carried over by special
arrangement. Consultants who are not able to take all of their annual leave
or to carry it over may be paid in lieu if this is in line with local agreements.
Consultants must seek formal permission to take leave. Up to two days’
leave may be taken with notification but without formal permission. Many
departments set leave rules that allow the continuation of clinical service.
These often include a minimum booking period, e.g. at least six weeks in
advance of the leave to be taken, and a maximum number of consultants who
can be away at the same time. All Trusts will have an agreed leave policy,
which should be referred to.
Sickness during annual leave
If a consultant falls sick during annual leave and produces a statement to that
effect, he/she will be regarded as having been on sick leave from the date of
the statement. Self-certification can cover up to seven days’ sickness.
Public holidays
A consultant is entitled to 10 days’ public holidays or days in lieu thereof,
which consists in England of eight public or Bank Holidays plus two ‘statutory
days’, and in Northern Ireland 10 public or Bank Holidays. Some Northern
Irish employers add these two additional days to annual leave entitlement.
A consultant who works or is on-call on a Bank Holiday is entitled to a
leave day in lieu. A common problem encountered is when a consultant
requests a day in lieu because they were on-call on the night before a Bank
18 19

Holiday, and was therefore on-call for the period from midnight to the time
of consultant on-call handover. The terms and conditions of service for
consultants are clear: if a consultant is disturbed by work between midnight
and 09.00 h of a Bank Holiday, that consultant is entitled to a leave day in
lieu. In the old (pre-2003) contract, consultants on-call the night before a
Bank Holiday were entitled to a lieu day whether or not they were working in
the hospital or disturbed by calls after midnight.
Study and professional leave
The distinction between professional leave and study leave can be confusing
as the terms may be used interchangeably. Study leave is essentially to enable
a consultant to participate in continued professional development (CPD) and
may include:
• Study, usually but not exclusively or necessarily on a course or
programme
• Research
• Teaching
• Examining and taking examinations
• Visiting and attending professional conferences
• Approved postgraduate purposes
• Working with colleagues in order to acquire new knowledge or skills
The recommended standard for consultants is leave with pay and expenses
within a maximum of 30 days (including non-clinical and non-duty days
falling within the period) in any three-year period. Leave will normally be
granted to the maximum extent and all reasonable expenses should be
met regardless of the employer’s financial constraints. The Department of
Health has clearly stated that professional leave is an allowance based on
an individual’s needs to attend to duties that are important for the broader
benefits of the NHS and necessitates the consultant being away from their
base of employment. Such duties can be recognised as ‘external duty’ PA
rather than as professional leave. Any grant of leave is subject to the need to
maintain NHS services.
What’s the difference between study leave and professional leave?
A good guide to the usual difference is:
Study leave is when you are a registrant at a meeting and your employer
should pay for you to attend it.
Professional leave is when you are part of the faculty at a meeting.
Where a consultant is employed by more than one NHS organisation, leave
must be approved by all these organisations. During study leave with pay, the
consultant should not undertake any remunerative work without the special
permission of the leave granting authority. Unlike supporting activity, study
leave facilitates absence for several days or even weeks at a stretch, where
necessary. Therefore, study leave is a means of achieving professional activity
goals in addition to (not in place of) SPA time.
Special leave with or without pay
The provisions of Section 3 of the terms and conditions of service will still
apply. This leave is granted without formal restriction and some consultants
find it useful in working for medical Royal Colleges or professional
associations.
Can my employers cancel my study, professional or special leave if it is
within my allocation of 30 days per three years?
Yes, they can. Your employers can cancel this leave if not to do so would
impair clinical activity in the hospital. However, employers should make
every reasonable effort to avoid cancelling this leave.
Sabbaticals
A consultant may apply for sabbatical leave according to existing
arrangements. Proposals for sabbatical leave should be made before annual
appraisal and considered in the annual job plan review. The contract in Wales
has provision for consultants to seek a paid sabbatical for up to three months
in order to pursue activity away from normal duties that will subsequently
benefit patient care.
Sick leave
A consultant is entitled to sick leave with pay where they are absent from
work due to illness, injury or other disability. If unable to work for more than
three days, a self-certificate can be submitted for up to the first seven days of
sickness. For longer absences, another medical practitioner should provide
regular medical certificates. The employer is entitled to ask for more frequent
certificates and to assessment by its own appointed medical practitioner.
Entitlement to paid sick leave relates to the duration of NHS service. This may
be extended at the employer’s discretion. Your employer will have a policy
that will determine whom you should tell if you have to take sick leave.
However, as a senior professional within the organisation, it would be right to
tell those people in the area in which you were to be working that day.
20 21

Maternity leave, domestic, personal and care relief
The regulations relating to these different forms of leave are determined by
local employers on the basis of the NHS terms & conditions. Consultants
should check with their employing hospitals.
7. On-call
Emergency work is an important aspect of the clinical duties of consultant
anaesthetists and intensivists. Indeed, it could be argued that all anaesthetists
and intensivists should have emergency work of some sort included in their
job plan. For the large majority of consultants, this will be provided within
the on-call service for their employing hospital. For the minority who do not
do on-call, emergency work can be conducted in the form of trauma lists,
daytime or evening emergency lists, covering the Accident & Emergency
Department during weekday hours or other activities likely to bring the
consultant into contact with emergency work.
The 2003 consultant contract includes payment of an on-call availability
supplement that takes into account the frequency and intensity of the on-call
duties (see table).
The work of consultant anaesthetists and intensivists is almost always in
intensity Category A. It is worth noting that this supplement does not include
payment for work conducted; it is simply for availability. The predictable
amount of work involved in doing on-call work should be included in the
DCC PAs within the consultant’s job plan, taking into account that most,
if not all, of this work is conducted in premium time, i.e. at weekends and
between 19.00 h and 07.00 h on weekdays. If there is doubt about the
amount of work performed during on-call duties, a diary monitoring exercise
that covers at least one full on-call cycle should be conducted. The results of
such an exercise can be used to inform the job planning process.
Compensatory rest after on-call
Consultants are subject to the provisions of the WTR, and therefore cannot
be expected to fulfil a work pattern that does not include 11 consecutive
hours of rest per day. Therefore, predictably onerous on-call duties that almost
always involve work at night should lead to a consideration of whether the
consultant should have clinical duties allocated during the daytime before
22 23

a night on-call or the day after a night on-call. If a consultant is required
to work during a night on-call, he/she is entitled to compensatory rest the
following day. Indeed, patient safety considerations will often mean that it
would be foolish to continue to work after a busy on-call night or period of
duty. If a consultant is scheduled to be working in the operating theatre on
the day after a night on-call that proves to be very busy, the consultant can
demand compensatory rest and miss the lists. In doing so, the consultant
should take into account any risks to safe patient care that this might involve.
In turn, the Clinical Manager of the department of anaesthesia (Clinical
Director, CD) should make every effort to ensure that tired consultants are not
expected to work after onerous nights on-call. A question that is commonly
asked is whether, having missed a list through compensatory rest after a night
on-call, the consultant can be expected to do an additional list to make up
for the list that was missed. The answer is no. Job plans should be designed
such that predictably busy nights on-call are not scheduled before a day of
clinical duties, or indeed SPA activity. In this way, compensatory rest can be
built into consultants’ job plans without compromising service, safe patient
care or CPD activities. A consultant should think carefully before conducting
other clinical activities during an identified period of compensatory rest after
on-call duties.
Question:
Answer:
Caveat No 1:
Caveat No 2:
If I have a very busy night on-call and miss an NHS list the
next day because I am taking compensatory rest, do I have
to pay that list back?
No, you do not have to pay the list back in any way.
Consultants’ job plans should be designed such that NHS
duties are not scheduled in the day after predictably busy
nights on-call.
Consultants should not deliberately arrange their on-call
duties so as to place them the night before NHS duties.
Coming off the on-call rota
Almost all consultant anaesthetists and intensivists are appointed to job plans
that include on-call duties. During their working life, some consultants seek
to relinquish their on-call duties for a variety of reasons that include illness,
increasing age, and family or other domestic or professional commitments. If
a consultant wishes to drop his/her on-call duties, he/she should discuss this
with his/her CD. If the reason relates to stress or illness, assessment by the
Occupational Health Department (OH) is appropriate. If OH recommends
that the consultant be removed from the on-call rota for health reasons,
employers should make every effort to make this possible. Consultants
should note that if they are released from on-call duties for health reasons,
they should think carefully before making themselves responsible for the
emergency cover of any patients out-of-hours. This might occur if the
consultant anaesthetises a private patient who stays overnight in a private
hospital. Under such circumstances, the consultant might wish to ensure that
another consultant is on call for this patient and that there exists a written
agreement confirming this.
The AAGBI has recommended that “there should be a review of on-call
responsibilities for anaesthetists over 55 years of age” [6]. Consultants have
no right to drop on-call duties at a set age, as this would be contrary to UK
age discrimination legislation, but CDs should consider reasonable requests
to discuss on-call duties from older members of the department. Small
departments may find allowing a consultant to come off the on-call rota
very difficult because of the increase in on-call frequency for the remaining
consultants. Larger departments will find it easier to allow people to leave the
on-call rota but should be wary of creating a rule that consultants over a set
age should not do on-call, first because this may be contrary to the provisions
of age discrimination legislation and second, as the demographics of the
consultant body may mean that a large group of consultants of a similar age
may all demand to come off the on-call rota at roughly the same time at some
point in the future, and this may severely compromise service provision.
Some CDs ask consultants coming off the on-call rota to take on additional
duties such as additional weekday lists or regular out-of-hours emergency
commitments such as evening or weekend trauma lists. Such arrangements
should be individually negotiated. No consultant has the right to come off
the on-call rota other than for health reasons. No CD has the right to demand
additional work to compensate for coming off the on-call rota. Contracts can
only be changed by mutual consent from employer and employee. Clinical
Directors should take reasonable steps to cooperate with consultants who
wish to come off the on-call rota for family reasons; Human Resources
Departments are useful points of contact when discussing the rights and
responsibilities of employers and employees in such matters. Again,
negotiation lies at the heart of such arrangements, and it is usually possible
to reach equitable agreements without formal referral to Human Resources or
senior managers. Where agreements cannot be reached, the BMA’s Industrial
Relations Officers (IROs) can be an invaluable source of support and advice.
24 25

Changes to the frequency of on-call
Changes in the number of consultants in the department, in the number of
active consultants in the on-call rota and in the number or nature of on-call
rotas provided by the department may produce changes in the frequency
of on-call duties. Consultants have a responsibility to help the department
fulfil its service commitments safely and effectively, but changes to a
consultant’s job plan and contract should only be made by mutual agreement
after negotiation. If changes to the frequency of on-call affect the on-call
availability supplement or number of DCCs paid for predictable work during
on-call periods, these should be reflected in the pay of consultants.
Consultant residency on-call
Consultants are not obliged to provide a resident on-call service. The 2003
contract states that “a consultant will only be resident during an on-call
period by mutual agreement” [1]. However, changes in trainee numbers and
working hours, and service reconfiguration within a hospital may mean that
consultant residency in out-of-hours periods in the form of shift working or
residency on-call may form part of a possible solution to service demands.
In these circumstances, the AAGBI recommends that the consultants
negotiate with their employers and in doing so make sure that adequate
recognition is made in their job plans and in their pay for the additional
work and inconvenience that such changes will involve. The LNC should
be involved in such a change; the BMA’s IROs can offer invaluable support
in negotiations. Consultants should not commit to such a change without a
formal written agreement that includes the opportunity to review and change
the arrangements after a period of their implementation. Some departments
consider responding to requests for consultants to do shift work or become
resident on-call by making them a requirement of recently appointed
consultants but not of established consultants in a department. The AAGBI
joins the BMA in arguing against such practice; it risks dividing the consultant
body and creating potential tensions that will not be conducive to safe and
effective patient care.
trainee as a last resort. If undertaking work of this kind, the consultant should
ensure that they possess all the necessary competencies required for the role.
For example, some trainee roles require training in safe patient transfer, and
consultants working in some subspecialties not requiring these skills may not
have current training. If a consultant agrees to do this, a written agreement
is highly desirable before the start of any resident work. Local Negotiating
Committees should be encouraged to prepare pro forma agreements to
facilitate these negotiations. The BMA provides a model agreement for LNCs
to use in such circumstances. If the agreement includes payment for the
consultant under these circumstances, the rate of pay should reflect the grade
of the doctor doing the work, not the grade of doctor being replaced, i.e. the
consultant should be paid to do this work as a consultant, not as a trainee.
Covering trainee absence on-call
A consultant has a duty to deputise for absent consultant colleagues so far
as is practicable, but this does not include joining trainee on-call rotas.
However, consultants do have a professional obligation to ensure that
emergency clinical services offered to patients are undertaken safely and
effectively. When faced with a situation in which a trainee scheduled to work
an overnight shift is unavailable because of illness or rota failure, consultants
have a responsibility to work with managers to obtain a locum. Sometimes,
this is not possible and the consultant may have to work in the place of the
26 27

8. Part-time and flexible working
The Department of Health has stated that the current consultant contract
should provide the necessary flexibility for those who wish to work either
part-time or flexibly in nature. Part-time contracts may be offered between
one and nine PAs. For appointments after January 2004, where the request
to work part-time is in order to undertake private practice, the contract
should not normally be for more than 6 PAs. Those with reasons other than
private practice, but who may wish to undertake some private work, can be
appointed to a contract of more than 6 PAs. Part-time consultants wishing
to undertake remunerated clinical work in their non-NHS time would be
expected to offer up to one extra PA on top of their normal working week.
Transitional arrangements from the old contract will require accurate diary
evidence to permit the transfer from notional half days (3.5 h) to programmed
activities (4 h). Any increase in workload can only occur by mutual
agreement and the award of extra PAs. The division of PAs between DCC and
SPA is roughly pro rata but it is acknowledged that part-time consultants need
the same opportunity to maintain their skills through CPD. Proportionally,
more of the PA time should be directed towards SPAs. Part-time consultants
will not carry the same clinical load as full time consultants. Recommended
numbers of SPAs for part-time contracts are shown in the box below.
Total number of PAs
Number of SPAs
2 or less 0.5
2.5 – 3.5 1.0
4.0 – 5.5 1.5
6.0 – 7.5 2.0
8.0 or more 2.5
Apart from the PAs, a part-time consultant should have no other NHS
commitments during the working week. Participation in an on-call rota will
receive remuneration with the same supplement as a full-time consultant on
that rota. Part-time consultants may undertake on-call either at a reduced
frequency – for example at a 90% frequency for a consultant working a 9 PA
job plan – or at the same frequency as full time colleagues. If the consultant
works on-call at a 90% frequency, the on-call supplement is calculated as
a percentage of 9 PAs. If they work on-call at the same frequency as other
full-time colleagues, the on-call supplement is calculated as a percentage of
a full-time, 10 PA salary. If the consultant undertakes an on-call duty on a day
that they do not normally work, then time off in lieu or additional payment
will be agreed.
Flexible training adds time within the training grade. This may make it
difficult for people who have undergone flexible training to reach the top
of the consultant pay scale. Where necessary, they will have their progress
through the thresholds adjusted so that they will reach the threshold they
would have reached if in training on a full-time basis.
The contract allows for flexibility in timing and location of consultants PAs.
Employers have a duty to make reasonable attempts to accommodate this.
The employee has a right to return to a regular pattern of work after a period
of flexible working. Examples of flexible work patterns include job-sharing,
annualised hours contracts, flexi-time and term-time working. Annualisation
allows employees to vary their weekly commitment, for example, during
school holidays, making the time up in term time.
Annualised working
Although the 2003 contract offers little detail to guide CDs and consultants
in devising and agreeing annualised contracts, it does make provision for
them. There are a number of ways that a job plan can be annualised, but
anaesthesia lends itself to such manipulations, as clinical care is readily
divisible into operating lists and clinics. The important principles are as
follows:
• Consultants should work an agreed annual total of PAs instead of the
same number each week.
• The arrangement must be compatible with best practice in job planning
for consultants.
• The arrangement must be agreed, as it would be for any job plan.
• The number of PAs to be worked in a year is usually the product of
the number of PAs per week in a base job plan multiplied by the
number of weeks in a year. For a 10 PA job plan, this would be 520 PAs.
• Consultants do not work 52 weeks per year, so reasonable allowance
must be made for Bank Holidays, annual leave, study and professional
leave, sick leave, maternity leave, special leave, etc. The usual range
of working weeks used in annualised working calculations is 40 – 42
weeks per year.
We will provide one sample calculation as an example. Dr HG is a
consultant anaesthetist whose outside activities include heavy commitments
to the RCoA, AAGBI, NICE and ACCEA. He wishes to annualise his contract
28 29

to give him the flexibility to attend a large number of meetings. His base
contract is for 10 PAs, and comprises 5.5 operating lists per week, 2.5 SPA
and 0.5 PA for predictable emergency work on-call.
He and his CD agree that his annual leave (6 weeks and 4 days) and Bank
Holidays together will amount to 8 weeks per year, his study/professional
leave will be 2 weeks per year and that his special leave allowance on top
of this, given his level of national activity, shall be an additional 1 week. This
means that the number of lists he will be expected to do will be 41 x 5.5 =
223 lists per year. He is allowed to work this fully flexibly given that he gives
at least 6 weeks’ notice of times of the week that he is available to work. He
agrees with his CD that he will also work his 41 x 2.5 = 102 SPAs flexibly
and will agree verifiable outcomes for this SPA time. They agree that if sick
leave is taken during periods of annual leave, time will be given back using
a formula of 6 sessions per week’s sick leave. Both Dr HG and his CD are
happy with this arrangement.
Annualised contracts are not the perfect solution for everyone, and a
department of anaesthesia would not wish too many of its consultants to work
in a fully flexible fashion. The AAGBI recommends that those consultants
working annualised contracts make it clear when they plan to take their
allocated annual leave in order to avoid any arguments if sick leave is taken
in non-working weeks, as sick leave taken during annual leave should be
‘paid back’, but sick leave during non-working periods that are not annual
leave need not be.
9. Job planning
Job planning is the process by which the aims and requirements of employer
organisations are translated into agreements detailing how individual
consultants will contribute to the delivery of those aims. All employing Trusts
want DCC and SPA activity aligned to the Trust’s needs; job planning is the
mechanism to ensure this. It allows Trusts to obtain maximum value from
DCC and SPA sessions. There are some minor differences in the devolved
countries. Country-specific information can be found in detail within the
terms and conditions of service for the country in which you are employed.
Job planning takes place at least annually and is a prospective process. All
consultants, whether or not they are employed under the 2003 consultant
contract arrangements, are obliged to undergo annual job plan reviews.
Job planning is a partnership process; job plans may not be imposed – the
agreement of both parties is required. Job planning is a separate process
to appraisal although outputs from the job plan review will inform the
appraisal mechanism. Should there be significant change to a consultant’s
commitments, then an interim job plan review can be requested at any stage.
There is extensive guidance describing job planning and how to undertake
it. Unhappily, although the requirement for consultant job plans has existed
since 1991, job planning can still be a poorly conducted process: the process
may focus simply on the development of a timetable or be seen as an
opportunity to reduce PAs. At its heart, job planning is really about objectives
and the SPAs that help deliver them. The process is intended as a partnership
activity that delivers benefit for both consultant and employer. It allows
consultants the opportunity to lead on service development both in quality
and productivity and to identify the resources needed to deliver objectives.
Employers are afforded the ability to extract the added value that consultants
bring. Both parties benefit from clarity about commitments.
Preparation for job plan review is essential. Some supporting information will
be required; a work diary is invaluable, where possible supported by activity
data, comparative workload and/or ideal workload data. Consultants must
have an appreciation of the process itself. It is helpful to have read some of
the available guidance ahead of the review meeting. Similarly, it is advisable
for consultants to consider what they need from the review and where they
might be challenged.
The process is based on agreement; job plans are not imposed. A draft job
plan should be prepared by the Clinical Manager – this forms the basis of
30 31

discussion at the review meeting. More than one meeting may be required.
Both parties may be assisted at the meeting(s) – the Clinical Manager by a
General Manager and the consultant by a colleague or advisor.
The job plan review should be systematic. Trusts may be keen to focus on
elective work; it is more appropriate to give early consideration according
to clinical priority or on areas where agreement may be more difficult.
Emergency work should be the first priority – time spent dealing with
predictable on-call work should be reviewed first followed by unpredictable
on-call. On-call activity should be averaged over a 1 – 8 week reference
period. Contentious areas may be, for example, work undertaken in premium
time, SPA allocation or Additional PAs and fee-paying services. Although
consultants cannot be required to undertake planned work in premium time,
there is an increasing need for consultant presence; it may be helpful to
consider a local agreement. Similarly, it should be borne in mind that SPAs
are not an automatic entitlement – they need to be justified and accounted
for with agreed outputs in objective setting.
After discussion the job plan is signed off as agreed by both parties. If
agreement has not been possible consultants may use the mediation and
appeal process.
Mediation and appeal
The mediation and appeal process is part of the 2003 consultant contract
process to help resolve disputes over job plans and pay progression. It
is not designed for use in other settings, for example disagreements over
CEAs. Although consultants on the pre-2003 contract are required to
undergo annual job planning, their contractual arrangements do not include
mediation and appeal.
Mediation and appeal are incremental processes. Mediation, a less formal
process, is tried first, before moving on to appeal where necessary. When
a job plan or pay progression cannot be agreed either the consultant or the
Clinical Manager may refer the matter, in writing, to the Trust’s Medical
Director within two weeks of the disagreement. The referral will describe
their view of the matter, and the other party will be invited to respond in
writing. It is recommended that all areas of dispute be brought to mediation
in case they need to be formally considered at some later stage by an Appeal
Panel. The Medical Director will convene a meeting between the Clinical
Manager, the consultant and him/herself within four weeks of receipt of the
referral. Agreement between parties is sought at the meeting; if this is not
possible then the Medical Director will decide the matter and will inform all
parties in writing.
If the consultant is still not satisfied, then he/she may lodge an appeal in
writing, outlining the basis of the appeal, to the Chief Executive within two
weeks of the outcome of mediation. The Chief Executive will convene an
Appeal Panel that should meet within four weeks of receipt of notification
of appeal. An Appeal Panel consists of three members, none of whom
should have been involved with the case previously. The panel is chaired
by a nominee of the Trust, often a senior non-executive director. The second
member is nominated by the consultant. The third member is chosen from a
list held by the Strategic Health Authority of approved independent appeal
panellists. Such members may either be from BMA/BDA backgrounds or have
managerial backgrounds, often within Human Resources. Either party can
object to the third member suggested and a new member will be appointed.
The 2003 consultant contract specifies that the Appeal Panel will be arranged
by the Chief Executive to meet within four weeks of the written request from
the consultant. Although delay is undesirable, in reality, given the difficulty in
arranging the attendance of consultants and other senior NHS personnel, the
four-week timescale may be subject to some slippage. When delay occurs the
appellant should not normally be penalised; any contested payments should
be backdated to at least the date on which the appeal was lodged.
Both parties make written submissions ahead of a hearing, and copies
are sent to all panellists and to the other party. At the hearing, at which
the consultant may be represented but not by a legal representative, both
parties present their case to the panel. Expert advice may be required by the
employer, the consultant or the panel. Panel members may ask questions of
both parties and of the expert advisor(s). The appeal hearing lasts no more
than one day. The Appeal Panel makes its judgement within two weeks of the
hearing, notifying both the Trust Board and the consultant in writing. The Trust
is not obliged to accept the panel’s recommendations but would normally be
expected to do so.
32 33

Job planning is by agreement, not decree: what to do if you cannot reach
agreement
CD and consultant fail to agree
2 weeks
Inform Medical Director (MD)
4 weeks
MD, CD and consultant have mediation meeting
2 weeks
Consultant appeals to Chief Executive (CE)
4 weeks
CE convenes Appeal Panel
Appeal Panel meets and makes judgement
10. Changes to job plan when services are
reconfigured
Clinical and other services will change with time and so will your job
plan. The usual principle applies – all changes should be agreed changes.
Furthermore, both parties should act reasonably, especially when considering
changing the job plan to fit in with changes in local service provision.
However, from time to time the employer will need to change a consultant’s
job plan to fit in with service changes, to reconfigure services, cut costs or
introduce new technologies.
When facing such a situation, and particularly if it seems likely to involve
a change to one’s own job plan, it would be important to think about the
potential changes and whether one is dissatisfied with them. For example,
would it substantially change the nature of the service that one provides?
Would it involve more or inconvenient travelling? Would it have an impact
on the ability to meet commitments, for example through having on-call
responsibility for a hospital that is further away? You should seek to discuss
such questions with your clinical manager at the earliest opportunity.
Nevertheless, at some point you may be faced with a change to your job plan
that is prompted or required by a reconfiguration and with which you are
unhappy. You should seek personal advice from a trade union representative
as soon as possible, either through the LNC or the BMA. The normal
processes of mediation and appeal are important but in this case there will
be other factors that will affect the judgment that an arbitrator will make on
the disagreement. A consultant would usually be badly advised to seek to
obstruct changes by attempting to veto changes to their job plan when, for
example, a hospital closes or reconfigures its services.
Agreeing or disagreeing with changes
Contractual changes should be by agreement unless an employer is prepared
to give notice of a change. You should know the circumstances under which
you give your agreement and what rights and support you have if you do not
wish to agree. Giving one’s agreement to a job plan change can be tacit as
well as explicit. Most changes to job plans over the years are implicit, and an
important function of job planning meetings is to codify such changes so that
there is an explicit written understanding; but a change need not be written to
be a contract variation. So, where an employer imposes a unilateral change
to a job plan, for example the timing or location of an operating list, and the
consultant carries on working without complaint, they will be treated by the
34 35

law as having agreed to that change. It is a common misconception that one
can preserve one’s rights through refusing to sign a document; it is not the
failure to sign, but the employee’s conduct, that is important.
Should you want to disagree, if you have not already done so, now is the
time to seek professional advice. You should also look for information on job
planning that may be available from the RCoA, AAGBI or BMA websites.
Any unilateral imposition of contractual changes may result in a claim for
breach of contract, or a resignation and then claim for constructive dismissal.
Except where intractable disputes arise or the business needs reorganisation,
Trusts are very unlikely to do this – in the vast majority of cases you will be
able to address problems through negotiation.
11. Academic contracts
This section illustrates principles for job planning in a post where the basic
week is roughly 50:50 divided between NHS and university. Clearly, other
arrangements are possible and may be explored using similar principles.
The basic week
The basic working week comprises 10 PAs. Regardless of whether academic
posts are fully funded by the university (some senior staff and some
Foundation Chairs) or co-funded by the NHS, the principles are the same.
In addition, the split of this 10 for planning purposes should be regarded as
about five to be planned with the university and about five to be planned
with the NHS – and, if you are a university employee, agreed with the
university. All basic contracts comprise 10 PAs and there is no obligation on
either the employer to offer or the employee to accept contracts >10 PAs.
Accordingly, all advertised jobs should include a base 10 PA job plan.
Five PAs for the university
This may be for research, teaching or management as agreed with your line
manager. Typically, for Research Excellence Framework (REF)-returned,
research-active staff, the major activity will be research. None of this time
is to be used for NHS management or other NHS clinical or non-clinical
activities.
Five PAs for the NHS
This comprises a mix of SPA time and DCC. The vigour with which the NHS
partner pursues clinical work from university-employed clinical academics
inevitably reflects their underpinning funding. If the clinical time is universityfunded,
then the NHS partner may reasonably take a ‘light touch’ approach.
Conversely, where the five PAs are NHS-funded (by recharge), then they may
have higher expectations in terms of clinical work delivery.
SPA time
Mindful of personal development, CPD requirements and the increasing
burden to be expected with revalidation, this will never be

elated and other specialty activities outside the Trust. This may include roles
in medical Royal Colleges, specialist societies, regional and national NHS
bodies, etc. This may, with agreement, be properly included in SPA time and
where such agreed activities are extensive then the allowance of SPA time
may be more than 2.5.
Clinical work (DCC)
This includes clinics, operating lists, ward-rounds as well as patient related
paper work and meetings. This must be agreed with the NHS partner. Note
that in order for clinical work to attract PAs over and above the basic week, a
clear and agreed account must be given for first five PAs for the NHS.
Additional PAs for the university
The university may offer additional academic time to clinical academic staff.
This additional academic time is discretionary and you may decline it if you
wish.
Additional PAs for the NHS
By agreement with the NHS and with the approval of your university line
manager, you may work additional PAs to a maximum of 12. On-call is
typically paid for in this part of the contract. Clinical work such as clinics
will only attract additional PAs if the basic 5 PAs for the NHS are clearly
described and justified.
Special activities for the NHS
Special roles for the NHS such as research work, Network Lead, R & D
Director, Clinical Manager, clinical governance, etc may be described in SPA
time. It may be appropriate to include these as additional SPAs for the NHS
provided that the underpinning description of the basic NHS commitment
is convincing and overall commitment is not impacting on academic
performance.
Actual contract
In practice almost all staff employed under the 2003 consultant contract opt
to agree additional activity. Where this is to be offered an alternate shadow
job plan will also be prepared illustrating how an agreed longer working
week might be structured. Typically, a job plan will comprise the university
sessions (paid for and managed by the university) and NHS sessions paid by
the university, managed (with joint appraisal and job plan agreement, see
overleaf) by the NHS partner and recharged at cost to the NHS partner by the
university.
University sessions
A typical academic contract will contain about five university sessions in the
basic 10; there are therefore about 20 h that the staff member should work
in an actively managed process against agreed the university activities, e.g.
management, teaching and research.
NHS time
NHS time will comprise a mixture of DCC PAs and SPAs. The NHS part of the
job plan must include a proportion of SPA time. It is important that the NHS
proportion of the job plan contains an adequate amount of SPA time in order
to give the clinical academic sufficient time to address the non-clinical part of
their NHS role and to ensure that this does not spill over into the Universityfunded
academic time. The following table indicates a typical DCC/SPA split.
This provision of SPA time should be regarded as a minimum and where the
post holder undertakes significant SPA activity for the NHS partner a greater
allocation may be appropriate.
NHS PAs DCC PAs SPAs
(total including on-call)
6 4 2
5 3.5 1.5
4 2.75 1.25
Total contract
The clinical academic consultant contract is a single contract, not two halfcontracts,
and it is ultimately accountable in its entirety to the university line
manager and the employing university, although the active management of
the clinical proportion of the job plan is typically delegated by agreement
to a clinical manager within the NHS partner. The total job plan should not
exceed 12 PAs.
Job planning, appraisal and accountability
NHS pay progression rules require that individuals complete a job planning
process and appraisal every year in order to be eligible for pay progression
and CEAs. Universities endorse and apply this principle. Appraisal of the
university staff with three or more NHS PAs in their job plan should be joint
appraisal (this means three people in one room at the same time, not separate
NHS and University appraisals). The job plan (final version as signed by the
NHS line manager) must be agreed with the university line manager and a
copy lodged with the university HR section (and updated every year).
38 39

Implementation guidance
Individual NHS partners have developed detailed implementation guidance
and this can usefully be applied to the university staff.
Management responsibilities
The university staff may (with the prior agreement of their university line
manager) adopt management roles within NHS partner organisations. Such
roles may be reimbursed by the NHS partner using varied mechanisms.
Typically this involves substitution of management for clinical activity
(without additional payment) or additional payment without allocation
of time or some combination of the two. All NHS management activities
whether paid or unpaid must be accommodated within the proportion of the
job plan allocated to NHS activities. University time is not to be used for NHS
management activities.
Teaching
The nature and quantity of teaching undertaken by clinical academics must
be prospectively and transparently agreed and unequivocally located within
the job plan. Typically, the university clinical academic staff will undertake
some teaching within their actively managed university sessions and will not
receive additional payment for this. Where (by prior agreement) teaching
takes place during the NHS proportion of their contract, it may take place
as an SPA (without additional payments), by substitution for fixed clinical
commitments (without additional payment) or as additional contracted
activity which must be included in the job plan and the total job plan must
not exceed 12 PAs. It is not acceptable for university staff to solicit or receive
supplementary payment for teaching (via NHS partners) and expect or be
expected to deliver this within their contracted university time.
Annualised contracts and additional leave
Some NHS clinicians operate annualised contracts wherein the total
quantum of work for the year is agreed and delivered flexibly (again by prior
agreement). In some cases working weeks beyond 12 PAs are recognised
by 12 PA contracts with additional annual leave. Such arrangements for the
university clinical academic staff should be regarded as exceptional and
should in all cases be prospectively approved by the university.
Universities recognise that clinical academics are hard working, versatile
individuals and expect that contractual arrangements may reasonably be
operated with considerable flexibility. A key principle is transparency,
accountability and continual clarity about time allocation and the proper
relation between NHS and the university duties.
12. Differences in the devolved nations
The 2004 contract in Northern Ireland
By 2010 over 98% of consultants had transferred to work on this contract,
which closely mirrors the 2003 English contract. Despite some years having
passed since the introduction of this contract, many consultants continue to
work to retrospective job plans – Trusts do not appear to have caught up with
prospective job planning. The two main reasons advanced for this are Trust
and NHS reorganisation and lack of medical managerial manpower or time.
It is likely that there will be major change, as the Northern Ireland Health
Service is under severe financial strain and faces further financial cutbacks.
A 2009 moratorium on study leave funding was lifted in some Trusts in 2010
but there is a requirement for annual savings of over £100 million in the
coming years, and there are suggestions that medical staff posts may remain
vacant to save money.
The 2004 Northern Ireland consultant contract has four main elements:
• Direct Clinical Care (DCC)
• Supporting Professional Activities (SPA)
• Additional HPSS (Health and Personal Social Services) Responsibilities
• External Duties
The recommended norm is for a 7.5 DCC to 2.5 SPA split in contractual
obligations. In recent times and associated with budgetary restrictions,
consultant SPA has come under very severe downward pressure with a
suggestion from DHSSPSNI (Department of Health, Social Services and
Public Safety of Northern Ireland) to Trusts that 1.5 SPA should be ‘core’
with all other SPA ‘earned on an individual basis’. Both the BMA and AAGBI
continue to recommend a 2.5 SPA allocation per consultant. In case of
dispute it is essential that each consultant has a detailed and accurate diary
outlining the actual work that they are doing should they need to follow the
contract dispute processes of Facilitation (called Mediation in England) and
thence Appeal.
There were moves from Trusts to assign Additional HPSS responsibilities and
External Duties to a new category of leave – ‘special leave’. However, this
work is outlined specifically in the terms and conditions of service and advice
should be taken from BMA / HCSA on the appropriate time to be included
within a negotiated and agreed job plan.
40 41

Each individual consultant anaesthetist should seek prospective job
plans for the year ahead and retain copy documentation of all contact /
communications seeking job planning.
The latest rates of pay can be found on the BMA website [7].
Take home pay is determined by considering the following:
• Basic salary
• Any additional Programmed Activities
• On Call Allowance / Intensity Supplement
• CEAs / Discretionary Points
• Additional allowances – such as travelling expenses
Since 2007 Northern Ireland has had five Trusts. Each Trust should have
an active LNC that engages with Trust management in negotiating local
contractual arrangements. Issues that are under Trust control include
payments for waiting list initiatives, resident consultant shift working out of
hours and relocation allowances for consultant anaesthetists affected by acute
service reconfigurations. In anaesthesia, resident shift working out of hours is
increasingly likely and contact should be made with the local LNC to ensure
the position and views of anaesthetists are properly represented.
The consultant contract in Wales
Unlike the contract in England, the Welsh contract is an amendment to the
original consultant contract and any points not covered in the amendment
are unchanged from the original contract [8]. The amendment document
is therefore much briefer than the necessarily more comprehensive English
contract. However, many of the principles are the same, though it is
important to appreciate that some of the points in the rest of this guide do not
apply to consultants working in Wales.
The main amendments that are different from the English contract include:
• A basic 37.5-h working week (10 sessions of variable length).
• Typically, 7 DCC and 3 SPA sessions. Increasingly, Health Boards
(formerly NHS Trusts) are appointing new consultants on 8 DCC and 2
SPA and there is pressure on existing consultants to come in line unless
they can demonstrate extra activity to justify the third SPA.
• The first 3 h per week (in place of 3.75 h) of work as part of on-call
(based on an average over 6 months) is counted as 1 session of DCC.
Time worked over this is counted towards additional 3.75-h sessions.
• Provision that 1 SPA may take place at home in the evening
(recognising the work by some consultants at home), allowing
uncontracted free time during the day.
• No requirement to provide an additional session of time to the NHS in
order to acquire the right to undertake private practice.
• Additional sessions for routine work are entirely voluntary with no
requirement for compulsory weekend or evening work.
• Extra sessions requested by the Health Board are voluntary and locally
negotiated for time and payment.
• In exceptional circumstances, resident on-call is remunerated at three
times the sessional payment with an agreed compensatory rest period
the following day.
• Commitment award scheme replaced discretionary points awarded
with progress depending on satisfactory job planning (though
expected to be universally awarded). This ensures continued pay
progression throughout a consultant’s career. National Excellence
Awards are currently the same as in England.
• Recognition of different patterns of work intensity, particularly later in
consultant’s career.
• There is good provision for part-time and academic working through
open, individualised job planning.
• A sabbatical scheme of up to three months of paid leave to undertake
activities away from normal duties that will subsequently benefit patient
care. The application and award of sabbatical leave is made locally.
• Flexibility and professionalism is encouraged as much as possible
within the contract.
• In the event of a job-planning dispute, an initial conciliation procedure
followed, if necessary, by a balanced appeals procedure that is binding
on the Trust and the consultant.
The consultant contract in Scotland
The Scottish model contract remains broadly similar to that in England
although three amendments have been made with respect to maternity
arrangements, flexible working and redundancy payments. Transitional
arrangements, salary scale and the pay progression timescales are similar
to those in England and an updated version of these may be accessed in
the NHS circular PCS(DD)2007/11. Also explicit in the circular are the
arrangements for payment of waiting list initiative work. They are: three times
the hourly rate at point 20 on the seniority scale or, alternatively, twice the
rate of pay with time off in lieu or standard rate plus twice the time off in lieu.
Premium time exists between the 20.00 and 08.00 h as opposed to the 19.00
42 43

and 07.00 h in England. In addition to this, non-emergency work may be
programmed on a Saturday between 09.00 and 13.00 h, although this work
is at premium rate and not standard.
As in England, the need for NHS employers to squeeze SPA time is evident
in the current advertisement of consultant posts with less than 2.5 PAs
identified for SPA in a 10 PA contract. The BMA (Scotland) and Academies
of the Royal Colleges in Scotland have reached a level of understanding
with the Management Steering Group (a self-appointed advisory group
to the Scottish Executive Health Department) whereby all new posts will
be advertised with time explicit for essential CPD. All other SPA must be
agreed during the job planning process. This places accurate diary evidence
as a priority for any consultant within NHS Scotland. All newly appointed
consultants are advised to keep accurate diaries and to request a job plan
review no later than three months after appointment if they feel their work
balance is inappropriate.
Mediation and appeals for the job planning process are handled in a similar
manner to England although the Divisional Chief Executive has a role in
Scotland and the appeal panel make-up differs slightly.
The Merit Award and Discretionary Points system (SACDA – the Scottish
Advisory Committee on Discretionary Awards) has been replaced by
SACCLEA (the Scottish Advisory Committee on Clinical Leadership and
Excellence Awards). Details of the new system are uncertain at the time of
publication.
Local Negotiating Committee involvement remains crucial for the following
issues where national arrangements do not exist: prospective cover
included, re-imbursement for consultants resident on-call, and provision for
leave for forms of leave not otherwise specified.
13. The pre-2003 contract
This section is primarily intended for those clinicians with responsibility for
management, leadership and job planning of consultant anaesthetists still on
the pre-2003 contract. It is assumed that holders of these contracts are fully
aware of the merits of both contracts and have elected to remain on the old
contract. It is not the remit of this document to advise on that choice. This
contract is not available to any consultant appointed since November 2003
or to those who have changed to the 2003 contract.
Types of contract
This contract, initially agreed in 1979, describes units of work in terms of
notional half days (NHDs) worked flexibly. Each NHD lasts 3.5 h. There is
no premium for work in unsociable hours although there is provision for
intensity payments. There are two main types of this contract for those who
work full-time: whole-time and maximum part-time. Holders of both have a
contractual commitment to devote substantially the whole of their working
time to NHS activities with a minimum of 10 NHDs. There is also provision
in this contract for part-time working in which there is no expectation that the
post-holder will devote substantially the whole of their professional time to
the NHS. Part-time contracts may range from one to nine NHDs.
Holders of whole-time contracts are limited to earning not more than 10
per cent of their gross NHS earnings in private practice and are required to
make an annual declaration confirming this. Holders of maximum part-time
contracts are not subject to any restriction on their private practice income
but forfeit 1/11th of their NHS salary. There is also an effect on accrual of
pension benefits in that holders of maximum part-time contracts will be
credited with 10/11ths of a year’s service for each year worked in pension
calculations.
Travel arrangements
Maximum part-time contract holders may count up to 30 min per journey
each way for travel between home or place of private practice and their NHS
place of work.
Job planning
All consultants should expect to have annual job planning meetings and
reviews in which both fixed and flexible work is defined. The same principles
apply to job planning and appraisal for those on the pre-2003 contract as to
those on the 2003 contract. Fixed commitments will largely be clinical work
and times and locations of each NHD should be determined and agreed,
44 45

although NHDs may be flexible in time, location and type of activity. There
is no difference in the number of fixed NHDs expected of full-timers and
maximum part-timers. Normally this is between 5 and 7.
Non-fixed or flexible work describes that work covered in 2003 contract as
SPAs as well as on-call and other irregular or unscheduled work necessarily
undertaken. Evidence of activity and output would be expected. There is no
reason why a consultant anaesthetist on the pre-2003 contract would need
any less time for those activities that underpin their professional knowledge
and skills. However, there may be an argument that those who spend
substantial amounts of time working in private practice should devote some
of their own time to supporting their professionalism and revalidation.
Additional NHDs
Consultants may be contracted for additional NHDs for clinical or nonclinical
work, normally up to a maximum of two NHDs. These are temporary
and non-pensionable activities that are remunerated at 1/11th of the full time
salary.
Question:
Answer:
If you are on the old contract, does it mean that you do
not have to undergo an annual job planning process and
do not have to account for activities performed in paid
non-clinical NHDs (notional half-days)?
The answers are definitely ‘no’ and ‘no’ respectively.
14. Starting out as a consultant
Obtaining a consultant job is just the beginning; it is really just the start of
even more hard work. Whilst new consultant anaesthetists must focus on
their clinical workload, the other roles of a consultant must not be forgotten.
With the likely introduction of revalidation, ongoing proof must be provided
that time has been spent on continuing professional development. There are
also a number of pitfalls to avoid. It is important not to take on every new role
offered to you when starting as a consultant. The majority of new consultants
are undoubtedly eager to get involved with their department but it is also
possible to be swamped. It is worth taking time to decide what your priorities
are and if necessary delaying these decisions until you are aware of the likely
workload. Courses are run to help with ‘saying no’; the ability to say ‘no’ can
greatly improve your working and personal lives.
Continuing Professional Development
Ongoing learning as CPD does not end on achieving a consultant post.
The Trust employing a doctor expects that they will achieve adequate and
appropriate CPD each year. Guidance from the RCoA and Medical Education
(England) will be taken into account in this process; for example, the RCoA
gives advice on how much CPD is provided per activity and which activities
are appropriate. Details of this and the number of CPD points you are
expected to achieve per year are available at from the College’s website.
These CPD points may be acquired by attending a mixture of departmental,
regional, national or international meetings as well as attending and teaching
on courses. Suitable educational activities not awarded CPD points by the
College may, however, be accepted by both the Trust and the individual to
contribute to professional development. Trusts are encouraged to provide
adequate study leave; if you have difficulties with your study leave allowance,
you should consider contacting the BMA. A detailed portfolio or personal
folder including certification should be kept of all activities to assist with the
appraisal process. As well as speciality specific training, you will be expected
to attend Trust mandatory training in areas such as child protection and
manual handling.
Supporting Professional Activity
The 2003 consultant contract specifies that posts should typically contain 7.5
DCCs and 2.5 SPAs per week. With the current financial climate, SPA time
is under scrutiny to ensure that it is being used effectively. If 1.5 SPAs per
week is considered sufficient to maintain revalidation purposes, qualification
for or maintain of the additional SPA may be based on evidence of activity.
This may vary from service improvement projects, formalised teaching, to
46 47

eing the departmental lead in a variety of different areas, e.g. paediatrics.
Some new consultants may be happy to start with 1.5 SPAs but it should be
noted that 2.5 SPAs are recommended by the AAGBI and other professional
bodies for all consultants, including those newly appointed. Should a
smaller number of SPAs be agreed, there must be opportunity for this to
increase as non-clinical workload changes. Anaesthetic departments may
pool their 2.5 SPAs per consultant, allotting more to those fulfilling a higher
non-clinical workload. Maintaining a diary of how SPA time is spent allows
the department to justify the ongoing allocation of such non-clinical time.
Some Trusts may insist on a fixed SPA session or being on site for at least
one of these; this is something that may need to be negotiated with your CD.
Regardless of the number of SPAs decided upon, a formal meeting should
be arranged at six months to reassess and adjust the number of sessions if
required.
senior mentors to junior consultants; the AAGBI supports this. Even if there
is no formal system within your department, you will usually find useful and
sympathetic help and support if you need it. If you wish to seek help outside
of your department, the AAGBI, RCoA and BMA offer support schemes. The
AAGBI supports the BMA Doctors for Doctors scheme, where support can be
found 24/7 for any welfare issue on 0845 920 0169. The AAGBI recognises
the importance of supporting members and the AAGBI Welfare Committee has
been established to help support all members, including those experiencing
problems during this difficult time of transition. Further information can be
found on the AAGBI’s website (www.aagbi.org) and a Welfare Resource Pack
is also available to download. For more practical career advice or less urgent
advice from the AAGBI, email wellbeing@aagbi.org.
Job planning and development
It is important to discuss, finalise and agree your job plan as soon as possible
after the consultant interview process. You must ensure that your job plan
when appointed matches the job plan advertised. A small alteration here
may lead to a dramatic change in your job or in your work-life balance. It
may be possible to adapt a job plan before starting work or even during the
appointment process. Recently appointed consultants should ensure that
their job plans do not involve a degree of professional isolation by scheduling
work primarily in locations away from main operating theatre suites. The
ready support and availability of experienced consultants can be valuable
in the first few months and years of consultancy. Job plans should continue
to evolve during your time as a consultant and it is important to meet with
your CD to review and update your plan on a regular basis, e.g. at least once
a year. You should sit down at the beginning of your new post and agree
with your CD what is expected of you and your clinical commitments. It
is better to find out exactly what is expected of you at the beginning of the
job. Ongoing diary monitoring of your job will help inform future job plan
discussions; in particular, the clinical burden may be either more or less than
expected when the job plan was instituted. A consultant post may be held for
30 years so this ongoing review process of your job plan is important to keep
you motivated and utilise your skills fully.
Where to get help
Consultants of any age may need help, but it is likely that those starting out
on their consultant careers will need more support and advice than those in
mid-career. Some hospitals have a Young Consultants Group that promotes
the discussion of common issues. Some departments of anaesthesia allocate
48 49

15. References
1) British Medical Association: Consultant’s terms and conditions 2009.
http://www.bma.org.uk/employmentandcontracts/
employmentcontracts/consultantscontracts/
consultantcontractdocuments.jsp (accessed 10/1/11)
2) Association of Anaesthetists of Great Britain & Ireland: Archive of past
issues of Anaesthesia News.
http://www.aagbi.org/publications/anaesthesia_news/2009.htm
(Page 11 of September issue) (accessed 10/1/11)
3) Academy of Medical Royal Colleges: Statements Archive.
http://www.aomrc.org.uk/publications/statements/111.html
(Statement of 8th February 2010) (accessed 10/1/11)
4) European Commission: Employment, Social Affairs and Inclusion –
Labour Law.
http://ec.europa.eu/social/main.jsp?langId=en&catId=157&newsId=603
&furtherNews=yes (accessed 10/1/11)
5) General Medical Council: Good Medical Practice (2006).
http://www.gmc-uk.org/guidance/good_medical_practice.asp
(accessed 10/1/11)
6) Association of Anaesthetists of Great Britain & Ireland: Guideline –
Fatigue and Anaesthetists (2004).
http://www.aagbi.org/publications/guidelines.htm#f (accessed 10/1/11)
7) British Medical Association: Current Pay Levels – Doctors Pay
Supplement October 2010.
http://www.bma.org.uk/employmentandcontracts/pay/doctorspaysupp.jsp
(accessed 10/1/11)
8) NHS Wales: Amendment to the National Consultant Contract in Wales.
http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=433&id=32473
(accessed 10/1/11)
50 51

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Workload for Consultant Anaesthetists in Ireland
Guidance on the 2008 (Connaughton) Contract
and Job Planning for Consultant Anaesthetists in Ireland
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org April 2010

Membership of Working Party
Dr Michael Staunton
Dr Kevin Bailey
Dr Anne Bergin
Dr David Honan
Dr John Kennedy
Dr Avine Lydon
Dr Geraldine Maloney
Dr John McAdoo
Dr Carlos McDowell
Dr Stephen Mannion
Dr Ellen O’Sullivan
Dr Rory Page
Chairperson, Member of Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Hon. Secretary, Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Member, Irish Standing Committee
Convenor, Irish Standing Committee
The Irish Standing Committee wishes to sincerely thank Mr Donal Duffy,
Assistant Secretary General, Irish Hospital Consultants Association, for his
helpful advice regarding this document.
1

Contents
1. Key points 3
2. Introduction 4
3. Overview of the consultant contract 5
4. Consultant contract types and regulation of private practice 9
5. Consultant work schedule 14
6. Clinical directors and clinical directorates 19
7. Academic consultants 22
8. Locum and temporary consultants 23
9. The European Working Time Directive 26
References 29
Appendices 33
© Copyright of The Association of Anaesthetists of Great Britain & Ireland.
No part of this book may be reproduced without the written permission of the
AAGBI.
2

1. Key points
• The consultant contract is an agreement between an individual
consultant anaesthetist and his or her employer.
• The 2008 (Connaughton) Consultant Contract contains many important
differences from the 1997 (Buckley) Consultant Contract.
• The Irish Standing Committee of the AAGBI advises that all consultants
are members of both a medical representative organisation and a
medical defence organisation.
• Each consultant anaesthetist who has signed the 2008 contract must
agree a consultant work schedule and a ratio of public to private
practice with his or her employer.
• All consultant anaesthetists who have signed the 2008 contract should
fully honour their 37-hour scheduled weekly commitment.
• The increase in weekly working hours under the 2008 contract should
include an increase in both clinical and non-clinical activities.
• As previously recommended by the AAGBI, approximately 25% of total
weekly working hours should be devoted to non-clinical activities.
• Failure to devote adequate time to non-clinical activities may adversely
affect the maintenance of professional competence and the quality of
patient care.
• Consultant anaesthetists within a department of anaesthesia may have
different clinical and non-clinical activities.
• Consultant anaesthetists with additional non-clinical responsibilities,
e.g. chairperson or secretary of department, clinical director, should
have a reduction in working hours devoted to clinical activities.
• The consultant work schedule should be supported by a robust diary
exercise.
• If workload changes, a change in the consultant work schedule may be
required.
• The measurement of the ratio of public to private practice may not
adequately capture many clinical activities which are regularly
performed by consultant anaesthetists.
• Consultant anaesthetists should consider maintaining their own records
of their public and private clinical activity.
• All changes in working patterns as a result of the European Working
Time Directive (EWTD) should be carefully evaluated for their effects on
the safety of patients and staff.
3

2. Introduction
The 2008 (Connaughton) Consultant Contract
The Irish Standing Committee of the Association of Anaesthetists of Great
Britain and Ireland (AAGBI) produced a guideline in 1992 and a supplement
in 1993 to advise members on the 1991 Irish Consultant Contract. The
Irish Consultant Contract was subsequently revised in 1997 and in 2008.
The 2008 (Connaughton) Consultant Contract contains many important
differences from the 1997 (Buckley) Consultant Contract. Therefore, the
Irish Standing Committee considered it appropriate to review and update its
previous guidance.
This new guideline will give members a broad overview of the principles of
the 2008 contract together with specific advice appropriate for consultant
anaesthetists. The objective of this guideline is to enable consultant
anaesthetists and, thus, their patients, to adapt to and benefit from the 2008
contract.
Professional advice on your contract
The Irish Standing Committee advises that you maintain membership of a
medical representative organisation, e.g. the Irish Medical Organisation
(IMO) or the Irish Hospital Consultants Association (IHCA). Both of these
organisations recommend that new consultants have their contracts reviewed
by them before signing. In addition, both organisations provide advice to
consultants regarding the local interpretation of their contracts.
The Irish Standing Committee and the Health Service Executive (HSE)
both advise that you take out supplementary membership of a defence
organisation or insurer of your choice, so that you have adequate cover for
matters not covered by the Clinical Indemnity Scheme, e.g. representation at
disciplinary and fitness to practise hearings or Good Samaritan acts outside
the jurisdiction of the Republic of Ireland (Section A, Part 27).
At the time of writing, at least 85% of consultants in the Republic of Ireland
have signed the 2008 (Connaughton) Consultant Contract. However, it is
important to note that many aspects of the contract are the subject of ongoing
negotiations between the HSE and the medical representative organisations.
4

3. Overview of the consultant contract
Definition
A contract is a set of statements governing the agreement between you
and your employer: what work you agree to perform; what facilities your
employer agrees to make available for you to do this work; and what your
employer agrees to reward you with for your work.
Components
The consultant contract is not a single document. It has several components,
all of which should be given to each consultant:
• Terms and conditions
• Appendices
• Correspondence exchanged between the parties as set out at Appendix
VII of the contract
• HSE Letter of Approval
• Job description
This section will outline the main features of the 2008 (Connaughton)
Consultant Contract. Where appropriate, differences between this contract
and the previous, 1997 (Buckley) Consultant Contract will be highlighted.
Throughout this guideline, the 2008 (Connaughton) Consultant Contract will
be referred to as ‘the 2008 contract’ or ‘the contract’.
Most important differences
The most important differences between the 2008 contract and the previous
contract are as follows:
• Reporting relationship
• Clinical directors and clinical directorates
• Consultant teams
• Increased total hours of work per week
• Longer normal working day
• Structured on-site attendance at weekends and on public holidays
• Re-introduction of a ‘public-only’ contract
• Regulation of private practice
5

Terms and conditions
Appointment and tenure
The qualifications required for the consultant post are set out in the HSE
Letter of Approval which is attached at Appendix 1 of the contract. The HSE
has published revised consultant qualifications with effect from 16 March
2009. These qualifications are given in Appendix 1 of this guideline. It
should be noted that the only special interests that are specified are those in
paediatric anaesthesia, intensive care medicine and pain medicine.
Reporting relationship
The contract states that the consultant’s “reporting relationship” and
“accountability for the discharge of his/her contract” is to “the Chief
Executive Officer/General Manager/Master of the hospital (or other
employing institution) through his/her Clinical Director (where such is in
place).” The contract also states that the hospital network manager “may
require the consultant to report to him/her from time to time.”
The previous contract did not specifically refer to a ‘reporting relationship’
or ‘accountability’, but did state that the consultant was responsible for
“producing a realistic agreed schedule,” “agreeing with management the
details of the service levels and mix to be provided” and “supplying to his
employing authority such information…as is necessary and reasonable to
establish that he is fulfilling his contractual commitment.”
6

Hours of work
The most important differences between the 1997 and 2008 contracts are
summarised below.
Total number of
hours per week
Total number
of sessions per
week
Types of
sessions
Definition of
normal working
day
Total duration
of shift
Splitting of shift
Weekend
sessions
1997 (Buckley) Contract 2008 (Connaughton)
Contract
33 37
11 (= 33 notional hours per
week)
“Mix of fixed and flexible
sessions, the ratio of which
will vary depending on
specialty”
“During the hours normally
worked within the Monday to
Friday working week”
No reference to total duration
of shift
No reference to splitting of
shift
No
No reference to
sessions
No reference to fixed
or flexible sessions
Between 8am and
8pm Monday to
Friday
“The Consultant will
not be obliged to
work more than 8
hours in any one day.”
“This will be
structured as a single
continuous episode.”
Yes
(see below)
In addition to the above 37-hour commitment per week:
• The consultant may be required to participate in an on-call roster.
• The consultant rostered on-call may be required to provide a “structured
commitment on-site of up to 5 hours on a Saturday and/or 5 hours
overtime on a Sunday and/or 5 hours on a public holiday.”
The structured on-site attendance at weekends and on public holidays will
be subject to premium payments of time-and-a-half on Saturdays and doubletime
on Sundays and public holidays. Consultants who have onerous on-call
rosters (1:4 or more frequent) “shall not be expected to deliver the upper end
of this requirement as determined by the Clinical Director.”
7

If a consultant remains in the hospital longer than the structured 5-hour
commitment or is required to re-attend the hospital later in the day, he/she
may claim C Factor (Call-Out) Payments for this additional working time.
The contract states that, where there is local agreement to implement
different work patterns (including any arrangements providing for up to
24/7 hour working), the involvement of any individual consultant in any
such arrangement(s) “shall be subject to his/her agreement.” Appendix VII
(‘Correspondence between the parties’) states that any issues regarding
such local agreements will be referred to the Contract Implementation
Group, a committee comprising representatives of the HSE and the medical
organisations.
Consultant teams
The contract states that the consultant will “generally work as part of a
Consultant team.” The purpose of such teams is “to ensure Consultant
provided services to patients on a frequent and continuing basis.”
The previous contract briefly mentioned the concept of a clinical directorate
being led by a member of its ‘consultant team’. The majority of consultant
anaesthetists in the Republic of Ireland already work as part of a consultant
team with regard to rostering arrangements and delivery of the clinical
service.
On-call commitment of consultants who work on multiple hospital
sites
The contract does not contain guidance regarding the on-call commitment
of consultants who work on multiple hospital sites. Nonetheless, it seems
reasonable that the on-call commitment should reflect the sessional
commitment, e.g. if a consultant has 50% of his sessions in hospital A
and 50% of his sessions in hospital B, and has an on-call commitment on
both sites, 50% of his/her on-call commitment should be in each hospital;
further, his/her on-call commitment in each hospital should be 50% that of
consultants with all their sessions in that hospital. Such arrangements should
be locally discussed and agreed by the departments of anaesthesia on these
hospital sites.
8

4. Consultant contract types and regulation of
private practice
Consultant contract types
A consultant holding contract type A (a ‘public-only’ contract) may not
engage in privately remunerated professional medical practice.
Consultant contract types B, B* and C
Consultants holding contract types B, B* and C may engage in privately
remunerated professional medical practice.
Several types of practice, e.g. preparation of reports relating to insurance
claims or for the courts, are not regarded as private practice (see Section A,
part 21).
The most important differences between these contract types are summarised
on the next page.
9

Consultants
eligible
to hold
contract
Type A Type B Type B* Type C
New
consultants,
category 1
consultants,
category 2
consultants
New
consultants,
category 1
consultants,
category 2
consultants
10
Category 2
consultants
Location of private practice
Public No Yes Yes Yes
hospital(s)
Co-located No Yes Yes Yes
private
hospital(s)
Outside No No Yes Yes
public
hospital(s)
Regulation of private practice
Volume
of public
practice
Volume
of private
practice in
locations 1
and 2
Must fully
discharge
standard 37-
hour weekly
commitment
Must fully
discharge
standard 37-
hour weekly
commitment
None Not > 20%
(not > 30%
for existing
consultants if
this is agreed,
see below)
Must fully
discharge
standard 37-
hour weekly
commitment
Not > 20%
(not > 30%
for existing
consultants if
this is agreed,
see below)
New
consultants
Must fully
discharge
standard 37-
hour weekly
commitment
Not > 20%
(not > 30%
for existing
consultants if
this is agreed,
see below)
Change in contract type
Consultants may apply to change contract type to type A, B or C at fiveyearly
intervals. Consultants who previously held a category 1 or category
2 contract may, 2 years after accepting the 2008 contract, and thereafter
at 5 yearly intervals, apply to transfer to contract type B*. Applicants must
demonstrate “that the change in Contract Type is consistent with the public
interest and that there is a demonstrable benefit to the public health system.”
Where a new or replacement post is designated as type C, the applicant
organisation must satisfy a number of criteria, including the following:

• “A clear indication as to why the post requirements cannot be met
through a Type A or B arrangement.”
• “A clear demonstration as to the added patient, service and public
system benefits and values to be achieved through establishment of the
post as a Type C rather than a Type A or B position.”
The total number of consultants holding category 2, type B* and type C
contracts will be subject to an upper limit of such posts within the system.
Appendix VII (‘Correspondence between the parties’) suggests that this upper
limit will be in the order of approximately 700 posts.
Regulation of private practice
Regulation of private practice for consultants who have type B, B* or C
contracts
For consultants who have type B, B* or C contracts, the contract states:
• The volume of private practice in the public hospital(s) and co-located
private hospital(s) may not exceed 20% of the consultant’s clinical
workload in any of his/her clinical activities, including inpatient,
day-patient and outpatient. Appendix VII (‘Correspondence between
the parties’) states that “Serving consultants whose public to private ratio
in 2006 was greater than 20% will be permitted to retain this higher
ratio, subject to an overriding maximum ratio of 70:30.” However, data
regarding the public to private ratio of individual consultant anaesthetists
were not collected in 2006 and, therefore, cannot be used to determine
their permitted public to private ratio under the new contract.
• The volume of practice shall refer to patient throughput adjusted for
complexity through the medium of the case mix system.
• The 80:20 ratio of public to private practice will be implemented
through the clinical directorate structure. The employer has full
authority to take all necessary steps to ensure that for each element of a
consultant’s practice; he/she shall not exceed the agreed ratio.
• The consultant will be advised on a timely basis if his or her practice
is in excess of the 80:20 ratio of public to private practice in any of his
or her clinical activities. An initial period of six months will be allowed
to bring practice back into line but if within a further period of 3 months
the appropriate ratio is not established, he/she will be required to remit
private practice fees in excess of this ratio to the research and study fund
under the control of the clinical director.
• The clinical director may exercise some discretion in dealing with the
implementation of the ratio either for an individual or a group of
11

consultants once the overall ratio in relation to the particular clinical
activity is satisfied.
• The implementation of the 80:20 ratio of public to private practice shall
be the subject of audit, including audit by the Department of Health and
Children.
Measurement of the ratio of public to private practice
Each hospital inpatient is admitted under the care of a single primary
consultant, e.g. a consultant physician, surgeon, paediatrician or obstetrician.
This primary consultant bears overall responsibility for the patient’s
management throughout his or her hospital stay. A patient may require
the services of other, secondary consultants, e.g. consultant radiologists,
consultant pathologists or consultant anaesthetists. However, he or she will
not be under the care of a single consultant radiologist, consultant pathologist
or consultant anaesthetist. For example, a patient who has several surgical
procedures and is admitted to an intensive care unit may be cared for by
many consultant anaesthetists during his or her hospital stay.
The Casemix System/Hospital In-Patient Enquiry (HIPE) Scheme will be
used to provide monthly reports of each consultant anaesthetist’s ratio of
public to private practice on a casemix adjusted basis. Data will be provided
separately for inpatients and day cases. All consultant encounters in a case
will be recorded and reported. However, the measurement of a consultant
anaesthetist’s ratio of public to private practice is predominantly based
on his or her direct provision of anaesthesia in the operating theatre. This
measurement may not adequately capture the many other clinical activities
that are regularly performed by consultant anaesthetists and are given in
Appendix 2 of this guideline.
Therefore, the measurement of a consultant anaesthetist’s ratio of public to
private practice may not accurately reflect either the number of patients for
whom he or she has cared or the ratio of ‘public patients’ to ‘private patients’.
Consultant anaesthetists should consider maintaining their own records of
their public and private clinical activity. These records should include the
number of patients and the duration of patient care. If consultants detect any
inaccuracies in the measurement of their ratio of public to private practice,
these should be brought to the attention of hospital management.
Control by consultant anaesthetists over their ratio of public to private
practice
Most consultant anaesthetists have no control over their ratio of public to
private practice. With the exception of consultants with a special interest
12

in pain medicine, they are not primary consultants and are not involved in
the scheduling of patients for elective surgery. They also have no control
over the number of patients with private health insurance who require
urgent admission to hospital and subsequently require the services of an
anaesthetist, e.g. patients who require urgent surgery, patients who require
obstetric care or patients who require admission to an intensive care unit.
The Irish Standing Committee believes that it is not rational to attempt to
control the ratio of public to private practice for patients who require urgent
hospital admission.
Measurement of the ratio of public to private practice for consultants
who work on multiple hospital sites
At present, a consultant anaesthetist who works on multiple hospital sites has
his/her ratio of public to private practice measured and reported separately
for each hospital site. The Irish Standing Committee believes that, as a
consultant anaesthetist’s post represents a single appointment, his/her ratio of
public to private practice from multiple hospital sites should be aggregated
and reported as a single ratio.
Regulation of private practice for consultants who remain on the 1997
(Buckley) Consultant Contract
According to the previous contract, a consultant holding a category 1
contract was permitted to engage in private practice only on the site of
the public hospital(s) (‘on-site’ only). A consultant holding a category 2
contract was permitted to engage in private practice on the site of the public
hospital(s) and outside the public hospital (‘on-site’ and ‘off-site’).
With regard to ‘on-site’ private practice, the previous contract stated “a
consultant’s overall proportion of private to public patients should reflect
the ratio of public to private stay beds designated under the 1991 Health
(Amendment) Act, which requires that all public hospital beds be classified as
public, private or non-designated.” This act does not stipulate any particular
ratio of public to private beds. However, the Department of Health has
determined that the ratio of public to private beds in public hospitals should
be 80:20 (the so-called ‘80/20 split’).
13

5. Consultant work schedule
Introduction
A ‘consultant work schedule’ or ‘practice plan’ is a detailed description of
the duties and responsibilities of a consultant and of the facilities required to
carry them out.
In the previous contract, the 33-hour working week was divided into 11
sessions. Each session had a duration of 3 hours. A session could be fixed
or flexible. A fixed session involved work that had to be performed at a
particular time and in a particular place, because it required the presence of
other members of staff and/or other resources, e.g. outpatient clinics, theatre
sessions, ward rounds, investigative and treatment sessions. A flexible session
involved work that could be performed more flexibly as regards time and
location, e.g. teaching, minor ward rounds, reporting, research, meetings,
hospital management and medical audit. The contract stated that “A
consultant’s commitment shall comprise a mix of fixed and flexible sessions,
the ratio of which will vary depending on specialty.”
The 2008 contract does not refer to sessions and does not refer to fixed or
flexible commitments. Therefore, it gives less guidance than the previous
contract regarding the type of work that may be performed as part of the
scheduled weekly commitment. Unlike the 2003 consultant contract in
the United Kingdom, it gives no guidance regarding the proportion of total
working hours that should be devoted to clinical activities (Direct Clinical
Care) and non-clinical activities (Supporting Professional Activity). Appendix
III of the contract contains a sample consultant work schedule, but the
range of clinical and non-clinical activities is very limited and some of the
clinical activities are undertaken by only a few consultant anaesthetists, e.g.
OPD. This section will outline the features of the contract that are relevant
to the consultant work schedule and give recommendations regarding the
formulation of work schedules for individual consultant anaesthetists.
Working greater than or less than 37 hours per week
The contract states: “If the time worked consistently and significantly varies
from the scheduled commitment, there will be a review of the commitment
to ensure that the Consultant is not working regularly in excess of or less
than the 37 hour weekly commitment. Where the commitment is being
unavoidably exceeded for reasons of a temporary nature, local arrangements
will be made to compensate the Consultant concerned.”
14

Non-clinical duties
The contract explicitly mentions the following non-clinical duties of
consultants:
• Medical education and training (Section A, part 1; Section A, part 14).
This may, with the agreement of the employer, include a structured
and scheduled commitment to a medical/dental school or a training
body for postgraduate medical education and training (Section A, part
14)
• Research (Section A, part 1; Section A, part 14)
• Maintenance of professional competence (Section A, part 11)
• Clinical audit (Section A, part 12)
• Proactive risk management (Section A, part 12)
• Formal review of “the execution of the Clinical Directorate Service Plan
with the Clinical Director/Employer.” This should occur “periodically, at
the request of the Consultant or Clinical Director/Employer.” (Section A,
part 12)
• Participation in the “development and operation of the Clinical
Directorate structure and in such management or representative
structures as are in place or being developed.” (Section A, part 12)
• Ensuring, “in consultation with the Clinical Director, that appropriate
medical cover is available at all times.” (Section A, part 12). This would
obviously include the appropriate rostering of consultant anaesthetists
and anaesthetic trainees for daytime and on-call clinical duties
• Participation in “selection processes for non-Consultant Hospital Doctors
and other staff as appropriate.” (Section A, part 12)
Maintenance of professional competence and clinical
governance
The Medical Practitioners Act 2007 places a statutory obligation on all
registered medical practitioners to maintain their professional competence
and cooperate with any professional competence scheme developed,
established or operated by the Medical Council. The Act also places
an obligation on the HSE or other employer to facilitate these activities.
Professional competence schemes will be delivered by the postgraduate
training bodies.
The College of Anaesthetists of Ireland is accredited by the Medical
Council to operate a continuing medical education (CME) credit system
for anaesthetists. CME activity is classified into the following categories: (i)
15

internal activities, (ii) external activities, (iii) personal activities, (iv) research
and (v) postgraduate examining, training and supervision (see Appendix
3). At least 50 CME credits must be obtained annually, of which at least 10
credits must be in the internal category and at least 20 credits must be in the
external category. The College of Anaesthetists of Ireland also recommends
that an individual specialist working in a typical hospital and participating
in the emergency on-call rota should have up to date knowledge of and
proficiency in the list of ‘core topics’ in anaesthesia agreed by the Union of
European Medical Specialists (UEMS). Consultants should aim to cover all
topics relevant to their practice once during a three year cycle.
It is likely that a professional competence scheme for anaesthetists will
include activities other than CME, such as peer review, multi-source
feedback and clinical audit. The report of the Commission on Patient
Safety and Quality Assurance recommends that all healthcare professionals
be involved in clinical governance activities, such as the establishment
and implementation of evidence-based standards and guidelines, clinical
audit, adverse event reporting and participation in CME and competency
revalidation programmes. It is essential that all consultant anaesthetists are
given adequate time and resources to maintain their professional competence
and be actively involved in clinical governance activities.
Performance monitoring
The contract contains several references to monitoring of a consultant’s
performance:
• “Both the Consultant and the Employer shall co-operate in giving effect
to such arrangements as are put into place to verify the delivery of the
Consultant’s contractual commitments.” (Section A, part 4)
• “The scope of this post is as set out in the HSE letter of approval for this
position at Appendix 1 and the Job Description as issued
by the Employer. These describe the Consultant’s service commitments,
accountabilities and specific duties…The Consultant’s annual Clinical
Directorate Service Plan will detail how these are to be implemented
and will be validated by a series of performance monitoring
arrangements.” (Section A, part 9)
• Standard duties and responsibilities include: “To participate in and
facilitate production of all data/information required to validate delivery
of duties and functions and inform planning and management of service
delivery.” (Section A, part 12)
16

As noted on page 16, the previous contract contained several similar
references.
Resources
The contract states that it is the responsibility of the employer to provide
adequate resources: “The determination of the range, volume and type of
services to be provided and responsibility for the provision of same within
available resources rests with the Employer. Services not provided as a
consequence of a resource limit are the responsibility of the Employer and
not the Consultant.” (Section A, part 4)
The resources that may be required for consultant anaesthetists to perform
their duties have been previously outlined by the AAGBI and are given in
Appendix 4 of this guideline.
Advocacy
The core principles of the contract include “recognition of the Consultant’s
role as an advocate.” However, the consultant also has a “responsibility, in
the first instance, to express any concerns within the employment context.”
(Section A, part 1)
Later, the contract states that “In the first instance…advocacy should take
place within the employment context through the relevant Clinical Director
or other line manager.” The contract also states that “Information given to
the public should be expressed in clear and factual terms. It must never
cause unnecessary public concern or personal distress, nor should it raise
unrealistic expectations.” (Section A, part 16)
17

Recommendations
• The consultant contract is an agreement between an individual
consultant anaesthetist and his or her employer.
• Each consultant anaesthetist who has signed the 2008 contract must
agree a consultant work schedule and a ratio of public to private
practice with his or her employer.
• The clinical activities of consultant anaesthetists are given in Appendix 2
of this guideline.
• The non-clinical activities of consultant anaesthetists are given in
Appendix 3 of this guideline.
• All consultant anaesthetists who have signed the 2008 contract should
fully honour their 37-hour scheduled weekly commitment.
• The increase in weekly working hours under the 2008 contract should
include an increase in both clinical and non-clinical activities.
• As previously recommended by the AAGBI, approximately 25% of total
weekly working hours should be devoted to non-clinical activities.
• Failure to devote adequate time to non-clinical activities may adversely
affect the maintenance of professional competence and the quality of
patient care.
• Consultant anaesthetists within a department of anaesthesia may have
different clinical and non-clinical activities.
• Consultant anaesthetists with additional non-clinical responsibilities,
e.g. chairperson or secretary of department, clinical director, should
have a reduction in working hours devoted to clinical activities.
• The consultant work schedule should be supported by a robust diary
exercise.
• A work diary does not have to be kept permanently. However, it is
important that it is representative of the usual hours worked.
• If workload changes, a change in the consultant work schedule may be
required.
18

6. Clinical directors and clinical directorates
Details of the appointment and profile of a clinical director are contained in
Appendix IV of the contract.
Appointment of clinical directors
The post of clinical director is appointed by the employer. Applications are
invited from all eligible consultants within the clinical directorate and all
applicants are interviewed. Alternatively, the body of consultants within the
directorate may nominate a candidate. Appointment is initially for two years.
Clinical director profile
A clinical director may cover one speciality area or a range of specialities.
Each directorate is headed by a clinical director, generally supported by
a nurse manager and a business manager. Each member of staff in the
directorate has a reporting relationship, through his/her line manager, to the
clinical director. Each consultant who has signed the 2008 contract reports to
the clinical director. Clinical directors in a HSE hospital report to the hospital
manager or the hospital network manager. Clinical directors in a voluntary
hospital or agency report to the chief executive of the hospital or agency.
Clinical directorates
The contract does not give any guidance on the size of clinical directorates.
Since the contract was agreed, the HSE has maintained that “Clinical
Directorates must be large enough to justify support by business managers…
In practice, this means that Clinical Directorates shall be based on a
minimum of 30-60 whole time consultant posts.” The clinical directors who
have been appointed appear to have areas of responsibility similar to those of
medical directors in the United Kingdom.
The role and responsibilities of clinical directors and the size and functioning
of clinical directorates will undoubtedly undergo considerable evolution in
the next few years.
A consultant anaesthetist applying for the post of clinical director should:
• Review and understand the principal duties and responsibilities of a
clinical director.
19

• Consider his/her need for additional training and/or support, either
before or after taking up the post of clinical director.
• Discuss the application with his/her lead clinician.
• Discuss the availability of supporting resources with the relevant hospital
or network manager(s). These resources may include accommodation,
staffing, administrative time and additional training and/or support.
• Discuss the functioning of the post and the important current issues with
the existing clinical director (if present).
The discussions with the lead clinician, local manager(s) and the existing
post-holder should include consideration of the necessity to reduce clinical
commitments and the effect of this reduction on clinical skills, the clinical
service and the requirement for locum cover. This is particularly important in
a small department or subspecialty group.
Relationship between clinical directors and departments of
anaesthesia
The relationship between clinical directors and individual clinical specialties
is not specifically discussed in the contract. However, the Irish Standing
Committee believes that departments of anaesthesia should ensure the
following:
• Each department of anaesthesia has a nominated lead clinician.
• Each department of anaesthesia considers the nomination of consultants
with responsibility for anaesthetic subspecialties.
• Arrangements for communication with the clinical director are locally
discussed and agreed.
• The clinical service is compliant with the standards set by the relevant
professional bodies.
Relationship between clinical directors and consultants
who remain on the 1997 (Buckley) Consultant Contract
Consultants who remain on the 1997 (Buckley) Consultant Contract do not
have a “reporting relationship” and “accountability for the discharge of his/
her contract” to a clinical director. However, as discussed above, they are
responsible for “producing a realistic agreed schedule,” “agreeing with
management the details of the service levels and mix to be provided” and
“supplying to his employing authority such information…as is necessary and
reasonable to establish that he is fulfilling his contractual commitment.”
20

The 1997 (Buckley) Consultant Contract contains the following statements
regarding involvement of consultants in management and the role of clinical
directors and clinical directorates:
“Consultants need to be involved in the management process. This
involvement commences with the consultant’s responsibility to manage
his/her own practice and will involve co-operation with colleagues and
other health professionals, at department, unit, hospital or hospital group
level, extending to involvement in the management of the hospital/hospital
grouping through direct membership or representation on the hospital
Executive Management Board.” (Consultant contract Section 7.1 and
memorandum of agreement Section 6.6.1)
“The recent experience of the pilot projects in a number of hospitals confirms
that the concept of a distinct unit, grouping the clinical functions together
under the leadership of a selected consultant (e.g. a Clinical Directorate
model), represents an effective model to facilitate participation of Hospital
Consultants in the management process.” (Consultant contract Section 7.2
and memorandum of agreement Section 6.6.2)
21

7. Academic consultants
All terms of the contract also apply to the holders of academic consultant
posts that have been approved by the HSE/Higher Education Authority. These
posts are joint appointments between universities or the Royal College of
Surgeons in Ireland and the HSE. In general, the posts are structured to ensure
a minimum 50% commitment to the academic institution, but this ratio may
vary with the agreement of the employers and the academic consultant.
22

8. Locum and temporary consultants
Definitions
A locum consultant post is defined as a consultant post that is occupied in a
non-permanent capacity by someone other than the legal post holder. The
locum acts in place of this post holder during, for example, annual or sick
leave.
A temporary consultant post is defined as a consultant post for the interval
between a permanent post becoming vacant and it being filled on a
permanent basis, or for the interval between a permanent post having been
approved by the HSE and it being filled on a permanent basis.
Requirement for locum cover
The Irish Standing Committee recognises that consultant locum cover is
necessary in many circumstances, e.g. to cover annual leave, study leave,
sick leave or maternity leave. The requirement for locum cover may increase
in the future because of the decreased working hours of anaesthetic trainees
as a result of the EWTD. The Irish Standing Committee believes that the
use of locum and temporary consultant anaesthetists should be minimised
and, where possible, these posts should be filled by permanent consultant
anaesthetists.
Recruitment and selection of locum and temporary
consultants
The HSE has published a revised procedure for recruitment and selection
of locum and temporary consultants, with effect from 07 May 2009. This
document states that the same qualifications apply to all permanent,
temporary and locum consultant appointments.An accompanying circular
(HSE HR Circular 014/2009) draws particular attention to the provision that
“an individual applicant who is not qualified for appointment as a Medical
Consultant on a permanent basis may not be appointed to a temporary or
locum position. New appointments to temporary or locum consultant posts
require that the appointee be registered on the Specialist division of the
register of Medical Practitioners maintained by the Medical Council.” This
advice differs from that of the Medical Council which has suggested that
entry in the specialist register may not be required for short-term locum
appointments. The Medical Council newsletter in June 2009 contains the
23

following statements: (i) “Trainee specialist registration only permits the
practice of medicine within the clinical site/health service setting stated on
a doctor’s Certificate of Registration or in the clinics/health service settings
associated with the training post. Trainees should therefore not fill locum
consultant appointments of more than three months’ duration. A trainee
specialist, in the final year of their training, can act up at consultant grade
in that specialty for a period of up to three months.” (ii) “The Council has
expressed particular concern about any medical practitioner, who is not in
the Specialist Division, taking up a locum Consultant appointment of more
than three months’ duration. Entry in the Specialist Division is the most
reliable indication of a doctor’s suitability to practise at a consultant grade.”
Many existing locum and temporary consultant anaesthetists do not have
their names entered in the Register of Medical Specialists in the division
of anaesthesia. The Irish Standing Committee believes that all permanent,
temporary and locum consultant anaesthetists should have the appropriate
knowledge, skills and attitudes to enable them to safely fulfil their role. In
addition, all temporary and locum consultants should have the appropriate
qualifications for appointment on a permanent basis. However, these new
rules will make it more difficult to appoint appropriate candidates to locum
or temporary posts. This may affect the delivery of anaesthesia services,
especially in smaller hospitals which are more dependent on locum and
temporary consultant staff.
Protection of Employees (Fixed-Term Work) Act 2003
This Act implements Directive No.1999/70/EC of 28 June 1999 of the
Council of the European Communities. The purpose of the Act is to improve
the quality of fixed-term work by applying the principle of non-discrimination
and provides a framework to prevent abuse through successive fixed-term
contracts.
While the Act specifically excludes persons such as defence force personnel,
trainee Gardaí and trainee nurses, there is no specific part of the Act relating
to either fully qualified medical staff or doctors-in-training.
“A fixed term employee is a person with a contract of employment entered
into directly with an employer where the end of the contract of employment
concerned is determined by an objective condition such as arriving at a
specific date, completing a specific task or the occurrence of a specific
event.”
24

A contract that contravenes Section 9(1) or 9(2) of the Act is deemed to be
a contract of indefinite duration (Section 9(3)). The terms and conditions of
this contract, except tenure, should be the same as the fixed-term contract
at the time of the breach of the Act. Broadly speaking Sections 9(1) and 9(2)
distinguish between those employed before and after 14 July 2003. The
employer is in breach of Section 9(2) if the aggregate duration of contracts
exceeds four years.
The legal situation is less clear for medical employees. In two recent
cases brought to the Labour Court by NCHDs in Psychiatry (FTC/07/6
DETERMINATION NO. FTD081 and PTW/05/13 DETERMINATION NO.
FTD064), the Court found in favour of the complainants and awarded them
contracts of indefinite duration. However, a case taken by a temporary
consultant orthopaedic surgeon was rejected (FTC 05/4 DETERMINATION
NO. FTD081).
The Irish Standing Committee recommends that independent legal advice on
employment law be sought should members have queries regarding this area.
25

9. The European Working Time Directive
The EWTD is health and safety legislation that is designed to protect you
from being exploited by your employer. From August 2004, the Directive
has applied to all hospital doctors (European Working Time Directive - IMO
AGM 2005 Briefing). The EWTD was originally issued in 1993 (Directive
93/104/EC) and excluded the activities of doctors in training from its
application in relation to key provisions regarding working hours. It was
amended in 2000 (Directive 2000/34/EC) to reverse this exclusion and
provide for a phased reduction of working hours (average 58 hours per week
by August 2004, average 56 hours per week by August 2007 and average 48
hours per week by August 2009). A consolidating Directive was published
in 2003 (Directive 2003/88/EC) which replaced the previous version of the
EWTD and took effect on 02 August 2004. The EWTD has been transposed
into Irish law by means of the Organisation of Working Time Act, 1997, and
the European Communities (Organisation of Working Time) (Activities of
Doctors in Training) Regulations 2004 (S.I. No. 494 of 2004).
Although the EWTD applies to consultants as well as doctors-in-training,
the original Directive (Directive 93/104/EC) stated that member states
may derogate from its requirements when, “on account of the specific
characteristics of the activity concerned, the duration of the working
time is not measured and/or predetermined or can be determined by the
workers themselves…particularly in the case of…managing executives or
other persons with autonomous decision-taking powers.” The Organisation
of Working Time Act, 1997, states that the requirements of the Directive
shall not apply to “a person the duration of whose working time (saving
any minimum period of such time that is stipulated by the employer) is
determined by himself or herself, whether or not provision for the making
of such determination by that person is made by his or her contract of
employment.” It can be argued that this derogation would apply to the
working arrangements of hospital consultants.
The requirements of the EWTD are as follows:
26

Maximum weekly working
time:
Minimum reference period:
Maximum reference period:
Reference period may
include:
Reference period may not
include:
48 hours, averaged over a reference
period
None
6 months
Study leave
Course leave
Exam leave
Interview leave
Annual leave
Sick leave
Maternity leave
Adoptive leave
Daily breaks: At least 15 minutes every 4 hours 30
minutes
or
At least 30 minutes every 6 hours
Daily rest:
At least 11 hours every 24 hours
Weekly/fortnightly rest: At least 35 hours rest (11 hour rest period
followed by 24 hours rest) once a week or
twice a fortnight
or
At least 59 hours rest (11 hour rest period
followed by 48 hours rest) once a fortnight
Compensatory rest must be given to a doctor who has not been granted his
or her daily break, daily rest or weekly/fortnightly rest; it must be equivalent
to the break or rest which the doctor has not had; and it must be taken before
the doctor begins his or her next period of work.
The 2008 contract states that the consultant should “ensure in consultation
with the Clinical Director that appropriate medical cover is available at all
times having due regard to the implementation of the European Working
Time Directive as it relates to doctors in training.” (Section A, Part 12)
However, the joint Royal College of Anaesthetists and Royal College
of Surgeons of England document, ‘WTD - Implications and Practical
Suggestions to Achieve Compliance’ (2009) states: “A 1:8 rota is the
minimum to be able to include prospective cover and adequate training.
A 1:10 rota allows for more flexibility and training opportunities but it is
acknowledged that many of the smaller specialties will be unable to achieve
this.” The Royal College of Physicians document, ‘Designing safer rotas
27

for junior doctors in the 48-hour week’ (2006) states: “A ‘cell’ of 10 junior
doctors is necessary for any post that provides 24-hour cover, plus specialty
work and training during weekdays.” The final report of the Irish National
Implementation Group (2008) states: “As NCHD (Non-Consultant Hospital
Doctor) rosters are currently structured, any roster of 10 doctors or less is
unlikely to comply with the EWTD either from the viewpoint of hours worked
or availing of rest periods. In particular it will not be possible to achieve
compliance in smaller acute units many of whom currently have duty roster
cells consisting of 3-6 doctors.”
Therefore, the EWTD can only be implemented when each on-call rota
contains at least eight to ten anaesthetic trainees. Many smaller hospitals
do not have an adequate number of trainees to achieve this. Attempts
to implement the directive with a smaller number of trainees may cause
unacceptable decreases in the level and safety of anaesthetic service delivery
and the quality of anaesthetic training.
It has been suggested that the two key measures to support EWTD
implementation are cross-cover and reductions in layered/tiered on-call.
These measures are usually not appropriate for anaesthesia and intensive care
services, for the following reasons: (i) trainees in other disciplines do not have
the knowledge or skills to provide anaesthesia services; and (ii) reductions
in the number of anaesthetic trainees on-call are often impractical because
of the necessity to cover multiple clinical areas and the short response time
required for many anaesthetic interventions.
Any decrease in the working hours and/or experience of anaesthetic trainees
has the potential to increase the workload of consultant staff. If this occurs,
changes in consultant work schedules or the appointment of additional
consultant anaesthetists may be required.
All changes in working patterns as a result of the EWTD should be carefully
evaluated for their effects on the safety of patients and staff.
28

References
Irish Standing Committee of the Association of Anaesthetists of Great
Britain and Ireland
• Irish Standing Committee of The Association of Anaesthetists of Great
Britain and Ireland. Workload for Consultant Anaesthetists in Ireland.
London: AAGBI, 1992.
• Irish Standing Committee of the Association of Anaesthetists of Great
Britain and Ireland. Workload for Consultant Anaesthetists in Ireland.
Supplement 1993. London: AAGBI, 1993.
The Association of Anaesthetists of Great Britain and Ireland
• The Association of Anaesthetists of Great Britain and Ireland. Guidance
on The 2003 (New) Contract and Job Planning for Consultant
Anaesthetists. London: AAGBI, 2005.
Health Service Executive
• Health Service Executive. Revised Consultant Qualifications. 16
March 2009. http://hsenet.hse.ie/HSE_Central/Human_Resources/
SServices/Recruitment/Consultants/Revised_Consultants_Qualifications.
pdf (accessed 28/02/2010).
• Health Service Executive. Procedures for the Regulation of Consultant
Appointments. 31 March 2008. http://hsenet.hse.ie/HSE_Central/
Human_Resources/SServices/Recruitment/Consultants/Procedures_
for_the_Regulation_of_Consultant_Appointments.pdf (accessed
28/02/2010).
• Health Service Executive. HR Circular 014/2009. 07 May 2009.
Revised Procedural Arrangements for Appointment of
Medical Consultants. http://hsenet.hse.ie/Intranet/Working_in_the_
HSE/HR_Documents/HR_Circulars/?importUrl=http://localhost:82/eng/
staff/HR/HR_Circulars/HSE_HR_Circular_014_2009_re_Revised_
Procedural_Arrangements_for_Appointment_of_Medical_Consultants.
pdf (accessed 28/02/2010).
• Health Service Executive. Procedures for the Recruitment and Selection
of Locum and Temporary Consultants. 07 May 2009. http://hsenet.
hse.ie/HSE_Central/Human_Resources/SServices/Recruitment/
Consultants/Procedure_for_Recruitment_and_Selection_of_Locum_and_
Temporary_Consultants.pdf (accessed 28/02/2010).
29

Medical Council
• Medical Council. Guide to Professional Conduct and Ethics for
Registered Medical Practitioners. 2009. http://www.medicalcouncil.
ie/Professional-Standards/Professional-Conduct-Ethics/The-Guide-to-
Professional-Conduct-and-Ethics-for-Registered-Medical-Practitioners-
7th-Edition-2009-.pdf (accessed 28/02/2010).
Measurement of the ratio of public to private practice
• Health Service Executive. Consultant Contract 2008 – Measurement
of Public:Private Mix. http://www.hse.ie/eng/staff/HR/tandc/Consultant_
Contract_2008_-_Measurement_of_Public_Private_Mix.pdf (accessed
28/02/2010).
• Health Service Executive. Public and private patients in public hospitals.
Guidance to health service management on the treatment of public
and private patients. 16 September 2009. http://www.hse.ie/eng/staff/
HR/tandc/Public_and_private_patients_in_Public_hospitals_-_Guidance_
to_health_service_management_on_the_treatment_of_public_and_
private_patients_16th_September_2009_.pdf (accessed 28/02/2010)
Maintenance of professional competence and clinical governance
• Medical Council. Performance in Practice. Maintenance of Professional
Standards. 2006.
• Royal College of Anaesthetists and The Association of Anaesthetists
of Great Britain and Ireland. Good practice. A guide for departments
of anaesthesia, critical care and pain management. 2006. http://www.
rcoa.ac.uk/docs/goodpractice(oct2006).pdf (accessed 28/02/2010).
• Part 11. Maintenance of Professional Competence. In: Medical
Practitioners Act 2007. http://www.dohc.ie/publications/pdf/medical_
practitioners_act_2007.pdf (accessed 28/02/2010).
• Dept. of Health and Children. Building a Culture of Patient Safety.
Report of the Commission on Patient Safety and Quality Assurance.
July 2008. http://www.dohc.ie/publications/pdf/en_patientsafety.pdf
(accessed 28/02/2010).
Clinical directors and clinical directorates
• Health Service Executive. Appointment of Clinical Directors throughout
the Health Service. August 2008.
• Irish Hospital Consultants Association. Position Paper on Clinical
30

Governance. August 2008.
Locum and temporary consultants
• Medical Council. Locum Cover. In: Medical Council Newsletter. June
2009. http://medicalcouncil.newsweaver.co.uk/
MedicalCouncil/1l5v9mc7ii4 (accessed 28/02/2010).
• Moffatt J. Employment Law (Law Society of Ireland Manual). Oxford:
Oxford University Press, 2006.
• The Labour Court. Synopsis of Fixed-Term Work Determinations made
by the Labour Court in 2005, 2006, 2007 and 2008. http://www.
labourcourt.ie/Labour/Information.nsf/8e26b9bae107240c80256a4900
5962ca/8b2a95b62cc57321802571b6004afafb?OpenDocument
(accessed 28/02/2010).
European Working Time Directive
• The Organisation of Working Time Act, 1997. http://www.oireachtas.ie/
documents/bills28/acts/1997/a2097.pdf (accessed 28/02/2010).
• The European Communities (Organisation of Working Time) (Activities
of Doctors in Training) Regulations 2004 (S.I. No. 494 of 2004). http://
www.dohc.ie/legislation/statutory_instruments/pdf/si20040494.
pdf?direct=1 (accessed 28/02/2010)
• Dept. of Health and Children. Guidance on the implementation of the
European Working Time Directive. July 2004. http://www.dohc.ie/issues/
european_working_time_directive/guidance.pdf (accessed 28/02/2010).
• Irish Medical Organisation. European Working Time Directive - IMO
AGM 2005 Briefing. http://www.imo.ie/IMOPage_2_574.aspx (accessed
28/02/2010).
• Royal College of Physicians. Designing safer rotas for junior
doctors in the 48-hour week. 2006. http://bookshop.rcplondon.
ac.uk/contents/779336a5-b884-4b5f-8c23-efd75d123868.pdf (accessed
28/02/2010).
• National Implementation Group (NIG). European Working Time
Directive & Non Consultant Hospital Doctors – Final Report. December
2008. http://www.dohc.ie/publications/pdf/NIG_Report_Dec08.pdf
(accessed 28/02/2010).
• Health Service Executive. European Working Time Directive
Implementation. Guidance to health service management on the
implementation of the EWTD and related Labour Court
Recommendation. 26 June 2009.
• Health Service Executive. European Working Time Directive
31

Implementation. Guidance to health service management on the EWTD
and use of compensatory rest. 09 September 2009.
• College of Anaesthetists of Ireland. The European Working Time
Directive and Specialist Training in Anaesthesia, Intensive Care and Pain
Medicine. 26 June 2009.
• Royal College of Anaesthetists and Royal College of Surgeons of
England. WTD - Implications and Practical Suggestions to Achieve
Compliance. 2009. http://www.rcoa.ac.uk/docs/rcs-rcoa_report.pdf
(accessed 28/02/2010).
32

Appendix 1. Qualifications for the post of
consultant anaesthetist
The HSE has specified that the following qualifications are required for
appointment to the post of consultant anaesthetist:
Consultant anaesthetist
Registration as a specialist in the Specialist Division of the Register of
Medical Practitioners maintained by the Medical Council in lreland in the
specialty of anaesthesia.
Consultant paediatric anaesthetist
Registration as a specialist in the Specialist Division of the Register of
Medical Practitioners maintained by the Medical Council in lreland in the
specialty of anaesthesia
and
Two years’ postgraduate training and experience in paediatric anaesthesia.
Consultant anaesthetist with a special interest in paediatric
anaesthesia
Registration as a specialist in the Specialist Division of the Register of
Medical Practitioners maintained by the Medical Council in lreland in the
specialty of anaesthesia
and
One year’s postgraduate training and experience in paediatric anaesthesia.
Consultant anaesthetist with a special interest in pain
medicine
Registration as a specialist in the Specialist Division of the Register of
Medical Practitioners maintained by the Medical Council in lreland in the
specialty of anaesthesia
and
One year’s postgraduate training and experience in pain medicine.
33

Consultant anaesthetist with a special interest in intensive
care medicine
Registration as a specialist in the Specialist Division of the Register of
Medical Practitioners maintained by the Medical Council in lreland in the
specialty of anaesthesia
and
One year postgraduate training and experience in intensive care medicine
and possession of the Diploma in Intensive Care Medicine or its equivalent.
The qualifications required for a post are set out in the Health Service
Executive’s Letter of Approval which is attached at appendix 1 of the
contract.
34

Appendix 2. Clinical activities of consultant
anaesthetists
The clinical activities of consultant anaesthetists may include but are not
limited to the following:
• Provision of anaesthesia in the operating theatre
• Provision of anaesthesia in locations other than the operating theatre,
e.g. intensive care unit, coronary care unit, emergency department,
radiology department
• Pre-operative assessment in hospital wards, day surgery units and preoperative
assessment clinics
• Post-operative care
• Acute pain management, including acute pain management ward
rounds
• Chronic pain management, including chronic pain management ward
rounds and outpatient clinics and chronic pain interventional
procedures
• Obstetric anaesthesia, e.g. epidural analgesia for labour
• Intensive care medicine, including the assessment and management of
patients who may need intensive care in locations other than the
intensive care unit, e.g. hospital wards, coronary care unit, emergency
department, radiology department
• Resuscitation
• Venous access
• Transfer of patients within the hospital and between hospitals.
• Supervison of the clinical work of anaesthetic trainees
• Handover, e.g. in the obstetric unit or in the intensive care unit
• Administration related to patient care, e.g. documentation,
correspondence
35

Appendix 3. Non-clinical Activities of Consultant
Anaesthetists
The non-clinical activities of consultant anaesthetists may include but are not
limited to the following:
Administration
• Chairperson of committee or department
• Secretary of committee or department
• Lead clinician in anaesthetic sub-speciality
• Clinical Director
• College Tutor
• Medical Student Tutor
• Membership of committee
• Attendance at multidisciplinary meetings
• Attendance at morbidity and mortality meetings
• Organisation of theatre rota
• Organisation of on-call rota
• Organisation of meetings
• Organisation of courses
• Clinical governance activity
• Organisation of orientation sessions
• Writing of clinical protocols and guidelines
• Audit
• Research
• Managing equipment and drugs in the local theatre environment, e.g.
maintenance, supply, reporting, compliance with standards
• Clinical management, e.g. examination of consultant anaesthetist
workload and requirements, preparation of application forms and job
specifications for new consultant anaesthetist posts
• Recruitment of hospital staff, including anaesthetic trainees, e.g.
advertising, short listing, interviewing and selection
• External duties, e.g. Chairperson, Secretary or membership of national
committee, Director of training programme, examining in Primary
and Final FCARCSI exams, acting as an external member of an advisory
appointments committee
• Job planning
• Appraisal
36

Teaching
• Medical students
• Trainees in Anaesthesia
• Other trainees
• Nursing staff
• Regional or national meetings
• Courses, e.g. ACLS, ATLS, APLS/PALS, exam preparation courses,
workshops
Continuing professional development (College of
Anaesthetists of Ireland classification)
Internal activities
• Audit meetings, hospital lectures, journal clubs, critical incident
meetings, grand rounds, appraisal training, morbidity & mortality
meetings
• Hospital lectures
• Attending another consultant’s session within the base hospital
• Internet lectures - non-interactive, watched with colleagues
External activities
• Attendance at CARCSI meetings
• Attendance at accredited international meetings
• Attendance at accredited national meetings
• Attending another consultant’s session outside the base hospital
• Training courses, e.g. ATLS, APLS, ACLS
• Video conference teaching with live interaction
Personal activities
• Independent study
• Distance learning
• Computer assisted learning
• Watching educational video without colleague interaction
• MCQs in medical journal
37

Research
• Research meetings
• Presentation of research findings
• Publication in recognised medical journal
• Publication of chapter or book
Postgraduate examining, training and supervision
• College or university examinations
• Trainer in ATLS, ACLS, APLS, etc.
• Preparation of a lecture
• Conducting tutorial
38

Appendix 4. Supporting resources
The resources which may be required for consultant anaesthetists to perform
their duties have been previously outlined by the AAGBI and may include
but are not limited to the following:
Staffing support
• Adequate staffing levels within department, to allow absence on
Continuing Professional Development activities and other leave
• Resident trainee staff to cover on-call work
• Trained anaesthetic assistance, with adequate orientation for new or
temporary staff
• Specialist nursing support, e.g. in pain management, pre-assessment
• Secretarial support
• Technical and information technology support
• Managerial support
• Audit support staff
•
Accommodation
• Office accommodation. The office should be located in a site which is
accessible during the normal working day
• Office space for supporting staff, e.g. allied health professionals in pain
service
• Secretarial office(s)
• Common room
• Teaching space
• Clinic space as required for pre-assessment, pain clinics or other
outpatient work
• Availability of intensive care unit/high dependency unit
• Appropriate space within all theatre areas for changing, rest and
refreshment
• 24 hour staffed recovery room
Equipment
• Up to date anaesthetic machines, monitors and other equipment, which
comply with published standards and which are regularly serviced
• A dedicated computer for each consultant with access to an appropriate
range of programmes and email/internet connection. Software should be
up to date
39

• Access to confidential telephone and fax facilities
• Access to equipment allowing suitable delivery of teaching, e.g.
projectors, flip charts
• Adequate secure storage space, both for paperwork and personal
belongings
• Secure locker space in theatre
• A constant supply of all sizes of theatre clothing and footwear
Other
• Funding for study leave
• Timely access to a full range of supporting services, such as laboratory
services, radiology
• Time allowed for administrative meetings within working hours.
• Access to up to date library services
• Car or bicycle parking, particularly out of hours, should provide for
personal safety as well as protecting the vehicle
40

41

42

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

AAGBI SAFETY GUIDELINE
UPDATE
Safety in Magnetic Resonance Units:
An update
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org July 2010

This update was originally published in Anaesthesia. If you
wish to refer to this update, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Safety
in magnetic resonance units: an update. Anaesthesia 2010; 65:
766-70.
This update should be read in conjunction with the Association’s
guideline, Provision of Anaesthetic Services in Magnetic
Resonance Units.

GUIDELINES
Safety in magnetic resonance units:
an update
Association of Anaesthetists of Great Britain and Ireland
Membership of the Working Party: PA Farling; Chairman; PA
Flynn; G Darwent; J De Wilde; D Grainger; S King; ME McBrien;
DK Menon; JP Ridgway; M Sury; J Thornton; SR Wilson.
This is a consensus document produced by expert members of a Working Party
established by the Association of Anaesthetists of Great Britain and Ireland
(AAGBI). It updates and replaces previous guidance published in 2002, and has
been seen and approved by the Council of the AAGBI.
Summary
The number of anaesthetists who are involved in magnetic resonance
(MR) units is increasing. Magnetic resonance systems are becoming more
powerful and interventional procedures are now possible. This paper
updates information relating to safety terminology, occupational exposure,
reactions to gadolinium-based contrast agents and the risk of nephrogenic
systemic fibrosis. Magnetic resonance examinations of patients with
pacemakers are still generally contra-indicated but have been carried out
in specialist centres under strictly controlled conditions. As availability of
MR increases, so the education of anaesthetists, who are occasionally
required to provide a service, must be considered.
Anaesthesia in MR units was first described in the 1980s. Guidelines on
the provision of anaesthetic services in MR units were published by the
Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2002
Re-use of this article is permitted in accordance with the Creative Commons Deed,
Attribution 2.5, which does not permit commercial exploitation.
Ó 2010 The Authors
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Safety in magnetic resonance units
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[1]. Since then, the number of hospitals with MR units, and hence the
number of patients requiring anaesthesia for MR, has increased. While the
issues relating to setting up anaesthetic services in MR have not changed,
there have been a number of developments that warrant this update:
1 Safety terminology and guidelines have changed.
2 MR systems utilise higher magnetic-field strengths and more open
designs are available.
3 Interventional and intra-operative MR are now routine in some
centres.
4 Mobile MR scanners are increasingly used to reduce waiting lists.
5 Although still generally contra-indicated, some patients with pacemakers
have been scanned under strictly controlled conditions in specialist
centres.
6 ‘MR safe’ medical implants are now being produced.
7 New equipment is now available for use in MR.
8 Out-of-hours availability of MR investigations has increased.
9 Reports of allergic reactions to MR contrast media have increased.
10 Gadolinium based contrast agents (Gd-CAs) are associated with a
varying degree of risk of nephrogenic systemic fibrosis in patients with
impaired renal function.
Safety guidelines and legislation
In 2007 the Medicines and Healthcare products Regulatory Agency
(MHRA) updated safety guidance as a Device Bulletin [2]. Three terms are
now to be used as standard in an attempt to remove any ambiguity caused by
the old MR compatible system. These terms are MR conditional, MR safe and
MR unsafe. MR conditional refers to an item that has been demonstrated to
pose no known hazards in a specified MR environment with specified
conditions of use. Many items in the MR environment will now be marked
as MR conditional, and the conditions under which they can be safely used
must accompany the device. This change of terminology has come about
because of reports of injuries and problems with MR compatible equipment
[3]. Conditions that define the specified MR environment include main
magnetic field strength, spatial magnetic field gradient, dB ⁄ dt (time rate of
change of the magnetic field), radio frequency (RF) field strength, and
specific absorption rate. Additional conditions, including specific configurations
of the item of equipment, may be required.
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Safety in magnetic resonance units
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Equipment is designated as MR safe if it presents no safety hazard to
patients or personnel when it is taken into the MR examination room,
provided that instructions concerning its use are correctly followed. This
does not, however, guarantee that it will function normally and not
interfere with the correct operation of the MR imaging equipment, with
degradation of image quality.
New equipment, such as infusion pumps [4], warming mattresses and
temperature probes are now available. It is important to understand the
manufacturers’ instructions of all equipment that is brought into the vicinity
of the MR scanner.
It should be recognised that the supervising MR radiographer is
responsible operationally for MR safety within the controlled area and
that anaesthetic staff should defer to him/her in relation to MR safety
matters, in particular control of access of staff and equipment into the
controlled area. Where staff are given access codes or swipe-card access
to the controlled area, they should not be shared with others, nor
should they provide access to others unless specifically authorised to
do so.
Inspired oxygen concentration
The use of 100% O 2 during anaesthesia should be reported to the reporting
radiologist as this can produce an artefact in the form of an abnormally high
signal in cerebrospinal fluid (CSF) spaces in the T2 weighted fluid
attenuated inversion recovery (FLAIR) sequence.
Acoustic noise
The time-varying magnetic field gradients produce audible noise within the
magnet interior. Since the guidelines were published by the AAGBI, the
Control of Noise at Work Regulations have been updated [5]. This
document introduced lower exposure limit values and action values in the
working environment. When the noise level exceeds 80 dB (A), it is
recommended that staff and others remaining in the scanning room should
wear ear protection.
Other documents have been published by the Health Protection Agency
relating to patient exposure guidance [6] and static field guidance [7]. The
website of the British Association of MR Radiographers (BAMRR)
remains an excellent resource for safety issues and provides links to many
useful safety sites [8].
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Safety in magnetic resonance units
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New MR systems
At the end of 2006, it was estimated that there were approximately 500
fixed MR scanners involved in human imaging, installed at some 350 sites
across the UK [6]. The SI unit of magnetic field strength or magnetic flux
density is the Tesla (T) and initially, most clinical MR systems were 0.5, 1.0
or 1.5 T. In 1992 there were two MR units in Northern Ireland. Today
there are 16, of which, one is a 3-T system. Other regions will have
experienced a similar expansion but, since the withdrawal of funding from
MagNET, up-to-date information for the UK is difficult to obtain.
Magnets operating at 3 T appeared in the early 1990s and by 2007 it was
estimated that 35 units had installed 3-T systems [5]. The benefits of the
higher field strength systems include improved image quality and higher
spatial resolution. While it is claimed that 3-T scans are quicker, more
efficient and require less Gd-CAs, practically these statements are
debatable. It is the responsibility of the equipment manufacturers to
indicate the field strength at which their equipment is MR safe or MR
conditional. It should not be automatically assumed that equipment that is
MR conditional at 1.5 T remains MR conditional at 3 T. A smaller
number of ultra-high field MR systems are in use in research institutions
world wide and these produce static fields in the range 4.7–9.4 T [6].
Anaesthetists may wish to be aware of the potential implications of
replacing a 1.5-T system by a 3-T system. In a magnetic field strength
survey of a 1.5-T system all spot measurements taken at 1 m above the
floor level were found to be below the 0.5-mT safety limit. A similar
survey for a 3-T system indicated that there were areas outside the magnet
room where levels exceeded the safety limit. Barriers and warning notices,
which indicate the risk of pacemaker malfunction, should be in place to
prevent inadvertent public access.
Open systems
The horizontal-bore cylindrical type of scanner is still the commonest, but
technology constantly changes and magnets are available with wider bores,
which are less claustrophobic. More open scanners have been developed
and units now exist that allow the patient to stand upright thus reducing the
feeling of claustrophobia. In a conventional MR system operating at 1.5 T,
because of its more closed design, it is less likely that radiological and
anaesthetic staff would be exposed to significant static and time varying
fields.
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Interventional procedures and intra-operative MR
Advances in technology mean MR image-guided surgery is now possible,
providing the surgeon with dynamic high-resolution images during
intricate stereotactic neurosurgery. Various MR systems have been
configured for this application, including ‘doughnut’ shaped magnets
permitting surgery with real-time concurrent imaging, and portable systems
set up to allow easy and rapid interchange between scanning and surgery.
All the hazards associated with diagnostic MR also apply to interventional
procedures. There are additional risks from patient repositioning, contamination
of the sterile field, and the proximity of ferromagnetic surgical
instruments, including scalpels, to the magnetic field. Incorporating MR
technology into the operating room provides new challenges [9].
Occupational exposure
It is difficult to measure occupational exposure to the various electro
magnetic fields in MR units routinely. Personal dosimeters have been
developed but are not, as yet, widely available. Some studies have suggested
that staff members can be exposed to higher than recommended levels of
time-varying gradient fields [10, 11]. In 2004, the European Union adopted
a directive restricting occupational exposure to electromagnetic fields,
including those used in MR. Some of the exposure limits threatened to
impact on the current use and future development of MR technology.
Known adverse effects are adequately addressed in the international standard
governing the manufacture of MR systems. Initially, unable to influence the
regulatory agencies, the MR community began to lobby both the UK and
European Parliaments. Implementation of the directive has been delayed
until 30 April 2012 to allow a permanent solution to be found. However,
the timescale is short given the political and scientific complexities of the
issue. A range of possible outcomes is explored in a report for the Institute of
Physics [12]. Each option has advantages and disadvantages, and a great deal
of detailed discussion and negotiation will be needed over the next 2 years to
ensure satisfactory resolution of the problem.
Pacemakers and medical implants
The MHRA safety guidance [2] still specifies that pacemakers are an
absolute contraindication to MR and it therefore remains the mantra of
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Safety in magnetic resonance units
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radiology departments that any individual with a pacemaker should not
enter the MR unit. This is due to the concern that the magnet
field strengths in excess of 0.5 mT (5 Gauss) could cause a fatal
malfunction of the pacemaker. Sudden deaths have been reported in
patients with pacemakers during or shortly after MR investigations [13, 14].
However, both pacemaker and MR technology are continually developing
and there are times when MR is needed to provide valuable clinical
information in patients with pacemakers. There have been a small number
of cases when a patient with a non-compatible pacemaker has required MR
imaging.
Approximately two million Europeans have implanted pacemakers, but
these patients are strongly discouraged from receiving MRI scans.
According to estimates, 50–75% of patients world-wide with implanted
cardiac devices are expected to need a MR scan during the lifetime of their
device [15]. Editorials in the American and European literature concluded
that the risk:benefit ratio for patients with pacemakers undergoing MR has
shifted towards safety, if guidelines are followed [16, 17]. Discussion in the
correspondence sections has been generated [18]. In summary, the presence
of a permanent pacemaker no longer represents a strict contra-indication to
MR in carefully selected clinical circumstances provided that specific
strategies are followed [19].
MR compatible pacemakers are now available and have been implanted
in some patients. One pacemaker manufacturer has received a Conformité
Européenne (CE) Mark for its second-generation MR safe pacing system.
However, approval has not yet been forthcoming from the Food and Drug
Administration in the USA [20].
Programmable shunts
The pressure setting of programmable hydrocephalus shunts may be
unintentionally changed by the magnetic field leading to over- or underdrainage
of CSF. If these patients are to undergo an MR examination, a
programmer and a trained clinician should be available to verify the correct
setting and to reprogram the device, if required, immediately following the
MR procedure. Advice must be given to the patient on how to recognise
over- and under-drainage and whom to contact should these conditions
develop [2].
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Neurostimulators
A wide variety of neurostimulators are now in use. Concerns about MR
safety relate to the RF and gradient fields that may interfere with the
operation of these devices or cause thermal injury. It is recommended that
patients implanted with neurostimulators should not undergo MR.
However, some manufacturers are suggesting that MR examinations of
specific devices may be safe if strict guidelines relating to scanning
parameters, in particular to RF exposure, are followed [2].
Out-of-hours MR imaging
There are many indications for urgent MR imaging, but they can be
grouped into two main areas: suspected spinal cord or cauda equina
compression; and investigation of acute neurological conditions. Hospital
trusts have faced litigation when treatment has been delayed due to lack of
24-h MR availability. Patients in intensive care units (ICUs) who require
urgent MR will need to be accompanied by anaesthetic staff. Intensive care
patients have additional sources of hazard including central lines and
intracranial pressure transducers [21]. Screening checklists have been
adapted for use in intensive care. It should be remembered that the ultimate
operational responsibility for safety issues remains with an appropriately
trained MR Authorised Person (usually the supervising radiographer) and
the MR radiologist [2].
Training
Training requirements for any staff entering the MR unit are detailed by
the MHRA [2]. The responsibility for safety training lies with the MR
Responsible Person who may be the clinical director, head of department,
clinical scientist or MR superintendent radiographer. The unit’s MR Safety
Advisor should provide technical advice. The wide range of staff from
differing disciplines who need access to the MR environment have been
designated into categories. Anaesthetists fall into MHRA category B; that is,
they may be present with a patient in the MR controlled area during
scanning. They should be aware of safety aspects related to the main static
magnetic fields, RF fields, gradient magnetic fields and electrical safety of
equipment. They must understand the significance of the MR controlled
area and the inner MR controlled area. They should be familiar with
emergency procedures arising from causes other than equipment failure and
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Safety in magnetic resonance units
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should be aware of the need to evacuate the patient from the inner
controlled area in order to deal with emergency resuscitation. Training also
includes an understanding of the projectile effect and the influence of the
magnetic field upon medical implants, prostheses and personal effects.
Anaesthetists should understand the consequences of quenching of superconducting
magnets, and be aware of the recommendations on exposure to
MR and the need for ear protection.
How can these training requirements be met? The potential for
e-learning should be considered. The Royal College of Anaesthetists
includes the physics of MRI in its basic science syllabus [22]. Trainees who
have completed an e-learning module and attended an elective MR list
would then be certified as suitable to accompany ICU patients for MR
imaging. Regular reviews of training status as well as updates and refresher
courses will be required. Hospitals will wish to apply local rules regarding
consultant supervision of anaesthetic trainees in MR units.
Contrast reactions
Gadolinium-based contrast agents are used in MR for demonstration of
vascular structures or to improve contrast resolution of tissues. In
comparison with other radiological contrast agents, Gd-CAs are relatively
safe with a high therapeutic ratio and low incidence of anaphylaxis
(approximately 1:100 000). The side-effects of Gd-CAs are generally mild
and include headache, nausea and vomiting, local burning, skin wheals
(2%), itching, sweating, facial swelling and thrombophlebitis [23]. More
severe reactions have occurred and radiology staff should be familiar with
guidelines related to the management of suspected anaphylaxis [24].
Nephrogenic systemic fibrosis
There has been recent attention to reports that patients with renal failure are
at risk of developing a rare, potentially life-threatening condition with
Gd-CAs called nephrogenic systemic fibrosis or nephrogenic fibrosing
dermopathy (NSF ⁄ NFD). The glomerular filtration rate (GFR) should be
estimated in all patients with kidney disease to identify those at risk of
developing NSF ⁄ NSD. If the GFR is estimated at less than 30 ml.min )1
per 1.73 m )2 , the risk of Gd-CAs should be balanced against benefit, and a
minimal dose of Gd-CAs only administered if an unenhanced scan proves
Ó 2010 The Authors
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insufficient [25]. The Gd-CA should not be administered again for at least
7 days. Current evidence suggests that contrast agents may be classified as
high-risk, e.g. gadopentelic acid, medium-risk, e.g. gadobenic acid, and
low-risk e.g. gadoteridol [26]. The use of high-risk agents is contraindicated
in neonates and during the peri-operative period in patients
undergoing liver transplantation. The Gd-Cas are not recommended in
pregnancy unless absolutely necessary.
Conclusions
While some safety terminology has altered, the basic recommendations
for provision of anaesthetic services in MR units have remained the
same since first published in 2002 [1]. Anaesthetists who are involved
with 3-T systems, open scanners or interventional and intra-operative
procedures should remain acquainted with the constantly changing
recommendations relating to occupational exposure. They should take all
practical steps to minimise the risk from exposure. MR examinations of
patients with pacemakers are no longer absolutely contra-indicated but
may be carried out under strictly controlled conditions in exceptional
cases. Increased requirements for MR imaging in intensive care and
postoperative patients have increased the need for repeated training. The
employment of e-learning modules may facilitate such training. There
has been an increase in the number of allergic reactions to Gd-CAs and
it is recognised that patients with renal failure are at risk of developing
NSF.
References
1 Association of Anaesthetists of Great Britain and Ireland. Provision of Anaesthetic
Services in Magnetic Resonance Units. The Association of Anaesthetists of Great
Britain and Ireland, 2002. http://www.aagbi.org/publications/guidelines/docs/
mri02.pdf (accessed 08/12/2009).
2 Device Bulletin Safety Guidelines for Magnetic Resonance Imaging Equipment
in Clinical Use DB2007(03) December 2007 http://www.mhra.gov.uk/
Publications/Safetyguidance/DeviceBulletins/CON2033018 (accessed 08/12/
2009).
3 Farling PA, McBrien ME, Winder RJ. Magnetic resonance compatible
equipment: read the small print! Anaesthesia 2003; 58: 86.
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4 Bradley PG, Harding SG, Reape-Moore K, Abeygunaratne R, Menon DK.
Evaluation of infusion pump performance in a magnetic resonance environment.
European Journal of Anaesthesiology 2004; 21: 729–33.
5 The Control of Noise at Work Regulations 2005. Statutory instrument
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6 Protection of patients and volunteers undergoing MRI procedures. Advice from
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7 Static Magnetic Fields. Health Protection Agency. 2008 http://www.hpa.
org.uk/web/HPAwebFile/HPAweb_C/1211184025757 (accessed 9/12/2009).
8 British Society of MR Radiographers http://www.bamrr.org/content.aspx?
Group=links&Page=links (accessed 08/04/2010).
9 Bergese SD, Puente EG. Anesthesia in the intra-operative MRI Environment.
Neurosurgery Clinics of North America 2009; 20: 155–62.
10 Vecchia P, Matthes R, Ziegelberger G, et al. (editors). Exposure to high frequency
electromagnetic fields, biological effects and health consequences
(100 kHz-300 GHz). International Commission on Non-Ionizing Radiation
Protection, 2008. http://www.icnirp.de/documents/RFReview.pdf (accessed
09/12/2009).
11 Bradley JK, Nyekiova M, Price DL, Lopez LD, Crawley T. Occupational
exposure to static and time-varying gradient magnetic fields in MR units. Journal
of Magnetic Resonance Imaging 2007; 26: 1204–9.
12 Keevil S, MRI and the Physical Agents (EMF) Directive. Reproduced by
permission of the Institute of Physics. 2008. http://www.iop.org/activity/
policy/Publications/file_32151.pdf (accessed 08/12/2009).
13 Ferris NJ, Kavnoudias H, Thiel C, Stuckey S. The 2005 Australian MRI safety
survey. American Journal of Roentgenology 2007; 188: 1388–94.
14 Bartsch CH, Irnich W, Risse M, Weller G. Unexpected sudden death of
pacemaker patients during or shortly after magnetic resonance imaging (MRI).
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15 Kalin R, Stanton MS. Current clinical issues for MRI scanning of
pacemaker and defibrillator patients. Pacing and Clinical Electrophysiolgy 2005; 28:
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16 Martin ET, Coman JA, Shellock FG, et al. Magnetic resonance imaging and
cardiac pacemaker safety at 1.5 Tesla. Journal of the American College of Cardiology
2004; 43: 1315–24.
17 Martin ET. Can cardiac pacemakers and magnetic resonance imaging co-exist?
European Heart Journal 2005; 26: 325–7.
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18 Gimbel JR, Wilkoff BL, Kanal E, Rozner MA. Safe, sensible sagacious:
resposible scanning of pacemaker patients. European Heart Journal 2005; 26:
1683–91.
19 Shellock FG. MR Imaging and electronically activated devices. Radiology 2001;
219: 294.
20 Press Release. http://wwwp.medtronic.com/Newsroom/NewsRelease
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21 Newcombe VF, Hawkes RC, Harding SG, et al. Potential heating caused by
intraparenchymal intracranial pressure transducers in a 3-tesla magnetic resonance
imaging system using a body radiofrequency resonator: assessment of the
Codman MicroSensor Transducer. Journal of Neurosurgery 2008; 109: 159–64.
22 Royal College of Anaesthetists http://www.rcoa.ac.uk/docs/eLA-Curriculum.
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23 Li A, Wong CS, Lee CM, Au Yeung MC. Acute adverse reactions to magnetic
resonance contrast media – gadolinium chelates. British Journal of Radiology 2006;
79: 368–71.
24 Harper NJN, Dixon T, Dugue P, et al. Guidelines: suspected anaphylactic
reactions associated with anaesthesia. Anaesthesia 2009; 64: 199–211.
25 Shellock FG, Spinazzi A. MRI safety update 2008: part 1, MRI contrast agents
and nephrogenic systemic fibrosis. American Journal of Roentgenology 2008; 191:
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26 Drug Safety Update 2010; 3: 3–5 http://www.mhra.gov.uk/Publications/
Safetyguidance/DrugSafetyUpdate/CON068297 (accessed 15/02/2010).
Ó 2010 The Authors
Journal compilation Ó 2010 The Association of Anaesthetists of Great Britain and Ireland 11

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Malignant Hyperthermia Crisis
AAGBI Safety Guideline
Successful management of malignant hyperthermia depends upon early diagnosis and treatment;
onset can be within minutes of induction or may be insidious. The standard operating
procedure below is intended to ease the burden of managing this rare but life threatening emergency.
1
Recognition
2
Immediate
management
• Unexplained increase in ETCO2 AND
• Unexplained tachycardia AND
• Unexplained increase in oxygen requirement
(Previous uneventful anaesthesia does not rule out MH)
• Temperature changes are a late sign
• STOP all trigger agents
• CALL FOR HELP. Allocate specific tasks (action plan in MH kit)
• Install clean breathing system and HYPERVENTILATE with 100% O2 high flow
• Maintain anaesthesia with intravenous agent
• ABANDON/FINISH surgery as soon as possible
• Muscle relaxation with non-depolarising neuromuscular blocking drug
3
Monitoring
& treatment
• Give dantrolene
• Initiate active cooling avoiding
vasoconstriction
• TREAT:
• Hyperkalaemia: calcium
chloride, glucose/insulin, NaHCO3¯
• Arrhythmias:
magnesium/amiodarone/metoprolol
AVOID calcium channel blockers -
interaction with dantrolene
• Metabolic acidosis: hyperventilate,
NaHCO3¯
• Myoglobinaemia: forced alkaline
diuresis (mannitol/furosemide +
NaHCO3¯); may require renal
replacement therapy later
• DIC: FFP, cryoprecipitiate, platelets
• Check plasma CK as soon as able
DANTROLENE
2.5mg/kg immediate iv bolus.
Repeat 1mg/kg boluses as required
to max 10mg/kg
For a 70kg adult
• Initial bolus: 9 vials dantrolene
20mg (each vial mixed with 60ml
sterile water)
• Further boluses of 4 vials
dantrolene 20mg repeated up to
7 times.
Continuous monitoring
Core & peripheral temperature
ETCO2
SpO2
ECG
Invasive blood pressure
CVP
Repeated bloods
ABG
U&Es (potassium)
FBC (haematocrit/platelets)
Coagulation
4
Follow-up
• Continue monitoring on ICU, repeat dantrolene as necessary
• Monitor for acute kidney injury and compartment syndrome
• Repeat CK
• Consider alternative diagnoses (sepsis, phaeochromocytoma, thyroid storm, myopathy)
• Counsel patient & family members
• Refer to MH unit (see contact details below)
The UK MH Investigation Unit, Academic Unit of Anaesthesia, Clinical Sciences Building, Leeds Teaching Hospitals NHS Trust,
Leeds LS9 7TF. Direct line: 0113 206 5270. Fax: 0113 206 4140. Emergency Hotline: 07947 609601 (usually available outside
office hours). Alternatively, contact Prof P Hopkins, Dr E Watkins or Dr P Gupta through hospital switchboard: 0113 243 3144.
Your nearest MH kit is stored
This guideline is not a standard of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan must be made
by the clinician in the light of the clinical data presented and the diagnostic and treatment options available.
© The Association of Anaesthetists of Great Britain & Ireland 2011

Recommended Contents of Malignant Hyperthermia Management Kit
(Ideally contained in designated and labelled compartments, e.g. drawers of a trolley)
AAGBI Safety Guideline
Storing together the majority of items required to manage malignant hyperthermia will reduce time spent gathering
equipment and hence expedite initiation of successful treatment.
Compartment 1: dantrolene
• 100 mls vial of sterile water for injection x 12
• 12 vials of dantrolene (20 mg per vial) (sufficient for an initial 2.5mg/kg dose
plus 2 repeat 1mg doses in an average adult)
• 10 x 50ml syringes
• Guideline for management of crisis and task allocations
• Details of location of reserve dantrolene supplies
Compartment 2: treatment
• Calcium chloride 10%
• Sodium bicarbonate (50ml 8.4% syringe)
• Amiodarone 300mg
• β blocker
• Glucose (20%)
• 50ml propofol vials/prefilled syringes for TIVA
Compartment 3: investigation/monitoring
• Blood bottles
• ABG
• FBC
• Coagulation
• Biochem
• Urine sample bottles
• Group & save
• Arterial cannulae and transducer sets
• CVC and transducer sets
Along with part-filled forms labelled ‘MH crisis’
and numbered; 1 st , 2 nd , 3 rd
To include CK and urinary myoglobin assay
Fridge pack
• 2 litres of cold sodium chloride 0.9% for IV administration
• Short-acting insulin
© The Association of Anaesthetists of Great Britain & Ireland 2011

Recommended Contents of Malignant Hyperthermia Management Kit
(Ideally contained in designated and labelled compartments, e.g. drawers of a trolley)
AAGBI Safety Guideline
Storing together the majority of items required to manage malignant hyperthermia will reduce time spent gathering
equipment and hence expedite initiation of successful treatment.
Compartment 1: dantrolene
• 100 mls vial of sterile water for injection x 12
• 12 vials of dantrolene (20 mg per vial) (sufficient for an initial 2.5mg/kg dose
plus 2 repeat 1mg doses in an average adult)
• 10 x 50ml syringes
• Guideline for management of crisis and task allocations
• Details of location of reserve dantrolene supplies
Compartment 2: treatment
• Calcium chloride 10%
• Sodium bicarbonate (50ml 8.4% syringe)
• Amiodarone 300mg
• β blocker
• Glucose (20%)
• 50ml propofol vials/prefilled syringes for TIVA
Compartment 3: investigation/monitoring
• Blood bottles
• ABG
• FBC
• Coagulation
• Biochem
• Urine sample bottles
• Group & save
• Arterial cannulae and transducer sets
• CVC and transducer sets
Along with part-filled forms labelled ‘MH crisis’
and numbered; 1 st , 2 nd , 3 rd
To include CK and urinary myoglobin assay
Fridge pack
• 2 litres of cold sodium chloride 0.9% for IV administration
• Short-acting insulin
© The Association of Anaesthetists of Great Britain & Ireland 2011

Malignant Hyperthermia Crisis Task Allocations
AAGBI Safety Guideline
The successful management of a malignant hyperthermia crisis requires multiple simultaneous
treatment actions. This is made far easier through effective teamwork and specific task allocation.
1 st anaesthetist - commence immediate management (on guideline sheet)
The anaesthetist diagnosing MH or the most senior anaesthetist responding should assume the role of
clinical leader once immediate management actions have been undertaken and avoid becoming focused
on a single task.
2 nd anaesthetist - resuscitation
• Ensure dantrolene is given in correct dose (2.5mg/kg initially then 1mg/kg every 10-15min)
• Commence TIVA
• Management of hyperkalaemia
• Management of arrhythmias
• Management of acidosis
• Renal protection (forced alkaline diuresis)
1 st anaesthetic nurse/ODP
• Collect MH kit
• Collect cold saline & insulin
• Set up lines (arterial/CVC)
• Runner for resuscitation drugs/equipment
2 nd anaesthetic nurse/ODP (ideally two people)
• Draw up dantrolene as requested by anaesthetist in charge of resuscitation
3 rd anaesthetist - lines/investigations
• Site arterial line
• Send bloods for
o ABG – repeated (approx every 30 min initially)
o U&Es
o CK
o FBC
o Coagulation screen
o Cross match
• Central venous access
• Urinary myoglobin
• Monitor core and peripheral temperatures
Surgical team
• Catheterise
• Complete/abandon surgery as soon as feasible
• Undertake cooling manoeuvres
Adapted from the Malignant Hyperthermia Australia and New Zealand (MHANZ) MH Resource Kit with permission

PROVISION OF ANAESTHETIC SERVICES
IN MAGNETIC RESONANCE UNITS
Published by
The Association of Anaesthetists of Great Britain and Ireland,
9 Bedford square, London WC1B 3RE, UK
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org May 2002

Membership of the Working Party
Dr Peter Farling
Dr Kate Bullen
Dr Juliet Britton
Ms Gail Darwent
Dr Janet DeWilde
Mrs Sharon Giles
Prof Paul Goddard
Dr Susan King
Dr Michael McBrien
Mrs Pat McDonald
Prof David Menon
Dr John Ridgway
Dr Michael Sury
Dr Sally Wilson
Ex-Officio
Professor Leo Strunin
Dr David Wilkinson
Dr Robert Buckland
Dr Michael Ward
Professor Michael Harmer
Chairman of Working Party
Council member
British Society of Neuroradiologists
British Association of MR Radiographers
MagNET
Department of Health
British Institute of Radiology
Royal College of Radiologists
Consultant Anaesthetist
Medical Devices Agency
Professor of Anaesthesia
Medical Physics
Consultant Anaesthestist
Consultant Anaesthestist
President
Honorary Treasurer
Honorary Secretary
Honorary Membership Secretary
Editor, Anaesthesia
To be reviewed by 2007

Contents
Page
Section I Summary 1
Section II Introduction 2
Section III Planning 3
Section IV Equipment 5
Section V Personnel 7
Section VI Health and safety 8
Section VII Risk management 11
Section VIII Appendix 1 – planning implications 12
Section IX Appendix 2 – glossary 13
Section X References 18
Section XI Further reading 19

Section I: Summary
1. The continuous presence of a strong magnetic field, and restricted access to the patient,
means that the provision of anaesthesia within MR units presents unique problems.
2 Whenever a new MR unit is planned, the possibility of managing sedated or
anaesthetised patients should be considered.
3. In the planning process, adequate space should be made available for the provision of
anaesthesia services.
4. A nominated consultant anaesthetist should be responsible for anaesthesia services in
MR units.
5. The level of assistance for the anaesthetist must be equal to that expected in the
operating theatre environment.
6. Immediate access from the scanning room to the anaesthetic preparation/ resuscitation
area is essential as in the event of an emergency, the patient must be removed from the
magnetic field without delay.
7. Anaesthetic equipment that is used in the scanning room should be MR compatible.
8. The monitoring of patients in MR units during anaesthesia, sedation and recovery must
comply with minimum monitoring standards.
9. It is essential that a remote monitoring facility is available to allow the anaesthetic team
to remain outside the scanning room once the patient’s condition is stable.
10. Only authorised personnel, who have received appropriate training and are fully
conversant with the local protocols, are allowed to enter the controlled area
unsupervised.
11. Resources should be provided to minimise the risk of personal exposure to strong
magnetic fields and noise levels.
1

Section II: Introduction
Magnetic resonance imaging (MRI) is now a routine investigation for many
conditions. The continuous presence of a strong magnetic field, and restricted
access to the patient, means that the provision of anaesthesia within MR units
presents unique problems. Some patients, e.g. children and adults with movement
and learning disorders or claustrophobia, are unable to lie still during the MR
scan and consequently sedation or general anaesthesia is required. Patients
requiring general anaesthesia are often difficult to manage e.g. rare paediatric
syndromes and critical care patients.
At the end of 2001 in Great Britain and Ireland there were approximately 3.9 MR
units per million head of population while the average ratio throughout the rest of
Europe was approximately 5.5 MR units per million. In order to reduce waiting
lists for MR scans, there is a need for investment in new and replacement MR
systems. Some of these may be located in hospitals that currently do not provide
anaesthesia for MR examinations.
This document aims to assist anaesthetists in the planning and provision of
anaesthesia services in new and existing MR units. When planning for a MR
service, radiologists, radiographers, referring clinicians and managers also need to
be aware of the problems associated with the provision of anaesthetic care in MR
units. When introducing a new MR service, it is important that funding is
identified to cover the cost of anaesthetic equipment and associated personnel
who are essential to the provision of anaesthetic care. This will be additional to
the MR equipment costs. (see Appendix 1).
Section III: Planning
Whenever a new MR unit is planned, the possibility of managing sedated or
anaesthetised patients should be considered. This will have specific staffing and
equipment implications as well as significant effects on capital and revenue costs.
Building
NHS Estates have published guidelines relating to accommodation for MR units [1-3].
Input from an anaesthetist, early in the planning process, will ensure that adequate
space is made available for the provision of anaesthesia services. While
recognising that space is at a premium, the unit should be designed to allow
patients to follow a logical progression through each area, with the appropriate
level of privacy.
The MR unit should contain a Controlled Area that contains the 0.5mT (5 gauss)
magnetic field contour. Only Authorised Personnel should have free access to the
controlled area to which there should be strict control of access via self-locking doors.
Consideration of the requirements to provide adequate space for an anaesthesia
service should occur during the design of the following areas:
• Reception area
• Waiting area and changing facilities
• Anaesthesia preparation/ resuscitation room
• Scanner room i.e. the MR examination room or Inner Controlled Area
• Control room
• Recovery area
The preparation area must be large enough to accommodate patients who arrive
on a bed. Adequate space must be available for transfer of patients onto the
scanning table. Anaesthesia should be induced on tables or trolleys with the
facility to tilt the patient head-down. This may require transfer to a MR
compatible trolley after the induction of anaesthesia.
It should be possible to observe patients from an area remote from the MR
examination room e.g. through a window from the control room, where the
radiographers operate the MR system. Once the patient’s condition is stable in the
scanner, the anaesthetist may choose to observe the patient and monitors from the
control room.
2
3

There must be immediate access from the MR examination room to the anaesthetic
preparation/ resuscitation area as it is essential that, in the event of an emergency,
the patient be removed from the magnetic field without delay. Ferromagnetic
equipment including oxygen cylinders, defibrillators or laryngoscopes must never
enter the MR examination room because of the strong magnetic field.
Piped gases and suction will be required in the anaesthetic room, the MR
examination room and the recovery area [4]. Adequate gas scavenging systems
will also be necessary. The installation of facilities such as piped gases is easiest
and least costly during the initial construction of the unit.
While it is recommended that the MR suite should be an integral part of a
radiology department [1], all MR units must be self-sufficient in terms of dealing
with emergency situations including cardiopulmonary resuscitation, anaphylaxis
and difficult airway management. This has staffing, training and equipment
implications. There should be an emergency call system in the MR examination
room and telephones in the anaesthetic room and recovery areas.
Function
A meeting between MR staff and potential users of the unit should be convened at
an early stage in the operational planning process. While this will indicate the
probable case mix of adult and paediatric cases, it should be remembered that this
is only accurate at the time of discussion. Experience has shown that there is
potential for change after the scanner opens. It will also alert staff to problems
associated with specific situations, for example, providing day case anaesthesia or
sedation, the management and transfer of critically ill patients from intensive care
units or children with difficult cardiorespiratory conditions. Children and their
parents attending for a routine examination should be kept separate from critically
ill patients.
Costs
The capital cost of MR compatible anaesthetic machines and monitoring
equipment should be considered when planning the funding of new units. The
revenue consequences of capital investment must be budgeted for and these
include staffing costs, day ward facilities, consumables and service contracts for
equipment. (see Appendix 1).
Section IV: Equipment
All equipment to be used within the scanning room should be passed and clearly
labelled as either ‘MR safe’ or ‘MR compatible’. Equipment is designated as MR
safe if it presents no safety hazard to patients or personnel when it is taken into
the MR scanning room, provided that instructions concerning its use are correctly
followed. This does not, however, guarantee that it will function normally and not
interfere with the correct operation of the MR imaging equipment, with
degradation of image quality. Equipment that is designated as MR compatible is
MR safe, functions normally in the MR environment, and does not interfere with
the correct operation of the MR imaging equipment providing instructions
concerning its proper use are correctly followed.
Clearly, all anaesthetic equipment that is used in the inner controlled area should
be MR compatible but equipment that is only used in anaesthetic rooms and
recovery areas need not be MR compatible.
It is vitally important that MR compatible equipment is easily distinguishable from
standard equipment. The hazards associated with using the wrong equipment include
the projectile effect [5], burns [6] and malfunction [7] e.g. non-MR compatible
syringe drivers may deliver drugs incorrectly with significant effects on patient safety.
The initial designation of MR compatible equipment is the responsibility of the
Responsible Person, but the day-to-day supervision of equipment entering the
inner controlled area is the responsibility of the radiographer in charge of the MR
session.
It is the responsibility of the equipment manufacturer to indicate the field strength
to which their equipment is compatible. To date, most clinical MR scanners have
had a field strength of 1.5Tesla (T) or lower. Recent technological developments
mean that 3T MR scanners will become clinically available in the near future. It
should not be automatically assumed that equipment that was MR compatible or
MR safe at 1.5T, remains compatible or safe at 3T.
Monitors
The monitoring of patients during anaesthesia, sedation and recovery must adhere
to previously published standards [8]. Suppliers of MR scanners may provide
basic monitoring devices as part of the system. These include ECG and
respiration monitors and are provided to facilitate the timing of certain types of
image acquisition. It is recommended that separate anaesthetic monitoring
equipment is available. Early MR compatible monitors may not include some
parameters that are now considered essential e.g. inspired oxygen concentration
and anaesthetic agent monitoring. These monitors will require replacement or
upgrading to meet current recommended standards.
4
5

MR compatible pulse oximeters must use fibreoptic cabling to avoid burns and
special ECG electrodes and cables are required. Padding should be placed between
cables and the patient’s skin and the avoidance of loops in cables within the scanner
is essential. The responsibility for safe placement of monitoring devices and leads
should be clearly and explicitly allocated.
It is essential that a remote monitoring facility is available to allow the anaesthetic
team to remain outside the scanning room once the patient’s condition is stable,
should they wish to do so. This will require the provision of waveguides between
the scanner and control rooms.
The MR environment will cause specific problems with ECG, capnography and
temperature monitoring. Aortic blood flow in a magnetic field generates currents
that result in significant artefact in the ST-T region of the ECG complex, and
monitoring of ischaemia may present significant challenges. There may be a delay
of up to 20 seconds in obtaining the capnograph signal due to the length of the
sampling tubing. While investigational devices allow temperature monitoring, clinical
monitors are only just beginning to provide this facility. The development of
improved monitoring modalities will alter the achievable standard of clinical
monitoring in MR.
The need for acoustic protection during MR imaging will necessitate the use of
ear-plugs or ear defenders, and make audible alarms inappropriate. Clear visible
alarms should be provided on all monitors when the attending anaesthetist is in
the MR examination room with the patient. Anaesthetists remaining in the control
room should have an unobstructed view of the remote monitor, anaesthetic
machine and patient.
Anaesthetic machine
A MR compatible anaesthetic machine should be located within the scanning
room. Only MR compatible vaporisers and gas cylinders must be used on
anaesthetic machines within the scanner room. Any attempt to replace these with
standard equipment will be extremely dangerous and is likely to cause a serious
accident [9].
Section V: Personnel
A nominated consultant anaesthetist should be responsible for anaesthesia services
in MR units. As well as suitably trained anaesthetists, the anaesthetic team will
include nurses, operating department practitioners and technical support. The level
of assistance for the anaesthetist must be equal to that expected in the operating
theatre environment [10]. The potential to encounter unusual cases exists [11]
and good communication between anaesthetic and radiological staff is vital.
All staff entering the MR unit must be aware of the local rules of that unit, which
may be different to those at other MR installations. It is essential that there is a
clear protocol that defines roles and responsibilities of all staff in the event of an
anaesthetic emergency or resuscitation. All staff must be fully aware of this
protocol e.g. the emergency medical resuscitation team should know not to enter
the inner controlled area. Protocols must take account of the possibility of the MR
unit being used outside routine working periods. Individual staff should be
designated to be responsible for regular checking and maintenance of anaesthetic
and resuscitation equipment.
All unauthorised staff entering the controlled area must first be medically screened,
and must be under the supervision of an authorised person for the whole time that
they remain in the controlled area. If their duties require them to enter the inner
controlled area on a regular basis, they should undergo training and be aware of
the local rules of that unit appropriate to their duties. Only authorised personnel,
who have received specific training and are fully conversant with the local safety
rules, are allowed to enter the controlled area unsupervised.
6
7

Section VI: Health and safety
Patient safety
Patient safety is a paramount consideration. Screening procedures to determine
specific contraindications to MR examination are the responsibility of the radiologist
and radiographer. The anaesthesia team should facilitate the adherence to strict
protocols to prevent untoward events. This is particularly important in unusual
situations e.g. critical care patients. Websites are available that indicate the
compatibility of implanted devices [12].
The most commonly used intravenous contrast agent is dimeglumine gadopentetate
(gadolinium DTPA). While there is an extremely low incidence of side effects, a
severe anaphylactoid reaction has been reported [13]. Other side effects include
nausea, vomiting and pain at injection. The recommended dosage is 0.2 ml.kg -1
body weight.
Staff safety
All staff entering the controlled area will be subject to the same safety screening
procedures as the patients. The occupational hazards to which anaesthetists and
their assistants may be subjected include exposure to:
• an intense magnetic field
• acoustic noise
• unscavenged anaesthetic gases
• possible hypoxia if quenching of a superconducting magnet occurs
Magnetic fields
The magnetic fields produced by MR scanners consist of:
• strong static magnetic field
• fast switching magnetic fields - gradient magnetic fields
• pulsed radiofrequency fields.
The switched gradient and radiofrequency fields are only present within or in the
immediate vicinity of the magnet. The static magnetic field extends well beyond
the confines of the magnet. The strength of this stray field depends on the
configuration and shielding of the magnet, and falls rapidly as the distance from the
magnet increases. Actively-shielded magnets are associated with more compact
fringe fields. However, the sharp fall in magnetic field strength with distance
implies a steep field gradient in the immediate vicinity of the magnet, which
substantially increases forces on ferromagnetic objects that are inadvertently
brought close to the magnet.
All those in close proximity to MR scanners may be at risk of injury from
unrestrained objects exposed to intense static magnetic fields, the projectile effect.
All staff should be fully aware of the implications of the projectile effect so that
such items are not taken into the examination room [5]. There is further potential
risk from the static magnetic field on any implanted ferromagnetic objects. These
devices may move or malfunction if exposed to a magnetic field, with potentially
fatal consequences, e.g. pacemakers, some aneurysm clips. The MR unit should
have a policy for screening all individuals for the presence of such metallic implants
and all anaesthetic staff should ensure that they are fully conversant with these
requirements.
Sudden movement of the human body within intense static magnetic fields may
cause very weak electrical currents to be induced in tissues causing symptoms such
as nausea and vertigo from extraneous excitation of the semicircular canals of the
inner ear or flashing lights by effects on the retina. However, there is currently no
scientific evidence for a cumulative harmful effect of intense static magnetic field
exposure on the human body.
Current recommendations for ‘safe’ levels of long term exposure to static magnetic
fields of healthcare personnel are a time-weighted average of 200mT over any 8-
hour period and should not be exceeded. This advice may change therefore
personnel should refer to current edition of the MDA recomendations. [14].
Those who work in close proximity to MR scanners should be made aware of
these safety levels. Risks may be small, but the current lack of evidence to
suggest a harmful effect of cumulative magnetic field exposure does not exclude
such a finding being made in the future. Individual workers should be provided
with the resources to minimise the risk of personal exposure to magnetic fields as
far as is reasonably achievable.
Acoustic noise
Significant levels of acoustic noise are produced during MR imaging due to the
vibration of the switched gradient coils. The magnitude of the noise depends on
the MR sequence and the strength of the magnet used. The trend towards higher
strength magnets and stronger and faster switching gradient fields indicates that
noise levels produced within MR scanners are likely to increase.
Noise at work regulations require employers to take actions to reduce noise
exposure of employees when it is at or above 85dBA (average daily exposure) [15].
Some MR sequences produce noise levels above these safety levels. Individual
MR units must undertake their own measurements and risk assessments.
Remaining at a remote location, e.g. in the control room while the scan is taking
place, will limit risks from noise exposure. Ear protectors should be provided if
staff remain within the examination room during the scan. All patients,
anaesthetised or non-anaesthetised, should be given ear protectors.
8
9

Scavenging of anaesthetic gases
The use of volatile anaesthetic agents and nitrous oxide in MR units must comply
with the Control of Substances Hazardous to Health (COSHH) regulations [16].
MR compatible scavenging systems for use in the MR examination room are
available.
Quenching of superconducting magnets
Quenching may occur due to a system fault or as a deliberate action to shutdown
the magnetic field. There should be no hazard from this procedure provided that
venting of the cryogens to the outside is adequate. There is a potentially lethal
hazard due to asphyxiation in oxygen-deficient atmospheres, if there is rapid
evaporation and escape of the liquid helium that surrounds and cools the
superconducting solenoid. Oxygen sensors should be located in the scanning
room and relayed to the control room to warn of the possible hypoxic effect of
escaped helium. Anaesthetists working in MR should be familiar with the
emergency procedures in the event of a quench being necessary.
Occupational hazards for female staff of childbearing age
For pregnant female staff working within MR scanning rooms, there are the
additional concerns of exposure of the fetus to magnetic fields, acoustic noise and
unscavenged anaesthetic gases. The current guidelines in the UK from the MDA
state that, until further evidence is available, it is prudent not to scan patients in
the first trimester of pregnancy [14]. In the case of female staff in the first
trimester of pregnancy, the MDA guidelines state that ‘it might be prudent to give
them the option of whether or not to enter the inner controlled area during the
first 3 months of their pregnancy’. Female staff of childbearing age working in the
MR environment should be made aware of:
• potentially harmful effects of excessive acoustic noise on the developing fetus
• COSHH regulations in respect to anaesthetic gas exposure
• MDA guidelines in respect to magnetic field exposure.
Section VII: Risk management
The nominated consultant anaesthetist should ensure that anaesthetic staff are
familiar with the anaesthetic machine and monitoring equipment which are often
of a non-standard configuration. All staff entering the MR unit, including anaesthetic
personnel, should have received training from the responsible person or their
designated deputy, usually the superintendent radiographer. Participation in such
training must be recorded and regular updates should be available annually.
Training should involve familiarisation with sections of the local rules of the MR
department which are appropiate to the individual role, and should include:
• Access to hazard notices and safety bulletins relating to MR Safety
• Personal safety i.e. removal of all metal objects and credit cards
• Information relating to safety issues of implants both passive and active
• The screening procedure and contraindications to MR
• Safe placement of monitors and radiofrequency (RF) coil leads
• Cardiac arrest procedure, siting of emergency equipment and emergency drugs
• Fire procedure
• Quench procedure
10
11

Section VIII: Appendix 1
Planning considerations and cost implications for the inclusion of an anaesthesia
service into a new or existing MR installation.
Building
The building plans should include the following (in addition to what is considered
as standard for an MR installation):
1. Adequate access to the MR unit (including ITU beds) may require modification
of corridors and doorways. Alternative access may be required for beds to
avoid passing through the waiting area.
2. Anaesthetic induction and recovery area(s) of sufficient size to accommodate
predicted patient throughput. Consideration of whether more than one patient
is likely to be in induction and/or recovery at any one time. Induction and
recovery should be separate areas.
3. Provision of sufficient storage (including drug fridge) for consumables and
anaesthetic machine when not in use.
4. Installation of piped gases, suction and scavenging units in each of MR
examination room, induction and recovery areas.
5. Provision of RF waveguides for piped gases, suction and monitoring
equipment. This normally needs to be specified at the time of MR equipment
specification as the RF screened room is often included in the tender process
for the MR equipment.
6. Provision of emergency call system and telephone in induction and recovery areas.
Purchase of Capital Equipment
The following additional capital equipment must be purchased:
1. MR compatible monitoring equipment to comply with minimum monitoring
standards.
2. MR compatible anaesthetic machine, vaporisers and ventilator.
3. Standard anaesthetic machine, suction and monitoring equipment for
induction/recovery area.
Revenue Cost Implications
1. Staffing - anaesthetist, anaesthetic assistant, technician, nurses.
2. Provision of day-case recovery facilities.
3. Consumables.
4. Service contract for anaesthetic and monitoring equipment - usually 8-10% of
purchase price per annum.
Section IX: Appendix 2
Glossary of Terms
Authorised Personnel/Person. In the context of the MR safety guidelines,
authorised personnel are able to access the controlled area without supervision.
They must have received appropriate training in MR safety and should be
conversant with the local safety rules of the MR unit appropriate to their duties. In
particular, they should be able to implement the emergency procedures contained
within the local rules. All authorised personnel should have been medically
screened prior to first being given access to the MR unit. They should be
sufficiently competent to supervise non-authorised personnel, patients and visitors
who may require access to the controlled area.
Controlled Area. The controlled area wholly contains the 0.5mT magnetic field
contour. Self-locking doors with coded locks control access to the controlled area.
Only authorised personnel have unsupervised access to the Controlled Area. All
patients, visitors and non-authorised staff should be medically screened before
entering the controlled area.
Cryogens. Cryogens are liquid coolants that are used by superconducting magnets
to keep the magnet coil windings at a superconducting temperature. Liquid
helium is the cryogen used in modern superconducting MR systems, although
older systems also used liquid nitrogen as a secondary coolant to help reduce the
rate at which liquid helium boils off. Rapid boil-off of the cryogen is
accompanied by a loss of superconductivity and is known as a quench.
Fringe field. The fringe field is the magnetic field that exists outside the external
housing of the MR system’s magnet. It decreases with distance from the centre of
the magnet. There are two important safety considerations. First is the position at
which the fringe field decreases to a value below 0.5mT. Persons fitted with
cardiac pacemakers should not be allowed to enter fields above this value. Second
is the rate at which the fringe field increases in close proximity to the magnet as
this determines the force on ferromagnetic objects which causes the projectile
effect. Magnetic shielding is used to make the fringe more compact. In addition to
presenting a safety hazard, the fringe field may also damage items such as wrist
watches, mobile phones and will erase the information stored on credit cards.
Gadolinium DTPA (dimeglumine gadopentetate). This is the most commonly used
MR contrast agent. It reduces the T1 and T2 of tissues (see MRI) with which it
comes in contact. This produces an increase in signal of T1-weighted images, and
a reduction in signal on T2-weighted images. It is most commonly used as a contrast
medium to identify tumours and also in Contrast-enhanced MR angiography.
12
13

Gauss (G) see Tesla. Gauss is a unit of magnetic field strength (the correct term
is magnetic flux density). It has been mostly superseded by the SI Unit, Tesla. 1
Gauss = 0.1 milliTesla (mT). 1 Tesla = 10,000 Gauss. The cardiac pacemaker field
contour is often referred to as the 5 Gauss line.
Gradient magnetic fields. The technique of magnetic resonance imaging uses
magnetic field gradients to localise and encode the MR signals with spatial
information to generate an image. The gradient fields are superimposed onto the
static field but are only switched on for short periods (typically just a few
milliseconds). The fast switching of the gradient fields generates rapidly varying
magnetic fields. This may cause interference on the patient’s electrocardiogram
and, on higher performance MR systems, may cause peripheral nerve stimulation.
The electromagnet coils that generate the switched gradient fields vibrate,
generating acoustic noise, which is often in excess of 100dB. Hearing protection
should always be provided to patients whether conscious or unconscious.
Inner Controlled Area. The Inner Controlled Area is a term which is often used
to describe the MR Examination room which contains the MR system magnet.
The attractive force of the fringe field is at its greatest in this room presenting a
significant projectile hazard. The Inner Controlled Area is always contained
within the Controlled Area.
Magnetic shielding. Magnetic shielding is used to reduce the extent and strength
of the fringe field. There are two main types of magnetic shielding. Passive
shielding uses several tons of steel to constrict the magnetic field. It can be
immediately surrounding the magnet or distributed around the walls of the room.
Active Shielding uses a secondary set of superconducting magnet coils that
reduce the fringe field outside the magnet housing. For active shielding and
passive self-shielding, the attractive forces increase rapidly close to the magnet.
For room shielding (or if no shielding is used), attractive forces are significant
throughout the MR examination room.
MR Examination Room. The MR examination room contains the MR system’s
magnet and is where the fringe field is at its strongest, thus presenting a projectile
hazard. It is often referred to in safety guidelines and local safety rules as the
Inner Controlled Area.
MRI. Magnetic Resonance Imaging (MRI) is the process of acquiring images
using the principle of Nuclear Magnetic Resonance (NMR). Hydrogen nuclei are
caused to resonate by applying a radiofrequency magnetic field in the presence of
a strong static magnetic field. The hydrogen nuclei emit a radiofrequency signal
which is spatially encoded by using magnetic field gradients to form images
which represent anatomical slices within the body. The signals mainly emanate
from both lipid and water-based tissue, and depend on both NMR properties of
the tissue and the acquisition parameters of the MR system set by the operator.
MRI is able to generate a wide range of soft tissue contrast, making it suitable for
a wide range of conditions and diseases. Two common parameters that dictate the
properties of signal evoked from different tissues are the T1 and T2 time
constants, which describe the characteristics of MR signal obtained. MRI
sequence parameters can be chosen to elicit T1 or T2 contrast.
MRS. Magnetic Resonance Spectroscopy (MRS) is the process of acquiring
spectroscopic data using the principle of Nuclear Magnetic Resonance. The MR
spectra obtained reveals the proportion in which many important chemical species
are present in tissue. Localised MR Spectroscopy allows MR spectra to be
obtained from small volumes of tissue in vivo. It can be combined with MRI to
provide both anatomical and metabolic information and is developing as an
important diagnostic tool.
MR safe. Equipment is designated as MR safe if it presents no safety hazard to
patients or personnel when it is taken into the MR examination room, provided
that instructions concerning its use are correctly followed. This does not, however,
guarantee that it will function normally and not interfere with the correct
operation of the MR imaging equipment, with degradation of image quality.
MR compatible. Equipment that is designated as MR compatible is MR safe,
functions normally in the MR environment, and does not interfere with the correct
operation of the MR imaging equipment providing instructions concerning its
proper use are correctly followed.
mT (milliTesla). See Tesla.
Projectile hazard/effect. The magnetic fringe field exerts an attractive force on
any ferromagnetic object that is brought into the vicinity of the magnet. Massive
objects, such as gas cylinders and patient trolleys, and smaller objects with sharp
edges, such as scissors or tools, will accelerate rapidly towards the magnet and
may cause serious injury to staff or patients. The MR system itself may also be
damaged. All personnel entering the Inner Controlled Area must first be screened
for such objects.
Quenching. Quenching refers to the rapid, almost explosive, boil-off of liquid
helium and the accompanying loss of superconductivity. The magnetic field is lost
and a large volume of helium gas is generated and should normally be vented to
the outside atmosphere through a quench pipe. If this pipe were to fracture it
would present a potentially lethal hazard caused by the rapid build-up of helium
gas in the MR examination room, leading to asphyxiation. Quenches can be
14
15

spontaneous, usually occurring when the magnet is being powered up or down
during installation or services, or can be deliberately activated in an emergency,
such as fire.
Radiofrequency (RF) Coil. Radiofrequency (RF) coils are used to detect the RF
signals emitted from the patient. The main RF coil of the system is known as the
Body Coil and is typically located inside the covers within the bore of the magnet.
This coil is also used to transmit the pulsed radiofrequency field. Additional
specialised coils (often known as Surface Coils) may be used to improve the
sensitivity of signal detection from a particular body area. The cables from these
coils must be carefully placed so that they are not in contact with either the
patient or monitoring cables as this can cause RF heating.
Responsible Person. In the context of MRI services, the chief executive or
general manager of the organisation has the ultimate responsibility to ensure that
the MR safety guidelines are implemented. This responsibility is normally
delegated to a specified responsible person who may be the clinical director or
superintendent radiographer in charge of the department in which the MR
equipment is located.
RF heating. The radiofrequency pulses used in MRI deposit energy into the
patient’s tissues, and therefore have a heating effect. The level of power deposition
is strictly controlled, and is calculated per kilogram of tissue for each scan (see
SAR). Metal implants, monitoring transducers and cables may preferentially take
up the RF power, resulting in excessive RF heating, causing burns to the patients
skin. To avoid this risk, only MR compatible monitoring equipment should be
used in the MR environment. Care should be taken when placing RF coil cables
and monitoring cables to ensure that no loops are formed and that they are not in
close contact with each other or the patient’s skin.
RF shielding. Radiofrequency (RF) shielding has a two-fold purpose. Firstly, the
radiofrequency pulses used by the MR system should not interfere with
equipment outside the MR examination room. Secondly, radio signals and other
electromagnetic interference in the external environment should be prevented
from interfering with the MR signal detection. RF shielding is achieved by
making the MR Examination room an RF screened room.
RF screened room. The radiofrequency (RF) screened room (also known as an
RF cabin) provides RF shielding for the MR system. It consists of cladding made
of thin copper or aluminium sheet that forms the inner surface of the walls,
ceiling and floor of the MR examination room. The door (copper clad with leaf
spring edges) and window (copper gauze sheet) of this room form an integral part
of the RF screen. The door must therefore be closed when the MR system is
operating and the screen must not be broken by passing electrical conducting
materials through it. Medical gas supplies and sample tubes for monitoring
equipment must be made of non-conducting material and must be passed through
specially-designed waveguides supplied with the RF screened room to maintain
the integrity of the screen. Cables that carry signals or power must either be
fibreoptic, or must pass through special electrical low pass filters supplied with
the RF screened room.
SAR. The Specific Absorption Rate (SAR) is a measure of the RF power deposited
into the patient, calculated per kilogram of tissue. The patient’s body weight is
entered into the MR system at the start of the examination, and the SAR is calculated
before each scan is commenced. The SAR is strictly limited by the MR system
manufacturer according to national or international guidelines. Higher values of
SAR may lead to core body temperature rises of up to 1 o C, and there is an increased
likelihood of RF heating of transducer cables.
T1-weighted image and T2-weighted image. The MR signal emitted by biological
tissue has an amplitude, which depends both on the properties of the tissue and
upon the timing parameters of the particular MR acquisition pulse sequence used.
The two most important properties are the T1-relaxation and T2-relaxation. The
pulse sequence parameters can be chosen either to emphasise signal differences
which are primarily dependent upon either T1 relaxation, or T2 relaxation,
resulting in images which have soft tissue contrast which is described as either
T1-weighted or T2-weighted respectively. Both types of image are normally
acquired as they provide complimentary diagnostic information.
Tesla (T). Tesla is the SI unit of magnetic field strength (the correct term for field
strength is magnetic flux density). The cardiac pacemaker field contour is often
referred to as the 0.5 milliTesla (mT) line. Typical nominal field strengths of
commercial MR systems are 0.5, 1.0 and 1.5 Tesla. More recently, higher field
strength (e.g. 3.0T) systems are becoming commercially available. MR spectroscopy
is normally performed at higher field strengths up to 7.0 Tesla.
Waveguide. A waveguide is a hollow tube made of brass that forms a conduit
through the wall of the RF screened room without breaking its integrity. Waveguides
are typically 2.5-5.0cm in diameter with the length, dependent on the diameter,
calculated to prevent the passage of radiofrequency interference. It allows nonelectrically
conducting pipes, sample tubes and fibreoptic cables to be passed into
the MR examination room for patient monitoring, and gas and drug delivery purposes.
16
17

Section X: References
1. Health Building Note 6 Supplement 1. Accommodation for magnetic
resonance imaging. NHS Estates 1994, London, HMSO. ISBN
0113217307
2. Health Guidance Note Magnetic Resonance Imaging. NHS Estates,
London, HMSO. ISBN 0113220510.
3. Facilities for Diagnostic Imaging and Interventional Radiology. NHS
Estates 2001, London, HMSO. ISBN 0-11-322000-0.
4. Immediate Postoperative Care. Association of Anaesthetists of Great Britain
and Ireland, 1993.
5. MDA Publication. ‘MRI static magnetic field safety considerations – the
projectile effect caused by the influence of the static magnetic field of
magnetic imaging systems’ 1998.
6. Dempsey MF, Condon B. Thermal injuries associated with MRI. Clinical
Radiology 2001; 56: 457-65.
7. MacIntyre PA, Sury MR. Is propofol infusion better than inhalational
anaesthesia for paediatric MRI? Anaesthesia 1996; 51: 517.
8. Recommendations for Standards of Monitoring during Anaesthesia and
Recovery. Association of Anaesthetists of Great Britain and Ireland, 2000.
9. Chaljub G et al. Projectile cylinder accidents resulting from the presence of
ferromagnetic nitrous oxide or oxygen tanks in the MR suite. American
Journal of Radiology 2001; 177: 27-30.
10. The Anaesthesia Team. Association of Anaesthetists of Great Britain and
Ireland, 1998
11. Andrzejowski J, Mundy J. Anaesthesia for MRI angiography in a patient
with Williams syndrome. Anaesthesia 2000; 55: 97-8.
12. http://www.mrisafety.com
13. Weiss KL. Severe anaphylactoid reaction after i.v. Gd-DTPA. Magnetic
Resonance Imaging. 1990; 8: 817-8.
14. The Medical Devices Agency. Guidelines for Magnetic Resonance Diagnostic
Equipment in Clinical Use with Particular References to Safety. London:
HMSO, 1993. To be revised 2002
15. Health and Safety Executive. Noise at Work Regulations. London: HMSO,
1990.
16. Health Service Advisory Committee. Anaesthetic Agents: Controlling
Exposure Under COSHH London: HMSO, 1995.
Section XI: Further Reading
Keengwe IN, Hegde S, Dearlove O, Wilson B, Yates RW, Sharples A. Structured
sedation programme for magnetic resonance imaging examination in children.
Anaesthesia 1999; 54: 1069-72.
Laurence AS. Sedation, safety and MRI. The British Journal of Radiology 2000;
73: 575-7.
McBrien ME, Winder J, Smyth L. Anaesthesia for magnetic resonance imaging: a
survey of current practice in the UK and Ireland. Anaesthesia 2000; 55: 737-43.
Menon DK, Peden CJ, Hall AS, Sargentoni J, Whitwam JG. Magnetic resonance
for the anaesthetist. Part 1: physical principles, applications, safety aspects.
Anaesthesia 1992; 47: 240-55.
Morton G, Gildersleve C. Noise in the MRI scanner. Anaesthesia 2000; 55: 1213.
NRPB Board statement on restrictions on human exposure to static and time
varying electromagnetic fields and radiation. Documents NRPB 1993; 4: (5)
ISBN 0859513661.
Peden CJ, Menon DK, Hall AS, Sargentoni J, Whitwam JG. Magnetic resonance
for the anaesthetist. Part II: anaesthesia and monitoring in MR units. Anaesthesia
1992; 47: 508-17.
Practical MR Safety Considerations for Physicians, Physicists and Technologists.
Editor Emanual Kanal. 2001 RSNA Course Syllabus.
Rafferty C, Burke AM, Cossar DF, Farling PA. Laryngeal mask and magnetic
resonance imaging. Anaesthesia 1990; 45: 590-1.
Sury MRJ, Hatch DJ, Deeley T, Dicks-Mireaux C, Chong WK. Development of a
nurse-led sedation service for paediatric magnetic resonance imaging. Lancet
1999; 353: 311-12.
Zorab JSM. A general anaesthesia service for magnetic resonance imaging.
European Journal of Anaesthesiology 1995; 12: 387-95.
Zorab JSM, Young AER, Brown PN. Anaesthesia for children and infants
undergoing magnetic resonance imaging: a prospective study. European Journal
of Anaesthesiology 1996; 13: 400-3.
18
19

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Hamilton House, Mabledon Place, London, WC1H 9BB
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Association of Anaesthetists of Great Britain & Ireland
Needlestick Working Party Report
Council of the Association of Anaesthetists of Great Britain & Ireland (AAGBI) established a
Working Party on Needlestick Injuries in December 2007. Its initial membership was:
Dr Andrew Hartle (Chair)
Dr Steve Yentis
Dr Stuart White
Dr Mark Hearn
Dr Dominic Bell
Dr Daniel Sokol
Ms Kim Sunley
Dr Andy Lim
Ms Janette Roberts
AAGBI Council
AAGBI Council
Consultant Anaesthetist, Brighton
GAT Representative
Intensive Care Society
Lecturer in Medical Ethics & Law
Royal College of Nursing
Royal College of Anaesthetists
Patient Liaison Group
The Working Party was to consider the testing of patients for Blood Borne Viruses (BBV) after
needlestick and other occupational injuries, especially in the light of recent legislative change
(Human Tissue Act 2004 [HTA] and Mental Capacity Act 2005 [MCA]), and the withdrawal of
previous guidance from the General Medical Council (GMC).
The legal ‘limbo’ surrounding the testing of patients who lacked capacity, and who had been
the source of a needlestick or other occupational injury had been described in detail in Stuart
White’s editorial in Anaesthesia (Needlestuck. Anaesthesia 2007; 62: 1199-201). Initial
guidance from the GMC had been that testing of such patients could take place in exceptional
circumstances. The introduction of HTA and MCA had led to that guidance being withdrawn,
and advice from Medical Indemnity organisations was now that such testing without the
patient’s consent was unlawful. This now meant that Healthcare professionals who sustained
occupational exposure were unable to know the viral status of the source when making
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
WP’s remit:
• Establish what changes were possible to the current legal situation and make
recommendations.
• Identify mechanisms by which change could be effected.
• Identify ways by which public support for such change could be achieved, including
identifying other stakeholders.
The WP discussed the apparent variability of response to the current situation. In some units
patients were never tested after occupational injury, but in others testing may still be
performed, either with or without the agreement of next of kin. This creates a ‘postcode
lottery’ in the management of occupational injuries, and also places healthcare workers at risk
of legal, disciplinary or regulatory action. Such inconsistency in management is not
acceptable.
After some discussion, the following possible changes were agreed, roughly in order of most to
least restrictive, and possibly in ascending order of likely public acceptability:
• Blanket testing of all patients.
• Testing of all patients who become the source of a needlestick/infective injury.
• ‘Presumed Consent’ for testing unless prior evidence of objection.
• The previous status quo, i.e. testing only after an individual risk/benefit analysis (to
include psychological as well as physical risk).
• Testing with the consent of next of kin.
• No testing without specific consent from the patient.
Members of the WP agreed to analyse each of these options, before making recommendations
to Council. Those analyses are attached.
The WP agreed that, before the situation of testing arose, first priorities for all stakeholders
should be:
• Prevention/preventative technology
• Improved (confidential) reporting
• De-stigmatisation

Three principle methods of achieving a change in the law were identified:
1. A change in the law (Statutory Instrument, amendment, primary legislation)
2. An elaboration of existing law
3. A test case
In order to establish public support, which will be vital for any change, the following themes
were explored:
• Exploring broader benefits and harms to -
o Individual patients
o Individual healthcare staff
o Employers
o Society
• The virtuous/responsible patient
• Comparisons with zero tolerance to violence
• Reciprocity
Other stakeholders included:
• British Association of Operating Department Practitioners
• Unison
• Unite
• Chartered Society of Physiotherapists
• Association of Occupational Health
• NHSE (including medical Directors)
• Patients Association
• Terrence Higgins Trust
• GMC
• NHSLA
• MPS/MDU/MDDUS
• BMA
• Court of Protection
• Office of Official Solicitor
• Health and Safety Executive
• Department of Health
• Human Tissue Authority

Methods to estimate/establish public support included:
• Properly conducted patient/lay person research
• Public opinion poll
• Letters/editorial in other journals
• Parliamentary spokesmen (especially for Trade Unions)
• BBC Online Poll
• Online Downing Street petition
• The general and medical press
The Working Party met again in June 2008, when initial drafts of the analyses were considered.
At a subsequent meeting in February 2009, the WP was joined by Veronica English of the BMA
Ethics Department. The RCN was represented on that occasion by Janice Gabriel, and David
Whitaker (Immediate Past President, AAGBI) was also present.
VE explained that the BMA had met with Lord Warner at the Department of Health.
Amendment(s) of the Human Tissue Act would probably not help clarify the current legal
limbo, as serum (ie not containing cells) was stored and tested for blood borne viruses (BBV),
so the HTA was not engaged.
The BMA would prefer not to stretch a best interests argument, although this might be possible
by changes to the Mental Capacity Act’s code of conduct.
After much discussion the WP narrowed its recommended options to Council as being:
1. All patients who were the source of an occupational injury should be tested for BBV.
This would be the greatest infringement of Human Rights and would need primary
legislation, but would be fair as all patients would be treated the same. An analogy
might be drawn with compulsory testing for alcohol and drugs following a Road Traffic
Accident. There was an impression that this was what lay people thought happened
anyway.
2. The restoration of the previous position whereby the merits of a particular case were
assessed and the decision to test or not could then be justified. This was the BMA’s
preferred option. Trusts could produce policies to ensure fairness, transparency and
accountability.

3. Testing could take place with the consent of next-of-kin or other delegated decision
makers.
Recommendations as to how the necessary legal change could be effected would depend on
meetings between the BMA and the DoH.
AH met with officials from the Department of Health on 15 th May 2009. They were very
interested in the WP’s work, particularly the bringing together of a ‘coalition’ involving such a
wide range of Health Care Workers, and the ethical analyses done by the WP. The
designation of an affected Health Care Worker as ‘patient 2’ was particularly compelling.
There was no doubt that DoH supports some change in the legal position, but was similarly
unsure of which proposal to advocate, or how best to bring this about. Legislation runs serious
risks of having unforeseen consequences, and is dependent on the political cycle.
AH was invited to join the DoH Stakeholder Group, which met in July 2009. DoH legal
advice was Option 1 would be unlikely to be helpful, as individuals who had had blood taken
without consent after road traffic accidents could still withhold consent for its testing, although
they would then be guilty of the offence of “refusing to give a sample”.
In November 2009 the Department of Health published Legal issues relevant to nonheartbeating
organ donation, which clearly endorses an expanded interpretation of best
interests with specific regard to virological testing using the assent of the next of kin. This
interpretation of legislation may be a basis on which to move forward.
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan
ce/DH_108825]
Current position
The WP has now fulfilled its first two objectives (determining whether the legal situation
should be changed, recommending what that change should be). The legal position remains
complicated and will need amendments to the Mental Capacity Act and/or its Code of
Conduct. This will require parliamentary time and political will.

Recommendations
The WP recommends:
1. That AAGBI Council should adopt as policy that the necessary legislative
change is effected at least to restore the previous position to allow individual
cases to be judged on their merits and testing of patients for Blood Borne
Viruses performed after occupational exposure when justified.
2. Council should consider whether to pursue legislative change that would allow
a. Processing of a blood sample taken for any other purpose in the event of
a patient refusal, and
b. presumed consent for testing where the patient lacks capacity and is
unlikely to regain this within a set timeframe, (e.g. 6-12 hours)
3. Pending such legislative change, Council should support the model of next of
kin assent pending the above resolution and for presumed consent where no
next of kin have been identified within the above timeframe of 6-12 hours.
4. Any legislative/policy change should accommodate the principle of reciprocity.
The decision to test should be based on defined, objective principles and avoid
arbitrary or varying decision-making. Logical and defensible solutions already
exist and are currently being applied in some units.
5. Council should approve a revision of its current guidance on ‘Blood Borne
Viruses and the Anaesthetist’. In particular this should focus on the
implications of an occupational injury, post exposure prophylaxis and follow
and the subsequent employment. [Note: a WP on ‘Occupational Health and the
Anaesthetist’ has been established with Dr Paul Clyburn as chair.]
6. Council should consider a survey of members to establish the frequency of
occupational exposure, particularly when the source patient is unable or refuses
to consent to testing [Note: a paper has been accepted for the September 2010
edition of Anaesthesia which describes an anonymised postal survey of current
practice in ICUs in England. This has an accompanying editorial by AH]
June 2010

Appendices:
1. Needlestuck
2. Analysis of benefits and harms of blanket testing
3. Analysis of Presumed Consent
4. Analysis of non-consensual testing
5. Analysis of Status Quo
6. Analysis of Next of Kin Assent/Consent
7. Patient perspectives

Anaesthesia, 2007, 62, pages 1199–1201
.....................................................................................................................................................................................................................
Editorial
Needlestuck
Enacted on the 15th November, 2004,
and fully enforced on the 1st September,
2006, the Human Tissue Act 2004
(HTA) [1] is the UK government’s
woefully impenetrable attempt to clarify
the statutory law in England and Wales
with regard to the use and storage of
human tissue, organs and bodies. The
HTA repeals the Human Tissue Act
1961, the Anatomy Act 1984, and the
Human Organ Transplants Act 1989.
In response to public concern over
the organ retention scandals at Alder
Hey Hospital [2] and the Bristol Royal
Infirmary [3], and the findings of the
Isaacs Inquiry [4], the government hurriedly
introduced a consultation document,
Human Bodies, Human Voices [5],
in July 2002, leading to the introduction
of the Human Tissue Bill, in December
2003.
In line with much recent legislation,
consent was proposed as a fundamental
protection for patients, such that virtually
all tissue taken from humans could
only be used or stored having obtained
appropriate consent (from the patient
if alive, from the parents of children,
or premortem if the patient was now
dead), under penalty of fine or imprisonment.
Some ramifications of the Bill
were immediately apparent, and elicited
considerable debate among, and opposition
from, the research, legal [6–8]
and transplant communities, especially
pertaining to anatomy demonstration,
research using human tissue [9, 10],
tissue databanking [11], genetic research
[12] and organ transplantation [13, 14].
Less apparent, unfortunately, were
some of the ramifications relating to
everyday clinical practice. One scenario
in particular has given rise to concern
about the protection of healthcare professionals
in the event of a needlestick
injury.
Accidental blood and body fluid
exposure is a daily risk for health care
workers, with an incidence of approximately
1–5 per 100 person-years [15].
Up to 40% of patients with HIV are
unaware of their status when they
are admitted to intensive care [16].
Needlestick injuries account for
approximately 80% of exposures, are
more common with more complex
procedures, and can lead to infection
with HIV, and hepatitis B, C and ⁄ or D
[17]. Seroconversion rates are low for
HIV (0.3%) and HCV (0.5%), but much
higher for HBV (18–30%) [18]. A
number of postexposure prophylaxis
(PEP) guidelines are available for HIV
[19], HBV and HCV [20]. In the case of
HIV, PEP should ideally be commenced
within an hour of exposure,
and continued at least until the HIV
status of the source patient is confirmed.
Delays in source patient HIV testing can
expose health care workers to inappropriate
continuation of PEP administration
of drugs with significant side-effect
profiles.
However, there is considerable confusion
surrounding the issue of consent
when testing a source patient for HIV
(or other blood-borne viruses). No
specific statute exists, and so the legality
of testing lies in the common law.
Testing involves physical contact with a
patient, and therefore the patient’s
consent is required. Their consent is
legally valid if they are appropriately
informed (about the nature and purpose
of the test, and the risks and consequences
of testing), competent to
decide (that is, they understand the
information presented to them, remember
it, and use it to decide whether or
not to have the test), and give consent
voluntarily [21]. Competent adult patients
can consent to, or refuse, testing for
any reason, or for no reason at all. At
present, no-one may give consent on
behalf of an incompetent patient (for
example, an unconscious patient in the
intensive care unit). Under the common
law in England and Wales, the
HIV testing of an unconscious patient is
legal if it is necessary and in the patient’s
best interests (for example, to establish
their HIV status for the purposes of
treatment).
Therefore, in theory at least, a doctor
may not test a source patient for HIV
for the benefit of an injured healthcare
worker either if the patient refuses a
test, or if the patient is incompetent
⁄ unconscious.
However, this is not the advice
offered in professional guidelines,
namely the General Medical Council’s
Serious Communicable Diseases guidelines
of 1997 [22] (the British Medical Association
and Department of Health defer
to the GMC in their own advice). The
GMC advises that ‘You must obtain
consent from patients before testing for
a serious communicable disease’ (s.4),
and ‘you may test unconscious patients
for serious communicable diseases,
without their prior consent, where
testing would be in their immediate
clinical interests’ (s.7), in line with the
common law. However, the GMC then
advise that ‘you may test an existing
blood sample, taken for other purposes’
if the patient has refused testing or is
unable to consent, and the doctor has
good reason to believe the patient may
have a communicable disease for which
prophylaxis is available, and an experienced
colleague has been consulted, and
the patient is unlikely to regain capacity
within 48 h (s.8 + s.9), which course of
action may not be in line with the
common law, even if the patient is
informed of the non-consensual test at
the earliest opportunity (s.10).
The advice states that ‘you must
therefore be prepared to justify your
decision (to test non-consensually)’ if a
complaint is made to the doctor’s
employer or the GMC, or if challenged
in court, but justification could prove
difficult. Several arguments might be
used. Firstly, the ‘best interests’ argument:
the patient was tested because
his ⁄ her symptoms were unexplained
and possibly attributable to HIV ⁄
HBV ⁄ HCV, requiring diagnosis and
Ó 2007 The Author
Journal compilation Ó 2007 The Association of Anaesthetists of Great Britain and Ireland 1199

Editorial Anaesthesia, 2007, 62, pages 1199–1201
.....................................................................................................................................................................................................................
treatment. This would require a high
standard of circumstantial medical evidence
suggesting this to be the case.
Second, the ‘good egg’ argument: the
unconscious patient is assumed to be a
kind person, who would consent to
testing if s ⁄ he were competent, and
therefore, have his best interests served
through not subjecting the injured
healthcare worker to either the anxiety
of not knowing the patient’s HIV status,
or the side-effects of PEP. Finally, the
‘rights’ argument: that the healthcare
worker’s right to discover the patient’s
HIV status (possibly with reference to
Articles 2 and 3 of the Human Rights
Act 1998 (HRA) [23]) is more pressing
than the patient’s right to not be tested
(possibly protected by Articles 2, 3 and
8 of the HRA).
In practice, such justification is yet to
be tested in a UK court [24], and is now
unlikely to be, as the GMC has recently
rescinded paragraphs 8–11 of Serious
communicable diseases, in light of the
Human Tissue Act 2004 and the Mental
Capacity Act 2005.
According to the HTA, appropriate
consent from living patients is legally
required [1(1)(d) + (f)] for storage and
use of human tissue (which includes
blood for HIV testing) for the purpose
inter alia of obtaining scientific or
medical information about a living or
deceased person which may be relevant
to any other person [Schedule 1, s.1(4)].
Storage and use of tissue from patients
who lack capacity (i.e. many intensive
care patients) is unlawful (s.6), unless
allowed by the Secretary of State, in this
instance according to the Human Tissue
Act 2004 (Persons Who Lack Capacity
to Consent and Transplants) Regulations
2006 [25]. The Regulations allow
for non-consensual storage and use of
tissue to ‘obtain scientific or medical
information about a living … person
which may be relevant to another’ (i.e.
an HIV test after needlestick injury),
provided inter alia that the nominated
doctor taking the blood does so in ‘what
s ⁄ he reasonably believes to be in the
best interests of the person lacking
capacity from whose body the material
came’. So again, blood may only be
taken if the intent is to benefit the
patient, and not the healthcare worker.
The Mental Capacity Act 2005 [26]
(MCA) is no more helpful in terms of
the non-consensual testing of patients
who lack legal capacity. From October
2007, patients over 16 years of age must
be assumed to have capacity unless they
are found to lack capacity. Any decision
to test a patient without capacity for
HIV must continue to be made in the
patient’s best interests, if there is no
other way to establish his ⁄ her HIV
status. Although it will remain the case
that the doctor will usually decide (s ⁄ he
must be able to justify that decision in
court), any decision must be made in
the patient’s best interests (i.e. not the
interests of the healthcare worker sustaining
a needlestick injury). Interestingly,
a properly appointed donee of an
Lasting Power of Attorney, or a courtappointed
deputy, may give proxy
consent for blood testing, but again
they must do so in the patient’s best
interests. In addition, a patient may, in
theory, consent to or refuse HIV testing
by means of an advanced directive.
Effectively, therefore, the combined
effects of the HTA and MCA have
firmly closed the backdoor to testing
afforded by the GMC’s previous guidelines,
and threatened doctors with
imprisonment if they test patients for
HIV non-consensually.
This problem was foreseen during
the passage of the Mental Capacity Bill,
but an attempt by the British Medical
Association to amend the Bill to allow
non-consensual HIV testing to ‘avert
the death of, or serious illness in,
another person’ was withdrawn, after
assurances from the government that
this circumstance would be clarified in
the Code of Practice accompanying the
Act [27]. Predictably it wasn’t – there is
no reference to HIV testing in all 302
pages of the Code of Practice [28].
Section 6 of the Code deals with the
protections that the Act offers for
healthcare workers (amongst others),
but repeats the maxim that any intervention
must be in the patient’s best
interests.
In an attempt to clarify the law in
relation to HIV testing, I contacted
both the HTA and the Court of
Protection (the latter via the Public
Guardianship Office). Both agencies
were very helpful. After consultation,
the HTA sent me the following statement
for publication:
‘The HTA are aware of the complex
issues this situation generates. The HTA
are currently part of discussions on this
issue being led by the Department of
Health, BMA and other organisations in
relevant sectors. The general status of
the situation is that this issue is still
under discussion and the regulations are
still being drafted. Therefore, at present
it is difficult for the HTA to comment
further on this area. We are waiting
further clarification from the Department
of Health at which point we will
be in a position to move forward on this
area of work. Please keep checking the
HTA and relevant websites in the sector
for any news on this issue’.
The Public Guardianship Office referred
me to the Human Tissue Branch
of the Department of Health, who
concurred with the above analysis of
the problem, and stated by letter: ‘We
are actively considering this complex
issue and have – as the HTA advised
you – been in discussion with a number
of interested bodies. We hope to be in a
position during the summer to consult
on new proposals for addressing some of
the concerns expressed’.
To summarise, anaesthetists must
beware: in the event of a needlestick
injury to a healthworker, blood may
only be drawn from an unconscious
patient for the purposes of communicable
virus detection, provided that to
do so would be in the best interests of
the patient.
The medical and nursing professions,
in partnership with the Department of
Health and the Courts, would be well
advised to strenuously seek an expeditious
solution to this impasse to optimise
the postexposure treatment of
healthcare workers after needlestick
injuries.
Acknowledgements
I would like to thank the Human Tissue
Authority, Public Guardianship Office
and Department of Health for their
prompt assistance, as well as Dr Steve
Yentis for initially raising the issue. An
interesting discussion of the ethics surrounding
these issues can be found on
Ó 2007 The Author
1200 Journal compilation Ó 2007 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia, 2007, 62, pages 1199–1201
Editorial
.....................................................................................................................................................................................................................
Radio 4’s Inside the Ethics Committee,
broadcast 12th September, 2007 [29].
Stuart M. White
Consultant in Anaesthesia
Brighton Anaesthesia Research Forum,
Brighton and Sussex University
Healthcare NHS Trust
Eastern Road
Brighton, East Sussex, BN2 5BE,
UK
E-mail: igasbest@hotmail.com
References
1 HMSO. The Human Tissue Act,
2004. http://www.opsi.gov.uk/acts/
acts2004/20040030.htm [accessed 10
October 2007].
2 Redfern M. The Royal Liverpool
Children’s Enquiry. January 2001.
http://www.rlcinquiry.org.uk/
download/index.htm [accessed 10
October 2007].
3 Kennedy I. The Bristol Royal Infirmary
Inquiry. Final Report. July 2001.
http://www.bristol-inquiry.org.uk/
final_report/index.htm [accessed 10
October 2007].
4 HM Inspector of Anatomy. The
Investigation of events that followed
the death of Cyril Mark Isaacs. May
2003. http://www.doh.gov.uk/cmo/
isaacsreport/ [accessed 10 October
2007].
5 Department of Health. Human Bodies,
Human Choices. The Law on
Human Organs and Tissue in England
and Wales. A Consultation Report.
July, 2002. http://www.doh.gov.uk/
tissue/humanbodieschoices.pdf
[accessed 10 October 2007].
6 Liddell K, Hall A. Beyond Bristol and
Alder Hey: the future regulation of
human tissue. Medical Law Review
2005; 13: 170–223.
7 McHale J. The Human Tissue Act
2004: innovative legislation – fundamentally
flawed or missed opportunity?
Liverpool Law Review 2005; 26:
169–88.
8 Mavroforou A, Giannoukas A, Michalodimitrakis
E. Consent for organ
and tissue retention in British law in
the light of the Human Tissue Act
2004. Medicine and Law 2006; 25: 427–
34.
9 Furness PN. The Human Tissue Act.
British Medical Journal 2006; 333: 512.
10 Editorial. Effective implementation of
the Human Tissue Act. Lancet 2006;
368: 891.
11 Underwood JC. The impact on
histopathology practice of new human
tissue regulation in the UK. Histopathology
2006; 49: 221–8.
12 Lucassen A, Kaye J. Genetic testing
without consent: the implications of
the new Human Tissue Act 2004.
Journal of Medical Ethics 2006; 32: 690–
2.
13 Bell MD. The UK Human Tissue Act
and consent: surrendering a fundamental
principle to transplantation
needs? Journal of Medical Ethics 2006;
32: 283–6.
14 Bell MD. Emergency medicine, organ
donation and the Human Tissue Act.
Emergency Medicine Journal 2006; 23:
824–7.
15 Elder A, Paterson C. Sharps injuries in
UK health care: a review of injury
rates, viral transmission and potential
efficacy of safety devices. Occupational
Medicine 2006; 56: 566–74.
16 Huang L, Quartin A, Jones D, Havlir
DV. Current concepts: intensive care
of patients with HIV Infection. New
England Journal of Medicine 2006; 355:
173–81.
17 Health Protection Agency. Eye of the
Needle. Surveillance of significant
occupational exposure to bloodborne
viruses in healthcare workers. January
2005. http://www.hpa.org.uk/
infections/topics_az/bbv/pdf/eye_
of_the_needle.pdf [accessed 10
October 2007].
18 Rapiti E, Prüss-Üstün A, Hutin Y.
Assessing the Burden of Disease from
Sharps Injuries to Health-Care Workers at
National and Local Levels. Geneva:
World Health Organization, 2005.
http://www.who.int/quantifying_
ehimpacts/global/7sharps.pdf
[accessed 10 October 2007].
19 UK Chief Medical Officer’s Expert
Advisory Group on AIDS. HIV postexposure
prophylaxis. http://
www.dh.gov.uk/assetRoot/04/08/
36/40/04083640.pdf [accessed 10
October 2007].
20 Puro V, Cicalini S, De Carli G, et al.
European recommendations for the
management of healthcare workers
occupationally exposed to hepatitis B
virus and hepatitis C virus. Euro
Surveillance 2005; 10: 260–4.
21 Consent. In: White SM, Baldwin TJ.
Legal and Ethical Issues in Critical Care
and Perioperative Medicine. Cambridge:
Cambridge University Press, 2004:
49–71.
22 General Medical Council. Serious
communicable diseases. October
1997. http://www.gmc-uk.org/
guidance/current/library/serious_
communicable_diseases.asp [accessed
10 October 2007].
23 White SM, Baldwin TJ. The Human
Rights Act, 1998: implications for
anaesthesia and intensive care. Anaesthesia
2002; 57: 882–8.
24 Halpern SD. HIV testing without
consent in critically ill patients. Journal
of the American Medical Association 2005;
294: 734–7.
25 Human Tissue Act 2004 (Persons
Who Lack Capacity to Consent and
Transplants) Regulations : SI no.
1659. 1. http://www.opsi.gov.uk/
SI/si2006/20061659.htm [accessed 10
October 2007].
26 White SM, Baldwin TJ. The Mental
Capacity Act, 2005. Implications for
anaesthesia and intensive care. Anaesthesia
2006; 61: 381–9.
27 Mental Capacity Bill. Hansard,
1st February 2005, 194. http://www.
publications.parliament.uk/pa/
ld200405/ldhansrd/vo050201/text/
50201-27.htm#50201–27_spnew1
[accessed 10 October 2007].
28 Department for Constitutional Affairs.
Mental Capacity Act 2005. Code of
Practice. http://www.dca.gov.uk/
legal-policy/mental-capacity/mca-cp.
pdf [accessed 10 October 2007].
29 British Broadcasting Corporation.
Inside the Ethics Committee. Can an
unconscious patient be tested for
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www.bbc.co.uk/radio4/science/
ethicscommittee_s3_tr3.shtml
[accessed 10 October 2007].
Ó 2007 The Author
Journal compilation Ó 2007 The Association of Anaesthetists of Great Britain and Ireland 1201

Analysis of Benefits and Harms of Compulsory testing
Patient Practitioner Team Trust Public
Benefits
Harms
Fair – all patients
treated the same
Possible early
diagnosis and Rx
Autonomy overridden
- coercion
Small risk from
procedure
False
positives/negatives
Certainty of need
for Rx
Better informed
decision
Feels “valued”
More likely to
report?
Uncertainty of –ve
result
False -ve
Team morale
Feel “valued”
Les likely to have
absence due to stress
May be less risk
averse
More likely to report
Additional procedure -
> additional exposure
May become less
careful
Practicality Additional storage of samples
Cost of testing, staff time
How to deal with results – confidentiality for patient and practitioner
Simplified Process
Primary medical/dental care?
Better Staff Morale
More focused Rx may reduce
costs
Reduced absence
Senior Mgt do not have to
spend time on individual
cases
Legal clarity
Improved Occupational
Health
Resistance from
GUM/Virology
Happier valued workforce
Enhance Recruitment
retention
Better prevalence
information
“right Thing to do”
HCPs may less risk averse
Potential Distrust of
doctors/NHS
Costs of testing/treatment
Potential Compensation to
patient/practitioner

OPTION 3 – PRESUMED CONSENT.
‘Presumed consent’, in the context of blood borne virus testing, assumes that consent has
been given for blood testing unless the patient has specifically refused testing. There is no legal
precedent for presumed consent in the United Kingdom.
Several commentators have decried the very notion of presumption, declaring that
‘presumed consent’ is equivalent to ‘no consent at all’ and that the presumption of consent
affords the patient little protection against what would otherwise be legally considered a battery.
Presumption places no duty on the doctor to ascertain whether the patient might indeed be
capable of giving consent (as should happen according to the Mental Capacity Act 2005), or to
provide information to the patient about the risks and benefits of BBV testing, or to assess
whether there is any voluntariness on the part of the patient to agree to what is proposed. In
addition, vulnerable groups (children, mentally incompetent adults) may not be in a position to
raise an objection. As such, presumed consent is contrary to the increasing emphasis placed on
patient autonomy by UK legislators, through consent.
Nevertheless, 4 arguments might be used to support the introduction of presumed consent
for BBV testing:
1) Public support. Overwhelming public support, through informed public debate, could
consolidate an ethical mandate for presumed consent in this specific instance.
2) Social contract. Doctors and nurses will continue to provide healthcare for patients, on the
understanding that consent will be presumed for BBV testing should a needlestick injury
occur and there is a genuine risk of inoculation (with safeguards similar to the GMC’s
withdrawn advice).
3) ‘Soft’ presumed consent ie presumed consent only with the confirmative assent of relatives or
close acquaintances.
4) Organ donation. The government have recently indicated at least an interest in presumed
consent with regards organ donation. Applied to BBV testing, this would mean that
individuals would have to specifically ‘opt out’ of testing, probably by indicating in written
form that they would not want to be tested. There is a danger that by setting a new legal
context in the case of BBVs, that a precedent of presumed consent could be extended to
organ donation.

AAGBI Needlestick Injuries Working Party
Daniel K. Sokol
Option: non-consensual testing of patients (on an existing or specifically taken sample) in
the event of a needlestick injury for the benefit of the injured healthcare professional.
This option is currently unlawful in England and Wales if the testing is not in the
patient’s best interests.
Several arguments can be presented in favour of the option:
1. The clinical, social and psychological benefits to the healthcare professional outweigh
the relatively minor infringement of autonomy associated with testing a sample.
2. In the case of unconscious patients, it is probable that the vast majority would not
object to the test, given the absence of pain, the virtually non-existent clinical risks of
the testing and the obvious benefits to the healthcare professional.
3. The injured worker’s colleagues who form part of the medical team may be reassured
by a) knowing their colleague’s state of infection, b) knowing that their colleague is
aware of his or her state of infection and c) knowing that testing is a lawful option in
the eventuality of sustaining a needlestick injury themselves.
4. In light of the incidence of needlestick injuries and the distress potentially caused by
ignorance of one’s disease status, allowing such testing is likely to boost staff morale,
reduce ‘burnout’ in the profession generally and may help retain staff. This should
benefit patients generally.
5. This option, which emphasises the autonomy and welfare of the healthcare
professional, may aid recruitment into high-risk specialties or, at least, will not
contribute to a fall in recruitment.
6. Reciprocity – one may argue that patients have certain duties towards the healthcare
professionals who are putting themselves at risk to help them (e.g. the duty not to be
physically or verbally abusive), as long as these duties are not too onerous. Allowing
oneself to be tested for HIV and hepatitis, even if only for the benefit of the
healthcare workers, may constitute a patient’s duty and should be enforced.
There are also arguments against the option:
1. Non-consensual testing may violate the autonomy of those who either explicitly refuse
to be tested or, if unconscious, who would have refused to be tested.
2. Is it really practicable or indeed desirable to obtain a sample from a conscious patient
who does not wish to be tested? One less coercive option, then, would be to permit nonconsensual
testing on unconscious patients only (except when it is known that the patient
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
patient is conscious but incapacitous, we could suggest that testing is permitted on an
existing sample only.
3. If testing is compulsory, patients in need of medical treatment may be reluctant to seek
treatment for fear of being tested against their will (albeit only in the rare eventuality of a
needlestick injury). This could have adverse effects on the patients’ health and have
negative cost implications to the National Health Service. This represents another reason
for preferring the non-mandatory option mentioned above.
A number of questions remain. If the test is performed against a competent patient’s will,
should the information obtained be offered to the patient? Should it be recorded in the
patient’s notes? If the patient was unconscious when the test was performed, when, how
and what should he or she be told?

AAGBI NEEDLESTICK INJURIES WORKING PARTY
OPTIONS FOR CHANGE
OPTION 5 – MAINTAIN STATUS QUO.
A competently made refusal of BBV testing by a patient prohibits a doctor from testing that
patient’s blood for BBVs in the event of a needlestick injury to a third party.
The effect of Mental Capacity Act 2005 and the Human Tissue Act 2004 on the non-consensual
testing for BBVs after needlestick injuries involving patients without capacity has been to countermand
the advice (now withdrawn) of the GMC (Serious Communicable Diseases guidelines, 1997) with
regard to this eventuality. Statute now demands that in the event of a needlestick injury to a
healthworker, blood may only be drawn from a patient who lacks legal capacity for the purposes of
BBV detection, provided that to do so would be in the best interests of the patient.
If BBV testing is prohibited, the injured third party must wait for 3-6 months before secondary
testing to confirm seroconversion, taking appropriate post-exposure prophylaxis (PEP) in the interim
exposing themselves to both the side-effects of PEP drugs, and associated psychological stress.
The prevention of needlestick injuries remains of primary importance. Nevertheless, injuries are
likely to still occur. Pragmatically, such injuries are rare; furthermore, needlestick injuries from a
known patient who is permanently unable to consent are likely to be extremely rare. Nevertheless, a
situation involving an untestable patient is likely to arise, and it is morally untenable that the ‘right’ to
treatment of the injured party should defer to any ‘right’ of an incompetent patient not to have a BBV
test, particularly if a more minimally invasive test can be used and appropriate safeguards regarding
confidentiality are observed.
Possible solutions include:
1) Covert, non-consensual testing – which is against the law;
2) Testing secondary to reassessment of a patient’s BBV risk, in which case testing would (probably)
be in the patient’s best interests
3) Non-consensual testing to provoke a legal test case. This is a high-risk strategy that could lead to
imprisonment, but could stimulate a thus far intransigent government into introducing secondary
legislation
4) Lobbying government to introduce secondary legislation, or MPs to introduce a Private Member’s
Bill
5) Increasing awareness among patients of how to assert their choice under existing legislation, for
example, via a Lasting Power of Attorney or Advance Decision.

Needle-stick injury and HIV testing of the incompetent adult
– the status of assent of the next-of-kin
MD Dominic Bell
The precise status of the next-of-kin in the healthcare management of the incompetent
adult remains ill-defined within the UK or indeed any jurisdiction. The Mental
Health Act 1959 removed any authority under English law and although the Mental
Capacity Act has extended ‘power-of-attorney’ to medical and personal welfare
matters, this will predictably be limited numerically and in the nature of the
undertakings. Responsibility continues to rest therefore with medical staff acting in
the ‘best interests’ of the patient, 1 but directives from both government and the
professional bodies specify the involvement of the next-of-kin in decision-making. 2 3
Furthermore, since ‘best interests’ are not limited to ‘best medical interests’, but
incorporate ‘the patient’s wishes and beliefs when competent, their general well-being
and their spiritual and religious welfare’, 2 3 it appears essential to consult the next-ofkin
to determine their interpretation of these factors.
Despite this somewhat ambivalent position and additional conflict with the duty of
confidentiality, it is routine practice therefore within critical care to engage the next of
kin not only to update them on condition, prognosis and plans, but to ensure their
understanding of and assent to interventions such as surgery, tracheostomy, or blood
transfusion, using Consent Form 4 in certain circumstances.
The responsibility of the next of kin is particularly increased in decision-making on
maintenance, escalation, or withdrawal of life-sustaining medical treatment [LSMT]
when the prognosis and longer-term benefits are doubtful, and the next of kin are
asked to express a view on what they believe the patient would have wanted in such
circumstances, knowing their values and beliefs. This principle is extended further
Appendix6 1

when asking for the family’s position as to whether the patient would have favoured
organ donation when active support is to be withdrawn following a consensus on
futility. The overwhelming benefit of organ donation falls to a third party and it can
be seen that with reference to non heart beating donation, further undertakings are
necessary to ensure that the transplanted organs are at optimal viability and safety,
including serological testing for HIV and other transmissible diseases prior to death,
an intervention endorsed by the Intensive Care Society. 4
The arguments for this
approach are that it is in no one’s interests to embark on the process of retrieval and to
subsequently discover the presence of transmissible disease, or to delay the
transplantation of vulnerable organs whilst awaiting the results of such tests or indeed
tissue typing, taken after death. 5
In this scenario the next of kin are provided with full information as to all the facets of
organ donation, including the above aspects, in line with previous government
directives on provision of information for valid consent, 6 and give assent on that
basis.
The proposal to adopt this approach for serological testing after needlestick injury is
not therefore radical. The historical stigmata associated either with testing or a
positive result have been largely eliminated through legislation and government
directives, as well as the advances in medical therapy such as HAART. The key
principles essential to make this approach ethically defensible would be provision of
full information on what the test involves and the implications of a positive result, full
information on the physical and mental health implications for the relevant healthcare
practitioner of either knowing or not knowing a test result, choice as to how the test
result is recorded and ultimately provided to the patient if and when they should
Appendix6 2

egain capacity, and the absence of coercion. By considering standards in other
settings, it would appear essential to provide a written booklet on the above aspects
and for the interview to be carried out jointly by senior practitioners from intensive
care and genitourinary medicine. [This strategy has been defined and carried out
within the critical care environment of the General Infirmary at Leeds over the last 18
months].
Legal, political and professional implications of these proposals
The above strategy would arguably not require any change in legislation since the
Human Tissue Act does not specifically prohibit serological testing but simply
dictates that any intervention be in the patient’s ‘best interests’. For the protection of
the involved health care practitioners, it would however clearly be helpful for
government to endorse an expanded interpretation of ‘best interests’ to include
‘values and beliefs’ as well as purely medical best interests, and the role of the next of
kin in determining those best interests for the individual patient. If such endorsement
were not to be forthcoming, it should be apparent that non heart beating organ
donation could no longer be considered viable, since the process is critically
dependent on a parallel expanded interpretation of best interests and the assent of the
next of kin. With such endorsement however, it would then fall to the health-care
professions to explicitly define process as above to ensure provision of all essential
information and avoid any consideration of coercion.
1
2
3
4
5
6
Re F (Mental Patient: Sterilisation) [1990] 2 AC 1 (HL)
Department of Health. Good Practice in Consent. HSC 2001/023
GMC. Seeking patients' consent: the ethical considerations. GMC November 1998
Ridley S, Bonner S, Bray K, et al. UK guidance for non-heart beating donation. Br J Anaesth
2005; 95:592-595
Bell MDD. Non-heartbeating organ donation – clinical process and fundamental issues Br J
Anaesth 2005; 94: 474-78
Isaacs Report. Department of Health. London May 2003
Appendix6 3

Needle-stick Injuries from a Patients Perspective
The options considered at the meeting of /May 9 th with regard to the testing of
patients who have been the source of needle stick injuries were discussed with a broad
range of people i.e.: Yorkshire Cancer Network, Members of the Membership Council
of the local Trust, Members of Cancer Connections, general members of the public
with the ages ranging from late teens to 70s.
There was a general concern that NHS staff (considered in the widest terms) could be
left in a vulnerable situation, emotionally and psychologically should there be a
needle stick injury, with no recourse to testing if there is no permission given by the
source of the possible infection. They did not believe that it should be an occupational
hazard that should be accepted. The general opinion was that all staff had the right to
work in a safe environment and that their rights were every bit as important as the
patients.
There was an overwhelming belief that there should be effective training in place for
all staff on how to deal with equipment that could cause a needle-stick injury and how
to dispose of it correctly; also that the correct equipment for disposal should be a top
priority for all Trusts regardless of costs. There was also a belief that the training
should be updated regularly so that standards of care were maintained. It was also felt
that all Trust should be aware of the safest equipment on the market and encourage
staff to use it, thereby having an environment of good practice. There was a wish
expresses that an environment of openness operates within the NHS so that staff felt
that they would be well supported if a needle-stick injury occurred.
All six options were presented to the individuals questioned. There was a range of
responses as to how the case for needle stick testing should take place,
A) Probably most felt that there should that there should be blanket testing, that a
form should be signed when admitted to hospital for any procedure. Even
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
(for fear of needles). The question was asked if a mouth swab would allow the
range of tests needed to confirm a blood borne disease thereby circumventing
the need to take blood.
B) The next most made response was, all patients should sign a form that should
they be the source of a needle-stick injury they would be prepared to be tested.
It was stressed in both response a / b that the consent forms should be
explained very clearly to all. Not one person spoken to said that they would
refuse consent for testing for them selves or for a relative should that relative
be unable to give permission due to their medical condition.
C) When asked what should happen if an accident occurred when a patient was
unconscious with no person present to give permission for testing to take
place, the general response was that a test should go ahead with a full
explanation given, either to the relatives when they arrive or the patient when
conscious again. Should the relatives be present then they should have a clear
picture drawn of the situation and be asked for permission to test.
D) There was a general resistance to the idea of presumed consent for both
competent and incompetent patients. What was strongly expressed was the
feeling that the treatment throughout a needle-stick injury incident should be
sensitively managed for patient and professional so that it would have the best
outcome for all concerned.
It should be appreciated the general public do not have the detailed knowledge of the
medical ethics that are being considered by the committee. The responses recorded
are their reactions to the six changes to be considered.
Everyone without exception was concerned for the safety of NHS staff, they were
concerned for the cost implications if staff were off sick and if other NHS personnel
did not declare a possible infection and go on to infect other colleagues or patients.
It was recognised by all that there will always be unreasonable people what ever
changes take place and some felt that if they did not co-operate with NHS personnel
then treatment could be refused.

OAA / AAGBI Guidelines for
Obstetric Anaesthetic Services 2013
3
Published by
Association of Anaesthetists of Great Britain & Ireland
Obstetric Anaesthetists’ Association
June 2013

Membership of the working party
Dr Felicity Plaat
Dr David Bogod
Dr Valerie Bythell
Dr Mary Mushambi
Dr Paul Clyburn
Dr Nuala Lucas
Dr Ian Johnston
Dr Sarah Gibb
Dr Iftikhar Parvez
Dr Anne Thornberry
AAGBI, Chair of working party
OAA, President
AAGBI
OAA
AAGBI
OAA
AAGBI
AAGBI, GAT representative
AAGBI, SAS representative
RCoA representative
Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
Website: www.aagbi.org
Obstetric Anaesthetists’ Association
21 Portland Place, London, W1B 1PY
Tel: 020 7631 8883
Fax: 020 7631 4352
Email: secretariat@oaa-anaes.ac.uk
Website: www.oaa-anaes.ac.uk
© The Association of Anaesthetists of Great Britain & Ireland and the Obstetric Anaesthetists’ Association 2013.

Contents
1. Key recommendations 2
2. Introduction 3
3. Staffing 4
4. Services and standards 8
5. Training and education 17
6. The labour ward team 20
7. Support services, equipment, facilities and accommodation 23
8. The future 27
9. List of recommended guidelines 28
10. References 30
This is a consensus document produced by expert members of a Working Party established by the
Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Obstetric Anaesthetists’
Association (OAA). It updates and replaces previous guidance published in May 2005. It has been
seen and approved by the AAGBI Council and the OAA Committee.
• What other guideline statements are available on this topic?
The Royal College of Obstetricians & Gynaecologists have produced guidelines on the provision
of maternity services:
1. High quality women’s health care: A proposal for change. RCOG press, London, 2011.
2. Safer childbirth: Minimum standards for the organization and delivery of care in labour. RCOG
press, London, 2007.
• Why was this guideline developed?
The original guideline published in 1998 was developed to ensure that obstetric patients received
the same standards of anaesthetic care as those recommended for the general surgical
population.
• How and why does this statement differ from existing guidelines?
This guideline concentrates on the roles and activities of the obstetric anaesthetist within the
multidisciplinary team required to deliver safe maternity care. The major changes compared with
the 2005 version include a section on maternity critical care and the recommendation for
increased dedicated consultant anaesthetic sessions.
The need to define anaesthetic services in maternity in 2013 reflect the expanding role of the
anaesthetist as peri-partum physician in caring for an increasingly challenging patient population
in a rapidly changing health service.
Date of review: 2018
1

1. Key recommendations
1. A duty anaesthetist must be immediately available for emergency work on the delivery suite
24 hours a day.
2. There must be a nominated consultant in charge of obstetric anaesthesia with time allocated
for this role.
3. There should be a clear line of communication from the duty anaesthetist to the supervising
consultant at all times.
4. The workload of the obstetric anaesthetist continues to increase. As a basic minimum there
must be 12 consultant sessions per week to cover emergency work on delivery suite.
5. Scheduled obstetric anaesthetic activities (e.g. elective caesarean section lists, clinic) require
additional consultant sessions over and above the 12 for emergency cover.
6. Women should have antenatal access to evidence based information about the availability
and provision of all types of analgesia and anaesthesia. This information should be provided
or at least ratified by the department of obstetric anaesthesia.
7. There should be an agreed system whereby the anaesthetist is given sufficient advance
notice of all potentially high-risk patients.
8. When a 24-hour epidural service is offered, the time from the anaesthetist’s being informed
that a woman is requesting an epidural and ready to receive one until attending the mother
should not normally exceed 30 minutes. This period should only exceed one hour in
exceptional circumstances. Responses times should be regularly audited and if the above
standards are missed frequently, consideration should be given to alteration of staffing
arrangements.
9. Provision should be made for those who cover the delivery suite on-call, but do not have
regular sessions there, to spend time on the delivery suite in a supernumerary capacity with
one of the regular obstetric anaesthetic consultants.
10. There must be separate provision of staffing and resources to enable elective work to run
independently of emergency work, in particular to prevent delays to both emergency and
elective procedures and provision of analgesia in labour.
11. The person assisting the anaesthetist must have no other conflicting duties, must be trained
to a nationally recognised standard and must work regularly and frequently in the obstetric
unit.
12. The training undergone by staff and the facilities provided in the maternity recovery unit must
be of the same standard as for general recovery, as defined in current, published guidelines.
13. Appropriate facilities should be available for the antenatal and peripartum management of the
sick obstetric patient as defined in the document Providing Equity of Critical and Maternity
Care for the Critically Ill Pregnant or Recently Pregnant Patient.
2

2. Introduction
This is the third version of the joint Association of Great Britain and Ireland/Obstetric Anaesthetists’
Association (AAGBI/OAA) guidelines [1, 2]. A major change from the last revision in 2005 is the
inclusion of a section on critical care in maternity. This reflects the belated recognition of this
increasingly important area of obstetrics [3]. The number of women requiring advanced levels of care
is set to increase as the trend towards an older obstetric population with increasing morbidities and
levels of obesity shows no sign of abating. As a result, obstetric anaesthetists will continue to be
required to take on the role of peripartum physician (paralleling a growing enthusiasm for that of perioperative
physician in non-obstetric practice [4]). This will inevitably mean involvement in training of
staff caring for high-risk parturients and adoption of management roles to develop and maintain
critical care facilities.
These guidelines recommend a further increase in the minimum number of weekly anaesthetic
consultant sessions to 12 in order to provide delivery suite cover plus further sessions for scheduled
work (caesarean section lists/clinic, etc). This arises from three developments. Firstly, recent surveys
have confirmed that the workload of obstetric anaesthetists is increasingly onerous and complex [5,
6]. Secondly, the presence of the obstetric consultant on the delivery suite is now mandatory, with the
number of hours per week determined by the number of deliveries [7]; this must be reflected in
anaesthetic input. Thirdly, the Clinical Negligence Scheme for Trusts has circulated a draft standard
that elective work should be independently staffed in order that it can run uninterrupted by
emergencies. This is expected to be adopted as a full standard in due course.
On-call rooms are disappearing from many maternity units despite the well-described benefits of
enabling periods of proper rest during night-time working [8]. Even when working to a shift-based rota,
the most common pattern for trainees, fatigue is more likely to affect performance and thus patient
safety at night. Even short periods of sleep can help mitigate these effects and we have therefore
recommended that appropriate facilities be made available.
Effective teamworking is crucial to maternity care as highlighted in a recent report on safety in
maternity services [9]. Obstetric anaesthetists play a pivotal role in the team itself and in delivering
training in teamworking. This is reflected in our recommendations for anaesthetic representation on all
maternity committees.
As noted in the previous version of these guidelines, we realise that our recommendations potentially
have major financial and organisational implications. However, they are based on consideration of the
safety of the women who deliver in our units and their babies. We have therefore stressed yet again
that consideration should be given to amalgamating units that are too small to support the costs of
providing these services.
3

3. Staffing
Anaesthetists are involved in the care of over 60% of pregnant women. The Audit Commission found
a wide variability of anaesthetic staffing on labour wards [10] and a recent survey confirms this [6].
Previous recommendations concerning anaesthetic staffing were based on delivery rates. Busy units
were defined somewhat arbitrarily as those with > 5000 deliveries per year, an epidural rate > 35%
and a caesarean section rate > 25%, tertiary referral centres and/or centres with a high proportion of
high-risk cases. It was proposed that there should one consultant session per 500 deliveries with at
least 10 sessions for units with over 3000 deliveries [2]. However, there are several problems with the
use of such definitions [11]. The use of crude delivery rates:
• Does not take into account the huge variation in casemix that exists between units
• Does not take into account the impact of changing obstetric demographics (increased maternal
co-morbidities such as obesity, increased maternal age, increased assisted conception,
increasing immigrant population)
• Does not take account of the impact of the changes to training in anaesthesia (in particular the
effect of the European Working Time Regulations on training, associated paperwork and reduced
trainee numbers)
• Does not reflect the increased demand for the delivery of additional anaesthetic services such as
anaesthetic clinics, maternity high dependency units (HDUs) and support for interventional
radiology, etc
• Does not take into account changes in obstetric practice, such as increasing rates of caesarean
section, trial of instrumental delivery, cervical cerclage and repair of complex tears, all of which
increase theatre workload
The calculation of consultant sessions will need to take into account the volume of clinical work, the
contribution by consultants towards administration and other non-clinical activities, and the numbers
and experience of trainees. It is essential that the contribution made by non-consultant career-grade
anaesthetists is included.
It is the unanimous opinion of this Working Party that a move towards obstetric anaesthetic services’
being fully consultant delivered is both desirable and inevitable. Obstetricians have already set this
as an objective and are in the process of working towards it [12]. Ultimately, obstetric consultant
sessions devoted to emergency and elective obstetric activities should be matched by anaesthetic
consultant sessions.
4

Recommendations
Medical staff
The term ‘duty anaesthetist’ denotes an anaesthetist who has been assessed as competent to
undertake duties on the delivery suite under a specified degree of supervision.
The duty anaesthetist should be immediately* available to attend the obstetric unit 24 hours per day,
and must therefore have no other responsibilities outside obstetrics. In all units offering a 24-hour
epidural service, the duty anaesthetist must be resident on site.
If the duty anaesthetist is not a consultant, consultant support and on-call availability is essential 24
hours per day and a clear line of communication from the duty anaesthetist to the on-call consultant is
essential at all times. If the duty anaesthetist is a consultant, the workload of the unit may dictate a
need for additional manpower in order to deliver a safe service, and contact details of a back-up
anaesthetist should be immediately available at all times.
The name of the on-call consultant must be prominently displayed at all times. The names of all
consultants who cover labour ward, and their contact numbers, should be readily available.
The duty anaesthetist should not be responsible for planned maternity work such as elective
caesarean section lists, anaesthetic antenatal clinics, etc. Such activities should be able to continue
uninterrupted in the face of non-elective activities (e.g. emergency caesarean section, requests for
regional analgesia in labour).
In consultant-led obstetric units where anaesthetic care is not primarily consultant-delivered, there
should be a minimum of 12 consultant anaesthetic sessions (direct clinical care) per week to cover
non-elective activity (i.e. a minimum of two sessions per working day, taking account of leave). Where
there is a high turnover of trainees (i.e. a three-month interval or more frequent), a third evening
session may be necessary in order to train and supervise trainees adequately.
In addition, there must be further consultant sessions for direct clinical care, to cover elective
caesarean section lists and anaesthetic clinics.
There must be a nominated lead obstetric anaesthetist who has an active role in leading and
managing services, with this adequately recognised in their job plan.
*Immediately available – able to attend within 5 min or less of being summoned, except in exceptional circumstances.
5

Induction
All trainee and non-trainee anaesthetists, regardless of prior experience in obstetric anaesthesia,
should receive a formal induction to the obstetric anaesthetic unit before commencing duties. This
ideally should include:
• Information regarding the obstetric anaesthetic clinical supervisor and, if relevant, the educational
supervisor for their attachment
• A physical tour of the delivery suite, obstetric theatres, learning environment and any other
relevant areas
• Equipment:
o A demonstration of relevant equipment, e.g. anaesthetic machine, epidural infusion devices
o Location of the difficult airway trolley and its contents, including subglottic airway equipment
o Depending on the stage of training/prior experience, location of other equipment such as
blood storage fridge, rapid infusor device, cell salvage
• Resuscitation:
o Location of the cardiac arrest trolley with demonstration of the defibrillator and any other
equipment if unfamiliar
o Location of lipid emulsion
o Use of the resuscitaire and location of equipment required for neonatal resuscitation
• A clear description of:
o Local arrangements for handover and contacting senior staff
o Local arrangements for contacting the obstetric anaesthetist in an emergency and for a
category-1 emergency caesarean section
o The trainee/non-trainees’ responsibilities whilst covering the delivery suite
• The location of local guidelines for obstetric anaesthesia.
Handover
Time for formal handover between shifts must be built into the timetable. The shift pattern of different
professional groups should be compatible, e.g. anaesthetic and obstetric shifts should start/finish at
the same times to allow multidisciplinary handover.
Anaesthetists not in training
A survey has shown that associate specialist/staff grade/specialty doctors contribute to the provision
of obstetric anaesthetic services in 61% of units in the UK [6].
All non-trainee anaesthetists who undertake anaesthetic duties on the delivery suite should have
successfully completed the Initial Assessment of Competence in Obstetric Anaesthesia (IACOA) and
have been deemed by the consultant in charge of obstetric services to be competent to perform their
duties in accordance with OAA and Royal College of Anaesthetists (RCoA) guidelines. The doctors
must work regularly on the delivery suite and must also regularly undertake non-obstetric anaesthetic
work to ensure maintenance of a broad range of anaesthetic skills. Non-trainee anaesthetists who are
6

appointed directly from other countries may not be familiar with the protocols in the UK. The following
recommendations are to ensure that they are safe and are supported in the new working
environment:
1. There should be a defined period of directly supervised obstetric sessions. The duration of
supervision will depend on individual circumstances and should be mutually agreed
2. The anaesthetist must have successfully completed the IACOA before being allowed to work
unsupervised.
Theatre staffing
Many units still use midwifery staff to assist in the operating theatre and this has an impact on
midwifery staff on the labour ward. Strategic Health Authorities and Health Boards have been urged to
make significant progress in replacing midwifery staff in the scrub/instrument role [13].
Staffing for theatre recovery and anaesthetic assistance
Parturients requiring anaesthesia have the right to the same standards of peri-operative care as any
other surgical patient, including anaesthetic assistance. Training must be to the standards defined for
the care of the general surgical patient [14].
If the person assisting the anaesthetist is a nurse or midwife, they must have current and effective
registration, and must have been appropriately trained and been assessed as having achieved the
required core competencies [15]. They must be experienced and should assist the anaesthetist on
labour ward on a regular basis in order to maintain competence. The team providing care for women
undergoing obstetric operations must include a dedicated anaesthetic assistant for each patient in an
operating theatre. The assistant should have no other duties in the operating suite concurrently.
Newly recruited assistants should undergo a period of induction before working on the maternity unit.
The training undergone by staff in recovery, whether they are midwives, nurses or Operating
Department Practitioners, must also be of the same standard as that required for general recovery
facilities [16]. Midwives with no additional training are not equipped to recover patients following
anaesthesia. Staff should work in a general theatre recovery unit on a regular basis to ensure
competence is maintained.
All staff must be given regular access to continuing professional development and complete all
mandatory training as frequently as required.
7

4. Services and standards
In consultant-led, as opposed to midwifery-led, units, anaesthetic services should be available to all
women. The exact nature and availability of the services offered should be clear both to women
choosing to book in a particular unit and to commissioning bodies.
Antenatal services
Information for mothers
Up-to-date, locally relevant information about the services offered should be available for mothers in a
range of formats appropriate to their needs (e.g. written, electronic, audio with translations), including
as a minimum:
• Analgesia for labour: benefits (including efficacy); risks; and availability of all options offered
• Anaesthesia for caesarean section: benefits; risks; relative merits of all options offered
• All women should be asked if they would be prepared to receive blood in the case of
haemorrhage and this should be documented in the notes.
Information should be given to mothers in a timely way – usually antenatally – that is relevant to them.
Anaesthetists must have central role in the development of all information about pain relief and
anaesthesia. All mothers should be given and encouraged to read information about analgesia for
labour and anaesthesia for caesarean section, as the need for these choices is unpredictable and
may arise in an emergency.
Antenatal assessment and multidisciplinary planning
Timely antenatal anaesthetic assessment services should be provided for women who:
• Might present difficulties should anaesthesia or regional analgesia be required
• Are at high risk of obstetric complications
• Have a body mass index (BMI) greater than 40 kg.m -2 at booking [17]
• Have had previous difficulties with, or complications of, regional or general anaesthesia
• Have significant medical conditions.
Locally agreed referral criteria should be in place. Sample guidelines regarding referral to anaesthetic
services and supporting information are available from the OAA [18].
Reviewing women antenatally allows for communication between obstetric anaesthetists,
obstetricians and other specialists as required, and enables planning for the safe provision of
anaesthesia for high-risk women.
8

Peripartum care
Pre-operative assessment of women scheduled to deliver by caesarean section
Before admission, women should receive information about anaesthesia, relevant investigations
should be undertaken and arrangements made for pre-operative preparation (fasting, antacid therapy
and any other medication that should be given or withheld). This pre-operative assessment and
preparation may be led by midwifery or other appropriate staff, but an anaesthetist must be available
to provide advice and, if necessary, to review patients during this process. The process for such preassessment
services must include anaesthetic input and review.
Women should be assessed by an anaesthetist before their operation, and the plan for the
anaesthetic and informed consent to the anaesthetic confirmed (this may be done verbally – see
below).
Fasting guidelines are discussed below.
Informed consent
Information for mothers about labour analgesia and obstetric anaesthesia is available in a variety of
languages and formats to aid the process of informed consent [19]. The principles of consent for
anaesthesia or analgesia are set out in national guidelines [20]; it is not usually considered necessary
to obtain written consent. Brief details of the discussion that has taken place, and of risks that the
patient has been informed about should be recorded.
Regional analgesia for labour
Regional analgesia is the most effective form of labour analgesia [21]. Regional analgesia should be
available 24 hours per day, seven days per week, to all women delivering in consultant-led obstetric
units. Local guidelines should be developed covering the initiation, maintenance and management of
complications of regional analgesia for labour, based on current national guidelines and/or best
evidence [22].
Time to attend a request for analgesia
Requests for analgesia should be met as soon as possible. The time taken for the anaesthetist to
attend requests for analgesia, and from request for analgesia to achieving analgesia, should be
audited regularly: at least once a year in smaller units and more frequently in larger units. The time
from request for analgesia to the anaesthetist’s attending should not exceed 30 minutes. The RCoA
suggests unit audit standards for the proportion of women attended by anaesthetist within 30 minutes
of requesting epidural analgesia in labour [23].
9

Aseptic technique
It is mandatory to prepare the skin before performing central neuraxial block, and to use full aseptic
precautions to reduce the risk of infective complications. Antiseptic solutions are neurotoxic, hence it
is necessary to develop a systematic process for avoiding accidental injection or contamination of
neuraxial injectate with antiseptic solution. A local policy should be in place taking into account these
factors. Antiseptic solution should not be poured into receptacles on the sterile field that is to be used
for regional blockade [24, 25].
Initiation and maintenance of analgesia
The anaesthetist should be immediately available for review of women and management of initial
complications such as hypotension for at least 20 minutes after administration of the initial dose of
regional analgesic. Local guidelines should address the management of initial complications.
Continuing availability of an anaesthetist for review of women receiving regional analgesia is required
throughout its duration.
Monitoring and care of women receiving regional analgesia in labour
Midwives caring for women receiving regional analgesia for labour should have been trained and
deemed competent to do so by a local mechanism. Competence to care for women with epidural
analgesia should be re-certified annually as a minimum. The specific recommendations set out in
current national guidance should be followed [22].
The workload of the midwife assigned to a woman with a epidural in labour should be such that care
of that woman is not compromised as specified by local guidelines. The anaesthetist must be satisfied
with the level of care available.
Ambulation of mothers following initiation of epidural analgesia
Many delivery units encourage mothers who choose regional analgesia to ambulate. If ambulation is
facilitated, a specific guideline should exist outlining the process in place for assessing whether
women are able to ambulate safely. Falls, slips and trips occurring in women mobilising during
epidural analgesia should be reported via local incident reporting systems and audited.
Post-delivery care following regional analgesia in labour
Removal of the epidural catheter and its integrity should be documented. Return of motor power
should be monitored by continuing observations of motor power until full recovery is present. Women
should be advised not to get out of bed unaccompanied in the first instance. Postnatal falls in women
who have had epidural or regional analgesia for labour should be reported via local incident
monitoring systems, and monitored.
10

Intravenous patient-controlled opioid analgesia in labour
Intravenous patient-controlled analgesia (PCA) may be offered as an alternative to regional analgesia.
Recently, the use of remifentanil PCA has increased [26]. There have been serious safety incidents
associated with the use of remifentanil PCA in labour [27]. Strict adherence to locally developed
guidelines [28], careful monitoring of the mother and baby, and the constant presence of a member of
staff who is trained and competent to monitor maternal respiration are the minimum that is necessary
to ensure that this technique is safe.
Caesarean section
Many aspects of preparation and anaesthesia for caesarean section have been comprehensively
reviewed in the clinical guidelines on caesarean section produced by the National Institute for Health
and Clinical Excellence (NICE) [29]. Some of the more important standards or aspects not covered
are dealt with in this section.
Classification of urgency of caesarean section
Existing national guidelines should be followed regarding classification of urgency of caesarean
section:
1. Immediate threat to the life of the woman or fetus
2. Maternal or fetal compromise which is not immediately life-threatening
3. No maternal or fetal compromise but needs early delivery
4. Delivery timed to suit woman or staff.
The following audit categories have been suggested:
• ≥ 90% category-1 caesarean sections should have a decision-to-delivery interval ≤ 30 min
• ≥ 90% category-2 caesarean sections should have a decision-to-delivery interval ≤ 75 min [23].
However, regardless of the classification, each case must be judged and managed on its own merits
with delivery achieved as quickly as it is safely possible to do.
Pre- operative preparation
Before elective surgery, standard adult fasting guidelines should be adhered to [30]. Women waiting
for planned surgery should not be subjected to long periods of starvation and/or fluid deprivation (they
should be encouraged to drink clear fluids up until two hours pre-operatively). This should be audited
and monitored.
Choice of anaesthesia
The choice of anaesthesia for caesarean section rests with the competent mother. Information for
mothers is available in a variety of formats via the OAA website and should be used to help women
choose. Units should audit the type of anaesthesia used continuously, and monitor the results
annually against the RCoA’s proposed audit standards (Table 1) [23].
11

Table 1 Suggested audit standards for use of regional anaesthesia for caesarean section (CS) [23].
Category 1 2-3 4
Proportion of CS* under regional anaesthesia > 50% > 85% > 95%
Presence of birth partners
Obstetrics stands alone in permitting members of the public (usually the birth partner) to accompany
patients during an operation. Inviting members of the public into the operating theatre environment
carries risks. These should be managed by ensuring that the purpose of the birth partner’s presence
is clear to all concerned, and that the birth partner agrees to follow certain codes of behaviour, which
should be set out in a local guideline and ideally clarified in a written information leaflet. The local
guideline should identify the member of staff responsible for looking after birth partners if they require
care or assistance unexpectedly during the operation.
Any particular needs that the birth partner has should be considered, and organised (if necessary)
antenatally. For example, partners with a raised BMI may require special seating.
Whilst most obstetric units encourage birth partners to support women during operations under
regional anaesthesia, few encourage their presence during general anaesthesia. This may be
distressing for both women and their partners, and policies should be clear. Safety of the woman and
her baby must be paramount. Development of antenatal information for birth partners would help to
address this issue and is encouraged.
Elective caesarean section lists
Women delivering by planned caesarean section should have their operations performed as part of a
scheduled list, resourced separately from the general workload of the delivery unit. A separately run
list requires a full theatre team and should include a consultant obstetrician and a consultant
anaesthetist. The list should be managed in the same way and to the same standards as other
elective surgery lists. This may not be cost effective in units with a low elective workload (e.g. one or
fewer elective caesareans per weekday or approximately 250 planned operations per year) but for all
other units, separate resources should be allocated.
Elective caesarean sections should neither interfere with delivery unit work nor be interrupted by
emergencies. Such interruptions and delays (to both the scheduled and the emergency workload)
should be audited and monitored, and any necessary action taken to correct recurrence.
Postoperative analgesia
Intrathecal or epidural diamorphine or morphine can provide adequate analgesia after caesarean
section without the addition of intravenous PCA opioid. The administration of parenteral opioids to
women who have received neuraxial opioids is discouraged as it increases the risk of respiratory
12

depression. In the absence of contra-indications, women should be prescribed regular oral analgesia
postoperatively. Pain scores on movement and sedation scores should be kept for all women
postoperatively, and additional analgesia should be offered without delay when required.
Recovery care
Local guidelines (based on relevant national standards) for standards of care in recovery should be
regularly updated, audited and monitored.
The following are recommendations of the AAGBI [16]:
• No fewer than two members of staff (of whom at least one must be a registered practitioner)
should be present when there is a patient in recovery who does not fulfil the criteria for discharge
to the ward
• All registered practitioners should be appropriately trained in accordance with the standards and
competencies detailed in the UK National Core Competencies for Post-anaesthesia Care [31].
All women leaving obstetric recovery areas should continue to receive appropriate post-operative
care. Staff caring for post-operative patients on post-natal wards must be trained to do so, and should
carry out post-surgical care as set out in local guidelines.
There should be a ratio of two recovery beds to one operating theatre [31]. It should be noted that
more space is required per bed area for obstetric theatre recovery, compared with general postoperative
recovery areas. This is because there is a need to accommodate birth partners, cots etc as
well as the patient in the same area.
To ensure privacy and dignity are maintained and that infection risk is reduced there should be
adequate space between beds, and the facility to have private conversations with mothers and to
conduct physical examinations (for example to check vaginal blood loss) [29].
Postnatal care
Following operative delivery, women need continuing care [29]. Any woman who has received
neuraxial opioids should have respiratory rate, pain and sedation scores monitored for a period
appropriate to the clinical situation.
Women who have received anaesthetic care (whether analgesia for labour or anaesthesia) should be
followed up routinely to obtain feedback and exclude complications. With early discharge following
delivery, it may be logistically impossible to achieve this, and significant complications may not
become manifest until after women have been discharged. Therefore, all women who have received
regional analgesia or anaesthesia should receive written information about when and how to seek
help if complications should arise; this is particularly important for women who are discharged within
13

24 hours of their procedure. Patients who have suffered significant complications (for example
awareness under general anaesthesia, accidental dural puncture) should be offered follow-up
outpatient review with a consultant anaesthetist in the postnatal period [23].
Resuscitation team
A team trained in advanced resuscitation of the pregnant woman should be available to all women in
obstetric units, and their skills should include the ability to carry out a peri-mortem caesarean section.
A system for calling and admitting the team urgently to the delivery unit should be in place. Regular
team training drills should be held.
Risk management
Units are expected to participate in relevant national audits, e.g. the Confidential Enquiries into
Maternal Deaths, the OAA’s National Obstetric Anaesthetic Database (NOAD), the UK Obstetric
Surveillance System (UKOSS), national incident reporting to the Medicines and Healthcare products
Regulatory Agency (MHRA) and other relevant bodies, local incident reporting and risk management.
Quality improvement, involving continuous monitoring of activity and outcomes to facilitate continuous
quality improvement, using appropriate formats, should be practised. The RCoA publishes a list of
relevant audits of obstetric anaesthesia services, which should be used to audit these standards [23].
Local safety procedures such as syringe labelling, double checking or both should be developed to
reduce the risk of wrong-route and other drug and infusion errors – and there should be adherence to
national standards in all locations, including in delivery rooms.
Local anaesthetic solutions intended for epidural infusion should be stored separately from
intravenous infusion solutions, in a locked cupboard or other safe area, to minimise the risk of
accidental intravenous administration of such drugs [32].
Maternal critical care
Maternity critical care is an important emerging area for obstetric anaesthetists that poses significant
organisational and clinical challenges. Compared with other areas of acute medicine, there is a
paucity of published evidence on which to base guidance.
Timely recognition of the sick parturient is key to ensuring a good outcome and reducing maternal
morbidity and mortality. Maternity services should implement NICE guidance on the recognition and
response to acute illness in adults in hospital [33]. Although these guidelines do not specifically
include the sick parturient, they provide a clear strategy for the delivery of care in this area.
Physiological observations should be recorded on admission for all women admitted to maternity
units, including midwifery-led units. A graded response strategy for patients identified as being at risk
14

of clinical deterioration, as recommended by the Maternity Critical Care Working Party [3], should be
agreed and delivered locally.
It is widely recognised that the quality of evidence for track-and-trigger systems in any area of
medicine is limited. Such systems allowing a graded medical response can be based on aggregate
scoring of physiological parameters (where points are allocated according to the degree of
derangement of physiological variables, and then combined into a composite score). Alternatively,
multiple parameter systems can be used (in which constituent criteria are not assigned a score but
instead trigger when combinations of criteria are met). Both systems have inherent advantages and
disadvantages. The recently published National Early Warning Score is an aggregate system but
specifically excludes the obstetric population [34].
Whether an aggregate or multiple parameter system is used, the response should consist of the
following three levels:
• Low-score group: increased frequency of observations and the midwife in charge alerted
• Medium-score group: urgent call to team with primary medical responsibility for the patient, plus a
simultaneous call to personnel with core competences for acute illness
• High-score group: emergency call to a team with critical care competences and a maternity team.
There should be an immediate response.
The Department of Health has defined a chain of response for the hospital team involved in the care
of the acutely ill patient in hospital (Fig. 1) [34]. This can be adapted for use in the maternity setting.
Non-clinical
Staff
→ Recorder → Recogniser →
Primary
Responder
→
Secondary
Responder
→
Tertiary
Responder
(Critical Care)
Communication and handover
Figure 1 Chain of response for acutely ill patients in hospital. Redrawn from [34].
Staffing
Where level-2 care (see below) is provided in the maternity unit, staff appropriately trained to provide
HDU care should be available 24 hours a day. The midwife/nurse-to-patient ratio must be at least one
midwife/nurse to two patients or one-to-one if care is provided in individual rooms. Midwives working
in this setting should have additional training that equips them with the necessary critical care
competences that have been clearly set out [3].
There should be a named consultant anaesthetist and obstetrician responsible for all level-2 patients,
24 hours a day.
15

High dependency care (level-2 adult critical care)
Since 2007, the obstetric population has been included in the Intensive Care Society (ICS) definitions
of levels of care in the adult population (Table 2) [35].
Table 2 Levels of care as defined by the ICS [35].
Level 0 Patients whose needs can be met by normal ward care
Level 1
Patients at risk of deterioration, needing a higher level of observation or those recently
relocated from higher levels of care
Level 2
Patients requiring invasive monitoring/intervention that includes support for a single
failing organ (excluding advanced respiratory support i.e. mechanical ventilation)
Level 3
Patients requiring advanced respiratory support alone or basic respiratory support in
addition to support of one or more additional organs
All units that care for high-risk patients must be able to access level-2 (HDU care) on site. Level-2
care may be provided within the maternity unit or within a hospital’s general adult critical care unit.
Level-2 care should be delivered to the same standard regardless of the setting.
Larger obstetric units should have a designated consultant (usually an anaesthetist) with relevant
skills who is responsible for delivery of obstetric HDU care. This lead person should ensure that local
standards are developed for identifying women who require critical care, based on existing national
standards [35].
In smaller units, the lead obstetric anaesthetist should ensure that local standards exist.
Intensive care (level-3 adult critical care)
Some patients on the maternity HDU (level 2) may progress to requiring level-3 critical care (ICU).
Delays in the transfer of critically ill obstetric patients to the ICU can significantly increase the mortality
rate. Therefore it is essential that every unit has clear pathways in place to facilitate transfer. There
should be close co-operation between the maternity HDU and the ICU teams at an early stage, with
consultant-to-consultant referral and early involvement of the ICU consultant. Formal, documented
local arrangements should exist for support and input from other disciplines (cardiology, respiratory
medicine and allied professionals) when required.
Escalation protocols should be in place for women requiring level-3 critical care.
All patients must be able to access level-3 critical care if required; units without such provision on site
must have an arrangement with a nominated level-3 ICU and an agreed policy for the stabilisation
and safe transfer of patients to this unit when required.
16

5. Training and education
Each obstetric anaesthetic unit should have a consultant with overall responsibility for the training and
education of trainee and non-trainee anaesthetists. They should be supported locally by trainers,
educational supervisors, College Tutors and Regional Advisors, and programmed activity time should
be allocated for work relating to this responsibility. Trainers must fulfil the RCoA [36] and General
Medical Council (GMC) criteria [37] and can include consultants, SAS doctors and senior trainees.
It is expected that in the future, the service is likely to be consultant-delivered; however, in the interim,
rotas should be designed to maximise training opportunities including, for example, an extended
working day for consultants [38].
Although a 24-hour obstetric anaesthetic consultant presence is the ideal, trainees also need to learn
to work without direct supervision and should develop their skills and confidence accordingly, without
compromising patient safety.
Induction
All trainee and non-trainee anaesthetists, regardless of prior experience in obstetric anaesthesia,
should receive a formal induction to the obstetric anaesthetic unit before commencing duties there
(see Section 3).
Levels of training
• A training programme appropriate to the educational opportunities offered by the unit should be in
place as documented in the RCoA 2010 Curriculum [36]
• Basic training for core trainees: this should consist of an absolute minimum of 20 directly
supervised sessions within a four-month period, during which time the trainee should achieve the
core clinical learning outcomes. It is recommended that at least half of these sessions are
supervised by a consultant obstetric anaesthetist
• Intermediate training for ST3/4 trainees: obstetric anaesthesia is one of the essential units of
intermediate level training. There should be a dedicated block of training over a 4-12 week period
and this should include 20 sessions as a minimum in order that all core clinical learning outcomes
can be completed. It would be anticipated that for most trainees, this would require several more
sessions than the 20 recommended
• Higher training: the majority of ST5/6/7 trainees will be expected to complete this level which is
required for any consultant covering delivery suite out of hours. It can be delivered in nonspecialist
units. Local arrangements should be in place to ensure that all the required learning
outcomes can be completed
• Advanced training for ST6/7 trainees: this should be undertaken by those trainees wishing to
develop a sub-specialty interest in obstetric anaesthesia and/or undertake daytime sessions in
obstetric anaesthesia, and those who are likely to go on to work in an obstetric tertiary referral
17

centre. This level of training can only be delivered in centres that allow the trainee the opportunity
to develop the skills required to manage the delivery suite and undertake complex obstetric cases
whilst building and consolidating knowledge of obstetric anaesthesia, obstetrics and neonatology
• Less than full-time (LTFT) trainees: at each level of training, LTFT trainees should be given an
appropriate period of training in obstetric anaesthesia, proportionate to the percentage of whole
time equivalent worked.
Assessment
Completion of the IACOA is mandatory for all core trainees before being allowed to work in an
obstetric unit without direct supervision. Achieving the IACOA, however, does not signal the
completion of the basic level unit of training in obstetric anaesthesia.
Supervision
All trainees should be supervised directly by a trainer present on delivery suite until the IACOA is
completed. In addition, a joint OAA/ RCoA survey in 2010 [5] recommended that:
• The IACOA should be used in conjunction with a local system of review that satisfies local clinical
governance arrangements before a trainee works without immediate supervision
• No trainee who feels unprepared to start obstetric on-call (regardless of completion of IACOA)
should be expected to join the on-call rota unless directly supervised. Departments should make
provision for this eventuality where rotas are written a long time in advance
• All trainees who have completed their basic obstetric training should have some opportunity to
cover the labour ward without immediate supervision, so that they are confident to take on this
responsibility once they are appointed to an ST3 post.
The first two of the above recommendations should also apply to non-trainee anaesthetists. All trainee
and non-trainee anaesthetists working without direct supervision on delivery suite must have a named
supervising consultant and both parties must be happy with the level of supervision available. In
addition, they must know how to contact the supervising consultant in the event of an emergency.
Simulation
Simulation-based educational techniques can be used to assist all anaesthetists to develop the skills
and attributes required to work safely and efficiently within the multidisciplinary obstetric team,
including:
• Technical skill development using part-task simulators e.g. epidural, cricothyroidotomy [39]
• Reinforcement of emergency drills e.g. failed intubation [40]
• Teaching and assessing clinical skills when clinical opportunities are limited e.g. general
anaesthesia for caesarean section
• Maternal and neonatal resuscitation [40]
• Teamwork training emphasising non-technical skills [9]
18

• Skills and drills training: anaesthetists should help organise and participate in regular
multidisciplinary drills covering delivery suite emergencies such as major obstetric haemorrhage,
maternal collapse and failed intubation [41]. These drills should be followed by debriefing and
feedback so that lessons can be learned at both an individual and a systems level.
Continuing professional development
All anaesthetists involved in the delivery of obstetric anaesthetic services should undertake
appropriate continuing professional development activities in line with revalidation guidelines.
19

6. The labour ward team
Maternity care is delivered by teams rather than individuals. Effective teamwork can increase safety;
poor teamwork can have the opposite effect [9]. A report on safety standards in the maternity services
identified the following problems:
• Differing goals of midwives and doctors with regard to the care of women
• Poor leadership and management
• Difficulties with communication between healthcare professionals during emergencies and shift
changes
It is essential that obstetric anaesthetists should establish clear lines of communication with other
professionals such as intensivists, neurologists, cardiologists, haematologists, other physicians,
surgeons, radiologists, outreach nurses, physiotherapists and pharmacists.
Team briefing and a safety checklist should be used routinely to facilitate good communication and
teamworking and reduce adverse incidents [42].
Checklists and team briefing
Pre-operative checklists and team briefing procedures should be used, both for elective and
emergency obstetric operations. Nationally-developed obstetric modifications of the standard format
exist and should be used or adapted for local use. In extreme emergencies, the procedure may be
truncated, but it must be borne in mind that these are the most error-prone situations. Use of the
checklist should be audited.
Anaesthetists and midwives
‘Midwifery-led care’ refers to all cases in which the lead professional for the case is a midwife rather
than an obstetrician. This type of care may be delivered in a variety of units. If regional analgesia is
required, the anaesthetist may be the only medically-qualified person involved with the
labour/delivery.
It is recommended that the following criteria should be met whenever a hospital or maternity unit is
proposing that anaesthetists should work directly with midwives who are acting as lead providers of
obstetric care:
• There should be a consultant-led obstetric service on site
• There must be guidelines in place for the management of regional analgesia that have been
agreed by anaesthetists, midwives and obstetricians. Midwives practising independently but
intending to make use of a regional analgesia service must agree to follow the guidelines of the
unit where they deliver their clients
20

• The midwife caring for a woman with an epidural must be trained in its management to a standard
acceptable to the anaesthetist responsible for the service, must undergo regular refresher
training, and must be managing regional analgesia on a regular basis
• The midwife must allow the anaesthetist access to any woman considering regional analgesia
who wishes to discuss pain relief options
• If the anaesthetist feels that an obstetric opinion is necessary, he/she should consult the midwife
in the first instance. However, if necessary, the anaesthetist may consult directly with the
obstetricians, but should inform the midwife that this is his/her intention
• All decisions regarding regional analgesia must rest with the anaesthetist.
Anaesthetists and obstetricians
• Anaesthetists should encourage and facilitate consultation in the antepartum period by making
themselves available when antenatal clinics are in progress and by ensuring clear lines of referral.
A system for the antenatal assessment of high-risk mothers should be in place with 24-hour
access to the information on the delivery suite
• Good communication on the delivery suite is vital in order to minimise last-minute referral and the
hasty decision-making that often ensues. Anaesthetists should make themselves known to
obstetricians who should, in turn, keep them informed of developing problems. Anaesthetists’
attendance at obstetric ward rounds is to be encouraged in order to be kept well informed of the
labour ward caseloads and casemix
• There should be formal arrangements in place and protected time for multidisciplinary handover
at the beginning and end of each shift
• Anaesthetists should be involved in planning decisions that affect the delivery of maternity
services. Anaesthesia should be represented on any committee that has relevance to anaesthetic
services on the labour ward such as the labour suite working party, obstetric directorate and risk
management forum.
Communication and classification of urgency
Whilst this section applies primarily to delivery by caesarean section, many of the items also apply in
principle to trial of operative vaginal delivery in the operating theatre. Standard classification of the
urgency of caesarean section as described in Section 4.6 should be used for caesarean section and
this classification should be considered for operative vaginal delivery. It is recognised that this grading
artificially categorises cases when in reality there is a continuum of risk, and that within a grade, some
cases may require delivery more urgently than others. Each case must be graded and managed
individually.
The situation may change after the decision to deliver has been made, and the classification should
be re-assessed following transfer to theatre by the responsible obstetrician, and kept under review
whilst anaesthesia is established.
21

Communicating both the planned procedure and its grade of urgency with the entire theatre team, as
soon as the decision to deliver is taken, is vital, and a process for doing this should be covered by
local guidelines. In addition, the anaesthetist responsible for the anaesthetic should be informed of
both the indication for the procedure and its urgency by the operating obstetrician in person whenever
possible.
Transferring patients to theatre may lead to delays, and measures to reduce such delays should be
covered by local guidelines.
Other professionals and roles
Neonatal resuscitation
Units differ as to their policies about the involvement of the anaesthetist in neonatal resuscitation.
Where they are given a role, anaesthetists should work with the neonatal team to ensure that
appropriate training is delivered and maintained.
Maternity care assistants
The role of maternity care assistants (MCAs) is to complement and not to substitute for midwives. In
some units they may be involved in monitoring and recording routine observations, or in assisting with
epidural placement or in theatre. Appropriate training must be provided if they are to adopt these
roles.
Support personnel
Increasing activity on the labour ward that requires information input, admissions and clerical duties
demonstrate the need for a ward clerk or receptionist to be available at all times. Housekeeping,
portering and maintenance teams need to be accessible on site because of the high turnover bed
occupancy, high technology environment and emergency service provision.
22

7. Support services, equipment, facilities and accommodation
For the efficient functioning of the obstetric anaesthetic service, the following support services,
equipment, facilities and accommodation are essential. The standards of equipment and monitoring
must be the same as that of non-obstetric anaesthetic service.
Support services
A supply of O rhesus-negative blood should be immediately (within five minutes) available to the
delivery suite at all times for emergency use. Grouping can be performed in about 10 minutes [42]
and group-specific blood should be delivered within 20 minutes of request. Standard issue of crossmatched
blood may take approximately 45 minutes [43] although some patients without antibodies
may be eligible for electronic issue which can be much quicker: if the laboratory is in receipt of two
‘group & save’ samples taken on separate occasions they may be able to issue cross-matched blood
as rapidly as group-specific [44].
In order to ensure that blood can be made available within the time frames stipulated, the transfusion
laboratory should ideally be situated on the same site as the maternity unit.
Due to changes in transfusion practice, apart from packed red cells, blood products such as fresh
frozen plasma (FFP), cryoprecipitate and platelets are now required earlier in the management of
haemorrhage. As part of the response to a major obstetric haemorrhage call, the laboratory should
make FFP available as rapidly as possible, enabling an approximate 1:1 ratio of red cells:FFP if
deemed appropriate [44]. Platelets are not stored by all laboratories. If a significant delay is
anticipated, the delivery suite should be notified in advance. The use of fibrinogen and prothrombin
complex concentrates should be considered early [45].
Haematology and biochemistry services must be able to provide rapid analysis of blood and other
body fluids. However, near-patient testing (see below) will guide blood and product replacement far
more quickly than standard laboratory tests and should be utilised whenever possible.
There must be rapid availability of diagnostic radiological services. In tertiary referral centres, 24-hour
access to interventional radiology services is highly recommended.
Medical physics technicians are required to maintain, repair and calibrate anaesthetic machines,
monitoring and infusion equipment.
Physiotherapy services should be available 24 hours a day, 365 days a year for patients requiring
critical care.
23

Hotel services must provide suitable on-call facilities including housekeeping for resident and nonresident
anaesthetic staff. Refreshments must be available throughout the 24-hour period.
There must be adequate secretarial support for the antenatal anaesthetic assessment clinic and other
duties of the consultant obstetric anaesthetist: teaching; research; audit; study; appraisal activities;
and other administrative work.
Equipment
Units should purchase appropriate equipment to enable safe delivery of neuraxial analgesia and
anaesthesia with regard to any relevant national or international safety guidance. It is mandatory that
local obstetric anaesthetists are involved in purchasing decisions involving equipment for neuraxial
analgesia and anaesthesia. Epidural infusion sets should conform to standards for colour-coding and
should be labelled.
A blood warmer allowing the transfusion of blood and fluids as well as warm air blankets must be
available. A Level 1® or equivalent rapid infusion device should be available for the management of
major haemorrhage.
A difficult intubation trolley with a variety of laryngoscopes, laryngeal mask airways and tracheal tubes
should be available. Second generation supraglottic airway devices that give some protection from
gastric contents [45] and other aids for airway management must be available in theatre. There
should be 24-hour access to a fibreoptic ’scope [46].
The maximum weight that the operating table can support must be known and alternative provision
made for women who exceed this. The operating table should be able to support a weight of at least
160 kg. Other equipment to facilitate the care of obese parturients such as weighing scales,
wheelchairs, equipment to assist with the transfer of patients between beds, equipment to assist with
ramping in order to optimise head and neck position for laryngoscopy, and appropriate ward beds
should be readily available [47].
Cell salvage equipment (and personnel trained it its use) should be available at all times for
emergency and elective caesarean sections in units that deliver women who decline to have blood
transfusion [48].
There must be equipment such as HemoCue® or blood gas analyser to enable bedside estimation of
haemoglobin concentration.
It is strongly recommended that there should be equipment to enable bedside estimation of
coagulation such as thromboelastography (TEG) or thromboelastometry (ROTEM) [43].
24

Equipment for PCA must be available for postoperative pain relief. Ultrasound machines should be
available for the use of ultrasound-guided central venous pressure lines insertion and transversus
abdominis plane (TAP) blocks, and to assist with central neuraxial blocks in obese patients.
Accurate clocks should be available in all delivery rooms and theatres.
Resuscitation equipment including a defibrillator should be readily available on the delivery suite and
should be checked regularly.
Facilities
The delivery suite rooms must be equipped with monitoring equipment for the measurement of noninvasive
blood pressure. There should also be readily available equipment for monitoring ECG,
oxygen saturation, temperature and invasive haemodynamic monitoring if required. All delivery rooms
must have oxygen, suction equipment and access to resuscitation equipment. Delivery suite rooms
must have active scavenging of inhalational analgesics to comply with Control of Substances
Hazardous to Health (COSHH) guidelines on anaesthetic gas pollution [49].
There must be easy and safe access to the delivery suite from the main hospital at all times of the
day.
There should be at least one fully-equipped obstetric theatre within the delivery suite. Where this is
not possible, a lift that can be commandeered for the rapid transfer of women to theatre must be
available. The number of operating theatres required should depend on the number of deliveries and
operative risk profile of the women delivering in the unit.
Obstetric theatres should be equipped and staffed to the same standards as other operating theatres.
[13, 49]. The standard of monitoring in the obstetric theatre must allow the conduct of safe
anaesthesia for surgery. The same standards of monitoring apply whenever an anaesthetist is
responsible for anaesthesia, whether general, regional or local [50].
Adequate post-anaesthesia care facilities, including the ability to monitor systemic blood pressure,
ECG, oxygen saturation and capnography, must be available within the delivery suite theatre
complex. The layout/lighting should conform to established standards; however, it must be
appreciated that obstetric recovery spaces need to be much larger than required for standard adult
recovery [16, 51].
There should be readily available ‘eclampsia boxes’ containing all necessary equipment and a
protocol for eclampsia [52].
25

Lipid emulsion, dantrolene and sugammadex may all be useful in anaesthetic emergencies. These
should be immediately available on the delivery suite and location of these drugs should be clearly
identified. Local anaesthetic and opioid solutions intended for epidural use should be available and
stored separately from intravenous fluids to minimise the risk of accidental intravenous administration
of such fluids.
All units that care for high-risk patients should be able to access level-2 HDU care on site (see
Section 4).
Accommodation
All consultant obstetric units should include dedicated office space for the sole use of the anaesthesia
team on the delivery suite, or close enough for the resident anaesthetist to be able to work there
between cases. This space should have adequate information technology facilities for both trainee
and trained staff to be able to deal with emails, complete mandatory online training, access journals
and search engines via the internet, complete portfolios and enter audit-related data. Local
multidisciplinary evidence-based guidelines must be available in the office. The office space, facilities
and furniture should comply with the standards recommended by AAGBI guidelines [53].
A library of specialist reference books/journals should be available. There should be a separate
anaesthetic consultants’ office available to allow teaching, assessment and appraisal, that complies
with AAGBI guidelines [53].
A communal rest-room in the delivery suite should be provided to enable staff of all specialities to
meet. A seminar room(s) must be available for training, teaching and multidisciplinary meetings.
We strongly support the provision of an on-call room containing a bed as there is good evidence that
even short periods of sleep improve performance during nightshift work (regardless of the length of
the shift) [8, 54].
Where a consultant is required to be resident, appropriate on-call accommodation should be provided
[55].
26

8. The future
The delivery of healthcare constantly needs to evolve to meet the challenges of a changing population
and deliver high-quality care; obstetric anaesthesia is no exception to this.
Changes in healthcare encompass both organisational and clinical aspects. Developments that the
Working Party supports include:
• An aspiration to develop a 24-hour consultant-delivered anaesthesia service in the maternity unit,
with the instigation of twilight and weekend sessions as an initial step
• An expanded role of the obstetric anaesthetist as a ‘peripartum physician’ – in particular, more
antenatal involvement in the management of women with high-risk/complicated pregnancies
• Developing relationships between the maternity team and other specialities in the hospital setting,
e.g. medical specialities such as cardiology, with maternity units receiving support from a named
cardiologist
• More extensive use of near-patient testing in the maternity unit
• Development of safe and effective alternatives to regional analgesia in labour
• Outcome-based research on the impact of intrapartum analgesia and anaesthesia on mother and
baby
• Further research into increased levels of anaesthetic safety
• Development of enhanced recovery programmes in obstetrics
• Confirmation at Department of Health level of the uninterrupted continuation of the Confidential
Enquiries into maternal death and morbidity with more timely and frequent reports
• Promoting equitable provision of anaesthetic services by ensuring anaesthetic representation on
commissioning bodies.
27

9. List of recommended guidelines
Departments should have written guidelines, setting out local standards of care (based on national
standards where these exist), including as a minimum the following (listed alphabetically):
• Analgesia post-caesarean section (including TAP blocks)
• Antacid prophylaxis for labour and delivery
• Antibiotic and thromboprophylaxis for caesarean section
• Awareness under general anaesthesia
• Cell salvage
• Conditions requiring antenatal referral to the anaesthetist
• Fasting before elective and emergency obstetric procedures
• General anaesthesia for caesarean section
• Guideline development
• HDU admission and discharge criteria
• High BMI (> 40 kg.m -2 )
• Intrauterine fetal resuscitation
• Intravenous opioid PCA (Including remifentanil PCA if available locally)
• Management of major haemorrhage (including trigger phrase to activate major haemorrhage
transfusion protocol)
• Management of pre-eclampsia and eclampsia
• Modified Obstetric Early Warning Score use
• Oral intake during labour
• Provision of information to patients including:
o Anaesthesia for caesarean section (general and regional)
o Pain management in labour
• Regional anaesthesia including:
o Hypotension during regional block
o Management of failed or inadequate regional block
o Management of high regional block
o Management of accidental dural puncture
o Management of epidural haematoma
o Management of post-dural puncture headache
o Management of regional techniques in patients receiving thromboprophylaxis
o Regional blocks for labour analgesia
o Regional blocks for surgery
• Recovery following general and regional anaesthesia
• Resuscitation of the pregnant patient
• Staffing levels
• Skills and drills training.
28

The following national guidelines should be displayed or be immediately available in all locations
where obstetric anaesthesia is delivered:
• Adult resuscitation guidelines [Resuscitation Council (UK)]
• Anaesthetic machine checklist [AAGBI]
• Management of:
o Anaphylaxis [AAGBI and/or Resuscitation Council (UK)]
o Failed intubation [to be produced by Dififcult Airway Society/OAA]
o Malignant hyperthermia [AAGBI]
o Neonatal life support [Resuscitation Council (UK)]
o Peri-arrest arrhythmias [Resuscitation Council (UK)]
o Severe local anaesthetic toxicity [AAGBI]
29

10. References
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Guidelines for Obstetric Anaesthesia Services. London: AAGBI, 1998.
2. Association of Anaesthetists of Great Britain & Ireland and Obstetric Anaesthetists’ Association.
Guidelines for Obstetric Anaesthetic Services 2. London: AAGBI, 2005.
3. Maternity Critical Care Working Group. Providing Equity of Critical and Maternity Care for the
Critically Ill Pregnant or Recently Pregnant Woman. London: Royal College of Anaesthetists, 2011.
4. Grocott MPW, Pearce RM. Perioperative medicine: the future of anaesthesia? British Journal of
Anaesthesia 2012; 108: 723-6.
5. Obstetric Anaesthetists’ Association. Joint RCoA-OAA obstetric anaesthetic training survey 2010.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=452 (accessed 26/04/2013).
6. Obstetric Anaesthetists’ Association. OAA-AAGBI workload survey. http://www.oaaanaes.ac.uk/content.asp?ContentID=467
(accessed 19/03/2013).
7. Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College
of midwives, Royal College Paediatrics and Child Health. Safer Childbirth: Minimum Standards for
the Organization and Delivery of Care in Labour. London: RCOG Press, 2007.
8. Association of Anaesthetists of Great Britain & Ireland. Fatigue and Anaesthetists. London: AAGBI,
2004.
9. The King’s Fund. Safe Births: Everybody’s Business. London: The King’s Fund, 2008.
10. Audit Commission. Anaesthesia under Examination: the Efficiency and Effectiveness of
Anaesthesia and Pain Relief Services in England and Wales. Oxford: Audit Commission, 1997.
11. Yentis SM, Robinson PN. Definitions in obstetric anaesthesia: how should we measure anaesthetic
workload and what is ‘epidural rate’? Anaesthesia 1999; 54: 958–62.
12. Royal College of Obstetricians and Gynaecologists. High Quality Women’s Health Care: a Proposal
for Change. London: RCOG Press, 2011.
13. College of Operating Department Practitioners. Staffing of obstetric theatres – a consensus
statement. http://www.codp.org.uk/documents/Staffing%20of%20Obstetric%20Theatres.pdf
(accessed 19/03/2013).
14. Association of Anaesthetists of Great Britain & Ireland. The Anaesthesia Team 3. London: AAGBI,
2010.
15. NHS Education for Scotland. Core competencies for anaesthetic assistants 2011
www.nes.scotland.nhs.uk/media/4239/anaesthetic_core_competencies_2011.pdf (accessed
19/03/2013).
16. Association of Anaesthetists of Great Britain & Ireland. Immediate Post-anaesthesia Recovery
2013. Anaesthesia 2013; 68: 288-97.
17. RCOG/CMACE. Joint Guideline Management of women with obesity in pregnancy. London:
RCOG/CMACE, 2010.
18. Obstetric Anaesthetists’ Association. Referral to anaesthetists. http://www.oaaanaes.ac.uk/content.asp?ContentID=339
(accessed 19/03/2013).
30

19. Obstetric Anaesthetists’ Association. Information for mothers. http://www.oaaanaes.ac.uk/content.asp?ContentID=83
(accessed 19/03/2013).
20. Association of Anaesthetists of Great Britain & Ireland. Consent for Anaesthesia 2. London: AAGBI,
2006.
21. Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of
systematic reviews. http://www.thecochranelibrary.com/details/file/1598141/CD009234.html
(accessed 19/03/2013).
22. National Institute for Health and Clinical Excellence. NICE Clinical Guideline 55. Intrapartum Care.
London: NICE, 2007. [being updated]
23. Royal College of Anaesthetists. Raising the Standard: a Compendium of Audit Recipes. 3 rd Edition
2012. London: RCoA, 2012.
24. Royal College of Anaesthetists. NAP3 National Audit of Major Complications of Central Neuraxial
Block in the United Kingdom, p75. London: RCoA, 2009.
25. Scott M, Stones J, Pane N. Antiseptic solutions for central neuraxial blockade: which concentration
of chlorhexidine in alcohol should we use? British Journal of Anaesthesia 2009; 103: 456-57.
26. Hinova A, Fernando R. Remifentanil for labor analgesia. Anesthesia and Analgesia 2009; 109:
1925-29.
27. Muchatula NA, Kinsella SM. Remifentanil for labour analgesia: time to draw breath? Anaesthesia
2013; 68: 227- 35.
28. Obstetric Anaesthetists’ Association. Remifentanil. http://www.oaaanaes.ac.uk/content.asp?ContentID=333
(accessed 26/03/13).
29. National Institute for Health and Clinical Excellence. Caesarean section clinical guidelines CG132.
http://www.nice.org.uk/CG132 (accessed 26/03/2013).
30. Association of Anaesthetists of Great Britain & Ireland. Preoperative Assessment and Patient
Preparation. The Role of the Anaesthetist 2. London: AAGBI, 2010.
31. Association of Anaesthetists of Great Britain & Ireland. UK National Core Competencies for Post-
Anaesthesia Care. London: AAGBI, 2013.
32. The Royal College of Anaesthetists. NAP3 full report. www.rcoa.ac.uk/document-store/nap3-fullreport
(accessed 26/03/2013).
33. National Institute for Health and Clinical Excellence. Acutely ill patients in hospital clinical
guidelines CG50. http://guidance.nice.org.uk/CG50 (accessed 26/03/2013).
34. Royal College of Physicians. National Early Warning Scores (NEWS).
http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warning-scorestandardising-assessment-acute-illness-severity-nhs.pdf
(accessed 26/03/2013).
35. Intensive Care Society. Levels of Critical care for Adult Patients. London: ICS, 2009.
36. Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics, 2 nd edn, London: RCoA,
2010.
37. General Medical Council. The Trainee Doctor. London: GMC, 2011.
31

38. Royal College of Anaesthetists. Working Time Directive 2009 and shift working: ways forward for
anaesthetic services, training, doctor and patient safety. https://www.rcoa.ac.uk/system/files/TRG-
WTR-Shift-Working.pdf (accessed 10/04/2013).
39. Uppal V, Kearns RJ, McGrady EM. Evaluation of the M43B Lumbar Puncture Simulator II as a
training tool for identification of the epidural space and lumbar puncture. Anaesthesia 2011; 66:
493-6.
40. Pratt S. Simulation in obstetric anaesthesia, Anesthesia and Analgesia 2012; 114: 186-90.
41. NHS Litigation Authority. Clinical Negligence Scheme for Trusts, maternity clinical risk
management standards.
http://www.nhsla.com/safety/Documents/Central%20Manchester%20University%20Hospitlas%20N
HS%20Foundation%20Trust%20-%20February%202012%20-%20Maternity.pdf (accessed
10/04/2013).
42. Haynes AB, Weiser TG, Berry WR, et al. The safe surgery saves lives study group. A surgical
safety checklist to reduce morbidity and mortality in a global population. New England Journal of
Medicine 2009; 360:491-9.
43. Association of Anaesthetists of Great Britain &Ireland. Blood Transfusion and the Anaesthetist.
Management of Massive Haemorrhage. London: AAGBI, 2010.
44. Medicines and Healthcare Products Regulatory Agency. MHRA guidance on electronic issue.
http://www.mhra.gov.uk/home/groups/is-insp/documents/websiteresources/con081801.pdf
(accessed 10/04/2013).
45. Sambasivan CN, Schreiber MA. Emerging therapies in traumatic haemorrhage control. Current
Opinion in Critical Care 2009; 15: 560–8.
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NAP4-Full.pdf (accessed 10/04/2013).
47. Association of Anaesthetists of Great Britain & Ireland. Peri-Operative Management of the Morbidly
Obese Patient. London: AAGBI, 2007.
48. Catling SJ, Freites O, Krishnan S, Gibbs R. Clinical experience with cell salvage in obstetrics: 4
cases from one UK centre. International Journal of Obstetric Anesthesia 2002; 11: 128-34.
49. Health and Safety Executive. EH40/96. Occupational exposure limits 1996. London: HMSO, 1996.
50. Association of Anaesthetists of Great Britain & Ireland. Recommendations for Standards of
Monitoring During Anaesthesia and Recovery. London: AAGBI, 2007.
51. NHS Estates. Revised schedules of accommodation. London: NHS, 2002.
52. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. Quality and
Safety in Health Care 2004; 13:127–129.
53. Association of Anaesthetists of Great Britain & Ireland. Department of Anaesthesia – secretariat
and accommodation guidelines. London: AAGBI, 1992.
54. Department of Health and Social Security. Anaesthetic Service Accommodation in District General
Hospitals. A Design Guide. London: DHSS, 1971.
55. Department of Health and Social Security. Secretarial and Support Services for Hospital Medical
and Dental Staff. Report of a Departmental Working Party. London: DHSS, 1987.
32

21 Portland Place, London, W1B 1PY
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Occupational Health and the Anaesthetist 2014
Published by
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650 Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org October 2014

Membership of the working party
(details correct at the start of the working party process)
Contents
Dr P Clyburn
Dr A Hartle
Dr F Plaat
Dr N Redfern
Dr I Walker
Dr E Anderson
Dr A Docherty
Dr C Shannon
Dr J Hartley
Chair and Immediate Past Honorary Treasurer, AAGBI
President, AAGBI
Honorary Membership Secretary, AAGBI
Honorary Membership Secretary Elect, AAGBI
Vice President, AAGBI
GAT Representative, AAGBI
GAT Representative, AAGBI
RCoA Representative
Occupational Health Representative
1. Summary of recommendations 3-5
2. Introduction – the role of occupational health 6
3. Occupational health and the sick doctor 7-8
4. Wellbeing 9-12
5. Health protection and management of workplace risk and hazard
a. Blood borne viruses 13-16
b. Respiratory infections 17-19
c. Manual handling and back care 20-22
d. Pregnancy 23-26
6. Advice on fitness to work 27-28
This guideline has been seen and approved by the AAGBI Board
The working party acknowledges the assistance from Dr E Davies
and Prof J Harrison.
7. Managing chronic conditions, including arrangements for return to work 29-32
8. Referral to regulatory authorities 33-34
9. References 35-37
10. Appendix 1 38
This is a consensus document produced by expert members of a Working Party
established by the Association of Anaesthetists of Great Britain and Ireland (AAGBI).
© The Association of Anaesthetists of Great Britain & Ireland 2014
Date of review: 2018
1

• What other guideline statements are available on this topic?
There is lot of information on occupational health for doctors. This guidance is
targeted specifically at anaesthetists and signposts much of the broader
available information.
• Why was this guideline developed?
This original guideline on Blood Borne Viruses (1992 and revised 1996) is
updated and extended to cover other occupational health issues relevant to
anaesthetists.
• How and why does this statement differ from existing guidelines?
Much of the information in this guideline is new and has not been previously
covered.
1. Summary
• The consultant occupational health physician’s role is wide-ranging and encompasses
health protection in the workplace, wellbeing, fitness for work, and support for staff with
chronic conditions. They may also have a role in assisting remediation when a doctor is
referred to the regulatory authority or professional assessment.
• Doctors sometimes fail to recognise the role of the occupational health physician,
believing them to be an arm of management.
• Sick doctors may be reluctant to seek help and, as a result, self-treat, seek help from
colleagues bypassing the usual channels, or delay seeking appropriate help and
treatment.
• Staff wellbeing is important to the quality of the delivery of patient care, staff retention
and engagement. Wellbeing is achieved by promoting a healthy lifestyle, providing good
working arrangements and environment, encouraging positive working relationships,
and effective support.
• Hospitals owe a duty of care to employees, and are required to provide prevention,
protection and post-exposure care. This includes the provision of personal protective
equipment and training in its use. Healthcare workers have professional responsibilities
and duties as employees to take up this training and use the equipment provided.
• Blood borne viruses are carried in the blood without necessarily causing symptoms in
the infected person. The most prevalent and important blood borne viruses are hepatitis
B, C and HIV.
• Blood borne viruses may be transmitted by needlestick injuries or by direct contact with
broken skin or mucus membranes. The risk of transmission from a deep penetrating
inoculation with a hollow needle is 1:3 for hepatitis B, 1:30 for hepatitis C and 1:300 for
HIV. Approximately 25% of reported high-risk injuries occur in the operating theatre or
intensive care unit.
• Pre-employment screening for transmissible diseases including tuberculosis and
hepatitis B is mandatory for all healthcare workers. Healthcare workers, who perform
exposure prone procedures, are required to have HIV and hepatitis C tests. Anaesthetists
are not deemed to undertake exposure prone procedures and so may be offered these
tests, but are not obliged to undergo them.
• Anaesthetists who have, or think they might have, any serious condition including a
blood borne virus must consult a suitably qualified colleague and ask for and follow
advice about investigations, treatment and changes to their practice that are considered
necessary.
• Occupational exposure to blood borne viruses is inevitable. Immediate first aid (washing
with soap and water, or irrigation) must be performed and then urgent assistance sought
2
3

from the occupational health department or the emergency department within an hour
of the exposure. Post-exposure prophylaxis for HIV for should be started within an hour
of exposure. Follow-up for hepatitis C must continue for at least 12 months or longer as
sero conversion may be delayed.
• Patients who are the source of exposure should be asked to consent to testing for a
blood borne virus. The decision to start post-exposure prophylaxis should be based on
a risk assessment of the exposure, and should never wait until patient testing has been
done. Post-exposure prophylaxis for hepatitis B and C is not available.
• Respiratory infections are an occupational hazard and anaesthetists should take
appropriate measures to protect themselves. These include immunisation, use of
personal protective equipment – masks, gloves and aprons/gowns, and good hand
hygiene.
• Infections that can cause severe illness if acquired include influenza, SARS, novel
coronavirus or tuberculosis. When managing patients who may have such infections,
doctors should seek and follow guidance from infection prevention and control team,
occupational health and/or health and safety teams.
• The consultant occupational health physician has a central role in advising and
supporting doctors with chronic illness and/or disability.
• Following a period of sick leave, the consultant occupational health physician will work
closely with the relevant manager to design a return to work package consistent with
good employment practice and the Trust’s attendance management policy. He or she
will monitor the individual doctor’s progress, and suggest modifications when needed.
• If an individual has a disability in the terms of the Disability Section of the Equality Act
2010, he or she may be entitled to ‘reasonable adjustment’ under the Act. The consultant
occupational health physician will advise on this, and work closely with the employee’s
manager to re-design the job and to modify equipment such that the individual can work.
• The consultant occupational health physician can advise on referral to the General
Medical Council or Medical Council of Ireland. If remediation is needed, the consultant
occupational health physician’s advice about the timing and nature of the remedial
package should be sought and followed.
• Work-related musculoskeletal disorders, including manual handling injuries, are the
most common type of occupational ill health in the UK accounting for approximately
40% of all sickness absence in the NHS.
• Anaesthetists should receive training in the principles of safe manual handling, and a
Patslide® or Hover Matt® employed whenever possible.
• Environmental factors may present risks to the pregnant mother and the developing
fetus during a normal pregnancy. Specific hazards include heavy physical work,
prolonged standing, long working hours and night shift work, exposure to chemicals
such as anaesthetic agents and to ionising radiation. A number of infections, including
cytomegalovirus, hepatitis A and B, HIV, listeria, parvovirus, rubella, toxoplasma, and
chickenpox are known to be a potential risk to the fetus or neonate and therefore
exposure to these should be avoided.
• The pregnant worker must inform the employer as soon as the pregnancy is known
as employers are required to carry out a risk assessment to decide how best to limit
exposure to hazards including infection and radiation.
• The occupational health physician has a responsibility to the employer to advise on
fitness for work and ‘reasonable adjustment’, and a responsibility to the individual to
advise on the natural history of the illness and potential effects on work, and to be their
advocate.
• Departments should have a defined and transparent process for referring a doctor to
the occupational health physician. This should include guidance on the background
information required and the importance of fully involving the doctor in the referral.
4
5

2. Introduction – the role of occupational health
3. Occupational health and the sick doctor
Consultant occupational health physicians advise both the individual doctor and the
organisation on the relationship between health and work. This includes the management
of any underlying illness within the workplace, and the effect work has on health. They also
have a lead role in ensuring that doctors receive appropriate healthcare support at work as
part of the management of health and wellbeing. The occupational health service should
ensure that factors such as working patterns and professional relationships are addressed
by organisations and by individuals [1].
The occupational health physician’s role is wide-ranging and encompasses:
• Health protection and management of workplace risk and hazard including:
■
Ergonomics and working hours
■ Biological chemical physical hazards such as chemical risks, blood borne
viruses and ionising radiation
■
Psychosocial – behaviour, teamwork, stress and organisational culture
• Wellbeing: Good health, good work, good relationships, good support
• Advice on fitness for work
• Managing chronic conditions
■
■
Regular review of employees with chronic conditions to promote work ability
Management of ‘return to work’ arrangements following a period of ill health
■ Advice on legal protections (e.g. ‘reasonable adjustment’ [2]) for those with
disabilities
■
Advice on early retirement on the grounds of ill health
• Advising the General Medical Council/Medical Council of Ireland and the National
Clinical Assessment Service in the UK
• Role in planning and managing remediation
The occupational health physician’s practice is governed by a set of ethical standards that
describe how issues of privacy and confidentiality about employees are managed [3]. Medical
practitioners sometimes fail to understand the role of the occupational health department,
believing it to be an arm of management. Doctors can be reluctant to seek advice from the
consultant occupational health physician, partly because of the potential impact of health
problems on future careers [1]. Doctors’ professional culture, ways of working and their
behaviour as patients, present particular challenges to the occupational health department.
Organisations should recognise this and provide appropriate resources and facilities to
support doctors in accessing occupational health services.
Sick doctors may be reluctant to seek help [4]. Those with chronic diseases describe
guilt about letting colleagues and patients down, and many come to work even when
unwell (presenteeism). They describe concerns about being stigmatised [5], worries about
confidentiality and loss of control [6] and a feeling of shame, of letting themselves down by
not meeting their own high personal standards, especially if they have a psychiatric illness.
Particular concerns amongst trainees are that they may lose the respect of others by showing
vulnerability, and that disclosing a mental illness may threaten their career and job prospects
[3]. As a result, doctors may self-treat or seek help from colleagues without going through
proper channels; they may not seek help until the condition has become severe [7].
The literature on doctors’ health focuses on mental ill health and substance abuse. Depression
is said to be as common or more prevalent [5] in physicians as in the general population,
although occurring later in life. However, the risk of suicide is greater [8]. Drug misuse is a
problem in the medical profession [9], particularly among trainee and non-consultant grade
doctors [10] and may begin as a coping strategy to manage psychological or stress-related
illness. Indeed, bipolar illness and substance abuse are the main health reasons that doctors
appear before regulators [1].
All employers, including the NHS, have a duty of care to its staff. The NHS Constitution for
England [11] states that all staff are entitled to a healthy working environment and commits
the NHS to providing support and opportunities to enable them to maintain their health,
wellbeing and safety wherever they work. There is a requirement for NHS occupational
health services to meet national quality standards [12, 13], to employ consultant occupational
health physicians [1], and for a doctor who has a health issue to seek and follow the advice
of the relevant specialist, i.e. a doctor on the specialist register.
The report of the working group on the health of health professionals, Invisible Patients
[5], proposed that a group of health professionals (GPs, occupational health physicians
and psychiatrists) should be developed with enhanced skills to treat their colleagues. It
proposed that this group should refer on to a small number of specialist services to manage
6
7

those whose complex problems cannot be dealt with locally and may adversely affect the
quality of care. This training is now underway in the UK, through the Royal Colleges of
General Practice and Psychiatry, the Faculty of Occupational Medicine and the Association
of National Health Service Occupational Physicians. In time, every hospital should have
immediate access to a consultant occupational health physician with these enhanced skills.
4. Wellbeing
NHS organisations that pay attention to the wellbeing of staff deliver higher quality of care,
make better use of resources, have lower patient mortality and have more satisfied patients
[14]. Staff engagement and retention is also better [5]. Good health includes healthy eating,
exercise and sensible drinking; wellbeing encompasses physical, social/relational and
psychological aspects. Components of a healthy workplace include effective leadership/
management, positive working relationships, competence and environmental mastery, a
sense of purpose, personal growth and aspiration and rewards, competent performance and
security [15].
Addressing the health and wellbeing of doctors involves many stakeholders. Until recently,
the medical profession had adopted a medical model that focussed on treating the impaired
physician at a distance from the workplace rather than a preventive biopsychosocial model
that is grounded in a positive work-life balance and centred on work arrangements [1].
A practical organisational model for delivering wellbeing, developed by Business in the
Community (BITC) takes an integrated, holistic and strategic approach and outlines action
that can be taken by both employers and employees to create a healthy workplace [16]. It
identifies four main areas for organisations to focus on:
• ‘good health’ is concerned with physical and mental health, including the social
determinants of health
• ‘good work’ addresses the work environment and work arrangements
• ‘good relationships’ focuses on managers and their ability to promote health and
wellbeing through implementation of best practices and good interpersonal skills
• ‘good support’ ensures that there are high quality support services, such as
occupational health or counselling services to support staff.
Good health
A good occupational health service should offer advice to employees on healthy lifestyle
choices and encourage the organisation to adopt policies that provide and develop a healthy
workplace. Several organisations provide information on aspects of wellbeing with advice on
sensible eating, maintaining hydration, time management, work-life balance and ‘workplace
wellness interventions’ including, advice on stopping smoking, how to access counselling,
‘burnout’ and ‘peer support’, examples include: British Medical Association website wellbeing
page [17]; Peninsula University Medical School [18].
8
9

Good work
Now that the implementation of the European Working Time Regulations [19] has reduced
the hours worked to an average of 48 hours per week or less , workload and shift work are
important considerations. Perception of workload is a function of the job demands and the
attendant time pressures [20]. Job demands in anaesthesia are both physical and mental.
Perception of workload is also affected by sleep loss and fatigue, which may result from
working shifts or from stressful working conditions. For short shift cycles, it is thought to
be better to maintain daytime rhythms by taking naps somewhere quiet and dark, paying
attention to the timing and content of meals and using stimulants such as caffeine. Even
long-term night shift workers have disrupted circadian rhythms, which means that they work
during their low period and try to sleep when alert [21]. Organisations should make efforts
to provide convenient quiet accommodation for those on night shifts to take naps, and offer
regular meal breaks. The occupational health department can provide advice and support
to the organisation about out-of-hours facilities and working arrangements for shift workers.
Stress levels are reduced by the higher levels of social support and role clarity provided by
working in good teams [22]. Working with less defined teams and continually having to forge
new working relationships are both associated with increased stress. This should be taken
into account in planning rotas, particularly for colleagues who are new to the organisation
or who are returning to work, e.g. from maternity leave or following illness. The consultant
occupational health physician may act as an advocate for the employee by providing advice
to management in such circumstances.
Shift work, dysfunctional teams, and poor communication can increase vulnerability to
mental health problems, as can interpersonal conflict, low levels of support and the feeling of
being poorly managed. Conversely, good relationships with colleagues and supervisors, high
levels of job satisfaction and a feeling of accomplishment can be protective. Staff shortages,
funding cuts, inadequate space, equipment and administrative back-up, and poor peer and
supervisory support also drive up stress levels [5].
Evidence suggests that the healthcare environment can be inherently more challenging than
that in other non-health sectors. The current organisation, culture and volume of work in
healthcare can combine to make health professionals vulnerable to unhealthy lifestyles. The
way work is structured and organised – at a personal and organisational level – seems
to have a much greater influence on the risk of developing a mental health problem than
dealing with sick and dying patients and their relatives.
The occupational health department can provide advice on the sorts of interventions that
might be helpful in addressing poor working relationships and difficult team dynamics.
The use of organisational psychologists and of coaching and mentoring can be useful in
managing such situations.
10
Good relationships
According to the BITC model [16], good relationships – at work and at home – provide the
‘social capital’ that individuals need to maintain good mental health and engagement. Key
relationships at work are with line managers and team colleagues. It has been shown that
the principal cause of workplace stress is ‘the boss’ [23], and support from managers is
important for wellbeing. The General Medical Council (GMC) recognises this, stating that:
‘You must support colleagues who have problems with their performance or health’ [24].
Medical managers need to understand how good relationships at work can promote health
and wellbeing and that the support of individuals with health problems can reduce the impact
of illness by reducing levels of anxiety [25]. An open, accountable and supportive workplace
culture in which any concerns can be raised without fear of reprisals reduces harassment
and bullying, enhances quality of care and boosts recruitment and retention [5].
Other recognised work-related stressors include: role-based stress (role ambiguity and
work role conflict); conflicting demands between work and home life; relationship problems;
career development factors (job insecurity, under or over promotion, and thwarted ambition);
and organisational structures and culture. These need to be managed to achieve good work.
The occupational health department may provide training to managers and others in promoting
good working relationships. They may have access to organisational psychologists and
other experts in this field.
Good support
Good occupational health support and counselling is essential to safeguard doctors’ health
and wellbeing. Key criteria for a bespoke occupational health service for doctors include [1]:
1. The services must be led by a consultant occupational health physician
2. The consultants should be experienced in assessing and managing the doctor who is
also a patient. This is not without challenges, as doctors often do not accept the patient
role readily. There are many reasons for this: some relate to issues described earlier
and others are concerned with beliefs and behaviours about illness, role conflict when
with colleagues and perceived loss of control [26]
3. Medical managers (clinical and medical directors, chiefs of service, lead clinicians)
must be trained in how to make appropriate referrals to occupational health and how to
conduct the pre-referral conversation with the referee. There should be transparency of
process and an appreciation of the ethics of practice
4. The service should be part of a larger support network. Many services have singlehanded
consultants who would benefit from being able to discuss difficult cases, and
the opportunity to use mentorship
11

5. There should be arrangements in place for onward referral to appropriate treatment
specialists. Confidentiality of the doctor-patient must be preserved, so arrangements
for such treatment would normally be to a different trust, hospital or health board and
may be in a different locality. It is helpful to develop links with local liaison psychiatrists
and/or psychiatrists specialising in substance abuse
6. There should be links with the postgraduate deanery. This can help to facilitate
interventions for trainee doctors when local solutions cannot be identified. It can also
provide opportunities to influence deanery practice and to build up relationships with
trainers in other specialties. Training in managing the trainee in difficulty is a GMC
requirement and occupational medicine input is often greatly appreciated.
Many telephone helplines have been established. A practitioner health programme has been
established in London to provide off-site help for doctors with health problems [27], and
similar service models exist elsewhere in the UK. This programme is similar to programmes
in the United States. A strength of such help facilities is that they are external to employing
health trusts, thus ensuring actual and perceived confidentiality of care. On the other hand,
the remoteness of such services means that they are unable to satisfactorily address
workplace issues. This means that strategic and operational health and wellbeing issues for
doctors have not been addressed.
5. Health protection and management of workplace risk and hazard
5a. Blood borne viruses
Blood borne viruses (BBVs) are, by definition, viruses carried in the blood without necessarily
causing symptoms in the infected person. The most prevalent and important BBVs are
hepatitis B, C and HIV. Blood borne viruses represent a risk to patients and healthcare
workers alike. Hospitals owe a duty of care to both groups, which may be summarised as:
• Prevention
• Protection
• Post-exposure care
The AAGBI first issued separate guidance about HIV/AIDS in 1988. This is now incorporated
into more generic guidance on occupational health.
Prevalence of hepatitis B [28]:
■
A total of 4756 cases of viral hepatitis from England and Wales were notified to the
Health Protection Agency in 2008. Of these, 1592 (about 33%) were caused by hepatitis
B; and the number of new reports of hepatitis B is increasing each year
■
■
The prevalence of people with antibodies to hepatitis B core antigen (anti-HBc) — a
marker of current or previous infection (sero prevalence) — is 1–2% in the UK. In parts
of China and South Korea, the sero prevalence is 96%
Worldwide, approximately 350 million people have chronic hepatitis B
o
o
The highest rates of chronic hepatitis B (up to 20% of the population) are seen
in South Asia, East Asia, and sub-Saharan Africa
In the UK, the prevalence of positivity to hepatitis B surface antigen (HBsAg) is
highest in those people who were born in countries with endemic infection.
Several thousand people with chronic hepatitis B are estimated to come to
the UK each year from endemic areas, but often they do not present until the
disease is advanced or they become pregnant
Prevalence of hepatitis C [28]
■
■
In the UK, this is estimated to be between 250,000 and 600,000, i.e. around 0.5% of the
population carry the virus, most unknowingly
The incidence of hepatitis C is believed to have peaked at about 15,000 per year in
the late 1980s, when injected drug use was particularly common, the virus had not been
identified, and needle exchange programmes did not exist
12
13

14
o
o
o
The present day true incidence of hepatitis C is not known
Between 1992 and 2007 there were 62,238 laboratory-confirmed cases
reported to the Health Protection Agency
In 2007 there were 7540 cases confirmed. This was an increase of 12% from
the previous year
■ Worldwide, hepatitis C is a major health problem, with an estimated 170 million people –
3% of the global population – infected. In some parts of Europe, Egypt, Japan, and the
Indian subcontinent, the prevalence is as high as 3–5%
Prevalence of HIV [28]
■
■
By the end of 2011, an estimated 96,000 people were living with HIV in the UK,
approximately one quarter of whom were undiagnosed and unaware of their infection
This is an increase from the 91,500 people estimated to have been living with HIV by
the end of 2010. The estimated prevalence of HIV in 2011 was 1.5 per 1000 population
of all ages: 2.1 per 1000 men and 1.0 per 1000 women
Since the late 1990s, following work related exposure, at least 17 healthcare workers have
contracted hepatitis C and there have been five documented cases of HIV transmission.
Methods and risks of transmission
Blood borne viruses may be transmitted by the percutaneous route (needlestick injuries) or
by direct mucocutaneous contact (broken skin or mucus membranes). Risks are highest
with a deep penetrating inoculation with a hollow needle where there is visible contamination
with blood. For such injuries, the risk of transmission is 1:3 for hepatitis B, 1:30 for hepatitis
C and 1:300 for HIV. Approximately 25% of reported high-risk injuries occur in the operating
theatre or intensive care unit.
Prevention
Screening for staff
Transmission of hepatitis B and C from infected healthcare workers to patients is well
documented. The risk of such transmission for HIV is very much less, and the Department
of Health undertook a consultation in 2012 on whether to allow HIV positive healthcare
workers to undertake exposure prone procedures (EPP), subject to strict health supervision.
In August 2013, it announced that such new arrangements will come into effect in April 2014.
Pre-employment screening for transmissible disease is mandatory for all healthcare workers
and includes (for example) tuberculosis and hepatitis B. Since March 2007, in England
(at later in other devolved nations), any new healthcare workers who will perform EPP, or
existing workers who are new to EPP, are additionally required to have HIV and hepatitis C
tests.
Anaesthetists are not deemed to undertake EPP and so may be offered these tests but are
not obliged to undergo them. Anaesthetic departments should liaise with their occupational
health department to ensure that the work of anaesthetists is correctly classified. Schools
of anaesthesia should liaise with the various hospitals to which trainees rotate to minimise
the number of pre-employment screens needed. This is particularly an issue where trainees
undertake many attachments of short duration. Consideration should be given to trainees
having either a lead employer for the whole of training, or a ‘health passport’ which would be
accepted by all hospitals within a school. These measures will save much time and cost for
individual hospitals, and minimise delays before new trainees may start work.
Where indicated, these tests will be carried out by the occupational health department with
appropriate advice, information and consent. The results of tests must be communicated
with due regard to the anaesthetist’s confidentiality; emails to lead clinicians or College
tutors, or results being left in pigeonholes would not meet the requirements for confidentiality
laid down by the Faculty of Occupational Medicine or the GMC.
As with any other serious condition, anaesthetists who have, or think they might have, a
BBV must consult a suitably qualified colleague [24] and ask for and follow advice about
investigations, treatment and changes to their practice that are considered necessary. They
must not rely on self-assessment of the risk they pose to patients [24].
Screening for patients
Routine screening of all patients for BBVs has not been considered practical, effective or
affordable. Patients may be offered screening in some high-risk environments, such as
renal dialysis units, but care cannot be contingent on accepting such screening. Ante-natal
screening for hepatitis B, HIV, syphilis and rubella susceptibility is offered, with a 97% uptake
in 2011 in England [29].
Protection
All hospitals owe a responsibility to employees to reduce the risks of employment, which
arises from numerous pieces of employment law legislation. This includes the provision of
personal protective equipment and training in its use. Healthcare workers have professional
responsibilities and duties as employees to take up this training and use the equipment
provided. Failure to do this may absolve employers of their responsibility in the event of
occupational exposure and harm.
15

European Directive 2010/32/EU specifically applies to the healthcare setting in the public
and private sector and brings together obligations to minimise the risk of harm from sharps
injury. Part of the directive mandates the provision of medical devices with safety-engineered
protection mechanisms. Concerns have been raised by some anaesthetists that some
devices are more difficult to use and may make failure more likely. Anaesthetists must
balance any safety benefit to the user against potential harm to the patient.
Post-exposure care
Occupational exposure to BBVs is inevitable, although some injuries in theatre and ICU
are judged to be preventable. As well as being trained and provided with the equipment to
minimise harm, all staff must be trained in the management of such injury.
Immediate first aid (washing with soap and water, or irrigation) must be performed and
then urgent assistance sought from the occupational health department or the emergency
department – this should be within an hour of the exposure.
Post-exposure prophylaxis (PEP) for HIV for should be started within an hour of exposure.
The decision to start PEP should be based on a risk assessment of the exposure, and should
never wait until patient testing has been done. PEP for hepatitis B and C is not available.
Patients who are the source of exposure should be asked to consent to testing for BBVs.
They should receive appropriate counselling, and are under no obligation to agree (although
most do). Patients must not be approached by the healthcare worker affected. Anaesthetised
patients must be allowed to recover from the anaesthetic before being approached.
Testing of patients who lack capacity (sedated on ICU for example) remains controversial.
Most authorities believe that such testing, while probably ethical, would not be lawful under
the Mental Capacity Act 2005, or Adults with Incapacity Act (Scotland) 2000, although this
has yet to be tested in court.
Healthcare workers exposed to BBVs must now also be considered to be patients of the
occupational health department and must be given time to attend for follow-up. This followup
will allow for consideration of continuing or stopping PEP for HIV in the light of any patient
results and counselling about personal safer sex practice and other matters. Follow-up
for hepatitis C must continue for at least 12 months or longer as sero conversion may be
delayed, the virus may be cleared, and treatment with interferon considered. Follow-up
for trainees rotating between hospitals is particularly challenging. Only 22% of high-risk
hepatitis C exposures are followed up correctly [30].
16
5b. Respiratory infections
Anaesthetists, as specialists in airway management, frequently come into contact with
respiratory secretions of patients, and hence respiratory infections are an occupational
hazard. This was brought into sharp focus during the SARS outbreak in Toronto, Canada,
in 2003 when four anaesthetists/intensivists were infected [31]. The experience of SARS
also highlighted the need for more rigorous infection control within anaesthetic practice. This
section outlines the measures that anaesthetists should take to protect themselves and their
patients from respiratory infections.
Background
All healthcare workers are at risk from acquiring infections from patients and need to take
appropriate measures to protect themselves. Healthcare organisations have a duty to provide
appropriate personal protective equipment and to train employees to use them appropriately
and effectively (Health and Safety at Work Act 1974). Anaesthetists are at particular risk
of acquiring infections from the respiratory tracts of their patients; rhinovirus has been
documented as a commonly acquired infection in anaesthetists [32]. While most would
consider this to be a minor infection of little consequence, patients who have respiratory
infections do not present with a known diagnosis. Such patients may have infections that
can cause severe illness if acquired and these include: influenza, SARS, novel coronavirus,
and tuberculosis.
When patients are being managed in the acute phase of an unknown respiratory infection,
a standard approach is needed to ensure that the anaesthetist is protected effectively from
all possible types of respiratory infection. This section provides general advice; please also
consult your local infection prevention and control policies. When a diagnosis is made, or,
in exceptional circumstances, such as a pandemic influenza year or an outbreak of SARS,
more specific infection prevention and control advice and action is required. This guidance
would be superseded by more specific guidance in those circumstances.
Prevention
There are three key measures that individual anaesthetists can take to prevent the acquisition
of respiratory infections from patients [33, 34]:
• Immunisation
• Personal protective equipment (PPE) – masks, gloves and aprons/gowns
• Hand hygiene
Other important measures include the use of filters on respiratory equipment to protect
machines from becoming contaminated and prevent efflux of infectious particles into the
environment around the respiratory equipment. Each critical care unit should also have
17

access to a negative pressure isolation room, which ensures that highly infectious patients
with air-borne infections can be isolated effectively through controlled ventilation of the
facility. More detailed discussion of these measures is outwith the remit of this section.
For more information on engineering controls and ventilation please see Health Technical
Memorandum 03-01 [35]. Information on appropriate filters for ventilators can be accessed
via the ventilator manufacturers.
AGPs include: bronchoscopy; sputum induction; tracheal intubation; post-mortem procedures
involving high speed devices; cardio-pulmonary resuscitation; high frequency oscillating
ventilation; non-invasive ventilation. This list is not exhaustive, local risk assessment may
identify additional procedures for which AGP precautions are indicated. For an illustration
of how to use and remove PPE follow this link – http://www.england.nhs.uk/ourwork/eprr/id
(accessed 31/08/2014).
Immunisation
Each year the World Health Organisation monitors the influenza viruses in circulation and
makes recommendations for the strain types that are to be included in the vaccine for the
following winter season. Due to the changing nature of influenza viruses, immunisation is
required on an annual basis. Immunisation against influenza is recommended annually for
healthcare workers to protect them and to prevent spread of influenza within the healthcare
setting. Occupational health departments will usually provide healthcare workers with
ample opportunities to take up the flu vaccine in early autumn [36]. Immunisation against
tuberculosis is also recommended for healthcare workers who are likely to have contact with
patients or clinical materials [37].
Personal protective equipment
PPE should be used to minimise the risk of infection in the healthcare worker. The level of
PPE used should be appropriate for the risk. Respiratory infections such as influenza are
transmitted by large particle droplets. When assessing patients with respiratory infections
of unknown cause, droplet precautions should be used. Staff should wear a fluid repellent
surgical mask; a visor should also be used if there is a risk of splash onto mucous membranes.
In addition to masks +/- visors, gloves and aprons/gowns should also be worn.
Hand hygiene
Hand hygiene remains the most important infection control measure to protect healthcare
workers and patients from infections. Clean hands may be decontaminated using alcohol
gel between patient contact; soap and water hand washing remains important if hands are
visibly dirty or contaminated. See Appendix 1 for hand hygiene methods.
Post-exposure protection
If appropriate PPE is not worn and the staff member is not vaccinated when undertaking
assessments and/or AGPs on a patient who is subsequently found to have influenza,
prophylaxis with oseltamivir may be offered [39]. Consult your local occupational health
physician and Infection Prevention and Control team for further advice. For cases of
tuberculosis, contact tracing and follow-up would routinely occur following the identification
of a case. Prevention of exposure by use of PPE and hand hygiene, and appropriate
immunisation are far more effective than any post-exposure measures. For SARS and other
novel coronaviruses there are no post-exposure treatments available.
If aerosol-generating procedures (AGP) are being undertaken, such as intubation, it is
recommended that a filtering face piece (FFP3) mask be used, in addition to eye protection,
gloves and a gown. A FFP3 device is a mask that provides the wearer with a high level
of protection against droplet carried infections and fine aerosols. These masks fit snugly
around the face so that air cannot pass around the mask, only through the filter. For effective
use, the wearer must be ‘fit tested’ to ensure that the mask fits properly and provides the
necessary protection. This is a requirement under Health and Safety Executive (HSE)
guidance [38]. It is imperative that healthcare workers are fit tested for the use of an FFP3
mask as one design of mask may fit an individual better than another. Anaesthetists should
know which make of FFP3 masks fits them and how to obtain them within their healthcare
organisation. Information regarding local arrangements for FFP3 mask fit testing can be
obtained from your local infection prevention and control team, occupational health and/or
health and safety teams.
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5c. Manual handling and back care
Manual Handling is defined as: "...any transporting or supporting of a load (including the
lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or bodily force."
Work-related musculoskeletal disorders, including manual handling injuries, are the most
common type of occupational ill health in the UK. Back pain and other musculoskeletal
disorders account for approximately 40% of all sickness absence in the NHS, resulting in a
cost in the region of £400 million each year [40].
The HSE is the national independent watchdog for work-related health, safety and illness.
The organisation is an independent regulator and acts in the public interest to reduce workrelated
death and serious injury across Great Britain’s workplaces. All employers have a
legal responsibility to ensure the health and safety at work of their staff, and this includes
the prevention of accidents and work related ill health such as musculoskeletal disorders,
back pain and upper limb disorders. There is a legal requirement for employers to consult
employees on health and safety matters, as well as union appointed safety representatives.
Numerical guidelines for lifting and lowering:
The manual lifting of people was condemned as unsafe practice in 1996.
Thus the principles of safe manual handling are:
• Avoid manual lifting
• Assess the patient/load and environment and plan the move
• Ensure the task is within your capabilities
• Get close to the patient/load
• Face the direction of movement, avoid twisting
• Flex or bend your knees
• Keep your back upright, avoid stooping
• Ensure your feet are apart, one foot in front of the other (walk stance)
• Ensure a secure hand grip
• Use the commands ‘ready, steady, move’, numbers can be confusing as some may
move on ‘three’ and some on the unspoken ‘four’
When starting in a new hospital environment, staff should receive an induction, including the
manual handling procedures in place and the location of suitable equipment.
In anaesthesia, we commonly participate in the lateral transfer of patients from bed to trolley
or operating table. Where possible the patient should be encouraged to move independently,
shuffling sideways from one surface to another, with or without the use of a Patslide® to
assist with the transfer.
If the patient is unable to move independently, a Patslide® or Hover Matt® technique may be
used. For the dependent patient, four handlers are required, and more if the patient is obese.
The technique is as follows:
• Tilt the patient towards the far side to insert the Patslide®, partially under the slide
sheets, and extending across to the receiving surface
• Bring receiving surface as close as possible and apply brakes
• Adjust heights so that the receiving surface is slightly lower
[from Manual Handling at Work: A Brief Guide – HSE; Contains public sector information
published by the Health and Safety Executive and licensed under the Open Government
Licence v1.0, http://www.hse.gov.uk/pubns/indg143.pdf (accessed 31/08/2014)]
20
• Two handlers take hold of the pull straps
• A third handler is required to support the head on the pillow, and a fourth for the feet
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• One handler to co-ordinate with a ‘ready, steady, slide’ command
• The two handlers, holding onto the pull straps, transfer their weight from their front leg
to their back leg, and slide the patient half way across the surfaces and then repeat to
pull the patient fully across onto the receiving surface and its slide sheet
When using a Hover Matt®, one handler must ensure that the air-supply coupling remains
intact throughout the manoeuvre and that the air-supply remains turned on.
5d. Pregnancy
Workforce implications of pregnancy
The number of female anaesthetists likely to be working when pregnant is increasing
year on year. Women make up over 30% of consultant workforce and female trainees are
approximately double this percentage. Approximately a quarter of consultants are aged 30
to 39 years with nearly all trainees being below the age of 40 years.
More information
NHS Employers
National Back Exchange
Health and Safety Executive
Backcare charity website
Society of Diagnostic Medical Sonography
Royal College of Nursing
www.nhsemployers.org/backinwork
www.nationalbackexchange.org
www.hse.gov.uk/msd
www.backcare.org.uk
www.sdms.org/msi
www.rcn.org.uk
Anaesthetists work in an environment where exposure to chemicals such as anaesthetic
agents and ionising radiation are common. There is an increasing reliance on complex
imaging techniques such as CT and MRI in medical diagnostics and anaesthesia is frequently
required to facilitate this. The nature of the work can be physically demanding and, although
hours of work have been reduced for trainees over the past few years, most trainees work
an increasing proportion of their time at night, with the introduction of shift working patterns.
Some of the consultant workforce has opted out of European Working Times legislation and
may still work in excess of 48 hours per week. The effects of these environmental factors
present risks to the pregnant mother and the developing fetus during a normal pregnancy
when the mother is well. Those with pregnancy-related complications would need more
individual consideration from their occupational health physician.
Evidence on the effects of working in anaesthesia while pregnant tends to be based on
observational studies.
The Royal College of Physicians in conjunction with NHS Plus, published a national
guidance document for occupational health professionals containing evidence-based advice
for working women during pregnancy and for their employers [41]. The document focuses
on a number of specific hazards including lifting/manual handling and heavy physical work,
prolonged standing, long working hours and shift work, including night shifts. There is
insufficient evidence to suggest that pregnant workers should completely avoid lifting and
handling or prolonged standing.
Adverse fetal outcomes include spontaneous miscarriage, stillbirth, low birth weight and preterm
delivery. The UK has one of the highest rates of pre-term delivery in Europe. Adverse
maternal outcomes relate to musculoskeletal problems, gestational hypertension including
PET, and pre-term early rupture of membranes with subsequent infection.
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Associated risks to the fetus
1. Physically demanding work, particularly lifting
Manual workers including healthcare workers have a significantly higher risk of:
• Intrauterine growth retardation
• Pre-term birth
• PET and hypertension (Relative Risk = 1.6)
Recommendation: moderate risk - employers should reduce risk of exposure where
possible.
2. Long hours (more that 40 h/week)
Low to moderate risk of:
• Pre-term delivery
• Spontaneous miscarriage
• Perinatal mortality
Recommendation: Working hours should be reduced to below 40 h/week, especially in
late pregnancy.
3. Prolonged standing – more than 3 h per day
• Pre-term birth – small risk
Recommendation: try to reduce standing to < 3 h/day.
4. Shift work/night work
• Pre-term birth
Conflicting evidence. Insufficient to make recommendation about risk of shift or night work.
Specific areas
Anaesthetic drugs
Exposure to high levels of volatile anaesthetic agents, particularly halogenated hydrocarbons
and nitrous oxide is associated with a risk of spontaneous abortion and pre-term labour. The
most significant risk of teratogenesis occurs during the first eight weeks of pregnancy, and
may occur before the woman is aware that she is pregnant. Most of the experimental work
was done in the 1970s when active scavenging systems were not in routine use. It is likely
that with modern low flow anaesthetic machines, active scavenging and the prevalence of
non-volatile based anaesthetic techniques, there is a very low risk of adverse outcomes.
However, it is the employer’s responsibility to ensure pregnant workers and those planning
pregnancy should be made aware of the potential risks and not work in environments where
there is no active scavenging.
The risks to the pregnant anaesthetist can be minimised by the use of well-designed
anaesthetic equipment, modern anaesthetic techniques (e.g. TIVA), and high standards
in scavenging and ventilation. However, in some areas, control measures cannot be as
effectively applied and it can be predicted that exposure may be increased in paediatric,
dental and, to some extent, in obstetric anaesthesia.
Employers have an obligation to ensure that environments are adequately ventilated,
scavenging systems are present and that they are well maintained and monitored (at least
once per year). They should comply with regulations BS6834 1987. Employers must comply
with occupational exposure standards, introduced in 1996, for nitrous oxide, halothane,
isoflurane and enflurane.
The Department of Health recommends a minimum supply of air of 0.65m3.s -1 in anaesthetic
rooms. In theatre and recovery areas, ventilation to allow 15 air changes per hour should
be provided, and where new ventilation is being installed, extract points should be located
near to the head of the recovery bed. In dentistry and midwifery, where Entonox is in use,
ventilation should allow five changes of air per hour.
Risks to mother
Manual handling has significant implications to the health of the pregnant worker (and the
fetus), particularly when associated with long periods of standing and/or walking. Hormonal
changes during pregnancy affect the ligaments and joint laxity, thereby increasing the risks
of injury during manual handling tasks. As pregnancy progresses, and in particular during the
last three months, it becomes difficult to achieve and maintain good posture and this further
reduces manual handling capability. Care should also be taken by postnatal women who
may handle loads, particularly in the three months following childbirth.
24
Active scavenging systems should meet Department of Health standards and the presence
of a visual flow indicator is essential. Awareness of techniques to minimise atmospheric
pollution (e.g. use of closed circuits, introduction of nitrous oxide when the patient is
connected to the breathing system, and capping off circuits at the end of each operation) to
avoid spill in the environment should be encouraged.
Infections
A number of infections are known to be a potential risk to the fetus or neonate and therefore
exposure should be avoided. These include: cytomegalovirus, hepatitis A and B, HIV, listeria,
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parvovirus, rubella, toxoplasma, and chickenpox. This list is not exhaustive and the advice
should be to take appropriate precautions and avoid unnecessary exposure to any infection.
Ionising radiation
Exposure to high levels of ionising radiation may result in abnormal organogenesis in the
developing fetus resulting in spontaneous miscarriage. Other risks include reduction in
mental capacity due to disruption in development of a normal CNS, and the development of
childhood cancers especially leukaemia. The highest risk to the fetus is in the first trimester
and the risk diminishes in later pregnancy.
The risks of these adverse events are related to total dose of radiation, so working in
environments where the dose of radiation per patient is high, e.g. CT or angiography, should
be avoided.
Typical occupational exposure for an x-ray worker would be 1 to 6 mSV per year and pregnant
workers should be exposed to no more that 1 mSv during the pregnancy. At this level of
exposure, there is no evidence to show any significant risk of radiation effects to the fetus.
When working in x-ray environments, the anaesthetist should wear a lead gown that wraps
around the abdomen, and sit behind lead shielding: good practice whether pregnant or not.
Non-ionising radiation:
MRI - The safety of MRI with respect to the fetus has not been established. The concerns
for the fetus include teratogenesis and acoustic nerve damage. The studies so far indicate
no increased fetal adverse outcome; however, because of the lack of evidence of long-term
effects of MRI on the fetus, it is advisable not to remain in the scan room.
Ultrasound - Pregnant staff working with diagnostic ultrasound do not need to alter their
working practice.
Risk assessment
The pregnant worker must inform the employer as soon as the pregnancy is known and
employers should carry out a risk assessment to decide how best to limit exposure to
hazards including infection and radiation. The assessment should establish what doses of
radiation are likely to be received and what can be done to reduce the risk to the baby. This
may include restricting time in the environment or being reallocated to non-x-ray lists for the
duration of the pregnancy.
6. Advice on fitness to work
Organisations should have systems and policies in place to promote fitness to work and
support work attendance. A good work attendance policy recognises that there may be
occasions when staff are unable to work because of ill health and should describe how
managers, and working with human resources and occupational health, can facilitate an
appropriate and supported return to work. The occupational health assessment will focus on:
• Assisting with return to work following sick leave
• Defining the doctor’s capability in a good environment
o
o
What can/can’t he or she do?
What support does he or she need?
• Enabling the doctor to tackle challenging situations
• Encouraging the doctor to develop robust attitudes to his or her health and wellbeing
The consultant occupational health physician should identify any work-related factors in the
illness and the interventions in working arrangements or the work environment necessary to
minimise the impact of the illness. The occupational health physician has a responsibility to
the employer to advise on fitness for work and ‘reasonable adjustment’, and a responsibility
to the individual to advise on the natural history of the illness and potential effects on work,
and to be their advocate.
Self-referral
It is possible for a practitioner to self-refer to an occupational health physician. This might be
helpful in planning a return to work after illness, to consider the natural history of a disease
and its likely impact on their future career, or to access counselling. Where an employing
organisation does not have a consultant occupational health physician who has enhanced
skills in managing doctors’ illness, it may be valuable to seek an opinion from an expert.
Referring a practitioner to the consultant occupational health physician
Ill health does not always present in a straightforward manner. When a practitioner is in
difficulty, it is often useful to refer them to the occupational health physician, even if only to
rule out illness as a cause of the problem. Becoming ill, recognising there is a problem and
reporting illness can happen at different times, sometimes several months or years apart.
Remember, whenever possible, to copy the practitioner into correspondence. As a general
rule, it is always better to work with the practitioner rather than to have discussions and make
decisions about the practitioner. The doctor-patient is the expert on his or her own illness.
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When making a referral to the occupational health physician it is important to provide all the
necessary background information. The National Clinical Assessment Service provides a
checklist [7].
7. Managing chronic conditions, including arrangements for return to work
The White Paper, Trust Assurance and Safety [42], recognises that the increasing complexity
of modern clinical practice has added to the pressures health professionals face in their
working lives. It proposes that there should be greater support for those with any kind of
health problem, to help them maintain their own health and wellbeing and make it easier for
them to seek appropriate advice or treatment should they become ill. Health professionals
should expect appropriate safeguards to maintain their confidentiality from both clinicians
and managers and so may need to receive treatment outside their local area.
Doctors have the same range of illnesses as others of a similar age, including psychiatric
illness, diabetes, epilepsy, inflammatory bowel disease, arthritis and multiple sclerosis.
The top three causes of sickness absence among NHS employees are: musculoskeletal
disorders; mental ill health (including stress, depression and anxiety); and skin problems.
Musculoskeletal disorders account for almost half of sick leave taken (45%) by NHS
employees. Allergic reactions to gloves and drugs and the need for frequent hand washing
as part of infection control measures may cause occupationally acquired dermatitis.
Coping with chronic physical illness includes managing the illness itself, the effects of
treatment and the psychological sequelae. It takes an average of two years for a doctor who
has a long-term condition to get fully back on track. Doctors who do well are those who learn
to recognise symptoms, use support appropriately and value what they can do rather than
grieve over what they can no longer do.
Developing a good working relationship with the occupational health physician can be an
important part of managing work with a chronic illness. Trust develops as the occupational
health physician demonstrates a robust approach to confidentiality, and gets the right balance
between support and challenge, showing respect to the individual and telling the truth about
the effects of the illness on work. The doctor-patient and the occupational health physician
can then identify and meet the needs of senior clinicians such as the clinical director and the
service. Topic areas the doctor might usefully discuss with the occupational health physician
include:
• Discussing difficulties identified by others
• Confidentiality
• Managing others' curiosity/hostility
• Taking sick leave
• Referral? To whom? By whom?
• Return to work – planning
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• On-going surveillance
• Monitoring progress
• Assessments – (especially for trainees, e.g. ARCP)
• Change of job description or role? Specialty change (for trainees)?
Following a period of sick leave, the occupational health physician will work closely with
the relevant manager to design a return to work package consistent with good employment
practice and the trust's attendance management policy. He or she will monitor the individual
doctor’s progress, and suggest modifications when needed. Further practical advice about
returning to work can be found in:
• The AAGBI’s Welfare Resource Pack at: http://www.aagbi.org/sites/default/files
welfare_resource_pack_2008_0.pdf
• The Academy of Medical Royal Colleges has advice at: http://www.aomrc.org.uk
doc_details/9486-return-to-practice-guidance
• The Royal College of Anaesthetists at http://www.rcoa.ac.uk/system/files/PUB
ReturnToWork2012.pdf
notice the signs and whom they should notify. It would be expected that such colleagues
receive training on managing the situation.
Employment Rights Act
If an individual has a disability in the terms of the Disability Section of the Equality Act
2010, he or she may be entitled to ‘reasonable adjustment’ under the Act. The consultant
occupational health physician will advise on this, and work closely with the employee’s
manager to re-design the job and to modify equipment such that the individual can work.
The occupational health physician will be able to advise on ‘access to work’ schemes, which
sometimes fund equipment.
A person has a disability under the Act if he has ‘a physical or mental impairment which has a
substantial (defined as more than ‘trivial’) and long-term adverse effect on his ability to carry
out normal day-to-day activities.’ The effect of an impairment is long-term if:
• It has lasted at least 12 months
• The period for which it lasts is likely to be at least 12 months; or
• It is likely to last for the rest of the life of the person affected
Useful articles article include:
• Anaesthesia News, May 2010, pages 12-13. Returning to work following a major
illness: http://www.aagbi.org/sites/default/files/may2010-1.pdf
• Anaesthesia News, Oct 2011, pages 8-9. Returning to work in a wheelchair:
http:/www.aagbi.org/sites/default/files/October ANews Final_0.pdf
• RCoA Bulletin, Mar 2011, pages 26-28. Returning to work - as a disabled
anaesthetist: http://www.rcoa.ac.uk/system/files/CSQ-Bulletin66.pdf
Security planning/safety net
It is sometimes helpful for the responsible manager to develop a signed agreement with a
practitioner who has a relapsing illness. Exemplar templates are provided on the National
Clinical Assessment Service (NCAS) website [7]. The agreement might identify early warning
signs (e.g. specific thoughts, feelings or behaviours) that the practitioner notices when he
is becoming unwell, and the actions the practitioner will take to ensure he gets appropriate
help and support. The practitioner can also identify any unwanted extra work-related stress
that can contribute to the problem and ways in which they, and the wider department, can
manage and limit these.
A similar plan describing the actions that close colleagues will take if a practitioner becomes
ill can also be useful. This covers what might happen as a result of the condition, who should
If the effect is likely to recur, it is treated as continuing, even if it does not currently have
a substantial adverse effect on a person’s ability to carry out normal day-to-day activities.
Thus, it is not the condition itself, but the impact it has on the individual’s ability to carry out
full daily duties that constitutes the disability.
Examples of steps which an employer may have to take in relation to a disabled person in
order to comply with the Equality Act include:
• Making adjustments to premises
• Allocating some of the disabled person’s duties to another person
• Transferring him or her to fill an existing vacancy
• Altering his or her working hours
• Assigning him or her to a different place of work
• Allowing him or her to be absent during working hours for rehabilitation, assessment
or treatment
• Giving him or her, or arranging for him or her to be given, training
• Acquiring or modifying equipment
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• modifying instructions or reference manuals
• modifying procedures for testing or assessment
Example:
A staff grade anaesthetist who develops back pain might have his job plan altered so he
works in a theatre environment where portering staff are on hand to lift patients, has the
equipment in his workplace assessed by the occupational health department and is provided
with a chair that is suitable for his needs.
A consultant anaesthetist with a depressive illness may temporarily come off the on-call
rota and have sufficient time made available in his working week to attend psychotherapy
sessions. He might stop working with a surgeon with whom he does not have a good working
relationship. Alternatively, the organisation may address the difficulties in communication
with the surgeon and wider team, perhaps with the support of the occupational health service
or an external organisational psychologist.
8. Referral to regulatory authorities
The consultant occupational health physician can also advise on referral to the GMC or
Medical Council of Ireland.
In some circumstances, referral to the GMC may be considered, for instance when substance
abuse forms part of the picture or the practitioner appears not to be following the appropriate
medical advice. The doctor’s consent must be sought but if it is not provided, the treating
doctor must notify the health professional of his/her intention to alert the regulator. The facts
regarding a person's health and management of the condition may be relevant in determining
whether, and if so how, s/he is able or unable to meet the regulator’s standards. However,
the detail of the diagnosis is not required for concluding whether or not a person's fitness to
practise is impaired.
Policy statement from the GMC on the meaning of fitness to practise
The GMC does not need to be involved merely because a doctor is unwell, even if
the illness is serious. However, a doctor’s fitness to practise is brought into question
if it appears that the doctor has a serious medical condition (including an addiction to
drugs or alcohol) AND the doctor does not appear to be following the appropriate
medical advice about modifying his or her practice. Referral will then be necessary to
minimise the risks to patients [5].
It is important not to confuse fitness for work with being ‘fit to practice’.
Role in NCAS/GMC
When a practitioner is referred to the NCAS or to the GMC, it is sometimes relevant to make
an assessment of the practitioner’s health. A recent survey carried out by the revalidation
support team found that around 25% of concerns about practice are related to health. NCAS
has a small team of experienced occupational health physicians whose responsibilities
include advising on whether the doctor has any underlying ill health or disability that could
affect practice, and on whether the practitioner is currently well enough to undergo a formal
assessment.
Role in planning and managing remediation
If remediation is needed, the consultant occupational health physician’s advice about
the timing and nature of the remedial package should be sought and followed. It is not
appropriate to add further stress to a doctor with a health difficulty by making unrealistic
demands or imposing unrealistic timescales.
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It takes about two years for a trainee who has been ill to get back to full achievement. It is
important to:
• Get well first
• Only make career moves when the trainee is moving to something better and not
away from something bad
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38. Respiratory protective equipment at work: A practical guide. London: Health and Safety,
Executive reprint with amendments, 2012.
39. TA158 – Oseltamivir, amantadine (review) and zanamavir for the prophylaxis of
influenza. London: NICE; 2008. http://guidance.nice.org.uk/TA158/Guidance/pdf/
English (accessed 31/08/2014).
40. Manual Handling. http://www.nhsemployers.org/~/media/Employers/Publications/
Manual%20handling.pdf (accessed 31/08/2014).
41. Physical and shift work in pregnancy: occupational aspects of management.
London: Royal College of Physicians; 2009. http://www.rcplondon.ac.uk/sites/
default/files/physical-and-shift-work-in-pregnancy-national-guideline-full-text.pdf
(accessed 31/08/2014).
42. Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st
Century. London: TSO; 2007. http://www.official-documents.gov.uk/document/
cm70/7013/7013.pdf (accessed 31/08/2014).
36
37

Appendix 1
Acknowledgement: Dr Jo Hargreaves, Public Health Wales Microbiology Cardiff for hand hygiene
illustration.
38
39

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Out of Hours Activity
(Anaesthesia)
Guiding Principles and Recommendations
JOINT POSITION STATEMENT
Association of Anaesthetists of Great Britain and Ireland
and
Royal College of Anaesthetists
October 2014
1

Definitions
The times that can be considered to be “out of hours” (OOH) may be defined contractually or by reference to
published national standards. In the current Consultant Contracts for England and Wales, OOH is defined by
the concept of “premium time”, i.e. that which is outside of 07.00 h – 19.00 h on non-Bank Holiday weekdays.
Current and future contract negotiations may change the periods covered by “premium time”. The National
Confidential Enquiry into Patient Outcome and Death (NCEPOD) defines OOH as: “any time outside 08.00 to
17.59 on weekdays, and any time on a Saturday or Sunday”. We will simply define OOH work as that done
outside of the normal working week.
Emergency work
Anaesthetic services delivered OOH are key to the provision of emergency care. Anaesthetists will
reasonably be expected to provide OOH cover for cases that come under the NCEPOD Classification of
Intervention as being “Immediate” or “Urgent”. Following clinical assessment, those cases classified as being
“Expedited” or “Elective” need not be done OOH. Immediate or urgent cases should be prioritised over
routine / elective care at all times.
Drivers for increased OOH activity
The NHS has always operated a 7 day service for patients requiring emergency admissions and surgery.
There is current pressure towards a “7-day NHS” based on the information that some patients admitted to
hospitals at the weekend have worse outcomes compared with those admitted during the working week. It
seems likely that more consultants will be required to be present in hospitals at the weekend, along with
support services. In some units it may be inevitable that the increased workload combined with sicker
patients with increased co-morbidity will require Consultant Anaesthetists to be in-hospital providing resident
shifts during part of the OOH period. The AAGBI and RCOA support measures to improve patient safety and
quality of care but note that this will have a significant impact on Anaesthesia workforce. It has been
suggested that with increased support services, it would be safe to perform elective operating lists at the
weekend, and the principle of elective work OOH in the form of ‘Waiting List Initiatives’ is well established.
Standards and operating procedures developed to make patient care as safe as possible during normal
working hours would be maintained for any elective care taking place out of hours. This should not be seen
as a solution to the failure to carry out this work successfully in normal hours during the week. An increasing
emergency workload and pressure on beds will increase the demand for daily trauma and emergency lists to
expedite surgery and speed patient throughput. Extending planned surgery throughout the week could
enable existing operating theatres to be used for more hours than at present, although it must be noted that
over 70% of theatre running costs relate to staff, drugs and disposables (information available on line from
Information Services Division, NHS Scotland).
The risks of OOH working
Different risks are posed by OOH working in the evening and overnight to working daytimes at weekends.
There are physiological differences between working during the day, and in the evenings or at night and
these differences cannot be fully mitigated. This must be taken into consideration when OOH working is
considered 1 . Studies have shown that human beings do not adapt despite prolonged exposure to night
work 2 . Working in the evening or night especially after having worked during the day may lead to significant
fatigue, as may work at weekends after a full working week 3 . A further factor in fatigue experienced by
anaesthetists is sleep disturbance caused by shifts and irregular patterns of work. Fatigue is associated with
an increased incidence of critical incidents and thus has a direct impact on patient safety 4 . There are
significant additional risks in OOH working that should be mitigated by limiting night-time work to that which
is clinically necessary and adjusting working patterns and arrangements to minimise fatigue. Onsite facilities
that help mitigate the effects of fatigue, such as the timely availability of healthy foods and appropriate areas
for rest, are important to the delivery of safe OOH care.
Patient considerations
Patients should receive appropriate treatment to national standards of care from competent and fit–for-work
clinicians in a timely fashion. However, there must be a balance between the need for speed with which
urgent and expedited surgery is performed in order to minimise the pain and anxiety, and the need to
maintain standards of safety if the provision of OOH is increased. Patient safety must always be prioritised
over patient convenience.
2

Considerations for anaesthetists
The implementation of the Working Time Regulations (WTR) means that trainees no longer work excessive
hours, although the shift patterns worked by the substantial majority do lead to fatigue 2 . Decreases in trainee
hours and overall numbers as well as an increasingly elderly population with greater co-morbidities mean
that career grade doctors, i.e. Consultants and Specialty Doctors, are doing an increasing proportion of OOH
work. As career grade doctors can derogate from WTR, there is a risk that pressure may be exerted to
increase both the amount of work performed and the proportion of work that is done OOH, and the current
government has signalled its intention to look again at the application of WTR to trainees 5 . The ability to
recover from sleep deprivation deteriorates with age, and particular attention should be paid to the impact of
excessive or irregular working hours on the older anaesthetist. It is essential that all anaesthetists are aware
of the potential impact of fatigue on their cognitive ability and ensure they are well rested before treating
patients 3 . Careful planning is required so that patient risk is not increased as a result of fatigue. Specialties
that conduct larger proportions of their clinical activity OOH may experience problems in recruitment and
retention.
Principles and recommendations
Emergency OOH work has always been a fundamental part of the work of anaesthetists. OOH services
should be planned carefully in order to deliver high quality patient care. The extension of planned and
elective clinical activities into periods outside of the normal working week carries with it patient safety risks
and must only happen with careful planning. The provision, capacity and quality of support services must be
provided to the same degree as those in normal working hours, making due allowance for human factors.
Extended work should not drain resources from other clinical areas
The conduct of planned OOH operating sessions is a matter for local discussion and agreement. The AAGBI
and RCoA are agreed that the following issues must be considered:
• Planned OOH sessions during which expedited or elective cases are performed must have the same
levels of pre and post-operative ward staffing, consultant supervision and training, diagnostic and
laboratory services, support services and critical care facilities as sessions done during working
hours.
• Start and finish times of elective operating sessions that extend into OOH periods must take into
account human performance factors.
• In the interests of providing the highest quality service to patients, appropriate compensatory rest
must be taken particularly after a prolonged duty period and rest should be taken at the earliest
possible opportunity.
• Theatre sessions should be fully staffed with cover for contracted breaks. If sessions extend beyond
normal working hours, there should be provision for additional support and breaks.
• Anaesthetists should only provide cover for elective surgery for more than 12 hours in any 24-hour
period in exceptional circumstances. Travel times should be taken into consideration.
• Only immediate or urgent procedures should be conducted at night (after 21.00hrs).
• Special consideration should be given to the very young, the very old and the clinically unstable
patient who should be operated on during the day where possible.
• There must always be sufficient backup and additional facilities to deal with any life or limb
threatening emergency without delay.
• Recovery units should be scheduled to be sufficiently staffed so that all elective cases admitted may
be fully recovered and transferred to the ward without interfering with the urgent/emergency
workload.
• Anaesthesia and surgery should not commence unless all the necessary arrangements are in place
for the complete perioperative patient care pathway.
• Audit of the outcome and productivity of OOH operating sessions must be conducted and compared
with comparable sessions done within normal working hours.
• Extending elective/expedited surgery into OOH periods will demand more financial and human
resources if patient safety is to be maintained. Clinical Directors of Departments of Anaesthesia must
work with clinical governance systems within hospitals to ensure that patient safety is put first and is
not compromised.
3

Members of the working party:
Dr Kathleen Ferguson (Chair), Dr Ramana Alladi, Dr Les Gemmell, Dr William Harrop-Griffiths, Dr Richard
Griffiths, Dr Barry Nichols, Dr Anna-Maria Rollin,Dr Caroline Wilson, Dr David Whitaker
Contributions were received from:
Dr Andrew Hartle, Dr Peter McGuire, Dr Felicity Plaat, Dr Samantha Shinde, Dr Sean Tighe, Dr Isabeau
Walker
The Joint Position Statement was reviewed by the Council of AAGBI and RCoA prior to publication.
References
1. Folkard S,Tucker P. Shift work, safety and productivity Occupational Medicine 2003; 53; 95‐101.
2. Howard SK, Rosekind MR et al. Fatigue in anaesthesia. Anesthesiology 2002; 97; 1281‐1294.
3. Fatigue and Anaesthetists 2014.
http://www.aagbi.org/sites/default/files/Fatigue%20Guideline%20web.pdf
4. Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP. Effects of health care
provider work hours and sleep deprivation on safety and performance. Joint Commission Journal on
Quality and Patient Safety 2007; 33: 7-18.
5. https://www.gov.uk/government/news/more-flexibility-for-nhs-doctors-under-european-working-timedirective
accessed September 2014
4

Peri-operative management
of the obese surgical patient 2015
Published by
The Association of Anaesthetists of Great Britain & Ireland
Society for Obesity and Bariatric Anaesthesia
March 2015

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Peri-operative
management of the obese surgical patient 2015. Anaesthesia 2015, 70,
pages 859–876.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/enhanced/doi/10.1111/anae.13101/
© The Association of Anaesthetists of Great Britain & Ireland

Guidelines
Peri-operative management of the obese
surgical patient 2015
Association of Anaesthetists of Great Britain and
Ireland
Society for Obesity and Bariatric Anaesthesia
Members of the Working Party: C. E. Nightingale, 1
M. P. Margarson, 1 E. Shearer, 1 J. W. Redman, 1
D. N. Lucas, 2 J. M. Cousins, 1 W. T. A. Fox, 1 N. J. Kennedy, 1
P. J. Venn, 3 M. Skues, 4 D. Gabbott, 5 U. Misra, 2
J. J. Pandit, 7 M.T. Popat 6 and R. Griffiths (Chair) 7
1 Society for Obesity and Bariatric Anaesthesia, 2 Obstetric Anaesthetists’
Association, 3 Royal College of Anaesthetists, 4 British Association of Day
Surgery, 5 Resuscitation Council (UK), 6 Difficult Airway Society, 7
Association of Anaesthetists of Great Britain & Ireland
Summary
Guidelines are presented for the organisational and clinical peri-operative
management of anaesthesia and surgery for patients who are obese,
along with a summary of the problems that obesity may cause peri-
This is an open access article under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly
cited, the use is non-commercial and no modifications or adaptations
are made.
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
1

operatively. The advice presented is based on previously published
advice, clinical studies and expert opinion.
....................................................................................................
This is a consensus document produced by expert members of a Working
Party established by the Association of Anaesthetists of Great Britain and
Ireland and the Society for Obesity and Bariatric Anaesthesia. It has been
seen and approved by the elected Board/Council of both organisations.
All AAGBI guidelines are reviewed to ensure relevance/accuracy and are
updated or archived when necessary. Date of review: 2020.
Accepted: 10 March 2015
• What other guidelines and statements are available on this topic?
The first Association of Anaesthetists of Great Britain and Ireland
(AAGBI) guidelines on the peri-operative management of the obese
patient were published in 2007 [1]. In 2012, a consensus statement
on anaesthesia for patients with morbid obesity was published by the
Society for Obesity and Bariatric Anaesthesia (SOBA) [2]. The Centre
for Maternal and Child Enquiries (CMACE) and the Royal College
of Obstetricians and Gynaecologists (RCOG) have published joint
guidance on management of women with obesity in pregnancy [3].
•
Why were these guidelines developed?
There is an increased recognition that obese patients present a different
set of challenges and require specific peri-operative care compared
with non-obese patients. These guidelines are intended to
inform anaesthetists about best practice management of obese surgical
patients throughout the peri-operative period, as members of a
multidisciplinary team.
•
How does this statement differ from existing guidelines?
These guidelines include new material on several topics including pharmacology,
positioning and sleep-disordered breathing. The advent of bariatric
(weight treatment) surgery has produced a subgroup of
anaesthetists with more specific experience in the management of obese
patients. The Society for Obesity and Bariatric Anaesthesia was set up in
2009 to share the knowledge gained from bariatric anaesthesia to improve
the anaesthetic care of obese patients in general. This experience forms the
basis of these guidelines.
2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Recommendations
1 Every hospital should nominate an anaesthetic lead for obesity.
2 Operating lists should include the patients’ weight and body mass
index (BMI).
3 Experienced anaesthetic and surgical staff should manage obese
patients.
4 Additional specialised equipment is necessary.
5 Central obesity and metabolic syndrome should be identified as risk
factors.
6 Sleep-disordered breathing and its consequences should always be
considered in the obese.
7 Anaesthetising the patient in the operating theatre should be considered.
8 Regional anaesthesia is recommended as desirable but is often technically
difficult and may be impossible to achieve.
9 A robust airway strategy must be planned and discussed, as desaturation
occurs quickly in the obese patient and airway management
can be difficult.
10 Use of the ramped or sitting position is recommended as an aid to
induction and recovery.
11 Drug dosing should generally be based upon lean body weight and
titrated to effect, rather than dosed to total body weight.
12 Caution is required with the use of long-acting opioids and sedatives.
13 Neuromuscular monitoring should always be used whenever neuromuscular
blocking drugs are used.
14 Depth of anaesthesia monitoring should be considered, especially
when total intravenous anaesthesia is used in conjunction with neuromuscular
blocking drugs.
15 Appropriate prophylaxis against venous thromboembolism (VTE)
and early mobilisation are recommended since the incidence of
venous thromboembolism is increased in the obese.
16 Postoperative intensive care support should be considered, but is
determined more by co-morbidities and surgery than by obesity per
se.
Introduction
The World Health Organization (WHO) uses a class system to define
obesity (Table 1). Statistics for 2013 from the UK, Health and Social Care
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
3

Table 1 World Health Organization classification of obesity [4].
Body mass index;
kg.m 2
Classification
< 18.5 Underweight
18.5–24.9 Normal
25.0–29.9 Overweight
30.0–34.9 Obese 1
35.0–39.9 Obese 2
> 40.0 Obese 3 (previously ‘morbid obesity’)
Information Centre show that in adults, 24% of men and 25% of women
are classified as obese and over 3% have class-3 obesity [5]. For an average
UK district general hospital serving an adult population of 200 000, this
equates to 52 000 obese and over 6000 class-3 obese patients [6].
Obese patients are more likely to present to hospital because they are
more prone to concomitant disease. Between 2001–2002 and 2011–2012,
there was an eleven-fold increase in the number of patients (from 1019
to 11 736) of all ages admitted to NHS hospitals with a primary diagnosis
of obesity (Fig. 1) [6]. In 2007, the UK Government’s Foresight Report
predicted that 50% of the UK population would be clinically obese by
2050, costing the NHS an extra £45.5 billion (€61.5 billion; $70.1 billion)
per year, but even this may be an underestimate [7].
This consensus guidance is a synthesis of expert opinion, current
practice and literature review, designed to replace the 2007 edition [1]
and act as a guide to the delivery of safe anaesthesia to this clinically
demanding group.
Pathophysiology of obesity
Fat distribution (patient shape)
Not all fat within the body is identical. Unlike peripherally deposited
fat, intra-abdominal fat is highly metabolically active and is known to
be a contributor to several disease states [8]. Patients with centrally distributed
or ‘visceral’ fat are at greater peri-operative risk than those with
peripherally distributed fat, and are far more likely to exhibit the metabolic
syndrome, which consists of central obesity, hypertension, insulin
resistance and hypercholesterolemia [9, 10].
Central obesity can be defined as a waist circumference greater than
88 cm in a woman and 102 cm in a man; or a waist-to-height ratio
greater than 0.55 [10, 11].
4 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

35
30
25
Prevalance (%)
20
15
10
5
0
Figure 1 Adult trends in obesity (BMI ≥ 30 kg.m 2 ) in the UK male (○)
and female (●) population, showing three-yearly averages. Redrawn
from Health Survey England 2013 data (see http://www.hscic.gov.uk/
catalogue/PUB16077) accessed 10/03/2015).
People who exhibit central, or visceral, obesity are often male and
can be described as ‘apple shaped’, while those with a predominantly
peripheral fat distribution are more likely to be female and are described
as ‘pear shaped’.
Respiratory system
Obesity results in reduced functional residual capacity (FRC), significant
atelectasis and shunting in dependent lung regions [12], but resting metabolic
rate, work of breathing and minute oxygen demand are increased.
This combination means that, following the cessation of breathing, arterial
oxygen levels decrease rapidly.
Wheeze in the obese may be due to airway closure rather than
asthma: 50% of patients diagnosed with asthma ‘recover’ with weight
loss [13]. Formal assessment of the effectiveness of bronchodilator therapy
may be useful in differentiating the two conditions [14].
Sleep-disordered breathing
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
5

Sleep-disordered breathing describes the spectrum of conditions ranging
from obstructive sleep apnoea (OSA) through obesity hypoventilation
syndrome (OHS). Each of these conditions has a spectrum of severity,
described according to the number and severity of oxygen desaturations
occurring every hour and their impact upon the patient [15].
Severe OSA occurs in 10–20% of patients with BMI > 35 kg.m 2
and is often undiagnosed. Overall, a diagnosis of OSA is associated with
a greater than doubling of the incidence of postoperative desaturation,
respiratory failure, postoperative cardiac events and ICU admission [16].
The presence of multiple and prolonged oxygen desaturations increases
the sensitivity to opioid-induced respiratory depression [17]. However, if
identified pre-operatively and treated appropriately with continuous
positive airway pressure (CPAP), the risk of complications is much
reduced [18].
Increasing severity of OSA is associated with older age, cardiovascular
disease secondary to heart strain, and the development of left ventricular
dysfunction. It is also associated with a difficult airway and
laryngoscopy. If untreated, OSA may progress to obesity hypoventilation
syndrome, a triad of obesity (BMI > 35 kg.m 2 ), sleep-disordered
breathing (usually OSA) and daytime hypercapnia (pCO 2 > 6 kPa) [19].
The combination of chronic hypoxaemia and hypercapnia make this
subgroup particularly susceptible to the effects of anaesthetic agents and
opioids, which may precipitate acute and chronic hypoventilation and
respiratory arrest in the early postoperative period [20].
Formal diagnosis of sleep-disordered breathing is with polysomnography,
but in the majority of cases, diagnosis can be made by overnight
oximetry testing at home [21]. Nocturnal CPAP is the usual treatment
in patients with significant degrees of OSA, but around 50% of patients
are poorly compliant with CPAP therapy and thus will not obtain benefit,
usually because of problems with the fitting of the mask. Seeking
information on compliance during pre-operative assessment is advised.
Cardiovascular system
Obesity leads to increased blood pressure, cardiac output and cardiac
workload. People with untreated OSA may have associated pulmonary
hypertension and heart failure [15].
There is an increased incidence of arrhythmias, predominantly secondary
to sino-atrial node dysfunction and fatty infiltration of the conducting
system. This results in a relative risk of 1.5 for atrial fibrillation
[22], and a markedly increased risk of sudden cardiac death [23]. There
6 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

is an increased incidence of prolonged QT interval with increasing BMI
[24], and therefore a potential increased risk with drugs such as ondansetron
[25].
Ischaemic heart disease and heart failure are more prevalent in the
obese population, with heart failure the predominant risk factor for
postoperative complications [26].
Thrombosis
Obesity is a prothrombotic state and is associated with increased
morbidity and mortality from thrombotic disorders such as myocardial
infarction, stroke and VTE [27]. The postoperative incidence of
VTE may be 10 times higher in obese women compared with their
healthy-weight counterparts [28]. Previous VTE is an independent
risk factor for patients having gastric bypass surgery [29]. A
hypercoagulable state may extend beyond two weeks, warranting
extended postoperative VTE prophylaxis depending on the type of
surgery and the patient’s BMI [30].
Diabetes
Obesity is strongly associated with increased insulin resistance [31].
Poor glycaemic control in the peri-operative period is associated with
increased morbidity, and good glycaemic control is recommended [32].
Gastric bypass surgery causes a unique neurohumeral response,
resulting in a rapid, dramatic reduction in insulin requirement, starting
immediately after surgery. In this cohort of patients, cautious
postoperative reintroduction of diabetic medication and frequent blood
sugar monitoring are essential [33].
Pharmacology
Body composition
There are a number of terms used to describe the weight of a patient;
the four most useful are shown in Table 2.
Drug dosing
There is limited information on the effect of obesity on the pharmacology
of commonly used anaesthetic drugs. Much of the excess weight is
fat, which has a relatively low blood flow. While lipophilic drugs will
have a larger volume of distribution than hydrophilic ones, the current
evidence indicates that changes in volume of distribution in the obese
are drug-specific, so generalisations are difficult [37]. For most anaes-
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
7

Table 2 The four most useful terms for describing patients’ weight.
Total body
weight (TBW)
Ideal body
weight (IBW)
The actual weight of the patient
What the patient should weigh
with a normal ratio of lean to fat mass.
Varies with age, and is usually
approximated to a function of
height and sex:
IBW (kg) ¼ height (cm) x (where x
¼ 105 in females and 100 in malesÞ
Lean body
weight (LBW)
The patient’s weight excluding fat. Many of the
formulae for calculating lean body weight are
complex but one of the most widely used is that
of Janmahasatian et al. [34]:
LBW (kg) ¼
LBW (kg) ¼
9270 TBW (kg)
6680 þð216 BMI (kg.m 2 ÞÞ ðmenÞ
9270 TBW (kg)
8780 þð244 BMI (kg.m 2 ÞÞ ðwomenÞ
Regardless of total body weight, lean body weight
rarely exceeds 100 kg in men and 70 kg in women
(Fig. 2) [35]
Adjusted body
weight (ABW)
Takes into account the fact that obese individuals
have increased lean body mass and an increased
volume of distribution for drugs. It is calculated
by adding 40% of the excess weight to the IBW [36]:
ABW (kg) = IBW (kg) + 0.4 (TBW (kg) IBW (kg))
thetic agents, dosing to total body weight is rarely appropriate and
increases the risk of relative overdose. Fortunately, most anaesthetic
agents are dosed to affect, e.g. loss of eyelash reflex, nerve stimulator
response or relief of pain. Given the paucity of information, the recommendation,
based on current practice amongst experts in bariatric
8 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Figure 2 Relationship between total body weight and body mass index
(BMI), showing how lean body mass effectively plateaus despite increasing
BMI. A male of height 190 cm and ideal body weight (IBW) is indicated,
demonstrating how IBW includes a normal 15% fat mass.
anaesthesia, is that lean or adjusted body weight are used as the scalars
for calculating initial anaesthetic drug doses rather than total body
weight (Table 3).
The fifth National Audit (NAP5) into accidental awareness under
anaesthesia (AAGA) included a disproportionate number of obese
patients who suffered AAGA. Half of the incidents of awareness occurred
during the induction of anaesthesia and neuromuscular blocking drugs
were used in 93% of these cases [38]. In the obese patient, after a bolus of
anaesthetic induction agent, anaesthesia will occur before redistribution
from the central compartment, and the induction dose required to produce
unconsciousness correlates well with lean body weight [39]. However,
more rapid redistribution of induction agents into the larger fat mass
means that patients wake up more quickly than non-obese patients after a
single bolus dose. With induction agents, a dose based on total body
weight will last longer than one calculated using lean or adjusted body
weight but is likely to result in significant hypotension. It is likely that in
the cases of AAGA found in NAP5, small doses of induction agent based
on lean or adjusted body weight were not quickly followed by the introduction
of maintenance anaesthesia, thus raising the risk of AAGA. Thio-
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
9

Table 3 Suggested initial dosing scalars for commonly used anaesthetic
drugs for healthy obese adults (notwithstanding the fact that titration to
a suitable endpoint may be necessary).
Lean body weight*
Adjusted body weight*
Propofol (induction)
Propofol (infusion; see text)
Thiopental
Antibiotics
Fentanyl
Low molecular weight heparin
Rocuronium
Alfentanil
Atracurium
Neostigmine (maximum 5 mg)
Vecuronium Sugammadex †
Morphine
Paracetamol
Bupivacaine
Lidocaine
*See Table 1 for definitions/calculations.
† See product literature.
pental is associated with a greater risk of awareness than propofol. It is
strongly recommended that additional induction agent be given if there is
a delay in commencing effective maintenance anaesthesia after induction.
Hydrophilic drugs such as neuromuscular blocking drugs are distributed
primarily in the central compartment and lean body weight
is a suitable dosing scalar. A dose of rocuronium based on total body
weight does not significantly shorten the onset time, but will markedly
increase the duration of action [40]. However, due to increased
plasma cholinesterase activity, total body weight is appropriate for
suxamethonium. Doses of neostigmine and sugammadex are related to
the timing and total dose of neuromuscular blocking drugs to be
reversed and can usually be titrated to effect.
For opioids, the clinical effect is poorly related to the plasma concentration
[41]. Dosing using lean body weight is therefore a sensible
starting point until the patient is awake and titration to effect is possible.
For target controlled infusions (TCI) of propofol, the Marsh and
Schnider formulae become unreliable for patients weighing over 140–
150 kg [40]. Because of this, none of the commercially available pumps
allow input of weights above 150 kg using the Marsh model, or BMI
> 35 kg.m 2 (female) and 42 kg.m 2 (male) using the Schnider model.
There is a lack of evidence as to the best weight scalar to use with TCI
10 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

techniques, and when used with neuromuscular blocking drugs,
awareness is a significant potential risk. In these situations, some form
of depth of anaesthesia monitoring is strongly recommended [42].
Pre-operative preparation
General considerations
The vast majority of obese patients presenting for surgery are relatively
healthy and their peri-operative risk is similar to that of patients of normal
weight. The patients at high risk of peri-operative complications are
those with central obesity and metabolic syndrome, rather than those
with isolated extreme obesity [10].
Particular attention should be focused on screening patients for
sleep-disordered breathing and those at particularly high risk of VTE. A
clear pathway for referral for specialist sleep studies should be identified.
The Obesity Surgery Mortality Risk Stratification score (OS-MRS)
(Table 4) has been validated for patients undergoing gastric bypass surgery
to identify the risk factors associated with mortality [43]. It
includes features of metabolic syndrome and sleep-disordered breathing.
Although only validated for bariatric surgical patients, it may be applicable
to obese patients undergoing non-bariatric operations. Patients who
Table 4 The Obesity Surgery Mortality Risk Stratification score: (a) risk
factors; (b) risk of mortality [43].
Risk factor
Score
(a)
BMI > 50 kg.m 2 1
Male 1
Age > 45 years 1
Hypertension 1
Risk factors for pulmonary embolism: 1
Previous venous thromboembolism
Vena caval filter
Hypoventilation (sleep-disordered breathing)
Pulmonary hypertension
Risk of mortality
(b)
Class A: 0-1 points 0.2–0.3%
Class B: 2–3 points 1.1–1.5%
Class C: 4–5 points 2.4–3.0%
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11

score 4–5 on the OS-MRS are more likely to require closer postoperative
monitoring.
All patients should have their height and weight recorded and BMI
calculated, and these should both be recorded on the operating list to
inform the teams that additional time, equipment and preparation may
be needed. There may be an advantage in estimating lean and adjusted
body weight and recording these in the patient’s records to aid the calculation
of drug doses.
Diagnostic testing should be based on the need to evaluate co-morbidity
and the complexity of surgery, rather than merely as a result of
the presence of obesity.
In bariatric surgery, it is routine to initiate a pre-operative ‘liver
shrinking’ diet to reduce the size of the liver and make access to the
stomach technically easier. There is evidence that 2–6 weeks of intense
pre-operative dieting can improve respiratory function and facilitate laparoscopic
surgery, and may be worth considering in the higher risk
patients [44].
Pre-operative discussion can promote smoking cessation, clarify the
importance of thromboprophylaxis and early mobilisation, plan the
management of medication before admission and remind relevant
patients to bring their own CPAP machine into hospital.
Respiratory assessment
Clinical evaluation of the respiratory system and exercise tolerance
should identify functional limitations and guide further assessment. It is
helpful to assess patients’ arterial saturation in the pre-assessment clinic.
Spirometry is also often useful.
The following features may indicate the presence of significant
underlying respiratory disease and should prompt consideration of preoperative
arterial blood gas analysis [45]:
Arterial saturation < 95% on air
Forced vital capacity < 3 l or forced expiratory volume in 1 s < 1.5 l
• Respiratory wheeze at rest
• Serum bicarbonate concentration > 27 mmol.l 1
An arterial PCO 2 > 6 kPa indicates a degree of respiratory failure
and consequently the likelihood of increased anaesthetic risk.
It is essential to screen for sleep-disordered breathing. Of the several
screening tools available, the STOP-BANG questionnaire (Table 5)
is the best validated in obese patients. It is easy to calculate and has
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Table 5 The STOP-BANG screening questionnaire for obstructive sleep
apnoea (adapted with permission [46, 47]. One point is scored for each
positive feature; a score ≥ 5 is a significant risk.
Snoring
Do you snore loudly (louder than talking or heard
through a closed door?)
Tired
Do you often feel tired, fatigued or sleepy during the
daytime? Do you fall asleep in the daytime?
Observed
Has anyone observed you stop breathing or choking or
gasping during your sleep?
Blood Pressure Do you have, or are you being treated for, high
blood pressure?
BMI BMI > 35 kg.m 2
Age
Age > 50 years
Neck
Circumference (measured around Adam’s apple) > 43 cm
(17 in) for males, > 41 cm (16 in) for females
Gender
Male
shown good correlation with the severity of postoperative apnoeas. A
STOP-BANG score of 5 or greater indicates the possibility of significant
sleep-disordered breathing and should prompt referral to a sleep
physician if time allows [46, 47]. Even in the presence of a low STOP-
BANG score, a history of marked exertional dyspnoea, morning headaches
and ECG evidence of right atrial hypertrophy may indicate the
presence of sleep-disordered breathing and should also prompt referral
for assessment.
Patients with undiagnosed OSA, or those unable to tolerate CPAP,
are at the highest risk of peri-operative respiratory and cardiovascular
morbidity [48], while patients fully compliant with CPAP (usually
indicated by symptomatic benefit) are at lower risk of peri-operative
events. In general, patients with adequately treated sleep-disordered
breathing do not have problems requiring high dependency care and
may even be suitable for day surgery [49] (see below).
Airway assessment
Obesity is associated with a 30% greater chance of difficult/failed intubation,
although predictors for difficult laryngoscopy are the same as for
the non-obese [50]. A large neck circumference is a useful additional
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13

indicator and when greater than 60 cm, is associated with a 35% probability
of difficult laryngoscopy [51].
Bag-mask ventilation is also known to be more difficult in the obese
[52, 53]. Beards in particular can cause problems with bag-mask ventilation
and are quite common in the obese male population. If time allows,
it is recommended that all facial hair should be removed pre-operatively,
or at the very least clipped short.
Cardiovascular assessment
Obese patients should be assessed in the same way as any other patient
group. Features of the metabolic syndrome should be actively identified
as there is a strong association with cardiac morbidity [54]. Assessment
of exercise tolerance can be a valuable tool. The requirement for specific
cardiac investigations should be based on: the degree of exercise tolerance;
the presence of additional co-morbidity; and the site and extent of
the anticipated surgery.
Cardiopulmonary exercise testing (CPET) may predict those at high
risk of postoperative complications and increased length of stay [55, 56].
Standard CPET equipment may not be suitable and recumbent bikes are
available for heavier patients.
Planning postoperative care
The planned postoperative management of most obese patients should
resemble the enhanced recovery programmes of many surgical specialities.
Obesity alone is not a clinical indication for high-dependency postoperative
care. Factors that warrant consideration for a level-2 or -3 setting
include the following:
Pre-existing co-morbidities
Indicated high risk (e.g. OS-MRS 4-5 or limited functional capacity)
Surgical procedure
• Untreated OSA plus a requirement for postoperative parenteral opioids
• Local factors including the skill mix of ward staff
An important consideration for all patients is the degree and site of
surgery. If longer acting opioids (e.g. morphine) are necessary, then
these patients will require closer monitoring, specifically watching for
developing hypercapnia, and level-2 care may be indicated [57].
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Intra-operative care
Preparation of patients
Patients’ dignity is important, so suitably sized theatre gowns and disposable
underwear should be available. Antacid and analgesic premedication
should be considered. As previously mentioned, it may be
appropriate to ask male patients with beards to shave/trim them before
surgery.
Preparation of staff
The specific peri-operative requirements of the obese patient should be
included in the pre-operative team brief of the WHO surgical checklist
to ensure the presence of appropriate equipment, including suitable
operating tables, beds and trolleys (see below).
Extra time should be allowed for positioning the obese patient and
performing anaesthesia. Anaesthetists should recognise when additional
personnel (another trained anaesthetist or additional operating department
practitioners) are needed.
The seniority of both the anaesthetist and the surgeon should be considered.
Patients with an OS-MRS score > 3 should be discussed with a
consultant, and those with a score of 4–5 should be anaesthetised by an
anaesthetist experienced in the management of such patients. An experienced
surgeon will reduce operative time and this will help to limit perioperative
morbidity.
Regional anaesthesia
Where possible, regional anaesthesia is preferred to general anaesthesia,
although a plan for airway management is still mandatory [58]. There is
a higher risk of failure of regional techniques in the obese, and appropriate
patient counselling/consent is advised. [59] If sedation is required
during regional anaesthesia, this should be kept to the minimum. Specific
equipment such as extra-long spinal or epidural needles should be
available and ultrasound might be a useful adjunct [60].
There are advantages to the patient (comfort) and practitioner (success
rates) in using the sitting position for neuraxial techniques, and it
may be helpful to tilt the bed towards the operator so the patient naturally
leans forward [61]. To reduce epidural catheter migration, it is recommended
that at least 5 cm catheter should be left in the epidural
space [62].
It is safer to calculate local anaesthetic drug dose using lean body
weight. Despite the potential reduction in neuraxial volume due to
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15

adipose tissue, standard doses of local anaesthetic are recommended for
central neuraxial blockade [63].
The anaesthetist should be aware that hypotension following neuraxial
anaesthesia may be more problematic in the obese as they are less
tolerant of lying flat or in the Trendelenberg position.
Induction of general anaesthesia
Easily reversible drugs, with fast onset and offset, are the agents of
choice for obese patients.
Anaesthetising the patient in the operating theatre has the advantages
of avoiding the problems associated with transporting an obese anaesthetised
patient, and will also reduce the risk of arterial desaturation
and AAGA associated with disconnection of the breathing system during
transfer [38, 64]. In addition, the patient can position him/herself
on the operating table and can help identify pressure points for protection.
There were a number of learning points from the fourth National
Audit Project (NAP4) which looked at airway complications that are
pertinent to the airway management of the obese patient [65]:
• There was often a lack of recognition and planning for potential airway
problems
• As a result of the reduced safe apnoea time, when airway complications
occurred, they did so rapidly and potentially catastrophically
•
There was evidence that rescue techniques such as supraglottic airway
devices and emergency cricothyroidotomy had an increased failure
rate
•
Adverse events occurred more frequently in obese patients when anaesthetised
by inexperienced staff
Since the work of spontaneous breathing is increased in the obese
patient, tracheal intubation with controlled ventilation is the airway
management technique of choice. Use of supraglottic airway devices as
the primary airway device should be reserved for highly selected patients
undergoing short procedures and, where the patient can be kept headup
during surgery. The upper airway should be accessible at all times
and there must be a plan for tracheal intubation if required.
During induction of anaesthesia, the patient should be positioned in
a ramped position with the tragus of the ear level with the sternum, and
the arms away from the chest (Fig. 3). This will improve lung mechanics,
thereby assisting oxygenation and ventilation and as a result, maxi-
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Figure 3 Ramping position for obese patients. Note the tragus of the
ear level with the sternum.
mising the safe apnoea time. The addition of positive end-expiratory
pressure (PEEP) may further facilitate pre-oxygenation [66]. Minimising
the time from induction to intubation will reduce the risk of oxygen desaturation
should bag-mask ventilation prove difficult. It has been demonstrated
that ramping improves the view at laryngoscopy in the obese
patient and this is therefore the recommended default position during
induction in all obese patients [67]. Any difficulty with/failure of direct
laryngoscopy should be promptly managed in accordance with the Difficult
Airway Society guidelines [68].
Suxamethonium-associated fasciculations increase oxygen consumption
and have been shown to shorten the safe apnoea time [69]; consequently,
it is unlikely to wear off before profound hypoxia occurs, and so
may not be the drug of choice for obese patients [70]. With the advent of
sugammadex, aminosteroids could instead be considered the neuromuscular
blocking drugs of choice. The use of rocuronium can minimise the
apnoea time from cessation of spontaneous ventilation to control of ventilation
via a secure airway if bag-mask ventilation is difficult. The dose of
sugammadex for emergency reversal should be pre-calculated and be
immediately available for preparation if required [71].
Ideal body weight should be used to size tracheal tubes and to calculate
tidal volume during controlled ventilation. Tracheal diameter
reduces slightly with increasing BMI [72]. During controlled ventilation,
no particular mode of controlled ventilation has been proven to be
superior; however, greater tidal volumes for a given peak pressure can
often be achieved using pressure-controlled, rather than volume-con-
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17

trolled, ventilation. The addition of sufficient PEEP and recruitment
manoeuvres will reduce intra- and postoperative atelectasis [73]. For
laparoscopic surgery, flexion of the patient’s trunk, i.e. a slight sitting
position, allows increased abdominal excursion and slightly lower airway
pressures [74].
As intravenous access is often difficult in the obese, it is prudent to
site two intravenous cannulae while in theatre. Ultrasound may prove
useful to help locate peripheral veins but consideration should be given
to unusual sites for intravenous access such as the upper arm and anterior
chest wall. Central venous access should only be used if peripheral
access is impossible, or if specifically indicated.
The ‘SDB-safe’ anaesthetic
A simple and safe principle is to assume that all obese patients have
some degree of sleep-disordered breathing (whether formally tested or
not) and to modify the anaesthetic technique accordingly. Useful
peri-operative strategies therefore include the following:
Avoidance of general anaesthesia and sedatives where possible
Use of short acting agents
•
Use of depth of anaesthesia monitoring techniques to limit anaesthetic
load, particularly when neuromuscular blocking drugs and/or
a total intravenous anaesthetic technique are utilised
•
Use of neuromuscular monitoring to maintain a level of block compatible
with surgery and to ensure complete reversal of block before
waking the patient
• Maximal use of local anaesthetic and multimodal opioid-sparing
analgesia
Maintaining the head–up position throughout recovery
• Monitoring of oxygen saturations until mobile postoperatively
If long-acting opioids are required and the patient is not stabilised
on CPAP pre-operatively, then the use of level-2 care is recommended.
Maintenance of anaesthesia
There is limited evidence at present to favour either TCI of propofol or
volatile agents for maintenance of anaesthesia in the obese. However,
due to the increased risk of AAGA in the obese, it is important that
maintenance is commenced promptly after induction of anaesthesia
[38]. Fat-insoluble volatile agents such as desflurane or sevoflurane have
a faster onset and offset than isoflurane. There is evidence of faster
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eturn of airway reflexes with desflurane compared with sevoflurane in
the obese [75].
Multimodal analgesia techniques, including local anaesthesia, enable
opioid sparing and are strongly recommended.
Emergence from anaesthesia
Both NAP4 and NAP5 showed a high incidence of problems during extubation
in the obese. An extubation plan must therefore be in place in
accordance with the Difficult Airway Society extubation guidelines [76].
Reversal of neuromuscular blockade should be guided by a nerve
stimulator. The aim is to restore motor capacity before waking the
patient [38]. Patients should have return of their airway reflexes and be
breathing with good tidal volumes before tracheal extubation, which
should be performed with the patient awake and in the sitting position.
In those patients with confirmed OSA, the insertion of a nasopharyngeal
airway before waking helps mitigate the partial airway obstruction
that is commonly seen during emergence from anaesthesia.
Postoperative care
Immediate post-anaesthesia care
Full monitoring should be maintained in the post-anaesthesia care unit
(PACU). The patient should be managed in the sitting position or with a
45° head-up tilt.
Oxygen therapy should be applied to maintain pre-operative levels
of arterial oxygen saturation and should be continued until the patient
is mobile postoperatively. If the patient was using CPAP therapy at
home, it should be reinstated on return to the ward or even in the
PACU if oxygen saturation levels cannot be maintained by the use of
inhaled oxygen alone [57]. If supplemental oxygen is necessary, this can
either be given via the patient’s CPAP machine or via nasal specula
under the CPAP mask.
Before discharge from the PACU, all obese patients should be
observed whilst unstimulated for signs of hypoventilation, specifically
episodes of apnoea or hypopnoea with associated oxygen desaturation,
which will warrant an extended period of monitoring in the PACU.
Ongoing hypoventilation will require anaesthetic assessment to establish
the need for further respiratory support and level-2 care.
The patient is safe to return to the ward only when:
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19

Routine discharge criteria are met
•
or apnoea for at least one hour
•
The respiratory rate is normal and there are no periods of hypopnea
The arterial oxygen saturation returns to the pre-operative values
with or without oxygen supplementation
Analgesia and ward care
An enhanced recovery protocol is essential [77]. Early mobilisation is
vital and most patients should be out of bed on the day of surgery. If
possible, restricting the patient with a urinary catheter, intravenous infusions
or other devices should be avoided. Calf compression devices can
be disconnected for mobilisation.
The intramuscular route of drug administration is to be avoided
owing to unpredictable pharmacokinetics.
The use of patient-controlled analgesia (PCA) systems needs careful
consideration because of the increased risk of respiratory depression in
those with undiagnosed sleep-disordered breathing. In those patients
with suspected or poorly treated sleep-disordered breathing, increased
postoperative monitoring in a level-2 unit is recommended if PCA is
required.
Subarachnoid block with an opioid adjunct is a useful technique
resulting in reduced postoperative opioid requirements. Epidural infusions
are associated with reduced postoperative mobility and may be
counterproductive.
In the ward, oxygen therapy should be continued until baseline
arterial oxygen saturations are achieved, and pulse oximetry should continue
until oxygen saturations remain at baseline without supplemental
oxygen and parenteral opioids are no longer required.
Postoperative tachycardia may be the only sign of a postoperative
complication and should not be ignored (see below).
Thromboprophylaxis
Obesity per se is a risk factor for VTE and it is recommended that all
obese patients, undergoing all but minor surgery, should receive VTE
prophylaxis. Guidelines for postsurgical VTE prophylaxis were published
by the National Institute for Health and Care Excellence in 2010
[78]. Strategies to reduce the risk of VTE include: early postoperative
mobilisation; mechanical compression devices; thromboembolic device
(TED) stockings; anticoagulant drugs; and vena caval filters. There is
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Table 6 Dosing schedule for thromboprophylaxis [80].
Enoxaparin
Dalteparin
Tinzaparin
< 50 kg 50–100 kg 100–150 kg > 150 kg
20 mg once 40 mg once 40 mg twice 60 mg twice
daily
daily
daily
daily
2500 units 5000 units 5000 units 7500 units
once daily once daily twice daily twice daily
3500 units 4500 units 4500 units 6750 units
once daily once daily twice daily twice daily
currently limited evidence to support the use of TEDs in obesity, but if
used, it is essential that they be fitted correctly to avoid vascular occlusion.
Current evidence does not support the routine use of venal caval
filters in the obese population [79].
The mainstay of VTE prophylaxis in obesity is pharmacological, with
the criteria for pharmacological prophylaxis including: prolonged immobilisation;
total theatre time > 90 min; age > 60 years; BMI > 30 kg.m 2 ; cancer;
dehydration; and a family history of VTE.
Oral agents such as rivaroxiban and dabigatran are licensed for
VTE prophylaxis following orthopaedic surgery, but there is limited evidence
for their use in obesity. At present, dose adjustment for oral
agents is not recommended for the obese.
There is evidence regarding dose adjustments for low molecular
weight heparins in obesity. The Haemostasis, Anticoagulation and
Thrombosis (HAT) Committee published the dosing schedule reproduced
in Table 6 in April 2010 [80].
Rhabdomyolysis
A rare but serious complication in the obese patient is rhabdomyolysis.
Apart from obesity, pre-disposing risk factors include hypotension,
immobility, prolonged operative procedures and dehydration.
Rhabdomyolysis should be considered if the patient has postoperative
deep tissue pain, classically in the buttocks. Serum creatinine kinase
concentration should be measured promptly, and if rising, aggressive
fluid resuscitation, diuretics and urinary alkalinisation may be required
to prevent further acute kidney injury [81].
Special circumstances
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21

Sedation
Pre-operative evaluation for patients undergoing sedation should be
similar to those having general anaesthesia. Patients with sleep-disordered
breathing are likely to have airway obstruction with even minimal
sedation. Obese patients are not suitable for solo operator-sedator procedures
[82].
Emergency surgery
It is particularly important that obese patients requiring emergency surgery
are managed by an anaesthetist experienced in the care of the
obese, along with an experienced surgeon in order to minimise the
operative time and the risk of complications [83]. Postoperative level-2
nursing care is far more likely to be required owing to the much higher
risk from emergency surgery complications.
Obese patients can look deceptively well and abdominal examination
can be notoriously difficult. Tachycardia, the new onset of abdominal
pain or unexplained fever may be the only signs of intra-abdominal
sepsis and should be an indication for measuring arterial blood gases
and serum lactate.
Day surgery
It is acceptable for obese patients to undergo surgery as a day case if:
the management would not be modified if they were admitted as an
inpatient; and being treated as a day case will not alter the peri-operative
risk.
The exclusion of obese patients from the advantages that day surgery
may offer should not be made on the basis of weight alone. There
is an increased risk of anaesthetic-related complications in obese
patients in the day surgery environment, but these tend to occur on
induction of anaesthesia, intra-operatively or in the early recovery phase
[84]. Obesity has no influence on the rate of unanticipated admission,
postoperative complications, readmission or other unplanned contact
with health professionals after home discharge [85].
Current guidelines advocate automatic acceptance of patients with
BMI < 40 kg.m 2 [86, 87]. A casenote review should be carried out by
an anaesthetist to determine whether individualised discussion and
assessment may be required before the day of surgery for those with comorbidities
or BMI > 40 kg.m 2 .
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A review and meta-analysis by the Society for Ambulatory Anesthesia
provides useful advice on day surgery for patients with sleep-disordered
breathing [49]. Patients with a known diagnosis of OSA can be considered
for day surgery: if they have, and are able to use, a CPAP device after discharge;
if any co-morbid conditions are optimised; and if postoperative
pain relief can be provided predominantly by non-opioid analgesics.
Laparoscopic cholecystectomy and laparoscopic gastric banding are
increasingly being performed as a day-case procedure [88–90].
Obstetrics
Maternal obesity is recognised as one of the most commonly occurring
risk factors seen in obstetrics, with outcomes for both mother and baby
poorer than in the general population [3].
The CMACE report and the Obstetric Anaesthetists’ Association
have made a number of recommendations regarding the care of obese
pregnant women [91, 92]. Obese women have an increased risk of comorbidity
during pregnancy, in particular gestational diabetes and preeclampsia
[93, 94]. Obesity and pregnancy are both significant risk factors
for the development of VTE in pregnancy.
Compared with a non-obese parturient, an obese woman is more
likely to have her labour induced and require instrumental delivery [95,
96]. There is an increased risk of operative and postoperative complications,
including increased rates of postpartum haemorrhage, prolonged
operative times, and infective complications such as endometritis and
wound infection [97].
Fetal outcomes in obese pregnant women are poorer compared with
the general population, with stillbirth rates in women with a BMI
> 35 kg.m 2 twice as high as the national stillbirth rate. There is an
increased risk of preterm delivery in pregnant obese women [98].
In addition, babies born to obese mothers are at increased risk of
shoulder dystocia, brachial plexus lesions, fractured clavicle and congenital
birth defects such as neural tube defects [99].
Specific anaesthetic considerations are similar to those in the nonobstetric
obese patient:
Obese patients are particularly vulnerable to aortocaval compression
• Vascular access may be more difficult and should be established
early in labour in a woman with a BMI > 40 kg.m 2 [3]
•
The provision of general anaesthesia and central neuraxial blockade
is associated with increased difficulties [100–102]. This can lead to
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23

an increased decision-to-delivery interval in women who require a
category-1 or -2 caesarean section.
The obese obstetric patient is particularly at risk of VTE and conversely,
postpartum haemorrhage. The recommended dosing of anticoagulants
is generally higher for pregnant women; the Royal College of
Obstetricians and Gynaecologists’ Green-top Guideline provides current
recommendations [103].
Critical care
Outcomes of obese patients in critical care remain controversial. In several
recent studies, obesity was not associated with increased mortality;
however, it was associated with a prolonged requirement for mechanical
ventilation, tracheostomy and prolonged length of stay in a critical care
unit [104, 105].
Airway interventions in the obese are associated with an increased
risk of hypoxia and complications and should only be undertaken by
appropriately skilled personnel. Many would advocate an early tracheostomy
if long-term airway management is anticipated. Custom-made tracheostomy
tubes with an adjustable flange may be required to ensure an
adequate length to reach the trachea. Tracheostomies are usually performed
in the intensive care unit using a percutaneous approach, but
surgical placement may be considered, depending on the experience of
the available medical staff.
For mechanical ventilation, ideal body weight is used to calculate
the initial recommended tidal volume of 5–7 ml.kg 1 , ensuring the peak
inspiratory pressure remains < 35 cmH 2 O [106].
Enteral absorption of drugs is not altered in the morbidly obese. However,
owing to the altered pharmacokinetics, monitoring of serum levels is
considered more important in this group of patients to ensure that drug
levels remain within the therapeutic range [37].
Prophylaxis against VTE is vitally important for the morbidly obese
patient in critical care and should follow the guidelines given above.
All critically ill patients are prone to develop protein malnutrition as a
result of metabolic stress and despite having excess fat stores, the morbidly
obese are no different. However, there is some evidence suggesting that
hypocaloric feeding regimens can achieve adequate nitrogen balance with
more favourable outcomes [107].
Early aggressive rehabilitation and physiotherapy should be undertaken
as soon as is possible to encourage early mobilisation. Increased
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numbers of staff are needed to roll these patients to prevent formation
of pressure sores.
Cardiopulmonary resuscitation
Morbid obesity presents additional problems during resuscitation. There
may be delays caused by difficulties in placement of defibrillator pads,
establishment of vascular access or securing an effective airway. Physical
and biological factors related to obesity may affect the quality of chest
compressions delivered, the efficacy of administered vasoactive drugs or
the efficacy of defibrillator shocks applied, because none of these measures
are standardised to a patient’s BMI. The American Heart Association
has concluded that no alterations to resuscitation have been shown
to affect outcome [108].
Inspiratory airway pressures will be higher than normal, and
excessive leak with supraglottic airway devices may mean that chest
compressions will have to be paused to enable ventilation (i.e. a standard
30:2 compression-ventilation ratio). The high airway pressures
that can occur during resuscitation of very obese patients may impair
coronary perfusion pressure and ultimately reduce the chance of survival
[109].
Chest compressions will be difficult to perform in many patients,
simply because of suboptimal positioning of rescuers. A step or platform
may be required, or compressions can be performed from the patients’
head end. Recommended defibrillation energies remain unaltered in the
morbidly obese, though there is evidence that the thoracic impedance is
higher [110]. If defibrillation remains unsuccessful, the defibrillator pads
should be repositioned and the shock energy increased to the maximum
setting.
If intravenous access is difficult, the intraosseous route for drug
delivery is recommended. The upper humerus is a well-established point
of access, and drug delivery during resuscitation is effective via this
route. Standard doses of adrenaline and amiodarone should be used.
Patients with adjustable gastric bands in situ
Laparoscopic adjustable gastric banding is a recognised treatment for
obesity. However, patients with a gastric band in situ are at increased
risk of pulmonary aspiration during general anaesthesia owing to
oesophageal dysmotility and dilatation above the band. The dilatation
may persist following band deflation. There are case reports of regurgitation
of food even after prolonged fasting and a tracheal tube is recom-
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25

mended in all patients who have a gastric band [111, 112]. Current
advice is not to deflate the band before surgery; however, depending on
the extent and type of surgery, a decision to deflate the band may be
made on an individual basis. Discussion with the bariatric surgical team
is advised.
An important side note is that patients with gastric bands in situ
who present with sudden onset of dysphagia or upper abdominal pain
should be considered as having a band slippage until proved otherwise.
This is a surgical emergency and should be treated by immediate deflation
of the gastric band and referral to a competent general surgeon.
Delay in deflating the band can lead to gastric infarction and perforation.
For the management of other bariatric surgical emergencies, readers
are referred to the American Society for Metabolic and Bariatric Surgery
website (see below).
Resources
Equipment
A 2011 review of incidents related to obesity reported to the National
Patient Safety Agency highlighted that many of these involved inadequate
provision of suitable equipment. This is a clinical governance issue
and hospitals need to invest in appropriate equipment to assist in the
safe management of obese patients. A suggested but not exhaustive list
of equipment to be considered is given in Table 7 [113].
An ‘obesity pack’ is useful; this can include specialised documentation,
the SOBA single-sheet guidelines (see below) and smaller items of
equipment plus a list of where the larger items are located.
Staff
All units managing obese surgical patients must have the ability to escalate
care appropriately in the event of acute deterioration of patients.
It is recommended that a single person in the anaesthetic department
be nominated as the obesity lead. It would be his/her responsibility
to ensure that equipment and training are up to standard and could
act as a point of contact for advice.
Theatre teams should have training in managing obese patients,
which can be provided either internally or externally. In hospitals where
there is a bariatric service, all staff should periodically observe practice
in this area. Specific training on moving the morbidly obese patient
should be provided.
26 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Table 7 Equipment for managing obese surgical patients.
Ward equipment
Specialised electrically operated beds that can raise a patient to standing
without the need for manual handling with
pressure-relieving mattresses
Suitable bathrooms with floor-mounted toilets, suitable commodes
Large blood pressure measuring cuffs
Extra-large gowns
Suitably sized compression stockings and intermittent compression devices
Larger chairs, wheelchairs and trolleys, all marked with the maximal
recommended weight
Scales capable of weighing up to 300 kg
On-site blood gas analysis
Continuous positive airway pressure or high-flow oxygen delivery device for
the post-anaesthesia care unit
Patient hoist or other moving device (may be shared with other
departments)
Theatre equipment
Bariatric operating table, able to incorporate armboards and table
extensions, attachments for positioning such as leg
supports for the lithotomy position, and shoulder and foot supports
Gel pads and padding for pressure points
Wide Velcro strapping to secure the patient to the operating table
Ramping device/pillows
Raised step for the anaesthetist
Large tourniquets
Readily available difficult airway equipment
Anaesthetic ventilator capable of positive end-expiratory pressure and
pressure modalities
Portable ultrasound machine
Hover-mattress or slide sheet
Long spinal and epidural needles
Long arterial lines if femoral access is necessary
Neuromuscular blockade monitor
Depth of anaesthesia monitoring to minimise residual sedation
In ideal circumstances, all anaesthetic trainees should complete a
module in bariatric anaesthesia to gain insight and hands-on experience
in the management of the morbidly obese surgical patient.
The SOBA single-sheet guide
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
27

This is designed as an aide memoire to be laminated and left in the
anaesthetic room for reference when required. It is available on the
SOBA website and updated every six months as new evidence becomes
available (see www.sobauk.com).
Useful websites
The Society for Obesity and Bariatric Anaesthesia UK: www.sobauk.com.
British Obesity Surgery Patient Association: www.bospauk.org.
British Obesity and Metabolic Surgery Society: www.bomss.org.uk.
American Society for Metabolic and Bariatric Surgery: www.asmbs.org.
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34 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
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AAGBI SAFETY GUIDELINE
Peri-operative Care of the Elderly 2014
Published by
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650 Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org January 2014

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Peri-operative
care of the elderly 2014. Anaesthesia 2014; 69 s1: pages 81-98.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.12524/abstract
© The Association of Anaesthetists of Great Britain & Ireland 2014

Anaesthesia 2014, 69 (Suppl. 1), 81–98
Guidelines
doi:10.1111/anae.12524
Peri-operative care of the elderly 2014
Association of Anaesthetists of Great Britain and Ireland
Membership of the working party: R. Griffiths, F. Beech, 1 A. Brown, J. Dhesi, 2 I. Foo, 3 J. Goodall, 4
W. Harrop-Griffiths, J. Jameson, 5 N. Love, K. Pappenheim and S. White
1 College of Emergency Medicine
2 British Geriatrics Society
3 Age Anaesthesia Association
4 Intensive Care Society
5 Royal College of Surgeons
Summary
1 Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures.
2 There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline,
frailty and polypharmacy.
3 Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after
elective and (especially) emergency surgery.
4 Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide
care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role
for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists
(consultants/associate specialists) and surgeons.
5 The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation
by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very
elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of
their community care when in hospital.
6 Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation.
Multimodal intervention strategies are recommended for preventing postoperative delirium.
7 Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively
impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published
guidance on the management of pain in older people.
8 Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good
communication is essential to this process. If they clearly lack that capacity, proxy information should be sought
to determine what treatment, if any, is in the patient’s best interests.
9 Anaesthetists must not ration surgical or critical care on the basis of age, but must be involved in discussions
about the utility of surgery and/or resuscitation.
10 The evidence base informing peri-operative care for the elderly remains poor. Anaesthetists are strongly encouraged
to become involved in national audit projects and outcomes research specifically involving elderly surgical patients.
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This is a consensus document produced by expert members of a Working Party established by the Association of
Anaesthetists of Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board.
Accepted: 25 October 2013
• What other guideline statements are available on
this topic?
This guideline updates the 2001 AAGBI guideline
Anaesthesia and Peri-operative Care of the
Elderly [1]. Other guidelines informing the perioperative
care of the elderly include those published
by the British Geriatric Society [2] and the
American College of Surgeons/American Geriatrics
Society [3]. The Royal College of Surgeons has
published guidelines concerning emergency surgery
[4] and surgery for high-risk patients [5], and the
College of Emergency Medicine has produced
guidelines concerning older people with urgent and
emergency care needs [6], all of which are relevant
to the peri-operative care of the elderly.
• Why was this guideline was developed?
This guideline was developed to update the 2001
AAGBI guideline in light of the National Confidential
Enquiry into Patient Outcome and Death’s
(NCEPOD’s) 2010 report Elective and Emergency
Surgery in the Elderly: An Age Old Problem [7],
which, taken together with the Francis Report [8]
and the Parliamentary and Health Service Ombudsman’s
2011 report Care and Compassion? [9],
indicates that peri-operative care of the elderly
surgical patient is fragmented and managed poorly,
resulting in potentially avoidable morbidity and
mortality.
• How does this statement differ from existing guidelines?
This guideline is intended specifically to inform anaesthetists
about best-practice management of the
older surgical patient throughout the peri-operative
period, as members of a multidisciplinary team. It
updates the only previous specific professional
guidance in this area [1].
• Why does this statement differ from existing guidelines?
This guideline is specific to the role of anaesthesia
within the multidisciplinary peri-operative care
given to elderly surgical patients. Other relevant
guidelines are either specialty-specific [4–6], disease-specific
(for example, hip fracture [10]) or
specific to only pre-operative assessment [3]. In
common with other guidelines, this guideline
reviews current evidence regarding best-practice
anaesthesia, but also recommends best-practice in
the numerous circumstances where evidence is controversial
or incomplete, based on expert consensus
opinion.
In light of the 1999 NCEPOD report Extremes of Age
[11], the AAGBI developed its guideline Anaesthesia
and Perioperative Care of the Elderly [1], which provided
a framework for the management of patients
aged over 80 years undergoing elective and emergency
surgery. In 2001, when the guideline was published,
~6% of the population were aged over 75 years, and
accounted for ~18% of surgical procedures performed.
In 2010, the NCEPOD report Elective and Emergency
Surgery in the Elderly: An Age Old Problem found that
the care of elderly surgical patients had not improved
significantly in the intervening decade [7]. Moreover,
numerous reports have been published since (including
the Francis Report [8] and Health Service Ombudsman’s
report Care and Compassion? [9]) that suggest
that a culture of inadequate, disjointed and unsympathetic
healthcare exists for elderly inpatients in the
UK. This has contributed to the excess of expensive
mortality and morbidity experienced postoperatively
by older patients, and is of concern, given the rapidly
changing demography of the population. Currently,
~8% of the population are now aged over 75 years and
account for ~23% of surgical procedures performed
(Fig. 1), but by 2025, ~10% of the population will be
aged over 75 years, which is likely to increase the economic
and clinical burdens on the National Health
Service, unless the effectiveness and efficiency of surgical
care can be rapidly and significantly improved for
this vulnerable patient group [12].
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In comparison with younger patients, older people
undergoing elective and (particularly) emergency surgery
are at higher risk of adverse postoperative outcomes,
resulting from combinations of age-related
physiological decline, multiple co-morbidity, polypharmacy,
cognitive dysfunction and geriatric syndromes,
including frailty. The provision of continuous, coherent,
quality care to elderly patients with complex needs
is difficult, but best achieved by a multidisciplinary
approach involving primary care, emergency medicine,
geriatricians, anaesthetists, intensivists, surgeons – and
patients. The Working Party includes representation
from all of these groups.
To reflect modern terminology, the concept of
chronological age defining ‘older’ has been abandoned.
Instead, the Working Party’s recommendations are
intended to guide the provision of high-quality anaesthesia
input for older people during each phase of
their surgical journey. Supporting evidence for this
advice is reviewed in the same Anaesthesia supplement
in which this guideline is published.
Pathophysiology of ageing
Physiological decline is a feature of normal ageing and
takes place in all organ systems at a rate of ~1% function
per year after 40 years of age. Fundamentally,
Figure 1 Population aged 90 years and over in England
and Wales 1981–2012. Graph reproduced from
the Office for National Statistics (see http://www.ons.
gov.uk/ons/rel/mortality-ageing/estimates-of-the-veryold–including-centenarians-/2002-2012/stbevo2012.
html?format=print under the Open Government
Licence v2.0).
there is a reduction in organ reserve, which limits the
physiological response to stressors, including acute
illness, anaesthesia and surgery. Functional decline of
the cardiovascular, respiratory, renal, central nervous,
haematological/immunological and musculoskeletal
systems is of greatest concern peri-operatively, and
may influence outcome from elective or emergency
surgery.
Cardiorespiratory systems
The inevitable physiological changes that occur in
the ageing cardiovascular system are associated with
changes in the autonomic nervous system, resulting
in reduced cardiac responsiveness to stress [13]. A
reduction in the responsiveness of beta-receptors
renders the older patient effectively ‘beta-blocked’,
which limits the ability to increase cardiac output
and to respond to fluid losses. Cardiac output is further
limited by age-related reductions in cardiac
compliance. Baroreceptor dysfunction and reduced
responsiveness to angiotensin II further limit the
response to hypovolaemia. These factors may be
compounded by co-morbid myocardial ischaemia
related to atherosclerosis, and consequent cardiac
polypharmacy.
Lung function declines with age due to loss of
both lung and chest wall compliance, and oxygen diffusion
capacity [13], more so if the patient has been a
smoker. The closing volume increases, and ventilation/
perfusion mismatch increases during tidal breathing
when supine.
Together with an age-related decline in oxidative
capacity, cardiopulmonary changes contribute to a
decline in both oxygen uptake and oxygen delivery
with age, rendering the patient at greater risk of perioperative
(myocardial and cerebral) ischaemia, resulting
in poorer outcome.
Renal system
There is considerable variation in the decline of renal
function with age, related to the nephrotoxic effects of
co-morbidities (hypertension, diabetes) and drugs (particularly
non-steroidal anti-inflammatory drugs and
ACE inhibitors) [14]. Renal function affects the pharmacokinetics
and pharmacodynamics of anaesthetic
drugs, and therefore should be assessed routinely
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before elective or emergency surgery in elderly patients
[15].
Central nervous system
Age-related decline in cerebral and cerebrovascular
function contributes to the relatively high prevalence
of postoperative delirium and cognitive dysfunction
experienced by elderly patients, which delays discharge
and ongoing functional recovery [16].
Haematological/immunological systems
Anaemia is common in the elderly (~10%), particularly
within the surgical population, and of often unexplained
aetiology possibly related to erythropoietin
resistance and stem-cell ageing [17]. ‘Immunosenescence’
describes the multifactorial deterioration of the
immune system with age that reduces the capacity to
counter infection and heal wounds, and may contribute
to the development of inflammation-mediated
organ dysfunction [18].
Musculoskeletal system
There is a general decline in muscle volume and function
that, together with arthritic and osteoporotic skeletal
changes, increases the likelihood of fragility
fracture requiring orthopaedic surgery, and of impaired
rehabilitation after all types of surgery. Immobility
contributes to a greater prevalence of thromboembolism
and pressure necrosis [19].
The surgical pathway
The peri-operative period is a continuum of inpatient
care that follows outpatient diagnosis and precedes
community rehabilitation after surgery, regardless of
whether the patient is admitted for elective, urgent or
emergency surgery. Rather than recommend management
according to the urgency of surgery, the Working
Party has considered clinical and organisational
themes that are important throughout the peri-operative
journey, and has placed particular emphasis on
interventions that improve the poorer outcomes associated
with emergency surgery.
In all cases, the Working Party recommends that:
• Continuity of care is best provided by the reciprocal
flow of information between patients, their
relatives/carers, and primary and secondary care
services [20];
• Patients who have conditions that may require
future surgery, such as abdominal aortic aneurysm,
should be given written information about symptoms
and signs that require urgent review, and how
to access this review;
• Where possible, treatment plans based on discussion
between patients and senior doctors must be clearly
documented in the patient’s notes in advance of hospital
admission. This discussion should include proposed
management of expected complications;
• Assessment and optimisation must start as early as
possible, but will need to be tailored to the time
available pre-operatively (longer for elective surgery,
shorter for emergency surgery);
• Opportunities to optimise the patient’s pathophysiological
condition must not be missed before surgery.
This may involve fluid resuscitation before emergency
surgery or the pharmacological manipulation
of chronic co-morbidities before elective surgery.
Pre-operative care
The role of the emergency services
Ambulance personnel should be aware of age-related
changes in the physiology of older patients, and appreciate
how these might affect their interpretation of
resuscitation protocols. For example, occult haemorrhage
may not be recognised in the absence of reactive
tachycardia.
Ambulance personnel are frequently able to assess
the need for surgery and warn emergency departments
in advance of arrival.
Priorities during ambulance transport include:
• Analgesia: An assessment should always be
recorded of pain intensity in the conscious patient,
regardless of cognitive impairment. Titrated
intravenous opioids are effective, but their dose and
time of administration must be recorded in writing
and communicated to emergency department personnel,
to minimise secondary overdosage. Alternative
analgesia includes (fracture) immobilisation,
Entonox and paracetamol. Non-steroidal antiinflammatory
drugs should be avoided until renal
function is ascertained [15];
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• Fluid resuscitation: Hypovolaemia may result from
haemorrhage, intestinal obstruction, inadequate
dietary intake or diuretic medication, and can be difficult
to assess. Intravenous access should be established,
but the benefits of fluid resuscitation must be
measured against the risks of fluid overload;
• Warming: Older patients may be hypothermic,
related to body habitus (thin and frail), reduced
temperature homeostasis and environmental factors
(for example, immobility after a fall in a cool
room). Core (tympanic) temperature should
be measured at the scene, and active warming
measures employed to normalise this to ~37 °C
[21];
• History taking: Ambulance personnel are often able
to speak to relatives/carers, who may not travel to
the hospital. Personnel should attempt to record
details of pre-morbid physical and cognitive status,
drug therapy and next-of-kin.
The role of the emergency department
Multidisciplinary assessment and treatment should be
available around the clock for all elderly surgical
patients, preferably in a distinct area of the emergency
department, with the aim of time-limited onward discharge
to more individually appropriate care. The College
of Emergency Medicine recommends that “given
the frequent presence of complex co-morbidities in these
individuals and their degree of need, early assessment
and resuscitation should commence and continue in the
ambulance and emergency departments. Rapid access to
geriatricians, anaesthetists, intensivists and surgeons is
essential to develop an early plan of intervention and
provide targeted management of existing co-morbidities
to decrease intra-operative and post-operative complications.
Early senior decision making is also essential to
provide the appropriate palliative care for people who
are dying who would not benefit from invasive management”
[6].
Pre-operative assessment
Pre-operative assessment in older people enables:
• Risk-stratification, informing doctors, patients and
their relatives/carers about the risks and benefits of
having, or not having, surgery;
• Proactive identification and optimisation of modifiable
risk factors, improving the likelihood of a successful
surgical outcome [3].
‘Peri-operative risk’ defines the likelihood of an
adverse outcome resulting from surgery and/or anaesthesia,
and represents the sum of risk related to both
the surgical procedure and the patient’s pre-morbid
age and pathophysiological condition. Pre-operative
assessment is more resource-efficient when targeted
towards patients with higher peri-operative risk.
• Risk related to the surgical procedure: Observational
data can be used to estimate the risk of adverse
outcome after a range of surgical procedure, but
are subject to operator and institution-specific variation
[4]. Adverse outcomes are much more likely
after emergency, rather than elective, surgery in
older people [22]. Procedural risk may be reduced
by using new surgical techniques, adapting perioperative
pathways to include high dependency/
intensive care, or by performing a less invasive
operation in the first instance to permit patient stabilisation
before definitive surgery [23];
• Risk related to the patient [24]: Age-related physiological
decline, multi-morbidity and frailty are
independently associated with increased perioperative
risk. Pre-operative assessment of the
higher-risk elderly patient, involving a structured
multifactorial approach [25], therefore, should be
undertaken by both a senior geriatrician and a
senior anaesthetist with specific subspecialty training
in geriatrics (depending on resources and time
available).
The Working Party recommends that the components
listed in Table 1 represent the minimum criteria for
adequate pre-operative geriatric assessment specific to
anaesthesia [3, 26–28]. Geriatricians and allied health
professionals properly assess other domains, such as
social circumstances, within a comprehensive geriatric
pre-operative assessment.
Pre-operative optimisation of the older surgical
patient
It is insufficient to undertake comprehensive assessment
of the older surgical patient without also attempting to
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Griffiths et al. | Guidelines: Peri-operative care of the elderly
improve his/her pre-operative health status. The benefits
of pre-operative optimisation, however, must be balanced
against the risks of delaying surgery to achieve
these. For instance, pre-operative delay before hip fracture
surgery and emergency laparotomy is associated
with poorer postoperative outcome, suggesting that
optimisation and surgery should take place simultaneously
rather than consecutively [23].
Pre-optimisation should focus on reducing the risk
of postoperative complications, namely:
• Organ-specific morbidity: Numerous guidelines are
available concerning the peri-operative management
of important co-morbidities, including diabetes,
cardiorespiratory disease and anaemia.
However, these should be tailored to suit the older
patient, and may require more than one guideline,
or conflicting guidance, to be taken into account,
along with any adverse effects relating to overinvestigation
or extending polypharmacy;
• Ischaemia: Age and disease-related declines in
physiological reserve render the older patient at
risk of organ-specific and generalised ischaemia.
The brain and heart have an absolute requirement
for oxygen, with peri-operative ischaemia increasing
the likelihood of cardiac and cerebral dysfunction.
Intervention, therefore, should aim to reduce
oxygen uptake (analgesia, thermoregulation, antibiotics)
and improve oxygen delivery (oxygen, fluids,
medication review, avoidance of hypotension and
severe anaemia);
• Postoperative cognitive disorders (postoperative delirium
(POD) and postoperative cognitive decline
(POCD) [16]: The process of identifying and reducing
the risk of POD/POCD should begin pre-operatively.
Patients are at higher risk of POD/POCD if
Table 1 Minimum components of pre-operative geriatric assessment specific to anaesthesia.
Domain Items to be assessed Appropriate assessment tools
Medical
Co-morbidity/severity:
● Cardiovascular
Vital signs, ECG, shuttle, CPET
● Respiratory
S p O 2 , (pulmonary function tests)
● Haematological
Full blood count
● Renal
Urea and electrolytes, estimated glomerular filtration rate
● Nutritional
Weight, body mass index, albumin (liver function tests)
● Musculoskeletal
Assessment of potential nerve block insertion sites
Previous anaesthesia
Enquiry after (age-related) problems
Anaesthesia-specific
Airway assessment, dentition
Alcohol intake
CAGE questionnaire for alcoholism
(Pain intensity)
(Visual analogue pain score)
Presenting pathology
Radiological
Medication
Medication review
Anticoagulant therapy
Relevant allergies
NSQIP pre-operative assessment
Coagulation screen
Cognitive
Functional capacity
Use of functional aids
Risk score
Mental capacity
Decision-making capacity
Communication
Risk factors for
postoperative delirium
Gait and balance
Mobility
Visual
Hearing
Mobility
Dentures
Pathology-specific
Frailty
Ask ‘Have you or (your carer) noticed a change in your memory?’,
Abbreviated mental test score
Vision, hearing, speech
NSQIP pre-operative assessment
6-metre walk
Walks unaided/with stick/with frame/does not walk
Housebound? (yes/no)
Glasses
Hearing aids
Walking stick, frame, wheelchair
e.g. Nottingham Hip Fracture Score
NSQIP pre-operative assessment
CPET, cardiopulmonary exercise test; NSQIP, National Surgical Quality Improvement Program.
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they are very old, frail, cognitively impaired, or
have cardio-/cerebrovascular disease and multimorbidity/polypharmacy.
Early recognition should be
communicated throughout the multidisciplinary
care team, and facilitates multimodal interventions
aimed at reducing the prevalence, severity and/or
duration of POD;
• Malnutrition: Oral nutrition and supplementation
counteract the effects of poor appetite and illness.
For example, iron, vitamin B 12 and folate supplementation
provided for subclinical nutritional anaemia
at least 28 days before elective orthopaedic
surgery reduces postoperative morbidity and mortality
[29, 30]. Prolonged pre-operative fasting
should be avoided (excepting possibly where there
is intra-abdominal pathology) [31];
• Functional decline: Although currently there is
insufficient evidence to support its use conclusively
as standard practice, anaesthetists should be aware
of their role in ‘prehabilitation’, that is, maintaining
or enhancing an older patient’s functional reserve
to facilitate postoperative rehabilitation and discharge
back into the community. This is a multimodal
process that involves effective
multidisciplinary communication about potential
risk factors for postoperative morbidity, patient
information and encouragement, enhanced recovery
protocols, fluid therapy and avoidance of
ischaemia, analgesia, thermoregulation, selection of
the most appropriate anaesthetic technique,
employment of postoperative care bundles, appropriate
postoperative care planning, and avoidance
of certain medications.
Decision-making
Pre-operative assessment allows for some determination
of the risk to a patient of undergoing a particular
intervention compared with the intended benefits. Risk
scores (such as the Nottingham Hip Fracture Score
[32]) are useful, but are derived from heterogeneous
observational data, and often require positive or negative
adjustment according to the individual patient.
Furthermore, there may be a disparity between what
doctors and patients view as ‘risk’ or ‘acceptable risk’.
Therefore, the manner and circumstances in which
risk is communicated are important. In law, the standard
of information is ‘that which a reasonable patient
in the patient’s circumstances might want to know’
[33]. In practice, this may include information about
the nature, purpose, (short-term and long-term) risks
and benefits of a specific procedure, an alternative procedure,
or no procedure at all (conservative therapy).
For older patients, the Working Party recommends
that information should be provided specifically about
how an intervention might affect the quantity or quality
of a patient’s remaining life; a pre-operative risk
calculator is available for this purpose [24].
All staff involved in the care of older people undergoing
surgery should be aware of their duties under the
Mental Capacity Act 2005 [34], and in relation to professional
guidance about ‘best interests’ determinations
if an older patient lacks the mental capacity to make
decisions [35–37]. Consultants should make decisions
in relation to patients without capacity, after taking
into account the expectations and known wishes of the
patient, his/her relatives and/or carers.
If a patient is critically unwell, then decisions
about the degree and appropriateness of intervention
will need to be made, requiring input from senior surgeons,
anaesthetists, intensivists, geriatricians and relatives/carers.
Management of expectation is important,
and the provision and intensity of postoperative support,
and end-of-life care should be discussed preoperatively.
High-risk surgery should not be carried out without
a pre-operative commitment to appropriate postoperative
care. Once the decision to operate has been
made, appropriately experienced senior personnel
should be available at all times of day to anaesthetise
and operate on the patient, and organise appropriate
postoperative care.
The nature of surgery
The Working Party strongly advocates senior multidisciplinary
communication about the nature of surgical
intervention before and during surgery. Anaesthetists
must ask their surgical colleagues exactly what procedure
is proposed and whether this is appropriate for
the pathophysiological status of the patient, to plan
anaesthesia accordingly. This may involve consideration,
for example, of the type of access proposed
(minimal access vs open approach), whether ‘damage
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Anaesthesia 2014, 69 (Suppl. 1), 81–98
control’ surgery (e.g. stenting, defunctioning colostomy)
[38] should be used in the first instance to allow
further patient stabilisation, or whether palliative surgery
is/becomes more appropriate.
Intra-operative management
Older people should expect the same level of dignity
and anaesthesia care as younger adult patients [33].
Additional time may be required to allow older people
to prepare themselves for surgery. Functional aids
(glasses, hearing aids, dentures) should remain in place
until just before the induction of anaesthesia.
Pre-operative checklist
The Working Party recommends use of a specific checklist
by anaesthetists caring for patients over the age of
75 years (Table 2). It includes two sections that should
be completed after the WHO Surgical Safety Checklist
[39] ‘sign in’, before induction of anaesthesia, and ‘time
out’ criteria, before surgical incision.
Temperature control
The importance of body temperature is often underestimated
in the elderly. Peri-operative hypothermia is
common, and associated with adverse outcomes that
include postoperative delirium, cardiac dysfunction,
prolonged hospital stay and poor wound healing [7, 40].
Elderly patients are at increased risk of hypothermia
in the peri-operative period, and are more difficult
to rewarm once hypothermic. Therefore, measures to
maintain temperature, including regular assessment
(tympanic pre- and postoperatively, tympanic/pharyngeal/oesophageal
intra-operatively) and treatment
(forced air warming, fluid warming) should be available
peri-operatively [41], including during transport to and
from theatres, and in the postoperative recovery area.
Griffiths et al. | Guidelines: Peri-operative care of the elderly
Monitoring
The patient should be monitored during anaesthesia
according to AAGBI guidelines [42]. Additional monitoring
is not used as frequently as it should be, given
the greater peri-operative risk of morbidity and mortality
in this patient population [7]. The Working
Party recommends that anaesthetists routinely consider
use of the following monitoring devices for the elderly,
particularly during major or emergency surgery:
• Intra-arterial blood pressure monitoring: Currently,
there is no internationally agreed definition of
hypotension [43]; however, the ‘least bad’ definition
is a fall in systolic blood pressure of more
than 20% from pre-induction baseline, and the
Working Party recommends that this is a suitable
limit. Ideally, intra-arterial cannulation and transduction
should commence before induction of
anaesthesia, to diagnose, treat and therefore prevent
the significant hypotension that can occur at
this time in elderly patients. Beat-to-beat monitoring
also reduces the incidence of hypotensive episodes
occurring between non-invasive blood
pressure measurements, and facilitates near-patient
testing (haemoglobin concentration, blood glucose,
arterial blood gases).
• Central venous pressure: There is a poor relationship
between central venous pressure and blood
volume, as well as poor correlation in response to a
fluid challenge, particularly in elderly patients with
poorly compliant ventricles and vasculature [44],
potentially resulting in fluid overload. Central
venous catheterisation may provide an additional
route of venous access after complex surgery when
vasoactive drug support or parenteral nutrition is
necessary, but must be balanced against the com-
Table 2 Recommended pre-operative amendments to WHO Surgical Safety Checklist for all patients aged over
75 years.
Sign in: before induction of anaesthesia
Have vital signs been recorded (heart rate, blood pressure,
heart rhythm, S p O 2 , temperature)?
Is the patient’s resuscitation status known?
Does the patient have dentures?
Does the patient have any pre-operative pressure sores?
Has the site of any nerve block been confirmed and marked?
Time out: before surgical incision
Have possible areas of pressure damage been padded?
What is the patient’s haemoglobin concentration?
What is the patient’s eGFR?
eGFR, estimated glomerular filtration rate
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plications of such access, including insertion
trauma and infection;
• Cardiac output monitoring: Although NICE guidelines
recommend that oesophageal Doppler monitoring
‘should be considered for use in patients
undergoing major or high-risk surgery’, there is
limited evidence in the elderly and, especially, in
emergency surgery [45]. Cardiac output monitoring
using Doppler directed at the aorta (e.g. oesophageal
Doppler/USCOM) may be less accurate in the
elderly, as flow through a poorly compliant aorta
may overestimate cardiac output, and result in insufficient
fluid resuscitation [46, 47]. Use of other
cardiac output monitoring technologies may also be
problematic; therefore, intra-arterial blood pressure
monitoring should be considered earlier in elderly
unwell patients. Regardless of monitoring used, fluid
therapy should be administered with great care and
in divided boluses to allow assessment of response;
• Cerebral oxygen saturation: If episodes of cerebral
oxygen desaturation (> 15%) are indicative of cerebral
ischaemia, then monitoring and early intervention
(systolic BP < 10% fall from baseline, S p O 2
> 95%) may reduce the prevalence of POD/POCD
[48], although further research is needed to confirm
this;
• Bispectral Index Monitors (BIS) or entropy monitors
should be used to guide depth of anaesthesia and
sedation. The doses of anaesthetic agents required to
induce and maintain general anaesthesia [49] and
sedation [50] decrease with increasing age, and failure
to adjust doses (which is common) can result in
relative overdose and prolonged, significant hypotension
[51]. Depth of anaesthesia monitors are recommended
as an option by NICE “during any type
of general anaesthesia in patients at higher risk of
adverse outcomes. This includes … patients at higher
risk of excessively deep anaesthesia” [52]. If depth-ofanaesthesia
monitors are unavailable, a Lerou nomogram
(see Appendix 1) should be used to calculate
the dose of inhalational anaesthesia according to
age-adjusted MAC values [49]. Age-adjustment algorithms
are built into the software of most new generation
anaesthetic machines, and are routinely used
for TIVA. A ‘triple low’ of low BIS and hypotension
despite low inspired inhalational agent concentration
is associated with higher mortality and prolonged
inpatient stay [53].
• Peripheral nerve stimulation: Pharmacokinetic and
pharmacodynamic changes in the elderly can result
in unpredictably prolonged neuromuscular blockade,
suggesting that neuromuscular function monitoring
should be used routinely for patients administered
neuromuscular blocking agents [54, 55].
Fluid and electrolyte management
Fluid and electrolyte therapy is challenging in older
surgical patients. Pathophysiological changes in elderly
patients reduce homeostatic compensation for blood/
fluid loss, but also for boluses of administered intravenous
fluids. Prolonged pre-operative fasting should be
avoided, with clear fluids normally allowed up to 2 h
before surgery to avoid dehydration. High-risk patients
undergoing major surgery appear to benefit from
‘restrictive’ fluid therapy that avoids hypovolaemia by
administering enough fluid to replace pre- plus intraoperative
losses [7, 11, 56]. Neither GIFTASUP [57]
nor NICE [58] guidance is specific tofluid therapy in
older patients.
Blood transfusion
Pre-operative and postoperative anaemia are common
in the older surgical patient, and are associated with
myocardial ischaemia, falls, poor wound healing and
rehabilitation. However, there is a lack of evidence
specific to the elderly surgical population about when
and how much to transfuse to optimise haemoglobin
concentration without incurring transfusion-related
complications.
Observational data suggest that patients aged
> 65 years have higher mortality after major noncardiac
surgery if there is ‘substantial’ operative blood
loss or they have a pre-operative haematocrit < 24%,
but lower mortality if pre-operative haematocrit is 30–
36%, and operative blood loss is < 500 ml [59]. It is
hoped that peri-operative transfusion requirements in
elderly patients are addressed by the forthcoming
NICE guidelines, due to be published in May 2015.
Positioning
Positioning of the patient on the operating table must
be sympathetic to his/her musculoskeletal condition,
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and take into account, for example, kyphoscoliosis,
arthritic joints and fixed flexion deformities. Functional
splints should not be removed, if practicable.
Older patients are at higher risk of (preventable)
peripheral nerve injuries during prolonged surgery,
including the ulnar nerve when supine, the common
peroneal nerve in lithotomy, the dependent radial
nerve in the lateral position and the brachial plexus
after prolonged periods of lateral neck flexion. Lower
limb compartment syndrome can result from the
lithotomy position, or prolonged intra-abdominal
insufflation or pelvic surgery. The Working Party recommends
that probable sites of nerve injury are comprehensively
padded before the start of surgery, and
assessed routinely every 30 min throughout surgery.
Elderly skin can be friable. Care should be taken
when transferring the patient between his/her bed and
the operating table, and when removing adherent
items from the patient, for example, diathermy pads,
tape holding the eyelids closed and surgical dressings.
Similarly, friable skin is more prone to thermal damage,
hence care should be taken with contact warming
devices. Hair should not be removed with a razor.
Reduced skin depth and vascularity, together with
reduced muscle mass, predispose the older patient to
(preventable) tissue pressure necrosis, usually over
bony protuberances, such as the heel. Prolonged hypotension
may contribute to the development of pressure
necrosis. ‘Pressure sores’ interfere with functional
recovery, may be complicated by infection and pain,
and contribute to delayed discharge.
Positioning, together with appropriate fluid therapy
and antithrombotic measures, reduces the risk of
peri-operative thrombo-embolism in the elderly [19].
Type of anaesthesia
The choice of anaesthesia – regional or general –
appears to be of less importance than how sympathetically
it is administered with regard to the patient’s
pathophysiological status. Observational studies and
meta-analyses do not reliably show any significant difference
in outcome between regional and general
anaesthesia, but this may be because the outcomes
measured are not specifically related to anaesthesia
(e.g. 30-day mortality, length of stay [22, 24] or
because regional anaesthesia is seldom administered
without sedation. The choice of technique, therefore,
should be made according to the individual patient.
Intuitively, sympathetically administered regional
anaesthesia, particularly with minimal/no sedation,
would appear to offer some benefit in terms of avoiding
short-term morbidities, including hypotension,
delirium, cardiorespiratory complications and the need
for opioid analgesia [60–62]. However, patients with
cognitive dysfunction may not be able to comply with
regional anaesthesia without heavy sedation, negating
the benefits of avoiding the postoperative cognitive
effects of general anaesthesia [63].
Age-related alterations in the pharmacokinetic and
pharmacodynamic profiles of all anaesthetic agents
render the older patient sensitive to relative overdose,
resulting in myocardial depression, reduced blood
pressure homeostasis and delayed recovery [64]. Particular
care should be taken with hypnotic agents: the
dose required to induce anaesthesia is lower, and the
onset time longer [55]. Depth of anaesthesia monitoring
is recommended.
End-of-surgery checklist
The Working Party recommends use of a specific
checklist by anaesthetists caring for patients over the
age of 75 years (Table 3) undergoing major and/or
emergency surgery. It should be completed after the
WHO Surgical Safety Checklist [39] ‘sign out’, before
the patient leaves the operating theatre for the recovery
area.
The Working Party supports the routine use of a
specific end-of-surgery bundle for older patients
undergoing emergency laparotomy (Table 4) [5].
Table 3 Recommended postoperative amendments to
WHO Surgical Safety Checklist for all patients aged
over 75 years.
Sign out: before patient leaves the operating theatre
What is the patient’s core temperature?
What is the patient’s haemoglobin concentration?
Have age-adjusted and renal function-adjusted doses
of postoperative analgesia been prescribed?
Has a postoperative fluid plan been prescribed?
Can the patient be returned safely to a general care
ward?
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Postoperative care
Definitions of levels of postoperative care are shown in
Table 5 [5]. It is recommended that all patients with a
predicted peri-operative mortality of more than 10%
should be admitted to a level 2 or 3 critical care facility
[5]. However, the Working Party recognises that,
although access to critical care should not discriminate
on the basis of age, there is a chronic mismatch
between the number of beds needed to satisfy the 10%
recommendation and the actual number of beds available,
with no imminent prospect of the number of
beds increasing significantly in the UK. Pragmatically,
therefore, the Working Party recommends that anaesthetists
routinely risk assess older patients towards the
end of surgery with regard to the level of postoperative
care they require, discharging patients into critical care
facilities if this is likely to reduce morbidity or mortality
significantly, or if identifiable organ support is
required.
Anaesthetists are instrumental in reducing the
need for, or required duration of, postoperative care,
through appropriate intra-operative management of
anaesthetic drug administration, blood pressure,
Table 4 Summary of end-of-surgery bundle for older
patients undergoing emergency laparotomy.
Towards the end of surgery
1. Risk score (P-POSSUM) to decide on final patient
destination (ward/high dependency/intensive care)
2. Measure lactate or base deficit
3. Assess fluid requirements
4. Assess reverse neuromuscular blockade
5. Assess temperature
Table 5 Levels of postoperative care.
Level Description Patient characteristics
0 Ward Basic observations
1 Enhanced ward At risk of deterioration, more
frequent observations, basic
resuscitation
2 High dependency Needs detailed observation,
intervention or single organ
support
3 Intensive care Multiple organ support,
complexity
patient temperature, fluid therapy and analgesia.
Despite optimum management, however, patient
pathophysiology may demand critical care admission.
If this cannot be provided immediately, then
postoperative care should be provided in the postoperative
care unit (PACU), to a critical care standard
and by suitably experienced personnel. The
Working Party supports the discontinuation of an
operating list (if appropriate) if anaesthetic personnel
are required to provide such care in PACU,
until such time as the patient can be transferred for
definitive critical care.
Assessment of fitness for discharge from PACU is
the decision of the responsible anaesthetist, and should
take into consideration the patient’s vital signs, temperature,
urine output, pain and cognitive status. Good
documented communication is essential to ensure the
continuation of appropriate postoperative care.
The elements of good peri-operative care continue
into the postoperative period, and are aimed at avoiding
complications and re-enabling the patient. These
include analgesia, maintenance of core temperature,
fluid therapy and pressure care. Basic monitoring
should be continued upon return to the ward, with all
hospitals ensuring employment of Modified Early
Warning Scores and provision of Critical Care Outreach
teams [65].
Pain management
Inadequate analgesia for elderly surgical patients contributes
to postoperative morbidity, including delirium
[66], cardiorespiratory complications [67] and failure
to mobilise [68]. Despite the general acknowledgement
of this fact, postoperative pain is poorly assessed [69]
and treated [70] in the elderly, particularly in patients
who are cognitively impaired [69, 71]. Older people
may also be more reluctant to acknowledge and report
pain.
The 2007 British Pain Society/British Geriatrics
Society guidelines include an algorithm for pain assessment
in older people of all cognitive abilities (Appendix
2) [69].
The use of peri-operative analgesia protocols is
recommended, and improves patient satisfaction [72],
but must be individualised for each patient, to take
into account, for example, his/her chronic pain status,
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Anaesthesia 2014, 69 (Suppl. 1), 81–98
Griffiths et al. | Guidelines: Peri-operative care of the elderly
frailty, pain assessment, concurrent medication, renal
function and cognitive impairment [73, 74].
Multimodal analgesia is not restricted to pharmacological
agents, and may involve, for example, postural
support, pressure care and patient warming. Nerve
blockade is effective, if not always reliable [64]. Paracetamol
is safe and should be considered first-line therapy.
Non-steroidal anti-inflammatory drugs should be
used with caution if paracetamol is ineffective, and at
their lowest doses and for the shortest duration, with
proton pump inhibitor gastric protection and routine
monitoring for gastric and renal damage.
Morphine is effective, but should be administered
(for moderate or severe pain) cautiously, particularly
to patients with poor renal or respiratory function,
and the cognitively impaired; consideration should be
given to the co-administration of laxatives and antiemetics,
as required.
Anaesthetists should be familiar with which medications
are potentially inappropriate for use in older
patients according to Beers Criteria [75].
Postoperative delirium and postoperative
cognitive dysfunction
The process of identifying and reducing the risk of
POD/POCD should continue postoperatively [16].
Recovery room delirium is a strong predictor for postoperative
delirium [76], and so the recovery area is an
appropriate area for delirium testing [77]. High-quality
peri-operative care reduces the incidence of delirium
[78]. NICE recommend that DSM-IV (Diagnostic and
Statistical Manual of Mental Disorders) criteria or
short-CAM (confusion assessment method) are used
to diagnose delirium [16]. Drugs that precipitate delirium,
and that should therefore be avoided if possible
in patients at risk, include benzodiazepines, opioids,
antihistamines (including cyclizine) [79], atropine [80],
sedative hypnotics and corticosteroids [75].
Nutrition
Nutrition should be continued from the pre-operative
period or instigated early after surgery to improve
wound healing and recovery; supplementation may be
required. Anaesthetists can facilitate enteral nutrition
by delivering age-appropriate anaesthesia and appropriate
fluid therapy, avoiding reliance on postoperative
opioid analgesia, and preventing postoperative nausea.
Enteral nutrition improves outcome compared with
parenteral nutrition in the elderly [81].
Re-enablement after surgery
‘Re-enablement’ describes patients’ return to their preoperative
level of function, and extends beyond remobilisation
or rehabilitation. Anaesthetists contribute
peri-operative components to the multidisciplinary
process of a patient’s re-enablement by providing
appropriate care, important elements of which have
been repeatedly emphasised above: age-appropriate
anaesthesia; fluid therapy; thermoregulation; analgesia;
communication; and risk assessment.
Ethicolegal issues
A stark conclusion common to many recent reports is
that hospital care disregards the dignity of older
patients [7–9]. This may contribute to poor continuity
of care and outcome and is symptomatic of a lowquality
culture of healthcare provision. Professional
leadership is required to reverse these attitudes, and
anaesthetists, as peri-operative physicians, are ideally
suited to managing such a change. The Working Party
strongly recommends that a consultant anaesthetist
within each NHS Trust is appointed Lead Clinician for
Geriatric Anaesthesia, and is encouraged to act as an
‘older person’s champion’ within the operating department,
responsible for improving the dignity and quality
of care received by older patients undergoing
surgery.
Issues concerning mental capacity and decisionmaking
are discussed above. These are also of importance
in discussing end-of-life care with patients or
their relatives/carers, when further intervention is considered
either futile or high-risk to the extent that
resuscitation wishes need to be considered [33]. The
Working Party recommends that all anaesthetists
familiarise themselves with professional guidance about
end-of-life care [36, 82], and, if in doubt about their
professional and legal obligations, contact their hospital’s
legal representative for advice.
Research and Audit
A recurring theme in guidelines (including this document),
reports, systematic reviews and meta-analyses of
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peri-operative care for elderly patients concerns the lack
of specific evidence on which to provide high-quality
care [22], most being extrapolated from research involving
younger surgical patients. This does not preclude the
benefit of formulating guidelines with the aim of
informing improvements in treatment where there is
diversity in practice and outcome [83]. However, the
Working Party strongly recommends that the evidence
base for peri-operative care of the elderly is improved,
and urgently. Randomised, controlled trials, although
important, are of less relevance to assessment of
multimodal interventions for elderly patients, and
before-and-after interventional studies and observational
studies may yield at least as much information.
To this end, the Working Party recommends that
anaesthetists:
• Participate in national audit initiatives, including,
for example, the National Emergency Laparotomy
Audit [23] and the National Hip Fracture Database
[10], to ensure the accuracy and completeness of
submitted data;
• Develop and assess the performance of quality
improvement metrics for elderly patients [84, 85];
• Undertake continuous quality improvement, as outlined
in Raising the Standard: a Compendium of
Audit Recipes [86] (especially sections 1.7, 1.10, 2.7,
3.4, 4.1-4.4, 4.7, 4.9, 11.3–11.6) and seek to adapt
these specifically for elderly patients.
Resources for training
The Working Party recommends that the frail elderly
are anaesthetised only by a senior anaesthetist with
appropriate training and expertise in geriatric anaesthesia.
However, given the anticipated increases in the
number of elderly patient expected to require surgery
in future, the Working Party recognises that the current
pool of ‘geriatric’ anaesthetists is insufficient to
fulfil this recommendation. The Working Party, therefore,
strongly recommends that geriatric anaesthesia is
specifically taught as a training module to anaesthetists
in training, and that peri-operative care of the elderly
surgical patient is included within the training
curricula of UK and Irish medical schools, the Royal
Colleges of Anaesthetists, Surgeons and Physicians
[87] and the College of Anaesthetists of Ireland.
Additional resources for doctors,
patients and carers
A number of documents are available that describe
what elderly patients are entitled to expect from their
inpatient care, and inform doctors about how to provide
dignified, quality care for elderly surgical patients.
These include:
1 The Royal College of Surgeons document Access
All Ages. Assessing the Impact of Age on Access to
Surgical Treatment makes recommendations about
how to improve access for older people who need
surgery by promoting age equality [88];
2 The Department of Health’s National Service
Framework for Older People sets quality standards
for health and social care, ensuring that older people
are treated with respect and fairness [89];
3 The Centre for Policy on ageing’s Ageism and Age
Discrimination in Secondary Health Care in the
United Kingdom found that age discrimination in
UK hospitals was rare after the introduction of the
National Service Framework, but that further work
needed to be done educating staff about ageism
[90];
4 The NHS Confederation’s Delivering Dignity.
Securing Dignity in Care for Older People in Hospitals
and Care Homes sets out recommendations
on how to tackle the underlying causes of poor
care of the elderly in hospitals and in care [91];
5 House of Lords and House of Commons Joint
Committee on Human Rights has examined how
the principles of The Human Rights of Older People
in Healthcare might be applied to ensure that
older people in hospital are treated with greater
dignity and respect [92];
6 The Patients Association report Listen to Patients,
Speak up for Change urges hospital staff, patients
and carers to bring poor NHS care to the attention
of senior hospital managers, the Department
of Health and government [93];
7 The King’s Fund has emphasised the importance
of maintaining the continuity of care when hospital
inpatients are admitted from, and discharged
back to, the community, in Continuity of
Care for Older Hospital Patients. A Call for
Action [20].
© 2013 The Association of Anaesthetists of Great Britain and Ireland 93

Anaesthesia 2014, 69 (Suppl. 1), 81–98
Acknowledgements
The working party acknowledges the assistance of Dr.
John Carlisle, Torbay Hospital, and Dr. Andrew Klein,
Papworth Hospital.
Competing interests
RG chaired the AAGBI Hip Fracture Guidelines
Working Party, was a member of the NICE guideline
development group for CG124, and founded the Hip
Fracture Perioperative Network; he is also Honorary
Secretary of the AAGBI. SW is a member of the
AAGBI Hip Fracture Guidelines Working Party,
advised NICE during development of CG124, is a
Council member of the Age Anaesthesia Association
(whom he represents at the NHFD), is national
research coordinator for the Hip Fracture Perioperative
Network, and is an Editor of Anaesthesia. IF has lectured
on geriatric anaesthesia on behalf of Baxter
Healthcare. No other external funding or competing
interests declared.
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discrimination_in_secondary_health_care-report.pdf (accessed
05/10/2013).
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for older people in hospitals and care homes. 2012. http://
www.nhsconfed.org/Documents/dignity.pdf (accessed 05/
10/2013).
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Human Rights. The human rights of older people in healthcare.
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jtselect/jtrights/156/156i.pdf (accessed 05/10/2013).
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Griffiths et al. | Guidelines: Peri-operative care of the elderly Anaesthesia 2014, 69 (Suppl. 1), 81–98
Appendix 1
Lerou nomogram [49] relating age, total MAC expressed in MAC units, and end-expired concentrations of volatile
agent and nitrous oxide. A result is found by drawing two straight lines. Example (dotted lines): if the measured
end-expired concentrations of sevoflurane and nitrous oxide are 1.8% and 67% (at 1 atm), respectively, then the total
age-related MAC is 1.3 in a 3-year-old. Reverse example: a total MAC of 1.3 in a 3-year-old, when using sevoflurane
and nitrous oxide 67% in oxygen, requires an end-expired sevoflurane concentration of 1.8%. © 2004 Oxford University
Press. Reproduced with permission [49].
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Griffiths et al. | Guidelines: Peri-operative care of the elderly
Appendix 2
Royal College of Physicians/British Pain Society/British Geriatric Society. Algorithm for the assessment of pain in
older people (Copyright © 2007 Royal College of Physicians. Reproduced with permission) [70].
98 © 2013 The Association of Anaesthetists of Great Britain and Ireland

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GUIDELINES
Perioperative fasting in adults and children: guidelines from
the European Society of Anaesthesiology
Ian Smith, Peter Kranke, Isabelle Murat, Andrew Smith, Geraldine O’Sullivan, Eldar Søreide, Claudia Spies
and Bas in’t Veld
This guideline aims to provide an overview of the present
knowledge on aspects of perioperative fasting with assessment
of the quality of the evidence. A systematic search was
conducted in electronic databases to identify trials published
between 1950 and late 2009 concerned with preoperative
fasting, early resumption of oral intake and the effects of oral
carbohydrate mixtures on gastric emptying and postoperative
recovery. One study on preoperative fasting which had not been
included in previous reviews and a further 13 studies
published since the most recent review were identified.
The searches also identified 20 potentially relevant studies
of oral carbohydrates and 53 on early resumption of oral
intake. Publications were classified in terms of their
evidence level, scientific validity and clinical relevance. The
Scottish Intercollegiate Guidelines Network scoring system for
assessing level of evidence and grade of recommendations was
used. The key recommendations are that adults and children
should be encouraged to drink clear fluids up to 2 h before
elective surgery (including caesarean section) and all but one
member of the guidelines group consider that tea or coffee with
milk added (up to about one fifth of the total volume) are still clear
fluids. Solid food should be prohibited for 6 h before elective
surgery in adults and children, although patients should not
have their operation cancelled or delayed just because they are
chewing gum, sucking a boiled sweet or smoking immediately
prior to induction of anaesthesia. These recommendations also
apply to patients with obesity, gastro-oesophageal reflux and
diabetes and pregnant women not in labour. There is insufficient
evidence to recommend the routine use of antacids,
metoclopramide or H 2 -receptor antagonists before elective
surgery in non-obstetric patients, but an H 2 -receptor antagonist
should be given before elective caesarean section, with an
intravenous H 2 -receptor antagonist given prior to emergency
1
caesarean section, supplemented with 30 ml of 0.3 mol l
sodium citrate if general anaesthesia is planned. Infants should
be fed before elective surgery. Breast milk is safe up to 4 h and
other milks up to 6 h. Thereafter, clear fluids should be given as in
adults. The guidelines also consider the safety and possible
benefits of preoperative carbohydrates and offer advice on the
postoperative resumption of oral intake.
Eur J Anaesthesiol 2011;28:556–569
Published online 28 June 2011
Why were these guidelines produced?
Widespread consultation suggested that guidelines on perioperative fasting would be useful to European Society of
Anaesthesiology (ESA) members.
Our guideline aims to provide an overview of the present knowledge on perioperative fasting with assessment of the
quality of the evidence in order to allow anaesthesiologists all over Europe to integrate this knowledge in their daily
care of patients.
What is similar to previous guidelines?
The ESA guidelines endorse a 2-h fasting interval for clear fluids and a 6-h interval for solids.
What is different from previous guidelines?
The ESA guidelines:
are recent and include several studies published since previous guidelines;
increase the emphasis on encouraging patients not to avoid fluids for any longer than is necessary;
offer practical, pragmatic advice on chewing gum, smoking and drinks containing milk;
consider the safety and possible benefits of preoperative carbohydrates;
offer advice on the postoperative resumption of oral intake.
From the University Hospital of North Staffordshire, Stoke-on-Trent, UK (IS), University Hospitals of Würzburg, Würzburg, Germany (PK), Armand Trousseau Hospital, Paris,
France (IM), Royal Lancaster Infirmary, School of Health and Medicine, Lancaster University, Lancaster (AS), Guy’s and St Thomas’ NHS Foundation Trust, London (GOS),
UK, Department of Anaesthesia and Intensive Care, Stavanger University Hospital, Stavanger, Norway (ES), Department of Anaesthesiology and Intensive Care Medicine,
Charité – Universitätsmedizin Berlin, Berlin, Germany (CS) and Department of Anesthesiology and Pain Medicine, Haaglanden Medical Centre, The Hague, The
Netherlands (BV)
Correspondence to Dr Ian Smith, Directorate of Anaesthesia, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent, Staffordshire ST4 6QG, UK
Tel: +44 1782 553054; e-mail: damsmith@btinternet.com
0265-0215 ß 2011 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e3283495ba1
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

Perioperative fasting in adults and children 557
1. Summary of recommendations
Evidence
Recommendation
Fasting in adults and children
Adults and children should be encouraged to drink clear fluids (including water,
1þþ
A
pulp-free juice and tea or coffee without milk) up to 2 h before elective surgery
(including caesarean section)
All but one member of the guidelines group consider that tea or coffee with milk added
(up to about one fifth of the total volume) are still clear fluids
Solid food should be prohibited for 6 h before elective surgery in adults and children 1þ A
Patients with obesity, gastro-oesophageal reflux and diabetes and pregnant women
2 D
not in labour can safely follow all of the above guidelines
However, these factors may alter their overall anaesthetic management
Patients should not have their operation cancelled or delayed just because they are
1 B
chewing gum, sucking a boiled sweet or smoking immediately prior to induction
of anaesthesia
The above is based solely on effects on gastric emptying and nicotine intake (including smoking,
nicotine gum and patches) should be discouraged before elective surgery
Fasting in infants
Infants should be fed before elective surgery. Breast milk is safe up to 4 h and
1þþ
A
other milks up to 6 h. Thereafter, clear fluids should be given as in adults
Prokinetic and other pharmacological interventions
There is insufficient evidence of clinical benefit to recommend the routine use of
1þþ
A
antacids, metoclopramide or H 2 -receptor antagonists before elective surgery in
non-obstetric patients
An H 2 -receptor antagonist should be given the night before, and on the morning of,
1þþ
A
elective caesarean section
The guidelines group recognises that most of the evidence relates to surrogate measures,
such as changes in gastric volume and pH, rather than a clear impact on mortality
An intravenous H 2 -receptor antagonist should be given prior to emergency caesarean
1þþ
A
section; this should be supplemented with 30 ml of 0.3 mol l S1 sodium citrate
if general anaesthesia is planned
The guidelines group recognises that most of the evidence relates to surrogate measures,
such as changes in gastric volume and pH, rather than a clear impact on mortality
Oral carbohydrates
It is safe for patients (including diabetics) to drink carbohydrate-rich drinks up to
1þþ
A
2 h before elective surgery
The evidence for safety is derived from studies of products specifically developed for perioperative
use (predominantly maltodextrins); not all carbohydrates are necessarily safe
Drinking carbohydrate-rich fluids before elective surgery improves subjective
1þþ
A
well being, reduces thirst and hunger and reduces postoperative insulin resistance
To date, there is little clear evidence to show reductions in length of postoperative stay and mortality
Fasting in obstetric patients
Women should be allowed clear fluids (as defined above) as they desire in labour 1þþ A
Solid food should be discouraged during active labour 1þ A
The guidelines group recognise that it may be impractical to stop all women from eating during labour,
especially low-risk women. Consideration should be given to easily digestible, low-residue foods
Postoperative resumption of fluids
Adults and children should be allowed to resume drinking as soon as they wish after
elective surgery. However, fluid intake should not be insisted upon before allowing
discharge from a day or ambulatory surgery facility
1þþ
A
, recommended best practice based on the clinical experience of the guidelines development group.
2. Purpose and development of the guideline
The European Society of Anaesthesiology (ESA) is
committed to the production of high-quality, evidencebased
clinical guidelines. After the formation of the
Guidelines Committee in 2008, a prioritisation exercise
suggested that guidelines on perioperative fasting
would be useful to ESA members and a task force was
established in June 2009 to produce this guideline. The
chairpersons of the relevant subcommittees (Evidencebased
Practice and Quality Improvement, Ambulatory
Anaesthesia, Obstetric Anaesthesia, Paediatric Anaesthesia
and Anaesthesia for the Elderly) of the ESA Scientific
Committee were asked to nominate an ESA member
with expertise in their field to join the task force. Further
experts were co-opted onto the task force as required.
Several European national anaesthesiology societies have
already produced recommendations for aspects of perioperative
fasting. Our guideline aims to provide an overview
of the present knowledge on the subject with
assessment of the quality of the evidence in order to
allow anaesthesiologists all over Europe to integrate –
wherever possible – this knowledge in their daily care
of patients.
Evidence to support the recommendations was obtained
as follows. A systematic search was conducted by
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558 Guidelines
members of Cochrane Anaesthesia Review Group of
the electronic databases Ovid, MEDLINE and Embase
to identify trials published between 1950 and late 2009
concerned with preoperative fasting, early resumption of
oral intake and the effects of oral carbohydrate mixtures
on gastric emptying and postoperative recovery. A total
of 3714 abstracts from MEDLINE and 3660 from Embase
were identified from the search. After elimination
of duplicates, irrelevant studies, non-clinical trials and
studies with a non-clinical outcome, one study on
preoperative fasting which had not been included in
previous reviews 1–4 and a further 13 studies published
since the most recent review 4 were identified. The
searches also identified 20 potentially relevant studies
of oral carbohydrates and 53 on early resumption of oral
intake.
These publications were classified in terms of their
evidence level, scientific validity and clinical relevance.
We used the Scottish Intercollegiate Guidelines Network
(SIGN) scoring system for assessing level of evidence and
grade of recommendations (Fig. 1). 5 Highest priority
was given to meta-analyses of randomised, controlled
clinical trials. In reaching consensus, particular emphasis
was placed on the level of evidence, ethical aspects,
patient preferences, clinical relevance, risk/benefit ratios
and degree of applicability. For example, a pragmatic
solution to an acceptable amount of milk in tea or
coffee was agreed based on the unpublished experience
accumulated by several members of the group over
many years.
These guidelines have undergone the following review
process. The final draft was reviewed by members of
the relevant Subcommittees of the ESA’s Scientific
Committee who were not involved in the initial preparation
of the guideline. It was posted on the on ESA
website for 4 weeks and all ESA members, individual and
national, were contacted by electronic mail to invite them
to comment on the draft. It was also sent to the International
Association for Ambulatory Surgery (IAAS) for
information and comment. All those who commented
are listed in the ‘Acknowledgements’ section below.
Comments were collated by the chair of the guideline
task force and the guideline amended as appropriate.
The final manuscript was approved by the Guidelines
Committee and Board of the ESA before submission for
publication in the European Journal of Anaesthesiology.
These guidelines are produced as a service to ESA
members and other anaesthesiologists and healthcare
staff in Europe. The ESA recognises that practice and
opinion varies in different European countries. Despite
the availability of the same scientific information, the way
in which healthcare services are organised may result in
different practices in the various European countries.
Thus, it is not always possible to produce guidelines
which will be both appropriate and relevant for every
European nation. Although national societies and
individuals are free to use the guidelines, modified as
necessary for local and national practice contexts, they are
under no obligation to do so. Further, the potential legal
implications may be a point of concern. 6 It cannot be
emphasised enough that guidelines may not be appropriate
for all clinical situations. The decision whether or
not to follow a recommendation from a guideline must be
made by the responsible physician on an individual basis,
taking into account the specific conditions of the patient
and the available resources. Therefore, deviations from
guidelines for specific reasons should remain possible and
can certainly not be interpreted as a base for negligence
claims. However, we hope that these guidelines will
both assist anaesthesiologists throughout Europe to
bring research evidence to bear on their clinical practice
and also provide support to colleagues and healthcare
funders in making changes and improvements necessary
to enhance patient care.
Differences from existing guidelines
Although there is little new evidence relating to fasting
for fluids and solids, the current guidelines review more
recent literature than any of the existing guidelines.
In addition, the American Society of Anesthesiology
(ASA) guidelines on the subject 7 were published in
1999 and contain little on preoperative carbohydrate,
whereas the UK Royal College of Nursing guidelines 4
deal with the safety aspect of preoperative carbohydrate,
but not possible benefits. In these current guidelines,
we have also tried to address practical problems such as
chewing gum.
3. Fasting
3.1. Fluids
Recommendation
Adults and children should be encouraged to drink clear
fluids (including water, pulp-free juice and tea or coffee
without milk) up to 2 h before elective surgery (including
caesarean section) (evidence level 1þþ, recommendation
grade A).
All but one member of the guidelines group consider that tea or
coffee with milk added (up to about one fifth of the total volume)
are still clear fluids.
Rationale
Since the landmark work of Maltby et al. 8 in 1986, a large
body of evidence has been accumulated to show that
the oral intake of clear fluids up to 2 h before an elective
operation is safe. 3,9,10 Many countries have, therefore,
changed their fasting guidelines, allowing most patients
take clear fluids (water, clear juices and coffee or tea
without milk) up to 2 h before elective surgery. 11
In addition to the liberalising of fasting guidelines, the
emphasis is now changing, with the realisation that
European Journal of Anaesthesiology 2011, Vol 28 No 8
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Perioperative fasting in adults and children 559
Fig. 1
Key to evidence statements and grades of recommendations
1 ++
1 +
1
High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2 ++
High-quality systematic reviews of case–control or cohort studies
2 +
Well conducted case–control or cohort studies with a low risk of confounding or bias and a moderate
probability that the relationship is causal
2 -
3
4
Case–control or cohort studies with a high risk of confounding or bias and a significant risk that the
relationship is not causal
Non-analytic studies, e.g. case reports, case series
Expert opinion
Grades of recommendation
Note: the grade of recommendation relates to the strength of the evidence on which the recommendation is
based. It does not refect the clinical importance of the recommendation.
A
At least one meta-analysis, systematic review, or RCT rated as 1 ++,
and directly applicable to the target population; or
a body of evidence consisting principally of studies rated as 1 +,
directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2 ++,
directly applicable to the target population, and demonstrating overall consistency of results; or
extrapolated evidence from studies rated as 1 ++ or 1 +
C
A body of evidence including studies rated as 2 +,
directly applicable to the target population, and demonstrating overall consistency of results; or
extrapolated evidence from studies rated as 2 ++
D
Evidence level 3 or 4; or
extrapolated evidence from studies rated as 2 +
Ḡood practice points
√
Recommended best practice based on the clinical experience of the guideline development group
Scottish Intercollegiate Guidelines Network (SIGN) grading system. RCT, randomised controlled trial. 5
prolonged fasting is an inappropriate way to prepare
for the stress of surgery. Abstaining from fluids for
a prolonged period prior to surgery is detrimental for
patients, especially the elderly and small children. Rather
than ensuring a minimal fasting interval has been
achieved, it is important to encourage patients to keep
drinking up until 2 h before surgery in order to reduce
their discomfort and improve their well being.
3.1.1. Milk in tea or coffee
Milk in large quantities curdles in the stomach and acts
like a solid, but smaller quantities are handled like other
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560 Guidelines
liquids and are safe. There is anecdotal evidence
(including from some members of this group) that when
milk is allowed to be added to tea or coffee consumed
before elective surgery, regurgitation and aspiration are
no more likely to occur, but no randomised studies
have looked specifically at the safety of this practice.
Some studies of preoperative tea and coffee 12–14 did
allow milk to be added if desired (R. Maltby, personal
communication), but this is not recorded in the published
text and the number of such patients was small. Unpublished
work has shown that adding small quantities of
milk (from a 12 ml single-portion pot) to a model stomach
caused no restriction in emptying, but that adding three
or more measures caused clumping (R. Maltby, personal
communication). However, the model comprised a glass
vessel with a fixed burette tap as an outlet and, therefore,
did not mimic either a sphincter which can relax or the
effects of churning from muscle contractions.
The lack of evidence from human studies and the
uncertainty in defining and controlling a safe amount
of milk, means that most guidelines only advocate black
tea or coffee. Although this may appear a safe approach,
some patients would rather have nothing at all if they are
denied milk in their morning cup of tea or coffee. With
one exception, the guidelines group considered that tea
or coffee with a modest amount of milk added (up to
about one fifth of the total volume) should still be
considered as clear fluids and, therefore, safe up to
2 h before the induction of anaesthesia. Drinks made
predominantly from milk, however, should be treated
as solids.
3.2. Solid food
Recommendation
Solid food should be prohibited for 6 h before elective
surgery in adults and children (evidence level 1þ, recommendation
grade A).
Rationale
No recent studies have attempted to define a minimal safe
period for preoperative fasting for solid food. One previous
study found no increase in gastric volume after a light
breakfast of tea and buttered toast consumed 2–4 h before
elective surgery, 15 but the presence of residual solids in the
stomach at induction of anaesthesia could not be ruled out
by the methodology used. It remains common practice to
avoid solid food for at least 6 h before elective surgery.
Most patients will accept this if they are permitted to
drink until closer to their surgery. There is no clear benefit
to reducing the fasting time for solids below 6 h.
3.3. Chewing gum, sweets and smoking
Recommendation
Patients should not have their operation cancelled or
delayed just because they are chewing gum, sucking a
boiled sweet or smoking immediately prior to induction
of anaesthesia
The above is based solely on effects on gastric emptying and
nicotine intake (including smoking, nicotine gum and patches)
should be discouraged before elective surgery.
Rationale
There is ongoing debate on how to deal with patients
chewing gum in the immediate preoperative period and
what constitutes a safe fasting interval. There are only
three (partly) randomised controlled studies concerning
the intake of chewing gum during the perioperative
fasting period.
In one comparison of 77 patients, 16 16 did not chew
any kind of gum, 15 patients were allowed to chew
gum until transfer to the operating room and 46 were
allowed to chew gum as long as they wished, even until
the time of anaesthesia induction. The last group was not
allocated by means of randomisation. Both gastric fluid
volume as well as pH did not differ significantly among
the three groups.
Another study compared 46 children between 5 and
17 years old who were allowed to chew either sugar-free
or sugared gum up to 30 min before transfer to the
operating room. Both the sugar-free and sugared gum
chewers had significantly higher gastric fluid volume and
pH than the control group who did not chew any gum. 17
Søreide et al. 18 compared 106 female patients scheduled
for elective gynaecologic surgery. They were either
smokers or non-smokers and were allowed to chew
nicotine-containing chewing gum or nothing (smokers)
or sugar-free gum or nothing (non-smokers), respectively.
Up to one chewing gum per hour was given until
transportation to the operating room. The non-smoking
chewers as well as the smokers (chewing or not) had
significantly higher gastric fluid volume than the nonsmokers
who did not chew gum. As far as gastric pH
values are concerned, the levels were higher in both
non-smoking groups than in both smoking groups.
No case of aspiration or other complication during anaesthesia
induction was reported. Although the differences
in pH and gastric volumes were statistically significant,
the authors did not believe the difference (30 versus
20 ml) was clinically significant (E. Søreide, personal
communication).
3.4. Patients with delayed gastric emptying
Recommendation
Patients with obesity, gastro-oesophageal reflux and
diabetes and pregnant women not in labour can safely
follow all of the above guidelines (evidence level 2 ,
recommendation grade D).
These factors may, however, alter their overall anaesthetic
management.
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Perioperative fasting in adults and children 561
Rationale
A great number of factors can potentially delay gastric
emptying. These include obesity, gastro-oesophageal
reflux and diabetes. Studies of preoperative fasting have
not evaluated these groups of patients adequately enough
to provide definitive evidence. However, the evidence
which does exist suggests that limitation of gastric
emptying is, at most, mild and that these patients can
follow the same guidelines as healthy adults. This advice
also applies to pregnant women who are not in labour.
Opioid analgesia can also delay gastric emptying, but
again there is insufficient evidence to make any
recommendation. However, patients who have recently
taken sufficient opioids to have a significant effect on
gastric emptying are unlikely to be undergoing elective
surgery often.
4. Medications
Recommendation
There is insufficient evidence of clinical benefit to
recommend the routine use of antacids, metoclopramide
or H 2 -receptor antagonists before elective surgery in nonobstetric
patients (evidence level 1þþ, recommendation
grade A).
Rationale
4.1. Prokinetic medications
In contrast to the prevalence of the perioperative use
of prokinetics, there is limited evidence to support
the prophylactic use of these agents to reduce the risk
of perioperative aspiration of gastric contents.
There are single studies that investigate the effect of
prokinetics on gastric pH and gastric fluid volume during
anaesthesia induction. Iqbal et al. 19 compared 75 women
undergoing caesarean section under general anaesthesia.
Twenty-five women were administered both an
H 2 -antagonist (ranitidine) with a prokinetic drug (metoclopramide),
whereas 25 women served as a placebo
control group (another 25 patients received only ranitidine).
The combination of the two drugs was significantly
more effective in increasing the pH and reducing the
gastric fluid volume than placebo. 19
Hong 20 investigated the effect of ranitidine and metoclopramide
versus placebo. Forty patients scheduled for
laparoscopic gynaecological surgery were administered
either 50 mg ranitidine with 10 mg metoclopramide
intravenously (n ¼ 20) or the same volume of isotonic
saline in the control group. Gastric fluid volume was
significantly higher in the placebo group, as was the
gastric pH in the treatment group. 20
Bala et al. 21 compared the combination of ranitidine–
erythromycin with ranitidine–metoclopramide. Forty
ASA I or II patients were given either erythromycin
250 mg and ranitidine 150 mg or ranitidine 150 mg and
metoclopramide 10 mg orally 60–90 min before induction
of anaesthesia. There was no significant difference in
either gastric pH or fluid volume. 21
So far, valid studies that investigate the effect of
preoperatively administered metoclopramide alone on
gastric pH and gastric fluid volume are lacking, although
metoclopramide significantly improves gastric emptying
in cardiac surgery patients 18 h postoperatively compared
with placebo. 22
So far, there is insufficient evidence that preoperatively
administered metoclopramide alone improves clinical
outcome, reduces gastric fluid volume or increases
gastric pH.
4.2. Histamine H 2 -antagonists and proton pump
inhibitors
The mechanisms of action of H 2 -antagonists and
proton pump inhibitors (PPIs) differ. The former block
H 2 -receptors on the stomach’s parietal cells, thereby
inhibiting the stimulatory effects of histamine on gastric
acid secretion; the latter block the enzyme system
of hydrogen/potassium ATPase (H þ /K þ ATPase), the
‘proton pump’ of the gastric parietal cell, such that the
stimulatory actions of histamine, gastrin and acetylcholine
are inhibited. Both have been applied with the
aim of decreasing the risk of deleterious effects resulting
from a potential acid aspiration syndrome.
A recent meta-analysis 23 comparing these medications
to therapeutic targets suggests that pre-medication
with ranitidine is more effective than PPIs in reducing
the volume of gastric secretions (by an average of
0.22 ml kg 1 , 95% confidence interval 0.04–0.41) and
increasing gastric pH (by an average of 0.85 pH units,
95% confidence interval 1.14–0.28). These conclusions
could be drawn based on nine randomised controlled
trials, of which seven were suitable for meta-analysis. In
these trials a total of 223 patients received ranitidine,
which was the sole H 2 -blocker used in the included trials,
and 222 patients received different PPIs (omeprazole,
lansoprazole, pantoprazole and rabeprazole). Overall, the
size of the trials is rather small. Further, heterogeneity
could also be detected with respect to preoperative fasting
time, route of administration, repeat administration
and the specific PPIs used. It is interesting to note
that patients in the trials received ranitidine at doses
equivalent to, or less than, the daily recommended dose
for the maintenance of peptic ulcer disease, whereas
patients received PPIs at doses higher than those recommended
for this purpose.
It is not clear how long the potential protective effect
on gastric volume or pH lasts. It is also unclear whether
these observed effects can be extrapolated to patient
populations with a higher risk of aspiration, as all the
included trials appeared to be in patients at very low
risk of aspiration and the observed parameters were used
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562 Guidelines
as a surrogate for the ‘true outcome’, that is, mortality or
adult respiratory distress syndrome following gastric
aspiration, which could not be evaluated.
5. Preoperative carbohydrates: gastric
emptying and potential benefits
Recommendation
It is safe for patients (including diabetics) to drink carbohydrate-rich
drinks up to 2 h before elective surgery
(evidence level 1þþ, recommendation grade A).
The evidence for safety is derived from studies of
products specifically developed for perioperative use
(predominantly maltodextrins); not all carbohydrates
are necessarily safe.
Rationale
Studies in animal models of severe stress, such as haemorrhage
and endotoxaemia, showed that several key systems
involved in the stress responses were markedly impaired
even if the animal had been fasted for a brief period before
the onset of a given stress. These key systems included
fluid homeostasis, stress hormone release, aspects of
metabolism, muscle function and gut integrity. 24 If these
models were fasted for as long as 24 h, there was also a
difference in survival. This indicates that the metabolic
change caused by a recent meal (as opposed to fasting)
and the loss of glycogen occurring even after a brief fast is
sufficient to alter the stress response.
Allowing patients to drink clear fluids up to 2 h prior to
surgery is not likely to produce any major change in
metabolism, as these drinks usually do not contain sufficient
energy. The best known method for changing
metabolism from the overnight fasted state to that of a
fed state is the use of carbohydrates. The key change
required to be achieved is a prompt insulin response,
preferably to an extent similar to that observed after
intake of a meal.
In the first instance, intravenous glucose has been
proposed and used for this purpose. The insulin response
to glucose infusions is determined by the rate of delivery
of glucose in a dose-dependent manner. Infusion of
glucose (and insulin) has been shown to induce an
insulin response to levels of about 60 mUml
1 , 25 reduce
postoperative insulin resistance 26 and retain substrate
oxidation. This is important because postoperative
insulin resistance and hyperglycaemia are associated with
an impaired outcome after surgery. 27 Preoperative oral
carbohydrate loading in humans also reduces postoperative
insulin resistance. Dietary interventions, therefore,
represent a promising and attractive therapeutic strategy
to optimise postprandial glycaemia. Thus far, interventions
with respect to the preoperative addition of
carbohydrates have focused on safety, metabolic effects,
personal perioperative well being and postoperative
length of stay.
5.1. Carbohydrates versus clear liquids or intravenous
infusion
Taniguchi et al. 28 investigated the safety and effectiveness
of oral rehydration as compared with intravenous
rehydration prior to general anaesthesia. Fifty patients
were randomised to either 1000 ml of oral rehydration
solution or 1000 ml of an intravenous electrolyte solution.
Volume of gastric contents, as measured directly after
induction, was significantly lower in the oral rehydration
group.
Kaska et al. 29 performed a randomised controlled trial
comparing preoperative fasting with preoperative
preparation with either oral or intravenous intake of
carbohydrates, minerals and water. 29 Oral intake shortly
before surgery did not increase gastric residual volume
and was not associated with any risk.
In the study by Nygren et al., 30 gastric emptying of a
carbohydrate-rich drink was investigated before elective
surgery and in a control situation. Patients served as
their own control pre and postoperatively. Despite the
increased anxiety experienced by patients before surgery,
gastric emptying did not differ between the experimental
and control situations.
Jarvela et al. 31 investigated the effect of a preoperative
oral carbohydrate drink versus overnight fasting on perioperative
insulin requirements in 101 non-diabetic
patients undergoing elective coronary artery bypass grafting.
According to their findings, it is safe to allow cardiac
surgery patients to drink clear fluids up to 2 h before
induction of anaesthesia, because gastric emptying of the
drink was almost total and no aspiration occurred.
Breuer et al. 32 studied the effects of preoperative oral
carbohydrate administration on gastric fluid volume.
Before surgery, 188 ASA physical status III–IV patients
undergoing elective cardiac surgery were randomised to
receive a clear 12.5% carbohydrate drink, flavoured water
(placebo), or to fast overnight (control). Carbohydrates
and placebo were treated in double-blind format and
patients received 800 ml of the corresponding beverage
in the evening and 400 ml 2 h before surgery. Ingested
liquids did not cause increased gastric fluid volume or
other adverse events.
In these five randomised studies, there was no evidence
of an increased gastric volume after ingesting carbohydrates.
Care should be taken in extrapolating this
evidence beyond those specific carbohydrates which
have been studied; not all oral carbohydrates will necessarily
behave similarly.
5.2. Diabetic patients versus healthy individuals
Investigators have been reluctant to give diabetic
patients oral carbohydrates because of the unknown
effects on preoperative glycaemia and gastric emptying.
Gustafsson et al. 33 investigated the effect of preoperative
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Perioperative fasting in adults and children 563
oral carbohydrate loading in type 2 diabetic patients.
Twenty-five patients with type 2 diabetes and 10 healthy
controls were studied. A carbohydrate-rich drink (400 ml,
12.5%) was given with paracetamol 1.5 g for determination
of gastric emptying. Patients with type
2 diabetes showed no signs of delayed gastric emptying,
suggesting that a carbohydrate-rich drink may be safely
administrated 180 min before anaesthesia without risk of
hyperglycaemia or aspiration preoperatively.
On the basis of this limited evidence, diabetes (of
either type) should not be seen as a contraindication to
preoperative oral carbohydrates.
5.3. New formulas for preoperative drinks
Beverages containing either amino acids (glutamine)
or peptides (soy peptides) have been studied with regard
to their safety. 34,35 Glutamine (15 g) with carbohydrate
in 300–400 ml of water seems to be safe to give 3 h
preoperatively in healthy volunteers based on stomach
emptying time. A drink containing soy peptide given to
patients admitted for elective bowel resections has been
shown to be safe. There was no difference in gastric
emptying time between the carbohydrate group (12.5 g
per 100 ml carbohydrate drink) and carbohydrate/peptide
group (12.5 g per 100 ml carbohydrate and 3.5 g per 100 ml
of hydrolysed soy protein). 35 More research is necessary
to determine the effects of clear liquids with amino acid
or hydrolysed protein in metabolic response and insulin
sensitivity after surgery.
5.4. Carbohydrates, metabolic response and
postoperative discomfort
Recommendation
Drinking carbohydrate-rich fluids before elective surgery
improves subjective well being, reduces thirst and hunger
and reduces postoperative insulin resistance (evidence
level 1þþ, recommendation grade A).
Rationale
In postoperative patients in need of intensive care,
studies have shown that, when glucose is controlled by
intensive insulin therapy, mortality and morbidity can be
reduced. 27 In addition, data suggest that postoperative
discomfort can be reduced when patients are given a
carbohydrate-rich beverage preoperatively.
In a placebo-controlled randomised trial of 252 patients
undergoing elective gastrointestinal surgery, it was shown
that the intake of carbohydrate-rich clear fluid until
2 h before the operation led to less thirst, restlessness,
weakness and concentration problems as compared
to placebo. 36 Two small placebo-controlled double-blind
studies in 15 37 and 14 38 patients, respectively, undergoing
hip surgery, showed that the intake of a carbohydrate-rich
clear fluid until 2 h before the operation
reduced insulin resistance on days 1 and 3. 37,38 Another
study of 14 patients displayed less reduced insulin
sensitivity after colorectal surgery following preoperative
oral carbohydrate administration as compared with
patients who were operated on after an overnight fast. 39
A recently published study in patients undergoing open
colorectal surgery also showed reduced postoperative
insulin resistance after preoperative oral carbohydrates,
as well as reduced thirst and hunger. 40 However, a preoperative
oral carbohydrate drink did not reduce postoperative
insulin resistance or postoperative nausea and
vomiting in an investigation of 101 non-diabetic patients
undergoing elective coronary artery bypass grafting. 31
In a randomised study in 65 patients undergoing
major abdominal surgery, carbohydrates contributed to
the maintenance of muscle mass. 41 In two randomised
trials in 86 42 and 172 patients 43 undergoing laparoscopic
cholecystectomy, there was either no effect 42 or only a
reduction in postoperative nausea and vomiting. 43 Faria
et al. 44 showed improved glucose metabolism and
organic response in 21 female patients participating in
a randomised controlled trial and undergoing laparoscopic
cholecystectomy.
Helminen et al. 45 studied 210 patients, undergoing
gastrointestinal surgery, randomly assigned to fasting,
intravenous or oral carbohydrates. Intravenous glucose
infusion did not decrease the sense of thirst and hunger as
effectively as in the oral intake group, but it did alleviate
the feelings of weakness and tiredness.
Taniguchi et al. 28 investigated 50 patients randomised to
either 1000 ml of oral rehydration solution or 1000 ml of
an intravenous electrolyte solution. Patients’ satisfaction
favoured oral rehydration as they experienced less
feelings of hunger, less occurrence of dry mouth and less
restriction of movement. Similar subjective benefits were
observed in a recent small study of gynaecological
patients. 46
Kaska et al. 29 performed a randomised controlled trial
comparing preoperative fasting with preoperative preparation
with either oral or intravenous intake of carbohydrates,
minerals and water. Consumption of the mix of
water, minerals and carbohydrates offered some protection
against surgical trauma in terms of metabolic status,
cardiac function and psychosomatic status.
Breuer et al. 32 studied the effects of preoperative oral
carbohydrate administration on postoperative insulin
resistance, preoperative discomfort and variables of organ
dysfunction in 188 ASA physical status III–IV patients
undergoing elective cardiac surgery, including those
with non-insulin-dependent type-2 diabetes mellitus.
Carbohydrates and placebo were administered in doubleblind
format and patients received 800 ml of the corresponding
beverage in the evening and 400 ml 2 h before
surgery. Blood glucose levels and insulin requirements
did not differ between the groups. Patients receiving
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564 Guidelines
carbohydrate and placebo were less thirsty compared with
controls. The carbohydrate group, however, required
less intraoperative inotropic support after initiation of
cardiopulmonary bypass weaning (P < 0.05). 32
One study of 36 patients undergoing colorectal surgery
has demonstrated a reduction in median length of stay
associated with oral carbohydrate therapy. 47 A retrospective
analysis of three small prospective randomised
trials (one matched-control study), primarily investigating
postoperative insulin resistance, 24 showed that
although the studies were too small to show a significant
reduction in length of stay individually, the combined
effect was a significant reduction of about 20%. 24 This
was confirmed in the randomised trial of Yuill et al. 41 in
2005 in 72 patients undergoing elective abdominal
surgery. However, the recently published randomised
trial of Mathur et al. 48 in 142 patients undergoing
colorectal surgery or liver resection did not confirm these
results.
6. Perioperative fasting in children and
infants
Recommendations
Children should be encouraged to drink clear fluids
(including water, pulp-free juice and tea or coffee without
milk) up to 2 h before elective surgery (evidence level
1þþ, recommendation grade A).
All but one member of the guidelines group consider that tea or
coffee with milk added (up to about one fifth of the total volume)
are still clear fluids.
Infants should be fed before elective surgery. Breast milk
is safe up to 4 h and other milks up to 6 h. Thereafter,
clear fluids should be given as in adults (evidence level
1þþ, recommendation grade A).
Rationale
The recommendations are based on reviews and
guidelines published in the late 1990s and more
recently. 2–4,7,11,49–52 Fasting is aimed at decreasing the
risk of pulmonary aspiration, but the incidence of this
complication is very low in recent series and, although the
risk of aspiration appears to be slightly greater in children
than in adults, 53 the difference is less than that previously
reported. All recent surveys indicate the relatively
good outcome of this event in the paediatric population
compared with previous series.
There is a lot of evidence that clear fluids can be given
up to 2 h prior to surgery in neonates, infants and
children. In neonates and infants, gastric emptying of
clear fluids follows first-order kinetics as in older children
and adults. 54 Allowing clear fluids prior to surgery
improves comfort of the child and the parents, decreases
thirst and decreases the risk of preoperative dehydration
in young infants. 55 The volume of fluids permitted in the
preoperative period does not appear to impact on the
intragastric volume or pH of children. 2 This also applies
to overweight and obese children. 56
6.1. Breast milk and infant formula
Fasting time for breast milk and infant formula is slightly
more controversial. It was demonstrated more than
25 years ago that the gastric emptying of 110–200 ml
of human milk was 82 11% after 2 h in neonates
and infants of less than 1 year of age, 84 21% after
whey-hydrosylated formula, 74 19% after whey-predominant
formula, 61 17% after casein-predominant
formula and 45 19% after cow’s milk. 57 Thus, human
milk and whey-predominant formula emptied faster than
casein-predominant formula and cow’s milk. Two other
studies performed before anaesthesia also demonstrated
that breast milk empties from the stomach faster than
most formulas in infants and both require more than 2 h
to ensure complete gastric emptying. 54,58 According
to these data, the American guidelines recommended
4 h fasting time for breast milk and 6 h for infant formula
and non-human milk. 7 These recommendations were
also endorsed by the Royal College of Nursing that
considered there was insufficient evidence to change
contemporary best practice (i.e. breast milk up to 4 h
and formula and cows’ milk up to 6 h). 4 Scandinavian
guidelines recommended 4 h fasting for breast milk but
also for formula milk in infants of less than 6 months
of age. 3 Thus, it is recommended to finish breast feeding
4 h before anaesthesia and to stop infant formula 4–6 h
prior to anaesthesia depending on the age and on local
considerations. Both cow’s milk and powdered milk are
considered as solid food.
6.2. Solid food
Recommendations for fasting of solid food in children do
not differ from those proposed for healthy adults. There
is no evidence against these recommendations.
6.3. Trauma
Data on fasting in injured children are minimal. One
study suggested that the volume of gastric contents may
depend on the nature of the trauma, but gastric content
was not related to the length of fasting. 59 Gastric volume
was better linked to the interval between the last
meal and the trauma. Thus, the injured child should
be considered as a patient with a full stomach. However,
an increasing number of minor surgical procedures are
done under sedation in the emergency department. The
available literature does not provide sufficient evidence
to conclude that pre-procedure fasting results in a
decreased incidence of adverse outcomes in children
undergoing either moderate or deep sedation. 60,61
6.4. Postoperative fluids
Oral fluid intake is usually allowed within the first 3
postoperative hours in most paediatric patients. Early
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Perioperative fasting in adults and children 565
oral fluid intake was previously required in most
institutions before discharging the patient from hospital.
This view was challenged, as it has been reported that
withholding oral fluids postoperatively from children
undergoing day surgery reduces the incidence of vomiting.
62,63 However, the most recent study did not find that
postoperative fasting reduces the incidence of vomiting
after general anaesthesia in children when compared
with a liberal regimen. 64 Thus, it seems reasonable to
let children eat and drink according to their own desires,
but not to insist on oral intake before discharge.
7. Fasting in obstetric patients
Recommendations
Women in labour should be allowed clear fluids (as
defined above) as they desire. (evidence level 1þþ,
recommendation grade A).
Solid food should be discouraged during active labour
(evidence level 1þ, recommendation grade A).
Pregnant women, including obese individuals, can
consume clear liquids until up to 2 h prior to surgery
(under regional or general anaesthesia) (evidence level
2 , recommendation grade D).
An H 2 -receptor antagonist should be given the night
before, and on the morning of, elective caesarean section
(evidence level 1þþ, recommendation grade A).
An intravenous H 2 -receptor antagonist should be given
prior to emergency caesarean section; this should be
supplemented with 30 ml of 0.3 mol l
1 sodium citrate
if general anaesthesia is planned (evidence level 1þþ,
recommendation grade A).
The guidelines group recognises that most of the evidence
relates to surrogate measures, such as changes in gastric
volume and pH, rather than a clear impact on mortality.
Rationale
7.1. Oral intake during labour
Surgery during labour is usually unplanned, and when it
occurs the degree of emergency can range from minimal to
surgery that is life saving for either mother or baby. Against
this background, logic dictates that all mothers should be
starved during labour. However, it is often argued that
allowing mothers to eat and drink during labour will
prevent ketosis and dehydration and, thereby, improve
obstetric outcome. There is currently wide variation in
practice with respect to eating during labour in Europe.
However, it has now been shown that although eating a
light diet during labour will prevent ketosis, it will also
increase gastric volume, 65 whereas when isotonic ‘sport
drinks’ are consumed during labour, 66 ketosis can be
eliminated without an increase in intragastric volume.
A recent randomised controlled study evaluated the
effect of food intake during labour on obstetric outcome.
Low-risk nulliparous women in labour (n ¼ 2443) were
randomised to either an ‘eating’ or a ‘water only’ group.
The results were analysed by intention to treat. No
significant difference was found in the normal vaginal
delivery rate; the instrumental vaginal delivery rate;
the caesarean section rate; the duration of labour; or
the incidence of vomiting. 67
Maternal death from aspiration of regurgitated gastric
content is now extremely rare, and its decline probably
owes more to the widespread use of regional anaesthesia
for operative obstetrics than to fasting policies. In view of
the predominant use of regional techniques on most
delivery units, rigid fasting policies are arguably no longer
appropriate during labour and mothers should, therefore,
be allowed to alleviate thirst during labour by consuming
ice chips and clear fluids (isotonic sports drinks, fruit
juices, tea and coffee, etc).
As eating confers no benefit to obstetric outcome, women
should be discouraged from eating solid food during
labour. However, in view of the almost negligible incidence
of deaths from aspiration, low-risk women could
consume low-residue foods (such as biscuits, toast or
cereals) during labour. In addition, when deciding
whether or not women should eat during labour, the
use of parenteral opioids should also be considered
because of their profound delay on the rate of gastric
emptying. Units who perform a significant volume of
their emergency obstetric surgery under general anaesthesia
should probably not allow women in labour to eat.
In high-risk pregnancies, it remains appropriate to not eat
during labour and to achieve hydration by limited
volumes of oral clear fluids or by the intravenous route.
7.2. Preparation for caesarean section
7.2.1. Preoperative fasting in elective obstetric surgery
Evidence suggests that pregnant women, including obese
individuals, can consume clear liquids until up to 2 h prior
to surgery (under regional or general anaesthesia) 68,69
(evidence level 1þ, recommendation A).
7.2.2. Recommended drug regimens in detail
7.2.2.1. Elective obstetric surgery All mothers should
be actively encouraged to have regional anaesthesia for
an elective caesarean section.
An H 2 -receptor antagonist (e.g. 150 mg ranitidine) or a
PPI (e.g. omeprazole 40 mg) should be given at bedtime
and again 60–90 min before the induction of anaesthesia.
The administration of oral metoclopramide 10 mg at the
same time as the H 2 -receptor antagonist or PPI should
also be considered.
7.2.2.2. Emergency obstetric surgery under regional
anaesthesia Intravenous H 2 -antagonist (e.g. ranitidine
50 mg) at time of decision for surgery. In high-risk women
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566 Guidelines
the use of oral H 2 -antagonists (ranitidine 150 mg), at
regular intervals during labour, should be considered.
7.2.2.3. Emergency obstetric surgery under general
anaesthesia Intravenous H 2 -antagonist and oral antacid
(e.g. 30 ml sodium citrate 0.3 mol l
1 ) prior to induction
of anaesthesia.
7.3. Eating and drinking after caesarean section
The beneficial effects of early postoperative feeding
have been clearly demonstrated in colorectal surgery.
Traditionally, eating and drinking after caesarean section
was not encouraged, food and fluid were usually withheld
for the first 12–24 h after surgery, after which fluids were
slowly introduced, with food being allowed once bowel
sounds had been heard or flatus was passed. A Cochrane
review published in 2002 (the review included six articles
published between 1993 and 2001) concluded that there
was no evidence to justify restricting oral fluids or food
following uncomplicated caesarean section. 70
More recent studies have indicated that clear fluids,
commenced between 30 min and 2 h after caesarean
section, are well tolerated and result in women requiring
less intravenous fluids, earlier ambulation and earlier
breast-feeding. Earlier solid intake appears to cause
more nausea which tends to be self-limiting. 71–73 Current
evidence, therefore, suggests that early oral hydration
following caesarean section is well tolerated and should
perhaps be encouraged. Solid foods should be introduced
more cautiously.
7.4. Effects of pregnancy on gastric function
Gastro-oesophageal reflux, resulting in heartburn, is a
common complication of late pregnancy. Pregnancy
compromises the integrity of the lower oesophageal
sphincter as a result of an alteration in the anatomical
relationship of the oesophagus to the diaphragm and
stomach, an increase in intragastric pressure and the
relaxing effect of progesterone on smooth muscle. A
pregnant woman at term, requiring anaesthesia, should,
therefore, be regarded as having an incompetent lower
oesophageal sphincter. These physiological changes are
less 48 h after delivery. 74
Gastric acid secretion is essentially unchanged during
pregnancy. 75 Pregnancy does not significantly alter the
rate of gastric emptying. 76 Gastric emptying is normal in
early labour, but becomes delayed as labour advances. 77
Parenteral opioids significantly delay gastric emptying
during labour, as do bolus doses of epidural and intrathecal
opioids. 78–80 Continuous epidural infusion of lowdose
local anaesthetic with fentanyl does not appear to
delay gastric emptying until the total dose of fentanyl
exceeds 100 mg. 68
Gastric emptying is not delayed in either obese or nonobese
parturients at term who ingest 300 ml water after
an overnight fast. 69,81 Lewis and Crawford 82 noted that
in patients undergoing elective caesarean section, a meal
of both tea (volume unknown) and toast 2–4 h preoperatively
resulted in an increased gastric volume and
a decreased gastric pH when compared with a control
group of patients. Particulate material was aspirated from
the stomachs of two of the 11 patients who consumed
both tea and toast. Consumption of tea without toast
resulted in an increase in gastric volume, but it did not
alter gastric pH.
7.5. Pharmacological prophylaxis against acid
pulmonary aspiration in obstetrics
The risk of failed intubation is three to 11 times greater
in pregnant patients than in non-pregnant patients. 83
Airway oedema, breast enlargement, obesity and the
high rate of emergency surgery, all contribute to the risk
of failed intubation in pregnant women. Aspiration
pneumonitis is often associated with difficult or failed
intubation during the induction of general anaesthesia.
Pregnant women undergoing caesarean section or other
surgical procedures (both elective and emergency)
should, therefore, receive antacid prophylaxis.
7.5.1. H 2 -receptor antagonists
H 2 -receptor antagonists block histamine receptors on the
oxyntic cell and, thus, decrease gastric acid production.
This results in a slight reduction in gastric volume in the
fasting patient. When given intravenously, an H 2 -receptor
antagonist begins to take effect in as little as 30 min,
but 60–90 min are required for maximal effect. After oral
administration, gastric pH is greater than 2.5 in approximately
60% of patients at 60 min and in 90% at 90 min.
Most studies have evaluated the administration of 50–
100 mg of ranitidine administered intravenously or intramuscularly
or 150 mg administered orally. 84–86 These
studies have noted that the administration of ranitidine
results in a gastric pH greater than 2.5 within 1 h.
Therapeutic concentrations of ranitidine are sustained
for approximately 8 h.
7.5.2. Proton pump inhibitors
Omeprazole (20–40 mg orally) and lansoprazole (15–
30 mg orally) inhibit the hydrogen ion pump on the gastric
surface of the oxyntic cell. 87,88 For elective surgery, the
efficacy of prophylaxis when using a PPI is similar to that
achieved with an H 2 -receptor antagonist. For emergency
caesarean section, studies have shown that H 2 -receptor
antagonists and PPIs, administered intravenously, are
equally effective adjuncts to 0.3 mol l
1 sodium citrate
for reducing gastric acidity and volume.
A recent meta-analysis on the effect of PPIs and
H 2 -antagonists (studies included both obstetric and
non-obstetric patients) concluded that H 2 -antagonists
were more efficacious than PPIs for both reducing gastric
volume and increasing gastric pH. 23
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Perioperative fasting in adults and children 567
As antacids such as 0.3 mol l
1 sodium citrate can
cause nausea and even vomiting, they need not be
administered prior to elective surgery under regional
anaesthesia if the parturient has already received an
H 2 -antagonist or a PPI. However, in the event of emergency
obstetric surgery under general anaesthesia, an
antacid should be administered shortly before induction
of general anaesthesia (e.g. within 20 min) with an H 2 -
antagonist, as time constraints may mean that the efficacy
of H 2 -antagonists cannot be guaranteed at the time
of induction.
Metoclopramide 10 mg can further decrease gastric
volume when used in conjunction with an H 2 -antagonist
prior to elective caesarean section 89 and its use should
be considered prior to both elective and emergency
caesarean section.
Acknowledgements
I.S. has received research funding from Abbott and Anaxsys for
studies unrelated to these guidelines and declares no conflicts of
interest. P.K. has received fees for lectures/consulting and/or study
material from Fresenius Kabi Deutschland GmbH (Bad Homburg,
Germany), ProStrakan Deutschland (Starnberg, Germany),
Merck Sharp & Dohme Corp. (New Jersey, USA), Nutricia
Deutschland (Erlangen, Germany), Essex Pharma (Munich,
Germany) and SonoSite GmbH (Erlangen, Germany). I.M. declares
no conflict of interest.
G.O.S. is part of a £3 million multi-centre trial investigating the
effect of epidural anaesthesia on the second stage of labour and a coauthor
of one of the included studies in the literature review. A.S.
has received gifts of equipment from Schering-Plough but not
related to the content of this guideline.
E.S. has received research funding from the Laerdal Foundation for
Acute Medicine. E.S. is the current President of the Scandinavian
Society of Anaesthesia and Intensive Care and co-author of their
2005 fasting guidelines.
C.S. has received honoraria and speaking fees from Akzo Nobel,
Fresenius, BBraun, Baxter, Abbott, Essex Pharma, GSK and grants
from Abbott, Akzo Nobel, Aspect, Baxter, BBraun, Deltex Medical,
Edwards, Fresenius, GSK, Köhler Chemie, Lilly, MSD, Novalung,
Orion Pharma, Pfizer, Pfrimmer Nutricia and Wyeth. B.V. declares
no competing interests in the last 5 years.
The guidelines group would like to acknowledge the following
individuals who made a valuable contribution to the searching or
reviewing of the literature or who contributed their expertise to the
development of the guidelines: Jan Breuer, Susanna Keilig, Laura
Coleman and Nick Truman.
The guidelines group would also like to acknowledge the following
who reviewed and commented on the draft guidelines, either as
individuals or as representatives of national or international
societies: Muhammad Ajmal, Gabriella Bettelli, Metha Brattwall,
Roland Braun, Jean François Brichant, Valerie Bythell, Akos
Csomos, Gordon Drummond, Gabor Erdoes, Anil Gupta, Jochen
Hinkelbein, Markus Hollmann, Pablo Ingelmo, Ian Jackson, Jean
Joris, Paulo Lemos, Diana Mathioudakis, Claudio Melloni, Victoria
Moral, Oya Ozatamer, Beverly Philip, Felicity Plaat, Paolo Primieri,
Ian Russell, Marc Samama, Daniele Sances, Samantha Shinde,
Daniel Smole, Susanne Sujatta, François Sztark, Claudia Teipelke,
the Dutch Society of Anesthesiology and Bernhard Walder.
Statements of interest of reviewers: Markus Hollmann has received
Lecture fees from Eurocept (The Netherlands), BBraun, Pfizer
Germany, Schering-Plough and Merck, but all are unrelated to
this subject. François Sztark received fees for lectures and
consulting from Fresenius Kabi France and Abbott France and is
co-investigator for Danone Research (study EUDRACT 2009-
A00898–49).
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European Journal of Anaesthesiology 2011, Vol 28 No 8
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AAGBI SAFETY GUIDELINE
Pre-operative Assessment and Patient Preparation
The Role of the Anaesthetist
2
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org January 2010

Membership of the working party
(details correct at the start of the working party process)
Dr R Verma
Prof M Y K Wee
Dr A Hartle
Dr V R Alladi
Dr A-M Rollin
Dr G Meakin
Dr R Struthers
Dr J Carlisle
Dr P Johnston
Mrs K Rivett
Mr C Hurley
Chairman
Vice President, AAGBI
Council Member, AAGBI
Council Member, AAGBI
Vice President, Royal College of Anaesthetists
President, Association of Paediatric Anaesthetists
Consultant Anaesthetist, Derriford Hospital
Preoperative Association representative
Vice Chairman, GAT
Patient Liaison Group representative
Royal College of Nursing representative
This guideline has been seen and approved by the Council of the
AAGBI.
The working party is grateful to Dr Helgi Johannsson for his contribution
to this guideline.
1

Contents
1. Recommendations 3
2. Introduction 5
3. Before planned admission 7
4. After planned admission 15
5. After unplanned admission 18
6. Children and young people 19
7. Tests and investigations 22
8. The patient’s perspective 24
References 26
Appendices 29
To be reviewed by 2015.
© Copyright of the Association of Anaesthetists of Great Britain & Ireland. No
part of this book may be reproduced without the written permission of the
AAGBI.
2

1. Recommendations
This guidance has been designed to help anaesthetists provide
high quality pre-operative assessment services and patient
preparation before surgery. In addition it defines the roles and
responsibilities of anaesthetists both after planned and after
unplanned admissions.
Anaesthetists should assume a central role in the organisation
of pre-operative services that encompass much more than
preparing the delivery of anaesthesia.
The anaesthetist has the skills necessary to assess, optimise and
estimate risk and support patients deciding whether to proceed
with surgery and anaesthesia.
Pre-operative anaesthetic assessment should minimise risk for all
patients as well as identify patients at particularly high risk.
The pre-operative anaesthetic clinic should co-operate with
primary care to achieve these aims.
Skilled nurse practitioners are safe and cost-effective in
preparing patients for anaesthesia and should work closely with
anaesthetists with a special interest in pre-operative assessment
and preparation.
After scheduled admissions, anaesthetists must confirm that
patients have been prepared adequately by pre-operative
services so that anaesthesia and surgery can proceed safely.
Tests performed before surgery should be limited to those
recommended by national and local guidelines and protocols.
Most anaesthetic departments should plan for one consultant
whole-time equivalent to run and manage daily high-risk clinics
with appropriate secretarial support.
3

Anaesthetic departments must establish clear pathways of
care for unplanned admissions with surgeons, emergency
departments, critical care and theatre personnel.
Special considerations must be given to children and young
people undergoing anaesthesia and surgery.
Operating sessions and the individual anaesthetist’s job plan
must be arranged to allow time for the anaesthetist responsible
for an individual’s care to visit him/her pre-operatively at an
appropriate time before surgery.
In all but exceptional circumstances this should take place in a
designated reception area, dedicated clinic room or in the ward
ensuring privacy and respecting patients’ dignity, and not in the
anaesthetic room.
Clinical Directors for anaesthesia and theatres should work with
appropriate managers to establish comprehensive and integrated
pre-operative assessment facilities and ensure that there is a lead
anaesthetist for pre-operative assessment.
4

2. Introduction
Preparing a patient for anaesthesia requires an understanding of
the patient’s pre-operative status, the nature of the surgery and
the anaesthetic techniques required for surgery, as well as the
risks that a particular patient may face during this time.
Anaesthetists are in the unique position that they can offer all
of these skills, and the ultimate responsibility for pre-operative
anaesthetic assessment lies with the anaesthetist. Therefore,
anaesthetists should take the lead in organising pre-operative
anaesthetic services.
Patients often have comorbidities that require careful assessment
and co-ordination. Preparation for surgery may take weeks
to achieve, and could therefore potentially cause delay and
cancellation of surgery if not done adequately.
Pre-operative anaesthetic assessment services decrease
cancellations on the day of surgery, improve the patient’s
experience of their hospital admission, and may reduce
complication rates and mortality. The pre-operative visit may
relieve anxiety and answer questions about both the anaesthetic
and surgical processes [1].
Effective communication and a team approach are vital in
the pre-operative period. Complications and malpractice
lawsuits are often attributable to poor preparation and failures
in communication [2]. Essential team members include
anaesthetists, surgeons, physicians and general practitioners.
Specialist anaesthetic pre-operative assessment nurses have
been shown to be safe and effective at pre-operative screening
and should be an integral part of the team [3].
5

The lead anaesthetist for pre-operative assessment and
evaluation should be given the responsibility to:
• Agree and co-ordinate policies and procedures with surgical
and anaesthetic departments.
• Liaise with the lead pre-operative assessment nurse to
establish a comprehensive service with appropriate input
from anaesthetists.
• Ensure with the lead pre-operative assessment nurse that the
pre-operative service nurses receive adequate education
and training to deliver this service safely.
• Ensure that the design of the service delivers a maximum of
18 weeks referral to treatment time (RTT) or less if locally
agreed.
• Ensure that Foundation and Speciality Doctors are able to
acquire the knowledge and competencies required to assess
and prepare a patient for surgery.
Due consideration should be given to vulnerable groups of
patients, (e.g. patients with learning disabilities or severe
physical handicap) who may require a greater degree of support
from family, carers and healthcare personnel.
6

3. Before planned admission
Pre-operative services should:
• Ensure every patient* is fully informed about their proposed
procedure and the interventions that will need to be
undertaken.
• Estimate the level of risk for every patient.
• Ensure every patient* understands their own individual risk
so that they can make an informed decision about whether
to proceed to surgery.
• Identify co-existing medical illnesses and optimally prepare
patients whilst taking into account the urgency of the
operation.
• Identify patients with a high risk of complications in the
peri-operative period and define the appropriate postoperative
level of care (day stay, inpatient, ward, HDU,
critical care).
• Plan discharge.
The visit to the pre-operative clinic also gives the patients an
opportunity to discuss the choices of anaesthetic technique,
methods for pain relief and the risks, in a calmer atmosphere
than immediately before the operation.
Senior anaesthetists with a special interest in pre-operative
assessment are ideally suited to this role.
There are several models available for the pre-operative
anaesthetic assessment clinic, most of which rely both on
anaesthetists and specialist nurses. All hospitals should aim
to provide appropriately staffed clinics. The number of clinics
required will depend on the size and throughput of the
individual trust.
* This assumes that all patients have the capacity to take in the information
provided and make an autonomous decision. For those who do not, attempts
must be made to provide appropriate information and readers are referred to
other guidance on consent issued by the AAGBI and GMC.
7

Pre-operative systems and communication
Recognising that at least 80% of patients could be treated as
day cases (

Pathologies that predictably progress from medical to surgical
treatment, such as aortic aneurysmal disease and osteoarthrosis,
would be particularly suitable for early attempts at optimising
health.
Shortened waits between GP referral and surgery have
decreased the time in which to prepare patients for surgery.
Surgical investigation and pre-operative preparation should
therefore take place in parallel. Early referral by primary care
and surgical teams for pre-operative management will increase
efficiency.
Nurse-led pre-operative assessment
Pre-operative anaesthetic assessment is an extended role for
nurses that has been shown to be safe and cost effective [3-
5]. These nurses usually work as an integral part of the preoperative
team and are a very important link between the
patient and the entire peri-operative team. Physician Assistants
(Anaesthetics) – PA(A) – may also have a role to play.
Nurses should work closely with the anaesthetists involved in
the service and have good communication skills and links with
the rest of the hospital.
Their purpose is to contribute to the pre-operative preparation of
all patients, to identify patients with a high peri-operative risk, to
institute investigations and to refer to the anaesthetist, as well as
to assess patients for suitability for day surgery. In addition, they
will implement the various pre-operative protocols, including
fasting and administration of regular medication, and are able to
answer many of the patient’s questions about their anaesthetic.
Current fasting guidelines are given in Appendix 1.
Protocols should empower the nurses to refer patients to
relevant services such as echocardiography when there is a
9

history of a heart murmur, or pulmonary function tests for chest
disease. These protocols should be written by senior anaesthetic
staff and should be regularly reviewed and updated.
In-clinic spirometry is useful and easy to perform, and may
decrease the number of patients referred for formal pulmonary
function tests.
Pre-operative assessment nurses should co-operate closely
with primary care services, particularly when administration
of specific medication is required, such as subcutaneous
anticoagulation or optimisation of diabetic treatment.
Liaison with secondary care diabetes teams and medical
outreach teams can be particularly helpful and may prevent
unnecessarily long stays in hospitals, both pre- and postoperatively.
It is important that pre-operative assessment nurses have
readily available communication channels with pre-operative
assessment anaesthetists; they should be able to discuss specific
cases and receive feedback from the anaesthetist.
The anaesthetist in the pre-operative
assessment clinic
Senior anaesthetists with a specialist interest in pre-operative
assessment and optimisation should staff pre-operative
assessment clinics with the number of sessions needed being
dependent on the throughput of the hospital and its casemix.
These anaesthetists should see all patients who are potentially at
high risk, make an assessment of the risks and benefits of surgery
and ensure that patients:
• Are confident that they want surgery.
10

• Have balanced the pros and cons of different surgical and
non-surgical alternatives.
• Are receiving optimum treatment if they have significant
medical co-morbities.
• Have had their risks assessed with regard to mortality and
common morbidities.
• Have been informed of these risks and had the opportunity
to discuss them.
• Have been informed how to reduce their risks preoperatively.
• Have been given the opportunity and time to reduce their
risks.
The pre-operative assessment anaesthetist therefore needs
to be skilled at assessing and managing these risks, and in
communicating them both to the patient and to the treating
surgeon [6].
Consultant-to-consultant communication between anaesthetists,
surgeons and critical care physicians is essential, particularly
when the patient is high-risk and the benefits of surgery may
be outweighed by the risks to the patient. Pre-operative
anaesthetists should be able to accept referrals from all
appropriate staff, including GPs, surgeons, pre-operative nurses
and specialist screening clinics.
Multidisciplinary meetings should help anaesthetic consultants
identify and manage high-risk cases, particularly when major
surgery is planned.
Estimating and managing peri-operative risk
Survival and risk in many populations is predictable. Risk
prediction can be used to guide the patient’s pre-operative care
and determine whether the patient needs to see an anaesthetist
in the pre-operative assessment clinic.
11

Anaesthetic, critical care and surgical departments should
discuss risk thresholds for:
• Referral by a pre-operative assessment nurse to an
anaesthetist.
• Pre-operative exercise and drug prescriptions.
• Multidisciplinary team meetings.
• Invasive intra-operative monitoring.
• Post-operative critical care admission and outreach
observation.
These thresholds can be used as markers to help hospitals
determine the level of resources they need to invest to provide
their catchment patient population with adequate pre-operative
services.
A combination of nine variables provide independent prognostic
information:
i. Age
ii. Sex
iii. Socioeconomic status [7]
iv. Aerobic fitness [8-10]
v. Diagnosed ischaemic heart disease (myocardial infarction
and angina)
vi. Diagnosed heart failure
vii. Diagnosed ischaemic brain disease (stroke and transient
ischaemic attacks)
viii. Diagnosed kidney failure [11]
ix. Diagnosed peripheral arterial disease
Pre-operative and post-operative risks of mortality and morbidity
can be estimated with these variables when adjusted for surgical
disease and surgical procedures respectively (see Appendix 2).
Aerobic fitness when measured objectively is an important
12

tool for survival prediction in addition to traditional risk factors
such as hypertension, hypercholesterolaemia, smoking, chronic
obstructive pulmonary disease (COPD) and diabetes [8-10].
In the pre-operative assessment clinic, aerobic fitness can
be estimated with the incremental shuttle walk test or more
precisely quantified with cardiopulmonary exercise testing (CPX/
CPET), which can also diagnose whether aerobic performance is
limited by pulmonary, cardiac or peripheral disease, and may be
a good screening test for ischaemic heart disease [12].
Resources and funding
Setting up pre-operative services where none exist requires
a substantial time commitment in order to put in place the
infrastructure, to recruit staff and to oversee the organisation,
administration and processes at all levels. This may well require
in the region of 5-10 programmed activities per week but this
may vary with the caseload and casemix of the organisation,
and will require the appropriate level of administrative support.
A time commitment is necessary for the lead anaesthetist
adequately to manage the pre-operative service. This role
includes liaison with surgeons, clinicians in other specialties,
doctors in training, primary care, other anaesthetists, theatres
and critical care.
The proportion of patients who would benefit from consultant
pre-operative assessment depends on the type of surgery
undertaken at the hospital, the age and socioeconomic status
of the population and the size of catchment area. Currently,
an average district general hospital might expect to commit
7.5 programmed consultant activities per week to provide one
anaesthetist-led clinic per day (five clinics per week).
The pre-operative assessment clinic provides valuable
opportunities for teaching – of both undergraduate and
13

postgraduate personnel. This may necessitate increased clinic
resources with regard to both the time taken and the space for
trainees and students to see patients.
Cardiopulmonary exercise testing, when undertaken by trained
personnel, takes about 30 minutes to perform and a similar time
to discuss the results with the patient. A specialist anaesthetist
working with a technician should be able to assess between four
and seven patients in a programmed clinical activity.
14

4. After planned admission
Anaesthetists are central to ensuring the safety of patients in the
peri-operative period.
Operating sessions must be planned to allow time for the
anaesthetist responsible for an individual’s care to visit him/
her pre-operatively. This should take place before arrival in the
anaesthetic room in all but exceptional circumstances.
It is the responsibility of the individual anaesthetist giving
the anaesthetic to ensure that the pre-operative assessment is
adequate and that the patient has sufficient information to make
a reasoned decision. It is the responsibility of the Trust to ensure
that sufficient time is made available for this, as a matter of
routine and without undue pressure. Pre-operative anaesthetic
assessment is an integral part of the surgical process, and must
be included in the estimates of time required for the operating
list.
The pre-operative assessment process should have identified
and addressed problems with individual patients, and provided
the patient with appropriate information on the probable perioperative
course. This should allow the pre-operative visit to
focus on the individual patient's needs and concerns.
As a part of the pre-operative visit the anaesthetist should:
• Establish a rapport with the patient and when relevant the
patient’s family.
• Determine the adequacy of pre-operative assessment and
preparation, including arrangements for intra-operative and
postoperative care.
• Confirm the plan and discuss anaesthetic and postoperative
care, including premedication, mode of anaesthesia,
analgesia and anti-emetics.
15

• Ensure the patient is aware of any risks particular to that
patient or associated with specific anaesthetic procedures.
• Ensure the patient understands the nature of the operation
and is happy to proceed (N.B. see footnote on page 7).
• Confirm the availability of HDU or intensive care unit beds
if appropriate, before proceeding.
Anaesthetists in training and non-consultant grades should
discuss high-risk patients with consultant colleagues. The
consultant contacted should ensure that the patient is cared for
by an anaesthetist with the expertise required for that particular
situation. Failure of the pre-operative service to match personnel
to the need of the patient may result in surgery being postponed
until the necessary expertise is available.
Cancellations have a negative impact on patients, families and
clinical services. Where possible, department protocols should
be adhered to and cancellations for idiosyncratic reasons
discouraged.
Occasionally, anaesthetists will cancel surgery in patients who
have been assessed and prepared by another senior anaesthetist.
Anaesthetists should alert their colleagues if there is a failure in
following protocol or when the protocol has been ineffective.
Differences of opinion should be discussed within a department
with the aim of avoiding future cancellations, and protocols
modified accordingly.
If surgery is cancelled the anaesthetist should:
• Explain the reasons for cancellation and ensure that the
patient and his/her family understand what will happen
next.
• Explain the cancellation to the surgical and pre-operative
assessment teams, and primary care where appropriate.
• Clearly document the reason for cancellation and any
16

ecommendations for optimisation in the patient’s medical
notes.
• Take steps to allow surgery to proceed safely at a future
date.
• Address deficiencies in the system to reduce the number of
late cancellations.
17

5. After unplanned admission
Patients requiring anaesthesia after unplanned admission are at
higher risk of medical errors and peri-operative complications
[13]. These patients are often cared for by junior staff.
The standards and principles for the care of elective patients
apply equally to those admitted in an emergency, even though
it is often more difficult to achieve them. Clear pathways of care
for unplanned admissions are vital and should include surgeons,
emergency departments and theatre departments. The purpose
of these pathways should be to enable a high standard of care,
avoid omissions and prevent excessive periods of starvation and
fluid deprivation – particularly in vulnerable groups such as the
elderly.
There must be clear communication between surgeons,
anaesthetists and intensivists with the common goal being the
welfare and best interests of the patient. Often a balance has
to be reached between prevention of deterioration caused
by delaying surgery and the benefit of optimising medical
conditions pre-operatively. Where possible, patients and/or
their next of kin should be included in these discussions. The
risks and benefits of surgery should be explained clearly. These
discussions should be documented clearly in the patient’s
medical notes, particularly when a decision has been made:
• To proceed with anaesthesia when potentially important
investigations have been omitted or when the patient’s
condition has not been optimised.
• Not to proceed with surgery when there is correctable
surgical disease.
High standards of care must be maintained and the patient’s
safety and best interests remain paramount.
18

6. Children and young people
Children and young people have special healthcare needs
because they are physically and emotionally different from
adults, and need the constant care and support of their parents
or guardians [14].
Children should receive care that is integrated and co-ordinated
around their particular needs and the needs of the family. At
least 90% of surgery in children can be performed on a day stay
basis.
They, and their parents, should be treated with respect,
and given the necessary support and information to enable
them to understand and cope with the proposed surgery and
anaesthesia. They should be treated as active partners in
decisions about their health and care, and, where possible, be
able to exercise choice [15].
Before admission
A clear explanation of the proposed surgery and admission
procedures should be given to the parents and the child at the
initial outpatient clinic visit.
Parents and children should be supplied with suitable written
information regarding the proposed surgery and anaesthesia as
well as instructions on what and when the child may eat and
drink before surgery. Such instructions should conform to recent
guidelines [16] (Appendix 1).
Pre-admission care may include attendance at a pre-operative
assessment clinic and/or a pre-admission tour of the hospital.
The pre-operative assessment should include a complete birth
history including the duration of gestation, any difficulties at
19

delivery and the presence of congenital and acquired disease
particularly those affecting the airway or the cardiovascular
system. A history of previous anaesthetics and family history of
anaesthetic problems should be obtained. Sickle-cell screening
should be performed in susceptible populations. The airway
should be assessed and the presence of any loose, usually
deciduous, teeth noted.
Telephone contact on the day before surgery provides an
opportunity to confirm attendance, re-enforce pre-operative
instructions and detect reasons for late cancellation such as
infections or family problems.
After admission
The child should be admitted to a children’s ward or the day
surgery unit staffed by medical and nursing staff trained in
dealing with children and their families. The décor should
be suitable for children, and toys, books, videos and a play
therapist should be available.
Children should not be cared for next to adults and, where
possible, there should also be separate facilities for adolescents
[17].
The law on consent in minors varies across the UK. In England
and Wales, parental consent is usually sought for operations
on a child aged less than 16 years, although the child him/
herself has the right to consent if he/she have achieved sufficient
understanding and intelligence to understand fully what is
proposed, i.e. they are ‘Gillick competent’. However, in cases
in which a child has refused or resisted medical treatment, the
courts have upheld the right of the parents to consent for the
treatment.
In Scotland, parents cannot overturn the decision of a
20

competent minor to refuse treatment. In such cases, much will
depend on the judgement of the doctor as to whether the child
is competent or not, taking into account the importance or
urgency of the proposed operation. In all cases it is important
that staff know who has parental responsibility [18].
The anaesthetist should see the parents and child before
surgery to confirm/perform pre-operative assessment, establish
a rapport, check compliance with guidelines on eating and
drinking, discuss anaesthetic techniques and postoperative pain
relief, and obtain verbal consents, e.g. for nerve blocks and
suppositories.
• All children should be weighed and have their pulse rate
and temperature recorded on admission.
• All communication should be comprehensible to the
parents and the child.
• The possible modes of induction (intravenous/inhalation)
should be discussed and the wishes of the parents and child
complied with where possible.
• If intravenous induction is planned, local analgesic cream
or gel should be applied to possible venepuncture sites in
all but extreme emergencies.
• Selected children may benefit from oral sedative
premedication. This must be carefully timed, and efficient
communication between the theatre team and the ward is
vital.
• Children should be allowed to wear suitable clothing of
their own to theatre.
• Parents should be invited to accompany the child at
induction of anaesthesia and his/her role in the induction
room discussed.
• A ward nurse should be present at induction to escort the
parent back to the ward.
• A parent should be called to the recovery room as soon as
the child is conscious.
21

7. Tests and investigations
Routine pre-operative investigations are expensive, labourintensive
and of questionable value, especially as they may
contribute to morbidity or cause additional delays due to
spurious results.
The National Institute of Healthcare and Clinical Excellence
(NICE) recommends the following pre-operative tests (surgical
severity scores are given in Appendix 3) [19]:
• Electrocardiography: if older than 80; if older than 60 and
surgical severity at ≥ 3; any cardiovascular disease; severe
renal disease.
• Full blood count: if older than 60 and surgical severity
≥ grade 2; all adults if surgical severity ≥ grade 3; severe
renal disease.
• Urea, electrolytes and creatinine: if older than 60 and
surgical severity ≥ grade 3; all adults if surgical severity
grade 4; any renal disease; severe cardiovascular disease.
• Pregnancy test for women who may be pregnant.
• Sickle-cell test on families with homozygous disease or
heterozygous trait; ancestry that is African, Afro-Caribbean,
Asian, Middle-Eastern, east-Mediterranean.
• Chest X-ray: patients scheduled for critical care.
History and examination performed by appropriately trained
and competent personnel remains the most efficient and
accurate way of initially detecting significant morbidity. There
is recent evidence that patients of any age with no major
comorbidities (ASA physical status 1 or 2 – see Appendix
4) presenting for day surgery do not need pre-operative
investigations [20].
Local departmental protocols should determine which
additional tests should be used based upon patient age,
22

comorbidity and complexity of the surgery.
Anaemia ( < 12 g.dl -1 for women and < 13 g.dl -1 for men
should be investigated and treated before planned surgery,
using haematinics such as oral/intravenous iron rather than
transfusion. The urgency and nature of surgery, plus patientspecific
factors, will determine the balance between reversing
anaemia and proceding with surgery. The aim, to avoid perioperative
blood transfusion, is best achieved when hospital
pre-operative services work with other departments and primary
care.
Evaluation of high-risk patients should estimate cardiovascular
risk according to the severity of systemic disease (see Appendix
5), functional capacity and the grade of the planned surgery
[21].
Tests of functional capacity include exercise ECG, CPX testing
and myocardial perfusion scans.
23

8. The patient’s perspective
This document defines the objectives of pre-operative
assessment, emphasising the need to:
• Support all patients as they prepare themselves for surgery.
• Identify important high-risk patients and promote safety.
• Reduce the risk to the patient and optimise the patient’s
condition pre-operatively.
• Identify and mitigate potential anaesthetic difficulties.
• Allay fear, anxiety and lack of understanding through clear
explanation, written information and appropriate discussion.
Many patients, however, will not see an anaesthetist before
admission as they will have been adequately assessed by skilled
practitioners using established protocols. Anaesthetists must
therefore ensure that the information provided not only allows
for efficiency on the day of admission but also addresses any of
the patient’s concerns previously noted. If these concerns are
not adequately dealt with by the practitioner, the patient should
have access to a consultation with an anaesthetist before the
day of operation.
Both assessment before admission and the pre-operative visit
allow patients to:
• Discuss their peri-operative care.
• Ask questions and discuss their fears and anxieties,
particularly about previous anaesthetic experiences.
Communication must be clear, with consistent messages given
to the patient regarding choices for anaesthesia, post-operative
analgesia, prevention and treatment of nausea and vomiting,
pre-operative starvation and any other concerns raised by the
patient.
24

It is extremely important that adequate explanation is given
by anaesthetists and other staff should it become necessary to
postpone surgery. In addition to the impact on the patient’s
medical condition, it is likely to cause considerable disruption
to both their work and their home life.
Information specifically targeted for patients is also available
in the patient information section of the Royal College of
Anaesthetists website (http://www.rcoa.ac.uk)
The prospect of anaesthesia remains daunting for many people.
Given the time constraints of ‘same-day’ admission it may be
difficult for the patients to receive the level of consultation that
would be considered ideal. However, the opportunity to talk to
a doctor who fully understands their needs may ensure a more
confident and co-operative relationship between the patient and
the doctor.
25

References
1. NHS Institute for Innovation and Improvement. Quality and
Service Improvement Tools. http://wwwnodelaysachiever.
nhs.uk/ServiceImprovement/Tools/IT130_PreOpAssessment.
htm (accessed 01/10/09)
2. Greenberg CC, Regenbogen SE, Studdert DM, et al.
Patterns of communication breakdowns resulting in injury
to surgical patients. Journal of the American College of
Surgeons 2007; 204: 533-40.
3. Rushforth H, Burge D, Mullee M, et al. Nurse-led paediatric
pre-operative assessment: an equivalence study. Paediatric
Nursing 2006; 18: 23-9.
4. Rai M, Pandit J. Day of surgery cancellations after nurse-led
pre-assessment in an elective surgical centre: the first 2
years. Anaesthesia 2003; 58: 685-7.
5. Kinley H, Czoski-Murray C, George S, et al. Effectiveness
of appropriately trained nurses in pre-operative assessment:
randomised controlled equivalence/non-inferiority trial.
British Medical Journal 2002; 325: 1323.
6. Geigerenzer G. Reckoning with risk: Learning to live with
uncertainty. London: Penguin, 2003.
7. Alter D, Chong A, Austin P, et al. Socioeconomic status and
mortality after acute myocardial infarction. Annals of
Internal Medicine 2006; 144: 82-93.
8. Win T, Jackson A, Sharples L, et al. Cardiopulmonary
exercise tests and lung cancer surgical outcome. Chest
2005; 127: 1159-65.
26

9. Older P, Hall A, Hader R. Cardiopulmonary exercise testing
as a screening test for perioperative management of major
surgery in the elderly. Chest 1999; 116: 355-62.
10. Carlisle J, Swart M. Mid-term survival after abdominal
aortic aneurysm surgery predicted by cardiopulmonary
exercise testing. British Journal of Surgery 2007; 94: 966-9.
11. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation
and prospective validation of a simple index for prediction
of cardiac risk of major noncardiac surgery. Circulation
1999; 100: 1043-9.
12. Chaudhry S, Arena R, Wasserman K, Hansen JE, Lewis
GD, Myers J, Chronos N, Boden WE. Exercise-induced
myocardial ischemia detected by cardiopulmonary
exercise testing. American Journal of Cardiology 2009; 103:
615-9.
13. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner
MJ. Risk factors for retained instruments and sponges after
surgery. New England Journal of Medicine 2003; 348: 229-
53.
14. The Audit Commission Report. Children first: a study of
hospital services. London: HMSO, 1993.
15. Department of Health. Getting the right start: the national
service framework for children, young people and maternity
services - standard for hospital services. London: HMSO,
2003.
16. Royal College of Nursing. Perioperative fasting in adults
and children. An RCN guideline for the multidisciplinary
team. London: RCN, 2005.
27

17. Hogg C, Cooper C. Meeting the needs of children and
young people undergoing surgery. London: Action for Sick
Children, 2004.
18. British Medical Association. Consent, rights, and choices
in health care for children and young people. London: BMJ
Publishing, 2000.
19. National Institute for Clinical Excellence. Pre-operative
tests, the use of routine pre-operative tests for elective
surgery. London: NICE, 2003.
20. Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT.
Elimination of preoperative testing in ambulatory surgery.
Anesthesia and Analgesia 2009; 108: 467-75.
21. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007
Guidelines on perioperative cardiovascular evaluation and
care for noncardiac surgery. Journal of the American
College of Cardiology 2007; 50: 1707-32.
28

Appendices
1. Fasting guidelines in adults and children
2. Survival prediction
3. Surgical severity
4. ASA physical status
5. Systemic disease
29

Appendix 1
Fasting guidelines for adults and children
(RCN pre-operative fasting guidelines, 2005)
Adults
Pre-operative fasting in adults undergoing elective surgery – ‘the
2-6 rule’:
• ‘2’ – Intake of water up to 2 h before induction of
anaesthesia.
• ‘6’ – A minimum pre-operative fasting time of 6 h for food
(solids, milk and milk-containing drinks).
• The anaesthetic team should consider further interventions
for patients at higher risk of regurgitation and aspiration.
Post-operative resumption of oral intake in healthy adults:
• Patients should be encouraged to drink when ready,
providing there are no contraindications.
Children
Pre-operative fasting in children undergoing elective surgery –
‘the 2-4-6 rule’:
• ‘2’ – Intake of water and other clear fluid up to 2 h before
induction of anaesthesia.
• ‘4’ – Breast milk up to 4 h before.
• ‘6’ – Formula milk, cow’s milk or solids up to 6 h before.
• The anaesthetic team should consider further interventions
for children at higher risk of regurgitation and aspiration.
30

Post-operative resumption of oral intake in healthly children:
• Oral fluids can be offered to healthly children when they
are fully awake following anaesthesia, providing there are
no contraindications. There is no requirement to drink as
part of the discharge criteria.
Chewing gum
Chewing gum may be allowed up to 2 h before induction of
anaesthesia.*
* This is AAGBI guidance and is not taken from the RCN fasting guidelines.
31

Appendix 2
Survival prediction
Age. The risk of dying doubles every 7 years from the age of
10 so that by 90 years the monthly mortality risk is 5000 times
the risk at the age of 10. Life tables for the United Kingdom,
its constituent countries and individual health authorities are
updated at www.gad.gov.uk
Sex. Men are 1.7 times more likely to die than women the
same age.
Socioeconomic status. The impoverished are twice as likely
to die as the rich.
Aerobic fitness. The predicted peak power in metabolic
equivalents (METs), where 1 MET requires an oxygen
consumption of 3.5 ml.kg -1 .min -1 ;
a) For men 18.4 – (0.16 x age)
b) For women 14.7 – (0.13 x age)
Mortality risk is multiplied by 1.2 for every MET short of
predicted, or by 0.84 for every MET in excess of predicted.
Diagnoses of myocardial infarction, heart failure, stroke,
peripheral arterial disease and renal failure ([creatinine] >
150 µmol.l -1 ) independently multiply long-term mortality risk by
1.5 times. Diagnoses of angina and transient ischaemic cerebral
events multiply risk by 1.2 times (in the absence of MI or stroke
respectively).
Please email john.carlisle@nhs.net for a more detailed and
referenced version including Excel spreadsheets that calculate
individual risk.
32

Appendix 3
Surgical severity (from NICE pre-operative
testing)
Grade 1 examples: diagnostic endoscopy or laparoscopy,
breast biopsy.
Grade 2 examples: inguinal hernia, varicose veins,
adenotonsillectomy, knee arthroscopy.
Grade 3 examples: total abdominal hysterectomy, TURP,
lumbar discectomy, thyroidectomy.
Grade 4 examples: total joint replacement, artery
reconstruction, colonic resection; radical
neck dissection.
33

Appendix 4
ASA physical status
ASA grade 1 A normal healthy patient: i.e. without any
clinically important comorbidity and without a
clinically significant past/present medical history.
ASA grade 2: A patient with mild systemic disease.
ASA grade 3: A patient with severe systemic disease.
ASA grade 4: A patient with severe systemic disease that is a
constant threat to life.
ASA grade 5: A moribund patient who is not expected to
survive without the operation.
ASA grade 6: A declared brain-dead patient whose organs are
being removed for donor purposes.
Adapted from: http://www.asahq.org/clinical/physicalstatus.htm
34

Appendix 5
Systemic disease (from NICE pre-operative
testing)
Cardiovascular disease: ‘mild’
• Mild angina pectoris (no/slight limitation of ordinary
activity, e.g. > 1 flight of stairs).
• Myocardial infarction > 1 month ago (including Q waves on
12 lead ECG).
• Compensated heart failure (no/slight limitation of activity,
comfortable at rest).
Cardiovascular disease: ‘severe’
• Severe or unstable angina pectoris (marked limitation of
ordinary activity).
• Myocardial infarction < 1 month ago.
• Decompensated heart failure (marked limitation of ordinary
activity or symptoms at rest).
• Severe valvular disease (exercise-induced syncope, angina,
dyspnoea, orthopnoea, fatigue, palpitations).
Renal disease: ‘severe’
• Creatinine > 150 µmol.l -1
35

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Regional Anaesthesia and Patients
with Abnormalities of Coagulation
Published by
The Association of Anaesthetists of Great Britain & Ireland
The Obstetric Anaesthetists’ Association
Regional Anaesthesia UK
November 2013

This guideline was originally published in Anaesthesia. If you wish to refer to this
guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’
Association and Regional Anaesthesia UK. Regional anaesthesia and patients
with abnormalities of coagulation. Anaesthesia 2013; 68: pages 966-72. This can
be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.12359/abstract

Guidelines
Regional anaesthesia and patients with
abnormalities of coagulation
The Association of Anaesthetists of Great Britain
& Ireland
The Obstetric Anaesthetists Association
Regional Anaesthesia UK
Membership of the Working Party: W. Harrop-Griffiths,
T. Cook, 1 H. Gill, D. Hill, 2 M. Ingram, M. Makris, S. Malhotra,
B. Nicholls, 3 M. Popat, H. Swales 2 and P. Wood
1 Royal College of Anaesthetists
2 Obstetric Anaesthetists’ Association
3 Regional Anaesthesia UK
Summary
Concise guidelines are presented that relate abnormalities of coagulation,
whether the result of the administration of drugs or that of pathological
processes, to the consequent haemorrhagic risks associated
with neuraxial and peripheral nerve blocks. The advice presented is
based on published guidelines and on the known properties of anticoagulant
drugs. Four separate Tables address risks associated with
anticoagulant drugs, neuraxial and peripheral nerve blocks, obstetric
anaesthesia and special circumstances such as trauma, sepsis and massive
transfusion.
© 2013 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of
The Association of Anaesthetists of Great Britain and Ireland.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial
and no modifications or adaptations are made.
1

Anaesthesia 2013 W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation
....................................................................................................
This is a consensus document produced by expert members of a Working
Party established by the Association of Anaesthetists of Great Britain &
Ireland, the Obstetric Anaesthetists’ Association and Regional Anaesthesia
UK. It has been seen and approved by the elected Councils/Committees of
all three organisations.
Accepted: 4 June 2013
• What other statements are available on this topic?
Guidance publications on regional anaesthesia in patients taking anticoagulant
or thromboprophylactic drugs are widely available, two
well-known guidelines having been published by the American Society
of Regional Anesthesia and Pain Medicine (ASRA) [1] or adopted by
the European Society of Regional Anaesthesia and Pain Therapy
(ESRA) [2].
•
Why was this guideline developed?
The available published guidance focuses on neuraxial blockade in
patients receiving drug therapy specifically aimed at modifying
coagulation, but does not address non-neuraxial regional blockade or
patients with abnormalities of coagulation for other reasons. Currently
available guidelines are lengthy and discursive, and do not
lend themselves to use in the acute clinical setting. The remit of the
Working Party that produced these guidelines was to create a concise
document that considered regional anaesthesia of all forms and
abnormalities of coagulation of both therapeutic and pathological
origins.
•
How does this statement differ from existing guidelines?
Although based on the available guidance and on published pharmacokinetic
and pharmacodynamic data pertaining to anticoagulant
drugs, this guidance is considerably more concise.
•
Why does this statement differ from existing guidelines?
These guidelines were developed in order to make useful and concise
guidance available to anaesthetists in the clinical setting.
Anaesthetists are often faced with the question of whether the risks of regional
anaesthetic techniques are increased when performed on patients with
2 © 2013 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of
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W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation Anaesthesia 2013
abnormalities of coagulation and, if so, whether they are so increased that
the techniques should be modified or avoided. This is not only because the
popularity of regional anaesthesia is on the rise but also because the use of
anticoagulant drugs in the prevention of venous thromboembolism is
expanding, as is the number of different drugs in use. The serious complications
of regional anaesthesia in patients without abnormalities of coagulation
are very rare indeed [3]. For example, in the third National Audit
Project (NAP3), the incidence of vertebral canal haematoma after neuraxial
blockade was 0.85 per 100 000 (95% CI 0–1.8 per 100 000). The extent to
which the risk of haemorrhagic complications is increased in patients with
abnormalities of coagulation is unquantifiable, but likely to be small. The
rarity of the complications means that it is difficult to make accurate estimates
of the incidence of complications related to abnormalities of coagulation,
and therefore offering patients and clinicians advice on the basis of
‘hard data’ is not possible, and is unlikely ever to become possible. We
are therefore reliant on expert opinion, case reports, case series, cohort
studies and extrapolations from drug properties such as the time taken to
achieve peak plasma levels and the known half-lives of drugs.
Published clinical guidance in relation to the risk associated with regional
anaesthesia in patients with abnormalities of coagulation is often binary.
For instance, it is often said that the performance of neuraxial block in
a patient with < 75 9 10 9 .l
1 platelets is not acceptable, whereas its performance
in the presence of > 75 9 10 9 .l
1 platelets is acceptable. However,
there can be no relevant difference in risk or outcome after neuraxial
blockade in two patients, one of whom has a platelet count of 74 9 10 9 1
.l
and the other 76 9 10 9 .l
1 . Risk is a continuum that runs from ‘normal
risk’ to ‘very high risk’, and this guidance seeks to emphasise this point.
This guidance must be interpreted and used after consideration of an
individual patient’s circumstances. None of the advice in this guidance
should be taken as being prohibitive or indicative. An abnormality of
coagulation – however severe – is always a relative contraindication to
the use of a regional anaesthetic technique. However, there may be circumstances
in which, although the use of a regional technique for a
patient with abnormal coagulation may put the patient at significant risk
as a result, the alternative for this patient (often a general anaesthetic)
may expose them to even greater risk. Experienced clinicians should be
involved in decisions about whether or not to perform a regional anaesthetic
technique on a patient with abnormal coagulation, and the patient
with capacity should be given all the information he/she needs to make
an informed choice.
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3

Anaesthesia 2013 W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation
Table 1 Recommendations related to drugs used to modify coagulation. Recommended minimum times are based in most circumstances
on time to peak drug effect + (elimination half-life 9 2), after which time < ¼ of the peak drug level will be present. For those
drugs whose actions are unrelated to plasma levels, this calculation is not relevant. Data used to populate this Table are derived from
ASRA and ESRA guidelines [1, 2] and information provided by drug manufacturers. These recommendations relate primarily to neuraxial
blocks and to patients with normal renal function except where indicated.
Drug
Time to
peak effect
Elimination
half-life
Acceptable time after
drug for block
performance
Acceptable
time after block
Administration
performance
of drug while
or catheter
spinal or epidural
removal for
catheter in place 1 next drug dose
Heparins
UFH sc prophylaxis < 30 min 1–2 h 4 h or normal APTTR Caution 1 h
UFH iv treatment < 5 min 1–2 h 4 h or normal APTTR Caution 2 4h
LMWH sc prophylaxis 3–4 h 3–7 h 12 h Caution 3 4h 3
LMWH sc treatment 3–4 h 3–7 h 24 h Not recommended 4 h 4
Heparin alternatives
Danaparoid prophylaxis 4–5 h 24 h Avoid (consider anti-Xa
levels)
Danaparoid treatment 4–5 h 24 h Avoid (consider anti-Xa
levels)
Not recommended 6 h
Not recommended 6 h
Bivalirudin 5 min 25 min 10 h or normal APTTR Not recommended 6 h
Argatroban < 30 min 30–35 min 4 h or normal APTTR Not recommended 6 h
Fondaparinux prophylaxis 5 1–2 h 17–20 h 36–42 h (consider anti-Xa
levels)
Not recommended 6–12 h
Fondaparinux treatment 5 1–2 h 17–20 h Avoid (consider anti-Xa
levels)
Antiplatelet drugs
NSAIDs 1–12 h 1–12 h No additional precautions No additional
precautions
Aspirin 12–24 h
o
Not relevant;
irreversible effect
No additional precautions No additional
precautions
Not recommended 12 h
No additional
precautions
No additional
precautions
Clopidogrel 12–24 h 7 days Not recommended 6 h
Prasugrel 15–30 min 7 days Not recommended 6 h
Ticagrelor 2 h 8–12 h 5 days Not recommended 6 h
Tirofiban < 5 min 4–8 h 6 8 h Not recommended 6 h
Eptifibatide < 5 min 4–8 h 6 8 h Not recommended 6 h
Abciximab < 5 min 24–48 h 6 48 h Not recommended 6 h
Dipyridamole 75 min 10 h No additional precautions No additional
6h
precautions
Oral anticoagulants
Warfarin 3–5 days 4–5 days INR ≤ 1.4 Not recommended After catheter
removal
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W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation Anaesthesia 2013
Table 1. (Continued)
Drug
Time to
peak effect
Elimination
half-life
Acceptable time after
drug for block
performance
Acceptable
time after block
Administration
performance
of drug while
or catheter
spinal or epidural
removal for
catheter in place 1 next drug dose
Rivaroxaban prophylaxis 5
(CrCl > 30 ml.min 1 )
Rivaroxaban treatment 5
(CrCl > 30 ml.min 1 )
3h 7–9 h 18 h Not recommended 6 h
3h 7–11 h 48 h Not recommended 6 h
Dabigatran prophylaxis or treatment 7
(CrCl > 80 ml.min 1 ) 0.5–2.0 h 12–17 h 48 h Not recommended 6 h
(CrCl 50–80 ml.min 1 ) 0.5–2.0 h 15 h 72 h Not recommended 6 h
(CrCl 30–50 ml.min 1 ) 0.5–2.0 h 18 h 96 h Not recommended 6 h
Apixaban prophylaxis 3–4 h 12 h 24–48 h Not recommended 6 h
Thrombolytic drugs
Alteplase, anistreplase,
reteplase, streptokinase
< 5 min 4–24 min 10 days Not recommended 10 days
UFH, unfractionated heparin; sc, subcutaneous; APTTR, activated partial thromboplastin time ratio; iv, intravenous; LMWH, low molecular weight heparin, NSAIDs,
non-steroidal anti-inflammatory drugs; INR, international normalised ratio; CrCl, creatinine clearance.
Notes to accompany Table 1
1 The dangers associated with the administration of any drug that affects coagulation while a spinal or epidural catheter is in place should be considered carefully. There are
limited data on the safety of the use of the newer drugs in this Table, and they are therefore not recommended until further data become available. The administration of
those drugs whose entry in this column is marked as ‘caution’ may be acceptable, but the decision must be based on an evaluation of the risks and benefits of administration.
If these drugs are given, the times identified in the column to the left (‘Acceptable time after drug for block performance’) should be used as a guide to the minimum
time that should be allowed between drug administration and catheter removal.
2 It is common for intravenous unfractionated heparin to be given a short time after spinal blockade or insertion of an epidural catheter during vascular and cardiac
surgery. Local clinical governance guidelines should be followed and a high index of suspicion should be maintained if any signs attributable to vertebral canal
haematoma develop.
3 Low molecular weight heparins are commonly given in prophylactic doses twice daily after surgery, but many clinicians recommend that only one dose be given
in the first 24 h after neuraxial blockade has been performed.
4 Consider increasing to 24 h if block performance is traumatic.
5 Manufacturer recommends caution with use of neuraxial catheters.
6 Time to normal platelet function rather than elimination half-life.
7 Manufacturer recommends that neuraxial catheters are not used.
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5

Anaesthesia 2013 W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation
Table 2 Relative risk related to neuraxial and peripheral nerve blocks in
patients with abnormalities of coagulation.
Higher risk
Normal risk
Block category
Epidural with catheter
Single-shot epidural
Spinal
Paravertebral blocks
Deep blocks
Superficial
perivascular
blocks
Fascial blocks
Superficial blocks
Local infiltration
Examples of blocks in category
Paravertebral block
Lumbar plexus block
Lumbar sympathectomy
Deep cervical plexus block
Coeliac plexus block
Stellate ganglion block
Proximal sciatic block (Labat, Raj, sub-gluteal)
Obturator block
Infraclavicular brachial plexus block
Vertical infraclavicular block
Supraclavicular brachial plexus block
Popliteal sciatic block
Femoral nerve block
Intercostal nerve blocks
Interscalene brachial plexus block
Axillary brachial plexus block
Ilio-inguinal block
Ilio-hypogastric block
Transversus abdominis plane block
Fascia lata block
Forearm nerve blocks
Saphenous nerve block at the knee
Nerve blocks at the ankle
Superficial cervical plexus block
Wrist block
Digital nerve block
Bier’s block
Notes to accompany Table 2
There have only been 26 published reports of significant haemorrhagic complications of peripheral nerve and
plexus blocks [1]. Half of these occurred in patients being given anticoagulant drugs and half in patients with
normal coagulation. Patient harm has derived from:
• Spinal haematoma after accidental entry into the spinal canal during attempted paravertebral blocks as
defined in the Table.
• Exsanguination.
• Compression of other structures, e.g. airway obstruction, occlusion of major blood vessels or tissue ischaemia.
The one death in this series was that of a patient on clopidogrel who underwent a lumbar plexus block and
subsequently exsanguinated. The majority of the 26 cases underwent deep blocks or superficial perivascular
blocks. From these data, and from other data relating to neuraxial blocks, we have placed blocks in the order of
relative risk shown in the Table.
Catheter techniques may carry a higher risk than single-shot blocks. The risk at the time of catheter removal
is unlikely to be negligible.
Ultrasound-guided regional anaesthesia, when employed by clinicians experienced in its use, may decrease
the incidence of vascular puncture, and may therefore make procedures such as supraclavicular blocks safer in
the presence of altered coagulation.
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W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation Anaesthesia 2013
Table 3 Relative risks related to neuraxial blocks in obstetric patients with abnormalities of coagulation.
Risk factor Normal risk Increased risk High risk Very high risk
LMWH – prophylactic dose > 12 h
6–12 h
< 6h
< 6h
LMWH – therapeutic dose
> 24 h
UFH – infusion Stopped > 4 h and
APTTR ≤ 1.4
UFH – prophylactic bolus dose
Last given > 4h
12–24 h
Last given < 4h
6–12 h
APTTR above normal range
NSAID + aspirin
Without LMWH
With LMWH dose
12–24 h
With LMWH dose
< 12 h
Warfarin INR ≤ 1.4 INR 1.4–1.7 INR 1.7–2.0 INR > 2.0
General anaesthesia* Starved, not in
labour, antacids
given
Pre-eclampsia Platelets
> 100 9 10 9 1
.l
within 6 h of block
Idiopathic thrombocytopenia Platelets
> 75 9 10 9 .l
1
within 24 h of
block
Intra-uterine fetal death FBC and
coagulation tests
normal within 6 h
of block
Cholestasis INR ≤ 1.4 within
24 h
Platelets 75–
100 9 10 9 .l
and normal
coagulation tests
Platelets
50–75 9 10 9 .l
1 (stable)
No clinical problems
but no investigation
results available
No other clinical
problems but no
investigation results
available
1
Full stomach or in
labour
Platelets
75–100 9 10 9 .l
(decreasing) and
normal coagulation
tests
Platelets
20–50 9 10 9 .l
1
1
Platelets < 75 9 10 9 .l
or abnormal
coagulation tests with
indices ≥ 1.5 or HELLP
syndrome
Platelets < 20 9 10 9 .l
With abruption or
overt sepsis
1
1
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Anaesthesia 2013 W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation
LMWH, low molecular weight heparin; UFH, unfractionated heparin; APTTR, activated partial thromboplastin time; NSAID, non-steroidal anti-inflammatory drug; INR,
international normalised ratio.
*Although general anaesthesia is not a risk factor per se for coagulation complications, it is included in this Table to highlight that the alternatives to regional anaesthesia
are not free of risk; thus a risk–benefit comparison is required when choosing one over the other. See notes below.
Notes to accompany Table 3
Risks: The risks are primarily those of vertebral canal haematoma with subsequent cord compression and permanent damage. Realistic alternatives to epidural analgesia
exist in labour, but, for caesarean section, the choice is that of general or neuraxial anaesthesia, and the risks of spinal haematoma in patients with abnormal
coagulation must be weighed against those of general anaesthesia, especially in patients who are in labour and have a full stomach. These risks include hypoxaemia
associated with difficulties maintaining the airway, pulmonary aspiration and thromboembolic complications.
Low platelets: The debate regarding the safety of neuraxial blockade in women with thrombocytopenia is guided by expert consensus opinion in the absence of clinical trials;
it is not therefore possible to give definitive values for a lower limit at which there is an increased risk of haematoma. For normal healthy women, there is no increased
risk of complications with platelet counts > 100 9 10 9 1
.l [4]. A count of > 75 9 10
9 .l
1 has been proposed as an adequate level for regional blocks when there are no
risk factors and the count is not decreasing [5]. In pre-eclampsia, a decreasing platelet count is accompanied by other coagulation abnormalities, and this is assumed to be
the case once the platelet count decreases to below 100 9 10 9 1
.l . If the platelet count is below this value, a coagulation screen should be performed – if this is normal, it
would be reasonable to perform a regional block down to a level of 75 9 10 9 .l
1 , depending on the rate of decrease in platelet count [6]. In idiopathic thrombocytopenic
purpura and gestational thrombocytopenia, there are reduced platelet numbers, but normal function. In these situations, expert opinion is that an experienced anaesthetist
might reasonably perform a neuraxial blockade providing the platelet count is > 50 9 10 9 1
.l and stable, but an individual risk–benefit assessment should be made
[7–11]. It is possible that spinal anaesthesia with platelet counts below this level may be safe if data are extrapolated from that derived from lumbar punctures in nonpregnant
patients performed by haematologists using needles considerably larger than those used by obstetric anaesthetists [9]. A stable level of 40 9 10 9 1
.l may be safe
for lumbar puncture in the absence of other coagulation abnormalities.
The platelet count should be checked before any neuraxial procedure if there is any suspicion of decreasing platelet numbers during routine antenatal testing, signs of the
development of pre-eclampsia, e.g. proteinuria or hypertension, or other clinical features suggesting coagulopathy, placental abruption or if the patient has been given recent
anticoagulant therapy. Platelet numbers can decrease in patients treated with regular heparin for > 4 days. Otherwise, it would not be routine to check platelet numbers
and delay neuraxial block whilst these results are awaited. It would be standard practice to perform a neuraxial procedure within 6 h of the last platelet count and clotting
studies in patients with mild or moderate pre-eclampsia. However, if the patient has severe or fulminating pre-eclampsia or HELLP syndrome, a platelet count and clotting
studies should be checked immediately before performing the procedure, as decreases in platelet count can occur rapidly in these circumstances.
Low molecular weight heparins with aspirin: Treatment with daily LMWH and aspirin 75 mg may be encountered when following NICE guidelines, which recommend
low-dose aspirin for obesity or hypertension. Provided the LMWH is stopped for > 12 h, the platelet count is > 75 9 10 9 1
.l and normal coagulation is confirmed,
neuraxial blocks can be categorised as ‘increased risk’ only.
Intra-uterine fetal death: After intra-uterine death, there is an increased risk of coagulopathy and sepsis, especially in the second week after fetal demise. Coagulation
abnormalities can occur on presentation in about 3% of women with apparently uncomplicated intra-uterine death, and this increases in the presence of abruption
or uterine perforation to around 13% [12]. It is therefore prudent to check coagulation status before any regional procedure. The onset of coagulopathy is variable,
but can be rapid.
Cholestasis: In obstetric cholestasis, coagulopathy may develop as a result of decreased absorption of vitamin K essential for activation of clotting factors. It is important
to check coagulation before regional blockade, but changes do not occur rapidly.
Removal of epidural catheters: The recommendations given in Table 1 for the removal of epidural catheters should be noted.
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W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation Anaesthesia 2013
Table 4 Risks of regional anaesthesia in patients with abnormalities of
coagulation – special circumstances.
Trauma
Sepsis
Uraemia
Liver failure
Massive transfusion
Disseminated
intravascular
coagulopathy
The coagulopathy of trauma is precipitated by tissue trauma,
shock, haemodilution, hypothermia, acidaemia and
inflammation. Following major trauma, it is recommended that
an assessment of potential coagulopathy be made before
performing any regional anaesthetic technique.
Severe sepsis is associated with a procoagulant state. Guidelines
support the use of chemoprophylaxis against deep venous
thrombosis. For advice on regional anaesthesia with intercurrent
thromboprophylaxis, refer to Table 1. Septic shock may be
associated with the development of a consumptive coagulopathy.
Clinically significant systemic sepsis remains a relative
contraindication to central neuraxial anaesthesia due to the
presumed increased incidence of epidural abscess and meningitis.
Uraemia may lead to coagulopathy secondary to
thrombocytopenia. It is recommended that all patients with
significant uraemia undergo assessment of platelet number and
function before regional anaesthesia. Platelet function may be
improved by the administration of DDAVP.
Patients with chronic renal impairment may be managed with
regular dialysis. The presence of residual anticoagulation after
heparin administration must be considered in patients after
dialysis, and heparin reversed if indicated. If regional
anaesthesia is performed, the safety of catheter removal must
be considered in patients likely to receive heparin during
further dialysis.
All coagulation factors except factor VIII are synthesised in the
liver. Liver failure is associated with haemostatic abnormality,
the extent of which must be assessed before regional
anaesthetic techniques are performed. There may be
thrombocytopenia and abnormal platelet function due to
associated hypersplenism. Patients in liver failure represent a
high-risk group for general anaesthesia. When regional
anaesthesia is considered as an alternative, coagulopathy must
be assessed and corrected when indicated.
Massive transfusion is associated with altered haemostasis, with
dilution and consumption of coagulation factors being the
primary causes in this pathophysiological change. In assessing
the degree of coagulopathy before regional anaesthetic techniques,
it is recognised that coagulopathy in massive transfusion is a
dynamic situation. Assessment should be made when haemorrhage
is controlled and the patient is cardiovascularly stable. An
assessment of platelet function should ideally occur in patients
who have been given platelet transfusions.
Disseminated intravascular coagulopathy (DIC) is the
pathological activation of coagulation mechanisms in response
to a disease process leading to a consumptive coagulopathy.
A diagnosis of DIC is incompatible with safe neuraxial
blockade. When peripheral blocks are considered, they should
be at compressible sites.
Notes to accompany Table 4
All of the conditions discussed can, in their ‘active’ state, be associated with significant
coagulopathy. When regional anaesthesia is thought to be of potential value, e.g. for postoperative
analgesia, it should be conducted with reference to the guidelines outlined in the
rest of this publication.
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9

Anaesthesia 2013 W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation
Advice is often offered that if regional anaesthesia is to be considered
in a patient with a known abnormality of coagulation, an ‘experienced
anaesthetist’ should perform the procedure. There are, of course,
no hard data to support this suggestion. However, it is advice that the
Working Party supports. It is likely that an experienced regional anaesthetist
will need fewer attempts to gain block success, and it is likely
that the complications related to bleeding are in part related to the
number of attempts at a block. It is reasonable to ask novices to perform
their blocks on patients at ‘normal risk’, reserving attempts in
patients at ‘increased risk’ for experienced clinicians.
Guidance is offered here in the form of four Tables, each with
explanatory notes: Table 1 contains recommendations related to drugs
used to modify coagulation; Table 2 suggests the relative risk related to
the performance of neuraxial and peripheral nerve blocks in patients
with abnormalities of coagulation; Table 3 indicates relative risks related
to obstetric patients; and Table 4 describes risks of regional anaesthesia
in special circumstances.
Some readers may question the absence of a section on haematological
conditions associated with abnormalities of coagulation – why do we
not mention Christmas disease or other forms of haemophilia? Most of
these diseases are the result of the absence or shortage in the body of a
particular clotting factor or group of factors. Most of the patients with
haematological diseases such as these reach surgery in the full knowledge
that they have the disease. The standard treatment of bleeding resulting
from a deficiency of a clotting factor or other contributor to normal coagulation
when faced with surgery is the administration of that factor or
other contributor after guidance from a haematologist. Therefore, for elective
surgery, the solution is almost always the performance of the regional
technique after acceptable normalisation of coagulation on the advice of a
haematologist. In the emergency situation, urgent advice should be sought
from on-call haematologists.
References
1. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving
antithrombotic or thrombolytic therapy. Regional Anesthesia and Pain Medicine
2010; 35:64–101.
2. Gogarten W, Van Aken H, Buttner J, Riess H, Wulf H, Burkle H. Regional anaesthesia
and thromboembolism prophylaxis/anticoagulation: revised recommendations of
the German Society of Anaesthesiology and Intensive Care Medicine. Anasthesiologie
und Intensivmedizin 2007; 48: S109–24.
10 © 2013 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of
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W. Harrop-Griffiths et al. | Guidelines: patients with abnormalities of coagulation Anaesthesia 2013
3. Cook TM, Counsell D, Wildsmith JAW. on behalf of the Royal College of Anaesthetists
Third National Audit Project. Major complications of central neuraxial block: report
on the Third National Audit Project of the Royal College of Anaesthetists. British
Journal of Anaesthesia 2009; 102: 179–90.
4. Rolbin SH, Abbott D, Musclow E, Papsin F, Lie LM, Freedman J. Epidural anesthesia
in pregnant patients with low platelet counts. Obstetrics and Gynecology 1988; 71:
918–20.
5. Douglas MJ. The use of neuraxial anaesthesia in parturients with thrombocytopenia:
what is an adequate platelet count? In: Halpern SH, Douglas MJ, eds. Evidence Based
Obstetric Anesthesia, 2nd edn. Boston, MA: Blackwell, 2005: 165–77.
6. Sharma SK, Philip J, Whitten CW, Padakandla UB, Landers DF. Assessment of
changes in coagulation in parturients with preeclampsia using thromboelastography.
Anesthesiology 1999; 90: 385–90.
7. Douglas M, Ballem P. Blood disorders. In: Gambling DR, Douglas MJ, McKay RSF,
eds. Obstetric Anaesthesia and Uncommon Disorders, 2nd edn. Cambridge: Cambridge
University Press, 2008: 303–20.
8. Kam PCA, Thompson SA, Liew ACS. Thrombocytopenia in the parturient. Anaesthesia
2004; 59: 255–64.
9. Gill KK, Kelton JG. Management of idiopathic thrombocytopenic purpura in pregnancy.
Seminars in Hematology 2000; 37: 275–89.
10. Van Veen JJ, Nokes T, Makris M. The risk of spinal haematoma following neuraxial
anaesthesia or lumbar puncture in thrombocytopenic individuals. British Journal of
Haematology 2010; 148: 15–25.
11. Frenk V, Camman W, Shankar KB. Regional anesthesia in parturients with low platelet
counts. Canadian Journal of Anesthesia 2005; 52: 114.
12. Maslow AD, Breen TW, Sarna MC, Soni AK, Watkins J, Oriol NE. Prevalence of
coagulation associated with intrauterine fetal death. Canadian Journal of Anesthesia
1996; 43: 1237–43.
© 2013 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of
The Association of Anaesthetists of Great Britain and Ireland.
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Safe vascular access 2016
Published by
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650 Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org May 2016

This guideline was originally published in Anaesthesia. If you wish to refer to this
guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Safe vascular access
2016. Anaesthesia 2016; 71: 573-585.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13360/full

Anaesthesia 2016
doi:10.1111/anae.13360
Guidelines
Association of Anaesthetists of Great Britain and Ireland*
Safe vascular access 2016
A. Bodenham (Chair), 1 S. Babu, 2 J. Bennett, 3 R. Binks, 4 P. Fee, 5 B. Fox, 6 A. J. Johnston, 7 A. A. Klein, 8
J. A. Langton, 9 H. Mclure 10 and S. Q. M. Tighe 11
1 Consultant, Anaesthesia and Intensive Care, Leeds Teaching Hospitals, Leeds, UK
2 Specialty Doctor, Anaesthesia, North Manchester General Hospital, Manchester, UK
3 Consultant, Anaesthesia, Birmingham Children’s Hospital, Birminham, UK
4 Nurse Consultant, Airedale Hospital, West Yorkshire, UK, and Faculty of Intensive Care Medicine, UK
5 Locum Consultant, Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
6 Specialist Registrar, Anaesthesia, East Anglia, and Group of Anaesthetists in Training, AAGBI, London, UK
7 Consultant, Anaesthesia and Intensive Care, Addenbrooke’s Hospital, Cambridge, UK
8 Consultant, Anaesthesia, Papworth Hospital, Cambridge, UK
9 Consultant, Anaesthesia, Plymouth Hospitals, Plymouth, and Royal College of Anaesthetists, UK
10 Consultant, Anaesthesia, Leeds Teaching Hospitals, Leeds, UK
11 Consultant, Anaesthesia and Intensive Care, Countess of Chester Hospital, Chester, and AAGBI Council, UK
Summary
Safe vascular access is integral to anaesthetic and critical care practice, but procedures are a frequent source of
patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for
all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available.
This guidance was created using review of current practice and literature, as well as expert opinion. The result is a
consensus document which provides practical advice on the safe insertion and removal of vascular access devices.
.................................................................................................................................................................
*This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists
of Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board of Directors.
(Date of review: 2020).
These guidelines have been endorsed by the Royal College of Anaesthetists, the Faculty of Intensive Care Medicine, and
the Association of Paediatric Anaesthetists of Great Britain and Ireland.
Accepted: 5 September 2015
Keywords: arterial cannulation; central venous catheterization; complication management; peripheral venous catheters;
vascular access
.................................................................................................................................................................
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use
is non-commercial and no modifications or adaptations are made.
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 1

Anaesthesia 2016
Bodenham et al. | Safe vascular access guidelines
Recommendations
1 Hospitals should establish systems to ensure patients
receive effective, timely, and safe vascular access.
2 All hospitals should have specific policies for insertion
and removal of vascular access devices including
clear documentation from insertion to removal.
3 Clinicians should be proactive in provision of,
training in and supervision of vascular access.
4 Ultrasound should be used routinely for internal
jugular central venous catheter insertion. The
Working Party recommends its use for all other
central venous access sites, but recognises evidence
is, at present, limited.
5 An understanding of landmark techniques for central
venous cannulation is useful for rare occasions
when ultrasound is not available or cannot be used.
6 The use of ultrasound should be considered early
if arterial or peripheral venous cannulation proves
difficult.
7 Intra-osseous access is useful in emergencies when
intravenous access is difficult. All acute care clinicians
should be familiar with techniques and have
ready access to devices.
8 Clinicians should review processes to improve the
safety and proficiency in vascular access and initiate
regular audit to assess compliance with the
standards identified in this and other guidance.
What other guideline statements are available on this
topic?
There are a small number of existing national and
international guidelines on vascular access [1–5].
Why was this guideline developed?
There is a need for up to date evidence-based guidance
focusing on patient safety. There continues to be cases
of severe morbidity and mortality related to vascular
access [6, 7].
How and why does this publication differ from existing
guidelines?
This is the first UK anaesthetic national guidance in
this field, primarily aimed at safety of insertion and
removal procedures. We also highlight organisational
and training issues.
Introduction
Vascular access is the most common invasive procedure
undergone by patients in secondary care. It is often
poorly undertaken and is the source of considerable
patient discomfort and inconvenience, as well as morbidity
and mortality. Vascular access is essentially a single,
often repetitive, task but providing a quality service
requires more; this includes all aspects of human factors
as well as education, training, audit and technical proficiency.
New technology such as ultrasound and other
imaging has increased the number of tools available.
Peripheral venous cannulation
Peripheral venous cannulation is the commonest, and
probably the most important invasive procedure practised
in hospitals. Principles are summarised in Table 1 [8–11].
An alternative and increasingly used technique is
so called midline catheters [12]. These are approximately
10–20 cm long and inserted into upper arm
veins with ultrasound (as with a peripherally inserted
central catheter, such that the tip lies outside central
veins and are used for short to medium-term access
(e.g. 1–4 weeks antibiotics). They should not be used
for infusions listed as requiring central venous administration.
Table 1 Guide to peripheral cannulation [8–11].
The smallest practical size of cannula should be used.
• Needle guards to reduce needle stick injury are recommended
in all procedures.
• Peripheral insertion is inappropriate for infusion of fluid
with high osmolality (> 500 mOsm.l
1 ) or low (< 5) or
high pH (> 9) or intravenous access for more than
2 weeks.
•
The relative safety of peripheral administration of vasopressors/inotropes
is contentious, but likely to be dependent
on vein size and its blood flow, infusion rate,
individual drug effect and dilution. This is a good area
for future studies.
• Insertion in a limb with lymphoedema should be
avoided, except in acute situations due to increased
risks of local infection.
• Transillumination, ultrasound and infra-red devices may
be useful.
• Routine changes of peripheral cannulae at 72–96 h is
not advocated.
• All cannulae must be flushed after use.
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Bodenham et al. | Safe vascular access guidelines Anaesthesia 2016
Intra-osseus access
Intra-osseus access (IO) access is useful in emergencies,
when intravenous (IV) access is difficult, and is
faster than central access [13]. It can be used for resuscitation
fluids and drugs. All acute care clinicians
should be familiar with techniques and have ready
access to devices. We suspect that to date this is not
the case in most centres. A number of manual and
automated devices exist.
The tibia and the humerus are preferred sites. For
the tibia, the insertion site is 2 cm distal to the tibial
tuberosity and 1 cm medial to the tibial plateau. Care
is needed to avoid the epiphyseal growth plate in children.
Success is evident by: aspiration of bone marrow
(painful in awake patients); saline flush with no
extravasation; support of the needle by the bone
cortex; and infusion under gravity alone.
Complications include: fracture; extravasation;
osteomyelitis; infection; compartment syndrome;
growth plate injury and pressure necrosis of the skin.
Devices should be removed as soon as suitable IV
access is achieved, ideally within 24 h of placement.
Arterial access
Relative contraindications include severe peripheral vascular
disease, coagulopathy and local synthetic grafts.
There is no evidence to support routine rotation of sites.
Compression of radial and ulnar arteries to assess collateral
perfusion (Allen’s test) is unreliable. Ultrasound can
be used to assess vessel patency and size.
Methods of insertion include: catheter-over-needle;
and catheter-over-wire, i.e. Seldinger or modifications.
A meta-analysis [14] suggested that radial
arterial cannulation with ultrasound is more successful
on first attempt. Major procedural complications
(e.g. permanent ischaemic damage, sepsis, pseudoaneurysm)
are reported to occur in < 1% of cases and
are similar for radial, femoral and brachial sites.
Some studies have found a higher incidence of catheter-related
infection in femoral sites. However, arterial
cannulation is generally considered safest at a suitable
peripheral site if possible.
There have been UK national alerts on severe
hypoglycaemia from misdirected administration of
insulin when glucose solutions are used to flush arterial
lines. The most recent AAGBI guidelines recommend
saline heparin as the only safe solution to
flush catheters [15].
Insertion & removal of central venous
catheters (CVCs)
Device choice
This depends on: patient diagnosis; the intended treatment
(irritant drugs normally require CVC); and
patient choice. Devices should have the appropriate
number of lumens required for the planned usage aiming
to avoid the risks of additional catheter placements
[16]. Smaller diameter devices, if appropriate, reduce
vein trauma on insertion and thereafter. Parenteral
nutrition requires a dedicated lumen. Fixed-length
catheters: 15 cm for right internal jugular vein (IJV),
20 cm for left internal jugular or right axillary/subclavian
vein, and 24 cm for left axillary/subclavian or
femoral vein, are the usual minimum selection length
for adults. See Table 2 for different features [16, 17].
Route of access
Central venous catheters
The internal jugular vein route may have a lower risk
of mechanical complications than the subclavian [1].
Recent work shows catheter-related bloodstream infection
rates are lower in patients in critical care using
the subclavian rather than IJV or femoral routes [18].
Although the groin may have a higher microbial
colonisation rate, tunnelling devices away from the
groin may reduce such risks. Some perceived differences
in complication rates may disappear with optimal
catheter tip positioning between insertion sites.
The right internal jugular/femoral route provides a
straighter course to central veins, making catheter
positioning easier without X-ray guidance. The external
jugular vein is an alternative visible vein, but central
catheter positioning can be difficult.
Peripherally inserted central catheters (PICCs)
These should be used with caution in patients at risk
of ipsilateral lymphoedema and those who may require
an arterio-venous fistula. The basilic and brachial veins
may have a lower thrombosis rate than the cephalic
vein. Ultrasound use may avoid damage to the median
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Table 2 Some features of different central venous catheter devices, all suitable for multiple infusions including veindamaging
substances. Adapted from [16, 17].
Non-tunnelled
Tunnelled
Total implanted
(Ports)
Peripheral insertion
(PICCs)
Features Common use Duration/comments
One to six lumens.
Insertion to subclavian, IJV or
femoral veins.
Some suitable for extra-corporeal
treatments.
One to three lumens. Insertion to
subclavian, IJV or femoral veins (entry).
Tunnelled to exit site.
Dacron cuff anchors device.
One to two lumens.
Insertion to subclavian, IJV, femoral or
upper arm veins (entry).
Tunnelled to port.
One to three lumens.
Insertion to basilic, cephalic and
brachial veins.
Short-term CVC.
Central venous pressure
and ScvO2.
Frequent long-term access.
Haemodialysis/extra-corporeal
treatments.
Frequent long-term access
Complex to insert/remove.
Uses needle access.
Simpler and safer to insert.
Up to 7–10 days.
Routine replacement not
required.
Months/years.
Lower infection than
non-tunnelled catheters.
Months/years.
Lower infection than
tunnelled catheters.
Least lifestyle disruption
1–6 months, or longer.
Suitable for short-term use.
IJV, internal jugular vein; ScvO2, central venous oxygen saturation.
nerve and brachial artery. Use of upper arm veins
avoids the elbow flexure.
Catheter tip position
A poorly positioned catheter tip may increase the risk
of complications, e.g. thrombosis, erosion and pericardial
tamponade [19]. The position of the tip moves
with respiration and patient position. Upper body
CVCs should be positioned with the tip parallel to the
vessel wall, usually in the lower superior vena cava
(SVC) or the upper right atrium (RA). Common sites
for tip misplacement include: high SVC; internal jugular
vein; angled at vein wall; low RA; right ventricle;
innominate vein and subclavian vein.
Assessment of tip position includes: post-insertion
chest X-ray, real-time fluoroscopy, and ECG guidance.
Stenosis or distortion of great veins is common in disease
states particularly with prolonged CVC placement.
Unusual congenital variants (e.g. left SVC) exist [20].
Misplacement can be reduced by the following: use of
the right IJV or femoral veins and pressure over the
IJV may reduce the incidence of IJV malposition when
inserting PICCs or subclavian lines. Catheters and
guidewires may pass centrally more easily on inspiration
as thoracic structures change shape. Ultrasound
can confirm catheter position with supraclavicular,
transthoracic and transoesophageal echocardiographic
views. Electrocardiograpy and electromagnetic guidance
are increasingly used to guide catheter tip positioning
as per recent guidance [21]. Fluoroscopy X-ray contrast
remains the gold standard for imaging.
Most misplaced CVCs are easily identified on chest
X-ray, but signs can be subtle [20]; judicious use of
contrast via the catheter (linogram) is helpful. The limitations
of single plane X-ray imaging must be appreciated.
Clues to misplacement include: pain on injection;
difficulty in aspirating blood from one or more lumens;
or an abnormal pressure waveform, or arterial pattern
blood gas on sampling. Management of misplaced
catheters within central veins includes: using the device
if it is safe to do so; manipulating the position under X-
ray guidance; or replacement, using fluoroscopic guidance
or other imaging as required. Misplacement outside
veins is considered later under complications.
Removal of CVCs
Devices should be removed when they are no longer
required or are causing problems. The patient should
lie flat with the exit site below the heart to reduce risks
of air embolus. Firm digital pressure should be applied
for at least 5 min, followed by an occlusive dressing.
Routine culture of tips is not considered necessary.
Persistent bleeding may require a skin stitch.
Cuffed devices/ports need surgical cut-downs as
they develop complex adherent fibrin sleeves and scar
tissue [22]. Fibrin sleeves are frequently left behind
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Bodenham et al. | Safe vascular access guidelines Anaesthesia 2016
within the vein (seen as ‘ghosts’ on ultrasound). Very
long-term catheters may become attached to the wall
of SVC/right atrium and cannot be removed by traction
alone; cutting off and leaving in situ or surgical
removal may be required. Devices can become knotted
within veins. Seek advice from vascular surgery or
interventional radiology if difficulties occur.
Procedures in coagulopathic patients
In the presence of a coagulopathy, a more experienced
operator should insert the CVC, ideally at an insertion
site that allows easy compression of vessels. Femoral
access may have a lower risk in this situation. Routine
reversal of coagulopathic abnormality is only necessary
if platelet count < 50 9 10 9 .l
1 , activated partial
thromboplastin time > 1.3 times normal and/or international
normalised ratio > 1.8, as the risk of haemorrhage
is not increased [23]. In selected patients,
different thresholds for correction may be acceptable.
Bleeding risks of insertion and removal vary with
the site, size of device, and operator experience. The
risks of correction (e.g. infection, lung injury, thrombosis)
may exceed that of local bleeding, and it may be
preferable to give blood products if problems occur,
rather than prophylactically.
Difficult central venous catheter insertion
Difficult access occurs frequently [24] and is more
likely with previous multiple attempts, insertion site
scars and long-term access. Distended superficial collateral
veins suggest deeper vein blockage or stenosis.
Doppler ultrasound of great vessels gives limited imaging
of the subclavian vein and SVC; contrast venography/CT/MRI
may be indicated, dependent on urgency.
If difficulty is predicted, insertions should be performed
under X-ray control with appropriate radiation
protection [25]. High-resolution ultrasound should be
used with colour Doppler to study flow. Input from
interventional radiology and surgery may be needed.
A ‘difficult access’ trolley is useful, with additional
instruments, X-ray contrast, sterile drapes and ultrasound
probe covers, standard (18G) and micro-puncture
needles (20-21G), and compatible guidewires
(0.018″ and 0.32″).
Guidewires come in various lengths, with different
coatings and tips (e.g. straight, angled, soft tip or full
‘J’). It is best to be familiar with a small range. Catheters
of 12–24 cm length should be available for adults.
Guidewires should be checked for damage and adherent
clot removed with a wet swab. A selection of
compatible dilators and peel-away sheaths is needed.
Use of a 4–5 Fr introducer sheath allows manipulation
of guidewires while minimising the risk of
damaging the wire or vein; it also acts as a conduit for
contrast injection or advancement of specialist catheters/wires.
X-ray contrast is used to image vascular anatomy,
identify complications and confirm line position/patency.
It may cause anaphylaxis. Contrast nephropathy
is unlikely in doses used for venous access [26].
Paediatric CVC insertion
Provision of CVCs for neonates through to adolescents
is challenging, despite similar techniques to adults.
Children are more likely to be seen with congenital
cardiac anomalies and there is a large range in the size
of vessels, which impacts on procedures and complications
[27]. Most procedures will be conducted under
general anaesthesia, except for peripherally inserted
central catheters.
Catheter choice depends on: vein calibre; indication;
duration of use; severity of illness and operator
experience. Neonatal long lines down to 28G are available.
Umbilical venous catheters remain popular for
short-term use in neonates, despite high complication
rates. Non-tunnelled, 5–6 cm long, 4.5-Fr triple-lumen
CVCs are available for neonates. Tunnelled cuffed
Broviac catheters for long-term use are available down
to 2.7Fr [28].
A full range of sizes of equipment is required.
Operators must be familiar with equipment and procedures.
Typical guidewires are narrower 0.021″ (0.032″
used in adults), and prone to kinking, particularly during
advancement of dilators. The diameter of a ‘J’ tip
may impede advance in a narrow vein. A less curved
tip is preferable. Skin dilators tend to be shorter and
narrower.
X-ray imaging of fine catheters is challenging,
and contrast may be required. There are few data on
the use of electromagnetic or ECG guidance to identify
CVC tip position in children. X-ray guidance
remains standard.
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Chlorhexidine of varying strengths is used for skin
antisepsis before CVC insertion in infants, but efficacy
and safety data comparing solutions is lacking so definitive
guidance cannot be given. Chlorhexidine, in particular
2%, has been associated with skin erythema and
burns in premature infants and caution is advised in
this group; the use of excessive quantities and pooling
on the skin should be avoided [29]. Many centres use
a 0.5% solution as an alternative.
Ultrasound-guided paediatric CVC insertion has
been shown to be superior to landmark techniques
[30]. Superficial vessels and lack of fat allows excellent
imaging. Probes need a small footprint for full skin
contact. Veins are prone to compression by the probe
and access needle, which risks transfixion and damage
to adjacent structures.
Small children are less likely to understand the
importance of their CVC with risks of damage, nor
the risks associated with replacing devices. Implanted
ports may not be tolerated by needle phobic children.
Rapid growth in small children may lead to the tip
migrating.
Peripheral access can be challenging and limit
placement of devices. Loss of peripheral veins is a serious
issue in chronic illness. Prolonged use of CVCs
may lead to central vein thrombosis with difficult or
impossible access. Open surgical cut-down remains a
common technique in paediatric surgery and often
leads to central vein occlusion near the entry site.
Prevention, recognition and
management of central venous
catheter complications
Deaths related to CVCs are often accompanied by
poor documentation [4]. All hospitals should have
clear, specific policies for insertion and documentation
of CVCs (type, insertion site and tip position), and
education on complications and their management.
Publications suggest complication rates of 1–26%
[31]. However, most series are small and lack precise
denominators. Appropriate training and surveillance
should avoid and identify most complications. Discussion
here is limited to more serious, well-recognised
complications (Table 3), which vary in frequency
depending on patient, catheter and operator experience.
There are many other reported rarer complications
listed as case reports in the literature. There is an
increased focus in the UK to reduce the risks of invasive
procedures including universal adoption of WHO
style theatre checklists, definition of so called ‘Never
Events’ (see later), and most recently the introduction
of local and National Safety Standards for Invasive Procedures
(NatSSIPs) [32]. Central venous access and
more central arterial cannulation would be considered
to be within this latter category of invasive procedure.
Infection
Central venous catheter-associated bloodstream infection
can be life-threatening, and is increasingly
regarded as a measure for quality of care. Treatment
should adhere to local guidance and may include CVC
removal [33].
Thrombosis/thrombo-embolism
Thrombosis related to CVCs has a reported incidence
of 3–32% [1], reflecting variations in definition and
imaging, and frequent asymptomatic cases. Prevention
measures include: insertion of the narrowest-bore
catheter possible for treatment needs; placement of the
tip in lower SVC/high right atrium; and early removal.
Evidence suggests that peripherally inserted central
catheters are associated with increased peripheral and
central thrombosis [34]. The femoral route may be
Table 3 Complications of central venous catheter
insertion.
• Infection
s Localised or bloodstream.
• Thrombosis/thromboembolism
s Symptomatic or asymptomatic
• Perforation of vessels and myocardium
s Arterial puncture/tear
s Arterial cannulation
s Venous injury/tear
s Myocardial perforation/cardiac tamponade.
• Pleural collections.
s Pneumothorax
s Haemothorax (haemoperitoneum)
Cardiac arrhythmias
Air embolism
Guidewire/catheter embolism
Catheter occlusion
Catheter breakage/leak/extravasation
Bleeding elsewhere.
Central venous stenosis
• Neurological injury
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Bodenham et al. | Safe vascular access guidelines Anaesthesia 2016
associated with a higher thrombosis risk [18, 19].
Some retrospective (but not prospective) studies show
an increased thrombosis risk when the subclavian vein
is used long-term [1]. Anticoagulation is not currently
recommended for asymptomatic thrombosis [1], or as
prophylaxis, except for patients at high risk (e.g. previous
DVT or PE) [35].
Thrombosis may present with a poorly functioning
line; a swollen limb; signs of SVC obstruction; pain
over the insertion site; or central embolism. Symptomatic
thrombosis is usually treated with full anticoagulation.
Removal of a functioning CVC depends on
the clinical situation, and ease of re-insertion.
Perforation of great vessels and myocardium
These complications usually occur at insertion and
may cause serious morbidity or mortality. Meticulous
technique, vigilance and early recognition prevent
progression to catastrophe. Bleeding may be evident
externally, but may also be covert, into pleurae, pericardium,
and peritoneum. Once a vessel is perforated
then the guidewire, dilator or catheter may pass into
any adjacent structure or organ, commonly the pleural
space, pericardium, mediastinum or lung in the upper
body.
Arterial puncture
Accidental arterial puncture is reduced with routine
use of ultrasound guidance [1, 36]. It is usually evident
by bright red, pulsatile blood, but confusion may occur
in infants and emergency situations. Manometer tubing
can be attached to a needle or cannula to differentiate
venous from arterial placement. Ultrasound
imaging can confirm the guidewire in the proximal
vein before dilatation. A PO 2 consistent with arterial
blood is strongly suggestive but may reflect atreriovenous
shunting. All tests have flaws; a fuller discussion
is available elsewhere [2].
Needle puncture is managed by removal and digital
pressure. Ultrasound imaging may define the size
of the haematoma, vessel injury and patency. Puncture
of the carotid artery, even with a 21G ‘searching’
needle, may cause stroke, particularly with existing
arterial disease [37]. If the needle also traverses a
vein, there is potential for an aterio-venous fistula.
An expanding neck haematoma in the neck may
fatally compromise the airway [38–40], and require
tracheal intubation and surgical intervention. Haemorrhage
associated with the femoral route may be
concealed in the retroperitoneum. Tense haematomas
elsewhere may require surgical evacuation/repair to
prevent local pressure effects.
Accidental arterial cannulation
The incidence is estimated as 0.1–1% [1]. There may
be excessive bleeding along the guidewire or on passing
dilators and introducers. Activation of high-pressure
alarms on infusion pumps and retrograde flow
within catheter/infusion sets are suggestive. Chest X-
ray may show an abnormal catheter path (to the left
mediastinum), but not if the catheter is in the right
carotid or ascending aorta which are adjacent to the
internal jugular vein and SVC. An arterial waveform
upon pressure transduction (check settings are for
arterial range) confirms arterial positioning. Contrast
injection will demonstrate arterial flow and CT shows
the catheter course. Carotid artery cannulation carries
a higher risk of morbidity and mortality than at other
sites, because of the risk of stroke and local pressure
effects from haemotoma.
Larger catheters/dilators (6Fr or greater) should be
left in place and their safe removal discussed urgently
with interventional radiologists or vascular surgeons.
Management of smaller catheters depends on the
insertion site, presence of arterial disease or thrombus,
and coagulation status; catheters (5Fr or less) are routinely
removed from the femoral artery following radiology
procedures. This is followed by direct pressure
for 10 min, or until haemostasis is achieved, then six
hours bed rest. Such guidance can be followed up for
accidental femoral artery catheterisation. Interventional
radiologists and surgeons should be consulted before
removing larger devices, any arterial catheter from the
neck or chest, or from any site in an anticoagulated
patient [39]. Routine anticoagulation following shortterm
accidental carotid or other artery catheterisation
is not recommended.
Venous tears
This is caused by trauma during insertion or later erosion
of the vein wall. Prevention includes meticulous
insertion technique; avoidance of advancing guidewires
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and dilators against resistance; and firmly holding
guidewires during dilation and catheter advancement.
Poorly positioned catheters need to be repositioned,
e.g. left-sided upper body CVCs that abut the SVC at
an acute angle. Narrow-bore soft catheters and dilators
are less likely to cause perforation.
Venous injury may manifest as a haematoma,
bleeding or extravasation into the mediastinum,
pleura, peritoneum, pericardium or other space. It
may cause haemodynamic compromise, cardiac tamponade,
haemothorax or pleural effusion [38, 40].
The catheter should remain in situ until a vascular
surgical or interventional radiology opinion has been
obtained.
Myocardial perforation/cardiac tamponade
This can be caused by trauma from guidewires or dilators
during insertion, or later erosion by a catheter.
Presentation is usually acute but may be delayed until
infusion of fluids via the catheter. The incidence is
reduced by careful insertion techniques. Infants and
those with dilated cardiomyopathy or previous cardiac
surgery are at higher risk. Guidewires should be
advanced gently and not beyond 20 cm (less in children)
without imaging. Dilators should only be
inserted as far as required to create a tract to the vessel.
Traditionally, it was advocated that catheter tips
should lie above the pericardial reflection but this is
frequently not possible, particularly with left-sided
catheters.
There may be signs of obstructed shock, an
abnormal pressure wave, or cardiac arrest. Chest X-
ray may show an enlarged cardiac outline, which
can be confirmed with echocardiography. Management
involves attempted fluid aspiration through the
catheter, urgent pericardiocentesis or surgical intervention
[40].
Pneumothorax
The incidence of pneumothorax is 0.3–2.3%, highest
with the subclavian route [1, 34]. It is typically caused
by needle penetration of the visceral pleura. Prevention
includes avoiding the subclavian vein, particularly during
early training, and using ultrasound guidance [41].
Recognising a pneumothorax can be difficult. It may
be invisible on initial post-procedure imaging. Staff
and patients should be warned to report late signs and
symptoms.
Treatment options include: observation; administration
of supplemental oxygen; and aspiration; or tube
drainage. Minimal or asymptomatic collections (up to
30% of the pleural cavity) may not require drainage in
spontaneously breathing patients.
Haemothorax
This may occur with central vein or arterial trauma
[42]. The pleurae are low-pressure spaces, where a
large volume of blood can accumulate. Catheters crossing
from a vein or artery into the pleura (or other
space) may be wholly or partially occluding the hole
and bleeding may worsen on removal. Further accumulation
of fluid/blood may occur if the catheter is
used for infusion, resuscitation or dialysis.
There may be clinical signs of respiratory and/or
circulatory failure. Chest X-ray, CT or ultrasound
imaging shows a dense pleural effusion, and aspiration/drainage
of blood confirms the diagnosis. Resuscitation
with drainage and repair of the damaged vessel
may be required.
Cardiac arrhythmias
Arrhythmias may be precipitated by guidewires or
catheters stimulating the heart [43]. They are usually
caused by insertion beyond the predicted length of
catheter for that insertion site, and usually settle on
guidewire/catheter withdrawal. Electrocardiographic
monitoring throughout all upper body CVC insertions
is advisable.
Venous air embolism
Air embolism may be fatal and occur at any time from
insertion to removal. The incidence may be as high as
0.8% [42]. Prevention requires careful insertion/removal
techniques, secure fixation and safe handling
when accessing the catheter. Presentation ranges from
subtle neurological, respiratory or cardiovascular signs
to shock, loss of consciousness and cardiac arrest.
Chronic forms may exist. If suspected, damaged catheters
should be clamped, pressure and wet dressings
applied, and occlusive dressings used. Head-down, left
lateral tilt and attempted aspiration of air via the line
may be useful.
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Bodenham et al. | Safe vascular access guidelines Anaesthesia 2016
Guidewire and catheter embolus
This risk is increased during difficult or multiple cannulation
attempts of the same vessel, or the presence
of an inferior vena cava filter [44]. Preventative measures
include minimising the length of guidewire
advanced, and maintaining hold of the outside section.
Guidewire counts or mandatory witnessed documentation
of guidewire removal may help identify unaccounted
wires during insertion. Retained guidewires
are usually asymptomatic and recognised incidentally
on X-ray. Guidewire retention is now categorised as an
NHS Never Event [45].
Catheter embolism occurs more often with longterm
devices. Catheter and port hub connections may
fracture/disconnect. Compression of the catheter
between the first rib and clavicle may result in ‘pinchoff’
[46]. Catheters are at risk during removal, especially
cuffed/implanted devices.
Both complications need referral for urgent radiological
or surgical retrieval.
Catheter occlusion
Occlusion may be due to thrombus, fibrin sheath or
precipitation within the catheter. The incidence of
catheter occlusion may be reduced by adhering to
standard procedures for accessing CVCs and managing
failing lines. A Cochrane review of heparin solutions
reported no reduction in intracatheter thrombus [47].
Occlusion is recognised by inability to aspirate or flush
one or more catheter lumens. It is common, and often
managed by a local protocol. A ‘linogram’ may identify
a kinked catheter, aberrant tip position or a fibrin
sheath with reflux of contrast. Thrombolytics can be
used to clear the lumen or surrounding thrombus [48].
In the case of precipitants, strong acid or alkali has
been used to unblock devices.
External catheter breakage
The portion of a CVC outside the body has the potential
to be cut, broken or split. Breakage is more common
in long-term lines. They may be repaired
according to local policy, or replaced.
Extravasation injury
Injury caused by leakage of infusate is usually associated
with catheter damage or withdrawal (placing a
luminal hole outside the vein), or vein perforation.
Rarely, fluid backtracking along a fibrin sheath may be
the cause. High-risk infusates include those with high
or low pH, high osmolality, vasopressors and
chemotherapy agents.
Secure fixation is important to minimise withdrawal,
which may be identified by the loss of a
venous waveform from the proximal lumen of the
catheter. Correct placement of the catheter tip will
help prevent venous erosion and ensure an adequate
length of catheter within the vein.
Leakage of infusate at the insertion site suggests
extravasation; this may be painful and cause tissue
damage. There may be a lack of clinical effect of infusions.
Chest X-ray may reveal a migrated catheter, or a
pleural effusion. Management of extravasation depends
on the nature of the infusate; protocols for extravasation
should be followed. Plastic surgical referral may
be needed if tissue injury occurs.
Nerve injury
This is uncommon [42]. Peripheral or cranial nerves
may be injured. The internal jugular vein is near the
brachial plexus and the vagus. The subclavian vein is
near the brachial plexus. In the upper arm, the
median nerve is adjacent to brachial veins and the
medial cutaneous nerves of forearms next to the
Table 4 Principles of infection prevention for vascular
access.
For peripheral venous access:
Thorough hand washing
Non-sterile gloves
• Skin disinfection with 2% chlorhexidine in 70% alcohol
For peripheral arterial access. As above but this will
generally require sterile gloves to allow procedural palpation
of the artery, and direct handling of needle,
guidewire and catheter.
For central vascular access devices:
Aseptic hand washing
Sterile gown, gloves, hat, facemask
• Surface disinfection with 2% chlorhexidine in 70% alcohol
(or povidone iodine in those sensitive to chlorhexidine),
with air-drying
Large sterile barrier drapes
• preference for upper extremity catheters
Once sited: appropriate anchorage and dressings; aseptic
access techniques; daily site review; and removal at the earliest
opportunity.
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 9

Anaesthesia 2016
Bodenham et al. | Safe vascular access guidelines
basilic vein. Ultrasound needle guidance should
reduce such risks.
Infection control
The recent Michigan-Keystone project in 103 ICUs in
the US reported major reductions in central venous
catheter (CVC) bloodstream infections from 7.7 to 1.4
per 1000 CVC-patient days [49]. In the UK, the similar
‘Matching Michigan’ project resulted in a reduction
from 3.7 to 1.5 infections per 1000 CVC-patient days
over 20 months [50]. Recent guidelines provide comprehensive
evidence-based recommendations to minimise
such infections. Detailed recommendations on
catheter selection, insertion site, anchorage and dressings,
replacement, removal, management and personal
protection can be found elsewhere [51, 52]. In the
absence of actual or suspected infection, there is no
evidence to support the routine changing of central
venous catheters. Key messages are summarised in
Table 4. Anaesthetists should compare their insertion
techniques and use of devices with these standards.
Training and experience
Descriptions of the competency levels required for
CVC insertion during training and assessment methods
are listed in the current Anaesthesia and ICM
Curricula (annex F, ICM in anaesthesia) (www.rcoa.ac.uk).
Competencies for ultrasound guidance have been
produced [53].
Current training includes: simulation based teaching
(part-task trainers); apprenticeship models; and
courses (local/national, basic/advanced).
The Working Party recommends:
• Phantom or manikin simulation techniques should
be routinely available to improve novice technique.
•
There should be regular training updates for skill
retention, especially for procedures seldom performed
(e.g. IO).
Consent and medicolegal aspects
Consent should follow local and national guidelines
[54]. Written consent is usual for a standalone procedure
or if particular risks are evident. The proposed
side and route of access should be explained, as well as
the potential need to move to other sites. In practice,
much will be verbal as part of a wider discussion of
provision of anaesthesia or critical care. While any
adverse event may lead to a complaint or litigation,
certain serious complications are evident in closed
claim analyses highlighted in the complications section
[38–40]. Early recognition of the problem, referral to
surgery or interventional radiology for help, and correct
management of complications is essential for a
safe outcome.
Use of in situ long-term devices
Many patients already have such devices in situ, e.g.
Hickman tunnelled cuffed type, Groschong valvedtype,
dialysis catheters, peripherally inserted central
catheters, and ports. With appropriate infection control,
such devices can be used for resuscitation, anaesthesia
or critical care. The risks/benefits of inserting
additional CVCs should be assessed. Staff should learn
about such devices and stock port access needles
(Huber type).
Blood should be aspirated and discarded if concentrated
heparin solution locks are in place. Fibrin
sleeves may cause obstruction or an extravasation risk.
Valved catheters preclude CVC pressure monitoring.
Some devices are CT power-injection compatible (e.g.
325 psi rating).
Ultrasound guidance
This has been well covered in the literature. Recent
consensus is that where the technology is affordable
(e.g. in the UK), it should be used routinely for internal
jugular CVCs (unless in emergency or other unusual
situations), and early in other procedures (arterial
and peripheral venous), if difficult [36]. Ultrasound
makes many steps safer including: evaluation of puncture
site; recognition of local pathology; avoidance of
the use of seeker needles, needle guidance; verification
of guidewire/catheters in a vessel; information on central
tip position and recognition of complications.
Two recent Cochrane analyses [55, 56] concluded
a benefit for using ultrasound for CVCs by the internal
jugular vein, but not femoral or axillary/subclavian
routes. The Working Party believe the latter is likely to
relate to a lack of adequate studies, rather than an
inherent failure of ultrasound at other sites, and recommends
that ultrasound guidance should be used for
10 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland

Bodenham et al. | Safe vascular access guidelines Anaesthesia 2016
all routes of access where the vessel cannot be seen
directly or palpated.
Operators need to be adequately trained and
experienced, and use a high-resolution device. It takes
considerable time and practice to become fully competent
in such techniques, and national guidance on
training has not quantified this [53].
Technology is moving quickly developing fast with
smaller, cheaper, simpler to use, higher resolution
machines. The efficacy and cost-effectiveness of echogenic
needles, electromagnetic sensors, needle guides
and other aids is at present unknown and should be a
focus for future studies.
In the UK, given the wide availability of ultrasound,
the Working Party believe it is not practical for
staff to continue to be trained to become fully competent
in all CVC landmark techniques. The only situations
where ultrasound cannot be consistently used are
extensive air emphysema and unavailability of a device
in emergencies. An understanding of landmark techniques
is useful for rare occasions when ultrasound is
not available or not able to be used. Landmark techniques
will still be used in countries where ultrasound
is not available.
Service provision for vascular access
The Working Party suggests that all acute hospitals
should provide the following for all age groups: local
algorithms/guidance for recognition and management
of complications; systems to improve procedures,
training, documentation and equipment.
Anaesthetists may have a prominent role, but
multiple disciplines are involved, depending on the
organisation and treatments provided. Services can be
nominally divided into acute and elective care as
below.
Acute care
Hospitals should organise and provide the following:
1 Timely (24/7) reliable insertion of peripheral
venous cannulae in all acute locations. This should
not necessarily be the sole responsibility of resident
medical staff.
2 Immediate insertion of peripheral IV or
intra-osseous access is required in emergencies.
3 Timely (24/7) insertion of peripheral arterial cannula
in specialised locations (high-dependency
unit, ICU, theatres).
4 Timely (24/7) insertion of short-term CVCs in
specialised locations (high-dependency unit, ICU,
theatres).
Elective care
5 Hospitals must organise and provide the following:
Timely (within 1–3 days) insertion (and
removal) of long-term CVCs in specialised locations
(wards, theatres, radiology) via a dedicated
service. This has been highlighted in the
context of total parenteral nutrition administration
[4].
All acute hospitals will have requirements for
long-term or repeated short-term central venous
access, both in the NHS and independent sector. There
are varied models dependent on local workload,
including: theatre or radiology suite-based, either ad
hoc in an acute setting or on separate standalone lists;
ward-based models, e.g. nurse-led peripherally inserted
central catheter service.
Facilities needed include: procedure room; highresolution
ultrasound; ECG guidance; fluoroscopy;
radiographer; admitting, discharge and recovery areas.
The cost-effectiveness of different models has not been
studied in depth. Savings are possible by rationalising
services, avoiding treatment delays, failed procedures,
and facilitating hospital discharge and outpatient therapy.
Audit
The vascular access organisations, and individual practitioners,
should initiate regular audit processes to
assess compliance with the standards identified in this
guidance. Specialist Societies and Colleges should consider
national audit to set benchmarks (e.g. the NAP
process).
Acknowledgements
AB has received payments from Vygon and Lake medical
for consultancy work. BF has received payments
from BBraun for lecturing. JB has received lecture fees
from Bard Access. AJ has received payments from
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 11

Anaesthesia 2016
Bodenham et al. | Safe vascular access guidelines
Bard and B Braun for consultancy work/speaker fees.
AK is the Editor-in-Chief of Anaesthesia, and this
manuscript has undergone additional external review
as a result.
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© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 13

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Anaesthesia 2016, 71, 1503
Correction
doi:10.1111/anae.13691
Following an item of correspondence, the authors of the guidelines [1] agree that the evidence for pH being an
important determinant for suitability for peripheral intravenous administration of fluids is equivocal and limited.
Therefore, the authors would like to correct the following advice given in the section on peripheral cannulation:
Peripheral insertion is inappropriate for infusion of fluid with high osmolality (> 500 mOsm.l
high pH (> 9) or intravenous access for more than 2 weeks.
1 ) or low (< 5) or
This should read:
Peripheral insertion is inappropriate for some fluids and drugs e.g. high osmolality > 500 mOsm.l
vasopressors or intravenous access for more than 2 weeks. Check local or national guidance.
1 , potent
Reference
1. Bodenham A, Babu S, Bennett J, et al. Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016. Anaesthesia
2016; 71: 573–85.
© 2016 The Association of Anaesthetists of Great Britain and Ireland 1503

AAGBI SAFETY GUIDELINE
Safe Management of
Anaesthetic Related Equipment
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org September 2009

Membership of the working party
Dr J A Carter
Dr L W Gemmell
Prof M Y K Wee
Dr C Meadows
Dr T Clutton-Brock
Dr C Waldmann
Dr D Scott
Dr P Bickford-Smith
Dr A Wilkes
Mr C Bray
Mr D McIvor
Mr H Cooke
Ex Officio
Dr R J S Birks
Dr D K Whitaker
Dr A W Harrop-Griffiths
Dr I H Wilson
Dr I G Johnston
Dr E P O’Sullivan
Dr D G Bogod
Chair
AAGBI Honorary Secretary
AAGBI Council Member
Immediate Past GAT Chair
Royal College of Anaesthetists
Intensive Care Society
AAGBI Standards Committee
AAGBI Standards Committee
Medical Device Evaluation Centre
Medicines and Heathcare products
Regulatory Agency
Medicines and Heathcare products
Regulatory Agency
Barema, Trade Association for
Anaesthetic & Respiratory Equipment
President
Immediate Past President
Immediate Past Honorary Secretary
Honorary Treasurer
Honorary Treasurer Elect
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia

Contents
1. Summary 2
2. Introduction 3
3. Responsibility of anaesthetists and Trust or other
healthcare providing organisation 4
4. Standards 8
5. Responsibility of manufacturers and suppliers 10
6. Choosing and trialling equipment 12
7. Public sector procurement regulations and directives
and the process of purchasing 15
8. Commissioning new equipment 19
9. Shared equipment 20
10. Maintenance 21
11. Replacement 24
12. Disposal 25
13. User training 27
14. Incident reporting and investigation 30
15. Audit 33
Glossary of acronyms 33
References 35
Useful numbers and websites 37
To be reviewed by 2015
© Copyright of the Association of Anaesthetists of Great Britain & Ireland. No
part of this book may be reproduced without the written permission of the
AAGBI
1

1. Summary
1.1 Safety, quality and performance considerations must be
included in all equipment acquisition decisions.
1.2 Each directorate should nominate one consultant with
responsibility for equipment management. This Nominated
Consultant should be a member of a Medical Devices
Management Group, which reports directly to the Trust
Board, and he or she should liaise closely with the
Technical Servicing Manager.
1.3 An inventory of all equipment, including donated
equipment, must be held by the technical department for
maintenance and replacement purposes.
1.4 A planned preventative maintenance programme must be
in place.
1.5 There should be a policy to cope with equipment
breakdown.
1.6 A replacement programme which defines equipment life
and correct disposal procedures should be in place.
1.7 Purchase of new equipment should include wide
consultation (especially involving users), and technical
advice to ensure practicality, cost effectiveness and
suitability for purpose.
1.8 There must be a commissioning or acceptance procedure
before any new equipment is put into use.
1.9 All users must be trained in the use of all equipment that
they may use.
1.10 All adverse incidents arising from the use of equipment
must be reported.
2

2. Introduction
The Association of Anaesthetists of Great Britain and Ireland has
long been committed to improving patient safety. The majority
of critical incidents in anaesthesia arise from human error and,
although about 20% of incidents are due to equipment failure,
many incidents that are initially thought to be equipment failure
turn out to be user error or inappropriate use, both of which
indicate a lack of training in the correct use of equipment.
The Association has produced a number of guidelines with
the intention of improving patient safety by reducing human
error and detecting potential equipment failure. These include
Checking Anaesthetic Equipment 3 (2004) and Standards of
Monitoring during Anaesthesia and Recovery Edition 4 (2007)
[1,2]. The Department of Health, through the MHRA, regularly
produces Medical Device Alerts concerning problems with
equipment, and it is essential that all anaesthetists are aware of
relevant publications.
This document gives guidance on choosing, purchasing,
maintaining, replacing and disposing of equipment. It also
emphasises the need to ensure that anaesthetists are trained in
the use of their equipment and that technicians are trained to
maintain the equipment. The MHRA publications, Managing
Medical Devices DB 2006(05) and Devices in Practice – a guide
for health and social care professionals (2008), are written from
a technical point of view and should be used as an adjunct to
the information in this booklet [3,4].
In addition, the MHRA, or their local or national counterpart,
is usually willing and able to give detailed advice on the safe
management of equipment, and their contact details are given
in the appendix.
Throughout this document, the term ‘Trust’ refers to NHS Trusts,
Health Boards, and any other hospital where anaesthetics are
given.
3

3. Responsibility of anaesthetists
and Trust or other healthcare
providing organisation
3.1 The individual anaesthetist
All anaesthetists must be adequately trained in the use of, and
familiar with, all equipment which they use routinely. This
training should be recorded, and individual anaesthetists should
keep their own record of training for appraisal purposes. They
should also be aware of Medical Device Alerts relevant to such
equipment. They should all participate in selection of new
equipment, training in the use of equipment, and reporting
equipment associated incidents.
3.2 The directorate – the nominated consultant or
equipment officer/controller
Anaesthetic directorates should nominate one consultant with
responsibility for equipment (the ‘equipment officer’). The
equipment officer will develop specific expertise with respect to
equipment and be responsible for a co-ordinated approach to its
management (including maintenance and training), replacement
and purchase. He or she may wish to enlist the support of other
colleagues or suitable operating department personnel to assist
with the duties as well as consulting regularly with all members
of the anaesthetic directorate. Identification of the departmental
equipment officer is the responsibility of the clinical director
who should ensure that the individual is identified to the various
heads of the technical department.
Large Trusts will need more than one consultant to fulfil this
role, and an ‘equipment or technical team’, answerable to the
Directorate Management Team, may be required.
4

3.3 Duties of the equipment officer
The equipment officer will represent the directorate on the
Medical Devices Management Group and liaise closely with the
head of the technical department. Their responsibilities include:
• Co-ordinating user input into the choice and procurement
of equipment and ensuring its suitability for the purposes
intended.
• Ensuring that training is available for staff in the use and
care of the equipment and ensuring that appropriate training
records are maintained.
• Acceptance of equipment into service.
• Ensuring that procedures for the use of equipment are
followed.
• Verification of service arrangements and effectiveness.
• Supervision of user servicing tasks.
• Ensuring there are documented contingency arrangements
for patient care in the event of equipment failure.
• Maintaining appropriate records.
• Ensuring that the Trust’s policy applies to all equipment
brought into the Trust irrespective of the source of funding,
e.g. university purchased equipment, loaned and donated
equipment.
• Ensuring that all adverse incidents involving medical
devices are reported in accordance with the instructions
contained in the first Medical Device Alert of each year
(titled ‘All Medical Devices’) issued by the MHRA
and that all MHRA and NPSA safety guidance is distributed
appropriately.
Adequate sessional time to fulfil these duties should be made
available by the Trust.
5

3.4 The Trust - Medical Devices Management Group and
Manager of Technical Servicing
Trusts should establish a Medical Devices Management Group
to develop and implement policies across their organisations.
This group should report directly to the Trust Board, where a
named director should have overall responsibility for medical
equipment.
The responsibility for the technical management of each item of
equipment must be assigned to one department (the ‘technical
department’). Most hospitals have a Manager of Technical
Servicing in post although their title and the department to
which they belong may vary, e.g. department of electronic
and biomedical engineering, department of medical physics or
estates department.
3.5 Inventory of equipment
Technical departments must maintain an ‘inventory of
equipment’ which should include the following information:
• Unique identifier of equipment – item labelled where
possible (if not possible, e.g. endoscope, serial number
recorded).
• Date of purchase and when it was put into service.
• Any specific legal requirements needed and whether they
have been complied with.
• Where it is located, and record of satisfactory
commissioning/installation.
• Recommended service schedule documentation.
• Service arrangements – in-house, supplier, or external
contractor details and service level agreement.
• Service reports.
• Records of incident investigations and product complaints.
• Manual or ‘Instructions For Use’ (IFU) readily available, and
record of where kept.
• End-of-life date.
6

In addition to items for which the technical department has
continuing responsibility, the inventory should also include
items such as laryngoscopes and non-clinical items such as
computers and printers. Although these may not need regular
maintenance they should be included in the replacement
programme.
Every item of equipment, including consumables, must be
identified by a unique number or batch number, and its location
must be recorded. This is particularly important in the case
of equipment recall due to a subsequent fault. All equipment
records should be held on one central record keeping system
where possible, e.g. software database managed by medical
engineering department. If this is not possible, adequate cross
referencing between record systems must be in place. This
is particularly important where equipment may be moved
between sites.
7

4. Standards
4.1 Medical Devices Directive and CE marking
The Medical Devices Directive of the European Union prohibits
the sale of medical devices within the EU that are not CE
(Conformité Européene) marked. A CE mark indicates that
devices meet all essential requirements of the Medical Devices
Directive and are safe and fit for their intended purpose.
However, the CE mark does not indicate clinical efficacy in
all circumstances, therefore user assessment is vital for any
purchase.
4.2 Standards
To ensure suitability for a given task, most devices are
manufactured to one or more verified standards. Standards are
produced by CEN, the Comité Européen de Normalisation,
or European Committee for Standardization, for mechanical
devices, and CENELEC for electrical devices. Many devices
used by anaesthetists use electricity to get mechanical results,
and have to meet standards of both organisations. ISO, the
International Organization for Standardization, and IEC the
International Electrotechnical Commission, produce standards
for the international market. The British Standards Institution
is a national member of the European Organization, and its
standards have gradually been integrated with their European
equivalents.
4.3 CE marking and non-medical equipment
CE marks for medical devices are awarded in four categories
of differing stringency. However, devices intended for nonmedical
use may also bear a CE mark that is indistinguishable
from those on medical devices, but they may not be suitable for
use as medical devices. An example is computer equipment,
including display units and recording devices, which may have
electrical leakage currents which far exceed the safe levels
for use near patients with external pacemakers or central lines
8

that can conduct electricity directly to the heart. A formal risk
assessment by an appropriate expert should be performed,
followed by suitable modification, before such equipment is
used close to patients.
4.4 Non-EU equipment
Equipment purchased outside the European Union may not
carry CE marks. For advice concerning such equipment, see
Medical Devices Regulations 2002 [5]. Use of non-CE marked
medical devices may leave the clinician, and their employer,
open to liability that would otherwise be assumed by the
manufacturer.
4.5 Permissible devices supplied without CE marking
There are three exceptions permissible for a device to be
supplied without a CE mark:
• Custom Made – this is a single device designed and
manufactured specifically for a specific patient as prescribed
by a healthcare professional.
• Device undergoing clinical investigations – the device must
be labelled as such and have the necessary approval
(see CA. ISO 14155).
• Exceptional use on humane grounds.
For both Custom Made and Clinical Trial devices the manufacturer
must adhere to all other requirements for compliance.
9

5. Responsibility of manufacturers
and suppliers
5.1 The Consumer Protection Act, Liability for Defective
Products Act, and the Medical Devices Regulations
The Consumer Protection Act 1988 (CPA) in Britain, the Liability
for Defective Products Act 1991 (LDPA) in Ireland, and the
Medical Devices Regulations in Great Britain and Ireland which
implement the EC Medical Devices Directives into law, embody
the current legislation which describes the manufacturer’s
responsibility with regard to equipment.
5.2 General responsibilities
The CPA, LDPA and Medical Devices Regulations place
absolute responsibility for the safety of products on the manufacturer.
In the event of a defect causing injury, the manufacturer
can be sued by any injured party, i.e. the patient or the
purchaser. This is provided that the device has been used for its
intended purpose, and in accordance with the manufacturer’s
instructions. Negligence need not be proved and it is not
possible for the seller to escape liability by exclusion clauses
in the contract of sale. The manufacturer’s responsibility, as
described in the CPA and LDPA, ends ten years after delivery of
the equipment.
After ten years, the purchaser, but not the patient, could still sue
the manufacturer under the Sale of Goods Act in Britain or the
Sale of Goods and Supply of Services Act in Ireland but it would
probably be difficult to convince the court that the equipment
was still ‘as supplied’.
5.3 Compliance with the regulations and the competent
authority
To place a device on the market a medical device manufacturer
must be in compliance with the applicable European
10

Regulations, including those transposed in each of the member
states, e.g. language requirements. With full compliance a
manufacturer is then able, where applicable, to affix a CE mark
demonstrating compliance with the essential requirements of the
Directive. The Medical Devices Directive and the application of
the CE mark was a legal requirement for all manufacturers with
effect from 14th June 1998, following a 5-year transition period.
Within the United Kingdom and Northern Ireland responsibility
for the enactment and compliance with the Medical Devices
Directives has been assigned to the Medicines and Healthcare
products Regulatory Agency {(MHRA) (Competent Authority
– CA)}, working in conjunction with the respective devolved
administrations of Northern Ireland, Scotland and Wales. The
CA for Ireland is the Irish Medicines Board, Medical Devices
Department.
11

6. Choosing and trialling equipment
6.1 General principles
Choosing anaesthetic equipment should address the
requirements of safety, quality, performance and affordability
(value for money). The selection process should take into
account local and national acquisition policies. The choice of
equipment should incorporate plans for standardisation and
rationalisation to meet existing and future needs. The Medical
Devices Management Group should ensure that acquisition
requirement takes into account the needs and preferences of
all interested parties including the user, the commissioning,
decontamination, maintenance and de-commissioning parties.
6.2 Criteria for choosing
There are many different categories of equipment used in
anaesthesia, ranging from low cost items purchased in large
volumes to high cost items purchased in small numbers.
Purchasers are encouraged to establish a list of available
manufacturers and suppliers. The choice can then be made on
evidence supplied on the following criteria:
• Fitness for intended purpose/application, including ease of
use.
• Safety, quality and performance information from the
manufacturer.
• Rationalising the range of models versus diversity.
• Requirement and availability of training and support
services.
• Single use where appropriate.
• Maintenance, repair support services and availability of
technical support.
• Decontamination and disposal procedures, including
recycling, compatible with local processes.
• Previous performance, reliability and warranty details.
• Lifetime costs.
12

6.3 Assessing equipment and the final choice
Equipment under consideration can be assessed by various
means. A literature review can be carried out to provide the
best evidence. Organisations such as the Centre for Evidencebased
Purchasing (CEP, which was part of the NHS Purchasing
and Supply Agency) and Emergency Care Research Institute (a
US-based organisation) publish reports on various categories
of equipment. For up-to-date information, purchasers should
contact and visit other users, trade exhibitors and sometimes
factories. In particular, previous performance by the
manufacturer in terms of delivery, stock held, training provided
and response to problems are rarely published, but details could
be obtained from users in other Trusts.
The Medical Devices Management Group, including the
anaesthetic equipment officer, should then carefully consider
the options from the information available. Once a choice is
made, a trial should be carried out on the selected equipment
by users. As many users as possible should be encouraged
to participate and to feedback to the equipment officer on an
agreed form. Such forms are often a compulsory part of the
purchasing procedure.
The outcomes from trials of some equipment can be assessed
against the known outcomes from ‘gold standard’ equipment,
for example first time insertion success of laryngeal mask
airways. The manufacturer will usually provide a free loan
of equipment or samples if the products are disposable. It is
important to remember that NHS contract terms impose full
responsibility on the suppliers for equipment on loan. All staff
using loan equipment must be trained by the supplier or an
authorised agent. It is the Trust’s responsibility to ensure that
loan equipment is decontaminated before return to prevent
cross-infection.
To avoid unnecessary duplication of trials, the anaesthetic
13

equipment officer is encouraged to collect all feedback from
the trial and publish the outcome in an appropriate format, for
example at a local or national meeting. The equipment officer
will then recommend the choice of equipment to purchase.
An editorial in Anaesthesia in June 2008 recommended
establishing a Device Evaluation Centre with a panel of experts
to critically appraise available evidence and publish the results
on a website [6]. Individual groups of anaesthetists would be
encouraged to undertake studies with support from the Device
Evaluation Centre in terms of pro formas for ethical approval
and protocols, and statistical help and advice. This would avoid
duplication of trials by individual Trusts and researchers, and
enable rapid removal of inferior products.
6.4 ‘One size suits all’
Having a variety of models for the same purpose can
increase the risk of operator confusion, leading to misuse and
complicating training requirements. In particular, having both
single-use and re-usable equipment intended for the same
purpose could result in re-usable equipment being discarded
and vice versa, resulting in increased costs or potential harm to
the patient and exposing the Trust to risk. Restricting purchase
and stockholding to one type of device reduces these risks and
may reduce maintenance costs. On the other hand, restriction
to one product will increase vulnerability to product faults,
and remove a degree of clinical freedom from individual
practitioners.
6.5 Leasing or purchasing
Consideration should be given whether equipment should be
purchased outright, leased or rented. For example, it may be
more cost effective to rent an expensive item for occasional use
when required.
14

7. Public sector procurement
regulations and directives and the
process of purchasing
7.1 Standing orders and standing financial instructions
(SFIs)
The process of procurement of goods and services in the NHS
is governed by SFIs. There is a financial value for an order or
contract above which a competitive process should be used;
often this is in the region of £15,000 to £30,000.
7.2 Procurement directives
All public sector procurement is subject to the principles of the
Treaty of Rome (transparency and fairness) and the significant
majority (including all medical equipment) is also subject to
the EU Procurement Directives. The Directives were updated
in 2006 to account for the use of eEnablement technologies
in public sector procurement and enable greater flexibility for
complex procurements.
The relevant Directive for medical equipment is the
Procurement Directive 2004/18/EC, 31 March 2004 for Public
Contracts for which the UK Regulation that enforces the
Directive is Public Contracts Regulations SI 2006 No 5 [7,8].
7.3 EU procurement thresholds
The EU Procurement Directives apply to all orders and contracts
for any given organisation (or groups of organisations when
collaborative procurement is undertaken). Splitting lots to avoid
the thresholds contravenes the Directives. A notice of intent
(indicative notice) of known future expenditure should be
placed.
15

EU procurement thresholds
Thresholds applicable from 1 January 2008 are given
below. Thresholds are net of VAT. Public contracts
regulations 2006 - from 1 January 2008
Other public
sector
contracting
authorities
Indicative
notices
SUPPLIES SERVICES WORKS
£139,893
(€206,000)
£509,317
(€750,000)
£139,893
(€206,000)
£509,317
(€750,000)
£3,497,313
(€5,150,000)
£3,497,313
(€5,150,000)
(NB. The Euro values are the reference quantities. The
conversion rate to pounds was based on a exchange rate of 0.68
which may vary).
7.4 Process of purchasing
Most Trusts will use the following process for the purchase
of medical equipment unless it is part of a more complex
procurement. The basic steps involved in this process are:
• Indicative notice (if relevant)
• Advert in the Official Journal of the European Union (OJEU)
• Suppliers express an interest
• Suppliers provide prequalification information (should be
via the NHS supplier information database, SID)
• Short listing and suppliers notified
• Issue of tender
• Presentations by suppliers, visits to suppliers
• Return of completed tender by suppliers
• Evaluation of tenders
• Award notified
• Standstill period (see 7.6)
• Award of contract
16

More guidance on the application can be found on the Office of
Government Commerce and NHS PaSA websites [9,10].
7.5 Purchasing and Supply Agency (PaSA) and ‘Buying
Solutions’
By 2010 the function of PaSA will be taken over by ‘Buying
Solutions’ – the national procurement partner for UK public
services. It is planned that a series of regional support units,
owned by the NHS, will provide a single point of contact for
suppliers in each region.
7.6 Mandatory standstill period
The 2006 UK Regulations also brought into force a
mandatory 10-day standstill period between the notification
of award decision and the date of contract conclusion for all
procurements that are subject to the full scope of the EU public
procurement directives. This is not part of the EU Directives but
follows the Alcatel court case [11].
7.7 Pre-purchase questionnaires
Medical equipment will often be subject to the completion
of a pre-purchase questionnaire (PPQ) by the supplier for the
Trust’s EBME Department. The PPQ is usually completed by the
supplier before or with the order.
7.8 Funding
Major items of equipment (e.g. workstations, monitors) are
funded by the Trust Capital Equipment Committee or similar.
Consumables and items below a threshold figure (usually about
£5000) come out of the directorate or theatre budget.
There should be a planned process of replacement for major
equipment, such as anaesthetic workstations and monitors, so
that each year a proportion of these are replaced in order to
spread the cost. It should be presumed that such equipment
will last about eight years, and the whole life cost taken into
consideration.
17

When negotiating a purchasing agreement for major equipment,
a training package should be included and consideration given
to awarding a servicing agreement. It is often advantageous
to bundle extras into the initial deal rather than pay for
expensive software upgrades at a later date. It is advisable to
compare the complete purchasing agreement from more than
one manufacturer, and in return for notifying the intention to
purchase future equipment from the same company it may
be possible to fix the price for a few years (plus inflation).
This allows the company to plan ahead and the hospital to
standardise equipment.
Advances in technology inevitably give rise to new equipment,
and justification of need through a business case may have to
be submitted to the Trust for approval. In some cases additional
funding has been made available from central sources for
‘essential’ new equipment, such as NICE funding for ultrasound
guided CVC placement. Charitable sources of funding also exist,
e.g. League of Friends, but such organisations prefer not to fund
items which should be bought by the Trust. A personal approach
to such organisations with details of how patient care will be
enhanced is recommended.
18

8. Commissioning new equipment
The MHRA Device Bulletin ‘DB2006(05) Managing Medical
Devices. Guidance for healthcare and social services
organisations’ gives comprehensive advice on commissioning
new equipment [3]. Key major points are summarised below:
• It is important that deliveries of new equipment are
recorded, and go to the right place.
• New anaesthetic equipment, which may not all come at the
same time, has to be unpacked, assembled, recorded on
an inventory, have identifying labels attached, and safety
checks performed. Medical engineering departments will
usually perform these tasks, although sometimes it is the
responsibility of the manufacturer or supplier.
• It should also be noted that Portable Appliance Testing
(PAT) applies to all equipment used in hospitals including,
for example, the coffee machine in the anaesthetic dept.
• Co-ordination between several departments may be
necessary, especially if permanent installation work or
additional services are required.
• Before equipment is used for the first time, full functional
checks must be performed, and staff trained in its use.
• If the equipment uses specialised consumable items,
arrangements to purchase them should be set up well before
the initial stock runs out.
• Loan equipment has to go through a similar process, and
should be subject to a written agreement defining responsibilities
and liabilities.
19

9. Shared equipment
Many types of equipment used by anaesthetists are also used
by other specialties in a variety of locations throughout a
hospital or unit. There are many safety, efficiency and cost
advantages in standardisation. In terms of the patient journey,
for example from admission through accident and emergency,
to radiology, operating theatre, intensive care unit and ward,
the process is considerably simpler and safer if the devices the
patient is attached to all use the same connections to monitoring
devices and infusion systems. It aids staff training and mobility if
similar devices are in use in most areas of a hospital, important
examples being defibrillators and infusion pumps. This may
be facilitated if the equipment officer and the Medical Devices
Management Group liaise closely with the departments using
similar equipment, e.g. intensive care, accident and emergency,
radiology, cardiology and respiratory medicine.
Although departments may wish to compile their own inventory
of equipment for which they have managerial and financial
responsibility, it is a requirement that a database of all such
equipment is maintained by the technical department.
Areas of uncertainty over ownership of equipment should
be clarified. Examples include infusion pumps, patient
controlled analgesia equipment, and blood warmers. It may
be appropriate for some high value items to be shared, and for
commonly used equipment like infusion pumps to be located in
a central store.
The financial implications of asset sharing should be clarified.
Each directorate may have to contribute to the costs of
depreciation, servicing, maintenance and replacement.
Responsibilities for organising and monitoring servicing and
maintenance schedules and for planning replacement must be
defined.
20

10. Maintenance
10.1 Planned preventative maintenance programme
Anaesthetic equipment which is not serviced regularly is liable
to break down with potentially life-threatening consequences.
A planned preventative maintenance programme is essential.
A maintenance log for each device must be kept, linked to the
technical department inventory. A record of all breakdowns
should also be kept. Regular review of each class of item
should reveal the incidence of breakdowns, which could
indicate the need for modification of equipment, frequency
of maintenance or its urgent replacement, or even a need for
further user training.
10.2 Choice of provider
All suppliers must support their equipment, and this includes
maintenance. At the time of purchase, the ‘life time’ cost should
be determined, including the frequency and cost of regular
servicing proposed by the supplier. It is recommended that the
cost of maintenance contracts should be inclusive of emergency
call outs and travel time for engineers, as well as fixed interval
servicing and parts. Cheaper alternatives usually exclude
the cost of emergency call outs and travel time and may be
appropriate for hospitals with sufficient back-up equipment.
Trusts may prefer ‘in-house’ maintenance, as this could have
logistic and cost advantages. The support to be provided by
manufacturers must be defined when equipment is purchased
and should include the provision of service manuals, on-going
technical training and spare parts. If upgrading or modification
of equipment is required at a later date, there are likely to be
additional costs even if the work is to be done in-house. An
annual maintenance budget of at least 10% of the equipment’s
purchase cost is necessary.
Software upgrades must only be undertaken by the supplier.
21

Third party servicing is another option which may be of
particular value for the maintenance of equipment which
requires specialist knowledge and testing, e.g. vaporisers.
Care should be taken to make sure only original equipment
manufacturers (OEM) spare parts are used.
Whichever of these options are chosen, it is essential that they
are fully integrated into the planned maintenance programme.
10.3 Equipment breakdown
The equipment officer should ensure that a complete set of
back-up equipment is available. If it is not, removal of faulty
equipment from service may result in the cancellation of
operating lists with consequent distress to patients and possible
implications for the fulfilment of contracts. The equipment
officer should agree a departmental policy covering the unusual
event that two identical items break down at the same time,
and should support colleagues who invoke this policy. The
policy should be written so that the patient’s best interests are
protected whatever the prevailing circumstances.
In the interests of patient safety, it is essential for all theatres to
keep available manual resuscitation equipment for emergency
use (see Checking Anaesthetic Equipment 3, 2004) [1]. All
theatre staff should be trained in the procedures to be followed
for instances of equipment failure.
10.4 Training in maintenance
Suppliers and their agents are externally audited in all their
procedures, and these include the provision of maintenance.
These standards for quality management systems aid effective
control through the definition and documentation of activities,
the keeping of records to prove that these activities are being
effectively executed and the audit of records by both internal
and external personnel.
22

For ‘in-house’ departments, quality manuals which document
operating policies and procedures need to be verified. These
will cover not only existing activities such as purchasing, repair
and pre-planned maintenance but also other activities such as
document control, corrective action and quality records.
If ‘in-house’ maintenance is chosen, enough time and money
must be allocated for training of technicians to a level
equivalent to that of the supplier so that they are able to provide
a high-quality, safe service. Regular on-going training provided
by the supplier should be the norm.
10.5 Spares
Suppliers have a responsibility to provide spares for seven years
after delivery of the last example of a particular model.
The responsibility for obsolete devices more than seven years
old is that of the Trust, and the need for insurance should be
assessed and acted upon.
10.6 Modifications
If a modification is undertaken on a CE marked device, other
than by the manufacturer, then responsibility for the safety and
liability for the modification changes to the organisation that
has completed the modification. One particular example is if a
device labelled as single-use is reprocessed for further use.
23

11. Replacement
11.1 Planned equipment replacement programme
Equipment must be condemned and replaced before it becomes
unreliable and endangers the patient, and it is recommended a
planned equipment replacement programme, which is phased
over a number of years, is prepared and continuously updated.
This should be planned in conjunction with Trust management
and the finance department. The choice of new equipment
can then be made after appropriate trials, and should take into
account department needs, such as plans for standardisation
and rationalisation (see section 6).
11.2 Timing of equipment replacement
Nationally recognised guidelines on the timing of equipment
replacement do not exist. Therefore it is recommended that
equipment be replaced when it has reached the end of an
agreed time-period, and in consultation with finance officers.
This time period will depend on the type of equipment that
needs replacing.
Replacement of electronic equipment should be considered at
five years and mechanical equipment at eight years. Financial
forecasting should take into account the agreed equipment life
cycle and budgets should be adjusted accordingly to ensure
replacement funding is available, thus avoiding delays and
potential associated patient risks. When delays are inevitable,
clinicians should seek, in writing, an ‘extension of use’ beyond
the agreed time-periods with the relevant medical and financial
officers.
In the past, many items of anaesthetic equipment were
mechanical. Today, most devices contain a high electronic
content, including software. This is placing an increasing burden
on equipment replacement budgets, owing to the increased
pace of obsolescence of electronic equipment.
24

12. Disposal
12.1 General
Unreliable, damaged or worn out equipment should be
removed from service and destroyed. Obsolete but functional
equipment has potential resale value but carries with it liabilities
under the CPA and LDPA. There are companies who can
manage such transactions. The DoH has issued guidelines on
the resale of medical equipment in MHRA DB2006(05) [3].
Alternatively, equipment can be donated to a charity. The donor
has a moral responsibility to ensure that the recipients are given
all relevant information about the equipment.
Full service history, usage, fault log, replacement parts and
decontamination status should be available when equipment is
offered for sale or donation.
Disposed equipment must be removed from the capital asset
register.
12.2 European WEEE Directive
The European WEEE Directive enforces the recovery and
recycling of certain types of electrical and electronic equipment
(EEE) when it is disposed of. The Directive places a requirement
on producers and/or final users to recover and recycle the
equipment in line with specific rules. Producers of electrical and
electronic items are required to register with the Environment
Agency, through organisations referred to as ‘compliance
schemes’, and are required to provide information relating to
material content and recycling [12].
12.3 Re-use of equipment
Equipment that may be used on more than one patient should
be decontaminated or sterilised according to manufacturer’s
instructions and the AAGBI guidelines (see Infection Control
in Anaesthesia 2, 2008) [13]. Some equipment has a limited
25

number of re-uses (e.g. re-usable LMAs) and a record card or
similar device must be used to maintain an accurate record of
the number of re-uses. Any equipment bearing the mark of a
figure 2 with a line crossed through it is for single use only and
must not be re-used.
26

13. User training
13.1 General
Anaesthetists must be trained in the use of all the equipment
that they may use. Training requirements clearly vary widely
between different devices, some requiring little or no additional
training apart from common sense, others being unusable
without complex and specific training. There is little or no
national framework for the standardisation of training in use of
devices in anaesthesia or indeed in any other clinical field, with
the result that currently it is the responsibility of the individual
clinician to ensure that he or she has received the appropriate
training and that it is kept up-to-date. A record of training
received by department members should be kept, and it should
form part of the annual appraisal process.
In more than half of the adverse incidents reported to the
Medicines and Healthcare products Regulatory Agency (MHRA)
there is no readily identifiable equipment fault. Although often
difficult to define precisely, it seems more than reasonable
to assume that many of these have resulted from user related
issues. In some cases it is clear that the user has been the sole
cause of the adverse incident which would not have occurred if
the device had been correctly used.
13.2 Manufacturers’ obligations
Manufacturers of medical devices have a legal obligation to
supply Instructions For Use (IFU) which cover not only how
to use the device but also a description of the intended use of
the device. Using the device outside of the IFU removes much
of the manufacturer’s responsibility and transfers it to the user.
Manufacturers should be encouraged to produce IFUs which
are easy to read and understand; there may be a significant
advantage in producing a summary of the important points or
key instructions. Where practical, these should be available on
the equipment, or held in close proximity.
27

Where new equipment is purchased the amount of training
offered and taken up is very variable. For example, with
complex devices, such as the new generation of anaesthetic
machine workstations, it is usual for manufacturers to supply a
significant amount of user training.
13.3 CCT and CPD
Training in anaesthesia, as described in the CCT documents
published by the Royal College of Anaesthetists, includes
numerous references to anaesthetic related equipment, and both
Primary and Final FRCA examinations cover the basic principles
and more advanced use of a range of medical devices.
Information about new devices and updates on existing ones is
frequently included in Continuing Professional Development
(CPD) programmes, and clinicians should use this as a way of
keeping up-to-date.
13.4 E-learning, simulation and revalidation
E-learning material is now becoming available, in particular
(from the MHRA) on the general principles in using medical
devices safely, e.g. electrosurgery and the anaesthetic machine.
These programmes underline the importance of maintaining
a good understanding of the basic principles behind device
function. For complex devices such as anaesthesia workstations
complementary device-specific educational material is required.
To maintain the necessary independence of bodies with national
regulatory roles means that this type of material will, most
probably, be developed by partnerships between manufacturers,
the Association of Anaesthetists and the Royal College of
Anaesthetists.
There is a coexistent need to develop effective training in the
use of equipment in unanticipated and emergency situations,
particularly in the recognition and management of equipment
failure. These situations fortunately occur infrequently, and
28

anaesthetic simulators already play an important role in
appropriate training.
Users of complex equipment outside of the healthcare setting
(for example in the aviation industry) are subject to much more
clearly defined appropriate training in safety. All responsible
clinicians will use the opportunities provided by CPD to keep
their equipment based skills up-to-date but there are concerns
that the less motivated can still function on a daily basis without
adequate checks on acquisition or retention of skills.
Revalidation of all clinical staff will help to ensure that all
practitioners have up-to-date equipment based skills and have
received appropriate training. Effective training material, with
meaningful assessments, need to be developed. Such material is
already available in some clinical disciplines through e-learning.
29

14. Incident reporting and
investigation
As a profession which emphasises life-long learning, we must
promote an open culture in which all staff will discuss and
report incidents where errors or service failures have occurred.
This encourages the profession to learn from mistakes and
identify any continuing risks.
Each NHS Trust should have risk management systems in place
involving the reporting, analysis, control and prevention of
incidents [14]. It is the responsibility of each anaesthetist to be
aware of the incident reporting procedures of their organisation.
This procedure may include risk managers, medical device
liaison officers and anaesthetic equipment officers.
In addition to the Trust’s local incident reporting system, there
are several organisations, listed below, that may need to be
made aware of adverse incidents associated with anaesthesia.
14.1 Medicines and Healthcare products Regulatory
Agency (MHRA)
The MHRA investigate reports of adverse incidents involving
medical devices or their instructions for use that have led to,
or could lead to, death, life-threatening illness or injury. The
manufacturers of medical devices must report such incidents to
the Competent Authority (the Vigilance System) and investigate
them as part of their post market surveillance responsibilities,
as required by the MDD. Therefore, manufacturers must be
informed of such incidents. However, medical devices (with
any packaging and labelling) which have been involved in an
incident have also to be kept and isolated until MHRA has been
given the opportunity to carry out an investigation.
Where the MHRA investigation concludes there are safety
30

implications for patients or users the Agency will issue a
Medical Device Alert (MDA). MHRA also publish Device
Bulletins and One-Liners to give safety information and
guidance on general safety issues.
There are separate user reporting systems for medical device
incidents which occur within the devolved administrations of
Northern Ireland, Scotland and Wales (see useful numbers and
websites section on page 37).
14.2 National Patient Safety Agency (NPSA)
The NPSA has implemented an anonymised National Reporting
and Learning System across England and Wales. This system
allows reporting of all failures, mistakes, errors and near misses,
with the aim of ensuring that lessons are both learned and
shared throughout the health service. They undertake various
safety initiatives, publish updates on the reports received, and
provide guidance in the form of bulletins and newsletters. The
anonymous reporting allowed under the NPSA system prevents
a full investigation, therefore the NPSA actively encourages
reporting of all medical device incidents directly to the MHRA.
There is an NPSA initiative underway with the Royal College of
Anaesthetists and the AAGBI to institute a specific anaesthetic
reporting system.
14.3 Health and Safety Executive
Incidents involving work-related deaths, major injuries or
injuries resulting in over three days off work, work-related
diseases, and dangerous occurrences (near-miss accidents)
whether involving medical devices or not, should also
be reported under the Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 1995 (RIDDOR ‘95) to
the relevant enforcing authority for the premises at which the
incident occurred. For healthcare premises, this will usually be
the local office of the Health and Safety Executive (HSE) but
for some it may be the local authority. Further information is
31

available from www.hse.gov.uk
14.4 DoH Estates and Facilities
Incidents involving non-medical equipment, including
engineering plant, parts of the fabric of the building and gas
pipelines should be reported to the Head of Engineering at the
DoH Estates and Facilities in the Department of Health. Further
information is available from www.nhsestates.gov.uk
14.5 Police
The police will investigate where there is the suspicion of
criminal activity, such as malicious tampering with medical
equipment. There is a concordat between the police, HSE and
DoH for the investigation of such incidents; therefore should
the police decide no further action is required the investigation
will pass to the HSE and DoH. Due to the rare and unusual
nature of these investigations there are no established national
guidelines; however advice should be available from your
hospital’s legal department, medical defence organisations,
MHRA and the Association of Anaesthetists.
14.6 Dissemination of safety information to users
Safety information from the MHRA and NPSA is distributed via
the DoH Central Alerting System (CAS) [15]. All internal and
external communications concerning equipment and patient
safety must be cascaded to all the users of equipment through
Trust communication channels.
14.7 Manufacturers
The manufacturer has a legal obligation under the provision
of the European MDD to monitor performance of their devices
in a post production phase, i.e. after placed into clinical
use. Typically this is achieved by a proactive post market
surveillance programme, of which incident reporting may be a
part.
32

15. Audit
15.1 Internal
This is part of the Trust’s clinical governance arrangements and
should consist of regular/annual review of policies and systems
for managing medical equipment.
Healthcare professionals must ensure their own training and
skills remain up-to-date, and this should form part of the annual
staff appraisal.
15.2 External
The Care Quality Commission undertakes audits and inspections
of healthcare organisations regularly to ensure that the MHRA
guidance on safe use of medical devices has been followed.
Strategic Health Authorities audit the performance of Trusts,
including performance against deadlines for action required by
the issue of DoH Safety Alert Broadcast System notices.
Glossary of acronyms
BSI
British Standards Institution
CA
Competent Authority (e.g. in the UK, the MHRA)
CCT Certificate of Completion of Training
CE
Conformité Européene
CEN Comité Européen de Normalisation (For
Mechanical Devices)
CENELEC Comité Européen de Normalisation (For
Electrical Devices)
CEP Centre for Evidence-based Purchasing (part of
PaSA)
CPA Consumer Protection Act 1988
CPD Continuing Professional Development
CVC Central Venous Catheter
33

DB
DoH
EBME
EC
EU
FRCA
HN
HSE
IEC
IFU
ISO
LDPA
LMA
MDA
MDD
MHRA
NICE
OEM
OJEU
PaSA
PAT
PPQ
RIDDOR
SFI
SID
WEEE
Device Bulletin
Department of Health
ElectroBioMedicalEngineering (Hospital
Equipment Technicians)
European Community
European Union
Fellowship of the Royal College of Anaesthetists
Hazard Notice
Health and Safety Executive
International Electrotechnical Commission
Instructions For Use
International Organization for Standardization
Liability for Defective Products Act
Laryngeal Mask Airway
Medical Device Alert
Medical Device Directive
Medicines and Healthcare products Regulatory
Agency
National Institute for Health and Clinical
Excellence
Original Equipment Manufacturer
Official Journal of the European Union
(NHS) Purchasing and Supply Agency
Portable Appliance Testing
Pre-Purchasing Questionnaire
Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations 1995
Standing Orders and Standing Financial
Instructions
Suppliers Information Database
Waste Electrical and Electronic Equipment
34

References
1. Association of Anaesthetists of Great Britain & Ireland.
Checking Anaesthetic Equipment 3, 2004. http://www.
aagbi.org/publications/guidelines/docs/checking04.pdf
2. Association of Anaesthetists of Great Britain & Ireland.
Standards of Monitoring during Anaesthesia and Recovery
4, 2007. http://www.aagbi.org/publications/guidelines/docs/
standardsofmonitoring07.pdf
3. Medicines and Healthcare products Regulatory Agency.
Device Bulletin, Managing Medical Devices DB2006(05)
http://www.mhra.gov.uk/Publications/Safetyguidance/
DeviceBulletins/CON2025142 [accessed 03.08.09]
4. Medicine and Healthcare products Regulatory Agency.
Devices in Practice - a guide for health and social care
professionals, 2008. http://www.mhra.gov.uk/Publications/
Safetyguidance/Otherdevicesafetyguidance/CON007423
[accessed 03.08.09]
5. Office of Public Sector Information. Statutory Instrument
2002 No. 618, The Medical Devices Regulations. http://
www.opsi.gov.uk/SI/si2002/20020618.htm [accessed
03.08.09]
6. Wilkes AR, Hodzovic I, Latto IP. Introducing new
anaesthetic equipment into clinical practice. Anaesthesia
2008; 63: 571-5.
7. Europa Publications Office. Procurement Directive
2004/18/EC, 31 March 2004 for Public Contracts,Official
Journal of the European Union, http://eur-lex.europa.eu/
LexUriServ/site/en/oj/2004/l_134/
l_13420040430en01140240.pdf [accessed 03.08.09]
35

8. OPSI. Statutory Instrument 2006 No 5 Public Contracts
Regulations http://www.opsi.gov.uk/si/si2006/
uksi_20060005_en.pdf [accessed 03.08.09]
9. Office of Government Commerce. European Procurement
Directives, http://www.ogc.gov.uk/procurement_policy_
and_application_of_eu_rules_european_procurement_
directives.asp [accessed 03.08.09]
10. NHS Purchasing and Supply Agency. EU Tenders, http://
www.pasa.nhs.uk/PASAWeb/Guidance/EUtenders.htm
[accessed 03.08.09]
11. Home Office. Procurement Competitions and the Alcatel
Judgement, http://www.homeoffice.gov.uk/about-us/
freedom-of-information/released-information/foi-archiveabout-us/4115-procurement-alcatel?view=Html
[accessed
03.08.09]
12. Department of Health. Sustainable Development - Waste,
http://www.dh.gov.uk/en/Managingyourorganisation/
Estatesandfacilitiesmanagement/Sustainabledevelopment/
DH_4119635 [accessed 03.08.09]
13. Association of Anaesthetists of Great Britain & Ireland.
Infection Control in Anaesthesia 2, 2008. http://www.
aagbi.org/publications/guidelines/docs/infection_control_08.
pdf [accessed 03.08.09]
14. Department of Health. Standards for Better Health, 2004.
http://www.dh.gov.uk/en/publicationsandstatistics/
publications/publicationspolicyandguidance/
dh_4086665 [accessed 03.08.09]
15. Department of Health. Central Alerting System, https://
www.cas.dh.gov.uk/Home.aspx [accessed 03.08.09]
36

Useful numbers and websites
For reporting adverse incidents and further information
MHRA
Tel: 020 7084 3080
Website: www.mhra.gov.uk
Email: aic@mhra.gsi.gov.uk
NPSA
Tel: 020 7927 9500
Website: www.npsa.nhs.uk
Email: enquiries@npsa.nhs.uk
RIDDOR
Tel: 0845 300 9923
Website: www.riddor.gov.uk
Email: riddor@natbrit.com
DoH Estates
Tel: 0113 254 5172
Website: www.nhsestates.gov.uk
Email: nhs.estates@dh.gsi.gov.uk
Northern Ireland
Tel: 028 9052 3704
Website: www.dhsspsni.gov.uk/niaic
Email: niaic@dhsspsni.gov.uk
Scotland
Tel: 0131 275 7575
Website: www.hfs.scot.nhs.uk
Email: enquiries@hfs.scot.nhs.uk
Wales
Tel: 029 2082 3505
Email: health.enquiries@wales.gsi.gov.uk
37

Eire
Tel: 00353 1 676 4971
Website: www.imb.ie
Email: imb@imb.ie
Buying Solutions
Tel: 0345 410 2222
Website: www.buyingsolutions.gov.uk
Email: info@buyingsolutions.gsi.gov.uk
38

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

AAGBI SAFETY GUIDELINE
Skin antisepsis for central
neuraxial blockade
Published by
The Association of Anaesthetists of Great Britain & Ireland
September 2014

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain & Ireland. Safety guideline:
skin antisepsis for central neuraxial blockade. Anaesthesia (ePub ahead of
print, 3 Sep 2014): doi: 10.1111/anae.12844
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/enhanced/doi/10.1111/anae.12844/
© The Association of Anaesthetists of Great Britain & Ireland

Guidelines
Safety guideline: skin antisepsis for central
neuraxial blockade
Association of Anaesthetists of Great Britain and
Ireland
Obstetric Anaesthetists’ Association
Regional Anaesthesia UK
Association of Paediatric Anaesthetists of Great
Britain and Ireland
Membership of the Working Party: J. P. Campbell, F. Plaat,
M. R. Checketts, D. Bogod, 1 S. Tighe, 2
A. Moriarty 3 and R. Koerner
1 Obstetric Anaesthetists’ Association, 2 Regional Anaesthesia UK,
3 Association of Paediatric Anaesthetists of Great Britain and Ireland
Summary
Concise guidelines are presented that recommend the method of choice
for skin antisepsis before central neuraxial blockade. The Working Party
specifically considered the concentration of antiseptic agent to use and
its method of application. The advice presented is based on previously
published guidelines, laboratory and clinical studies, case reports, and
on the known properties of antiseptic agents.
....................................................................................................
© 2014 The Association of Anaesthetists of Great Britain and Ireland 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.

All AAGBI guidelines are reviewed to ensure relevance/accuracy and are
updated or archived when necessary. Date of review: 2019.
Accepted: 4 August 2014
• What other guideline statements are available on this topic?
The Royal College of Anaesthetists [1], the American Society of
Anesthesiologists [2] and the American Society of Regional Anesthesia
[3] have all published guidance on prevention of infectious complications
associated with neuraxial techniques.
•
Why was this guideline developed?
Although the current published guidelines comprehensively cover
aseptic technique when performing central neuraxial blockade
(CNB), they are lengthy and discursive documents that are impractical
for use in the acute care setting. The remit of this Working Party
was to produce a concise document that specifically considered
which agent (including the concentration) to use for skin antisepsis
before CNB, and the method of application.
•
How does this statement differ from existing guidelines?
This statement specifically considers which agent to use for skin
antisepsis before CNB, and is more concise than currently available
guidelines. Unlike existing guidance, this statement includes a recommendation
on which concentration of antiseptic agent to use.
•
Why does this statement differ from existing guidelines?
This statement was written to provide useful and concise guidance
for anaesthetists in the clinical setting.
Recommendations
1 Optimum aseptic technique for CNB requires thorough handwashing
with surgical scrub solution and the use of barrier precautions
including the wearing of a cap, mask, sterile gown and gloves, and
the use of a large sterile drape.
2 Chlorhexidine in alcohol should be used for skin antisepsis before
performing CNB.
3 The anaesthetist must be meticulous in taking measures to prevent
chlorhexidine from reaching the cerebrospinal fluid (CSF):
a Chlorhexidine should be kept well away from the drugs and
equipment to be used for CNB and should not be poured into
containers on or near the same surface as the equipment for
2 © 2014 The Association of Anaesthetists of Great Britain and Ireland

CNB. Equipment should be covered or protected while the antiseptic
is applied by swab, applicator or spray.
b The solution must be allowed to dry before the skin is palpated
or punctured.
c The operator should check his/her gloves for contamination with
chlorhexidine. If there is any doubt, they should be changed
before continuing the procedure.
4 Given the lack of convincing evidence of the antimicrobial superiority
of a 2% solution of chlorhexidine in alcohol over a 0.5% solution,
but the presence of clear evidence of the neurotoxicity of
chlorhexidine, the Working Party has concluded that the use of a
0.5% solution should be preferred over a 2% solution for skin antisepsis
before CNB.
5 In children under two months of age, the volume of chlorhexidine
used should be the minimum necessary while still ensuring
antisepsis.
Introduction
The most appropriate and safe antiseptic solution to use on the skin
before CNB remains controversial. A survey of consultant obstetric anaesthetists
in 2009 revealed a wide range of practice across the UK in
terms of both the antiseptic used and its method of application [4].
The ideal antiseptic agent should be effective against a wide range
of micro-organisms, have immediate onset of action, exert a long-term
effect, not be inactivated by organic material (e.g. blood), and have minimal
toxic effects on the skin [3]. Commonly used antiseptic agents for
CNB include chlorhexidine gluconate and povidone iodine. Both of
these antiseptics are available as aqueous and alcoholic solutions.
Chlorhexidine vs povidone iodine
Chlorhexidine gluconate is a potent, broad-spectrum antiseptic that is
effective against nearly all bacteria and yeasts. It has a faster onset and
longer duration of action than povidone iodine, and it retains its efficacy
in the presence of blood. It also has a lower incidence of skin reactions
than povidone iodine [3].
Several investigators have compared the antiseptic efficacy of
chlorhexidine and povidone iodine under a variety of experimental conditions
[5–12]. In all but one investigation [7], chlorhexidine resulted in
a more rapid and superior bactericidal effect that lasted several hours
© 2014 The Association of Anaesthetists of Great Britain and Ireland 3

eyond its initial application. In one of these studies, Kinirons et al. [5]
compared colonisation of epidural catheters following skin preparation
using 0.5% chlorhexidine in alcohol with skin preparation using an
aqueous solution of 10% povidone iodine. Catheters inserted following
the use of chlorhexidine were six times less likely to be colonised than
when povidone iodine had been used.
Chlorhexidine: aqueous vs alcoholic
Sakuragi et al. [10] investigated the effect of chlorhexidine and povidone
iodine on the growth of Staphylococcus aureus (the pathogen most commonly
associated with epidural space infections) in vitro. They found
that both methicillin-resistant and -sensitive strains of the pathogen
grew colonies after exposure for 60 s to aqueous 10% povidone iodine
or aqueous 0.5% chlorhexidine. In contrast, no bacteria grew after 15 s
of exposure to 0.5% chlorhexidine in 80% alcohol.
Chlorhexidine: 0.5% vs 2%
The choice of concentration in the UK and Ireland is between 0.5%
chlorhexidine in 70% alcohol (e.g. Hydrex â solution, Ecolab Ltd, Leeds,
UK) and 2% chlorhexidine in 70% alcohol (e.g. ChloraPrep â ,
CareFusion UK Ltd, Reigate, UK).
Adams et al. [13] compared the efficacy of 2% chlorhexidine in
alcohol with several other antiseptics including 0.5% chlorhexidine in
alcohol against growth of a single strain of Staphylococcus epidermidis
in vitro. In three out of four tests, no difference in efficacy could be
demonstrated. In the fourth test (involving a biofilm with added
human serum), all the antiseptics failed the test of efficacy (log 10
reduction factor in colony-forming units per ml of > 5), although the
failure of 2% chlorhexidine in alcohol was less than for 0.5% chlorhexidine
in alcohol. The authors recommended in-vivo studies to assess
the clinical efficacy of 2% chlorhexidine in alcohol. Crowley et al.
found no difference in bacterial colony counts from skin and epidural
catheter tips after preparation with 0.5% and 2% chlorhexidine in alcohol
[14].
Pratt et al. [15] recommend that before insertion of a central venous
access device, the skin should be decontaminated using 2% chlorhexidine
in 70% alcohol. However, no such guidance exists for CNB, possibly
because of concerns about neurotoxicity associated with
chlorhexidine.
4 © 2014 The Association of Anaesthetists of Great Britain and Ireland

Chlorhexidine, alcohol and neurotoxicity
Recently, the issue of which antiseptic to use before CNB, and in
which concentration, has become contentious. This follows cases of
permanent neurological injury in obstetric patients in which chlorhexidine
was alleged to have been responsible. In one of these cases
[16], a whole syringe of 0.5% chlorhexidine in alcohol was mistakenly
injected into the epidural space; in another case it was suggested that
a syringe of bupivacaine injected spinally had become contaminated
with ‘a measurable quantity’ (defined as 0.1 ml or more) of 0.5%
chlorhexidine in alcohol [17]. All patients developed a chronic adhesive
arachnoiditis with a similar clinical course of progressive neurological
deterioration leading to paraplegia [16–19].
Limited information is available on the risk of neurotoxicity with
chlorhexidine. In 1955, Weston-Hurst reported that the neurotoxic
concentration of aqueous chlorhexidine when injected into the CSF
of monkeys appeared to be in the region of 0.05% [20]. In 1984,
Henschen and Olsen showed that injection of just 5 ll of 0.05%
aqueous chlorhexidine into the anterior chamber of the eye produced
adrenergic nerve degeneration in rats, and the authors postulated that
the thin unmyelinated nerves of the central nervous system might be
equally affected [21]. More recently, Doan et al. found that chlorhexidine
was neurotoxic at a concentration of 0.01% (the lowest concentration
tested) when applied directly to neurons [22]. However, in a
rat model using a radioactive tracer, the same authors estimated
mathematically that provided the antiseptic is allowed to dry fully,
the concentration of antiseptic that could be delivered to the neuaxis
would be extremely low [22].
It has been suggested that alcohol, which constitutes the main component
of chlorhexidine solutions, might be the causative neurotoxic
agent [23]. Alcohol-induced neurolysis is well established and is used
therapeutically in a number of procedures [24]. Accidental injection of a
syringe of alcohol (with or without chlorhexidine) into the epidural
space may therefore be expected to result in neurological injury,
although the effect of the tiny quantities that may contaminate a spinal
needle has been questioned [25].
In a recent editorial on skin antisepsis for CNB [26], the author
concluded that chlorhexidine in alcohol should still be used as the
potential for neurotoxicity was outweighed by the superiority in reducing
surgical site infection. Other bodies have drawn the same conclu-
© 2014 The Association of Anaesthetists of Great Britain and Ireland 5

sion: the Royal College of Anaesthetists (in its Third National Audit
Project (NAP3)) [1], the American Society of Anesthesiologists [2] and
the American Society of Regional Anesthesia [3] all recommend chlorhexidine
in alcohol as the skin disinfectant of choice for CNB. None of
these guidelines specifies the concentration of chlorhexidine to use,
although the authors of the NAP3 report have stated that in their
opinion, based on the limited evidence available, 0.5% chlorhexidine in
alcohol is the optimal skin preparation for CNB [27].
The Working Party is aware that some anaesthetists choose to use
2% chlorhexidine in alcohol because they consider it reduces the risk of
infectious complications compared with the 0.5% solution. As neuraxial
infectious complications are rare, and cases of chronic adhesive arachnoiditis
even rarer, the Working Party acknowledges that there is a lack
of data to support the use of one concentration of chlorhexidine over
another for CNB. However, evidence for the greater efficacy of 2%
chlorhexidine compared with 0.5% is lacking, while the neurotoxicity of
chlorhexidine is well established in vitro and in animal models. It is
consequently the opinion of the Working Party that skin antisepsis for
CNB using 0.5% chlorhexidine in alcohol provides the safest compromise
between the risk of infection and the risk of neurotoxicity. The
Working Party acknowledges that meticulous attention to the method of
application of the antiseptic, and to other infection control precautions,
are likely to be more important factors in reducing the risks of neurotoxicity
and infection than the choice of concentration of chlorhexidine.
Method of application
As it is possible that cases of arachnoiditis have been caused by accidental
contamination with antiseptic of needles, syringes and catheters used
for CNB, a method of skin application that minimises the risk of contamination
of equipment should be used.
Traditionally, antiseptic solutions were poured into a gallipot on the
anaesthetist’s sterile field. However, if there is another open container
for a fluid intended for neuraxial injection (e.g. saline), the potential for
a crossover error is created (the aetiology in one of the reported cases of
arachnoiditis [15]). Moreover, Evans et al. [28] have shown that pouring
chlorhexidine into a gallipot generates splash that spreads at least
40 cm. The authors recommended that antiseptic solutions should not
be poured into containers located on the same tray as equipment for
CNB, and that the equipment should be covered until the back has been
prepared with antiseptic.
6 © 2014 The Association of Anaesthetists of Great Britain and Ireland

Pre-soaked antiseptic sponge applicators (‘swabsticks’) are now
commonly used for skin preparation before central venipuncture and
other procedures. The applicators are manufactured with a reservoir
containing 3 ml or 10.5 ml of antiseptic, and the solution may be dyed
to allow identification of the area of prepared skin. Because the antiseptic
solution is contained within the hollow of the handle, crossover
errors are impossible and fluid spillage should be minimised. However,
it has been observed that leakage of antiseptic solution over the operator’s
gloves may occur via a hole at the end of the handle when the
device is held upside down (the hole below the level of the antiseptic
reservoir) to clean a patient’s back [19]. Currently, the ‘swabstick’ applicators
available in the UK and Ireland contain a 2% solution of chlorhexidine
in alcohol. The manufacturer has advised that a 0.5% version is
unlikely to come onto the market in the near future (CareFusion, personal
communication). The Working Party is aware that some anaesthetists
prefer to use these devices for skin preparation for CNB, and
would encourage the development of applicators containing 0.5%
chlorhexidine in alcohol.
Skin antisepsis before CNB using 0.5% chlorhexidine in 70% alcohol
(Hydrex) from a multi-use spray bottle is widely practised in the UK.
Advocates of this technique argue that contamination is minimised: the
fluid is kept in a closed container and it can be applied at a distance
from the sterile field, before or during preparation of the equipment for
CNB. However, others have suggested that spraying might result in aerosol
contamination of equipment with chlorhexidine and may compromise
sterility by missing an area of skin [29]. Malhotra et al. [30]
showed that a single spray application of 0.5% chlorhexidine in alcohol
sterilised the skin over the lumbar spine in healthy volunteers. The
authors concluded that repeated application was unnecessary, and might
increase the risk of contamination of the CSF if the antiseptic was not
allowed to dry completely. Robins et al. [31] compared application of
chlorhexidine using a spray with application from a sachet in parturients
undergoing combined spinal-epidural anaesthesia. Both techniques
were effective in reducing skin colonisation, but the time to achieve skin
preparation was significantly shorter in the spray group.
Use of chlorhexidine in children
Chlorhexidine has been used for vaginal lavage, whole body cleansing
and umbilical cord care in large, well-designed clinical trials on tens of
thousands of neonates without significant adverse events [32, 33].
© 2014 The Association of Anaesthetists of Great Britain and Ireland 7

Despite chlorhexidine’s proven efficacy, there are concerns about the
risk of skin reactions and percutaneous absorption into the bloodstream,
particularly in preterm and low birth weight infants. Transient
contact dermatitis has been reported in preterm, very low birth weight
infants after long-term placement of chlorhexidine-impregnated dressings
for central venous catheters [34]. However, it has been suggested
that the effect may have been caused by external pressure from the
dressing rather than the chlorhexidine itself [35]. Alcohol-based
chlorhexidine preparations have been reported to cause burns in
infants of 24–26 weeks’ gestational age [36, 37]. There are few data
addressing the potential for chlorhexidine absorption following topical
application. Cowan et al. [38] took blood samples from 24 infants
after whole body bathing with 4% aqueous chlorhexidine and found
that five had detectable chlorhexidine levels. All were < 36 weeks’ gestational
age and the authors suggested that their immature skin was
likely to have increased the permeability of the epidermis. The clinical
significance of traces of chlorhexidine in the blood is unknown. There
are no established values for a safe concentration of chlorhexidine in
the blood, and there are no reports of adverse consequences as a result
of absorption of chlorhexidine in neonates [39]. Because of the limited
safety data in neonates, the Society for Healthcare Epidemiology of
America states that ‘chlorhexidine products are not approved by the
US Food and Drug Administration for children younger than
2 months of age’ [40]. Despite this recommendation, chlorhexidine is
commonly used in neonatal intensive care units in the USA, mostly
for skin preparation and maintenance for central venous access [41].
Allergic reactions to chlorhexidine
Several hypersensitivity reactions due to chlorhexidine have been
described. These include allergic contact dermatitis (commonly after prolonged
and repeated application) [42], contact urticaria [43], photosensitivity
[44], occupational asthma [45] and anaphylaxis [46–48]. Most of
the cases of anaphylaxis to chlorhexidine involved topical application to
mucous membranes [46] and the use of chlorhexidine-impregnated medical
devices (e.g. central venous catheters) [47], although anaphylactic
reactions have also followed application of chlorhexidine to intact skin
[48]. The severity of these cases prompted the Medicines and Healthcare
products Regulatory Agency (MHRA) to issue a Medical Device Alert in
2012 about the potential for anaphylactic reactions due to the use of
medicinal products and medical devices containing chlorhexidine [49].
8 © 2014 The Association of Anaesthetists of Great Britain and Ireland

Other infection control precautions for CNB
Application of antiseptic to the skin is only one component of aseptic
technique before CNB. Both the Association of Anaesthetists of Great
Britain and Ireland and the Obstetric Anaesthetists’ Association have
issued guidance on the other precautions that should be employed [50,
51]. These include thorough handwashing with surgical scrub solution,
the wearing of a cap, mask, sterile gown and gloves, and the use of a
large sterile drape [3]. The Working Party is aware that some anaesthetists
do not employ this level of asepsis for spinals or ‘one-shot’ epidurals,
but believes that full aseptic precautions are required whenever
CNBs are performed. The NAP3 report stated that aseptic technique
had been suboptimal in a number of the reported cases of epidural
abscess [1].
Skin antisepsis for peripheral nerve blocks
These guidelines address only CNBs. However, as the nerves targeted by
some peripheral nerve blocks lie a shorter distance beneath the skin
than the neuraxis, and the evidence of the neurotoxicity of chlorhexidine
is not restricted to the neuraxis, the Working Party considers it
reasonable to recommend that 0.5% chlorhexidine in alcohol be used
for peripheral nerve blocks as well.
Suggestions for further research
The duration of antiseptic action required for different types of CNB
may vary. A single intrathecal injection may only require antisepsis for
a few minutes, whereas insertion of an epidural catheter requires antisepsis
to be maintained throughout the time the catheter remains in
situ. Isopropyl alcohol causes a rapid reduction in the number of skin
micro-organisms, but does not have any residual activity. In comparison,
chlorhexidine exerts an antiseptic effect for up to 24 h [52]. Hibbard
et al. [53] compared the effect of 70% isopropyl alcohol with 2%
chlorhexidine in alcohol on abdominal sites. The authors found that
both maintained antimicrobial activity for at least 6 h, but the chlorhexidine
solution was more effective at 24 h. It may be that isopropyl alcohol
alone could provide adequate antisepsis for a single-injection CNB,
obviating the need for chlorhexidine and therefore avoiding exposure of
the neuraxis to a second neurotoxic substance. A CNB involving an
indwelling catheter, on the other hand, probably requires the more prolonged
action of a chlorhexidine solution. Research is needed comparing
© 2014 The Association of Anaesthetists of Great Britain and Ireland 9

the duration of antimicrobial activity of 0.5–2% chlorhexidine in alcohol
with 70% isopropyl alcohol when used for CNB.
Costerton has shown that S. epidermidis exists at depths of up to
five cell layers in the skin [54]. Dead skin cells are constantly being
shed, along with the colonising bacteria. These, together with sebum,
sweat and environmental material, form an oily layer covering the skin.
It is possible that a single application of antiseptic to the skin removes
bacteria from this oily layer covering the surface, but is ineffective at
removing bacteria at depth. It might be more effective first to apply an
antiseptic that will dissolve this oily surface layer and remove its bacteria.
This could then be wiped away before applying antiseptic again to
remove bacteria living within the epithelium. This ‘apply-wipe-apply’
technique requires both in vitro and in vivo investigation.
Several cases of severe neurological damage have been attributed to
contamination of equipment for CNB with chlorhexidine in alcohol,
caused by splashes, aerosols, or insertion through solution that has not
dried on the skin, or through chlorhexidine crystals that have dried on
the skin [17–19]. Further studies are needed to address the risk of 0.5%
over 2% chlorhexidine in 70% alcohol, and 70% alcohol alone, in causing
neurological damage from such sources of contamination.
Competing interests
FP and DB have provided expert opinions in cases of neurological damage
following neuraxial block, in which the possibility of antiseptic contamination
of injectate was considered. DB has received hospitality from
Care Fusion, manufacturers of Chloraprep, and consequently took no
part in any discussions relating to the use of this product. No external
funding or other competing interests declared.
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30. Malhotra S, Dharmadasa A, Yentis SM. One vs two applications of chlorhexidine/
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single use sachets for skin preparation before regional nerve blockade for elective
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newborn infants. Archives of Disease in Childhood 1979; 54: 379–83.
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39. Chapman AK, Aucott SW, Milstone AM. Safety of chlorhexidine gluconate used for
skin antisepsis in the preterm infant. Journal of Perinatology 2012; 32: 4–9.
40. Marschall J, Mermel LA, Classen D, et al. SHEA/IDSA practice recommendation:
strategies to prevent central line-associated bloodstream infections in acute care
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care unit: results from a national survey. Infection Control and Hospital Epidemiology
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42. Reynolds NJ, Harman RRM. Allergic contact dermatitis from chlorhexidine diacetate
in a skin swab. Contact Dermatitis 1990; 22: 103–28.
43. Wong WK, Goh CL, Chan KW. Contact urticaria from chlorhexidine. Contact Dermatitis
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Dermatologica 1971; 143: 376–9.
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chlorhexidine and alcohol aerosols. British Medical Journal 1989; 298: 929–30.
46. Wicki J, Deluze C, Cirafici L, Desmeules J. Anaphylactic shock induced by intraurethral
use of chlorhexidine. Allergy 1999; 54: 768–9.
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chlorhexidine impregnated central venous catheters: a case cluster or the tip of the
iceberg? British Journal of Anaesthesia 2009; 103: 614–5.
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of chlorhexidine. Clinical and Experimental Allergy 1996; 26: 112.
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chlorhexidine on intact skin following a single application. Pathologie Biologie
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53. Hibbard JS, Mulberry GK, Brady AR. A clinical study comparing the skin antisepsis
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54. Costerton JW. The Biofilm Primer, 1st edn. Berlin: Springer, 2007.
© 2014 The Association of Anaesthetists of Great Britain and Ireland 13

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Controlled Drugs in
Perioperative Care
2006
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org
January 2006

MEMBERSHIP OF THE WORKING PARTY
Professor Alastair Chambers Chairman. Honorary Secretary, AAGBI
Ms Chrissie Allan
Association for Perioperative Practice
Dr Richard Birks
Honorary Treasuer, AAGBI
Dr Beverly Collett
British Pain Society
Dr John Curran
Royal College of Anaesthetists
Mr Chris Edwards,
Home Office
Dr Ben Fitzwilliams Group of Anaesthetists in Training
Mr Bill Kilvington
Association of Operating Department Practitioners
Dr Peter Nightingale Royal College of Anaesthetists
Dr Anna-Maria Rollin Royal College of Anaesthetists
Dr Cathy Stannard
British Pain Society
Ex Officio
Professor M Harmer
Dr P G M Wallace
Dr D Whitaker
Dr D Dickson
Dr D Bogod
President
Immediate Past President
Immediate Past Honorary Secretary
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia
The working party gratefully acknowledges the assistance of the Royal College
of Nursing and the Royal Pharmaceutical Society of Great Britain who reviewed
and commented on the document
(c) Copyright of the Association of Anaesthetists of Great Britain and
Ireland. No part of this book may be reproduced without the written
permission of the Association of Anaesthetists.

Contents
Section 1. Introduction 3
Section 2. Medicines Act 1968 4
Section 3.
Issue of Controlled Drugs Within the Operating
Department and Key Holding 7
Section 4. Guidelines 8
Section 5. Multiple Dosing 11
Section 6. Solutions for Infusion 12
Section 7. Disposal of Controlled Drugs 14
Appendix 15
References 16
1

SUMMARY OF THE RECOMMENDATIONS
1. Local guidelines should be established to promote good, safe and
legal practice for handling controlled drugs. These must ensure
compliance with the Medicines Act, the Misuse of Drugs Act, the
Misuse of Drugs (Safe Custody) Regulations and the Misuse of
Drugs Regulations.
2. When patient controlled analgesia or other infusion devices are
being used, it is best practice to use pre-filled syringes rather than
make up a solution by diluting ampoules.
3. The Misuse of Drugs Regulations should be amended to take
account changes in the roles and titles of staff in modern clinical
practice. The terms ‘sister or acting sister’ which are widely referred
to are now archaic and should be changed. The Association
recommends that ODPs should be able to be responsible for
possessing and issuing controlled drugs and that senior ODPs could
also have the authority to order controlled drugs.
4. Although controlled drugs must be stored in a secure place this
must allow an appropriate level of access and availability for
immediate clinical use.
5. Unused controlled drugs must be disposed of in an approved
manner and this should be included in local guidelines.
6. The sharing of the contents of any ampoule between patients is poor
practice.
2

SECTION 1. INTRODUCTION
When the Association of Anaesthetists of Great Britain and Ireland
(AAGBI) published a document (1981) on controlled drugs, their use as
far as anaesthetists were concerned was essentially confined to the
anaesthetic rooms and operating theatres. In addition, the quantities of
drugs used were relatively modest.
The situation was different by the time these guidelines were revised in
1994 and developments in clinical practice have continued.
Nowadays patients may receive large doses of opioids as a major part
of their anaesthetic, there is a wide range of controlled drugs available
and the responsibility of anaesthetists in prescribing and administering
controlled drugs has extended not only into the recovery room and
Intensive Therapy Unit, but also to acute and chronic pain services in
all parts of the hospital and home care. An additional factor is the issue
of substance abuse. Because of these extended uses of controlled
drugs, particularly in relationship to acute pain services, a much wider
range of preparations is necessary to meet these requirements, e.g. the
development of Patient Controlled Analgesia (PCA).
This publication recommends what the Association considers best
practice for the safe preparation, distribution and disposal of controlled
drugs to meet current clinical demands in peri-operative care.
3

SECTION 2. MEDICINES ACT 1968
The Medicines Act 1968, together with its secondary legislation,
provides a regulatory scheme of licences, registrations and exemptions
which control all aspects of the production and distribution of all
medicinal products.
A Product Licence is issued when the Medicines and Healthcare
products Regulatory Agency (MHRA) is satisfied regarding a product’s
inherent safety, quality and efficacy for the indicated purpose.
A product licence specifies not only the nature of the drug, but also its
pharmaceutical form, strength and packaging. Thus, for example, an
ampoule of morphine sulphate 30mg may be a licensed product, but,
if used to make and supply a pre-filled syringe or PCA device, the
resulting product will be unlicensed.
As part of the application for a Product Licence, the manufacturer will
have to submit evidence regarding the stability of the product which
will then be assigned a shelf-life.
The Association of Anaesthetists of Great Britain and Ireland
recommends that wherever a pre-filled syringe or PCA device is
marketed as a licensed medicinal product, it should be used in
preference to an equivalent but unlicensed product.
A Manufacturer’s Licence is issued when the Licensing Authority is
satisfied that an applicant can manufacture medicinal products to
acceptable standards, so as to ensure the safety, quality and efficacy of
those products. A manufacturer’s licence enables the holder to produce
either a licensed medicinal product or an unlicensed special. A
manufacturer’s licence may be granted to commercial organisations
and to some NHS hospitals.
Specials are medicinal products in respect of which a Product Licence
is not in existence but which have been made by the holder of a
Manufacturer’s Licence to the order of a medical practitioner.
4

Section 9 of the Medicines Act allows a medical practitioner to prepare
or order a medicinal product for a particular patient. The practitioner
assumes responsibility for all aspects of the safety of such products
including compatibility of ingredients, their stability and sterility. The
patient, or patients, must be named.
A shelf-life of several weeks or months may be appropriate for some
Specials, but it is the responsibility of the manufacturer to ensure that
the shelf-life is supported by suitable stability data. Notice must always
be taken of expiry dates on all products.
Prepared Medicines are medicinal products in respect of which a
Product Licence is not in existence but which have been made under
the supervision of a pharmacist in a retail or hospital pharmacy, neither
of which is the holder of a Manufacturer’s Licence.
This activity is carried out under Section 10 of the Medicines Act which
allows a pharmacist to prepare medicines in accordance with a
prescription given by a medical practitioner or in anticipation of such
a prescription.
Thus, a medicinal product may by classified as:
• a licensed medicine
• a special medicine
• a prepared medicine
Many injectable medicines, although supplied as licensed products,
have to be reconstituted or diluted before administration to the patient
and thus become prepared medicines. When this dilution is carried out
by a registered prescriber, he or she is responsible for seeing that the
procedure is performed properly and accurately.
The working party has given particular consideration to filled syringes
and other devices which are either made up in advance or which
remain with the patient for long periods of time and move with the
patient from one clinical are a to another. A common example are the
medicines used for Patient Controlled Analgesia.
5

In order of preference, the supply of pre-filled syringes and devices
forming part of a PCA or similar system should be as follows:
(i)
A licensed medicinal product wherever such an item is available.
(ii) A ‘special’ produced in a licensed facility which may be a
commercial supplier or hospital pharmacy.
(iii) A prepared medicine made in a retail or hospital pharmacy, under
the direct supervision of a pharmacist.
(iv) Prepared by a trained member of staff near the patient according
to a local protocol.
6

SECTION 3. ISSUE OF CONTROLLED DRUGS
WITHIN THE OPERATING DEPARTMENT AND KEY
HOLDING
The Misuse of Drugs Regulations 2001 place the responsibility for the
possession, safe custody and issue of controlled drugs within hospital
wards and departments with the sister or acting sister in charge of that
ward or department.
Over the last few years, staffing practice in operating departments and
related areas has undergone considerable change; the titles “sister” and
“acting sister” are often no longer used. However, in purely legal terms,
responsibility for the safe custody and issue of controlled drugs rests
with the most senior registered nurse on duty in the department.
Some operating departments have several operating theatres, each of
which will have its own controlled drugs cabinet. The sister or acting
sister in charge of the operating department is responsible for supplies
from all the controlled drugs cabinets. To ensure controlled drugs are
readily available, the sister or acting sister in charge may delegate
control of access (key holding) to another registered nurse or a medical
practitioner (e.g. anaesthetist) or an operating department practitioner
(ODP). This access must be strictly controlled in practice and set out in
locally agreed written guidelines. A registered nurse or an ODP may
remove controlled drugs from a controlled drugs cabinet and return
them to the cabinet on the specific authority of either the sister or a
medical practitioner. However, the responsibility for all controlled
drugs remains with the senior registered nurse on duty, even if the
nurse decides to allow access by others.
As many operating departments are now staffed with ODPs and some
are managed by ODPs, the Association of Anaesthetists of Great Britain
and Ireland believes that the Misuse of Drugs Regulations 2001 should
be amended so that ODPs may also be specifically authorised and be
responsible for possessing and issuing controlled drugs. The
terminology of ‘sister or acting sister’ is now archaic and should
be amended.
7

SECTION 4. GUIDELINES
The development of local guidance is essential. Such guidelines should:-
• recognise and adhere to the relevant legal requirements
• promote good, safe practice
• take account of local staffing arrangements
• not restrict the use of opioids in a manner which would be
detrimental to patient care
• be understood and accepted by all staff
While individual hospitals should have their own local guidelines,
there are a number of points which need to be considered. The
Department of Health Report, Guidelines for the Safe and Secure
Handling of Medicines, (Duthie Report 1988) may be of assistance.
Responsibility
The system established for ordering and security should be that agreed
between the senior pharmacist, the operating department manager and
appropriate senior nursing staff. Current legislation states that
controlled drugs may be requisitioned only by the sister or acting sister
in charge of a department.
Responsibility of individuals within the operating department are those of:
(a) The sister or acting sister in charge for:
(i) ordering, receiving, checking, recording and storing stock;
(ii) recording the amount issued to medical staff;
(iii) returning unused ampoules to stock;
(iv) amending balances accordingly.
8

(b) Medical staff for:
(i) signing for the controlled drugs received in the operating
theatre controlled drugs register;
(ii) properly recording in the patient’s records the amount of
drugs administered;
(iii) returning any unopened ampoules;
(iv) safe disposal of any unused controlled drugs that remain in an
open ampoule or syringe.
(c) The pharmacist for:
(i) supply of controlled drugs to each stock location;
(ii) regular audit of local policies;
(iii) checking controlled drug stocks and registers at least once every
three months.
Issue of drugs from a register to anaesthetists or other prescribers
(a) When controlled drugs are issued, they must be checked by the
prescriber with the nurse (or other designated person) and the
controlled drugs register signed.
(b) The same responsibility and recording procedures apply for the
drawing up of controlled drugs for a PCA or other infusion regimen.
Ordering and Transfer of Drugs
(a) An agreed stock level and usage pattern should be decided between
medical staff and those responsible for ordering.
(b) If computer ordering systems are used, a printout signed by the
sister is required to provide the necessary requisition.
(c) Where ordering is carried out using computer technology, access to
passcodes/terminals should be restricted to designated persons.
9

(d) Controlled drugs coming into the operating department should,
ideally, be received at one central point and distributed from there
to individual operating theatres, or be issued directly to the
controlled drug stock in a specific theatre. There is no legal
requirements for registers to be held at individual theatre level, but
good practice and Department of Health guidance dictates that the
theatre suite register should include a record of all drugs issued for
administration to patients in the individual theatres.
Unused Controlled Drugs
There should be a local protocol describing the procedure for the
disposal of individual doses of controlled drugs which are prepared but
not administered. The Department of Health is expected to issue
guidance on the disposal of controlled drugs shortly.
SECURITY
Controlled drugs must be stored in a secure place. The Misuse of Drugs
(SafeCustody) Regulations 1973 define in great detail the type of
cabinet or safe required and the type of steel, locks and hinges of
which it should be made.
Neither the Misuse of Drugs Act 1971 nor the Safe Custody Regulations
1973 state that controlled drugs must be stored in a double-locked
cabinet, with or without a red light. However, it is worth noting that a
locked refrigerator is a complying receptacle.
Numerous amendments have added substances to, and subtracted
others from, the comprehensive list of those that need or need not be
stored in the controlled drugs cabinet. These relate to Schedule 2
drugs, i.e. the opioids and other potent analgesic agents. They are listed
in the Appendix A. The pharmacist would be able to advise, should
there be any doubts, as to whether a particular drug is subject to the
Safe Custody Regulations.
10

SECTION 5. MULTIPLE DOSING
Containers whose contents are designed to be used for more than one
patient are labelled in such a way as to indicate that they are intended
for multiple use. The contents of any other type of ampoule, whatever
the size, should not be shared between patients.
Financial pressures and a simple wish not to be wasteful of resources
often led anaesthetists to share the contents of one ampoule amongst
multiple syringes. The possibility of mistakes in administration, cross
infection and the admittedly theoretical risk of theft from an open
ampoule are not over-ridden by the small cost benefit of using one
large ampoule rather than several smaller ones. This should not be
construed as including the preparation in pharmacy of individual
prepared syringes.
11

SECTION 6. SOLUTIONS FOR INFUSION
Opioid containing solutions are increasingly being used for parenteral
PCA and epidural analgesia techniques. They commonly contain a
solution of a single controlled drug in diluted format, or a mixture in
combination with a local anaesthetic or other drug.
Preparation
As described in Section II of this document, the Association of
Anaesthetists of Great Britain and Ireland recommends that, wherever
possible, the best practice is that such pharmaceutical preparations
should be purchased from a manufacturer, or prepared under sterile
conditions in a hospital pharmacy. This practice is preferable to
preparing the solution on an individual basis in the operating
department or ward, for the following reasons:-
(a) sterility is guaranteed, which is especially important as the solution
may be administered over several days.
(b) the solution will be clearly labelled, showing the constituent drug(s),
concentration(s), diluent, date of manufacture and expiry date.
Hospitals without a licensed manufacturing facility may prefer to obtain
ready prepared PCA and epidural solutions from a Manufacturers’
Licence holder. This may be another local hospital.
On rare occasions, it may be clinically advisable to administer an unusual
mixture or concentration of drugs. In such cases, it would prudent for the
reasons for this to be documented in the patient’s notes and for senior staff
to be aware of the situation.
Storage
Once prepared, it is recommended that PCA and epidural solutions of
controlled drugs should be supplied in individually sealed bags to
suitable locations such as operating theatres, recovery rooms and labour
wards and post operative wards. Prepared solutions must be accounted
12

for in the ward controlled drug register in the same manner as controlled
drugs.
Solutions must be stored in a complying locked cabinet in each location.
Bags of solution for epidural administration need to be clearly identifiable
and must be stored separately from those for intravenous infusion.
Serious harm to patients can result from the inadvertent parenteral
administration of solutions intended for epidural administration.
13

SECTION 7. DISPOSAL OF CONTROLLED DRUGS
A controlled drug ceases to be classified as such once it is denatured,
dissipated, is not re-usable or has been rendered irretrievable. All drugs,
once disposed of, should be unrecognisable as such. Syringes containing
residual unused controlled drugs should be emptied before being
discarded.
All unused, unopened or out of date products must be returned to the
issuing pharmacy for recording and disposal in accordance with the law.
Sites outside the operating department
It is common practice for infusions of controlled drugs to be set up in
the operating theatre or recovery area. These infusions may then
accompany the patient to the ward. Unused volumes of these infusions
should be disposed of on the ward, thus avoiding unnecessary
transport of controlled drugs (and consequent security implications)
around the hospital.
It is impractical to record the disposal of these volumes in the
controlled drugs register at their site of issue, which may be different
from the site of disposal. In the ward, disposal should be recorded and
a “disposals” page in the controlled drug register should record the site
of drug issue and the volume of drug discarded.
14

APPENDIX
The Misuse of Drugs Act provides the basis of control for certain drugs.
It contains three sets of regulations.
1. The Misuse of Drugs Regulations defines five schedules of drugs.
Schedule 1 contains drugs with no recognised medical use, which are
the most tightly controlled. These include hallucinogens, raw opium
and coca leaf.
Schedule 2 is the most important and covers pharmaceutical opioids
and amphetamines. It is the most relevant to this document and the
routine practice of anaesthesia.
Schedule 3 contains barbiturates and some slimming preparations.
Schedule 4 contains benzodiazepines.
Schedule 5 includes products containing low concentrations of drugs
which would be in Schedule 2 if in a stronger preparation.
There have been various amendments since 1985.
2. The Safe Custody Regulations, followed by several recent
amendments, refers to Schedules 2 and 3, but then actually exempts
many of the Schedule 3 drugs.
A list of the commonly used Schedule 2 drugs include:-
Alfentanil
Cocaine
Diamorphine
Fentanyl
Methadone
Morphine
Pethidine
Remifentanil
3. The Misuse of Drugs (Notifications of a Supply to addicts)
Regulations. Not relevant to this publication.
15

REFERENCES
Report of a Working Party on the use of Controlled Drugs in Operating
Theatres. Association of Anaesthetists of Great Britain and Ireland 1981
(revised 1994)
Medicines Act 1968.
Guidance to NHS Hospitals on the licensing requirements of the
Medicines Act. Published by the Medicines Control Agency now the
Medicines and Healthcare products Regulatory Agency (MHRA).
Misuse of Drugs Act 1971 and its secondary legislation:
The Misuse of Drugs Regulations 2001
The Misuse of Drugs (Safe Custody) Regulations 1973
The Misuse of Drugs (supply to addicts) Regulations 1997
The safe and secure handling of medicines: A team approach. A
revision of the 1988 Duthie report. The Royal Pharmaceutical Society
of Great Britain. 2005 (www.rpsgb.org)
16

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org
Designed and produced by the r2 Partnership Ltd

Practical advice from the GAT Committee
on surviving the first two years as an anaesthetic trainee
Editor: Dr E H Shewry
GAT Committee
AAGBI
October 2009
1

Welcome
to the first edition of the
Core Survival Guide
I hope this new GAT guide is a useful and
enjoyable read. Starting a new specialty
can be difficult, so I hope this booklet will
answer some of your questions and help
you through those first few weeks and
months. Postgraduate medical training
has changed continuously as this guide
has been developed; please let us know
if there are any top tips we’ve missed and
we’ll aim to add them to the next edition!
Finally, good luck in your new career and
enjoy it!
Liz Shewry
Editor
Vice Chair,
GAT Committee
Acknowledgements
The GAT Committee would like to thank
the Medical Protection Society for its
generous contribution towards the cost
of this publication.
We also wish to thank Dr Nevil Hutchinson
for his contribution in producing the original
SHO Survival Guide.
23

Contents
Foreword 4
1. Introduction 5
2. The Association of Anaesthetists of 6
Great Britain & Ireland and the Group
of Anaesthetists in Training
3. The Royal College of Anaesthetists 8
4. Preparing for the first day as an anaesthetist 8
5. Health and safety 12
6. Portfolio and logbook 12
7. Training in anaesthesia 15
8. Acute Care Common Stem training 24
9. The ARCP (Annual Review of
Competence Progression) 25
10. The Primary FRCA examination 25
11. Getting a ST3 post in anaesthetics 28
12. Anaesthetic training in Scotland 31
13. Anaesthetic training in Northern Ireland 32
14. Professionalism and accountability 33
15. Whom to ask for help? 34
16. Final checklist 36
17. Appendices:
(i) Abbreviations 36
(ii) Useful addresses 37
(iii) Essential reading 38
Disclaimer: The GAT Committee emphasises that this booklet is intended as an introduction to the specialty and
the advice provided must be interpreted as guidance. We acknowledge that the rapid changes in postgraduate
medical training means that although we have ensured that the guidance in this booklet is applicable and up to
date, it may soon need revision. Please use the links for the Royal College of Anaesthetists and the Association of
Anaesthetists of Great Britain & Ireland to augment the information provided in this booklet.
© Copyright of the Association of Anaesthetists of Great Britain & Ireland. No part of this book may be
reproduced without permission of the AAGBI.
23

Foreword
The GAT Committee has produced the
Core Survival Guide as a replacement
to the previous ‘SHO Survival Guide’
– a booklet that most of us found
invaluable during our initial training
years. Its aim is to help you through
those first two years of ‘Core Training’,
as you progress from standing around
feeling like a spare part to being able
to ‘fly solo’ and eventually pass the
Primary FRCA exam and obtain an
ST3 post. It contains many ‘top tips’
to make life just that little bit easier,
and also lists the many benefits of
membership of the AAGBI. This update
has evolved during the many changes
to the structure of medical training over
the last two years, but as always these
things have a tendency to move quickly
and change seems almost continuous.
We recommend that in addition to
utilising this guide you also visit our
web pages at www.aagbi.org/gat.htm.
Dr Felicity Howard
GAT Committee Chair
Hard copies of this booklet are being
distributed to anaesthetic departments
and it is available online at
www.aagbi.org/gat/publications.htm.
I would like to thank our Vice Chair,
Dr Liz Shewry, for all her hard work in
leading this project, the authors who
have contributed articles to this booklet,
the GAT Committee for their help with
the editing process and the staff at
Portland Place for all their help and
support.
45

Introduction
Anaesthetics has traditionally been a
specialty which junior doctors entered
after two to three years of postgraduate
training. The broad clinical base
developed in those pre-anaesthetic
years has always been a great fallback
to help meet the challenging demands
of the specialty. However, the ongoing
changes in postgraduate medical
training mean that the majority of junior
doctors are now entering anaesthetics
directly following the Foundation
Programme. This means that appropriate
support and guidance are even more
important to ensure the welfare
and success of future anaesthetic
consultants.
The Group of Anaesthetists in Training
(GAT) Committee is formed of elected
representatives from the anaesthetists
in training in the United Kingdom.
We have produced this booklet as an
introduction to the specialty, aimed at
the early training years, and hope you
may gain from some of our personal
experiences. This guide starts from day
one and leads to obtaining a ST3 post.
We hope it will provide some useful
pointers and be an interesting read at
the same time.
45

The Association of Anaesthetists of Great Britain & Ireland
and the Group of Anaesthetists in Training
The Association of Anaesthetists of
Great Britain & Ireland (AAGBI)
was established in 1932 ‘to promote
the development of anaesthesia; to
coordinate the activities of anaesthesia;
to represent anaesthetists and their
interests; and to encourage friendship
among anaesthetists’. It was responsible
for the development of the Faculty of
Anaesthetists of the Royal College of
Surgeons in 1948. This led ultimately to
the formation of the separate College of
Anaesthetists, which received its Royal
Charter in 1992.
Trainee anaesthetists were first
permitted to become associate
members of the AAGBI in 1956, but
they had no representation or voting
rights. The Group of Anaesthetists in
Training (GAT) was established as the
Associates in Training Group in 1967
and was the first single-specialty trainee
representative body in the country. In
1971 it became the Junior Anaesthetists
Group, before changing its name to
GAT in 1991. The membership of
GAT continues to grow year on year
and currently stands at over 3900,
accounting for approximately one-third
of the Association’s membership. GAT
is the only elected body that represents
trainees in anaesthetics at a national
level. All trainee members of the AAGBI
are automatically members of GAT,
and all members of GAT are given the
opportunity to nominate and vote for
members of the GAT Committee.
Besides organising the GAT Annual
Scientific Meeting (ASM), the
Committee represents trainees’ views
on Working Parties, Committees and
Councils of the Association and the
Royal College of Anaesthetists. GAT is
also represented at meetings held by
the Postgraduate Medical Education
and Training Board (PMETB), the British
Medical Association (BMA) and the
Department of Health (DoH). Our role
at these meetings is to represent the
views of anaesthetic trainees and to
pass information back to GAT members.
The GAT Committee runs a number of
seminars aimed primarily at trainees,
such as the Consultant Interview
Seminar. These are continuously
evolving to meet trainees’ needs. We
also hold the flagship ASM at a different
location within the UK each summer.
Other GAT publications include: ‘The
GAT Handbook’ (9 th Edition), the GAT
‘Organising a Year Abroad’ handbook
and ‘Your Career in Anaesthesia’ (for
medical students and FY trainees).
Further information can be found at
www.aagbi.org/gat.htm.
67

JOIN THE ASSOCIATION OF ANAESTHETISTS
AND YOU’LL BE IN GOOD COMPANY
10,000 members are already benefiting
from the Association’s unique
membership package:
• Personal injury and life insurance
cover of up to £1 million for patient
transfer
• Free subscription to Anaesthesia -
the renowned international monthly
journal
• Free copies of the Association
guidelines
• Free monthly newsletter Anaesthesia
News keeping you up to date with
new developments
• Special rates for scientific meetings
• Priority booking and special rates for
seminars at Portland Place
• Free advice and information
• Free information handbooks for
trainees & SAS Grade Doctors
• Representation at Westminster and
the DoH
• New AAGBI website with up-todate
news on the Association and
anaesthesia
• Private members’ forum hosted by
Doctors.net
• Opportunities to apply for grants
and awards
• 20% discount on textbooks from
Oxford University Press and
Wiley-Blackwell Publishing
• AAGBI subscription is on the
HMRC approved list of professional
organisations for tax relief
For further details please refer to the application form at the centre of this guide.
Or contact:
Membership Department, Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
t: 020 7631 8801
e: members@aagbi.org
67

The Royal College of Anaesthetists
The Royal College of Anaesthetists
(RCoA) is the professional body
responsible for the specialty of
anaesthetics throughout the United
Kingdom. The Royal Charter gives
the RCoA responsibility for ensuring
excellence in anaesthesia, critical
care and pain management through
setting and maintaining standards
of patient care. In addition to
safeguarding excellence in clinical
care, the responsibilities of the RCoA
include the maintenance of standards
of postgraduate training, governing
examinations and the ongoing
continuing medical education and
professional development of all doctors
working within anaesthesia, pain
management and intensive care. Their
website is: www.rcoa.ac.uk.
The RCoA Tutors (‘College Tutors’)
are trainers who represent the RCoA
and ensure that training is properly
organised, occurs when time-tabled
and is accessible to the trainees. The
College Tutors act as the organisers
and co-ordinators of training. The
delivery of high quality training requires
contributions from all consultants but
the College Tutors are the prime points
of contact for the trainees with the
RCoA.
All UK training hospitals are contained
within schools of anaesthesia. Within
each school an anaesthetist is appointed
as a Programme Director - this is a
deanery appointment - and another as
Regional Advisor, a RCoA appointment.
The Programme Director organises
rotations to ensure exposure to all
appropriate anaesthetic specialities. The
Regional Advisor ensures that standards
of anaesthetic training are maintained,
and represents the policies and views of
the college.
Finally, we recommend that you register
with the RCoA as soon as possible.
Failure to register means you are unable
to apply for the FRCA examination.
Preparing for the first day
as an anaesthetist
Anaesthetics can be an extremely
challenging specialty for any trainee.
With this in mind, there are some
simple things you can do to ease
yourself into this new environment.
Your new hospital should provide you
with an induction pack before you start
and it is perfectly reasonable to ask for
one if you have not received it. This
will give you an idea of the structure
of the department and hospital. The
month before you start is a good time
to contact the College Tutor, the rota
co-ordinator and the ‘novice’ trainees
in the anaesthetic department. The best
person to contact to arrange a time for
this visit is the anaesthetic department
89

co-ordinator or secretary. It always
helps to befriend them and get them
‘on your side’, as they can make your
life easy, or difficult, depending on your
attitude. Although you should be shown
around on your induction day, if you
time a pre-visit correctly, you may be
able to spend time talking to the current
incumbent in your position.
The first day....
Your first one or two days are for
‘induction’ into the Trust and the
Department.
Trust induction
Trusts require all new staff to undergo
a hospital induction. This may be
in the form of lectures or it may be
available online. Some Trusts expect
trainees to complete online modules
before their first day. There are also
other competencies that you are
obliged to complete yearly, such as
manual handling, fire safety and child
protection. You may be expected to
attend a Basic Life Support update. In
addition, you will need to:
• Obtain a security / ID card and
a parking permit when given the
chance as the opening times are
often limited. This may require
having your photo taken.
• Deliver all your personal details
to Human Resources and Payroll
including payslips, GMC Certificate,
P45 / P60. Take the originals along
yourself and ask them to photocopy
them whilst you wait so you can
take the originals away again. If
they get lost you will have to pay for
replacements and the chances are
the Trust will not be forthcoming to
reimburse you for this.
• Attend Occupational Health
bringing a ‘smart card’ if available
and evidence of up-to-date
vaccination status.
• Submit signatures for pharmacy and
pathology.
• Visit the IT department for hospital
login / passwords and to access
email and lab results.
• You may need to attend specific
training sessions to access online
radiology.
• Register with the data controller
before you start an electronic
logbook. (Chapter 6)
Departmental induction:
some suggested aims
Staff - Find out who the following
individuals are: College Tutor, Rota
Co-ordinator, Clinical Lead / Director,
Educational Supervisor.
RCoA Tutor - Every department with
trainees has at least one College Tutor,
who is responsible for overseeing
training according to the guidelines laid
out in the various training documents.
The College Tutor may also act as your
Educational Supervisor or you may
be allocated a separate consultant to
undertake this.
89

Educational Supervisors - An
Educational Supervisor is defined by
PMETB as ‘a trainer who is selected
and appropriately trained to be
responsible for the overall supervision
and management of a specific
trainee’s educational progress …..The
educational supervisor is responsible
for the trainee’s educational agreement.’
You will need a signed educational
agreement to obtain study leave.
Their role is to help plan your training
and reach your personal objectives.
You should arrange to meet them
to formulate an educational plan,
preferably within the first two weeks.
As a novice you will follow a set route,
but if this is a subsequent post then
you should have already considered
how your training should progress.
Most departments have a series of
three to four meetings / appraisals per
post, so at the end of your first meeting
you should make plans for the next. It
is important to keep a signed record
of each meeting. They can assist you
with finding and starting a logbook,
joining the RCoA and understanding
the workplace assessments that you
are required to undertake. Most of
this information can be found on the
RCoA website, but your educational
supervisors may be better able to help
you locate it. It is worth considering the
appropriate time for you to undertake
the Primary FRCA examination early,
as options are now more limited
Study leave - Make sure you are
aware how the annual and study
leave application processes work.
Most departments have rules about
how many trainees of each grade
can be away at one time and keep a
log of current bookings that allows
you to determine availability. It is
important to keep a record of study
leave taken in a Portfolio or Continuing
Professional Development (CPD) diary
as this information may be required at
appraisals and at the Annual Review of
Competence Progression (ARCP).
Annual leave - Planning annual leave
can be very frustrating as a first-comefirst-served
system invariably operates.
Check whether the department requires
prospective cover as if so, you must
swap any on-calls within your leave
period.
Meetings - Obtain lists of departmental
audit, morbidity and mortality meetings,
journal clubs and teaching sessions /
tutorials.
Lockers - As an anaesthetist you will
spend most of your working time in
theatre scrubs. Obtaining a locker is
vital and you should also be issued with
‘theatre shoes’. Be prepared to stand
your ground on this one, and put your
name on the waiting list if required.
Take a padlock/combination lock along
on your first day in case this is required
Access codes - Obtain access codes to
changing rooms and for other doors that
are locked out of hours.
Theatre lists - Discover how to access
theatre lists, whether via email,
electronically or paper, e.g. theatre
reception/secretaries office.
10 11

Equipment competencies - You may be
required to undergo training to ensure
safe use of equipment such as IV, PCA
and epidural pumps, and anaesthetic
machines. These will need to be signed
off and a copy kept in your portfolio.
Computers - Each department will
provide computer access to the internet,
including the GAT website at www.
aagbi.org/gat.htm. Find out how to do
this, so you can keep yourself up to
date by visiting the website regularly.
The AAGBI has recently introduced
online accounts for members to allow
them access to specialist facilities such
as Anaesthesia. Signing up with Oxford
Journals will permit free access to the
British Journal of Anaesthesia (BJA) and
its educational supplement (CEACCP).
Medical indemnity - Trainees are often
unsure of the differences between
Crown Indemnity provided by the
NHS Trust and the cover that medical
defence organisations offer. Whereas
Crown Indemnity may cover you for
negligence claims incurred during
your work in the Trust, the defence
organisations will actually support you
by representing your interests at Fatal
Accident Inquiries, Coroners’ Inquests
and GMC hearings. The GAT Committee
consider it essential to maintain
personal medical indemnity cover with
a medical defence organisation. The
AAGBI will insure members against
death and personal injury for up to
£1 million when involved in patient
transfers. This level of cover is not
provided by the majority of medical
defence organisations or by the NHS.
Finally most trainees remember feeling
exhausted during their first few weeks
of anaesthetic training, so you won’t be
alone if you do too!
Induction: orientation
During induction there are certain
places and things that you should be
made aware of. Here is a checklist:
The hospital
• Canteen facilities and opening times
• Library – times and access
• Parking
• Accommodation
• ID page and access
• Hospital facilities, e.g. sports centre
• Occupational health department
• Doctors’ Mess
Anaesthetic department
• On-call room
• Administrative staff
• Rota
• Access codes and telephone
numbers
• Annual and study leave
• College tutor
• Educational Supervisor / Mentor
Theatres
• Department protocols
• Changing room
• Recovery
• Difficult airway trolley
• Paediatric trolley
• Arrest trolley
• Dantrolene – treatment for
malignant hyperthermia
• Intralipid – treatment for LA toxicity
10 11

Other departments
• Day surgery units
• Radiology
• Obstetrics
• Emergency department
• Intensive care unit
• Remote theatres - eye, ECT,
angiography suite
Health and safety
As an anaesthetist patient safety is
paramount. However it is equally
important to ensure your own.
• Whatever your normal practise, it
is vital to become accustomed to
wearing gloves for every patient
contact. Anaesthetics has a high
incidence of exposure to patient
saliva and blood. For certain
procedures a full aseptic technique is
also required, including a mask, hat,
gloves and gown.
• If you suffer a needle stick injury
it is important to follow Trust
protocol. This may require attending
occupational health department
or the emergency department out
of hours.
• Working in theatre involves
transferring patients. Attending a
manual handling course will help
protect you during these manoeuvres.
• It is important to look after your
mental, as well as physical wellbeing.
Training in anaesthetics, as with all
specialties, can be stressful at times.
Please see Chapter 15 on how to
obtain support and advice.
Portfolio and logbook
The RCoA states that ‘at the
commencement of Core Training the
trainee should create a Personal Training
Record or portfolio into which he/she
places all documentation relevant to
training, including details of assessments
completed.’
It is vital to keep detailed
documentation of your training using
a training portfolio. The aim of the
portfolio is to provide factual data
of the training and the professional
development exercises undertaken.
This will ensure that you have all the
required information for your formal
record of assessment and achievement
with your educational supervisor both
at the start of and end of the post.
It should contain the following as a
minimum:
• Up-to-date CV
• Up-to-date logbook summary as per
RCoA recommendations
• All workplace assessments / DOPS /
MiniCEXs / CBDs.
• Appraisals and signed Educational
Agreements
• Training certificates and certificates
of attendance at meetings /
conferences
• Record of audits / surveys / research
or other ongoing projects
• Summaries of MSF (Multi-Source
Feedbacks)
The portfolio will also help you to
12 13

summarise your training, assessment
and achievements before starting formal
training in anaesthetics. The RCoA
provides an example of a portfolio, the
Appraisal Portfolio for Anaesthetists in
Training in the NHS which is available
to download on its website.
You should read the RCoA publications,
‘The CCT in Anaesthesia I: General
Principles’ and, ‘The CCT in
Anaesthesia II: Competency Based
Basic Level Training’ at the start of
your post. Both of these are available
at www.rcoa.ac.uk. Knowing what is
expected of you places you in the best
position to formulate a career plan
with your Educational Supervisor. The
conflict between service provision and
training can be fierce, and as a trainee
you must be prepared to act if your
training requirements are not met. If you
are unaware of the requirements you
may discover the shortcomings of your
training too late. Novice anaesthetists
will tend to follow a specified path,
details of which are given in Chapter 7.
Logbooks
An up-to-date logbook is an essential
requirement for the portfolio as it
provides the evidence of training
exercises undertaken. This should
include all cases in whose anaesthetic
care you were actively involved.
The logbooks will provide a detailed
summary of the cases, level of
supervision, procedures undertaken
(central lines, arterial lines, regional
anaesthesia) and the experience gained.
The link: http://rcoa.ac.uk/index.
asp?PageID=968 lists the electronic
logbooks that are supported by the
college. They include programmes
that are compatible with commonly
available IT platforms, including
Windows, Macintosh, handhelds and
netbooks.
The logbook is a vital part of both the
appraisal and assessment processes.
Keeping up to date with entries is the
only way of maintaining a correct
logbook. Once all the data are entered,
the logbook programme allows you
to produce summaries and reports
(Diagram 1). No identifying information
should be kept within this record,
e.g. hospital number or date of birth.
Trainees should be aware that if taken
off the Trust premises, such electronic
documentation renders them liable
under the Data Protection Act. You are
advised to register as Data Controllers
with the Data Commissioner’s Office
if this applies to you. The cost of this
registration is an annual notification fee,
which will be a lot less than a fine.
Training in anaesthesia
12 13

Royal College of Anaesthetists
Record of Training Period 09/08/07 to 28/08/09
Sample Report
ST Years 1 & 2
Random Hosp NHS Trust
Number of Total % Supervised Solo Teacher 80yrs
Cases
Cardiothoracic 0 0% 0 0 0 0 0 0 0 0
Dental 46 6% 40 6 0 0 0 12 34 0
ENT 42 5% 37 5 0 0 3 8 30 1
General 234 29% 127 107 0 2 1 5 189 37
Gynae 100 12% 23 77 0 0 0 0 98 2
ITU 0 0% 0 0 0 0 0 0 0 0
Maxillo-facial 10 1% 9 1 0 0 2 2 6 0
Misc 29 4% 6 23 0 0 0 0 25 4
Neuro 0 0% 0 0 0 0 0 0 0 0
Obstetrics 112 14% 20 92 0 0 0 0 110 2
Ophthalmics 10 1% 9 1 0 0 0 0 3 7
Orthopaedics 108 13% 17 91 0 1 0 0 98 9
Pain 2 0% 2 0 0 0 0 0 2 0
Plastics 1 0% 1 0 0 0 0 0 1 0
Psych 2 0% 2 0 0 0 0 0 2 0
Radiology 0 0% 0 0 0 0 0 0 0 0
Trauma 37 5% 13 24 0 1 0 2 24 10
Urology 41 5% 15 26 0 0 0 0 36 5
Vascular 31 4% 12 19 0 0 0 0 26 5
Totals 805 333 472 0 4 6 29 684 82
ASA (No of Cases)
Age Criteria (No of Cases)
ASA Total Solo Age Group
1 489 281 80yrs 82
Hours of Work (No of Cases)
Priority (No of Cases)
0800-1800 601 Scheduled 578
1800-0000 164 Urgent 188
0000-0800 40 Emergency 3
Diagram 1: This is an example of an anaesthetic logbook summary, demonstrating the variety of information that can be
stored.
14 15

The current training programme,
overseen by the RCoA, ‘is a
competency-based, supervised,
continuously evaluated and tightly
regulated programme, with the
potential for tailoring to suit individual
requirements and interests’. The
recommended minimum duration of
training is seven years: two years of
Basic Level training (CT1 and 2); two
years of intermediate level training (ST
3 and 4); and three years of advanced
level training (ST 5-7). The actual
duration of training is not fixed to
seven years, but will depend on the
individual needs and the rate at which
the competencies are achieved. The
aim of such a programme is to produce
anaesthetists of high quality.
Core (Basic) Level Training
Overview
Basic level training for anaesthetists
consists of two years training including
a minimum of 21 months in anaesthesia
and three months in intensive care
medicine. Progression depends
on the appropriate competencies
being achieved. The aims during this
important period of an anaesthetist’s
career are: to acquire an overview
of the multi-profession complex
work environment; and to learn the
basic principles of safe and effective
anaesthesia, pain management and
peri-operative resuscitation.
The first six months
Anaesthetists spend the majority of
their time in the theatre suite and it is
important to familiarise yourself with its
workings. The Operating Department
Practitioners (ODPs) will teach as well
as assist, and you will find yourself
relying on their expertise in difficult
situations.
Your patients’ safety is your
responsibility. This not only includes the
obvious, such as ensuring the patient is
asleep, but also safeguarding the patient
by protecting their eyes, pressure points
etc. You will learn the necessary skills
and knowledge during your training,
but when working in an unfamiliar
environment ensure you know the
location of the nearest defibrillator,
emergency drugs and whom to contact
in an emergency.
Many trainees new to anaesthesia
find themselves frustrated during the
first few weeks of work. Having been
competent to work independently
after qualification, you find yourself
back at the beginning, in an unfamiliar
environment, learning the basics under
constant supervision. Knowing what is
expected of you enables you to focus
on what you need to achieve.
The initial assessment of
clinical competency
The first hurdle of training is the
RCoA ‘initial assessment of clinical
competency’. This is at the end of the
14 15

introductory period and is a RCoA
requirement for anaesthetic trainees. It
must be passed before progressing to
indirect clinical supervision and until
this is completed you should have
immediate supervision at all times.
When the assessment takes place
depends on any previous anaesthetic
experience you may have, and the
speed at which you progress. The RCoA
envisages that most trainees would pass
this assessment after three months, and
certainly by six months of training.
The initial assessment of clinical
competency contains six assessments,
each of which must be completed
twice:
1. Pre-operative assessment of patients
2. General anaesthesia (GA) for ASA * 1
or 2 patients without intubation
3. GA for ASA 1 or 2 patients with
tracheal intubation
4. Rapid sequence induction
5. Cardiopulmonary resuscitation
6. Clinical judgement, attitudes and
behaviours
* The ASA (American Society of
Anesthesiologists) grade 1 or 2 patients are
those who are fit and healthy, or have mild
systemic disease.
After completion of this initial
assessment of clinical competency, the
trainee may undertake uncomplicated
general anaesthesia and simple
peripheral nerve blocks under
guidance of a consultant with indirect
supervision. The trainee may commence
solo lists at this time during normal
working hours, but only with the
presence of a trainer working in the
same theatre suite.
Workplace assessments and appraisals
Anaesthetic training is competencybased,
although it currently runs
according to a time-based plan.
Trainees undergo summative
assessments throughout the anaesthetic
training programme. These are designed
to assess whether you have reached
the specified standards in the training
programme, to quantify experience,
and to estimate the individual trainee’s
eligibility to progress to further stages
of training. The RCoA has designed
common tools and documentation that
should be used for workplace based
assessment. For ‘novices’ in anaesthesia
the ‘initial assessment of competency’
takes precedence over the assessments
listed below. The tools used are:
• Multi-Source Feedback (MSF)
• Mini-Clinical Assessment Evaluation
Exercise (MiniCEX)
• Direct Observation of Procedural
Skills (DOPS)
• Case Based Discussion (CBD)
These forms can be downloaded
from the link: http://rcoa.ac.uk/index.
asp?PageID=982
The training programme
16 17

Foundation doctor (two years)
(Or after another specialty e.g. general medicine)
Core training in anaesthetics:
Years 1 and 2
(OR two-year Acute Care Common Stem plus CT2 in anaesthetics)
During which time: Primary Fellowship examination
Competitive application to specialist training in anaesthetics:
Years 3 and 4
During which time: Final Fellowship examination
Specialist training in anaesthetics:
Years 5 to 7
(Potentially including work abroad or a research fellowship)
Certificate of Completion of Training (CCT) awarded
Consultant post
16 17

Supervision of trainees
When working ‘solo’ it is key to know
whom to contact, and exactly how and
how long it will take them to reach you.
More importantly, you should not begin
anything you feel unhappy about. If you
find yourself wondering whether or not
to contact someone senior, you almost
certainly should. It is often during
normal working hours when such lines
of communication become blurred, so
get into the habit of finding out who is
your point of contact before starting a
list on your own.
You are encouraged to seek advice
and/or assistance as early as possible
whenever you are concerned about
patient management. Patient safety
must never be compromised.
Grades of clinical supervision
Clinical supervision of daytime and out
of hours’ duties for anaesthesia falls into
two categories: direct and indirect:
Direct supervision This means working
directly with a senior supervisor who is
actually present or can be within seconds.
This proximity maintains patient safety but
allows a degree of independence in order
to develop confidence.
Indirect supervision Indirect
supervision falls into two categories,
local and distant:
• Local supervision – this means that the
supervisor is on the same geographical
site, is immediately available for
advice and is able to be present within
10 minutes of being called.
• Distant supervision – this means
the supervisor is available rapidly
for advice but is off the hospital site
and/or separated from the trainee by
over 10 minutes.
Named consultant
The RCoA document Guidelines for
the Provision of Anaesthetic Services
(1999) states that ‘all services provided
in the National Health Service are
under the supervision of a consultant.
This applies to all anaesthetic services.
Where trainee or non-consultant career
grade anaesthetists are providing
clinical services this principle must be
applied.’ Anaesthetic departments now
need to ensure that named supervising
consultants are available to all nonconsultant
anaesthetists. When a trainee
is doing a list or a case without a
consultant, he or she should check that
a supervising consultant:
• Has been allocated by the
department
• Is aware that he or she is supervising
a non-consultant
• Is able to assist personally with the
case within an agreed time frame
• Has discussed the anaesthetic
management plan with the nonconsultant
if appropriate
• Has agreed the level and extent of
supervision
Trainees should record the following on
the anaesthetic record:
• The name of the supervising
consultant
• The level of supervision as defined
above
18 19

• Whether the case was discussed
with the supervising consultant and,
if so, the anaesthetic management
plan agreed.
Ultimately, the trainee giving the
anaesthetic is responsible for his or her
own actions. As a qualified medical
practitioner, you are professionally
accountable in your own right.
In summary, it is imperative that you:
• Know when to ask for help
• Know whom to ask for help
• Do not act beyond the level of your
own competence
Many departments operate a starred
consultant scheme. A consultant
working within the same theatre suite
during elective sessions is nominated
to be the focal point for trainees or Staff
and Associate Specialist (SAS) grades
with queries/problems. This consultant
is often paired up with a senior trainee
so that they’re able to leave their theatre
in times of need. In some hospitals the
starred consultant will wish to speak
with a trainee before they start a solo
case or list. In others the consultant may
be floating, for example not attached to
an actual list.
Speak to any trainee and they will
recount a story of being ‘forced’ to take
on something they felt was outside
their comfort zone / above their level
of competence. A common example
is the transfer of a critically ill patient
to another hospital. While we all have
to do things for the first time at some
point during our training, we should
always be able to say no if we feel that
it is in the patient’s best interests. If you
find yourself in such a situation don’t
hesitate to voice your concerns. If you
are working with a senior trainee, tell
them, otherwise inform the consultant
on duty. If you still feel unhappy then
you may have to contact your mentor,
College Tutor, the Head of Department,
or simply another consultant with
whom you get on well. If you feel you
require further help both the BMA and
AAGBI provide such services, as well as
other groups.
Please see Chapter 15 for further details
of how to find help.
Running a list on your own
‘Going solo’ seems sudden and can be
quite daunting but it is actually reached
gradually. Initially you will work with
a senior colleague supervising you
directly in the anaesthetic room and
theatre. This ’one on one’ supervision
will slowly be removed such that you
will provide maintenance of anaesthesia
18 19

unsupervised, then extubation and
then induction. This will progress to
supervision from the coffee room
and you will begin managing single
cases unsupervised until you are
assigned your own theatre list. Here
you will anaesthetise several patients
unsupervised and begin to learn the
art of ‘running a list’. When this day
happens there will be a supervising
consultant available in the theatre
complex and you should make them
aware that this is your first your solo
list. The next step, and perhaps the
biggest one of all, is to progress from
the presence of fellow colleagues in
the theatre suite who are available
for immediate help and support
to anaesthetising with no other
anaesthetists around, i.e. a night on call.
The list that you most often get to
run is the emergency or trauma list.
This can be a challenging experience
as it involves patient assessment,
optimisation of co-morbidities, planning
peri-operative care including postoperative
pain management. With
three months experience in anaesthesia
you will NOT be expected to know
everything or deal with every case, but
to recognise when to ask for advice and
assistance.
The rest of the first six months...
Emphasis is placed on the role of
the anaesthetist in the peri-operative
care of the surgical patient. Thus, a
guided introduction to pre-operative
assessment and post-operative care
is just as important as the practice of
anaesthesia.
The following basic units should be
covered within this six month period:
• Care of the patient
• Anaesthetic equipment
• Basic techniques in general
anaesthesia
• Basic techniques in local
anaesthesia
• Anaesthetic pharmacology
Training for the next 18 months
The following areas of basic training
should be covered in this period:
• Obstetric anaesthesia, analgesia and
resuscitation
• Pain management/ control/ treatment
• The upper airway and its problems
• Peri-operative care of the patient for
major surgery
• Anaesthesia for day case surgery
• Paediatric anaesthesia
• Anaesthesia in the elderly
• Anaesthesia for patients with specific
medical problems
• Intensive care medicine (ICM)
Trainees who have completed a fulltime
basic level training post in ICM
can count up to three months of this
training towards their basic level
training in anaesthesia. Trainees who
enter the Anaesthesia CCT programme
via Acute Care Common Stem (ACCS)
training may also have acquired some
intermediate level ICM competences in
that programme.
During this 18 month period trainees
will widen their experience to
obtain the RCoA Basic Level Training
Certificate and become eligible to
20 21

move to intermediate level training in
anaesthesia, ST3.
By the end of basic level training,
trainees should be able to:
• Undertake the anaesthetic care of
most routine cases
• Assist in the anaesthetic care for
more complex surgery
• Provide anaesthetic care for routine
obstetric practice
• Organise, with the surgical team,
an emergency list; identify potential
problems and seek appropriate help
• Understand the principles
underlying the care of patients
in intensive care and high
dependency units
• Understand the principles of pain
management
• Participate in audit
• Pass an assessment of knowledge
and certain skills by examination
e-Learning
The ‘Integrated Anaesthesia Learning
Portal’ or e-LA is a recently developed
web-based educational resource
produced by the RCoA in partnership
with e-Learning for Healthcare (e-LfH).
It is available, for free, to all UK
anaesthetists practicing in the NHS,
and aims to deliver key knowledge
and concepts from the anaesthetic
curriculum helping trainees to prepare
for the FRCA examination.
e-LA comprises:
• e-Learning Sessions – Knowledge
and scenario-based sessions
covering the first two years of the
anaesthetic curriculum. Each session
takes around 20-30 minutes to
complete.
• e-Library – Access to thousands of
full-text journal articles which have
been cross-referenced and mapped
to the anaesthetic curriculum.
• e-CPD – Articles and associated
MCQs to support general and core
topic based continuing professional
development for trainees and trainers.
• e-Assessment – Formative
assessments with feedback that
will test the user’s understanding of
the knowledge based session and
introduce students to the standard
expected at the FRCA exam.
Simulation medicine
Simulation training is increasingly
being used in medicine and its use
is supported by recent publications
from the Department of Health. ‘The
RCoA encourages the use of simulators
for relevant aspects of postgraduate
training in anaesthesia especially
for events of high importance but
infrequent occurrence (as exampled by
anaphylaxis), for situations where there
might be a high risk to patients, for team
building and working under pressure.
Simulators are also used as assessment
tools in the Primary FRCA Examination.’
Anaesthetic departments are utilising
simulators to varying degrees and
many are currently developing this
service. Now that simulation is a
feature of the primary FRCA it is well
worth familiarising yourself with this
method. If your department does not
20 21

offer simulator training there are many
courses run at the larger simulation
centres across the country.
Basic Level Training Certificate (BLTC)
All trainees progressing to ST3
(Intermediate Level Training), including
those moving from Fixed Term Specialty
Training Appointments, are required to
have the Basic Level Training Certificate
before they can start their intermediate
level training. The BLTC confirms
completion of basic level competencybased
training in anaesthesia and
ICM, of which the second year must
be in the UK. The certificate should be
signed off by at least two designated
consultants, one of whom must be the
College Tutor. There are ten workplace
assessments to get signed up. These are
outlined in ‘The CCT in Anaesthesia
II: Competency Based Basic Level (CT
years 1 and 2) Training and Assessment’
available at www.rcoa.ac.uk. Along
with passing the Primary exam (Chapter
10), these will be the core aims of any
educational planning. Besides these
formal assessments, you should also
have regular appraisals to discuss
matters informally. You must maintain
formal records of both appraisals and
assessments.
Appraisal and assessment
‘The RCoA regards the regular appraisal,
assessment and review of trainees as
an integral part of the postgraduate
educational process. It is also a
non-negotiable requirement for all
doctors employed by the NHS and for
revalidation with the GMC.’ The three
parts of the process are:
1. Appraisal
Appraisal of trainees is intended:
• To provide constructive dialogue
that will identify, anticipate and
lead to action on the strengths
and weaknesses in a trainee’s
performance
• To review educational targets
• To review the results of any
assessments or examinations
• To provide provisional feedback and
support towards progress
• To meet the NHS requirement for the
annual appraisal of all employees
• To facilitate the production of a
personal development plan
• To provide evidence for GMC
revalidation
2. Assessment
The purpose of assessment is to:
Determine fitness for professional
practice. This means more than the
performance of clinical skills, no
matter how complex. Very importantly
it carries an in-built commitment to
standards, and the attitudes which will
maintain those standards throughout
professional life.
Provide evidence of competence in a
trainee. This is to confirm the possession
of the appropriate knowledge, skills
and attitudes required to undertake
safe clinical practice at a level
commensurate with their level of
training.
Provide evidence of confidence and
competence in a consultant. This
22 23

is to confirm the possession of the
confidence, knowledge, skills and
attitudes necessary for independent
professional practice.
3. Annual Review of Competence
Progression (ARCP)
The three key elements supporting
trainees through the training curriculum
are brought together each year in the
ARCP. They are:
Appraisals
Assessments
Planning of trainee’s development
Information taken from the RCoA
publications ‘The CCT in Anaesthetics and
Guidance for Trainers and Trainees’.
Intensive care medicine
Intensive care medicine (ICM) is an
integral part of training in anaesthesia,
with all trainees having to complete
three months during Basic Level
Training and a further six months during
Intermediate Training. However, some
trainees may be interested in dual
accreditation, achieving a CCT in both
anaesthesia and ICM. Anyone interested
in ICM should contact the Intercollegiate
Board for Training in Intensive Care
Medicine (IBTICM) Educational
Supervisor in their hospital, or failing
that the IBTICM Regional Adviser, as
soon as they can. To obtain further
information, go to www.ibticm.org.
Intermediate Training post. On some
rotations, it is possible to end up doing
three months of ICM during a year at
one hospital, and arrive at the next
hospital to find that you are down to
do another three months of ICM. If you
find yourself in this situation, we advise
you to take the matter up with your
College Tutor or Regional Adviser as
soon as possible.
Trainees wishing to obtain dual
accreditation (e.g. advanced level
ICM or intermediate level training)
need six months of acute medicine
experience (of which three months
may be emergency medicine). This
complementary medical experience is
usually acquired at CT1/2 level and the
easiest route to acquire this is via the
ACCS programme.
Intensive care logbook
The Intercollegiate Board for Training in
Intensive Care Medicine has stipulated
that all anaesthetic trainees should
keep a record of cases under their care
in the ICU. This should include cases
that the trainee has admitted, or had
a substantial input into, and also all
procedures.
Attention must be drawn to the fact
that trainees must complete at least
21 months of training in anaesthesia
before they are eligible to move to an
22 23

Workplace based assessment in ICM
IBTICM have made recommendations
for the quantity of workplace based
assessments for the ICM component of
the anaesthesia training programme.
The following is currently suggested as
the minimum number of assessments
required to achieve the basic level of
training (a three month period during
the first two years of training):
Multi Source Feedback x 1
Direct Mini-Clinical Assessment
Evaluation Exercise x 2
Direct Observation of Procedural
Skills x 3
Case based Discussion x 1
For further information see: RCoA ‘The CCT
in Anaesthesia Part II Appendix C, section 7’.
Acute Care Common
Stem training
The Acute Care Common Stem (ACCS)
training programme has emerged as part
of the overhaul of postgraduate medical
training that is ‘Modernising Medical
Careers’.
The ACCS training programme is two
years long and designed to follow
on from the Foundation Training
programme. The rotation consists of
six months of acute General Internal
Medicine, six months of Emergency
Medicine, six months of Intensive
Care Medicine and six months of
Anaesthesia.
The aim of the ACCS programme is to
‘produce trainees able to identify and
manage the acutely unwell patient,
in particular by providing training
in complementary specialties in a
structured programme of training ’ . The
introduction of the programme should
improve the acute clinical skills in
trainees going onto any one of these
specialities.
Since the splitting of training
programmes, trainees are now
considered as Core Trainees (CT)
and must apply again in their chosen
specialty to become a specialty trainee
(ST). Completion of the ACCS rotation
allows entry to CT2 in Anaesthesia
and ST3 in Emergency Medicine and
Acute Medicine. Another benefit of the
programme is that it allows trainees
24 25

to gain the complementary specialty
experience required for a dual ICM
CCT, which is otherwise difficult within
the current training scheme.
As with anaesthetics, ACCS is a
competency-based training programme,
but with different objectives for each
specialty. The RCoA gives further detail
of the training programme in ‘The Acute
Care Common Stem Core Training:
A manual for trainees and trainers’,
available on their website www.rcoa.
ac.uk. And there is a new website for
ACCS trainees: www.accsuk.org.uk.
The ARCP (Annual Review
of Competence Progression)
The ARCP replaces the previous RITA
(Record of In Training Assessment)
process and has been introduced in
line with changes to training via MMC.
It is an annual assessment process for
all trainees which is based on the more
explicit use of evidence to inform the
annual assessment of progress.
In general, appraisal processes are
based around the GMC’s document
‘Good Medical Practice’ (Good Medical
Practice, General Medical Council
2006), which describes the principles
of good medical practice, and the
standards of competence, care and
conduct expected of doctors in all
aspects of their professional work.
These are:
• Good clinical care
• Maintaining good medical practice
• Teaching, training, appraisal
and assessment
• Relationships with patients
• Working with colleagues
• Probity
• Health
The first heading of Good Medical
Practice - good clinical care - is
specialty specific and for the majority
of trainees, the information provided
will be their College logbook and
assessment documents. The other
headings of GMP are common to all
doctors and the information required is
detailed in this document.
The Primary FRCA examination
The Fellowship of the Royal College
of Anaesthetists (FRCA) is a hurdle
to overcome and there are ongoing
changes to the examination structure.
These will be finalised and introduced
progressively over the next few years.
The FRCA is divided into 2 parts,
‘The Primary’ and ‘The Final’. Formal
24 25

assessments of knowledge must be
passed before a trainee can progress
from Basic to Intermediate training
and from Intermediate to Higher
training. These assessments form the
Primary and Final FRCA examinations
or prospectively approved equivalent
qualification.
Passing the primary part of the exam is
a requirement for progression to a ST3
post and intermediate level training.
The Primary exam is designed to assess:
• The candidate’s understanding of the
fundamentals of clinical anaesthetic
practice including equipment and
resuscitation.
• The candidate’s knowledge of the
fundamental principles of anatomy,
physiology, pharmacology, physics,
clinical measurement and statistics
as is appropriate for the discipline of
anaesthesia.
• Whether the candidate’s skills and
attitudes are appropriate to the level
of training.
A full syllabus and exam timetable is
available on the RCoA website (www.
rcoa.ac.uk). People tackle the exam
in different ways but it is important
not to underestimate the amount
of work and commitment required.
Attending one of the many primary
courses helps with preparation. Which
of the many courses to attend comes
down to personal choice and financial
constraints. Do not forget to use the
e-learning package provided by the
RCoA and other websites, e.g. www.
anaesthesiauk.com.
Also use the GAT website for links:
www.aagbi.org/gat.htm.
There are 3 parts to the primary
examination:
1. Multiple Choice Questions (MCQ)
2. Objective Structured Clinical
Examination (OSCE)
3. Structured Oral Examination (SOE)
The MCQ
Eligibility to sit the MCQ component
of the Primary FRCA is achieved upon
obtaining a RCoA approved training
post in anaesthesia or ACCS. All
trainees must be registered by the
RCoA.
The MCQ consists of a three hour
multiple choice question paper of
90 questions, each with five stems.
Negative marking has recently been
abandoned and so marks will no longer
be deducted for incorrect answers.
The pass mark is approximately 80%.
The Primary MCQ exam may be
attempted a maximum of five times
and a pass in the MCQ will be valid
for two years; if the Primary has not
been completed by this stage it must be
repeated.
OSCE
The Objective Structured Clinical
Examination (OSCE) consists of up to 18
stations of which 16 count towards the
result. The OSCE lasts approximately
one hour 50 minutes and covers all
aspects of anaesthesia, including
resuscitation, technical skills, anatomy,
26 27

history-taking, physical examination,
communication skills, anaesthetic
equipment, monitoring equipment,
measuring equipment, anaesthetic
hazards and the interpretation of X-rays.
One or more stations may incorporate
the use of an anaesthetic simulator.
The pass mark for each question
depends on its difficulty and the level
of knowledge expected of a ‘borderline’
candidate. The pass mark for the exam
is the sum of all the individual 16 pass
marks and will vary depending on the
combination of questions used.
SOE
From September 2009 there will be
a single Structured Oral Examination
(SOE) or viva examination, which
will be conducted as two separate
sessions. One SOE tests physiology and
pharmacology and the other clinical
anaesthesia, physics and clinical
measurement.
At the first attempt the OSCE and SOE
must be taken at the same sitting. If you
pass one but fail the other component
then you can re-take just the failed
component. As with the MCQ, a pass in
either will be valid for two years.
From September 2009 closed marking
(1, 1+, 2, 2+) has been removed and
now each section of the exam must be
passed in order to gain the
Primary FRCA.
Bibliography for the Primary FRCA
General:
Anaesthesia and Intensive Care A-Z
Yentis SM, Hirsch NP, Smith GB
An excellent first anaesthetic book. A
summary of just about everything you will
come across and much more detailed than
it sounds.
Fundamentals of Anaesthesia
Pinnock C, Lin T, Smith T
This useful basic textbook follows the
primary syllabus.
Oxford Handbook of Anaesthesia
Allman K, Wilson I
Doesn’t teach you the basics, but great for
looking up specific cases prior to a list.
Drugs in Anaesthesia & Intensive Care
Sassada M, Smith S
A pocket guide to all drugs you may come
across, good for tricky MCQ answers,
structuring of drug information for a viva
question and as a reference book
Primary specific:
Basic Physics and Measurement in
Anaesthesia
Kenny G, Davis P
Previously Parbrook, the ‘classic’ physics
textbook.
Respiratory Physiology: The Essentials
West JB
Again, a ‘classic’ primary textbook.
26 27

Pharmacology for Anaesthesia and
Intensive Care
Peck T, Hill S
Excellent pharmacology textbook for FRCA
exam revision.
Essentials of Anaesthetic Equipment
Al-Shaikh B, Stacey S
Excellent for the OSCE.
Guide to the FRCA Examination - The
Primary
The Royal College of Anaesthetists
Contains sample questions, some of which
still appear.
QBase MCQs for the Primary FRCA
series 1, 4, 7
Hammond E, McIndoe A
Anatomy for Anaesthetists
Ellis H
A number of books are also available
based on the Primary FRCA OSCE and
SOE examinations.
Getting an ST3 post in
anaesthetics
Progressing to intermediate level
training:
Before a trainee can progress to
intermediate level training (ST3-4) they
must have:
a) obtained the Basic Level Training
Certificate (BLTC)
b) demonstrated reasonable attitudes
and behaviour
c) passed the Primary FRCA or an
exempting examination
The actual duration of an individual’s
training will be determined by the rate
at which they achieve the necessary
competences. The principles of the UK
CCT training programme are that it:
• is competency based
• is planned
• is evaluated
• has clear objectives
• is supervised
• is delivered by appropriately
appointed trainers
• allows time for study
• accommodates the specific career
needs of individuals
There are certain generic professional
skills, essential to the training of all
specialists that should be covered.
These include:
• Skills, attitude and behaviour
• Communication
• Presentation
• Audit
• Teaching
• Ethics and law
• Management
The Basic Level Training Certificate is
the minimum requirement for an ST3
post and for those who must undergo
further selection before entering
Intermediate Training.
28 29

But, it does not help to answer the
question...
“How do I get onto a Specialty Trainee
rotation?”
So what else might be useful to help
you to stand out during the selection
process?
Word-processing your application
form, checking for spelling mistakes
and having a clearly set out Curriculum
Vitae (CV) is a rather obvious place
to start. Update your CV at least
every six months. Studying the Person
Specifications for upcoming ST3
posts may enable you to tailor your
CV for specific posts. Research and
publications impress selectors and
allow them to differentiate between
candidates with similar qualifications.
A letter in a peer-reviewed journal is
probably the easiest way to start your
publication portfolio. Scan the journals
for topics which are of interest to you or
your department, and ask an interested
consultant to help you submit your first
letter. Once you have joined the AAGBI,
you will receive the Association’s scientific
journal Anaesthesia and the newsletter
Anaesthesia News monthly. These are
obvious publications to target first.
Publishing papers based on research
is more difficult because of the time
required to produce anything substantial.
If you are lucky enough to persuade
someone to allow you to contribute to
a project that is already up and running,
check whether they intend to include
you as one of the authors.
You might consider presenting your
paper orally at one of the many national
or international scientific meetings. The
AAGBI awards the Registrars’ Prize for
an original paper presented at the GAT
Annual Scientific Meeting.
Audit projects, as well as being an
essential part of training, are often a good
way to impress, especially if published.
This is more likely to be the case if you
cover something ‘topical’, or currently
controversial, and include an element
of literature review and discussion.
Completing the audit cycle is vital and
impressive. Furthermore, the AAGBI
awards a trainee poster prize (the Audit
Prize) at the GAT Annual Scientific
Meeting each year, which is audit-based.
Always register your audit with your
hospital audit department to prevent any
unforeseen problems before you start.
There is more to publishing than just
primary clinical research. Case reports
are worth considering whenever you find
yourself involved with a rare or unusual
case. Articles on topics of interest can
also, for example, be sent to Anaesthesia
News or to the RCoA Bulletin. The
AAGBI also awards the Anaesthesia
History Prize jointly with the History
of Anaesthesia Society; each year the
winning essay is presented at the GAT
Annual Scientific Meeting.
Many of those competing for posts
will have completed courses such as
Advanced Life Support (ALS), Advanced
Trauma Life Support (ATLS), European
Paediatric Life Support (EPLS) or
28 29

Advanced Paediatric Life Support (APLS),
and you could consider becoming
an instructor on such a course.
Unfortunately many such courses only
allow you to become instructors if
you are in ST 3 or above. You could
offer your services to your hospital’s
Resuscitation Officers, as they are often
looking for doctors to teach on in-house
resuscitation courses.
Management skills, which can be as
basic as organising a social event for the
department, writing rotas and getting
involved with teaching, also enhance any
application.
Finally, there are other aspects to your
career that may not seem relevant at first
glance but are important in enabling you
to stand out from other candidates. These
include any positions of responsibility
you may have undertaken within the
department or outside of medicine, such
as organising an event or involvement
with charity work. In some regions
having worked abroad in medicine also
gains you points.
30 31

Anaesthetic training in Scotland
Author: Dr Adam M Paul
Since political devolution in 1999, the
Scottish Parliament has had control
over the NHS in Scotland, and with
this employment and training for the
doctors within the NHS. However
Anaesthesia retains a UK wide training
programme, through the Royal College
of Anaesthetists. Therefore a CCT in
Inverness will be exactly the same as
one in Plymouth, but there may be
subtle differences in gaining a training
post and in the working environments.
It is refreshing to see how hard and
how successfully the RCoA and AAGBI
have worked to keep training a UK
wide process despite the increasing
differences between home nation NHS
systems. The AAGBI has a Scottish
Standing Committee, which specifically
looks at Scottish anaesthesia issues
and contains at least one trainee
representative.
Across Scotland there are four schools
of anaesthesia: South-East Scotland
(based in Edinburgh, incorporating
Lothian, Fife and Borders);
East of Scotland (based in
Dundee, incorporating Tayside and
Perthshire); North-East Scotland (based
in Aberdeen and Inverness, also
coordinates the new Highlands and
Islands); and West of Scotland (based
in Glasgow, incorporating Greater
Glasgow and Clyde, Ayrshire and Arran,
Dumfries and Galloway, Forth Valley
and Lanarkshire).
Overall these schools fall under the
governance of NHS Education for
Scotland (NES - http://www.nes.scot.
nhs.uk/) which was set up in 2002 to
allow a coordinated national approach
to medical education - this is what
Medical Education: England (MEE) has
been based on. NES is responsible for
the implementation of MMC Scotland
(http://www.mmc.scot.nhs.uk/). Within
NES there are 7 specialty boards, of
which one is Emergency Medicine and
Anaesthesia.
Overall, the application process is like
elsewhere in the UK, ever evolving, and
candidates must keep up to date using
the above websites. There is no bar to
applying to Scotland as well as other
areas in the UK. Moreover, candidates
can still freely move across borders
between different NHS systems because
the training has been kept UK wide.
30 31

Anaesthetic training in
Northern Ireland
Authors: Dr Paul Johnston, Dr Clive Stanley
Currently in Northern Ireland
postgraduate medical training is
managed by the Northern Ireland
Medical and Dental Training Agency
(NIMDTA).
Local recruitment to anaesthesia for
the 2009 process will take the form
of core training in anaesthesia alone.
This may change for the 2010 process
and beyond. Information pertaining
to a change in this process within
Northern Ireland will be advertised
via the NIMDTA web site. The switch
to core training in 2008 followed
three successful years of run through
training, as a pilot in 2005 / 2006 and
subsequently as part of the national
scheme in 2007.
Core training will consist of a two year
period (CT1, CT2) of initial, basic level
training, which must be successfully
completed (including the Primary FRCA
exam) before a candidate is eligible to
apply competitively for a position at
ST3 level. Following successful entry
to ST3 there will be a five year training
programme, incorporating intermediate
and higher level training, culminating
in the completion of training and the
award of a CCT document. A small
number of anaesthetic posts per year
are allocated to allow ACCS emergency
medicine trainees access to anaesthesia
and intensive care medicine, a
requirement of their training scheme.
ACCS trainees themselves, however, are
no longer recruited into the anaesthesia
training scheme. Currently there are no
FTSTA anaesthesia posts in Northern
Ireland.
Of note, following a recent review of
recruitment to specialty training by the
Health Minister in Northern Ireland,
is that the total number of anaesthetic
training posts is expected to fall slightly
over the coming years. This has been
proposed as an attempt at workforce
planning to match training places to the
expected need for senior and consultant
level medical staff. However, as with
EWTD, preparedness is not yet fully
achieved and reductions in training
numbers seem less likely.
The Northern Ireland Deanery is in
the process of seeking legal advice
concerning its responsibility towards
junior doctors whom it acts to employ.
It is in the process of affirming its
position as a recruitment agency in
order to devolve responsibility for
terms and conditions of employment to
individual Trusts which will hold junior
doctor contracts.
32 33

Professionalism and accountability
Author: Sarah Whitehouse, MPS
Professionalism in the medical world
means constantly adapting to the
changing needs of society. How do you
know what is professional? What are
the standards, who should set them,
and how are these standards judged?
Professionalism as a trainee anaesthetist
is about knowing your limits, being
appropriate and working to reduce risk.
The GMC, as the standard bearer for
professionalism, bases good medical
practice on good clinical care, good
relationships with patients, working
with colleagues, teaching and training,
probity and health.
The GMC’s Good Medical Practice
(2006) states that patients must be able
to trust doctors with their lives and
health, and doctors must show respect
for human life, making the care of
patients their first concern. Anaesthetists
and all other healthcare professionals
should protect and promote the health of
patients and the public, while providing
a good standard of practice and care.
Professional responsibilities go beyond
a mere contract of employment. The
Royal College of Anaesthetists sees
maintaining standards as a core element
of professionalism. Raising the standard
(2006) focuses on audit as part of
clinical governance, looking at ways to
improve patient care.
Professionalism is shown through welldeveloped
communication skills. The
RCoA places emphasis on establishing
the confidence of the patient,
promoting meaningful dialogue, and
communicating any risks in a way that a
patient can understand.
Being professional means treating all
patients equally and with empathy;
even so-called difficult or ‘heart-sink’
patients. Labelling a patient can cause
offence to the patient, blind your
clinical judgment, and cause you to
underestimate the severity of physical
symptoms, perhaps bringing your fitness
to practise into question.
Since 1858, the GMC has promoted
high standards of medical education,
dealing firmly with healthcare
professionals whose fitness to practise
is in doubt. In 2007, the GMC spent
£49.1 million on fitness to practise, and
between April 2006 and February 2007,
there were 389 fitness to practise cases.
Professionalism is not about never
making mistakes, but it is about dealing
with adverse events promptly and
correctly – handling any impact on
patient care, giving a full and frank
account of the facts, apologising where
appropriate, and conducting a critical
incident or significant event review to
reduce recurrence.
32 33

Being professional is about being
prepared if things do go wrong and
having the right indemnity support
when facing challenging medico-legal
situations.
For more information on
professionalism and good medical
practice, or for professional indemnity
advice, visit www.mps.org.uk, or
contact MPS on 0845 605 4000.
Whom to ask for help?
Sometimes things in life don’t go to
plan and are much more difficult than
anticipated. There are always a number
of options and whilst it can seem
that you are the only person having a
particular issue with your training; we
can assure you that you will not be
alone. It is important not to bottle things
up, and it is never seen as a weakness,
but more as a sign of maturity to seek
help when it is required.
Often having a chance to speak to
your fellow colleagues in a social
environment can reassure you that you
are on track and others are having the
same concerns as yourself. If you feel
however that you require more help
there are a number of people you can
turn to.
Many departments now offer a
mentoring programme, where you are
paired up with either a senior trainee or
consultant. Mentors tend to fulfil a more
pastoral role than your educational
supervisor and may be your first point
of contact. If you have not been given a
mentor you can request one.
Others to consider within your place
of work include your Educational
Supervisor, College Tutor, the Head of
Department, Programme Director or
simply another consultant with whom
you get on well. You may prefer to
speak to a non-anaesthetist and there
is normally a nominated consultant as
a point of contact for junior doctors,
or you could consider the Head of
Medical Education.
Sometimes it’s easier to speak to
someone outside the work environment
and many feel more comfortable in this
situation. Your GP is a good starting
point and can refer you on to a third
party if you both agree.
Furthermore, your occupational health
department may also be extremely
helpful and they are worth approaching
for not only physical problems.
If you feel you require further help the
BMA and AAGBI both provide support
services, as do other groups:
34 35

The BMA Counselling Service for
doctors and their families provides
instant access to a telephone
counselling service that operates 24
hours a day, 365 days a year. It is there
to help all doctors and their families
with personal, emotional and workrelated
problems. The BMA’s Doctors
for Doctors Unit deals with a wide
range of problems such as drug and
alcohol problems, bullying at work,
mental health issues, and doctors who
have been referred to the GMC/NCAA.
BMA Counselling Service
Tel: 08459 200 169
BMA Doctors for Doctors Unit:
www.bma.org.uk/doctorsfordoctors
or tel: 020 7383 6739. This service
provides 24 hour support and a number
of these advisors are anaesthetists.
Please note that although the service
is 24 hour, an anaesthetist may not be
available at all times.
practical aspects of their career
management or employment or who
have problems of a less urgent nature
should email wellbeing@aagbi.org
or call the AAGBI Secretariat who
will direct your call to members of
Executive or the Welfare Committee as
appropriate.
The AAGBI Welfare Committee has
recently produced a Welfare Resource
Pack. This is available online at http://
www.aagbi.org/publications/guidelines/
docs/welfare_resource_pack_2008.pdf.
Further details of help can be
found in the GAT Handbook and
on the Association of Anaesthetists
website: http://www.aagbi.org/
memberswellbeing.htm.
Finally, remember you are not alone.
Many anaesthetists will have felt
the same at sometime or have been
through similar experiences - you just
need to ask for support.
The AAGBI recognises the importance
of supporting members’ welfare.
Contact is welcomed from members
with regard to any welfare issue. If for
any reason this does not address your
problem, call the AAGBI during office
hours on 020 7631 1650 or email
wellbeing@aagbi.org and you will
be put in contact with an appropriate
advisor.
Members who need to discuss more
34 35

Final checklist
We hope that the information
contained within this guide proves
useful for your future anaesthetic
career.
So, remember to:
• Fill in the form and join the AAGBI
• Register with the Royal College of
Anaesthetists
• Start a logbook today
• Start a portfolio
• Keep a list of all study leave used,
internal and external. This should
include clinical governance
meetings, etc.
• Don’t leave all your workplace
assessments until the last minute!
Appendices
Abbreviations
AAGBI
ACCS
36 37
Association of
Anaesthetists of Great
Britain & Ireland
Acute Care Common Stem
ALS Advanced Life Support /
Advanced Cardiac Life
Support
APLS
Advanced Paediatric Life
Support
ARCP
ASA
ATI
ATLS
BMA
CCT
CT
DoH
EPLS
FRCA
GAT
GMC
IBTICM
ICM
LTFT
Annual Review of
Competence Progression
American Society of
Anesthesiologists
Anaesthetists in Training
in Ireland
Advanced Trauma Life
Support
British Medical
Association
Certificate of Completion
of Training
Core Trainee
Department of Health
European Paediatric Life
Support
Fellow of the Royal
College of Anaesthetists
Group of Anaesthetists in
Training
General Medical Council
Intercollegiate Board for
Training in Intensive Care
Medicine
Intensive Care Medicine
Less-Than-Full-Time
Training

MMC
Modernising Medical
Careers
SAS
Staff and Associate
Specialists
ODP/ODA Operating Department
Practitioner: you will
however notice that they
are often referred to as
Operating Department
Assistant, which was the
title used in previous
years. There may also be
anaesthetic trained nurses
and Physicians’ Assistants
(Anaesthesia) - previously
described as Anaesthetic
Practitioners - within your
department.
OOPT
PALS
PMETB
RCoA
RCSI
Out-of-Programme
Training
Paediatric advanced life
support, now EPLS
Postgraduate Medical
Education and Training
Board
Royal College of
Anaesthetists
Royal College of Surgeons
of Ireland (College of
Anaesthetists)
SpR
ST
Useful Addresses
Specialist Registrar
Specialty Training / Trainee
Group of Anaesthetists in Training
(GAT)
The Association of Anaesthetists of
Great Britain & Ireland
21 Portland Place, London W1B 1PY
tel: 020 7631 1650
fax: 020 7631 4352
email: gat@aagbi.org
website: www.aagbi.org/gat.htm
The Association of Anaesthetists of
Great Britain & Ireland (AAGBI)
21 Portland Place, London W1B 1PY
tel: 020 7631 1650
fax: 020 7631 4352
email: info@aagbi.org
website: www.aagbi.org
Royal College of Anaesthetists (RCoA)
35 Red Lion Square, London WC1R
4SG
tel: 020 7092 1500
fax: 020 7092 1730
email: info@rcoa.ac.uk
website: www.rcoa.ac.uk
36 37

RCoA Examinations Department
tel: 020 7908 7312
fax: 020 7636 8280
email: exams@rcoa.ac.uk
The College of Anaesthetists, Royal
College of Surgeons of Ireland (RCSI)
22 Merrion Square North, Dublin 2,
Ireland
tel: 353 1 661 4412
fax: 353 1 661 4374
email: info@coa.ie
website: www.anaesthesia.ie
The Intercollegiate Board for Training
in Intensive Care Medicine (IBTICM)
c/o The Royal College of Anaesthetists
35 Red Lion Square, London WC1R
4SG
tel: 020 7092 1556
fax: 020 7092 1730
Email: ibticm@rcoa.ac.uk
website: www.ibticm.org
The College of Anaesthetists, Royal
College of Surgeons of Ireland (RCSI)
22 Merrion Square North, Dublin 2,
Ireland
tel: 353 1 661 4412
fax: 353 1 661 4374
email: info@coa.ie
website: www.anaesthesia.ie
Anaesthetists in Training in Ireland
(ATI)
PO Box 6526, Dublin 4
email: ati@coa.ie
Website: http://www.anaesthesia.ie/
sections/Default.asp?cms=training_ATI+
Group&cmsid=59_83&id=83&secid=5
The Bernard Johnson advisors
LTFT Training
c/o The Royal College of Anaesthetists
Training Department
35 Red Lion Square, London WC1R
4SG
tel: 020 7092 1553
fax: 020 7092 1730
email: training@rcoa.ac.uk
website: www.rcoa.ac.uk
Essential Reading
• The GAT Handbook – 9th edition.
AAGBI, London, 2009
• The CCT in Anaesthesia I: General
Principles: A manual for trainees and
trainers. Edition 1: January 2007
• The CCT in Anaesthesia II:
Competency Based Basic Level
(ST Years 1 and 2) Training and
Assessment. A manual for trainees
and trainers. Edition 1: January 2007
38 39

38 39

Published by: The Group of Anaesthetists in Training
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
t: 020 7631 1650 f: 020 7631 4352
e: gat@aagbi.org
www.aagbi.org/gat.htm
40

Inter-hospital transfer of the critically-ill
patient in the Republic of Ireland
Guidelines for Anaesthetists in referring units
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 76311650 Fax 020 7631 4352
www.aagbi.org
June 2006

Membership of the working party
CONTENTS
Dr. Rory Page
Dr. Ellen O’Sullivan
Dr. Eamon Tierney
Dr. Brian Pickering
Dr. Anne Bergin
Dr. John Kennedy
Dr. John Loughrey
Dr. Michael Power
Chairman, Working Party / Secretary,
Irish Standing Committee, AAGBI
Convenor, Irish Standing Committee, AAGBI
Deputy Convenor, Irish Standing Committee,
AAGBI
Co-opted, Anaesthetists in Training in Ireland
Member, Irish Standing Committee, AAGBI
Member, Irish Standing Committee, AAGBI
Member, Irish Standing Committee, AAGBI
Co-opted, Irish Intensive Care Society
1. Summary of Recommendations 2
2. Introduction 4
3. Background 5
4. Reasons for transfer in the Republic of Ireland 7
5. Selection of patients requiring anaesthesia care 8
during transfer
6. The transfer 10
7. The base hospital during transfer 12
8. Post-transfer 15
9. The future 16
10. References 17

1. SUMMARY OF RECOMMENDATIONS
1. A 7-day 24-hour inter-hospital retrieval service should be available
for all critically ill patients.
2. Pending the establishment of a full retrieval team for all patients,
extra arrangements for the continuation of the anaesthetic service
need to be put in place in the event of a transfer.
3. Many hospitals caring for critically ill patients on a 24-hour basis
do not have adequate resources to provide the modern standard
of care initially required for these patients prior to transfer. The
funding needs to be put in place to correct these inadequacies.
4. The need for anaesthetic care of a patient during the period of
inter-hospital transfer is determined by the anaesthetic team
attending the patient in the referring hospital.
5. The patient should be resuscitated and his clinical condition
should be as stable as possible before transfer.
6. Any procedures which are reasonably likely to have to be
performed on an emergency basis in the transfer vehicle should be
performed electively in the referring hospital prior to transfer.
7. Interhospital communication between referring teams should be at
an experienced level.
8. Care of the patient during transfer should not be compromised and
should be to a standard as close as possible to that available in an
intensive care unit.
9. Inter-hospital transfer should be undertaken calmly but with
minimum delay. If requested, a police escort should be available
to facilitate travel through traffic black spots or other delays.
Decisions during transfer regarding speed, sirens and degree of
urgency should be determined by the accompanying doctor, in
consultation with the emergency medical technician (EMT) team.
10. Care of the anaesthetist-accompanied patient during transfer is
the responsibility of the referring anaesthetic team. There should
be excellent communication between the referring consultant
anaesthetist and the transfer team en route.
11. The anaesthesia service at the base hospital may need to be
curtailed as a result of losing staff to inter-hospital transfer duties.
12. Each referring and receiving hospital should have a set of guidelines
available to doctors to minimise problems of patient transfer.
13. Each hospital should have a brief, formal review of each transfer
within a few days of the transfer. This should be led by a
consultant anaesthetist. The purpose of this review would be to
discuss any issues of difficulty that arose during the transfer and to
create policies to help prevent future clinical and organisational
problems.

2. INTRODUCTION
Inter-hospital transfer of the critically ill patient in Ireland necessitates
the accompaniment of a transfer team, usually led by the consultant
anaesthetist at the base hospital. This absence of anaesthesia personnel
from their base hospital has subsequent deleterious effects on the
Department of Anaesthesia’s ability to provide the usual breadth of
service locally.
The purpose of this document is to provide a broad set of guidelines
to consultant anaesthetists and their trainees in referring hospitals as
to how to effect the patient transfer safely and efficiently and how to
maintain the safest possible service at the base hospital in the absence
of the resident non-consultant hospital doctor (NCHD) anaesthetist.
The emphasis of this document is on quality care for all patients.
3. BACKGROUND
From an inter-hospital transport perspective there are three types of
hospitals in Ireland.
1. Many hospitals in urban areas have tertiary speciality units such
as Neurosurgery, Cardiothoracic surgery, Spinal Injuries units,
Paediatric surgery, Haematology and Complex Intensive Care.
These are specialties to which all hospitals may refer. In the main,
the transfer of patients to these hospitals is inward. Occasionally,
however, the transfer is outward to another hospital.
2. Other hospitals, currently described as regional, have varying
degrees of capability to handle complex cases e.g. trauma,
vascular, complex medical cases, complex paediatrics, and
complex maternity on a 24-hour/ 7-day week basis. These
hospitals may transfer patients to the tertiary centres as well as
accepting patients from smaller acute hospitals.
3. The remaining acute units, over twenty in number in General
Hospitals around the country, have large variations in their ability
to deal with acute cases as a result of decentralised policy that
may or may not have reflected local need. Some support acute
adult general surgical, medical, paediatric and maternity services.
Others only have a general adult medical service and a general
surgical service.
Many of these hospitals have a 24-hour accident and emergency
(A&E) service but do not have the staff and facilities to cater for
more complex emergencies. For example, many of these hospitals
do not have an A&E consultant available out-of-hours or even
within the normal 9 to 5 working week, nor do they even all have
experienced A&E doctors at non-consultant level at all times. Not
all A&E departments have a CT scanner available to them on-site
24 hours a day. It is difficult to justify having an A&E department
open for emergencies such as major head injuries or spontaneous
brain haemorrhage without a CT scanner being made immediately

available, and without immediate transfer of the CT images to the
nearest neurosurgical unit. The role for this third layer of hospitals
in the management of critically ill patients is primarily triage,
stabilisation, treatment and / or transfer for further management.
4. REASONS FOR TRANSFER IN THE REPUBLIC
OF IRELAND
Patients are transferred because of their need for specific medical
attention that is not available on-site in the relevant hospital. Examples
of this directed referral include transfer of cardiac patients to one of the
nation’s five cardio-thoracic units (Mater Hospital, Crumlin Hospital,
St. James’ Hospital, Cork University Hospital, University College
Hospital, Galway). Alternatively a patient with multiple injuries may
require referral to a spinal or neurosurgical unit, or a critically ill child
may need transfer to a paediatric ICU.
In addition, patients are also transferred within local HSE areas to
more specialised units for further care, e.g. orthopaedics or intensive
care. An anaesthetist is needed to provide care to those patients whose
requirements include major resuscitation, including management
of the airway and ventilation. This anaesthetic transfer may occur
with further assistance from other disciplines as per national or local
guidelines.
Sometimes the anaesthesia team that is responsible for complex
resuscitative care may make the decision to transfer to another
anaesthetic service rather than to a surgical or medical service
elsewhere. This may be recognition of the existence of limited
resources locally and to obtain more complex treatment elsewhere in
the best interests of the patient.

5. SELECTION OF PATIENTS REQUIRING
ANAESTHESIA CARE DURING TRANSFER
The anaesthetist on call is the person responsible for deciding
whether a patient being transferred requires anaesthetic care during
the transfer. While an intubated patient in hospital does not need a
doctor in attendance at all times, the transfer of an intubated patient
should involve a doctor capable of providing a definitive airway. Other
specialty groups (e.g. A&E medicine) are developing skills in the area
of intubation and ventilation. The Standing Committee is of the view
that it is wholly appropriate for other doctors who possess these skills
to accompany patients, and particularly if they initiate ventilation.
Critically ill children have special needs with regard to transfer.
Special conditions attaching to the transfer of critically ill children are
included in our previous document “Care of the critically ill child in
Irish Hospitals” (Published by the AAGBI and Faculty of Paediatrics,
RCPI, 2005).
Many patients do not need anaesthetic support during inter-hospital
transfer.
These patients include:
• patients who are not likely to need airway or ventilatory support
• patients who are not for resuscitation measures
• patients being transferred for acute definitive management for whom
anaesthesia support will not affect their outcome
• when the request for anaesthetic care during transfer exceeds the
Department of Anaesthesia’s resources to do so safely at that time.
Although the patient would benefit from anaesthesia management
the issue may be one of either delaying transfer until such resources
are available or alternatively sending the patient without an
accompanying anaesthetist but with another doctor.
The Standing Committee is also of the view that, in patients for
whom life-support measures have not been initiated but there exists
a reasonable likelihood that they may become necessary en route to
the receiving hospital, such life-support measures should be initiated
electively prior to transfer. This is in order to avoid the complications
of roadside procedures being performed under sub-optimal conditions.
Such procedures include tracheal intubation, ventilation, peripheral
and central venous cannulation and insertion of chest drains.

6. THE TRANSFER ITSELF
The anaesthesia team transferring a patient must be confident that
the accepting unit understands the patient’s needs and has the
resources to accept them. As a practical point, communication on
as high a level as possible should take place prior to transfer, ideally
Consultant anaesthetist to Consultant anaesthetist but certainly from
one experienced anaesthetist to another. In addition, there should be
senior communication between the referring team in the base hospital
to the admitting team in the receiving hospital.
Telephone communications from the ambulance to the consultant
anaesthetist and the base hospital should always be available.
Key decision-making during transfer is the responsibility of the
transferring anaesthetic team. This team should consult on patient
management issues with the receiving team but the transferring team,
being the team physically attending the patient, should make the key
decisions.
The principle behind safe transfer is that the patient should receive the
same quality of care during transfer as in the base ICU. Care should
be provided by experienced personnel, including a critical care
nurse, an anaesthetist, and, when necessary, other experienced staff.
Although the accompanying anaesthetist is usually in a training grade,
nevertheless he should be sufficiently experienced to complete the
transfer to a high standard of patient care, and with immediate advice
available at all times from the consultant in the base hospital. The
patient should be resuscitated and as stable as possible on departure.
Although inter-hospital transfer is usually urgent, The Standing
Committee feels that there is little to be gained by speeding between
hospitals. Transfer should take place in a calm manner to allow for
the maximum comfort of the patient and team. Sirens and blue lights
should only be used in the case of obstructing traffic. Garda escorts
should be requested in areas of traffic black spots to facilitate calm
and steady progress. The Standing Committee feels that the Emergency
Medical Technician (EMT) ambulance crew should consult the
anaesthetist in this regard.
The transfer team should be covered by insurance cover adequate
to protect it from any claims arising from incidents en route. The
insurance cover should also include cover for members of the transfer
team itself for any injury or loss of employment which might arise
following an accident en route.
10
11

7. THE BASE HOSPITAL DURING TRANSFER
Usually a member of the Department of Anaesthesia is in charge of the
transfer of a critically ill patient both during normal hours and in the
out-of-hours setting. This duty is usually carried out by an anaesthetic
NCHD. In most referring hospitals there is only one anaesthetic NCHD
on call out-of-hours so that the referring hospital is bereft of its only inhouse
anaesthetic doctor for long periods. The consultant on call from
home is the only anaesthetist then available and he must prioritise his
role and resources to balance clinical demands and personnel. This
may leave key areas of the acute hospital service with anaesthetic cover
that is less than optimal. For example, in many hospitals, when the
anaesthetic NCHD on call has left the hospital on inter-hospital duties,
the consultant anaesthetist is left alone to cover the competing needs
of maternity, emergency general surgery, intensive care, resuscitation
and accident/emergency. This is clearly an impossible task, resulting in
the consultant anaesthetist reluctantly having to prioritise certain areas
above others.
The Standing Committee feels than out-of-hours transfers should only
take place when immediate active management of the patient will take
place in the receiving hospital. If surgery, for example, will not take
place until the following day then an early morning transfer should
be arranged rather than conduct an unnecessary middle-of-the-night
transfer with resultant loss of anaesthetic cover locally.
The recommendation of the Standing Committee is that, when an
anaesthetist finds himself alone to cover competing units in the absence
of his colleague on transfer duties, he should hold the obstetric unit,
where present, as his clinical priority. Specifically the anaesthetist
should keep himself free for emergency Caesarean sections. If there
is an epidural service in the obstetric unit it should be temporarily
suspended until the resident anaesthetist returns to base. Secondly, the
single-handed anaesthetist should keep himself free for involvement
in the management of ICU patients to whom he is already clinically
committed.
With regard to provision of anaesthesia for theatre cases other than
Caesarean sections, it is imperative to stress that the provision of
anaesthesia by an anaesthetist to a patient means that he is fully
occupied with that patient to an exclusive level for the duration of the
anaesthetic and cannot become involved in the management of other
patients during that time. The vast majority of non- Caesarean section
cases must therefore be transferred to the nearest appropriate hospital
if surgery is urgent or alternatively must wait until the transferring
anaesthetist returns to base.
The primary recommendation of the Standing Committee is that when
an anaesthetist finds himself single-handedly covering a number
of areas simultaneously, he should contact hospital and nursing
management on duty at that time, and outline the problem of
inadequate anaesthetic cover to them. He should inform management
of his recommendations, as follows:
1. That, until the resident anaesthetist returns, critically ill patients
should not be delivered by ambulance to the A&E department, nor
admitted to the wards. Instead, these cases should be transferred to
the nearest appropriate unit.
2. That he, the anaesthetist on-call, will keep himself free for
emergency Caesarean sections and will not bring any other cases
to theatre. The Standing Committee recognises that, on a very rare
occasion when there is an immediately life-threatening situation,
such as massive haemorrhage or major airway problems, a patient
will have to be brought to theatre immediately as an urgent lifesaving
measure. In this circumstance the anaesthetist should ensure
that the grave state of the patient is carefully documented by the
admitting consultant. The anaesthetist should then inform the
consultant obstetrician and the labour ward that there will be no
anaesthetic cover for Caesarean sections until this urgent patient
has left the operating theatre or alternatively until the transfer team
returns.
3. That the epidural service will be temporarily suspended until the
resident anaesthetist returned.
12
13

4. No other anaesthesia-accompanied transfers can take place until
the return of the first transfer team.
The above situation may pertain less in the normal working hours
when there are more staff members available. In addition the
national mobile Intensive Care Unit (M.I.C.A.S.) is available for
planned inter-hospital transfer 9 to 5 Monday to Friday.
The members of the Department of Anaesthesia should discuss the
problems at the base hospital during inter-hospital transfer:
• within their own department to ensure a consistent response from
all anaesthetists
• at clinical directorate level to ensure hospital-wide plans are put in
place to deal with transfer associated difficulties and
• at the hospital medical board to ensure that consultants in all
specialties are aware of the difficulties.
8. POST-TRANSFER
After a transfer the return to base of the transfer team should be effected
as comfortably and as rapidly as possible.
The Standing Committee wishes to stress that, when a transfer team
returns to base, its members should not be expected to immediately
dive straight into their work schedule without having had a significant
rest break.
There should be a debriefing discussion after each inter-hospital transfer
between the transfer team and the referring hospital consultants.
Problems should be highlighted and policies established to prevent
recurrence of similar problems. Organisational difficulties between
referring and receiving hospitals should be discussed by the relevant
consultants in both hospitals and policies implemented to prevent
recurrence of these difficulties.
Each anaesthetic department should keep formal minutes of these
debriefing sessions. The minutes should be available to inspection on
request by teams from the College of Anaesthetists RCSI and the Irish
Medical Council.
Both referring and receiving hospitals should have a broad set of
guidelines available in their ICU and A&E departments so that doctors
engaged in referring or receiving patient transfers can refer to these
guidelines when confronted by transfer difficulties. These guidelines
should be broad and should cover both clinical and organisational
aspects of patient transfer. The guidelines should be reviewed
annually.
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15

9. THE FUTURE
The current limited retrieval service run by Dublin hospitals operates
only from 9 to 5, five days a week. In addition the service is available
only to ICU patients and excludes other patients.
A 7-day, 24-hour inter-hospital retrieval service should be available for
all critically ill patients needing transfer. This would include trauma
patients.
Pending this arrangement, all hospitals should have enough levels
of anaesthetic cover to ensure that there is a continuous in-house
anaesthetic presence even when inter-hospital transfers are taking
place.
10. REFERENCES
1. “Transport of the Critically Ill.”
Intensive Care Society of Ireland. 1991.
2. “Care of the Critically Ill Child in Irish Hospitals.”
Association of Anaesthetists of Great Britain and Ireland. 2005
3. “OAA / AAGBI Guidelines for Obstetric Anaesthetic Services 2.”
OAA / AAGBI Revised Edition 2005.
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17

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org
Designed and produced by the r2 Partnership Ltd

Day Case and Short Stay Surgery
2
Published by
The Association of Anaesthetists of Great Britain & Ireland
The British Association of Day Surgery
May 2011

This guideline was originally published in Anaesthesia. If you wish to refer to
this guideline, please use the following reference:
Verma R, Alladi R, Jackson I, et al. Day case and short stay surgery: 2,
Anaesthesia 2011; 66: pages 417-434
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06651.x/pdf
This guideline has been endorsed by the Association of Surgeons of
Great Britain and Ireland and the Association for Perioperative Practice.
© The Association of Anaesthetists of Great Britain & Ireland and the British Association of Day
Surgery 2011

GUIDELINES
Day case and short stay surgery: 2
Association of Anaesthetists of Great Britain and Ireland
British Association of Day Surgery
Membership of the Working Party: R. Verma (Chairman), R. Alladi,
I. Jackson, I. Johnston, C. Kumar, R. Page, I. Smith, M. Stocker,
C. Tickner, S. Williams and R. Young
This is a consensus document produced by expert members of a Working Party
established by the Association of Anaesthetists of Great Britain and Ireland
(AAGBI) and British Association of Day Surgery (BADS). It has been seen and
approved by the Councils of the AAGBI and BADS.
Summary
1 Day surgery is a continually evolving speciality performed in a range of
ways across different units.
2 In recent years, the complexity of procedures has increased with a wider
range of patients now considered suitable for day surgery.
3 Effective pre-operative preparation and protocol-driven, nurse-led
discharge are fundamental to safe and effective day and short stay surgery.
4 Fitness for a procedure should relate to the patient’s health as
determined at pre-operative preparation and not limited by arbitrary
limits such as ASA status, age or body mass index.
5 Patients presenting with acute conditions requiring urgent surgery can be
efficiently and effectively treated as day cases via a semi-elective pathway.
6 Central neuraxial blockade and a range of regional anaesthetic
techniques, including brachial plexus and paravertebral blocks, can be
used effectively for day surgery.
Re-use of this article is permitted in accordance with the Creative Commons Deed,
Attribution 2.5, which does not permit commercial exploitation.
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7 Each anaesthetist should develop techniques that permit the patient to
undergo the surgical procedure with minimum stress and maximum
comfort, and optimise his ⁄ her chance of early discharge.
8 Every day surgery unit must have a Clinical Lead with specific interest
in day surgery and whose remit includes the development of local
policies, guidelines and clinical governance.
9 Good quality advice leaflets, assessment forms and protocols are in use
in many centres and are available to other units.
10 Effective audit is an essential component of good care in all aspects of
day and short stay surgery.
11 Enhanced recovery is based on established day surgery principles and
is aimed at improving the quality of recovery after inpatient surgery
such that the patient is well enough to go home earlier and
healthier.
The definition of day surgery in the UK and Ireland is clear: the patient
must be admitted and discharged on the same day, with day surgery as the
intended management. Although still counted as inpatient treatment
(except in the US), 23-h and short stay surgery apply the same principles of
care outlined in this document and can improve the quality of patient care
whilst reducing length of stay.
Since the previous guideline was published in 2005, the complexity of
procedures has increased with a wider range of patients now considered
suitable for day surgery. Despite these advances, the overall rates of day
surgery remain variable across the UK. Whereas the target of 75% of
elective surgery to be performed as day cases from the NHS plan
remains [1], the true picture is difficult to determine, since the only
nationally reported data are limited to 25 procedures [2]. Ten years on,
the advancement of minimally invasive surgery is allowing more
procedures to be performed as day surgery and even higher rates should
be possible.
There was a major drive to promote day surgery around the turn of
this century, but the political focus moved on before all of the lessons
learned were fully implemented [3]. Nevertheless, the recent drive to
reduce length of stay and improve the quality of postoperative recovery
has ensured that day surgery principles are fundamental to modern
patient care. Shortened hospital stays and earlier mobilisation also reduce
the risk of hospital-acquired infections and venous thromboembolism
(VTE).
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Recent reports
The NHS Modernisation Agency produced an operational guide detailing the
facilities available in, and the management of, day units [4]. This was further
refined in the Ten High Impact Changes document in which the principle of
treating day surgery as the default option for elective surgery was set out [3].
The NHS Institute for Innovation and Improvement has also produced a
document focusing on day case laparoscopic cholecystectomy [5]. Whereas
this document is specific to one procedure, many aspects of the ideal patient
pathway are equally applicable to a wide range of day surgery procedures.
Effective pre-operative assessment and preparation with protocol-driven,
nurse-led discharge are fundamental to safe and effective day and short stay
surgery. Several recent publications provide useful advice on the establishment
and running of both services [6–10].
The British Association of Day Surgery has produced a directory of
procedures that provides targets for day and short stay surgery rates for over
200 different procedures [11]. These procedure-specific targets serve as a
focus for clinicians and managers in the planning and provision of short stay
elective surgery and illustrate the high quality of service achievable in
appropriate circumstances.
In March 2010, the Department of Health published the enhanced
recovery guide that extends day surgery principles to inpatient surgery [12].
Selection of patients
Patients may be referred for day surgery from outpatient clinics, accident
and emergency departments or primary care.
Recent advances in surgical and anaesthetic techniques, as well as the
publication of successful outcomes in patients with multiple comorbidities,
have changed the emphasis in day surgery patient selection. It is now
accepted that the majority of patients are appropriate for day surgery unless
there is a valid reason why an overnight stay would be to their benefit. If
inpatient surgery is being considered it is important to question whether any
strategies could be employed to enable the patient to be treated as a day case.
Full-term infants over 1 month are usually appropriate to undergo day
surgery. A higher age limit is advisable for ex-premature infants (60 weeks
post-conceptional age). The significant risk posed by postoperative apnoea
must be considered and infants with recent apnoea episodes, cardiac or
respiratory disease, family history of sudden infant death syndrome and
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adverse social circumstances should be considered for overnight admission
and close monitoring. Day surgery units should not perform surgery on
children unless they have suitable staff and facilities.
It is recommended that a multidisciplinary approach, with agreed
protocols for patient assessment including inclusion and exclusion criteria
for day surgery, should be agreed locally with the anaesthetic department.
Patient assessment for day surgery falls into three main categories:
Social factors
(a) The patient must understand the planned procedure and postoperative
care and consent to day surgery.
(b) Following most procedures under general anaesthesia, a responsible
adult should escort the patient home and provide support for the first
24 h.
(c) The patient’s domestic circumstances should be appropriate for
postoperative care.
Medical factors
(a) Fitness for a procedure should relate to the patient’s health as
determined at pre-operative assessment and not limited by arbitrary
limits such as ASA status, age or BMI [13–15].
(b) Patients with stable chronic disease such as diabetes, asthma or epilepsy
are often better managed as day cases because of minimal disruption to
their daily routine.
(c) Obesity per se is not a contraindication to day surgery as even morbidly
obese patients can be safely managed in expert hands, with appropriate
resources. The incidence of complications during the operation or in
the early recovery phase increases with increasing BMI. However,
these problems would still occur with inpatient care and have usually
resolved or been successfully treated by the time a day case patient
would be discharged. In addition, obese patients benefit from the
short-duration anaesthetic techniques and early mobilisation associated
with day surgery [16].
Surgical factors
(a) The procedure should not carry a significant risk of serious complications
requiring immediate medical attention (haemorrhage, cardiovascular
instability).
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(b) Postoperative symptoms must be controllable by the use of a
combination of oral medication and local anaesthetic techniques.
(c) The procedure should not prohibit the patient from resuming oral
intake within a few hours.
(d) Patients should usually be able to mobilise before discharge although
full mobilisation is not always essential.
Pre-operative preparation
Pre-operative preparation (formerly known as pre-operative assessment) has
three essential components:
1 To educate patients and carers about day surgery pathways.
2 To impart information regarding planned procedures and postoperative
care to help patients make informed decisions – important information
should be provided in writing.
3 To identify medical risk factors, promote health and optimise the
patient’s condition.
All patients must be assessed by a member of the multidisciplinary team
trained in pre-operative assessment for day surgery. Consultant-led and
nurse-run clinics have proved very successful.
Pre-operative preparation is best performed within a self-contained day
surgery facility, where available. This allows patients and their relatives the
opportunity to familiarise themselves with the environment and to meet
staff who will provide their peri-operative care [17]. One-stop clinics,
where pre-operative preparation is performed on the same day as decision
for surgery, offer significant advantages.
Screening questionnaires (Appendix 1), in conjunction with pre-set
protocols, can offer guidance on appropriate investigations, as routine
pre-operative investigations have no relevance in modern anaesthesia.
Although the National Institute of Health and Clinical Excellence
(NICE) guidance on pre-operative investigations [18] is widely
used, one recent study showed no difference in the outcomes of day
surgery patients even when all pre-operative investigations were omitted
[19].
Pre-operative preparation clinics can improve efficiency by enabling
early review of the notes of complex cases, ensuring appropriate
investigations are carried out and that patients are referred for specialist
opinion if deemed necessary.
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Day surgery for urgent procedures
Patients presenting with acute conditions requiring urgent surgery can be
efficiently and effectively treated as day cases via a semi-elective pathway
[20]. After initial assessment many patients can be discharged home and
return for surgery at an appropriate time, either on a day case list or as a
scheduled patient on an emergency list, whereas others can be immediately
transferred to the day surgery service. This reduces the likelihood of
repeated postponement of surgery due to prioritisation of other cases. A
robust day surgery process is key to the success of this service. Some of the
procedures successfully managed in this manner are shown in Table 1
[21–25]. Essential components of an emergency day surgery pathway are:
1 Identification of appropriate procedures.
2 Identification of a theatre list that can reliably accommodate the
procedure (e.g. a dedicated day surgery list or a flexibly run emergency
theatre list).
3 There should be clear pathways for day surgery in place.
4 The condition must be safe to be left untreated for a day or two and
manageable at home with oral analgesia (standardised analgesic pack for
the patient to take home).
5 There should be provision of clear pre-operative patient information,
ideally in writing.
Documentation
Detailed documentation is important within the day surgery environment
as the patient’s experience is often condensed into a few hours. All aspects
Table 1 Types of urgent surgery suitable for day case procedures.
General surgery Gynaecology Trauma Maxillofacial
Incision and drainage
of abscess
Laparoscopic
cholecystectomy
Laparoscopic
appendicectomy
Temporal artery
biopsy
Evacuation of retained
products of conception
Laparoscopic ectopic
pregnancy
Tendon repair
Manipulation
of fractures
Plating of
fractured
clavicle
Manipulation of
fractured nose
Repair of fractured
mandible ⁄ zygoma
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of treatment and care must be recorded accurately to ensure that each
patient follows an effective and safe pathway.
Documentation should be a continuum from pre-operative preparation
to discharge and subsequent follow-up. Single care plans reflecting a
multidisciplinary approach are favoured in many units. Variations for
specific groups including children and patients undergoing procedures
under local anaesthesia should be available. Procedure-specific care plans
reflecting integrated care pathways may be used for more complex and
challenging cases [26]. Such care plans are also useful for audit and
evaluating outcome.
Patients should be provided with general as well as procedure-specific
information. This should be given in advance of admission to allow time for
questioning and preparation for same day surgery. Verbal comments should
be reinforced with written material. General information should include
practical details about attending the day surgery unit whereas procedurespecific
information should include clinical information about the patient’s
condition and surgical procedure (Appendix 2). The anaesthetic information
leaflets developed jointly between the AAGBI and the Royal College
of Anaesthetists (RCoA) may also be used [27]. Information for children is
also available [28].
Management and staffing
Every day surgery unit must have a Clinical Lead with specific interest in
day surgery and whose remit includes the development of local policies,
guidelines and clinical governance. A consultant anaesthetist with
management experience is ideally suited to such a role and job plans must
reflect this responsibility [4]. Day surgery must be represented at Board
level [4].
The Clinical Lead should be supported by a day surgery manager who
has responsibility for the day-to-day running of the unit. The manager will
often have a nursing background and should have the knowledge and skills
to make informed decisions and lead on all aspects of day surgery
development.
Nurses, operating department practitioners, physicians’ assistants
(anaesthesia) (PA(A)s), and other ancillary staffing levels will depend
on the design of the facility, casemix, workload and local preferences
and ability to conform to national guidelines. Staff working in these
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Guidelines: Day case and short stay surgery
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units should be specifically trained in day surgery care. Many units
favour multiskilled staff who have the knowledge and skills to work
within several different areas of the day surgery unit. Efficient use of
resources is best achieved by a well-trained, flexible and multiskilled
workforce [29].
Extended roles facilitate job satisfaction and encourage personal development
and staff retention. Many health care assistants in the day surgery
unit are now able to perform duties traditionally only undertaken by
qualified nurses [30–32]. Individual units should formulate a staffing
structure that takes into consideration local needs.
Each unit should have a multidisciplinary operational group that oversees
the day-to-day running of the unit, agrees policies and timetables, reviews
operational problems and organises audit strategies.
Facilities
Day surgery should ideally be provided in a self-contained unit that is
functionally and structurally separate from inpatient wards and theatres
[33]. It should have its own reception, consulting rooms, ward, theatre
and recovery areas, together with administrative facilities. The operating
theatre and first stage recovery areas should be equipped and staffed to
the same standards as an inpatient facility, with the exception of the
use of trolleys rather than beds. Several patients per day can occupy the
same trolley space, providing far greater efficiency than on wards where
one day case may occupy a bed for a whole day. Car parking or
short stay drop-off and pick-up areas should be provided adjacent to the
unit.
An alternative to a purpose-built unit is the use of a day case ward with
patients transferred to the main operating theatre. This model allows a more
straightforward transition from overnight stay to day case for complex
procedures as there is little impact on theatre equipment or staffing.
However, day case beds dispersed around many wards do not achieve these
efficiencies, nor do they provide the targeted service that is required to
achieve good outcomes.
Typical day unit opening hours would be 07:00–20:00 Monday to
Friday, but with the increasing complexity of surgery many units now open
until about 22:00.
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Many hospitals provide care for day surgery patients who require
anaesthesia in specialised units, e.g. ophthalmology or dentistry. It may not
be possible or appropriate to centralise these services; however, all such
patients should receive the same high standards of selection, preparation,
peri-operative care, discharge and follow-up as those attending dedicated
day surgery facilities.
Facilities should ensure the maintenance of patients’ privacy and
dignity at all times. Side rooms are particularly useful when caring for
patients requiring an increased level of sensitivity, or for those with
special needs.
Children should be cared for in a facility that reflects their emotional
and physical needs, separate from adult patients and conforming to the
standards required by paediatric units. Nursing staff should be skilled in
paediatric day surgical care. Parents and carers, wherever possible, should
be involved in all aspects of care and appropriate facilities provided for
them.
Anaesthetic management
Day surgery anaesthesia should be a consultant-led service. However, as
day surgery becomes the norm for elective surgery, consideration should
be given to education of trainees as recommended by the RCoA. This
requires appropriate training and provision of senior cover, especially in
stand-alone units. Staff grade and associate specialist anaesthetists who
have an interest in day surgery should be encouraged to develop this as a
specialist interest and take an important role in the management of the
unit.
Appropriate selection and patient preparation is crucial for day surgery.
National guidelines for patient monitoring and assistance for the anaesthetist
should be followed [34, 35].
Anaesthetic techniques should ensure minimum stress and maximum
comfort for the patients and should take into consideration the risks and
benefits of the individual techniques. Analgesia is paramount and must be
long acting but, as morbidity such as nausea and vomiting must be
minimised, the indiscriminate use of opioids is discouraged (particularly
morphine). Prophylactic oral analgesics with long-acting non-steroidal antiinflammatory
drugs (NSAIDs) should be given to all patients if not
contraindicated. For certain procedures (e.g. laparoscopic cholecystectomy)
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there is evidence that standardised anaesthesia protocols or techniques
improve outcome. Anaesthetists should adhere to such clinical guidelines
where they exist.
Although early mobilisation should be beneficial, extending the range
and complexity of day surgery procedures may increase the risk of VTE.
National guidelines for VTE risk assessment and prophylaxis should be
followed.
Policies should exist for the management of postoperative nausea and
vomiting (PONV) and discharge analgesia. Prophylactic antiemetics are
only recommended in patients with a strong history of PONV, motion
sickness and those undergoing certain procedures such as laparoscopic
sterilisation ⁄ cholecystectomy or tonsillectomy. However, it is important
that PONV is treated seriously once it occurs. Routine use of intravenous
fluids can enhance the patients’ feeling of wellbeing and further reduce
PONV [36].
Regional anaesthesia
Local infiltration and nerve blocks can provide excellent anaesthesia and
pain relief after day surgery. Patients may safely be discharged home with
residual sensory or motor blockade, provided the limb is protected and
appropriate support is available for the patient at home. The expected
duration of the blockade must be explained and the patient must receive
written instructions as to their conduct until normal power and sensation
returns. Infusions of local anaesthesia may also have a place [37]. The use of
ultrasound is increasingly gaining popularity, particularly in upper limb
surgery, and is recognised as a useful tool in several areas of regional
anaesthesia.
Central neuraxial blockade (spinal or caudal) can be useful in day
surgery and is increasing in popularity, although residual blockade may
cause postural hypotension or urinary retention despite the return of
adequate motor and sensory function. These problems can be minimised
by choosing an appropriate local anaesthetic agent or by the use of lowdose
local anaesthetic ⁄ opioid mixtures [38]. Suggested criteria before
attempting ambulation after neuraxial block include the return of
sensation in the perianal area (S4-5), plantar flexion of the foot at preoperative
levels of strength and return of proprioception in the big toe
[39].
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Sedation is seldom needed but, if used, suggested discharge criteria
should be met and the patient must receive an appropriate
explanation.
Oral analgesics should be started before the local anaesthesia begins to
wear off and also given subsequently on a regular basis.
The patient’s hydration should be checked. Concerns about post-dural
puncture headache (PDPH) have limited the use of spinals in day surgery
patients in the past, but the use of smaller gauge (‡ 25-G) and pencil-point
needles has reduced the incidence to < 1%. Information about PDPH and
what to do if this occurs should be included in the patient’s discharge
instructions as well as the provision of alternative analgesics. Further
information on the use of spinal anaesthesia in day surgery and examples of
patient information leaflets can be found on the BADS website (http://
www.bads.co.uk).
The current nationally agreed curriculum limits the scope of PA (A)s. On
completion of training they are not qualified to undertake regional
anaesthesia or regional blocks [40].
Postoperative recovery and discharge
Recovery from anaesthesia and surgery can be divided into three phases:
1 First stage recovery lasts until the patient is awake, protective reflexes
have returned and pain is controlled. This should be undertaken in a
recovery area with appropriate facilities and staffing [41]. Use of
modern drugs and techniques may allow early recovery to be complete
by the time the patient leaves the operating theatre, allowing some
patients to bypass the first stage recovery area [42]. Most patients who
undergo surgery with a local anaesthetic block can be fast-tracked in
this manner.
2 Second stage recovery ends when the patient is ready for discharge from
hospital. This should ideally be in an area adjacent to the day surgery
theatre. It should be equipped and staffed to deal with common
postoperative problems (PONV, pain) as well as emergencies (haemorrhage,
cardiovascular events). The anaesthetist and surgeon (or a deputy)
must be contactable to help deal with problems. Nurse-led discharge
using agreed protocols is appropriate (Appendix 3). Some of the
traditional discharge criteria such as tolerating fluids and passing urine are
no longer enforced. Mandatory oral intake is not necessary and may
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provoke nausea and vomiting and delay discharge. Voiding is also not
always required, although it is important to identify and retain patients
who are at particular risk of developing later problems, such as those who
have experienced prolonged instrumentation or manipulation of the
bladder [43]. Protocols may be adapted to allow low-risk patients to be
discharged without fulfilling traditional criteria. Mild postoperative
confusion in the elderly after surgery is common. This is usually
insignificant and should not influence discharge provided social circumstances
permit; in fact, the avoidance of hospitalisation after minor
surgery is preferred [15, 44]. Patients and their carers should be provided
with written information that includes warning signs of possible
complications and where to seek help. Protocols should exist for the
management of patients who require unscheduled admission, especially
in a stand-alone unit.
3 Late recovery ends when the patient has made a full physiological and
psychological recovery from the procedure. This may take several weeks
or months and is beyond the scope of this document.
Postoperative instructions and discharge
All patients should receive verbal and written instructions on discharge and
be warned of any symptoms that might be experienced. Wherever possible,
these instructions should be given in the presence of the responsible person
who is to escort and care for the patient at home.
Advice should be given not to drink alcohol, operate machinery or drive
for 24 h after a general anaesthetic [45]. More importantly, patients should
not drive until the pain or immobility from their operation allows them to
control their car safely and perform an emergency stop. Procedure-specific
recommendations regarding driving should be available.
All patients should be discharged with a supply of appropriate analgesics
and instructions in their use. Analgesia protocols (Appendix 4) relating
to day surgery case mix should be agreed with the pharmacy. Free
pre-packaged take-home medications should be provided as they are
convenient and prevent delays and unnecessary visits to the hospital
pharmacy.
Discharge summary
It is essential to inform the patient’s general practitioner promptly of
the type of anaesthetic given, the surgical procedure performed and
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postoperative instructions given. Patients should be given a copy of this
discharge summary to have available should they require medical assistance
overnight.
Day surgery units must agree with their local primary care teams how
support is to be provided for patients in the event of postoperative
problems. Best practice is a helpline for the first 24 h after discharge
and to telephone the patient the next day. Telephone follow-up is
highly rated by patients, provides support for any immediate complications,
and is useful for auditing postoperative symptoms and patient
satisfaction.
Audit
Effective audit is an essential component of assessing, monitoring and
maintaining the efficiency and quality of patient care in day surgery units.
Systems should be in place to ensure the routine collection of data regarding
patient throughput and outcomes. There have been a variety of tools
developed to determine patient outcomes. Questionnaires, which rely on
the patients’ completing documentation and returning them to the day
unit, are notoriously inaccurate and response rates are often very low. The
most successful units collect data electronically at all stages of the day
surgery process.
The RCoA’s compendium of audit recipes devotes a section to possible
audits relevant to day surgery [46]. It must be stressed that the most
reliable way of improving service is continuous audit and review of
outcomes rather than one-off snapshots. Information regarding trends in
the patients’ outcomes should be widely distributed amongst the members
of the team.
Audit of day surgery services relate primarily to quality of care and
efficiency. Examples of day surgery processes amenable to audit that have
some measurable outcomes are shown in Table 2.
Audit of patients’ satisfaction should be carried out routinely. A robust
database is helpful; however, the best databases fail to effect change unless
the information is clearly displayed and freely disseminated to the day
surgery users. Monthly graphs and figures detailing all outcomes and trends
should be disseminated to everyone, particularly to key individuals
empowered to influence change.
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Table 2 Day surgery processes amenable to audit.
Component of process
Outcome measure
Booking process
Patients failing to attend for surgery ⁄ theatre utilisation
Pre-operative preparation Patients cancelled on the day of surgery ⁄ patients failing to
attend
Admission process
Theatre start times
Anaesthesia quality
Unplanned admission rates ⁄ postoperative symptoms
Surgery quality
Unplanned admission rates ⁄ postoperative symptoms
Recovery Discharge times ⁄ unplanned admission rates ⁄
postoperative symptoms
Discharge process
Episodes of unplanned contact with primary care ⁄ out of
hours health services
Postoperative follow-up Episodes of unplanned contact with primary care ⁄ out of
hours health services
Audit
Quality and efficiency improvements
Teaching and training
The RCoA has placed Day Surgery as a core module in all three
components of anaesthetic training: Basic (year 1 ⁄ 2) [47], Intermediate
(year 3 ⁄ 4) [48] and Higher (year 5 ⁄ 6 ⁄ 7) [49]. It also recommends day
surgery as a specialty for advanced level training [50]. However, formal
day surgery training programmes for anaesthetic (and surgical) trainees are
rare.
The competencies required by the RCoA cover the entire day surgery
process, not simply the anaesthetic component. It is essential to design a
well-structured module that provides training in anaesthesia for all
aspects of day surgery and exposure to the organisational challenges of
running a day surgery unit. To facilitate this, it is recommended that
advanced training should take place in a dedicated day surgery unit [50],
yet few such units exist. It is important to remember that high quality
day surgery requires the experience of senior anaesthetists (and surgeons)
and that although the day surgery unit is an ideal environment for
training junior medical staff, relying on them to deliver the service
results in poorer quality patient outcomes and reduced efficiency
[51, 52].
A list of topics that might be included in a day surgery module is shown
in Appendix 5.
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The training delivery should be audited; some suggestions for this are
given in the RCoA audit compendium [46].
The day surgery unit is an excellent environment for surgical and nursing
training and many of the aspects covered above are equally applicable to
surgical and nursing colleagues.
Day surgery in special environments
A number of complex and highly specialist procedures are beginning to
enter the day surgery arena. Awake craniotomy for tumour resection has
been performed as a day case in the UK [53]. In the interventional X-ray
suite, uterine artery embolisation is a day case procedure, whereas
endovascular aneurysm stents and several other procedures are appropriate
for a short stay approach. Optimal care for these procedures should be
developed by those with expertise in day and short stay surgery, working in
collaboration with specialists in the management of the specific procedure.
Many of these procedures are undertaken in challenging environments,
such as X-ray departments. All the accepted standards for delivery of
anaesthesia, assistance for the anaesthetist, minimal monitoring and the
availability of appropriate recovery (post-anaesthesia care unit (PACU))
facilities should be achieved.
Introducing new procedures to day surgery
The successful introduction of new procedures to day surgery depends on
many factors, including the procedure itself and surgical, nursing and
anaesthetic colleagues. It is important to evaluate the procedure while still
performing it as an overnight stay and identify any steps in the process
that require modification to enable it to be performed as a day case, e.g.
timing of postoperative X-rays, modification of intravenous antibiotic
regimens, physiotherapy input and analgesia protocols [54]. A multidisciplinary
visit to another unit where the procedure is performed
successfully as a day case can be very helpful. Initially limiting the
procedure to a few colleagues (surgeons and anaesthetists) allows an
opportunity to evaluate and optimise techniques and to implement step
changes so that the patient can be discharged safely and with good
analgesia. Support from community nursing can be helpful, especially in
these early stages. Once the procedure has been successfully moved to the
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day surgery setting it can be expanded to include other surgeons and
anaesthetists as appropriate. Clear clinical protocols help to ensure that all
the lessons learned during the evaluation phase are clearly passed on to
colleagues.
Isolated day surgery units
Many day surgery facilities in the UK and Ireland are isolated and the
number of these is increasing. Currently, there is no set absolute
minimum distance between any stand-alone unit and the nearest acute
or associated hospital, although large distances are uncommon. The
commissioning of any new isolated stand-alone unit requires analysis of
its suitability for the provision of intended services. These facilities may
or may not be purpose-built and the Clinical Lead must be aware of this
in managing any risk. Any association with a nearby acute unit should
be reviewed regularly.
Remoteness is a factor to be considered in the delivery of a safe and
efficient service. A minimum of two anaesthetists on site should be
considered at any one time. Prolonged travel time may be an issue for
visiting staff. On-call commitments must be taken into account so as to
avoid accidents and fatigue either in theatre or when travelling.
The operational policy must agree clear management of certain key
issues. These include:
• Management of patients who cannot be discharged home.
• Management of patients with problems after discharge.
• Appropriate cover for the service and patients until they are
discharged.
• Appropriate patient screening and selection with availability of medical
records.
• Management of medical emergencies, e.g. cardiac arrest and major
haemorrhage, and the availability of materials and skilled personnel to
deal with complications when the anaesthetist is in theatre.
• Transfer agreements with local hospitals and intensive care facilities
• Robust, tested communications between the stand-alone unit, the
nearest acute hospital and the ambulance services.
• Teaching, training and supervision and opportunities for research.
This list is not meant to be exhaustive but gives guidance to some of the
important areas that require consideration.
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Short stay surgery and enhanced recovery
New approaches to the assessment and management of patients undergoing
more complex surgery are being used to improve the quality of recovery,
reduce the incidence of postoperative complications and reduce lengths of
stay. Many of these techniques are based on the wider application of wellestablished
day surgery principles and are aimed at improving the quality of
recovery so that the patient is well enough to go home sooner. These
strategies are variously called enhanced recovery, fast-track [55], accelerated
or rapid recovery. For any surgical operation there is a large variation in
average lengths of stay in hospitals across the UK and Ireland. Increasing
numbers of hospitals are focusing on the short stay pathway and plan to
manage the majority of their elective patients with stays of fewer than 72 h.
To achieve the maximum benefit from this, hospitals are developing 24-h
stay facilities (some as part of their existing day units) and are embracing
these principles.
Principles of enhanced recovery
Enhanced recovery is the outcome of applying a range of multimodal
strategies that are designed to prepare and optimise patients before, during
and after surgery, ensuring prompt recovery and discharge [12]. Most of
these principles are already well established in day surgery, which can be
considered the ultimate example of enhanced recovery. Anaesthetic
departments should play a major role in this as they can contribute
extensively to all phases of the patients’ management. Many of these
interventions are derived from day surgery.
Pre-operative factors
Pre-operative preparation of the patient plays a crucial role and identifies
additional risk factors and ensures that their medical condition is
optimised. Cardiopulmonary exercise testing provides further information
to enable anaesthetists to discuss these risks with their patients and ensure
that high-risk patients are counselled appropriately. An appropriate level
of intensive or high dependency care can also be put in place if
necessary. Patients and their carers should receive a careful explanation
about the procedure and what will happen to them at every stage of the
peri-operative pathway. This includes resumption of food, drink,
mobilisation and information about discharge and when this is likely
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to take place. As with day surgery, the provision of written information
is vital.
Patients should usually be admitted on the day of surgery with minimal
starvation times (i.e. 3 h for fluids) and consideration given to the use of
oral carbohydrate loading. Analgesia with paracetamol and NSAIDs
should be started pre-operatively if not contraindicated, and hypothermia
avoided.
Intra-operative factors
Minimally invasive surgery should be combined with use of regional
anaesthesia where possible. Thoracic epidurals or other regional anaesthetic
techniques should normally be used for abdominal surgery in patients likely
to require more than oral analgesia postoperatively. Long acting opioids,
nasogastric tubes and surgical drains should be avoided. Intra-operative fluid
therapy should be goal directed to avoid sodium ⁄ fluid overload and
attention should be paid to maintaining normothermia. Anaesthetic
techniques are otherwise similar to day surgery with the expectation that
patients will mobilise and eat ⁄ drink later in the day.
Postoperative factors
Effective analgesia that minimises the risk of PONV and allows early
mobilisation plays a vital role in enhanced recovery. Systemic opioids
should be avoided where possible and regular oral (or intravenous) analgesia
with simple analgesics (paracetamol and NSAIDs) should be used. For more
invasive procedures, epidural analgesia should be maintained in the
postoperative period. Hydration should be maintained with intravenous
fluids but discontinued as soon as the patient returns to oral fluids, and
PONV should be treated aggressively using a multimodal approach to
therapy.
The patient should be mobilised within 24 h. They should be aware and
encouraged to meet milestones for mobilisation, drinking and eating. This
requires active involvement from both the medical and nursing teams in the
immediate postoperative period. The provision of a specified dining room,
with access to high calorie drinks and where meals can be taken, encourages
the patient to mobilise.
There should be a target discharge date set for which the staff, patients
and relatives should aim, and as in day surgery the discharge should be a
nurse-led process and not dependent on consultant review.
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The patient’s perspective
A Mayo Clinic study in 2006 showed that patients want their doctors to be
confident, empathetic, humane, personal, forthright, respectful and thorough
[56]. Interestingly, there was no mention of competence, implying
that patients inherently believe their doctors to be competent. A survey
carried out by MORI on behalf of the RCoA in May 2000 found that 35%
of the general public did not believe that anaesthetists were medically
qualified doctors [57]. Hence, there is a credibility gap that anaesthetists
need to address. It is important to ensure that patients are made aware that
anaesthetists are highly qualified professional doctors. The patient information
leaflets produced by the AAGBI and the RCoA can be useful in this
regard.
It is important to realise that to most patients, anaesthesia means general
anaesthesia with loss of consciousness during the procedure, and the patient
sees this as ceding total control to someone else. Nobody is really
completely comfortable with this. The psychology of surrendering control
can result in patient attitudes that may not be explicitly communicated to
the anaesthetist. This can cause a lot of stress and anxiety. Patients are
therefore worried about:
• Never waking up.
• Dying during an operation.
• Waking up during surgery.
• Feeling pain and possibly not being able to make anyone else aware.
In a recent study [58], the top three were identified as being of most
concern to day case patients. The same study highlighted that the factor that
alleviated most anxiety was the presence of a partner or friend, especially
during recovery. Importantly, patients were more receptive to anaesthetists’
visiting and giving information about the procedure than to information
provided by the nursing staff.
Other concerns that are relatively common to patients having a general
anaesthetic are also associated with loss of control:
• Embarrassment about perceived loss of control of bodily functions e.g.
wetting the bed, or saying something inappropriate while still drowsy.
• Nausea and vomiting.
It is important for the anaesthetist to offer reassurances, as this has the
greatest impact compared with delegating this responsibility to the nursing
staff. Apprehensive patients don’t easily absorb big words. Explanations
should be given in simple terms, avoiding jargon and not using emotive
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language. This is particularly important in helping children understand the
planned procedure and what is to follow. Information provided in writing
before the day of surgery also helps.
A patient about to undergo elective surgery often has contradicting
feelings. On the one hand they are glad that the surgery will cure their
medical problem and provide a life enhancing experience. On the other
hand they are riddled with innumerable anxieties and although it might
seem routine and straightforward to the doctor, the patient will inevitably
view it all very differently. No patient expects surgery to be actually
enjoyable, but what is most appreciated is information delivered by a
respected, highly trained professional, who is empathetic and regards the
patient as a person and not merely as a statistic.
An information leaflet designed to help patients prepare themselves for
day surgery is available on the BADS website [59].
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Further reading
1 Association for Perioperative Practice. Staffing for Patients in the
Perioperative setting. Harrogate: AfPP, 2008.
2 Department of Health. Getting the right start. National Service Framework
for Children – Standard for Hospital Services. London: DoH, 2003.
3 Department of Health and Children. Children First: National Guidelines
for the Protection and Welfare of Children. London: DoH, 1999.
4 Health Service Executive. HSE National Service Plan 2010. Dublin:
HSE, 2010.
5 Jakobson J. Anaesthesia for Day Case Surgery. New York: Oxford
University Press, 2009.
6 Lemos P, Jarrett P, Philip B eds. Day Surgery Development and Practice.
Porto: International Association for Ambulatory Surgery, 2006.
7 National Association for the Welfare of Children in Hospital. Caring for
children in the Health Services. Just for the Day. London: The Stationery
Office, 1991.
8 National Leadership and Innovation Agency for Healthcare. Day
Surgery in Wales: a guide to good practice. Cardiff: The Welsh Assembly
Government, 2004.
9 NHS Estates. HBN 26 Facilities for Surgical Procedures. Volume 1.
London: The Stationery Office, 2004.
10 NHS Management Executive Value for Money Unit. Day Surgery.
Making it happen. London: HMSO, 1991.
11 NHS Modernisation Agency. National Good Practice Guidelines on
Pre-operative Assessment for Day Surgery. The Stationery Office,
2002.
12 Raeder J. Clinical Ambulatory Anesthesia. New York: Cambridge
University Press, 2010.
13 Scottish Health Planning Note 52: Accommodation for Day Care: Part
1: Day surgery unit. Glasgow: Health Facilities Scotland, 2001.
14 Smith I, ed. Day Care Anaesthesia. Fundamentals of Anaesthesia & Acute
Medicine Series. London: BMJ Books, 2000.
15 The Office of the Comptroller and Auditor General. Accounts of
Public Services 2008. Dublin, Government of Ireland, 2009. http://
www.audgen.gov.ie/documents/annualreports/2008/Appropriation_
Account_2008Rev1.pdf (accessed 11 ⁄ 01 ⁄ 2011).
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Appendix 1
Sample screening questionnaire for use in day surgery. University Hospital of
North Staffordshire, with permission.
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Appendix 2
Sample patient information sheet for use in day surgery. Royal Surrey County
Hospital NHS Foundation Trust, with permission.
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Appendix 3
Discharge checklist for day surgery. Reproduced from: British Association
of Day Surgery. Nurse Led Discharge. London: BADS, 2009, with
permission.
Criteria Yes No N ⁄ A Initials Details
Vital signs stable
Orientated to time, place & person
Passed urine (if applicable)
Able to dress & walk (where appropriate)
Oral fluids tolerated (if applicable)
Minimal pain
Minimal bleeding
Minimal nausea ⁄ vomiting
Cannula removed
Responsible escort present
Has carer for 24-h post op
Written & verbal post op instructions
Knows who to contact in an emergency
Follow up appointment
Removal of sutures required?
Referrals made
Dressings supplied
Patient copy of GP letter
Carbon copy of consent
Sick certificate
Has take home medication
Next Dose:
Information leaflet for tablets
Post op phone call required
Discharged by: Nurse’s Signature
___________________________________________________
Date ⁄ Time ____________ Print Name
___________________________________________________
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Guidelines: Day case and short stay surgery
.....................................................................................................................................
Appendix 4a
Acute pain protocol for adult surgery.
Pain intensity
Discharge medication
Doctor’s signature
(sign one box only)
A None None
B Mild Paracetamol 1 g qds
C Moderate Paracetamol 1 g qds
Plus
Ibuprofen 600 mg qds
C* Moderate
(NSAID intolerant)
Paracetamol 500 mg ⁄ codeine
30 mg 1–2 tabs qds
D Severe Paracetamol 500 mg ⁄ codeine
30 mg 1–2 tabs qds
Plus
Ibuprofen 600 mg qds
D* Severe
(NSAID intolerant)
Paracetamol 1 g qds
Plus
Oral morphine 20 mg qds
Appendix 4b
Pain categories for common procedures in the day surgery unit, to be used
in conjunction with the above.
A B C D
EUA ears
Cystoscopy
Restorative
dentistry
Cataract surgery
Grommets ⁄
T-tube removal ⁄
insertion
Prostate biopsy
Sebaceous cyst surgery
Sigmoidoscopy
Skin lesion surgery
Urethral surgery
Anal surgery
Apicectomy
Arthroscopy
Axillary clearance
Breast lumps
Dupuytren’s contracture
Carpal tunnel
decompression
Cervical ⁄ vulval surgery
Hysteroscopy ⁄ D&C
Middle ear surgery
MUA ± steroid injection
Vaginal sling
Varicose vein surgery
Vasectomy
Non-wisdom tooth
extraction
ACL reconstruction
Circumcision
Endometrial ablation
Laparoscopy
Haemorrhoidectomy
Hernia repair
Joint fusions ⁄ osteotomy
Shoulder surgery
Squint surgery
Testicular surgery
Tonsillectomy
Wisdom tooth extraction
Dental clearance
EUA ⁄ MUA, examination ⁄ manipulation under anaesthesia; ACL, anterior cruciate ligament
Ó 2011 The Authors
Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 29

Guidelines: Day case and short stay surgery
.....................................................................................................................................
Appendix 5
Suitable topics for a training module in day case anaesthesia.
1 Patient selection and preparation:
• The role of patient selection in day surgery
• Medical, social and surgical factors
• Unit protocols for patient selection
• The role of pre-operative preparation in day surgery
• Instructions for ⁄ preparation of patients for day surgery
• Management of patients with complex medical conditions
• Recognition of patients who are unsuitable for day surgery
2 Anaesthetic techniques for day surgery:
• General anaesthetic techniques
• Antiemetic therapy
• Analgesia including the role of nerve blockade
• Fluid therapy
• Airway management
3 Surgical techniques appropriate for day surgery:
• Surgical advances enabling procedures to transfer to day surgery
• Limitations of day surgery
• Risks ⁄ concerns
4 Recovery assessment and discharge criteria:
• Adequacy of analgesia
• Fitness for discharge
• Role of early intervention in prevention of unplanned admissions
• Instructions for patients
• Discharge medication
5 Postoperative follow up and audit:
• Value of postoperative follow-up to patients and the unit
• Use of information technology for audit of outcomes and service development
6 Team working:
• The day unit as a multidisciplinary team
7 Children in the day surgery unit:
• National Service Framework for Children’s requirements for provision of children’s services
• Preparation of children for surgery
8 Management of a day surgery unit:
• Role of day surgery managers
• Role of day surgery within the trust
• Government’s agenda for day surgery
• Booking processes for day surgery
• Knowledge of local and national day surgery performance
• Advances and controversies in day surgery
Ó 2011 The Authors
30 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland

The Association of Anaesthetists of Great Britain & Ireland
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Peri-operative management of the
surgical patient with diabetes 2015
Published by
The Association of Anaesthetists of Great Britain & Ireland
Sept 2015

This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please use the following
reference:
Association of Anaesthetists of Great Britain and Ireland. Peri-operative management of the surgical patient with diabetes
2015. Anaesthesia 2015; 70: 1427-1440.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13233/full

Anaesthesia 2015
Guidelines
doi:10.1111/anae.13233
Peri-operative management of the surgical patient with diabetes
2015
Association of Anaesthetists of Great Britain and Ireland
Membership of the Working Party: P. Barker, P. E. Creasey, K. Dhatariya, 1 N. Levy, A. Lipp, 2
M. H. Nathanson (Chair), N. Penfold, 3 B. Watson and T. Woodcock
1 Joint British Diabetes Societies Inpatient Care Group
2 British Association of Day Surgery
3 Royal College of Anaesthetists
Summary
Diabetes affects 10–15% of the surgical population and patients with diabetes undergoing surgery have greater complication
rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes
focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c
< 69 mmol.mol
1 ); deciding if the patient can be managed by simple manipulation of pre-existing treatment during
a short starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion;
and safe use of the latter when it is the only option, for example in emergency patients, patients expected not
to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it
is imperative that communication amongst healthcare professionals and between them and the patient is accurate
and well informed at all times. Most patients with diabetes have many years of experience of managing their own
care. The purpose of this guideline is to provide detailed guidance on the peri-operative management of the surgical
patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.
.................................................................................................................................................................
This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists of
Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board of Directors. Date of review: 2020.
Accepted: 12 August 2015
• What other guideline statements are available on this
topic?
The NHS Diabetes Guideline for the Peri-operative
Management of the Adult Patient with Diabetes [1] was
published in 2011 by NHS Diabetes (now part of NHS
Improving Quality), and is due to be updated in 2015.
• Why was this guideline developed?
This guideline was developed to improve both the
safety and the outcome of patients with diabetes
undergoing surgical procedures.
.................................................................................................................................................................
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 1

Anaesthesia 2015
Barker et al. | Guidelines on peri-operative management of diabetes
• How and why does this statement differ from existing
guidelines?
The 2011 guideline [1] deals with the whole patient
pathway, from referral for surgery from primary
care to discharge and follow-up. It is too broad in
scope to be a working document for anaesthetists.
This guideline summarises the existing guideline
and focuses specifically on peri-operative care.
Introduction
The demographics describing the dramatic increase in
the number of patients with diabetes are well known.
Patients with diabetes require surgical procedures more
frequently and have longer hospital stays than those
without the condition [2]. The presence of diabetes or
hyperglycaemia in surgical patients has been shown to
lead to increased morbidity and mortality, with perioperative
mortality rates up to 50% greater than the
non-diabetic population [2]. The reasons for these
adverse outcomes are multifactorial, but include: failure
to identify patients with diabetes or hyperglycaemia [3,
4]; multiple co-morbidities including microvascular and
macrovascular complications [5]; complex polypharmacy
and insulin prescribing errors [6]; increased peri-operative
and postoperative infections [2, 7, 8]; associated
hypoglycaemia and hyperglycaemia [2]; a lack of, or
inadequate, institutional guidelines for management of
inpatient diabetes or hyperglycaemia [2, 9]; and inadequate
knowledge of diabetes and hyperglycaemia management
amongst staff delivering care [10].
Anaesthetists and other peri-operative care providers
should be knowledgeable and skilled in the care
of patients with diabetes. Management of diabetes is a
vital element in the management of surgical patients
with diabetes. It is not good enough for the diabetic
care to be a secondary, or sometimes forgotten, element
of the peri-operative care package.
Previous guidelines
In April 2011 NHS Diabetes (now part of NHS
Improving Quality) published a document: NHS Diabetes
Guideline for the Peri-operative Management of
the Adult Patient with Diabetes, in association with the
Joint British Diabetes Societies (JBDS) [1] (an almost
identical version, Management of Adults with Diabetes
Undergoing Surgery and Elective Procedures: Improving
Standards, is available at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm).
This comprehensive guideline
provided both background information and advice to
clinicians caring for patients with diabetes. Some of
the recommendations in that document were due for
review in the light of new evidence and, in addition, it
was felt that anaesthetists and other practitioners caring
for patients with diabetes in the peri-operative period
needed shorter, practical advice. The Association
of Anaesthetists of Great Britain and Ireland (AAGBI)
offered to co-author this shortened guideline, in collaboration
with colleagues involved with the 2011 document.
The previous 2011 NHS Diabetes guidelines
will also be updated in 2015.
The risks of poor diabetic control
Studies have shown that high pre-operative and perioperative
glucose and glycated haemoglobin (HbA1c)
levels are associated with poor surgical outcomes.
These findings have been seen in both elective and
emergency surgery including spinal [11], vascular [12],
colorectal [13], cardiac [14, 15], trauma [16], breast
[17], orthopaedic [18], neurosurgical, and hepatobiliary
surgery [19, 20]. One study showed that the adverse
outcomes include a greater than 50% increase in mortality,
a 2.4-fold increase in the incidence of postoperative
respiratory infections, a doubling of surgical site
infections, a threefold increase in postoperative urinary
tract infections, a doubling in the incidence of myocardial
infarction, and an almost twofold increase in acute
kidney injury [2]. Paradoxically, there are some data to
show that the outcomes of patients with diabetes may
not be different from, or may indeed be better than,
those without diabetes if the diagnosis is known before
surgery [21]. The reasons for this are unknown, but
may be due to increased vigilance surrounding glucose
control for those with a diagnosis of diabetes.
Referral from primary care and
planning surgery
The aim is to ensure that diabetes is as well controlled as
possible before elective surgery and to avoid delays to
surgery due to poor control. The Working Party supports
the consensus advice published in the 2011 NHS
Diabetes guideline that the HbA1c should be
< 69 mmol.mol
1 (8.5%) for elective cases [1], and
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Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015
that elective surgery should be delayed if it is
≥ 69 mmol.mol
1 , while control is improved. Changes
to diabetes management can be made concurrently with
referral to ensure the patient’s diabetes is as well controlled
as possible at the time of surgery. Elective surgery
in patients with diabetes should be planned with the aim
of minimising disruption to their self-management.
•
Recommendation: Glycaemic control should be
checked at the time of referral for surgery. Information
about duration, type of diabetes, current
treatment and complications should be made available
to the secondary care team.
Surgical outpatient clinic
The adequacy of diabetes control should be assessed
again at the time of listing for surgery, ideally with a
recorded HbA1c < 69 mmol.mol
1 in the previous three
months. If it is ≥ 69 mmol.mol
1 , elective surgery should
be delayed while control is improved. In a small number
of cases it may not be possible to improve diabetic control
pre-operatively, particularly if the reason for surgery,
such as chronic infection, is contributing to poor control,
or if surgery is semi-urgent. In these circumstances, it
may be acceptable to proceed with surgery after explanation
to the patient of the increased risks. Patients should
be managed as a day case if the procedure is suitable
and the patient fulfils the criteria for day-case surgery
management. Well-controlled diabetes should not be a
contra-indication to day-case surgery.
Patients with poorly controlled diabetes at the time
of surgery will need close monitoring and may need to
start a variable-rate intravenous insulin infusion (VRIII).
• Recommendation: Patients with diabetes should be
identified early in the pre-operative pathway.
Pre-operative assessment
Appropriate and early pre-operative assessment should
be arranged. A pre-operative assessment nurse may
undertake the assessment with support from either an
anaesthetist or a diabetes specialist nurse. It should
occur sufficiently in advance of the planned surgery to
ensure optimisation of glycaemic control before the
date of proposed surgery. The aim is to ensure that all
relevant investigations are available and checked in
advance of the planned surgery, that the patient understands
how to manage his/her diabetes in the peri-operative
period, and that the period of pre-operative
fasting is minimised.
• Recommendation: Tests should be ordered to assess
co-morbidities in line with National Institute for
Health and Care Excellence (NICE) guidance on
pre-operative testing [22]. This should include urea
and electrolytes and ECG for all patients with diabetes;
however, a random blood glucose measurement
is not indicated.
Planning admission (including day surgery)
The aim is to minimise the fasting period, ensure
normoglycaemia (capillary blood glucose (CBG) 6–
10 mmol.l
1 ) and minimise as far as possible disruption
to the patient’s usual routine. Ideally, the patient
should be booked first on the operating list to minimise
the period of fasting. If the fasting period is
expected to be limited to one missed meal, the patient
can be managed by modification of his/her usual diabetes
medication (see below). Patients should be provided
with written instructions from the pre-operative
assessment team about management of their diabetes
medication on the day of surgery, the management of
hypo- or hyperglycaemia in the peri-operative period,
and the likely effects of surgery on their diabetes control.
Patients should be advised to carry a form of glucose
that they can take in case of symptoms of
hypoglycaemia that will not cause surgery to be cancelled,
for example a clear, sugar-containing drink
(glucose tablets may be used instead, but some anaesthetists
may feel they should not be taken within 6 h
of the start of anaesthesia). Patients should be warned
that their blood glucose control may be erratic for a
few days after the procedure.
• Recommendation: When possible, admission should
be planned for the day of surgery, with both the
patient and the ward staff aware of the planned
peri-operative diabetes care, including a plan to
manage hypo- and hyperglycaemia. Surgery should
be scheduled at the start of the theatre list to
minimise disruption to the patient’s glycaemic
control.
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 3

Anaesthesia 2015
Barker et al. | Guidelines on peri-operative management of diabetes
Management of existing therapy
With appropriate guidance, patients with diabetes
should be allowed to retain control and possession of,
and continue to self-administer, their medication.
Many patients will have several years’ experience and
be expert in self-medication.
The aim is to avoid hypo- or hyperglycaemia
during the period of fasting and the time during and
after the procedure, until the patient is eating and
drinking normally. In people who are likely to miss
one meal only, this can often be achieved by manipulating
the patient’s normal medication using the guidance
provided in Tables 1 and 2.
Glycaemic control in patients with diabetes is a
balance between their carbohydrate intake and utilisation
(for example, exercise). It also depends on what
medication they take and how those medications
work. Some agents (e.g. sulphonylureas, meglitinides,
Table 1 Guideline for peri-operative adjustment of insulin (short starvation period – no more than one missed
meal).
Day of surgery
Insulin
Day before
admission Surgery in the morning
Once daily (e.g. Lantus â , Levemir â , Tresiba â , Insulatard â , Humulin I â , Insuman â )
Evening
Reduce dose Check blood glucose on
by 20% admission
Morning
Reduce dose Reduce dose by 20%; check
by 20% blood glucose on admission
Surgery in the afternoon
Check blood glucose on
admission
Reduce dose by 20%;
check blood glucose on
admission
Whilst a VRIII is
being used*
Continue at 80%
of usual dose
Continue at 80%
of usual dose
Twice daily
Biphasic or ultra-long
acting (e.g. Novomix
30 â , Humulin M3 â ,
Humalog Mix 25 â ,
Humalog Mix 50 â ,
Insuman â Comb 25,
Insuman â Comb 50,
Levemir â , Lantus â )by
single injection, given
twice daily
Short-acting (e.g.
animal neutral,
Novorapid â , Humulin
S â , Apidra â ) and
intermediate-acting
(e.g. animal isophane,
Insulatard â , Humulin I â ,
Insuman â ) by separate
injections, both given
twice daily
No dose
change
No dose
change
Halve the usual morning dose;
check blood glucose on
admission; leave evening meal
dose unchanged
Calculate total dose of morning
insulin(s); give half as
intermediate-acting only in
the morning; check blood
glucose on admission; leave
evening meal dose unchanged
Halve the usual morning
dose; check blood
glucose on admission;
leave the evening meal
dose unchanged
Calculate total dose of
morning insulin(s); give
half as intermediateacting
only in the
morning; check blood
glucose on admission;
leave evening meal
dose unchanged
Stop until eating
and drinking
normally
Stop until eating
and drinking
normally
Three to five injections daily
No dose
change
Basal bolus regimens:
Omit morning and lunchtime
short-acting insulins; keep
basal unchanged*
Premixed morning insulin:
Halve morning dose and omit
lunchtime dose; check blood
glucose on admission
Give usual morning
insulin dose(s); omit
lunchtime dose; check
blood glucose on
admission
Stop until eating
and drinking
normally
* If the patient requires a VRIII then the long-acting background insulin should be continued but at 80% of the dose the patient
usually takes when he/she is well.
VRIII, variable-rate intravenous insulin infusion.
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
Table 2 Guideline for peri-operative adjustment of oral hypoglycaemic agents (short starvation period – no more
than one missed meal).
Day of surgery
Surgery in the
Agent
Day before admission morning
Drugs that require omission when fasting owing to risk of hypoglycaemia
Meglitinides
Take as normal Omit morning dose if
(e.g. repaglinide,
nil by mouth
nateglinide)
Sulphonylurea
(e.g. glibenclamide,
gliclazide, glipizide)
Take as normal
Omit morning dose
(whether taking
once or twice daily)
Drugs that require omission when fasting owing to risk of ketoacidosis
SGLT-2 inhibitors*
(e.g. dapagliflozin,
canagliflozin)
No dose change Halve the usual
morning dose; check
blood glucose on
admission; leave
evening meal dose
unchanged
Surgery in the
afternoon
Give morning dose if
eating
Omit (whether taking
once or twice daily)
Halve the usual
morning dose; check
blood glucose on
admission; leave the
evening meal dose
unchanged
Whilst a VRIII is
being used
Stop until eating and
drinking normally
Stop until eating and
drinking normally
Stop until eating and
drinking normally
Drugs that may be continued when fasting
Acarbose Take as normal Omit morning dose if
nil by mouth
DPP-IV inhibitors
(e.g. sitagliptin,
vildagliptin, saxagliptin,
alogliptin, linagliptin)
GLP-1 analogues
(e.g. exenatide,
liraglutide, lixisenatide)
Metformin (procedure
not requiring use of
contrast media†)
Give morning dose if
eating
Stop until eating and
drinking normally
Take as normal Take as normal Take as normal Stop until eating and
drinking normally
Take as normal Take as normal Take as normal Take as normal
Take as normal Take as normal Take as normal Stop until eating and
drinking normally
Pioglitazone Take as normal Take as normal Take as normal Stop until eating and
drinking normally
* Also omit the day after surgery.
† 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
omitted on the day of the procedure and for the following 48 h.
VRIII, variable-rate intravenous insulin infusion; SGLT-2, sodium-glucose co-transporter-2; DPP-IV, dipeptidyl peptidase-IV;
GLP-1, glucagon-like peptide-1.
insulin and to some extent, thiazolidinediones) act by
lowering glucose concentrations, and doses need to
be modified or the agents stopped during periods of
starvation. Others work by preventing glucose levels
from rising (e.g. metformin, glucagon-like peptide-1
analogues, dipeptidyl peptidase-4 inhibitors); these
drugs may be continued without the risk of hypoglycaemia.
The time of day and the expected duration
of the operation need to be considered, as will
whether a VRIII will be needed. Patients with continuous
subcutaneous insulin infusions only missing one
meal should be advised to maintain their CBG at
6–10 mmol.l
1 . If longer periods of starvation are
predicted, a VRIII should be used and specialist
advice sought.
Tables 1 and 2 have been designed to take all of
these factors into consideration. They are a pragmatic
approach to the pre-operative management of all the
available classes of agent used to manage diabetes.
Use of a variable-rate intravenous insulin
infusion
Variable-rate intravenous insulin infusions are preferred
in: patients who will miss more than one meal;
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 5

Anaesthesia 2015
Barker et al. | Guidelines on peri-operative management of diabetes
those with type-1 diabetes undergoing surgery who
have not received background insulin; those with
poorly controlled diabetes (defined as a HbA1c
> 69 mmol.mol
1 ); and most patients with diabetes
requiring emergency surgery. Variable-rate intravenous
insulin infusions should be administered and monitored
by appropriately experienced and qualified staff.
An example of a VRIII regimen is provided in
Appendix 1.
Intra-operative care and monitoring
The aim of intra-operative care is to maintain good
glycaemic control and normal electrolyte concentrations,
while optimising cardiovascular function and
renal perfusion. If possible, multimodal analgesia
should be used along with appropriate anti-emetic prophylaxis,
to enable an early return to a normal diet
and the patient’s usual diabetes regimen.
• Recommendation: An intra-operative CBG range of
6–10 mmol.l
1 should be aimed for (an upper limit
of 12 mmol.l
1 may be tolerated at times, e.g. if
the patient has poorly controlled diabetes and is
being managed by a modification of his/her normal
medication without a VRIII). It should be understood
by all staff that a CBG within the range of
6–10 mmol.l
1 is acceptable and that there is no
requirment for a CBG of 6 mmol.l
1 to be the target.
The CBG should be checked before induction
of anaesthesia and monitored regularly during the
procedure (at least hourly, or more frequently if
the results are outside the target range). The CBG,
insulin infusion rate and substrate infusion should
be recorded on the anaesthetic record. Some charts
use colour-coded areas to highlight abnormal
results requiring further intervention or a change
of treatment (see Appendix 2).
Management of intra-operative hyperglycaemia
and hypoglycaemia
If the CBG exceeds 12 mmol.l
1 and insulin has been
omitted, capillary blood ketone levels should be measured
if possible (point-of-care devices are available). If
the capillary blood ketones are > 3 mmol.l
1 or there
is significant ketonuria (> 2+ on urine sticks) the
patient should be treated as having diabetic ketoacidosis
(DKA). Diabetic ketoacidosis is a triad of ketonaemia
> 3.0 mmol.l
1 , blood glucose > 11.0 mmol.l
1 ,
and bicarbonate < 15.0 mmol.l
1 or venous pH < 7.3.
Diabetic ketoacidosis is a medical emergency and specialist
help should be obtained from the diabetes team.
If DKA is not present, the high blood glucose
should be corrected using subcutaneous insulin (see
below) or by altering the rate of the VRIII (if in use).
If two subcutaneous insulin doses do not work, a
VRIII should be started.
Treatment of hyperglycaemia in a patient with type-1
diabetes
Subcutaneous rapid-acting insulin (such as Novorapid
â , Humalog â or Apidra â ) should be given (up to
a maximum of 6 IU), using a specific insulin syringe,
assuming that 1 IU will drop the CBG by 3 mmol.l
1 .
Death or severe harm as a result of maladministration
of insulin, including failure to use the specific insulin
syringe, is a ‘Never Event’. If the patient is awake, it is
important to ensure that the patient is content with
proposed dose (patients may react differently to subcutaneous
rapid-acting insulin). The CBG should be
checked hourly and a second dose considered only
after 2 h.
Treatment of hyperglycaemia in a patient with type-2
diabetes
Subcutaneous rapid-acting insulin 0.1 IU.kg 1 should
be given (up to a maximum of 6 IU), using a specific
insulin syringe. The CBG should be checked hourly
and a second dose considered only after 2 h. A VRIII
should be considered if the patient remains hyperglycaemic.
Treatment of intra-operative hypoglycaemia
For a CBG 4.0–6.0 mmol.l
1 , 50 ml glucose 20%
(10 g) should be given intravenously; for hypoglycaemia
< 4.0 mmol.l
1 a dose of 100 ml (20 g) should
be given.
Fluid management
There is a limited evidence base for the recommendation
of optimal fluid management of the adult diabetic
patient undergoing surgery. It is now recognised that
Hartmann’s solution is safe to administer to patients
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Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015
with diabetes and does not contribute to clinically significant
hyperglycaemia [23].
Fluid management for patients requiring a VRIII
The aim is to provide glucose as a substrate to prevent
proteolysis, lipolysis and ketogenesis, as well as
to optimise intravascular volume status and maintain
plasma electrolytes within the normal range. It is
important to avoid iatrogenic hyponatraemia from
the administration of hypotonic solutions. Glucose
5% solution should be avoided. Use of glucose 4%
in 0.18% saline can be associated with hyponatraemia.
The substrate solution to be used should be based
on the patient’s current electrolyte concentrations.
While there is no clear evidence that one type of
balanced crystalloid fluid is better than another, halfstrength
‘normal’ saline combined with glucose is, theoretically,
a reasonable compromise to achieve these
aims. Thus, the initial fluid should be glucose 5% in
saline 0.45% pre-mixed with either potassium chloride
0.15% (20 mmol.l
1 ) or potassium chloride 0.3%
(40 mmol.l
1 ), depending on the presence of hypokalaemia
(< 3.5 mmol.l
1 ).
The Working Party recognises that these fluids
may not be available in all institutions. It is our view
that they should be made available in all areas where
patients with diabetes will be managed. (Hospitals caring
for children will usually have these solutions
already available for general paediatric use).
Fluid should be administered at the rate that is
appropriate for the patient’s usual maintenance
requirements – usually 25–50 ml.kg 1 .day 1 (approximately
83 ml.h 1 for a 70-kg patient) [24].
Very occasionally, the patient may develop hyponatraemia
without signs of fluid overload. In these circumstances,
it is acceptable to prescribe one of the following
solutions as the substrate solution: glucose 5% in saline
0.9% with pre-mixed potassium chloride 0.15%
(20 mmol.l
1 ); or glucose 5% in saline 0.9% with premixed
potassium chloride 0.3% (40 mmol.l
1 ). (Again,
hospitals caring for children will usually have these solutions
available).
Additional Hartmann’s solution or another balanced
isotonic crystalloid solution should be used to
optimise intravascular volume status.
Fluid management for patients not requiring a
VRIII
The aim is to avoid glucose-containing solutions unless
the blood glucose is low. It is important to avoid
hyperchloraemic metabolic acidosis; Hartmann’s solution
should be administered to optimise the intravascular
volume status. If the patient requires prolonged
postoperative fluids (> 24 h), a VRIII should be considered
and glucose 5% in saline 0.45% with pre-mixed
potassium chloride given as above.
Returning to ‘normal’ (pre-operative)
medication and diet
The postoperative blood glucose management plan,
and any alterations to existing medications, should be
clearly communicated to ward staff. Patients with diabetes
should be involved in planning their postoperative
care. If subcutaneous insulin is required in
insulin-na€ıve patients, or the type of insulin or the
time it is to be given is to change, the specialist diabetes
team should be contacted for advice.
Transferring from a VRIII back to oral
treatment or subcutaneous insulin
If the patient has type-1 diabetes and a VRIII has been
used, it must be continued for 30–60 min after the
patient has had their subcutaneous insulin (see below).
Premature discontinuation is associated with iatrogenic
DKA.
Restarting oral hypoglycaemic medication
Oral hypoglycaemic agents should be recommenced at
pre-operative doses once the patient is ready to eat and
drink; withholding or reduction in sulphonylureas may
be required if the food intake is likely to be reduced. Metformin
should only be restarted if the estimated glomerular
filtration rate exceeds 50 ml.min 1 .1.73 m 2 [25].
Restarting subcutaneous insulin for patients already
established on insulin
Conversion to subcutaneous insulin should commence
once the patient is able to eat and drink without nausea
or vomiting. The pre-surgical regimen should be
restarted, but may require adjustment because the insulin
requirement may change as a result of postoperative
stress, infection or altered food intake. The diabetes spe-
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 7

Anaesthesia 2015
Barker et al. | Guidelines on peri-operative management of diabetes
cialist team should be consulted if the blood glucose
levels are outside the acceptable range (6–12 mmol.l
1 )
or if a change in diabetes management is required.
The transition from intravenous to subcutaneous
insulin should take place when the next meal-related
subcutaneous insulin dose is due, for example with
breakfast or lunch.
For the patient on basal and bolus insulin
There should be an overlap between the end of the
VRIII and the first injection of subcutaneous insulin,
which should be given with a meal and the intravenous
insulin and fluids discontinued 30-60 min later.
If the patient was previously on a long-acting insulin
analogue such as Lantus â , Levemir â or Tresbia â ,
this should have been continued and thus the only
action should be to restart his/her usual rapid-acting
insulin at the next meal as outlined above. If the basal
insulin was stopped, the insulin infusion should be
continued until a background insulin has been given.
For the patient on a twice-daily, fixed-mix regimen
The insulin should be re-introduced before breakfast
or before the evening meal, and not at any other time.
The VRIII should be maintained for 30-60 min after
the subcutaneous insulin has been given.
For the patient on a continuous subcutaneous insulin
infusion
The subcutaneous insulin infusion should be recommenced
at the patient’s normal basal rate; the VRIII
should be continued until the next meal bolus has
been given. The subcutaneous insulin infusions should
not be re-started at bedtime.
Resumption of normal diet
The key to successful management of the surgical
patient with diabetes is resumption of his/her usual
diet. This allows resumption of normal diabetes medication.
Hospital discharge is only feasible once the
patient has resumed eating and drinking.
Other anaesthetic considerations
Use of dexamethasone
Dexamethasone can lead to hyperglycaemia and should
be used with caution in patients with diabetes [26]. If
it is decided that the possible benefits of earlier
resumption of normal diet outweigh the disadvantages
of hyperglycaemia, it should be ensured that the CBG
is measured hourly for at least 4 h after administration.
Use of regional anaesthesia
Local anaesthetic techniques, when used as the sole
anaesthetic, reduce the risk of postoperative nausea
and vomiting. Furthermore, when used as part of the
multimodal technique in general anaesthesia, they have
opioid-sparing actions, with resultant reduction of opioid-related
side-effects. However, evidence suggests
that patients with diabetes are more prone to epidural
abscesses and haemodynamic instability after central
neuraxial blockade (in patients with an autonomic
neuropathy), and, possibly, increased risk of neuropathy
after peripheral nerve blocks [27–29].
Enhanced recovery after surgery
Enhanced recovery of patients undergoing surgery utilises
several strategies to promote earlier resumption of
normal diet, earlier mobilisation, and reduced length
of stay [30]. This has particular relevance for patients
with diabetes as it promotes eating and drinking
(reducing the risk of iatrogenic harm from a VRIII),
and by promoting earlier discharge.
Use of oral carbohydrate loading drinks
Carbohydrate loading may compromise blood glucose
control and should not be used in patients with insulin-treated
diabetes who are likely to have a short period
of fasting. There is some evidence that oral
carbohydrate loading may be safe in patients with
type-2 diabetes [31], and if a VRIII is to be used in
any case there is no reason to withhold oral carbohydrate
loading drinks in any patient with diabetes.
Patients with diabetes requiring
emergency surgery
There are three ways of managing diabetes in the
patient requiring emergency surgery:
1 Modification of normal medication. This is only
possible if the patient is physiologically well and is
being operated on a scheduled list, for example a
8 © 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
regular trauma list for minor hand surgery, or
evacuation of retained products of conception on
a regular gynaecology list.
2 Use of a VRIII. This should be the default
technique to manage a patient undergoing emergency
surgery because of the unpredictability of
the starvation period caused by the erratic nature
of emergency lists.
3 Use of a fixed-rate intravenous insulin infusion
(see below). This should only be used if the
patient requires immediate surgery and has concurrent
DKA.
The aim is for the patient to be taken to the
1
operating theatre with a CBG of 6–10 mmol.l
1
(6–12 mmol.l may be acceptable), without overt
DKA, and having been adequately resuscitated.
•
Recommendation: In patients undergoing emergency
surgery, the CBG should be checked regularly
(hourly as a minimum whilst acutely unwell),
and a VRIII established using dextrose 5% in saline
0.45% with pre-mixed potassium chloride as the
substrate.
The patient should be checked for ketonaemia
(> 3.0 mmol.l
1 ) or significant ketonuria (> 2+ on
urine sticks) if the CBG exceeds 12 mmol.l
1 . If the
patient has DKA and requires emergency surgery, the
involvement of senior multidisciplinary input from
intensivists, anaesthetists, surgeons and diabetologists
should be considered to agree optimal peri-operative
management. Operating on a patient with DKA carries
significant mortality and should be avoided if at all possible.
The discussion should include: the requirement
for surgery, because DKA can be associated with
abdominal pain (negative laparotomies have been
reported); the area in which the patient should be resuscitated
before theatre; whether saline 0.9% with premixed
potassium chloride or Hartmann’s solution
should be the main resuscitation fluid; whether a VRIII
or a fixed-rate infusion should be used to treat DKA in
theatre; and the area in which the patient will be recovered
after surgery. Recent guidelines and evidence suggest
that a fixed-rate intravenous insulin infusion is
superior to a VRIII in treating DKA in a ward environment
[32]. However, use of a fixed-rate infusion is associated
with hypoglycaemia and requires administration
of glucose 20% if the CBG is under 14 mmol.l
1 .
Early involvement of the diabetes inpatient specialist
team should be sought.
If possible, long-acting insulins (Levemir, Lantus,
Tresiba) should be continued in all patients at 80% of
the usual dose. This is to avoid rebound hyperglycaemia
when intravenous insulin is stopped.
Safety
Errors in insulin prescribing are common and insulin
has been identified as one of the top five high-risk
medications in the inpatient environment [33]. The
wide range of preparations and devices available for
insulin administration (currently > 60) increases the
potential for error. One third of all inpatient medical
errors leading to death within 48 h of the error involve
insulin administration. Common errors include mistakes
when abbreviating the word ‘units’, failure to use
a specific insulin syringe, and errors when preparing
insulin infusions. Use of pre-filled syringes of insulin
for infusion may reduce the risk and should be considered
by Trusts.
Safe use of VRIIIs
Variable-rate intravenous insulin infusions are overused
in the peri-operative setting. Their use is
associated with hypoglycaemia, hyperglycaemia and
ketosis on cessation, and hyponatraemia. There
seems to be a significant risk of hypoglycaemia in
1
patients with a CBG of 4–6 mmol.l and on a
VRIII. Patients often return to surgical wards from
theatre with an intravenous insulin infusion in place
but no directions for its withdrawal. Hospitals
should have written guidelines for both the safe use
of the VRIII and conversion from the VRIII to the
usual diabetes treatment.
To ensure a steady supply of substrate it is recommended
that glucose 5% in saline 0.45% with potassium
chloride 0.15% or 0.3% should be administered
concurrently with the VRIII, at a rate to meet the
patient’s maintenance fluid requirements. It is imperative
that there is hourly monitoring of the CBG (to
keep the CBG at 6–10 mmol.l
1 ), and that in patients
with type-1 diabetes, the VRIII is not discontinued
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 9

Anaesthesia 2015
Barker et al. | Guidelines on peri-operative management of diabetes
until alternative subcutaneous insulin has been administered.
Metformin
A number of guidelines available for the use of
metformin recommend withdrawing treatment peri-operatively.
However, evidence for this approach is lacking
and there is some evidence that peri-operative continuation
of metformin is safe. Metformin is renally excreted
and renal failure may lead to high plasma levels which
are associated with an increased risk of lactic acidosis
[34]. Metformin should be withheld if there is pre-existing
renal impairment or significant risk of the patient
developing acute kidney injury. Anaesthetists should be
vigilant about the dangers of the use of nephrotoxic
agents, including contract media [35].
Non-steroidal anti-inflammatory drugs (NSAIDs)
There are several additional considerations to the use
of NSAIDs in patients with diabetes, including the
redistribution of renal blood flow in the presence of
hypovolaemia and the risk of oedema, especially if
given concurrently with metformin and glitazones.
Quality control and audit
A number of bodies have published quality standards
pertinent to the peri-operative care of patients with diabetes.
These include NICE, the Royal College of Anaesthetists
(RCoA) and NHS Diabetes (the latter no longer
exists and the Joint British Diabetes Societies Inpatient
Care Group has taken over some of its roles).
National Institute for Health and Care
Excellence
Quality Standard 6, Diabetes in Adults, includes an
auditable standard relating to inpatient care: “People
with diabetes admitted to hospital are cared for by
appropriately trained staff, provided with access to a
specialist diabetes team, and given the choice of selfmonitoring
and managing their own insulin” [36].
Royal College of Anaesthetists
The RCoA’s Guidelines for the Provision of Anaesthetic
Services [37] contains much advice relating to the perioperative
care of patients, including those with diabetes.
In addition, the RCoA publication Raising the
Standard – a Compendium of Audit Recipes contains
details on audit and quality improvement topics pertinent
to patients with diabetes [38]. These focus on
peri-operative care and are suitable for use by anaesthetists
wishing to assess the quality of local provision.
For example, topics include availability of guidelines
for, and management of, chronic medication during
the peri-operative period, and peri-operative fasting.
NHS Diabetes
The NHS Diabetes guideline contains a number of
suggested audit standards covering medication, safety,
training and institutional issues [1].
National Diabetes Inpatient Audit
Whilst the audit standards suggested above may be
used within an organisation, national audit projects
provide a broader picture and allow benchmarking.
The National Diabetes Inpatient Audit (NaDIA) is an
annual snapshot audit of surgical and medical inpatients
with diabetes. The majority of Trusts in
England and Wales are now taking part. The audit is
commissioned by the Healthcare Quality Improvement
Partnership as part of the National Clinical Audit and
Patient Outcomes Programme. The results are available
online in the spring of each year and enable
organisations to assess their performance in caring for
inpatients with diabetes [39].
Included in the audit are questions relating to
whether diabetes management minimises the risk of
avoidable complications, harm resulting from the
inpatient stay, patient experience and the change in
patient feedback on the quality of care since
NaDIA began. Of particular relevance to anaesthetists,
NaDIA includes comparative data on the prevalence of
medication errors, intravenous insulin infusions, glycaemic
control and patient harm. In addition, there
are considerable data from patients’ feedback questionnaires
concerning their experience and involvement in
their own care.
• Recommendation: Anaesthetists interested in perioperative
diabetes management should access the
National Diabetes Inpatient Audit and look up the
results for their own organisation.
10 © 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
Acknowledgements
This guideline and the text are based in large part on
the guidelines available from the JBDS [1]. The Working
Party and AAGBI are grateful to the JBDS Inpatient
Care Group for permission to use its document
as the basis for this guideline.
Competing interests
No external funding and no competing interests
declared.
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28. Hebl JR, Kopp SL, Schroeder DR, Horlocker TT. Neurologic complications
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30. Varadhan KK, Neal KR, Dejong CH, et al. The enhanced recovery
after surgery (ERAS) pathway for patients undergoing
major elective open colorectal surgery: a meta-analysis of
randomized controlled trials. Clinical Nutrition 2010; 29:
434–40.
31. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate
loading may be used in type 2 diabetes patients.
Acta Anaesthesiologica Scandinavica 2008; 52: 946–51.
32. Joint British Diabetes Societies Inpatient Care Group. The management
of diabetic ketoacidosis in adults, September 2013.
http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_DKA_Adu
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33. National Patient Safety Agency. The fourth report of the Patient
Safety Observatory. Safety in doses: medication safety incidents
in the NHS, January 2007. www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-safety/?entryid45=59822&q=0%
c2%acsafety+in+doses%c2%ac (accessed 11/08/2015).
34. Duncan AI, Koch CG, Xu M, et al. Recent metformin ingestion
does not increase in-hospital morbidity or mortality
after cardiac surgery. Anesthesia and Analgesia 2007; 104:
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35. Royal College of Radiologists. Standards for Intravascular Contrast
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RCR, 2010.
36. National Institute for Health and Care Excellence. Diabetes in
Adults. Quality Standard 6, March 2011. www.nice.org.uk/
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37. Royal College of Anaesthetists. Guidelines for the Provision of
Anaesthetic Services 2015. www.rcoa.ac.uk/GPAS2015 (accessed
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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
Appendix 1
Example of a variable-rate intravenous insulin infusion prescription. Glucose concentration is usually measured in capillary blood.
Glucose
concentration;
1
mmol.l
Standard rate (use unless otherwise indicated)
No basal insulin
< 4 0.5 IU.h 1 + give
100 ml glucose 20%
intravenously
4.1–6.0 0.5 IU.h 1 + consider
50 ml glucose 20%
intravenously
Basal insulin
continued No basal insulin
STOP + give 100 ml
glucose 20%
intravenously
STOP + consider
50 ml glucose 20%
intravenously
Reduced rate (e.g. insulin-sensitive patients
(i.e. < 24 IU.day 1 ))
0.2 IU.h 1 + give
100 ml glucose 20%
intravenously
0.2 IU.h 1 + give
50 ml glucose 20%
intravenously
Basal insulin
continued No basal insulin
STOP + give 100 ml
glucose 20%
intravenously
STOP + consider
50 ml glucose 20%
intravenously
Increased rate (e.g. insulin-resistant patients
(i.e. > 100 IU.day 1 ))
0.5 IU.h 1 + give
100 ml glucose 20%
intravenously
0.5 IU.h 1 + give
50 ml glucose 20%
intravenously
Basal insulin
continued
STOP + give 100 ml
glucose 20%
intravenously
STOP + consider
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
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
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
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
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
> 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
> 24.1 Ensure insulin is running and that the measured blood glucose concentration is not artefactual
50 ml glucose 20%
intravenously
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland 13

Anaesthesia 2015
Barker et al. | Guidelines on peri-operative management of diabetes
Appendix 2
Example of a variable-rate intravenous insulin infusion regimen observation chart. Reproduced by kind
permission of the Norfolk and Norwich University Hospitals NHS Foundation Trust.
BLOOD GLUCOSE MONITORING CHART (adults, not pregnant)
B
Paent Name:
Hospital Number:
Date of birth:
Consultant:
Date
(dd/mm/yyyy):
Time:
Blood glucose
reading (mmol/L)
OR PATIENT LABEL
A SINGLE reading in a RED area requires acon
TWO consecuve readings in the AMBER areas
require acon
This is the ACCEPTABLE glucose range
This is the IDEAL glucose target range
Ward:
Blood glucose readings (mmol/L)
Ketone levels
Diabetes Inpatient Specialist Nurse bleep - 0407 - available Monday to Friday 9am to 5pm
Urine
Blood
30
25
20
15
10
5
0
++++
+++
++
+
Nil
ALL ACTION TAKEN MUST BE DOCUMENTED IN THE HOSPITAL NOTES
Inials
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21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Do Not Attempt Resuscitation (DNAR) Decisions
in the Perioperative Period
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org May 2009

Membership of the working party
Dr L Gemmell
Dr M E McBrien
Dr G Heyburn
Ms M Hassell
Dr V Bythell
Mrs K Rivett
Prof J Bion
Dr S Williams
Dr C Stack
Prof A Cunningham
Chairman and AAGBI Honorary
Secretary
Consultant Anaesthetist
Associate Specialist in
Orthogeriatrics
HM Coroner, Cardiff & Vale of
Glamorgan
AAGBI Council Member
Lay Representative, Patient Liaison
Group, RCoA
RCoA
GAT representative
Consultant Anaesthetist
College of Anaesthetists, Ireland
Ex Officio
Dr R J S Birks
Dr D K Whitaker
Dr I H Wilson
Dr I G Johnston
Dr A W Harrop-Griffiths
Dr E O’Sullivan
Dr D G Bogod
President
Immediate Past President
Honorary Treasurer
Honorary Treasurer Elect
Immediate Past Honorary Secretary
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia

Contents
Section 1 Recommendations 2
Section 2 Introduction 4
Section 3 Definitions 6
Section 4 Ethical framework 8
Section 5 Legal framework 9
Section 6
Why is it necessary to review a DNAR
decision before surgery and anaesthesia? 14
Section 7 How to review a DNAR decision 16
Section 8 Conflict resolution 20
Section 9
Duration of the DNAR management
option 22
Section 10
Summary for patients, proxy decision
makers and relatives 23
Section 11 References 25
Appendix 1 28
© Copyright of the Association of Anaesthetists of Great Britain and Ireland.
No part of this book may be reproduced without the written permission of the
AAGBI.
1

1. Recommendations
1. Management of patients with DNAR decisions in the
perioperative period should focus on what resuscitative
measures will be embarked on rather than on what
will not be done.
2. It is essential that patients who may require surgical
procedures with DNAR decisions in place are referred as
early as possible to the anaesthetic and surgical teams.
3. A review of the DNAR decision by the anaesthetist and
surgeon with the patient, proxy decision maker, other doctor
in charge of the patient’s care, and relatives or carers, if
indicated, is essential before proceeding with surgery and
anaesthesia.
4. There are three options for managing the DNAR decision:
Option one: the DNAR decision is to be discontinued.
Surgery and anaesthesia are to proceed with
cardiopulmonary resuscitation (CPR) to be used if
cardiopulmonary arrest occurs.
Option two: the DNAR decision is to be modified to
permit the use of drugs and techniques commensurate with
the provision of anaesthesia.
Option three: no changes are to be made to the DNAR
decision. Under most circumstances this option is not
compatible with the provision of general anaesthesia for any
type of surgical intervention.
5. The agreed DNAR management option should be
documented in the patient’s notes.
6. The DNAR management option should be communicated
to all the healthcare staff managing the patient in the
operating theatre and recovery areas.
2

7. The law provides a clear hierarchy in terms of legal standing
to make DNAR decisions:
a. The competent patient’s direct instructions.
b. The patient’s advance decision or proxy decision maker
if competence is lacking.
c. The senior clinician in charge of the patient’s care, acting
in the patient’s best interests, if there is not a legally valid
advance decision or proxy decision maker for a patient
lacking competence.
8. If, after discussion, there is no agreement on which DNAR
decision option should be adopted, the decision of the
person with the legal right or responsibility for making the
decision should be accepted.
9. If an anaesthetist or other health care provider cannot agree
with the outcome of the review of the DNAR decision, they
must ensure that arrangements are made for another
suitably qualified colleague to take over the role in
accordance with GMC guidelines.
10. If it is unclear who has the right or responsibility to make
the decision, or if there is doubt over the legal validity of an
advance decision or proxy decision maker, or doubt as to
what is in the best interests of the patient, then seek legal
advice immediately.
11. In an emergency, the doctor must make decisions that they
view to be in the best interests of the patient using whatever
information is available.
12. The DNAR management option should, under most
circumstances, apply for the period when the patient is in
the operating theatre and recovery areas. The DNAR
decision should be reinstated when the patient returns to
the ward, unless in exceptional circumstances.
3

2. Introduction
In the past, decisions about treatment and resuscitation status
were often made by doctors with little discussion with the
patient. This paternalistic approach is being replaced with
one based on the concept of autonomy, in which the rights of
an individual to have control over their own body and to be
allowed to make decisions about their medical treatment are
paramount. In this approach, decisions result from a partnership
between the patient and the clinical team and may now involve
proxy decision makers.
DNAR decisions pose a conundrum where patients are
scheduled to undergo anaesthesia because techniques routinely
undertaken in the course of anaesthesia would ordinarily be
classified as resuscitation. Yet it is increasingly common for
patients to be scheduled for anaesthesia and surgery with a preexisting
DNAR decision in place. While this often applies to
older patients, it may also apply to younger patients or children.
These guidelines apply only to adult patients.
Medical conditions that may require anaesthesia for operative
interventions in a patient with a DNAR decision include:
• provision of a support device (e.g. a feeding tube),
• urgent surgery for a condition unrelated to the underlying
chronic problem (e.g. acute appendicitis),
• urgent surgery for a condition related to the underlying
chronic problem but not believed to be a terminal event
(e.g. bowel obstruction),
• procedure to decrease pains (e.g. repair of fractured neck of
femur),
• procedure to provide vascular access.
Guidelines from the American Society of Anesthesiologists (ASA)
have existed to assist in the management of this ethical and
clinical dilemma since 1993 [1] and Canada since 2002 [2], but
4

none have been published in the UK to date.
Revised guidelines providing a framework to support decisions
relating to CPR were published in a joint statement from the
British Medical Association, the Resuscitation Council (UK) and
the Royal College of Nursing in 2007 [3]. This document is
hereafter referred to as the Joint Statement. The Joint Statement
recommends that a DNAR decision is reviewed before surgery
and anaesthesia, but detailed guidance on how the decision
should be managed is not provided.
McBrien and Heyburn have outlined the dilemmas posed by
the need for anaesthesia and surgery in patients with an existing
DNAR decision in place [4]. Although it has been a common
presumption that DNAR decisions should be fully withdrawn
during the perioperative period, this may not be in the
patient’s best interests. A review of the basic legal and ethical
principles involved is needed in order to decide how individual
anaesthetists and anaesthetic departments should manage this
situation.
The AAGBI Council has therefore decided to provide these
guidelines on the management of DNAR decisions in the
perioperative period. This guidance is intended for all clinicians
and healthcare workers involved with adult patients during the
perioperative period, and should be used in conjunction with
the Joint Statement [3].
Decisions regarding DNAR decisions in the perioperative
period form part of the consent process for anaesthesia and
should be viewed as such. The principles outlined in the
AAGBI document ‘Consent for Anaesthesia’ [5], and the GMC
document ‘Consent: patients and doctors making decisions
together’ [6] and Section E ‘Confidentiality and Consent’ in the
Irish Medical Council’s Guide to Ethical Conduct and Behaviour
[7] should also be used in conjunction with these guidelines.
5

3. Definitions
Do not attempt resuscitation (DNAR) decision
DNAR decisions are implemented on the assumption that
cardiopulmonary arrest will be a spontaneous event that is the
culmination of the dying process in a patient who has a terminal
illness or a poor quality of life. These decisions arose out of
the realisation that resuscitation, including cardiopulmonary
resuscitation, is inappropriate in such cases, as it has a poor
outcome and is against the wishes of patients and families.
The Joint Statement provides a framework for the decision
making process in the formation, consequences and
implications of a DNAR decision [3].
In the implementation of a DNAR decision the patient, proxy
decision maker or senior clinician in charge of the patient are
indicating that it is in the patient’s best interests to die naturally
without resuscitative interventions that would be considered
unnecessary and undignified.
Following implementation of the DNAR decision, the patient is
not to be resuscitated with chest compressions, defibrillation of
the heart, artificial respiration or large doses of vasoactive drugs.
However, the highest standards of medical and nursing
care are still to be provided at all times.
Location sensitive DNAR decisions
This is a DNAR decision that is intended to apply in a specific
named location only.
Cardiopulmonary resuscitation (CPR)
CPR is undertaken in an attempt to restore breathing and
spontaneous circulation in a patient in cardiac and/or
respiratory arrest. CPR usually includes chest compressions,
attempted defibrillation, large doses of vasoactive drugs and
ventilation of the lungs.
6

Proxy decision makers
Within these guidelines, this term refers to those who an adult
with capacity has appointed to make decisions about medical
treatment for them once that capacity has been lost. In England
and Wales the legal requirements surrounding the appointment
of a proxy decision maker, known as a Lasting Power of
Attorney (LPA), are covered in the Mental Capacity Act 2005
[8]. In Scotland the proxy decision maker, known as the welfare
attorney, is legislated for in the Adults with Incapacity Act 2000
[9]. In both Northern Ireland and the Republic of Ireland there
are currently no statutory provisions for proxy decision makers
in relation to healthcare decisions.
Competent/incompetent adults
Adults are considered legally unable to make decisions for
themselves if they are unable to:
1. understand the information relevant to the decisions,
2. retain that information,
3. use or weigh that information as part of the process of
making the decisions,
4. communicate the decisions (by talking, sign language, visual
aids or by other means).
Independent Mental Capacity Advocate (IMCA)
The Mental Capacity Act 2005 [8] in England and Wales
includes the provision of a statutory right to advocacy for
people who lack the capacity to make their own decisions
about serious medical treatment or significant changes in their
care arrangements and have no family or friends to support
them. This advocate is called the Independent Mental Capacity
Advocate and is appointed by the local authority or health
board. The role of the IMCA is to indicate to decision makers
the patient’s wishes, feelings, beliefs and values.
7

4. Ethical framework
Advance decisions, such as DNAR decisions, have arisen from
the need for greater respect for patients’ autonomy. Autonomy
forms one of the four principles of biomedical ethics proposed
by Beauchamp and Childress [10], and refers to respect for
the decision making capacities of individuals enabling them
to make informed choices about their healthcare. The other
three principles are beneficence (overall benefit to the patient),
non-maleficence (avoiding the causation of harm) and justice
(fair distribution of benefits to all patients). Unfortunately,
when applied to an ethical dilemma, the four principles often
conflict with each other and so they only provide a framework
for discussion. The paternalistic primary ethical principle of the
past, namely the doctor’s view of the immediate benefit to the
patient, is now in competition with other conflicting principles.
The GMC provides guidance on withholding and withdrawing
life-prolonging treatments [11]. The guiding principle is that
doctors should have respect for human life and make their
patients’ best interests their first concern.
8

5. Legal framework
United Kingdom
The process of devolution within the UK has resulted in
differences in the legal framework between the devolved
nations. However, policies relating to DNAR decisions must
comply with the Human Rights Act 1998 [10] in every legal
setting as this Act applies throughout the UK. A review of the
legal issues surrounding DNAR decisions has been necessary as
a result of changes in society’s expectations which are reflected
in current legislation. The Joint Statement highlights the articles
in the Human Rights Act 1998 that are of particular importance
when considering DNAR decisions [3]. The spirit of the Act,
which aims to promote human dignity and transparent decision
making, is reflected in the recommendations found in the Joint
Statement. A wider review of the implications of the Human
Rights Act in anaesthesia and intensive care was published by
White and Baldwin in 2002 [13], but this did not address the
issue of DNAR decisions in the perioperative period.
The Mental Capacity Act 2005 [8] provides a protective
statutory framework for decision making on behalf of adults who
lack competency in England and Wales. White and Baldwin
have also reviewed the implications of the Mental Capacity
Act in the practice of anaesthesia and intensive care [14]. The
Adults with Incapacity (Scotland) Act 2000 [9] provides a similar
statutory framework for residents in that country. Northern
Ireland currently has no formal legislation covering adults who
lack competency and relies on the common law position that
has developed in this area.
Republic of Ireland
There is currently no specific legislation in relation to advance
decisions in the Republic of Ireland. The Irish Council for
Bioethics has taken the opportunity to examine the ethical and
legal issues surrounding advance directives in the Republic of
Ireland and has published their findings [15].
9

As in the UK, this publication highlights the fact that treatment
carried out without the consent of a competent patient in the
Republic of Ireland is considered both trespass and battery. In
addition, the publication explains that there is currently no
provision for an individual in the Republic of Ireland to make
a legally binding advance decision, or for the appointment
of proxy decision makers to make decisions on matters of
healthcare if and when a patient lacks competence. The Law
Reform Commission in the Republic of Ireland has suggested
that it should be possible for advance decisions to be made
legally binding. They are also considering an amendment to
the existing Powers of Attorney Act 1996 to enable appointed
attorneys to make decisions on minor and routine medical
treatment, in addition to managing the property and affairs
of the person who appointed them, as is the case at present.
Until this becomes law, there is no provision for proxy decision
making for incompetent individuals and the final authority to
make decisions on medical treatment for them rests with the
High Court in Ireland.
Not surprisingly, the lack of clarity in the legal status of advance
decisions such as DNAR decisions in the Republic of Ireland has
led some to express their dissatisfaction with the process there
[16]. The authors of this paper have requested that national
guidance on DNAR decisions is provided in the Republic of
Ireland.
10

Who can implement a DNAR decision?
A DNAR decision may arise:
1. Following the direct instructions of a competent patient.
2. Following a properly executed advance decision by a
patient who now lacks capacity. England and Wales have
different legislation to the rest of the UK concerning advance
decisions:
England and Wales
Advance decisions are covered by the Mental Capacity Act
2005 [8]. To be effective they must:
• Be applicable in the circumstances that have arisen
and include recognition that the patient gives these
instructions ‘even if life is at risk’.
• Be in writing, signed and witnessed.
If an advance decision does not meet these criteria but
appears to set out a clear indication of the patient’s wishes,
it will not be legally binding but should be taken into
consideration in determining the patient’s best interests.
Scotland and Northern Ireland
Advance decisions are not covered by statute but it is likely
that they are binding under common law.
An advance refusal of CPR is likely to be legally binding in
Scotland and Northern Ireland if:
• The patient was an adult at the time the decision was
made (16 years old in Scotland and 18 in Northern
Ireland).
• The circumstances that have arisen are those that were
envisaged by the patient.
11

If an advance decision does not meet these criteria but
appears to set out a clear indication of the patient’s wishes,
it will not be legally binding but should be taken into
consideration in determining the patient’s best interests.
Republic of Ireland
There is no specific legislation in relation to advance
decisions.
3. If a patient lacks capacity and no advance decision exists.
Different legislation regarding proxy decision makers
applies between England and Wales, Scotland, Northern
Ireland and the Republic of Ireland:
England and Wales
If the patient lacks capacity, a decision to implement a
DNAR decision may be made by the person appointed by
the patient’s Lasting Power of Attorney (LPA) as appointed
under the Mental Capacity Act 2005 [8]. Written permission
must have been given to the LPA by the patient, when
competent, to make decisions relating to life-prolonging
treatment.
Under the Mental Capacity Act 2005 [8], a proxy decision
maker must have been instructed in relation to life
sustaining treatment if DNAR is under discussion.
Scotland
If the patient lacks capacity, a decision to implement a
DNAR decision may be made by the patient’s welfare
guardian as appointed under the Adults with Incapacity
(Scotland) Act 2000 [9].
Northern Ireland and the Republic of Ireland
There is no provision for anybody close to the patient,
whether relatives or close friends, to make decisions for the
12

patient if they lack capacity. However, relatives and close
friends should be consulted to determine what the wishes
of the patient would be if they were able to competently
express them.
4. If the patient lacks capacity and there is no advance
decision and no legally empowered proxy decision maker, a
DNAR decision may be implemented by the senior
clinician in charge of the patient’s care. Consultation
with relatives or carers may clearly assist in discovering
any wishes formerly expressed by the patient. In England
and Wales, the Mental Capacity Act 2005 requires an
Independent Mental Capacity Advocate (IMCA) to be
consulted if the patient lacks capacity and has no one
(family, friends or carers) to represent their wishes regarding
‘serious medical treatment’ [8]. The Joint Statement says
that ‘where there is genuine doubt about whether or not
CPR would have a realistic chance of success, or if a DNAR
decision is being considered on the balance of benefits
and burdens, in order to comply with the law an IMCA must
be involved in every case’ [3]. Local guidance should
clearly identify how an IMCA can be contacted. The
role of the IMCA, as with relatives or carers, is to reflect
what the patient’s wishes would have been if they were able
to express them. A relative, carer or IMCA (unless they have
been appointed proxy decision maker) cannot make a
decision about CPR; the decision is that of the treating
clinician.
It must be remembered that patients, relatives, carers and
proxy decision makers cannot demand treatment which
is judged in medical opinion to be against the patient’s
interests.
13

6. Why is it necessary to review a
DNAR decision before surgery and
anaesthesia?
Surgery and anaesthesia constitute a change in the medical
status of a patient with a pre-existing DNAR decision because
of changes in physiology which can add additional risks to
the patient. However, survival rates following cardiac arrest
in the operating theatre are significantly greater than in the
general ward or residential setting where the DNAR decision
was originally intended to apply. Survival rates following
anaesthetic related cardiopulmonary arrest can be as high as
92% [17]. This compares with survival rates of 15-20% after
other in-hospital cardiopulmonary arrests [18]. This therefore
alters the likelihood that CPR in the perioperative period will
be successful and so can impact the original presumptions on
which the DNAR decision was made.
When anaesthesia is considered for a patient with a current
DNAR decision in place the patient and the anaesthetist face
two additional dilemmas. Firstly, anaesthesia itself, whether
regional or general, will promote cardiopulmonary instability
that will require support.
Secondly, many of the routine interventions used in giving an
anaesthetic may be classified as resuscitative measures used
in CPR in another setting. These include the insertion of an
intravenous cannula, administration of intravenous fluids,
insertion of an artificial airway, delivery of oxygen, provision of
respiratory assistance, cardiac monitoring and administration
of vasopressor and other resuscitative drugs. The surgical
procedure itself may also require resuscitative measures to be
implemented.
14

If the anaesthetist was to proceed and strictly obey the
general understanding of a DNAR decision, which excludes
cardiovascular and respiratory support, their actions could be
construed as an act of euthanasia or assisted suicide as they
would be initiating cardiopulmonary compromise and yet be
unable to treat this once it had occurred.
However, if the anaesthetist insists that the DNAR decision is
suspended in order for surgery and anaesthesia to take place,
the patient may be denied their rights to certain Articles of the
Human Rights Act including:
• The right to life (Article 2),
• To be free from inhuman or degrading treatment (Article 3),
• To be free from discriminatory practices, such as ageism, in
respect of these rights (Article 14) [10].
In addition, if an anaesthetist were to treat a patient against their
wishes, for example by implementing CPR when it was clear
that the patient had stated they did not wish this to take place,
this would constitute assault under both the criminal and civil
law. It would also violate the guidance given by the GMC [6].
The Mental Capacity Act 2005 states that an advance decision
must be applicable to the circumstances that subsequently
arise if it is to remain valid [8]. In the case of a DNAR decision
that exists as a result of an advance statement, it is likely that
the circumstance of anaesthesia for an operative procedure
that is considered appropriate will not have been specifically
considered when the advance decision was originally made.
For these reasons, all DNAR decisions must be reviewed before
patients undergo anaesthesia and surgery. The complexity
of these situations makes it essential that decisions regarding
modification of DNAR decisions in the perioperative period
are made by senior staff and, if necessary, with reference to the
hospital’s legal team.
15

7. How to review a DNAR decision
It is important that patients who may require surgical procedures
with DNAR decisions in place are referred as early as possible
to the anaesthetist and surgical team. Time is required to
enable sensitive and effective communication with all the
relevant individuals and to formulate a plan that is acceptable
to all involved with the patients’ care and most importantly
the patients themselves. However, this should be done with
sufficient urgency to avoid delay to surgery in this vulnerable
group of patients.
At the end of the decision making process patients, proxy
decision makers, relatives, carers, friends and IMCAs (if
indicated) should feel that they have received adequate
information in a form they can understand and that the
decisions taken truly reflect the wishes of the patient. If patients
or others feel they have not had the chance to have a proper
discussion with the healthcare team, or are not happy with the
discussions they have had, they should be given the option of
a consultation with other designated individuals within each
hospital.
Emergency situation
In emergency situations it may not be possible to review
a DNAR decision, or any other advance decision, prior to
anaesthesia, surgery or resuscitation as there is insufficient time.
However, attempts must still be made to clarify any advance
decisions that are made known to the doctors involved by
discussion with relatives, proxy decision makers or even the
patient if this is possible.
If an advance decision cannot be discussed with these
individuals, doctors must decide what they view to be in the
best interests of the patient using whatever information is
available.
16

Preoperative phase
Provision must be made for confidential discussion to take
place between the relevant individuals involved in the case:
patient, proxy decision makers, family and carers if appropriate,
anaesthetist, surgeon, physician and nursing staff. The following
points act as guidance to the preliminary assessment of the
patient and enable a treatment plan to be formulated:
a. The patient’s medical condition, including their mental
competence,
b. The surgical intervention required,
c. The history of the DNAR decision including:
• the duration of the decision,
• who was responsible for implementing the decision,
• whether the decision was intended to be ‘location
sensitive’,
• the presumptions on which the decision was based.
The first decision required is whether anaesthesia and surgery
are appropriate, taking into consideration the views of the
patient, relatives, proxy decision makers, surgeons and
anaesthetists. If surgery is deemed appropriate, measures must
be taken to ensure the patient is medically optimised. A decision
must then be taken as to what resuscitative measures are
acceptable in the perioperative period with open, detailed and
frequent communication with the patient, relatives and proxy
decision makers.
Once the plan for the DNAR decision has been agreed, it should
be recorded in the patient’s notes, signed by the relevant parties
and dated. Surgery should proceed as soon as practical after the
decision is made and the medical condition of the patient has
been optimised.
We recommend that one of the following three options is
adopted following review of the DNAR decision, and with
agreement from all the relevant decision makers involved:
17

Option one: The DNAR decision is to be discontinued during
anaesthesia and surgery and fully reinstated once discharged
from the recovery room.
Surgery and anaesthesia are to proceed with CPR to be used if
cardiopulmonary arrest occurs.
Option two: The DNAR decision is to be modified to permit
the use of drugs and techniques commensurate with the
provision of anaesthesia.
In most circumstances, this would include:
1. Monitoring of ECG, blood pressure, oxygenation and any
intraoperative monitors which are considered essential for a
good outcome.
2. Temporary manipulation of the airway and breathing
with intubation and ventilation, when needed; and
with understanding that the patient will be breathing
spontaneously at the end of the procedure.
3. Use of vasopressor or antiarrhythmic drugs to correct
cardiovascular stability related to the provision of anaesthesia
and surgery.
The use of electrical cardioversion or defibrillation to correct
arrhythmias should be considered and discussed with the
patient or proxy decision makers in advance. Attempts of
electrical cardioversion or defibrillation may be considered and
agreed to treat arrhythmias if indicated.
A decision must also be taken about the potential use of chest
compressions. These may be deemed unacceptable in view of
the possible complications involved.
Option three: No changes are to be made to the DNAR
decision.
Under most circumstances this option is not compatible with
the provision of general anaesthesia for any type of surgical
intervention.
18

The patient may wish to undergo a minor surgical procedure
while their DNAR decision remains in place. The anaesthetist
should reach agreement, if possible, with the patient or proxy
decision makers as to exactly what, if any, interventions are
permitted, such as intravenous cannulation, intravenous fluid
administration, sedation, analgesia, monitoring, vasopressor
medication, antiarrhythmic medication, administration of
oxygen or other interventions.
The Joint Statement makes it clear that ‘If a clinician believes
that the procedure or treatment would not be successful with
the DNAR decision still in place, it would be reasonable not to
proceed.’ [3]
Appendix 1 provides an example of a proforma adapted from
the options on page 18. The working party recommends the
adoption of a formal document such as this describing the
procedures the patient has consented to undergo during the
perioperative period. However, it must be remembered that
completing the proforma should not take priority over the
discussion. The purpose of the proforma is to record for clarity
and certainty the decisions that have been made, and the
parties to it. The quality of the medical advice, the exploration
of alternatives and adherence to the patient’s wishes are the
essence of the process.
19

8. Conflict resolution
When dealing with a situation involving the modification of a
pre-existing DNAR decision, the medical team may be faced
with different wishes from the patient, family members and
friends. In attempting to resolve such conflict, the law provides
a clear hierarchy in terms of who can legally make decisions
about the treatment a patient receives:
a) The competent patient’s direct instructions
A competent patient’s direct instructions are always
paramount.
b) The patient’s advance decision or proxy decision
maker
If the patient has made an advance decision and has
appointed a proxy decision maker, and they are both
applicable to exactly the same situation, then which ever
action was taken later (i.e. most recently) takes priority.
It is likely that the situation of anaesthesia and surgery will
not have been considered when making an advance
decision DNAR order which will then invalidate its
application in these circumstances.
The decision will then need to be taken by the proxy
decision maker, if one exists, or the senior clinician in
charge of the patient’s care, as to what management option
should be pursued.
20

c) The senior clinician in charge of the patient’s care
If the patient is not competent to make their own decisions,
and has not appointed a proxy decision maker or made
an advance decision, then the senior clinician in charge
of the patient’s care must make the decision, based on the
patient’s best interests.
Again, consultation with relatives or carers may clearly
assist in discovering any wishes formerly expressed by the
patient. In England and Wales an Independent Mental
Capacity Advocate (IMCA) may be consulted to reflect
the patient’s wishes if there is no relative, friend or carer
to represent the patient. However, the power to make the
decision resides with the treating clinician, not with the
relatives, friend, carers or IMCA.
If, after reasonable effort, agreement or compromise cannot
be reached through dialogue, the decision of the person with
the right or responsibility for making the decision should be
accepted. If there is doubt as to the validity of the appointment
of a proxy decision maker or an advance decision, or what is in
the best interests of the patient, then the Trust legal team should
be contacted immediately for advice. An application may very
quickly be made to court to seek a declaration as to whether a
particular course of action is lawful.
If an anaesthetist or other healthcare provider cannot agree with
the outcome of the review of the DNAR decision, they must
ensure that arrangements are made for another suitably qualified
colleague to take over the role in accordance with GMC
guidelines [19].
21

9. Duration of the DNAR
management option
Intraoperative phase
The DNAR management option should apply for the duration of
the patient’s stay in the theatre environment. If premedication
is prescribed it must be used with extreme caution to avoid
alterations in the patient’s physiological status before transfer to
theatre.
All theatre staff should be made aware of the DNAR
management option of the patient throughout their time in the
theatre suite and recovery area. The anaesthetist and surgeon
involved in preoperative consultation should be present in
theatre throughout the procedure to enable shared responsibility
of resuscitation decisions. In some circumstances this may
not be possible; good communication of decisions from the
preoperative consultation is therefore essential.
Postoperative phase
The DNAR management option should be communicated to the
recovery staff on transfer to the recovery area. This option will
continue until the patient is discharged from the recovery area.
The prior DNAR decision should be reinstated on handover of
the patient to the nursing staff from the ward. In exceptional
circumstances, arrangements may be made to prolong the
DNAR management option following transfer to the ward
postoperatively: for example, if a patient-controlled analgesia
device or epidural infusion is to be used in the postoperative
period. A postoperative review of the patient should be
carried out with communication to the patient, relatives or
proxy decision makers about the perioperative management if
necessary.
There should be regular audits of the management of patients
with DNAR decisions scheduled for surgery.
22

10. Summary for patients, proxy
decision makers and relatives
This section summarises the guidance given in this document
regarding the implications of a DNAR decision, and how the
presumptions on which the DNAR decision was implemented
are altered by the proposed surgery and anaesthesia. This
summary is not intended to be used directly as patient guidance,
but might be useful for lay persons. It is suggested that Trusts
should consider producing appropriate patient guidance on this
matter.
These guidelines apply only to adult patients.
The purpose of reviewing the DNAR decision is to provide an
opportunity for agreement over what treatment will be provided
during surgery and anaesthesia. The three DNAR management
options provide a range of alternatives that should be
considered. The legal hierarchy of the competent patient, their
advance decision or their proxy decision maker, then the senior
clinician in charge of the patient’s care exists to determine who
decides the DNAR management option to be followed.
Although relatives should be involved in decisions about
proposed treatment, they have no legal authority in determining
the DNAR management option. Their inclusion in discussions
for patients who lack capacity is to reflect what the wishes of the
patient would have been if they were able to express them.
It must also be remembered that neither patients nor proxy
decision makers can demand treatment, which is judged in
medical opinion to be against the patient’s interests. Patients
may however refuse treatment, as can proxy decision makers, so
long as they have legal authority to do so. Advance decisions
refusing treatment must be relevant to the situation of the
proposed surgery and anaesthesia.
23

At the end of the decision making process patients, proxy
decision makers, relatives, carers, friends and IMCAs (if
indicated) should feel that they have received adequate
information in a form they can understand and that the
decisions taken truly reflect the wishes of the patient.
Further information on decisions relating to CPR has been
published by the British Medical Association [20], but the
issue of DNAR decisions in the perioperative period is not
considered. If patients feel they have not had the chance to
have a proper discussion with the healthcare team, or are not
happy with the discussions they have had, they should be given
the option of a consultation with other designated individuals
within each hospital.
24

11. References
1. American Society of Anaesthetists Committee on Ethics, 2001.
Ethical guidelines for the anesthesia care of patients with do-notresuscitate
orders or other directives that limit treatment. www.
asahq.org/publicationsAndServices/standards/09.html (accessed
01/08/08).
2. Canadian Anesthesiologists’ Society Committee on Ethics, 2002.
Peri-operative status of ‘do not resuscitate’ (DNR) orders and
other directives regarding treatment. www.cas.ca/members/
sign_in/guidelines/do_not_resuscitate/ (accessed 01/08/08).
3. Resuscitation Council, Decisions Relating to Cardiopulmonary
Resuscitation. A Joint Statement from the British Medical
Association, the Resuscitation Council (UK) and the Royal College
of Nursing, London: 2007. www.resus.org.uk/pages/DNAR.htm
(accessed 18/11/08).
4. McBrien ME and Heyburn G. Anaesthesia 2006; 61: 625–7.
5. Consent for Anaesthesia, 2nd edition 2006. London, The
Association of Anaesthetists of Great Britain and Ireland. www.
aagbi.org/publications/guidelines/docs/consent06.pdf (accessed
01/08/08).
6. General Medical Council. Consent: patients and doctors making
decisions together, 2008. www.gmc-uk.org/news/articles/
Consent_guidance.pdf (accessed 01/08/08).
7. Medical Council of Ireland. A Guide to Ethical Conduct and
Behaviour, Sixth Edition, 2004. www.medicalcouncil.ie/
professional/ethics.asp (accessed 18/11/08).
8. Mental Capacity Act 2005. http://www.opsi.gov.uk/ACTS/
acts2005/ukpga_20050009_en_1 (accessed 29.1.09).
9. Adults with Incapacity (Scotland) Act 2000. http://www.opsi.gov.
uk/legislation/scotland/acts2000/asp_20000004_en_1 (accessed
29.1.09).
25

10. Human Rights Act 1998. http://www.opsi.gov.uk/ACTS/acts1998/
ukpga_19980042_en_1 (accessed 29.1.09).
11. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 5th
edn. Oxford: Oxford University Press, 2001.
12. General Medical Council. Withholding and withdrawing life
prolonging treatments: Good practice in decision-making, 2002.
www.gmc-uk.org/guidance/current/library/witholding_
lifeprolonging_guidance.asp#67 (accessed 18/09/08).
13. White SM, Baldwin TJ. The Human Rights Act, 1998: implications
for anaesthesia and intensive care. Anaesthesia 2002; 57: 882–8.
14. White SM, Baldwin TJ. The Mental Capacity Act 2005 –
implications for anaesthesia and critical care. Anaesthesia 2006;
61: 381-9.
15. Irish Council for Bioethics. Is it time for advance healthcare
directives? Opinion, 2007. www.bioethics.ie/uploads/docs/
AdvanceDirectiveReport.pdf (accessed 18/11/08).
16. Butler MW, Saaidin N, Sheikh AA, Fennell JS. Dissatisfaction with
do not attempt resuscitation orders: A nationwide study of Irish
consultant physician practices. Irish Medical Journal 2006; 99:
208-210.
17. Olsson GL, Hallen B. Cardiac arrest during anaesthesia.
A computer-aided study in 250,543 anaesthetics. Acta
Anaesthesiologica Scandinavica 1988; 32(8): 653–64.
18. Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac
arrest: incidence, prognosis and possible measures to improve
survival. Intensive Care Medicine 2007; 33: 237-45.
19. General Medical Council. Good medical practice, 2006.
www.gmc-uk.org/guidance/good_medical_practice/index.asp
(accessed 01/08/08).
26

20. British Medical Association. Cardiopulmonary resuscitation
model patient information leaflet, 2008. www.bma.org.uk/
health_promotion_ethics/cardiopulmonary_resuscitation/
CPRpatientinformation.jsp (accessed 18/09/08).
27

Appendix 1
DNAR management consent form
This patient has been scheduled for surgery and anaesthesia.
A DNAR decision is already in place. In order for surgery and
anaesthesia to take place, one of the following three options has
been agreed upon.
Option one: The DNAR decision is to be discontinued during
anaesthesia and surgery and fully reinstated once discharged
from the recovery room.
Option two: The DNAR decision is to be modified to permit
the use of drugs and techniques commensurate with the
provision of anaesthesia.
This will include:
1. Monitoring of ECG, blood pressure, oxygenation and any in
traoperative monitors which are considered essential for a
good outcome.
Agreed/ Not agreed
2. Temporary manipulation of the airway and breathing
with intubation and ventilation, when needed; and with
understanding that the patient will be breathing
spontaneously at the end of the procedure.
Agreed/ Not agreed
3. Use of vasopressor or antiarrhythmic drugs to correct
cardiovascular stability related to the provision of anaesthesia
and surgery.
Agreed/ Not agreed
28

4. The use of electrical cardioversion or defibrillation to correct
arrhythmias.
Agreed/ Not agreed
5. The use of chest compressions.
Agreed / Not agreed
Option three: No changes are to be made to the DNAR
decision. Under most circumstances this option is not
compatible with the provision of anaesthesia for any type of
surgical intervention.
The anaesthetist should reach agreement, if possible, with
the patient or proxy decision maker as to exactly what, if any,
interventions are permitted.
Interventions permitted ................................................................
....................................................................................................
....................................................................................................
....................................................................................................
....................................................................................................
....................................................................................................
....................................................................................................
....................................................................................................
29

DNAR management option agreed: Option 1
Option 2
Option 3
The DNAR management option will apply while the patient is
in the operating theatre environment. The DNAR decision is
to be reinstated on discharge from the recovery area unless in
exceptional circumstances.
Signatures
signature of patient with capacity ...............................................
date................................................
OR, if patient does not have capacity
signature of proxy decision maker
instructed in life sustaining treatment...........................................
date..........................................
OR
signature of relative, carer, friend or IMCA
consulted to reflect patient’s wishes.............................................
date............................................
30

AND
signature of clinician in
charge of patient’s care................................................................
date...............................................................
AND/OR
signature of the anaesthetist
who has had the discussion.........................................................
date.........................................................
AND/OR
signature of surgeon, if different to
clinician in charge of patient’s care.............................................
date.............................................
31

32

33

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Drug and Alcohol Abuse amongst Anaesthetists
Guidance on Identification and Management
2
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org March 2011

Membership of the working party
(Details correct at the start of the working party process)
Dr Diana Dickson
Dr Valerie Bythell
Dr Jane Marshall
Dr Ruth Mayall
Dr Ranjit Verma
Prof Michael Wee
Dr Susan Williams
Chair and AAGBI Welfare Committee Member
AAGBI Council Member
AAGBI Welfare Committee Member
AAGBI Welfare Committee Member
AAGBI Council Member
AAGBI Welfare Committee Chair
GAT Representative
This guideline has been seen and approved by the Council of the
AAGBI.
The working party is grateful to Dr James Clarke, Professor David Hatch,
Mr Blake Dobson, Dr Fiona Moss, Dr Mike Peters, Dr Iain Wilson and Dr
Isabeau Walker for their contributions to this guideline.
The working party would like to acknowledge the helpful advice of Mr Bertie
Leigh of Hempsons Solicitors.
1

Contents
1. Summary 3
2. Introduction 4
3. Factors influencing substance abuse 6
4. The substance abusing anaesthetist 8
5. Initial interventions 12
6. The GMC and substance abusing doctors 14
7. Treatment, support and monitoring 15
8. Return to work 18
References 20
Appendix 1:Definitions 24
Appendix 2:Sources of support 27
Appendix 3:Example of a Trust alcohol and substance 30
abuse policy
Appendix 4:Identifying unsafe drinking habits 35
© The Association of Anaesthetists of Great Britain & Ireland 2011
2

1. Summary
The vast majority of anaesthetists will be unaffected by substance abuse, but
for those few that are affected the consequences can be devastating both for
them and for their patients.
Drug and alcohol abuse is a problem for some anaesthetists, as it is in the
general population. Drug abuse is more common than alcohol abuse in
trainees.
The most immediate risk is of harm to patients.
A report of drug or alcohol abuse in an anaesthetist should be taken seriously
and investigated without delay. Physical or behavioural symptoms at work
indicate advanced addiction.
Anaesthetists are more likely than other doctors to abuse narcotics as a drug
of choice, to abuse drugs intravenously and to be addicted to more than one
drug.
Concerns should be reported to the clinical director in the first instance. A
one-to-one confrontation should be avoided and efforts should be made to
obtain objective evidence.
Clinical managers should be aware of policies and sources of assistance for
managing these doctors.
Many addicted doctors find it difficult to seek help and tend to become
isolated.
There is a danger of self-harm following intervention. Plans must be made
in advance to facilitate treatment and for admission to a specialist unit if
necessary.
The ultimate objective should always be to try and resume a normal pattern
of personal and professional life; this may be difficult particularly for
anaesthetists.
Anaesthetists willing to engage in treatment often experience a significant
improvement in physical, psychological and social wellbeing. Support is
required on a long-term basis.
3

2. Introduction
The vast majority of anaesthetists will be unaffected by substance abuse, but
for those few that are affected the consequences can be devastating both for
them and for their patients.
Illicit drug and alcohol use is relatively common in the general population
and continues to increase in prevalence in many western societies. The
lifetime risk of dependence has been estimated as 7% -15% in doctors [1, 2,
3].
Over 90% of the adult population in the UK drink alcohol, with 31% of men
and 20% of women exceeding the recommended daily intake [4]. Studies
suggest that the incidence in doctors of disorders of alcohol use over a
lifetime is 13-14%, similar to that in the general population [2, 5]. Evidence
suggests that alcohol dependence is more common in older anaesthetists [6,
7], but is less common than in other specialities [8].
Nationally, 10.5% of the population use illicit drugs, particularly in younger
age groups. Drug dependence has been assessed as affecting 2.2% of
the adult population [9]. Doctors are less likely to use illicit drugs than
the general population but more likely to use benzodiazepines and minor
opioids as a result of privileged access [2]. In anaesthetists illicit drug use is
more common under the age of 40 years, and 80% of cases are male [7].
Studies from the US and Australia have reported a 0.4 - 2% prevalence of
drug dependence in anaesthetic trainees [6, 10-12]. Anaesthetists are at a
greatly increased risk of suicide and drug-related death compared to matched
controls in the general population, and the time of highest risk is in the first
five years following graduation [13].
Data from the US indicate that anaesthetists, psychiatrists and emergency
medicine physicians are up to three times more likely to access specialist
treatment facilities for substance abuse disorders than other speciality groups
[6, 8, 14, 15]. Anaesthetists are more likely to abuse opioids as a drug of
choice, to abuse drugs intravenously and to be addicted to more than one
drug [6, 16]. Some of those in treatment actually cited drug availability or
access as a reason for choosing anaesthesia as a career [14]. In 2007, 66%
of the General Medical Council (GMC) annual caseload involved health
problems – 43% involved alcohol abuse, 20% abuse of other substances and
26% involved affective disorders [17].
4

Opioid abuse
The incidence of non-alcohol substance abuse in all grades of anaesthetist
has remained consistent at 1-1.6%, over the last three decades. Rapidly
acting drugs are most commonly used, particularly fentanyl [11, 16, 18].
Rapid tolerance and dependence occur, and tolerance to doses of fentanyl of
over 100 ml.day -1 (5 mg.day -1 ) may develop over a six month period [19].
Propofol abuse
This has been reported since the mid-1990s, with many fatalities. These
were predominantly in anaesthetic trainees, but also in operating department
practitioners and intensive care unit staff. One American survey showed
a 5-fold increase in propofol abuse in anaesthetic trainees over a 10 year
period, with 18% of departments having reported at least one case of
propofol abuse in that decade (incidence 1:1000 anaesthetists per decade).
Of those reported to be abusing propofol the mortality was 28% [20]. Users
may erroneously feel that propofol is safe to use as the quick recovery after
sub-anaesthetic doses prevents overt signs of abuse such as drowsiness.
Death is often the only sign of drug abuse.
Ketamine abuse
Ketamine is known to be a drug of abuse in the general population, with
a prevalence rate of 1.9% [9]. Ketamine abuse has been reported in
anaesthetists [21]. Its short duration of action and predominant use outside
the workplace may account for the paucity of recent literature. Like
propofol, ketamine abuse is best detected by hair sampling.
Cocaine abuse
It is known that cocaine use has escalated recently, with a 6.6% increase in
the general population in the UK in the last year [9]. Anecdotally, cocaine
use has also increased in the medical profession. Cocaine and cannabis are
amongst the five drugs most frequently used by doctors, particularly those in
training [11, 22].
Inhalation agents
In a recent national survey, 22% of anaesthetic departments reported one
or more cases of abuse of inhalational agents, with a mortality rate of 26%.
These agents are often used in conjunction with other substances, often to
ease withdrawal from opioids [23].
Recent review articles that describe the incidence and outcomes of addicted
physicians in general [24-26], and with specific reference to anaesthetists
[27-30] are listed.
5

3. Factors influencing substance abuse
Many factors influencing drug and alcohol abuse are not exclusive to either
doctors or anaesthetists, but some may be particularly relevant to those
undertaking an anaesthetic career.
Environmental factors
The use of alcohol and/or drugs is more acceptable in different social and age
groups. This influences the initial exposure to the substance and ongoing
opportunities for their use. Home or social circumstances are also important
– in one study, 60% of addicted physicians reported physical or emotional
abuse at some stage in their life [31].
Genetic/biochemical factors
There is evidence to suggest that some individuals may have an underlying
susceptibility to addiction; there is a significantly higher risk of dependence
where a parent or other family member is a substance abuser [22, 32]. In
addition, dopamine D2 receptor (DRD2) gene dysfunction and GABA
receptor variants are associated with the risk of addiction [33, 34].
Stress
Anaesthetists often work long hours in an isolated and stressful environment
over which they have little control. Long and unsociable hours of work,
high levels of responsibility, a demanding training and a competitive career
structure may create difficulties for individuals both at work and at home.
There is also the potential in anaesthetic practice for serious medical errors.
Some individuals under stress will use drugs or alcohol as an inappropriate
coping strategy. In an AAGBI study of 1000 anaesthetists in 1997, 92% of
respondents reported consuming alcohol with a median weekly consumption
of 15 units; some anaesthetists reported consumption of up to 70 units per
week [7].
Psychological factors
Approximately one third of all individuals will at some time in their lives
suffer from significant psychological disturbance, usually in the form of
anxiety and/or depression, occasionally progressing to severe mental illness.
In some, this may lead to abuse of several drugs and/or alcohol. Of those
with a mental health disorder, 29% also have an addictive disorder [5].
6

Availability
The fact that anaesthetists have easy access to a wide range of psychoactive
drugs may well influence the likelihood of trying them.
Having become dependent, staying at work helps the addicted doctor to
maintain his/her supply of drugs.
7

4. The substance abusing anaesthetist
Risks
The most immediate risk is of harm to patients.
If the doctor concerned is working while under the influence of drugs or
alcohol there is a risk of harm to patients, and this must be the over-riding
concern. Both decision-making powers and clinical competencies may be
affected with resulting slowed or impaired reactions to urgent situations.
End-stage addicted anaesthetists are so distracted by their addiction that they
are also more likely to take risks.
The second and longer term risk is to the anaesthetist him/herself including
his/her mental and physical health, family and personal relationships and, of
course, career.
Warning signs of alcohol abuse [35]
The first clues that a doctor may have a drug and/or alcohol problem are
often non-specific and not obvious except to the most hawkish of eyes.
Particular attention should be paid to locum doctors, particularly to long-term
locums who have been moving around the country. Doctors with mental
health problems may be at particular risk as some will turn to alcohol or
drugs as a coping strategy. A drink-driving charge should be reported to the
Trust and should be taken seriously
• Subtle change in personality – ‘something not quite right’
• Mood swings and/or anxiety – at times flushed and full of bonhomie, at
other times irascible and irritable
• Gets drunk rather easily at departmental events and behaves bizarrely
and out of character
• Dishevelled appearance, forgetful, disorganised
• Unexplained minor injuries, e.g. facial bruising
• Staff members report the smell of alcohol
• Drug errors, illegible handwriting
• Secretive, socially isolated, regularly turns up late for work, or misses
meetings
• Frequent changes of address
• Marital/relationship problems, call for help from family members,
including children
8

Warning signs of drug abuse [6, 27]
• Behavioural changes
• Needle marks on the arm, long sleeves
• Unexplained regular facial bruising (propofol abuse)
• Physical signs of withdrawal
• Regular absences from theatre
• Volunteering to draw up drugs for others
• Patients in excessive amounts of pain
• Insisting on personally administering opioids in the recovery room
• Excessive or unnecessary prescribing of opioids
• False recording of drug administration
• Improper recording on the anaesthetic record
• Failure to discard wastage
• Over-anxious to give breaks
• Presence in hospital out-of-hours
• Enthusiasm for long, difficult or complicated cases
• Volunteering to work extra shifts or to do extra or late cases on a list
• Offering to stay late, or working overtime especially if likely to be
working alone
Raising concerns
Self-referral
Individuals who self-refer have recognised their need for treatment. They
are likely to seek help from outside agencies and treatment may even have
started without those at work being aware of the problem. Stigmatisation
and the potential loss of livelihood are barriers to self-referral even where an
individual has insight into his/her problem.
Family and friends
While family and friends may not wish to feel that they are betraying the
affected individual they should be made aware that such action is in the best
interests of both patients and the doctor.
Patients
Patients may complain that the doctor smells of alcohol or is acting strangely.
Colleagues and other staff
Altered behaviour is a common sign. Paradoxically, it may be more evident
to those who know them less well, while closer colleagues may rationalise
odd behaviour. An alteration in behaviour on return to theatre after a break
should also raise concern.
9

Locums and trainees
It may be more difficult to obtain evidence about trainees or locums who
rotate to several hospitals for short periods and it is important to work with
regional advisers and schools of anaesthesia.
Doctors in independent practice
They may work at several different hospitals and therefore it may be more
difficult to spot inappropriate patterns of activity. Unless an individual
hospital has a specific protocol, any suspicions should be reported
confidentially to the chairman of the medical staff committee of that hospital.
Taking action is not difficult where the evidence of drug or alcohol abuse is
plain to see. Unfortunately, more often, the changes are subtle and we may
be less alert to them or tend to make excuses for them, and avoid addressing
the possibility of substance abuse. As a result we delay helping for too long.
Where we have such concerns, we have a duty of care, in the interests of
both patients and of the affected doctor, to raise these sooner rather than
later.
Likewise, it is the duty of all anaesthetists, who suspect that they themselves
have, or are developing, substance abuse problems, to refer themselves for
treatment.
Actions that should be taken
What should you do if you suspect an anaesthetic colleague of
substance abuse?
Concerns about an anaesthetist should normally be reported to the clinical
director in the first instance. All those involved including clinical directors
should keep written and confidential records of all relevant interviews and
events, meetings and discussions.
Junior doctors may find it easier to raise the subject with their educational
supervisor or mentor. Non-medical staff may report to their line manager. It
is important that all staff are aware of their duty to relay this information to
the clinical director while maintaining confidentiality.
Hospitals should have a formal policy concerning drug and/or alcohol abuse;
a typical policy is demonstrated in Appendix 3. Clinical directors have a duty
of care to inform the medical director of each case in line with the local Trust
or hospital policy.
10

Where the individual is a trainee, there are specific Trust and deanery
reporting systems. In the case of rotating trainees, information will need to
be passed on when they rotate. This is the responsibility of the college tutor.
Confirming suspicions
Efforts should be made to obtain objective evidence. A single reported
episode of working under the influence of alcohol or drugs may be a marker
of a significant underlying problem and should be considered very seriously
with due investigation.
Evidence must be sought to confirm or refute any report of substance abuse.
Full confidentiality must be maintained during these investigations as there
is always a possibility of malicious reporting. Isolated events reported by
a single witness should be treated with great care, (e.g. drug theft, or drug/
alcohol consumption in the workplace). Prescribing and nursing records
must be examined carefully in order to substantiate the inappropriate use of
drugs.
11

5. Initial interventions
In deciding when or if to intervene, it must be remembered that our first duty
of care is to the patient. A one-to-one confrontation should be avoided.
The term ‘intervention’ is used here to describe the process of enabling the
substance abusing doctor to admit that he/she has a problem that needs
urgent attention. Many abusing doctors are in denial and can only begin
meaningful treatment when they can admit there is a problem.
If there is substantial evidence to suggest that an individual has been abusing
alcohol or drugs and particularly if there is evidence of potential or real
harm to patients, urgent intervention is required. Those with knowledge of
the situation must be prepared to present the evidence regarding the drug
or alcohol abuse. The aim of intervention is to resolve concerns at an early
stage.
Where there are significant allegations, the doctor should be interviewed
by the medical director and the clinical director. Plans must be made in
advance of the interview to facilitate support and treatment, including
identification of specialist treatment centres and other specialised facilities
if available. Many specialist units will provide free assessment. The GMC
will discuss a case and give advice on an anonymous basis ahead of an
intervention. The doctor concerned may find it valuable to be accompanied
by a colleague or other individual representing his/her interests or to be
represented by the British Medical Association (BMA) or similar organisation.
Clinical directors should be familiar with these avenues of help and explore
the possibilities before an intervention (see Appendix 2).
The doctor should be informed of the concerns being raised (without
necessarily divulging the source of information) and any plans for further
investigation or intervention. In this difficult situation the doctor should be
offered the opportunity to undergo an assessment, rather than insisting he/
she has an addiction problem and needs treatment. The process should also
involve occupational health and a psychiatrist with special experience in the
field – this may come via the treatment centre.
It is important to remember that addiction is recognised as a disease [36], and
a substance abusing colleague should be offered treatment as for any other
chronic illness. It is appreciated that a sympathetic attitude may be difficult
if there has been a history of repeated absences, covering for the suspected
doctor and other problems.
12

There is a real possibility of self-harm following intervention. Immediate
referral to a specialist unit may minimise this risk. The doctor concerned
should not be left unsupported following this initial interview. Contact with
a member of the local British Doctors and Dentists Group (BDDG) may be
helpful in this role (see Appendix 2).
Actions to protect patients
Where harm has occurred to a patient as a result of substance abuse
The doctor should be formally excluded from work with a clear statement
as to the reasons for this and what further actions are to be taken. The
GMC should be informed. These actions must be backed up via written
confirmation through the normal disciplinary procedures in the hospital.
The doctor should be offered treatment and support. He/she should be
advised concerning opportunities for support from the BMA and his/her
medical defence organisation, and should also be strongly advised to accept
the plans to initiate treatment.
Where there is clear evidence of abuse but no harm to a patient has
occurred
The doctor should be offered treatment and support, usually through a
mechanism of sick leave. All continuing contact with patients should cease.
The doctor should then be offered an appropriate management plan as
detailed below.
• The doctor accepts that there is a problem. If the situation is largely
confidential then the doctor could be offered psychiatric help outside
his/her own region. If the situation is common knowledge and the
doctor is comfortable with local treatment, this could be provided.
• The doctor refuses to accept that there is a problem. If there is
corroborating evidence to the contrary, the situation is more complex.
The doctor should be asked to consent to random testing of breath,
blood, urine or hair samples as appropriate, under the supervision of
occupational health. No patient contact should be allowed
while further investigation takes place. Referral to an agency in
Appendix 2 is advised for a full independent assessment to take place.
13

6. The GMC and substance abusing doctors
Advice from the GMC must be sought at an early stage where there is any
danger to patients from doctors who are abusing alcohol or drugs. This
will usually be by the medical director who should be in possession of all
available evidence. The GMC has a statutory primary obligation to protect
the public but at the same time aims as far as possible to support doctors in
overcoming their addiction problems through medical supervision.
GMC medical assessment
The GMC will arrange for medical assessment of the doctor to take place,
which will involve two examinations by experts in substance abuse.
Following this a decision will be made as to whether or not the doctor should
have restrictions placed upon his/her registration. The majority of cases are
resolved without the need to appear at Fitness to Practise Panel. In those
cases where restrictions are felt necessary, the GMC will arrange for ongoing
supervision (see Appendix 1). This will be done through an appropriate
supervisor who will report back to the GMC – the supervisor will often have
been one of the experts conducting the original assessments.
The addicted doctor will remain under supervision until the GMC is satisfied
that his/her impairment has been resolved – usually a period of several years
for substance abusing doctors.
Any doctor who appears in court for any reason is automatically referred
to the GMC. This also applies to drink-driving offences. Whether a doctor
is using, abusing, or actually addicted, possession of recreational drugs is
illegal. The GMC does recognise that some kinds of criminal behaviour,
e.g. buying controlled drugs on the street or stealing from employing
organisations, are often driven by addiction, and will arrange for medical
assessment as part of their investigation.
It is in the interests of both the doctor and his/her advisors to ensure that the
best possible medical advice and support is provided in order to optimise the
chances of a return to a satisfactory medical career.
14

7. Treatment, support and monitoring
Treatment
Addiction is a disease that has biological, behavioural, and social
components and any effective treatment must address these issues [19].
Addiction should be managed through professional colleagues and support
agencies listed in Appendix 2.
Treatment may involve admission to hospital or an addiction facility for
detoxification, further physical and psychological assessment, family work,
and introduction to self-help organisations such as Alcoholics Anonymous
or the British Doctors and Dentists Group (BDDG). For doctors, the goal
is typically abstinence, as return to work is not otherwise feasible. Treating
psychiatrists and other professionals usually work with occupational health
physicians in setting up a back-to-work programme, which will involve
a network of professionals including the general practitioner (GP), a
designated workplace supervisor, a mentor (see below), and if the GMC is
involved, a medical supervisor.
Inpatient detoxification and rehabilitation at a specialist unit may be
required. The overall treatment may last for months or years and long periods
of leave may be required.
It must be emphasised that treatment outcomes for doctors have consistently
been shown to be effective and lead to a significant improvement in physical,
psychological and social wellbeing for those doctors willing to engage in a
treatment programme.
The goal of a substance dependent doctor is life-long abstinence from all
mood altering substances.
Signs and symptoms of opioid withdrawal
• Craving
• Restless sleep
• Sneezing, eyes watering, yawning
• Piloerection and recurrent chills
• Pupillary dilatation
• Abdominal and muscle aches and pains
• Nausea, vomiting and diarrhoea
15

Signs and symptoms of stimulant withdrawal
• Increased appetite
• Insomnia or hypersomnia
• Dysphoric mood
• Craving for drugs
• Lethargy and fatigue, depression, suicidal thoughts
Signs and symptoms of alcohol withdrawal
• Tremor: tongue, eyelids, outstretched hands
• Agitation, insomnia
• Transient visual, auditory, tactile hallucinations or illusions
• Nausea, retching, vomiting, sweating
• Delirium tremens – confusion, disorientation, hallucinations, agitation,
pyrexia
• Grand mal convulsions
Support
Addicted doctors feel isolated and need intense and long term support. This
can come from a network of family and close friends. In addition there are
many other agencies that can support the doctor in his/her return to a healthy
life at home and at work (see Appendix 2).
Support is likely to include attendance at self-help groups. This may need to
continue indefinitely as there is a continuing risk of relapse. It is recognised
by Alcoholics Anonymous that those who stop attending regular meetings or
lose contact with peer support group members are more likely to relapse. It
has also been observed that doctors who present for treatment generally do
very well and are less likely to relapse if they regularly attend meetings of the
BDDG in addition to Alcoholics Anonymous or Narcotics Anonymous.
Mentoring
Many doctors find it very valuable to have support and advice from a
colleague outside his/her line management structure.
16

Monitoring
Mandatory biochemical monitoring
This is important especially in the first two years post-treatment when relapse
is most likely to occur. Mandatory testing of breath, hair, urine and blood,
both regularly and at random, should be used to ensure that the individual
remains drug or alcohol abstinent. Hair testing can show the presence of
drugs taken several weeks earlier.
Clinical monitoring by a specialist
Specialist clinical monitoring, such as by a psychiatrist, will enable early
identification of signs or triggers of impending relapse.
Relapse
Relapse may occur with the return to substance abuse in a diagnosed addict
following discharge from a recognised treatment centre or after a period of
abstinence following attendance at Alcoholics or Narcotics Anonymous. The
substance used is not necessarily the initial drug of choice. The belief by
primary opioid abusers that alcohol is an acceptable alternative has led to
many relapses.
Relapse occurs most commonly in the first two years of recovery – the major
risk factors are primary opioid addiction, a co-morbid psychiatric illness and
a family history of substance abuse disorder [32]. Other contributory factors
include previous relapse, failure to focus on abstinence and failure to attend
help groups plus workplace or legal difficulties. If evidence of further abuse
is found the individuals will need to re-enter treatment and their jobs are
likely to be at risk.
17

8. Return to work
The ultimate objective should always be to try and resume a normal pattern
of personal and professional life; this may be difficult, particularly for
anaesthetists (see below).
Where the doctor has been referred to the GMC, the GMC will determine
fitness to practise – whether and when a doctor can return to work.
At a local level the decision to return to work will be a joint decision
involving the doctor, his/her GP, the treating psychiatrist, the medical director
and/or clinical director. Occupational health may also be involved.
There are a number of important considerations that need to be addressed
before a doctor can resume work.
1. Stress in the workplace
If stress in the workplace has been a major contributing factor then it may
be unrealistic for the affected individual to return to the same stresses unless
there has been a fundamental change in the dynamics of the job. The
advantages and disadvantages of return to the same type and place of work
must be discussed in depth with the doctor. If he/she is early in his/her career
then retraining in a different specialty should be considered. This may be
difficult for more senior staff but at the very least, his/her job plan should
be modified realistically. This could include undertaking part time work or
undertaking more administrative or teaching commitments. Return should
be gradual, with allowance made for attending treatment and monitoring
appointments.
2. Drug abuse and anaesthesia
Return to work and continuing in anaesthesia is a subject of much current
debate [26, 30, 37]. Where the operating theatre was the source of drugs
abused, there is some evidence that the risk of relapse in those continuing
employment in the operating theatre is very high [12]. This is usually in
those with the major risk factors for relapse noted above, and those who did
not adhere to recommended treatment and recovery guidelines [15]. The
prospects for those without major risk factors and who were compliant with
treatment and other recommendations are more favourable [32].
Despite earlier reports of poor outcomes in opioid addicted anaesthetists
[12], there are more encouraging recent reports [8, 16]. A significant
proportion of anaesthetists do not relapse and it would therefore be wrong
18

to label all anaesthetists with opioid addiction as being unable to return to
full normal activity. Addiction impairs more doctors than any other disease
[38] but there is evidence that, given the appropriate treatment, follow-up
and support, a large number of addicted anaesthetists do as well as other
specialities in recovery, and remain in anaesthesia [8, 16, 32].
19

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Anaesthesia and Intensive Care 1993; 21:151-5.
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11. Booth JV et al. Substance abuse among physicians: a survey of
academic anesthesiology programs. Anesthesia and Analgesia 2002;
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12. Collins GB, McAllister MS. Jensen M, Gooden TA. Chemical
dependency treatment outcomes of residents in anesthesiology: results
of a survey. Anesthesia and Analgesia 2005; 101:1457–62.
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mortality risks of anesthesiologists. Anesthesiology 2000; 93: 922-30.
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Georgia’s impaired physicians program review of the first 1000
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PO. Relapse and recovery: Five to ten year follow-up study of
chemically dependent physicians - the Georgia experience. Maryland
Medical Journal 1992; 41: 315-9.
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you need to know and when you need to know it. American Society
of Anesthesiologists 2002; Committee on Occupational Health of
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asahq.org/publicationsAndServices/chemical.pdf. (accessed 24/10/09).
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anesthesia programs. Anesthesia and Analgesia 2007; 105:1066-71.
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21. Moore NN, Bostwick JM. Ketamine dependence in anesthesia
providers. Psychosomatics 1999; 40: 356-9.
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substances in three medical specialties: anaesthesia, medicine and
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anaesthetic abuse in anaesthesia training programmes. Anaesthesia
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physician. Mayo Clinic Proceedings 2009; 84: 625-31.
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anesthesiology. www.asahq.org/clinical/curriculum.pdf (accessed
15/10/2009).
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anesthesiology. Anesthesiology 1993; 79: 354-75.
30. Oreskovich MR, Caldeiro RM. Anesthesiologists recovering from
chemical dependency: can they safely return to the operating room?
Mayo Clinic Proceedings 2009; 84: 576-80.
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a substance abuse monitoring programme in Canada: prospective
descriptive study. British Medical Journal 2008; 337:a2098.
32. Domino KB, Horbein TF, Polissar NL, et al. Risk factors for relapse
in health care professionals with substance use disorders. Journal of
the American Medical Association 2005; 293: 1453-60.
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33. Foll B Le, Gallo A, Strat Y Le, et al. Genetics of dopamine receptors and
drug addiction: a comprehensive review. Behavioural Pharmacology
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34. Drgon T, D’Addario C, Uhl GR. Linkage disequilibrium, haplotype
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cluster: Candidate gene variants for addictions. American Journal of
Medical Genetics Part B: Neuropsychiatric Genetics 2006; 141B: 854-
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35. Marshall EJ. Doctor’s health and fitness to practise: treating addicted
doctors. Occupational Medicine 2008; 58: 334-40.
36. Morse R, Flavin D. The definition of alcoholism. Journal of the
American Medical Association 1992; 268:1035-9.
37. Earley PH, Berry AJ. Re-entry after addiction treatment: research or
retrain? Anesthesiology 2009; 110:1423-4.
38. Talbott GD, Wright C. Chemical dependency in healthcare
professionals. Occupational Medicine 1987; 2: 581-91.
39. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. DSM-IV-TR Criteria for Substance Dependence, 4th
edn (text revision). Washington DC: American Psychiatric Association,
2000.
40. World Health Organization. The ICD-10 classification of mental and
behavioural disorders: clinical descriptions and diagnostic guidelines.
http://www.who.int/substance_abuse/terminology/
ICD10ClinicalDiagnosis.pdf (accessed 19/10/10)
41. Saunders JB, Aasland OG, Babor TF, et al. Development of the alcohol
use disorders identification test (AUDIT): WHO collaborative project on
early detection of persons with harmful alcohol consumption - II.
Addiction 1993; 88: 791-803.
23

Appendix 1: Definitions
The recognition of substance dependence as a disease and its
definitions, some of which are detailed below can be obtained from
the World Health Organization (ICD criteria), the American Psychiatric
Association (Diagnostic and Statistical Manual [DSM] classification)
and American Society of Addiction Medicine websites.
Impairment
An impaired doctor is one who is unable to practice medicine with
reasonable skill and safety to patients because of physical or mental illness,
including deterioration through the ageing process, characterological or
psychiatric difficulties or excessive use of alcohol or other drugs.
Substance abuse (DSM IV-TR criteria) [39]
• Recurrent substance use resulting in a failure to fulfil major role
obligations at work, school or home
• Recurrent substance abuse in situations in which it is physically
hazardous
• Recurrent substance-related legal problems
• Continued substance use despite having persistent or recurrent social
or interpersonal problem caused or exacerbated by the effects of the
substance
The equivalent to substance abuse in the International Classification
of Disease (ICD) is termed ‘harmful use’, and is defined as “A
pattern of psychoactive substance use that is causing damage to
health. The damage may be physical (as in cases of hepatitis from
the self-administration of injected drugs) or mental, (e.g. episodes of
depressive disorder secondary to heavy consumption of alcohol).” [40]
The term ‘substance’ is used to cover alcohol, illicit drugs and prescription
medications taken inappropriately. It is used to describe:
• The use of a substance that leads to impairment in physical and
psychological health and in social dysfunction
• The inappropriate use of prescription drugs
• Use of illegal drug use that will probably lead to harmful health
consequences either by virtue of the quantity of drug or method of use
(e.g. injecting)
There is an important difference between substance abuse and dependence
(addiction).
24

Dependence syndrome (addiction)
The dependence syndrome is “A cluster of physiological, behavioural, and
cognitive phenomena in which the use of a substance or a class of substances
takes on a much higher priority for a given individual than other behaviours
that once had greater value.” [40]
A definite diagnosis should only be made if three or more of the following
criteria have been experienced or exhibited at some time during the previous
year.
a. A strong desire or sense of compulsion to take the substance;
b. Difficulties in controlling substance-taking behaviour in terms of its
onset, termination, or levels of use;
c. A physiological withdrawal state when substance use has ceased or
have been reduced, as evidenced by: the characteristic withdrawal
syndrome for the substance, or use of the same (or closely related)
substance with the intention of relieving or avoiding withdrawal
symptoms;
d. Evidence of tolerance, such that increased doses of the psychoactive
substance are required in order to achieve effects originally produced
by lower doses (clear examples of this are found in alcohol – and opioid
– dependent individuals who may take daily doses sufficient
to incapacitate or kill non-tolerant users);
e. Progressive neglect of alternative pleasures or interests because of
psychoactive substance use, increased amount of time necessary to
obtain or take the substance or to recover from its effects;
f. Persisting with substance use despite clear evidence of overtly harmful
consequences, such as harm to the liver through excessive drinking,
depressive mood states consequent to periods of heavy substance use,
or drug-related impairment of cognitive functioning; efforts should
be made to determine that the user was actually, or could be expected to
be, aware of the nature and extent of the harm. [40]
GMC definitions
1. Your (day-to-day work/surgery etc) must be directly supervised by
a registered medical practitioner of consultant/GP Principal grade. (See
Glossary for full definition)
2. Your (day-to-day work/surgery etc) must be closely supervised by a
registered medical practitioner of consultant/GP Principal grade. (See
Glossary for full definition)
25

3. Your (day-to-day work/surgery etc) must be supervised by a registered
medical practitioner of consultant/GP Principal grade. (See Glossary for
full definition)
Glossary
Directly supervised
The doctor’s work must be directly supervised at all times by a supervising
consultant based in the same place of work. The level of supervision
required is equivalent to that of an FY1 trainee.
Closely supervised
The doctor’s day-to-day work must be supervised by a consultant, who must
be on site and available at all times. The doctor’s work must be reviewed
at least twice per week with the supervising consultant. The level of
supervision required is equivalent to that of a novice anaesthetist.
Supervised
The doctor’s day to day work must be supervised by a consultant, who may
be off site but available on-call. The doctor’s work must be reviewed at least
once a fortnight with the supervising consultant. The level of supervision
required is equivalent to that of a middle grade trainee.
Royal College of Anaesthetists definitions (for comparison):
Direct supervision
Immediately available – in the theatre or available in the theatre suite and
without other responsibilities.
Indirect supervision
Local – on the same geographical site and able to attend within 10 minutes.
Distant supervision
On a different geographical site or unable to attend within 10 minutes.
26

Appendix 2: Sources of support
More details and relevant documents may be found on the AAGBI website,
www.aagbi.org/memberswellbeing.htm
Alcoholics Anonymous (AA)
www.alcoholics-anonymous.org.uk 0845 769 7555
Do you think you may have a problem? Check lists: http://www.alcoholicsanonymous.org.uk/newcomers/?pageID=77
The British Doctors and Dentists Group (BDDG)
www.bddg.org 07792 819 966 (national secretary)
This is a countrywide network of doctors and dentists at various stages in
recovery from addiction, who meet on a monthly basis at one of 18 groups
covering the UK. Following initial contact, callers may be put in touch with
a doctor (in some cases another anaesthetist) nearer to their home who may
then introduce a new doctor to the group at the local meetings.
Problems can be discussed at these meetings that may not be appropriate to
discuss at Alcoholics or Narcotics Anonymous meetings; for example, GMC
proceedings and issues surrounding return to work, etc.
There is also an associated families group, where direct relatives of addicted
doctors and dentists can obtain help and support. Each BDDG meeting
usually has a families group. Support for family members of addicted doctors
can be obtained via the Families Group of the BDDG –
www.bddgfamilies.org.uk
Doctors’ Support Line (DSL)
0844 395 3010
A confidential and anonymous peer support helpline for doctors who need
to talk to someone whatever their concerns. Doctors in the group have
themselves been troubled at some stage in their lives, and help is offered to
those who are beginning the process of re-establishing themselves after a
breakdown or other mental crisis.
Doctors’ Support Network (DSN)
www.dsn.org.uk 0871 245 8376
A group with regular meetings throughout the country for help with stress,
burnout, anxiety, depression, psychoses and eating disorders. This may be
helpful for addicted doctors with dual diagnoses.
27

GMC Investigation Team
0161 923 6402 practise@gmc-uk.org
Healthcare Professionals Recovery Group (HPRG)
01327 262 823
These monthly meetings are attended by doctors, dentists, nurses,
pharmacists and other healthcare professionals who have addiction
problems. They too are confidential and offer similar help and support to
that of the BDDG.
Narcotics Anonymous (NA)
www.ukna.org 0300 999 1212
Narcotics Anonymous is for recovering addicts who meet regularly to help
each other stay clean. It is not restricted to those with opioid abuse problems
as the name may suggest, but any drug including tranquillisers, recreational
drugs and alcohol. The website contains some questions and information for
those who think they may have a problem.
Do you think you may have a problem? – checklists may be found at: http://
www.na.org/admin/include/spaw2/uploads/pdf/litfiles/us_english/IP/EN3107.
pdf
The majority of AA or NA meetings are ‘closed’ and are only for recovering
addicts/alcoholics and those who think they may have a drug problem. A
meeting described as ‘open’ may be attended by anyone, e.g. professionals
working with addicts or family members, friends etc. Meetings lists are on
the AA or NA websites with details of open meetings at each venue.
Practitioner Health Programme (PHP)
www.php.nhs.uk 020 3049 4505
This is an NHS funded but entirely confidential service open to doctors and
dentists living or working in the London area. Care is multidisciplinary in
nature and provides appropriate specialist care and support for any doctor
with addiction, mental or physical health concerns. Where inpatient
therapy is thought necessary, this will be organised and funded by the PHP/
NHS. Follow-up, monitoring and help with returning to work are also part of
the services offered. Unfortunately this is currently only available to Londonbased
doctors, but plans for expansion to cover other areas of the country are
in place. Advice can be obtained by phone even if outside the M25 area.
28

Royal Medical Benevolent Fund (RMBF)
www.rmbf.org 0208 540 9194
The RMBF offers financial support and is also developing a helpline. It was
set up by doctors to help colleagues and their dependants in need.
Sick Doctors Trust (SDT)
www.sick-doctors-trust.co.uk 0370 444 5163*
The SDT is an independent charity established over 14 years ago, which
provides a 24-hour helpline manned exclusively by experienced doctors who
are either in recovery from addiction themselves, or trained counsellors. It
provides help and support to doctors who think they may have a problem
with their use of alcohol or other drugs, whether prescribed or not. Calls are
treated with strict confidentiality, and callers may remain anonymous if they
wish.
Help offered includes assessment, advice, referral for treatment when
appropriate and introduction to long term befriending and support services.
The helpline also accepts calls from family members or friends, concerned
colleagues and others.
* please note change of number since publication of the AAGBI
Welfare Resource Pack.
Other resources
Addaction 020 7251 5860
www.addaction.org.uk
Adfam 020 7553 7640
(for families affected by drugs and alcohol) www.adfam.org.uk
Al Anon
(for families/friends of problem drinkers)
020 7403 0888 (24 hours)
www.al-anonuk.org.uk
Alcohol Concern 020 7264 0510
www.alcoholconcern.org.uk
Drinkline 0800 917 8282
National Drugs Helpline 0800 77 66 00
www.talktofrank.com
29

Appendix 3: Example of a Trust alcohol and
substance abuse policy
1. Introduction
The Trust recognises that the prevalence of substance abuse and
alcohol related problems within the general population means that
there will inevitably be members of staff with such problems. Drugs
and alcohol have an impact on cognitive performance and are
associated with cognitive failures at work. This may have implications
for the care of patients and the health and safety of an employee and
his/her colleagues.
1.1 Alcohol and substance abuse related problems at work are defined as:
• any drinking of alcohol
• any use of illicit non-prescribed drugs
• any misuse of prescribed drugs
• any use of any other substance of abuse, e.g. solvents
that has the potential to interfere with an employee’s functioning
and performance in any aspect of his/her job. This definition
covers usage outside the workplace but where the effects have or
may have an impact on an employee’s functioning at work.
Throughout the remainder of this document the term substance will
be used for alcohol, prescribed and non- prescribed drugs and any
other substances used in the circumstances described above.
2. Policy aims
The principal aims of this policy are:
2.1 To ensure that the Trust meets its obligations to safeguard the health,
safety and welfare of its employees and patients using its services.
2.2 To prevent and reduce the incidence of substance related problems in
the workplace.
2.3 To recognise that substance dependency is a health issue and to ensure
that employees experiencing these difficulties have access to
appropriate help.
30

2.4 To foster a climate that will encourage individuals experiencing these
problems to come forward for help in the knowledge that they will
receive support and fair treatment.
2.5 To facilitate the rehabilitation of employees who develop substance
abuse problems.
2.6 To give managers a clear framework within which to deal with
substance abuse problems constructively.
3. General provisions
3.1 No-one will report for duty under the influence of any substance that
affects his/her ability to carry out his/her duties.
3.2 No-one will consume alcohol or use substances of abuse whilst at work,
including breaks.
3.3 Any individual found drunk or under the influence of any substance
on duty will be subject to the Trust’s Disciplinary and Capability
Policy and Procedure. Managers should ensure that the employee
leaves the workplace and arrange to interview him/her after a suitable
interval.
3.4 The supplying of drugs of abuse to other people is a criminal offence.
Any employee found or suspected of undertaking this activity will be
reported to the police.
4. Roles and responsibilities
4.1 The Director of Human Resources is responsible for the implementation
of this policy and ensuring regular review is undertaken.
4.2 Line managers are responsible for ensuring employees are aware of this
policy and for investigating and referring to the Occupational Health
Service (OHS) when an employee is suspected of having a substance
abuse related problem.
4.3 Managers may recognise a problem by a changing attitude to work
by employees which may be evidenced through poor punctuality,
poor attendance, declining performance, the smell of alcohol on the
breath or behaviour suggestive of intoxication, changes in mood
31

and levels of co-operation with colleagues and declining personal
standards of dress and hygiene.
4.4 The OHS is responsible for advising on an affected employee’s fitness
for work and ensuring that the employee who accepts help is referred
on to an appropriate agency. The OHS operates within strict rules of
medical confidentiality and any medical information obtained within
the context of clinical activities will not be released without the consent
of the individual concerned other than in exceptional circumstances as
laid down by the General Medical Council, Nursing and Midwifery
Council etc.
4.5 Employees have a responsibility to ensure that they are fit to undertake
their duties in a safe and appropriate manner at all times.
4.6 Employees are responsible for seeking help if they have a substance
abuse problem that is likely to have an impact on their performance at
work.
4.7 Employees are required to encourage colleagues whom they suspect
have a problem to seek help via the OHS or by discussion with their
line manager. If the colleague refuses to seek help, employees have a
duty to bring their concerns to the attention of their line manager,
otherwise they may be vulnerable in the event of a health and safety
issue.
5. Employees with substance related problems
5.1 It is recognised that substance abuse problems are primarily matters of
health and social concern with which sufferers need help.
5.2 Employees who suspect or are aware that they have a substance abuse
related problem are encouraged to seek medical help through the OHS
(including the staff support and counselling service), their GP, or directly
with an appropriate agency. (See list at Appendix 2).
5.3 Any employee who has been identified as possibly having an
alcohol or substance abuse problem affecting his/her conduct and/
or performance at work will be asked to discuss the matter with his/her
line manager.
5.4 The employee will be offered the opportunity to seek assessment from
32

the OHS who will refer for treatment from an appropriate agency if
necessary. With the employee’s consent the OHS will keep the
employee’s GP informed of progress.
5.5 Whilst the OHS make every effort to arrange an urgent appointment for
employees following a request, in the event of a delay and where
there is concern that an employee may not be fit in the meantime,
the manager, in conjunction with the Divisional Human Resources
Manager, will make a decision as to the appropriate interim action. This
may include special paid leave, suspension on full pay or sick leave.
5.6 In any discussion of an alcohol or drug related problem (whether
at the initiative of the individual or manager) the same rules of
confidentiality would apply with respect to these conditions as to any
other health complaint. However, behaviour associated with misuse
may have to be disclosed where there is evidence of criminal activity,
abuse of a professional position or potential harm to patients or
colleagues.
5.7 Leave to undergo treatment will be dealt with under the normal sick pay
provisions.
5.8 The OHS will advise on fitness to return to work and any job
modification, temporary or permanent redeployment necessary as a
result of the individual’s substance abuse problems.
5.9 An employee identified as having a potential problem who declines
help and whose behaviour or performance at work continues to be a
source of concern will be subject to normal disciplinary procedures.
This may result in termination of employment, which can be on health
grounds in appropriate circumstances.
5.10 It is recognised that relapses do occur. Therefore an employee with an
identified problem who receives help but whose performance
subsequently relapses due to a recurrence of the substance abuse
problem will have the new situation considered on its merits. If
appropriate, a further opportunity to seek/accept help will be offered.
6. Testing for alcohol and substances of abuse in the workplace
6.1 This Trust does not operate a systematic screening programme for the
use of drugs or alcohol.
33

6.2 However, as being under the influence of alcohol or substances of
abuse in the workplace may represent a risk to the safety of the
employee, his/her colleagues or patients, individuals suspected of
abuse may be tested for such substances or markers of misuse as part of
the occupational health assessment.
6.3 Testing will be part of a clinical occupational health assessment and
informed consent will be obtained at the time of testing. The OHS will
monitor employees using blood and/or breath tests for alcohol and
urine testing for drugs and would generally expect to see a return to
normal blood tests and consistently negative urine tests before a return
to work would be considered. On a return to work the employee will
remain under review by the OHS and a system of unannounced testing
will usually be agreed for a period, typically six months. Each
employee is assessed on an individual basis.
6.4 Results of testing are medically confidential and as such are defined as
sensitive personal data under the Data Protection Act. These results
will not be released to the employer or any other third parties without
the consent of the employee. They will assist the occupational health
practitioner in assessing fitness for work and formulating an appropriate
occupational health management plan.
6.5 Refusal to undergo testing or repeated non-attendance will result in the
OHS making recommendations regarding the employee’s fitness to
work on the information available and without the benefit of the test
results.
34

Appendix 4: Identifying unsafe drinking
habits
Over recent years a number of screening questionnaires have been
developed with the objective of identifying hazardous, harmful and
dependent drinking. The 10-item Alcohol Use Disorders Identification Test
(AUDIT) is the gold standard, but shorter versions of this questionnaire
are also available (e.g. AUDIT-C). The AUDIT questionnaires are useful in
detecting problem drinking, but are not diagnostic and should not be used in
isolation. They are freely available on the internet. Readers are referred to the
Department of Health sponsored Alcohol Learning Centre website.
The 10-item AUDIT can be administered as a structured or self-report
interview and takes about 2-3 minutes to complete.
Older screening questionnaires include the CAGE and the Michigan
Alcoholism Screening Test (MAST). These questionnaires tend only to identify
severe or dependent drinking.
AUDIT questionnaire: screen for alcohol misuse [41]
1. How often do you have a drink containing alcohol?
• Never (0)
• Monthly or less (1)
• 2-4 times a month (2)
• 2-3 times a week (3)
• 4 or more times a week (4)
2. How many standard drinks containing alcohol do you have on a typical
day when drinking?
• 1 or 2 (0)
• 3 or 4 (1)
• 5 or 6 (2)
• 7 to 9 (3)
• 10 or more (4)
35

3. How often do you have six or more drinks on one occasion?
• Never (0)
• Less than monthly (1)
• Monthly (2)
• Weekly (3)
• Daily or almost daily (4)
4. During the past year, how often have you found that you were not able
to stop drinking once you had started?
• Never (0)
• Less than monthly (1)
• Monthly (2)
• Weekly (3)
• Daily or almost daily (4)
5. During the past year, how often have you failed to do what was
normally expected of you because of drinking?
• Never (0)
• Less than monthly (1)
• Monthly (2)
• Weekly (3)
• Daily or almost daily (4)
6. During the past year, how often have you needed a drink in the morning
to get yourself going after a heavy drinking session?
• Never (0)
• Less than monthly (1)
• Monthly (2)
• Weekly (3)
• Daily or almost daily (4)
7. During the past year, how often have you had a feeling of guilt or
remorse after drinking?
• Never (0)
• Less than monthly (1)
• Monthly (2)
• Weekly (3)
• Daily or almost daily (4)
36

8. During the past year, have you been unable to remember what
happened the night before because you had been drinking?
• Never (0)
• Less than monthly (1)
• Monthly (2)
• Weekly (3)
• Daily or almost daily (4)
9. Have you or someone else been injured as a result of your drinking?
• No (0)
• Yes, but not in the past year (2)
• Yes, during the past year (4)
10. Has a relative or friend, doctor or other health worker been concerned
about your drinking or suggested you cut down?
• No (0)
• Yes, but not in the past year (2)
• Yes, during the past year (4)
Scoring the audit
Scores for each question range from 0 to 4; thus the maximum score is 40. A
score of 8 or more is associated with harmful or hazardous drinking; a score
of 13 or more in women, and 15 or more in men, is likely to indicate alcohol
dependence.
The AUDIT-C comprises the first three questionnaires of the AUDIT. Anyone
scoring 5 or over on the AUDIT-C is AUDIT-C positive and should go on to
complete the 10-item AUDIT.
37

38

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Best practice in the
management of epidural
analgesia in the hospital
setting
FACULTY OF PAIN MEDICINE
of The Royal College of Anaesthetists
Royal College of
Anaesthetists
Royal College of
Nursing
Association of
Anaesthetists of Great
Britain and Ireland
British Pain Society
European Society of
Regional Anaesthesia
and Pain Therapy
Association of Paediatric
Anaesthetists of Great
Britain and Ireland
November 2010

Contents
Page
1 Introduction 2
2 Scope of recommendations 2
3 Patient selection and consent 3
4 Personnel, staffing levels and ward environment 3
5 Catheter insertion 4
6 Equipment 5
7 Drugs for epidural analgesia 6
8 Patient monitoring 7
9 Epidural analgesia in children 8
10 Documentation, guidelines and protocols 10
11 Audit and critical incidents 10
12 Education 10
References 11
Guideline development 12
1

1 Introduction
1.1 Epidural analgesia is highly effective for
controlling acute pain after surgery or
trauma to the chest, abdomen, pelvis
or lower limbs. It has the potential to
provide excellent pain relief, minimal
side-effects and high patient satisfaction
when compared with other methods of
analgesia. However, epidural analgesia can
cause serious, potentially life-threatening
complications; safe and effective
management requires a co-ordinated
multidisciplinary approach.
1.2 This document is a revised version of the
guideline published in 2004. 1 In 2009,
the Royal College of Anaesthetists published
the results of a nationwide audit of major
complications associated with central
neuraxial block in the UK. 2 These data have
significantly informed this guideline.
1.3 All practitioners should be aware of the
complications associated with the use of
epidural analgesia. Some complications
can be fatal or result in permanent harm.
Frequent complications include:
hypotension;
respiratory depression (opioid use);
motor block;
urinary retention;
inadequate analgesia;
pruritus (opioid use).
Infrequent but well recognised
complications include:
cardiovascular collapse;
respiratory arrest;
unexpected development of high block,
e.g. catheter migration, intrathecal
injection; local anaesthetic toxicity;
post dural puncture headache syndrome
(including sub-dural haematoma);
drug administration errors (especially
wrong route);
pressure sores;
superficial infection around catheter;
epidural haematoma or abscess;
meningitis;
spinal cord ischaemia;
permanent harm, e.g. paraplegia, nerve
injury.
2 Scope of recommendations
2.1 These guidelines are concerned with the
management of epidural analgesia in
the hospital setting, including continuous
infusions, patient-controlled epidural
analgesia (PCEA) and intermittent top-up
injections. They are not concerned with
the management of epidural analgesia for
obstetrics, palliative care or management of
persistent non-cancer pain.
2.2 The features of an epidural pain
management service are described. These
recommendations should be considered
with other guidelines on the provision of
acute pain services. 3–4
2 Best practice in the management of epidural analgesia in the hospital setting

3 Patient selection and consent
3.1 Patient selection for epidural analgesia should be based
on a careful risk/benefit analysis for each patient. Risk
factors include: impairment of coagulation (pathological or
therapeutic); infection; compromised immunity; duration of
epidural catheterisation; cardiovascular stability; and inadequate
postoperative monitoring capability.
3.2 Continuous epidural analgesia is a significant procedure with
specific and potentially serious complications; therefore,
informed patient consent should be obtained. The process
of obtaining consent should comply with national and local
guidance. There should be a discussion of the risks and
potential benefits of epidural analgesia, including information
on late complications that may occur after discharge from
hospital. A summary of this discussion should be documented
in the patient’s notes. Consent should be facilitated by written
patient information. A suitable leaflet 5 is available on the Royal
College of Anaesthetists’ website; it is not copyrighted and can
be modified to account for local factors.
4 Personnel, staffing levels and ward
environment
4.1 The Department of Anaesthesia should ensure that there are
designated personnel and clear protocols to support the safe
and effective use of epidural analgesia. This should be the
responsibility of a multidisciplinary Acute Pain Service including
a consultant anaesthetist and clinical nurse specialist(s) with
support from pharmacy. 3–4 The service should ensure that
appropriate documentation, administrative routines and audit
are in place.
3

4.2 Ultimate responsibility for the epidural
infusion remains with the practitioner who
instituted it (or supervising consultant if
inserted by a trainee). However, immediate
supervision of the patient may be passed
to the Acute Pain Service and properly
trained ward staff. An agreed form of
communication should be used to facilitate
this transfer of supervision.
4.3 Trainee and Staff and Associate Specialist/
Specialty doctors must possess appropriate
competencies before performing epidural
injections and establishing infusions without
the direct supervision of a consultant or
senior colleague. These are well defined,
regularly reviewed and available from the
Royal College of Anaesthetists and Faculty
of Pain Medicine websites.
4.4 There must be adequate handover of
information between on-call staff about
patients who are receiving epidural
analgesia. Ideally, an up-to-date list of
ongoing epidurals should be maintained
and readily available.
4.5 Nurses with specific training and skills in
the supervision of epidural analgesia and
management of its complications must be
present on the ward and on every shift
(i.e. 24-hour cover). Staffing levels and
expertise should be sufficient to enable
adequate monitoring and care to be given
to all patients receiving epidural analgesia.
These staff must be immediately available
to respond to adverse events. Oxygen
and full resuscitation equipment must be
available.
4.6 Patients receiving epidural analgesia should
be situated close to the nurses’ station, thus
ensuring close supervision. If nursing in a
single room is being considered, a full risk
assessment with respect to the epidural
should be undertaken and staff should be
sure that appropriate monitoring and care
can take place in this environment.
4.7 Before the patient returns to the ward, the
responsible anaesthetist should be assured
that the ward is sufficiently staffed to ensure
safe management of the epidural. A system
of communication should exist to inform
the anaesthetist and theatre staff if this is
inadequate.
4.8 There should be 24-hour access to:
i medical staff, trained and competent
in the management of epidurals,
immediately available to attend patients;
ii senior anaesthetic advice and
availability; and
iii a resuscitation team with a resident
doctor with appropriate competencies.
5 Catheter insertion
5.1 Epidural catheter insertion must be
performed using an aseptic technique. This
should include hand washing, sterile gloves,
sterile gown, hat, mask, appropriate skin
preparation and sterile drapes around the
injection site.
4 Best practice in the management of epidural analgesia in the hospital setting

5.2 The tip of the epidural catheter should be positioned at a spinal
level appropriate for the surgery. A catheter placed in a low
position may be associated with poor analgesia and need for
large volumes of infusion in adults.
5.3 The catheter should be secured in order to minimise
movement in or out of the epidural space. The dressing should
allow easy visibility of the insertion site and catheter.
5.4 Anaesthetists inserting epidural catheters should be aware
of, and adhere to, local infection guidelines (including use of
prophylactic antibiotics in special circumstances).
5.5 Local guidelines should be in place with respect to the insertion
and removal of epidurals in patients on anticoagulants or with
impaired coagulation. All staff should be aware of, and adhere
to, these guidelines.
6 Equipment
6.1 Ideally, equipment for epidural insertion and infusion should
be standardised throughout the institution so that it is familiar
to all staff providing or supervising epidural analgesia. Staff
must be trained in the use of this equipment.
6.2 Infusion pumps should be configured specifically for epidural
analgesia with pre-set limits for maximum infusion rate and
bolus size; lock-out time should be standardised if used for
PCEA. Pumps should be designated for epidural analgesia
only and should be labelled as such. 6 There should be a
documented maintenance programme.
6.3 The epidural infusion system between the pump and patient
must be considered as closed; there should be no injection
ports. An anti-bacterial filter must be inserted at the junction of
epidural catheter and infusion line.
5

6.4 Effective management of epidural analgesia
may require the administration of a bolus
injection of solution into the system. This
may be performed using the syringe within
the pump, thus not breaching the system.
If a separate handheld syringe is used, the
injection must be performed using a strict
aseptic technique. Bolus injections must be
performed by staff with appropriate training
and competencies and more intensive
monitoring of the patient is required
immediately after the injection.
6.5 Epidural infusion lines should be
clearly identified as such. The National
Patient Safety Association (NPSA) has
recommended the use of yellow tubing
to differentiate epidural/spinal lines from
arterial (red), enteral (purple) and regional
(grey) infusions. 7
6.6 In November 2009, the NPSA
recommended that equipment should be
developed that will enable NHS institutions
to perform all epidural, intrathecal and
regional infusions and boluses with devices
that will not connect with intravenous Luer
connectors or intravenous infusion spikes. 8
Practitioners involved in the use of epidural
analgesia should be aware of this project
and respond to further national guidance.
6.7 Resuscitation equipment, oxygen and
appropriate drugs must be readily available
wherever epidural infusions are employed.
7 Drugs for epidural analgesia
7.1 There should be a limited number of
solutions approved and available for
epidural infusions in every hospital. 6
They should be prepared under strict
sterile conditions in specifically designed
units. Many are available commercially.
Any variation from this should occur in
exceptional circumstances only and with the
agreement of the responsible consultant
after a risk/benefit analysis.
7.2 Epidural infusions should be labelled ‘For
Epidural Use Only’. 6
7.3 Epidural infusions should be stored in
separate cupboards or refrigerators from
those holding intravenous and other types
of infusions in order to reduce the risk of
wrong route administration. 6
7.4 The lowest possible effective concentration
of local anaesthetic should be used in order
to preserve motor function as much as
possible. This improves patient satisfaction
and aids detection of neurological
complications. If higher concentrations
are required, the infusion rate should be
reduced periodically to allow assessment of
motor block.
7.5 The use of drugs beyond licence should
be consistent with local hospital guidelines.
and informed by recommendations of the
British Pain Society. 9
6 Best practice in the management of epidural analgesia in the hospital setting

8 Patient monitoring
8.1 Patients must be monitored closely throughout the period of
epidural analgesia. It should be performed by trained staff
aware of its significance and action required in response to
abnormal values. Monitoring should include:
heart rate and blood pressure;
respiratory rate;
sedation score;
temperature;
pain score;
degree of motor and sensory block.
8.2 In addition, requirements for monitoring will be determined by
the nature of the surgery, and condition and age of the patient.
8.3 The frequency of observations should be determined by
normal clinical considerations. With respect to the epidural,
they should be more frequent in the first 12 hours of the
epidural infusion, after top-up injections, changes of infusion
rate and in periods of cardiovascular or respiratory instability.
8.4 Monitoring should follow clear written protocols and
compliance to these should be audited.
8.5 Epidural blockade can cause hypotension. However, when
hypotension occurs after surgery, other common causes
should be considered and excluded, e.g. bleeding, myocardial
insufficiency, sepsis, pulmonary embolus, dehydration.
8.6 Pain scores (at rest and on movement or deep breathing) and
sedation scores will help to identify inadequate or excessive
epidural drug administration. Monitoring protocols should give
clear guidance on actions required if analgesia is inadequate.
8.7 Sedation is often the most sensitive indication of opioidinduced
respiratory depression.
7

8.8 Monitoring of sensory and motor block
is essential for the early detection of
potentially serious complications. The
Bromage Scale is an accepted tool for
the measurement of motor block. 10 An
increasing degree of motor weakness
usually implies excessive epidural drug
administration. However, it can indicate
very serious complications including
dural penetration of the catheter, or the
development of an epidural haematoma
or abscess. Therefore, it is essential
that protocols are in place to manage
the scenario of excessive motor block.
Examples of suitable algorithms and specific
advice on protocols for this situation
are given in the report on the audit of
major complications of central neuraxial
block performed by the Royal College of
Anaesthetists. 2
8.9 An epidural abscess or haematoma can
cause severe, permanent neurological
damage and must be detected and treated
as soon as possible. This diagnosis must
be considered if excessive motor block
does not resolve rapidly after stopping the
epidural infusion. A clear protocol should
be in place describing the actions required
in this situation, including informing senior
anaesthetic staff and immediate availability
of suitable imaging and surgical expertise.
8.10 Records must be kept of the monitoring
described above as well as epidural infusion
rate, total amount used, inspection of
epidural insertion site, patency of intravenous
access and integrity of pressure
areas.
8.11 Staff should be aware that increased or
breakthrough pain may indicate surgical
complications including the development
of compartment syndromes. Special care
should be taken when interpreting physical
signs in patients who may have sustained
neurological damage.
9 Epidural analgesia in children
9.1 All the recommendations in this guideline
apply also to neonates, infants and
children but methods of monitoring and
assessment scores must be appropriate for
developmental age. 11
9.2 Dosing regimens for children must be
adapted for age and weight with maximum
dosage clearly defined to minimise the
risk of cumulative local anaesthetic toxicity,
especially in neonates and infants < three
months of age. 11
9.3 Clear protocols for prescription, monitoring
and troubleshooting of paediatric epidural
infusions should be used. Infusion devices
should be programmed and double
checked with extreme care as there is an
increased risk of error when managing
small infants and neonates. 12
8 Best practice in the management of epidural analgesia in the hospital setting

9.4 Hourly assessments are recommended, especially in the first 12
hours. There should be regular review of the need to continue
the infusion, especially after 48 hours.
9.5 Motor block should be assessed and documented formally
using an age-appropriate assessment. A clear action plan
should be in place if motor block persists or progresses.
9.6 Spread of local anaesthetics in neonates and infants is extensive
and low catheters can be used to provide an effective block for
thoraco-lumbar dermatomes without using unacceptable doses
of local anaesthetic. Whilst caudal catheters are effective, these
can become soiled unless carefully dressed or tunnelled away
from the insertion site.
9.7 Compartment syndrome is a particular concern after very
prolonged procedures, after lower limb surgery and when the
patient has been positioned during surgery in other than the
standard supine position. 12
9.8 An anaesthetist with appropriate competencies and training
should be immediately available to attend a child who is
receiving an epidural infusion.
9.9 The use of drugs beyond licence has been discussed in 7.5.
Specific advice with respect to children has been published by
the Association of Paediatric Anaesthetists of Great Britain and
Ireland. 11
9.10 Written and verbal advice should be provided to patients
and carers alerting them to the signs and symptoms of an
epidural abscess and what to do if they occur. Many children
are discharged before the mean time of onset of these signs
and symptoms. An information leaflet for parents and older
children 13 is available on the Royal College of Anaesthetists’
website.
9

10 Documentation, guidelines
and protocols
10.1 Contemporaneous records must be kept of
events throughout the period of epidural
analgesia. This includes consent, insertion
and removal of the catheter, prescription of
the infusion, monitoring, additional doses
and notes about any complications or
adverse events.
10.2 Safety is enhanced by the use of standard
pre-printed prescription forms rather than
hand written prescriptions that might be
misinterpreted.
10.3 Contact telephone and/or bleep numbers
for expert medical and nursing personnel
must be printed on documents that are
kept on the ward, and near to the patient.
10.4 Protocols and guidelines should include;
overall management of patients with
epidural infusions;
instructions for the use of the pump;
description of the drug concentrations
used in the hospital;
description of infusion rates and how to
adjust them;
instructions for changing epidural solution
bags or syringes;
frequency of observations;
maintenance of intravenous access
throughout the infusion period;
identification and management of early
and late complications;
management of inadequate analgesia;
management of accidental catheter
disconnection;
instructions for removal of the epidural
catheter and monitoring for complications;
insertion and removal of epidural catheters
in patients receiving anticoagulants;
pain management after cessation of the
epidural infusion;
management of opioid and local
anaesthetic toxicity;
mobilisation after epidural removal,
e.g. during enhanced recovery
programmes.
11 Audit and critical incidents
11.1 There should be regular audits concerned
with epidural analgesia. These could
include:
efficacy and patient satisfaction;
incidence of complications;
adherence to management protocols.
11.2 There should be clear procedures for the
reporting of, and response to, critical incidents
associated with the use of epidural analgesia.
12 Education
12.1 There should be formal, documented
training in place for doctors and nurses who
are responsible for supervising patients
receiving epidural analgesia.
12.2 Training programmes should include
induction and regular update sessions and
be commensurate with the responsibilities
of the staff involved.
10 Best practice in the management of epidural analgesia in the hospital setting

References
1 Good practice in the management of continuous epidural analgesia in
the hospital setting. RCoA, London 2004 (www.rcoa.ac.uk/docs/Epid-
Analg.pdf).
2 The 3rd national audit project of the Royal College of Anaesthetists. Major
complications of central neuroaxial block in the United Kingdom. RCoA,
London 2009 (www.rcoa.ac.uk/index.asp?PageID=717).
3 Guidelines for the provision of anaesthetic services. RCoA, London
2009 (www.rcoa.ac.uk/index.asp?PageID=477).
4 Pain management services: good practice. RCoA and BPS, London
2003 (www.rcoa.ac.uk/docs/painservices.pdf).
5 Epidurals for pain relief after surgery. RCoA, London 2008 (www.rcoa.
ac.uk/index.asp?PageID=1499).
6 Patient safety alert: Safer practice with epidurals injections and infusions.
NPSA, London 2007 (www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.
axd?AssetID=60063&type=full&servicetype=Attachment).
7 Design for patient safety: a guide to the design of electronic
infusion devices. NPSA, London 2010 (www.nrls.npsa.nhs.uk/
resources/?EntryId45=68534).
8 Patient safety alert: Safer spinal (intrathecal), epidural and regional
devices – Part B. NPSA, London 2009 (www.nrls.npsa.nhs.uk/
resources/?EntryId45=65259).
9 The use of drugs beyond licence in palliative care and pain management.
A position statement prepared on behalf of the Association for Palliative
Medicine and the British Pain Society. APM and BPS, London 2005
(www.britishpainsociety.org/pub_professional.htm#drugsmain).
10 Description of the Bromage Scale. The 3rd national audit project of the
Royal College of Anaesthetists. Major complications of central neuroaxial
block in the United Kingdom. RCoA, London 2009 (pg 142) (www.rcoa.
ac.uk/index.asp?PageID=717).
11 Good practice in postoperative and procedural pain. APAGBI, London
2008 (www.britishpainsociety.org/pub_professional.htm#apa).
12 Llewellyn N, Moriarty A. The national pediatric epidural audit. Pediatric
Anesthesia 2007;17:520–533 (http://onlinelibrary.wiley.com/
doi/10.1111/j.1460-9592.2007.02230.x/full).
13 An epidural for pain relief after surgery in children. RCoA, London 2009
(www.rcoa.ac.uk/docs/EPRASC.pdf).
11

Guideline development
Members of the working group considered the original version of the guidelines 1 in detail and modified
them in accordance with the current evidence base and recent guidelines published by relevant
professional bodies. Where there was a paucity of evidence to inform changes, these were derived
by obtaining the consensus opinion of the group members. The proposed new guidelines were then
submitted to the governing bodies of the endorsing professional organisations for consideration and
approval. In addition, views of the Regional Advisors of the Faculty of Pain Medicine were obtained.
This process led to further minor changes and the final published version.
The original version 1 did not consider the use of epidurals in obstetric practice. The present working
group decided that this was entirely appropriate as many obstetric factors influence their safe and
effective management.
Members of guideline development group
Professor David Rowbotham (Group Chair, Faculty of Pain Medicine)
Dr Jeremy Cashman (Faculty of Pain Medicine)
Dr David Counsell (British Pain Society)
Ms Felicia Cox (Pain Management Nursing)
Dr Paulah Crawford (Clinical Pharmacist)
Dr John Goddard (Paediatric Anaesthesia and Pain Medicine)
Dr Simon Higgs (Royal College of Nursing)
Dr Roger Laishley (Faculty of Pain Medicine)
Dr Neil Morton (Association of Paediatric Anaesthetists of Great Britain and Ireland)
Dr Barry Nicholls (European Society of Regional Anaesthesia)
Dr Felicity Plaat (Association of Anaesthetists of Great Britain and Ireland)
Professor Ian Power (Faculty of Pain Medicine)
Mrs Kate Rivett (Patient and Public Representative)
Revision date: November 2015
12 Best practice in the management of epidural analgesia in the hospital setting

INSIDE BACK COVER – TO BE LEFT BLANK

faculty of pain medicine
Churchill House 35 Red Lion Square London WC1R 4SG
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Fatigue and Anaesthetists
Published by
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650 Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org October 2014

Membership of the working party
(details correct at the start of the working party process)
Dr Kathleen Ferguson
Dr Felicity Howard
Dr Chris Idzikowski
Dr Barry Nicholls
Dr Mike Peters
Dr Felicity Plaat
AAGBI, Chair of working party
GAT
Edinburgh University Sleep Centre
AAGBI
BMA
AAGBI
© The Association of Anaesthetists of Great Britain & Ireland 2014

Contents
1. Preface 2
2. Recommendations 3
3. Introduction 4
4. Why are anaesthetists at risk of fatigue? 6
5. What are the risks? 7
6. How can fatigue be avoided, modified, or managed? 8
7. References 9-11
8. Appendices 1-4 12-16
This is a consensus document produced by expert members of a Working Party
established by the Association of Anaesthetists of Great Britain and Ireland
(AAGBI). It updates and replaces previous guidance published in July 2004. It has
been seen and approved by the AAGBI Board.
• What other guideline statements are available on this topic?
There are several guideline statements published by other healthcare
professional groups within the UK and overseas. Some high fidelity industries
provide evidence-based guidance on fatigue management to their employees
[1-4].
• Why was this guideline developed?
The original guideline (2004) was developed as a reference document for
individuals and departments when considering the effects of hours of work and
type of work undertaken in anaesthesia on clinician’s performance and
wellbeing. The primary goal was to improve patient safety.
• How and why does this statement differ from existing guidelines?
This new guidance is an update on the previous document. Additional research
on the impact of the European Working Time Directive on clinician performance
and fatigue provides new evidence to support the recommendations.
Date of review: 2018
1

1. Preface
The first edition of the Fatigue and Anaesthetists guideline was published in 2004
in paper and extended web versions. The document provided recommendations
on how to anticipate and mitigate the effects of fatigue for anaesthetists in the
workplace. A major driver in producing the document was to reduce risk to patients
by considering the impact of fatigue on anaesthetists’ performance and wellbeing
and thus, in turn, on the incidence of critical incidents in practice.
Since 2004, the effects of the New Deal agreement for junior doctors’ working
hours and the enforcement of the European Working Time Directive (EWTD) have
taxed departments in their ability to deliver service and training. Hours of work
were cut drastically; previously rotas often covered over 80 hours per week. Acute
care specialities have been adversely affected and anaesthesia, in particular, due
to the intensity of out-of-hours work and the number of rotas to be covered by single
departments.
Nine years on, 48 hours are the suggested contractual maximum for job plans.
Out-of-hours rotas have survived the move by variable means: introduction of
hybrid rotas, complex on-call arrangements and full and partial shift patterns. The
resulting squeeze on training time has produced a knock-on effect on consultant
working patterns: many departments have consultants first or second on-call in
theatre, labour ward and intensive care medicine.
Evidence is growing of new working patterns, shift types and their effects in the
healthcare setting. There is also increasing evidence of the detrimental effects of
extended working hours and shift patterns on individual wellbeing [5, 6].
The Fatigue and Anaesthetists publication is being refreshed, adding current
evidence to support the recommendations. Changing service and training demands
plus increased requirement for professional accountability all add to the pressure of
a high-intensity time-pressured job. This AAGBI resource hopes to serve as an aid
to managing fatigue in individuals and departments.
2

2. Recommendations
• In keeping with the General Medical Council (GMC) guidance in Good Medical
Practice [7], every doctor is required to provide safe and effective care and
therefore should be aware of the issues of fatigue. (2004)
• Departments must have a plan to manage staff of all grades who have
undertaken an onerous duty period and consider themselves unfit to continue
work. (2004)
• Job plans should be constructed such that they are not likely to lead to
predictable fatigue. (2004)
• Routine rest breaks should be implemented [8]. (2004)
• Handover protocols should be used before and after every rest break. (2004)
• Rest facilities and on-call rooms should be available for staff to nap during
shifts or sleep post-call. (Updated 2013)
• Resident on-call staff should have suitable accommodation. (2004)
• Refreshments should be available at all times. (2004)
• On-call responsibilities should be reviewed regularly and, particularly in the
older anaesthetist, take into consideration subjective assessment of fatigue
(consider seeking advice from an accredited specialist in occupational
medicine). (Updated 2013)
• Education on fatigue, its causes, mitigating factors, and its impact on healthcare
should be a priority for anaesthesia departments. (New 2013)
3

3. Introduction
What is fatigue?
Fatigue is a subjective feeling of the need to sleep, an increased physiological drive
to fall asleep and a state of decreased alertness [9]. Its consequences include a
decreased capacity to perform mental or physical tasks and are manifest in reduced
physiological performance and cognitive impairment [3]. Inadequate sleep is the
most important single factor impacting on fatigue. Common scenarios leading to
sleep-related fatigue include insufficient sleep, prolonged wakefulness and being
awake when normally one would be asleep [10].
Fatigue may manifest itself in characteristic behaviour patterns that vary between
individuals: yawning and difficulty staying awake, poor concentration and coordination,
head drooping, eye rubbing or heavy eyelids, general feelings of lethargy,
lacking motivation, error events and lapses in attention [4]. As an alternative to
self- or colleague-assessment of observed behaviours, the risk of fatigue may
be quantified subjectively using tools such as the Samn Perelli checklist
(Appendix 1) [11]. Objective assessment is out of the individual’s capability but
subjective assessment along with a sleep diary (Appendix 2) and good practices
can be used to demonstrate appropriate rest during and between periods of work.
What is sleep and how much of it is optimum?
Sleep is a complex physiological process during which the brain remains active
but is less responsive to external stimuli, while undertaking tissue healing and
repair and consolidation of learning and memory. Normal sleep consists of several
phases and is associated with specific EEG patterns and physiological changes.
Sleep follows a diurnal rhythm sleep-wake cycle and is controlled by a circadian
pacemaker in the suprachiasmatic nucleus in the hypothalamus. Research has
demonstrated that the circadian pacemaker would naturally function within a 25-
hour cycle. Light input via the retina and other external stimuli called zeitgebers
act to maintain the sleep-wake cycle within the 24-hour day/night cycle [12, 13].
Sleepiness peaks twice in any 24-hour period: 02.00-04.00 and 13.00-15.00.
The circadian rhythm ensures that the best sleep is achieved when going to bed
between 22.00 and 02.00 and that there is difficulty in sleeping during 08.00-12.00
and 17.00-21.00. The potential adverse impact upon shift workers is obvious.
4

Most adults require eight hours of restorative sleep each night. This varies
between individuals. Restorative sleep may be inadequate due to reduced quality
(awakenings during sleep periods) or insufficient time afforded to sleep. When
sleep is restricted for two or more consecutive nights, a sleep debt accumulates.
Two consecutive nights of restorative sleep is required to recover from significant
sleep loss [14]. Evidence shows that moderate sleep restriction to six hours per
night for two weeks leads to performance reduction equivalent to one night with
total sleep deprivation [15].
When wakefulness is extended beyond what is normal (16-18 hours), cognitive
function is impaired [15, 16]. This may manifest as slow response time, increase in
attention lapse frequency and impaired memory functions, addition and subtraction
ability, and decision-making. Periods of extended wakefulness may be quantified
in terms of the effects of an equivalent blood alcohol level [17]: after 20 hours
of wakefulness (coincident with a circadian low point) performance is impaired
equivalent to that with a blood alcohol of 0.1% (100 mg.100 ml -1 blood). The legal
limit for driving in the UK is 80 mg.100 ml-1 blood. Night workers have been shown
to be at increased risk of vehicle accidents in association with sleep-related fatigue
[18, 19].
Sleep patterns change with age. The requirement for eight hours sleep remains but
the periods of REM sleep are reduced, leading to sleep fragmentation [20]. There
is a reduction in the depth and consolidation of sleep. Older people suffer from
frequent and early awakenings with an exaggerated dip in arousal mid afternoon.
The ability to recover from a sleep debt is decreased and so the older anaesthetist
may be less able to cope with night shift work [21, 22]. Although those over 55
years are considered aged persons in terms of work physiology, intolerance to night
shift and shift work may begin as early as 45-50 years of age. There is considerable
individual variation in susceptibility and physical, psychological and social factors
all play a role [23].
Fatigued individuals may suffer from sleep lapses or ‘microsleeps’ where they
remain unresponsive to external stimuli for very short periods of time (seconds
to minutes). These episodes of sleep are spontaneous, brief and uncontrolled
[24]. Sleep inertia is characterised by a temporary disturbance in performance on
awakening. Its duration depends on the depth of sleep at the time of wakening and
sleep deprivation enhances its appearance [25, 26].
5

4. Why are anaesthetists at risk of fatigue?
Intensity and type of working
Fatigue is a function of time on task; the longer the hours of working, the greater
the risk of fatigue developing [27]. It is also important to recognise that time spent
awake may be substantial given the other demands when balancing daily living and
working. This may be particularly relevant to staff with young families and those
with other responsibilities. There is a near exponential rise in errors associated with
increased time on task. Long shifts (12 hours) lead to a doubling of risk compared
with an eight-hour shift [27]. This must be taken into consideration when planning
for long surgical procedures. The previous working party concluded that ”a 12-hour
working day is not acceptable working practice for an individual anaesthetist of any
grade”. Current evidence would agree with this statement.
The complexity of tasks affects the state of fatigue. Regular activity serves to
reduce fatigue while mundane and lengthy tasks increase the likelihood of fatigue
developing [28].
Sleep disturbance – on-call
On-call patterns of work predispose to poor quality sleep for several possible
reasons: unplanned interruptions move sleep opportunities out of sync with
circadian rhythm and poor timing of zeitgeber stimuli adversely affect the circadian
sleep/wake cycle. In a recent online survey of AAGBI members (Appendix 3), >
60% of respondents reported working out-of-hours as an on-call pattern. This
activity was associated with post-call tiredness and sleep debt.
Sleep deprivation – shift patterns
Individuals who work shift patterns are at risk of developing poor sleep patterns due
to circadian rhythm disruption. The relative risk of adverse incidents increases as
shifts move from morning to afternoon to night. Risk is greatest at the beginning of
a night shift, and increases over successive night shifts from 17% on the first night
to 36% on the fourth [29].
6

5. What are the risks?
Performance and safety
With adverse effects of fatigue on performance and safety accepted, work should
be organised to take place in daytime hours, making use of increased alertness
and peak performance [29, 30]. Regular breaks should be incorporated into the
working day [31] with comprehensive handover protocols used in support [32].
Wellbeing
Evidence is accruing to support claims of an association between impaired health
and sleep disturbance/deprivation. Shift workers may experience poor dietary
habits, peptic ulceration, increased prevalence of obesity and the development
of the diabetic state. Other conditions associated with fatigued shift workers
include hypertension, transient ischaemic attacks and cerebrovascular accidents.
Further research is required to prove causation following a report on an increased
breast cancer risk in Scandinavian nurses working night shifts [33]. Disturbed
circadian homeostasis is implicated in the pathophysiology of these conditions [34].
Individuals should be encouraged to follow good sleep hygiene practices and to
prepare for periods of duty by ensuring adequate restorative sleep before and after
rostered duties.
Service provision
Restricted hours of work, in conjunction with reducing trainee numbers and central
control of career grade expansion, creates a staffing void for service delivery.
Career grade staff cannot fill this gap without appropriate consideration of the
consultant and staff and associate specialist doctor role in job planning and the
effects of fatigue [35].
All grades of anaesthetist perform out-of-hours work either in an on-call capacity
or in shift patterns. The provision of rest breaks within and at the end of periods
of work must be catered for within department rostering [34]. Planning of shifts
must take into account lengths of shift, numbers of nights worked consecutively
and periods of rest before return to work. Rotas should not consist of more than
four nights in a row. Rotas of nine hours provide the minimum effect on cognitive
function but are difficult and costly (staffing) to organise. Rotas in a forward rolling
pattern (day-evening-night) provide the least adverse effects on sleep patterns [18].
The effects of ageing on sleep and fatigue mean that specific consideration must be
made when allocating of out-of-hours duties to the older anaesthetist.
7

6. How can fatigue be avoided, modified, or managed?
Strategies to reduce and mitigate the effects of fatigue include: good sleep
hygiene, techniques to minimise sleep disturbance (Appendix 4), napping, caffeine
ingestion, bright light exposure, regular rest breaks and exercise, avoiding hunger
and dehydration, maintaining alertness and avoiding alcohol ingestion before a
period of duty [2, 3, 36].
Several industries and organisations such as aviation, transport services, the oil
industry and the Queensland Government Health Department [4] have introduced
fatigue management systems into their practices. This proactive approach
to managing fatigue in the workplace is based on education for all levels of the
team. Diary evidence of sleep patterns and hours of work are kept and assessed
to determine the risk to the individual and the service caused by fatigue. The
initiative in Queensland Health is supported by Government legislation [37] and
departments are required to have contingency plans to support staff when fatigue
raises the risk level unacceptably high. Monitoring is routine.
Electronic devices and apps are available, both to facilitate maintaining a diary of
activity and sleep (Appendix 2), and also for self-assessment of mental performance
[38].
Less is known of the effects that non-technical skill development in individuals
and teams may have on the monitoring, reporting and management of fatigue in
medical practice. The recent GMC review of the effects of the EWTD alludes to this
point and highlights this as an area for research in the future [4, 6].
8

7. References
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to Managing Fatigue. Ottawa: Transport Canada, 2007. http://www.tc.gc.ca/eng/
civilaviation/publications/tp14572-6038.htm (accessed 04/06/2013)
2. Managing Shiftwork: Health and Safety Guidance. London: HSE, 2006. http://www.hse.
gov.uk/pubns/priced/hsg256.pdf (accessed 04/06/2013)
3. Managing fatigue in the workplace. London: IPIECA/OGP, 2007 http://www.ogp.org.uk/
pubs/392.pdf (accessed 04/06/2013)
4. Fatigue Risk Management System Resource Pack. Brisbane: Queensland Health, 2009.
http://www.health.qld.gov.au/hrpolicies/other/FRMS_web.pdf (accessed 13/01/2012)
5. The Impact of the Working Time Regulations on Medical Education and Training:
Literature Review. Durham: Durham University, 2012. http://www.gmc-uk.org/The_
Impact_of_the_Working_Time_Regulations_on_Medical_Education_and_Training___
Literature_Review.pdf_51155615.pdf (accessed 04/06/2013).
6. The Impact of the Working Time Regulations on Medical Education and Training:
Final Report on Primary Research. Durham: Durham University, 2012. http://www.
gmc-uk.org/The_Impact_of_the_Working_Time_Regulations_on_Medical_Education_
and_Training___Final_Report_on_Primary_Research.pdf_51157039.pdf (accessed
04/06/2013).
7. Duties of a doctor. London: General Medical Council. http://www.gmc-uk.org/guidance/
good_medical_practice/duties_of_a_doctor.asp (accessed 04/06/2013).
8. The Working Time Regulations 1998 http://www.legislation.gov.uk/uksi/1998/1833/
contents/made (accessed 04/06/2013)
9. Murray D, Dodds C. The effect of sleep disruption on performance of anaesthetists – a
pilot study. Anaesthesia 2003; 58: 520-25.
10. Akerstedt T. Work hours, sleepiness and the underlying mechanisms. Journal of Sleep
Research 1995;4:15-22
11. Estimating aircrew fatigue: a technique with implications to airlift operations. Fort
Belvoir, VA: Defense Technical Information Center Online, 1982. http://www.dtic.mil/cgibin/GetTRDoc?AD=ADA125319
(accessed 04/06/2013).
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Disorders and Stroke. http://www.ninds.nih.gov/disorders/brain_basics/understanding_
sleep.htm (accessed 04/06/2013).
13. Toh KL. Basic science review of circadian rhythm biology and circadian sleep disorders.
Annals of the Academy of Medicine, Singapore 2008; 37: 662-8.
9

14. Bonnet MH. Sleep Deprivation. In: Kryger MH, Roth T, Dement WC, eds. Principles and
Practice of Sleep Medicine. 3rd edn. Philadelphia: Saunders, 2000: 53-71.
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wakefulness: dose response effects on neurobehavioural functions and sleep physiology
from chronic sleep restriction and total sleep deprivation. Sleep 2003; 26: 117-26.
16. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM,
Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns’ work hours
on serious medical errors in intensive care units. New England Journal of Medicine
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17. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388:
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18. Horrocks N, Pounder R. Working the night shift: preparation, survival and recovery- a
guide for junior doctors. Clinical Medicine 2006; 6: 61-7.
19. Horne J, Reyner L. Vehicle accidents related to sleep: a review. Occupational
Environmental Medicine 1999; 56: 289-94.
20. Redline S, Kirchner HL, Quan SF, Gottlieb DJ, Kapur V, Newman A. The effects of age,
sex, ethnicity, and sleep-disordered breathing on sleep architecture. Archives of Internal
Medicine 2004; 164: 406-18.
21. Katz JD. Issues of concern for the aging anesthesiologist. Anesthesia and Analgesia
2001; 92: 1487-92.
22. Folkard S. Shift work, safety, and aging. Chronobiology International 2008; 25: 183-98.
23. Cost G. Di Milia L. Aging and shift work: a complex problem to face. Chronobiology
International 2008; 25: 165-81.
24. Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in anesthesia: implications and
strategies for patient and provider safety. Anesthesiology 2002; 97: 1281-94.
25. Muzet A, Nicolas A, Tassi P, Dewasmes P, Bonneau A. Implementation of napping in
industry and the problem of sleep inertia. Journal Sleep Research 1995; 4(S2): 67-9.
26. Tassi P, Muzet A. Sleep inertia. Sleep Medicine Reviews 2000; 4: 341-53.
27. Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003;
53: 95-101.
28. Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic
vigilance and monitoring performance in the operating room environment.
Anesthesiology 1990; 73: 995-1021.
29. Folkard S, Lombardi DA, Tucker PT. Shiftwork: safety, sleepiness and sleep. Industrial
Health 2005; 43: 20-3.
10

30. Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP. Effects of
health care provider work hours and sleep deprivation on safety and performance. Joint
Commission Journal on Quality and Patient Safety 2007; 33: 7-18.
31. Tucker P, Folkard S, Macdonald I. Rest breaks and accident risk. Lancet 2003; 361:
680.
32. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers.
London: BMA. http://bma.org.uk/-/media/Files/PDFs/Practical%20advice%20at%20
work/Contracts/safe%20handover%20safe%20patients.pdf (accessed 04/06/2013).
33. Kolstad HA. Nightshift work and risk of breast cancer and other cancers – a critical
review of the epidemiologic evidence. Scandinavian Journal of Work, Environment and
Health 2008; 34: 5-22.
34. Health effects of working unsocial hours and shift work. A briefing paper from the BMA
Board of Science. London: BMA. http://bmaopac.hosted.exlibrisgroup.com/exlibris/
aleph/a21_1/apache_media/77N84N5KQ1LVMF7XR5FUI6MQNG287F.pdf (accessed
04/01/2013).
35. Association of Anaesthetists of Great Britain and Ireland. Working Arrangements
for Consultant Anaesthetists in the United Kingdom. London: AAGBI, 2011. http://
www.aagbi.org/sites/default/files/images/working_arrangements_for_consultant_
anaesthetists_web.pdf (accessed 30/12/2013)
36. Garbariono S, Mascialino B, Penco MA, et al. Professional shift-work drivers who adopt
prophylactic naps can reduce the risk of car accidents during night work. Sleep 2004;
27: 1295-302.
37. Work-related fatigue. Summary of recent regulatory developments. Australian
Government, 2006. http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/
Documents/419/Workrelated_Fatigue_Summay_Recent_Regulatory_Development.pdf
(accessed 04/06/2013).
38. Sleep Well: Your pocket guide to better sleep. Mental Health Foundation; 2011.
http://www.mentalhealth.org.uk/content/assets/PDF/publications/MHF-Sleep-Pocket-
Guide-2011.pdf?view=Standard (accessed 27/03/2014).
11

8. 8. Appendix 1 1
Subjective Subjective assessment assessment of of fatigue fatigue –– Samn Samn Perelli Perelli checklist checklist
(Accessed via via http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA125319)
1. Fully alert, wide awake
2. Very lively, responsive, but not at peak
3. Ok, somewhat fresh
4. A little tired, less than fresh
5. Moderately tired, let down
6. Extremely tired, very difficult to concentrate
7. Completely exhausted, unable to function effectively
12

Appendix 2
Sample Sleep Diary
Date and Name Mon Tues Wed Thurs Fri Sat Sun
Time to bed
Time to wake
Hours of sleep
No. of wakenings
Total time awake
How long to fall asleep
How awake did I feel when I got up
1 = wide awake
2 = awake but a little tired
3 = sleepy
Caffeinated drinks and times
Alcoholic drinks and times
Exercise and times
How sleepy did I feel l during the day
1 = so sleepy I struggled to stay awake
2 = somewhat tired
3 = fairly alert
4 = wide awake
1
13

Appendix 3
Membership Questionnaire 1 (Errors and Fatigue countermeasures)
Have you ever napped/fallen asleep/microslept whilst undertaking anaesthesia?
Total number responding 178
Yes
No
89 89
Do you have knowledge of a colleague who has napped/fallen asleep/microslept 120 58
whilst undertaking anaesthesia?
How old are
you in years?
24-29
8
30-34
31
35-39
28
40-44
28
45-49
27
50-54
28
55-59
21
60-64
7
65+
0
Which grade do you work in?
Training
45
SAS
11
Consultant
121
Which pattern of work do you
undertake to provide out-of-hours
service?
Shift
46
Rostered
extended hours
7
On-call
109
Other
13
Have you made mistakes in your work which you relate to tiredness? 127 49
Have you experienced tiredness at your work which you relate to your work pattern? 165 13
Has fatigue affected your personal life outside the workplace? 178 16
How do you counteract fatigue related to your work?
% (n) Always Usually Sometimes Never Rating average
Napping 2.9 (5) 15.6 (27) 59.0 (102) 22.5 (39) 3.01
Caffeine 31.3 (55) 30.1 (53) 28.4 (50) 10.2 (18) 2.18
Leave 5.3 (9) 9.9 (17) 41.6 (71) 43.3 (71) 3.23
Post-call sleep 15.8 (27) 36.3 (62) 32.7 (56) 16.2 (26) 2.47
Sleep debt 12.3 (20) 33.7 (55) 44.2 (72) 9.8 (16) 2.52
Early to bed 9.6 (17) 36.7 (65) 50.8 (90) 2.8 (5) 2.47
↑Activity level 0.6 (1) 19.0 (33) 50.6 (88) 29.9 (52) 3.10
Frequent 1.2 (2) 17.3 (30) 52.6 (91) 28.9 (50) 3.09
breaks
Ask for help 0.6 (1) 4.6 (8) 51.4 (90) 43.4 (76) 3.38
14
14

Membership Questionnaire 2 (Health & Wellbeing)
Have you ever napped/fallen asleep/microslept whilst undertaking anaesthesia?
Total number responding 187
Do you have knowledge of a colleague who has napped/fallen asleep/microslept
whilst undertaking anaesthesia?
How old are 24-29 30-34 35-39 40-44 45-49 50-54 55-59
you in years? 7 34 27 28 28 29 27
Which grade do you work in?
Training
SAS
48
11
Which pattern of work do you Shift
Rostered
undertake to provide out-of-hours
extended hours
service?
48
8
How many hours of sleep do you consider you need 0-5 5.5- 7.5 8-9
each night before work the following day?
4 114 65
How many hours on average do you actually get on 0-5 5.5- 7.5 8-9
nights before clinical work?
15 144 26
Do you think you get sufficient sleep to meet the demands of your job?
Yes No
94 93
Yes No
125 63
60-64 65+
8 0
Consultant
127
On-call Other
113
15
9.5-11 >11
5 0
9.5-11 >11
1 2
Yes No
123 61
Do you regularly have to catch up on sleep following routine clinical duties?
Yes No
55 132
Do you regularly have to catch up on sleep following out-of-hours clinical duties?
Yes
No
146 38
15

Appendix 4
Minimise sleep disturbance:
• Maintain a sleep diary alongside an hours-of-work record
• Regular bedtime and wake-up time
• Sustained adequate sleep
• Two nights of good sleep before work period
• Bedroom quiet, dark and cool
• Avoid heavy eating and drinking before bedtime
• No alcohol, caffeine, nicotine close to bedtime
• No exercise < 3 h before bedtime
16

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

AAGBI SAFETY GUIDELINE
Management of Proximal Femoral Fractures 2011
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org June 2012

This guideline was originally published in Anaesthesia. If you wish to refer to
this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Management of
proximal femoral fractures 2011. Anaesthesia 2012; 67: pages 85-98. This
guideline can be viewed online via the following URL: http://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2044.2011.06957.x/abstract
The following bodies have endorsed this guideline:
Age Anaesthesia Association
The Association for Perioperative Practice
British Orthopaedic Association
The College of Emergency Medicine
© The Association of Anaesthetists of Great Britain 2012

Guidelines
Management of proximal femoral fractures
2011
Association of Anaesthetists of Great Britain
and Ireland
Membership of the Working Party: R Griffiths (Chairman), J Alper,
A Beckingsale, D Goldhill, G Heyburn, J Holloway 1 , E Leaper,
M Parker 2 , S Ridgway, S White, M Wiese 3 and I Wilson
1 Age Anaesthesia Association, 2 British Orthopaedic Association,
3 College of Emergency Medicine
Summary
1. There should be protocol-driven, fast-track admission of patients with
hip fractures through the emergency department.
2. Patients with hip fractures require multidisciplinary care, led by
orthogeriatricians.
3. Surgery is the best analgesic for hip fractures.
4. Surgical repair of hip fractures should occur within 48 hours of
hospital admission.
5. Surgery and anaesthesia must be undertaken by appropriately
experienced surgeons and anaesthetists.
6. There must be high-quality communication between clinicians and
allied health professionals.
Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution
2.5, which does not permit commercial exploitation.
Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 1

Anaesthesia 2011
Griffiths et al. | Guidelines: proximal hip fractures
7. Early mobilisation is a key part of the management of patients with
hip fractures.
8. Pre-operative management should include consideration of planning
for discharge from hospital.
9. Measures should be taken to prevent secondary falls.
10. Continuous audit and targeted research is required in order to inform
and improve the management of patients with hip fracture.
..................................................................................................
This is a consensus document produced by expert members of a Working
Party established by the Association of Anaesthetists of Great Britain and
Ireland (AAGBI). It has been seen and approved by the AAGBI Council.
* This article is accompanied by an Editorial. See page 2 of this issue.
Accepted: 11 September 2011
• What other guideline statements are available on this topic?
A number of guidelines concerning best practice management of hip
fracture have recently been published [1–6].
• Why was this guideline developed?
However, existing guidelines are inconclusive about either the involvement
of anaesthetists or the provision of anaesthesia for patients
sustaining hip fracture.
• How and why does this statement differ from existing guidelines?
This guidance is intended specifically to help anaesthetists manage
patients with hip fracture.
In common with other guidelines, this guideline reviews current
evidence regarding best practice anaeathesia. Crucially, however, this
guideline also recommends best practice in the numerous circumstances
where evidence is controversial or incomplete, based on expert consensus
opinion.
Proximal femoral fractures present unique challenges for anaesthetic
departments throughout Great Britain and Ireland, involving the perioperative
care of large numbers of older patients with significant comorbidities.
Despite guidance since the early 1990s concerning best
practice management for these vulnerable patients [1–6], there remains
considerable variation in models of peri-operative care, rehabilitation and
orthogeriatric input.
Approximately 77 000 hip fractures occur in the UK annually,
accounting for 1.5 million bed days, at an inpatient cost of £0.785 billion.
2 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011
Approximately 65 000 of these occur in England, with a median
postoperative length of stay of 23 days and a 30-day mortality that has
remained consistently around 8–10% for the last two decades – although,
again, there is considerable hospital variation in these figures [6, 7]. The
majority (95%) of hip fractures occur in patients over the age of 60, 75%
occurring in females. Among the elderly, 90% of hip fractures occur after a
simple, mechanical fall from standing height in patients with osteoporotic
bone (Fig. 1) [8]. Other important causes of hip fracture include
neuromuscular pathology, peripheral neuropathy, infection, arrhythmia,
postural hypotension, valvular heart disease and polypharmacy. More than
98% of fractures are repaired surgically, for the purposes of analgesia
and early rehabilitation. Approximately 25% of patients with hip fractures
have at least moderate cognitive impairment (abbreviated mental test
score < 7), 20% are institutionalised, and 50% require walking aids or are
immobile.
As a result of the inadequacies of the evidence base on which most
guidance is founded, there is limited consensus on best-practice anaesthetic
management for hip fracture patients, which this document hopes
to redress.
Neuromuscular status
Cognitive status
Fall Initiation
Fall direction
Energy content and fall height
Fall Descent
Impact location
Soft tissue attenuation
Impact
Bone mineral density
Bone geometry
Structural capacity of the
femur < applied loads
HIP FRACTURE
Figure 1 Mechanical factors leading to a hip fracture.
Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 3

Anaesthesia 2011
Griffiths et al. | Guidelines: proximal hip fractures
These guidelines will mainly focus on the acute hospital episode,
particularly the pre-operative period, intra-operative management and
immediate postoperative phase. Where evidence is limited, issues controversial
or guidelines uninformative, the Working Party has provided
pragmatic consensus opinions.
In addition, these guidelines will describe the logistics of providing a
high quality service for these patients, together with the important
relationships that must be developed between departments to ensure
quality care.
This has been a multidisciplinary collaboration that has resulted in
advice for anaesthetists and other health-care professionals on how to
create, develop and manage a service for patients with proximal femoral
fracture.
Facilities and services required
Older patients with hip fracture are at risk of significant morbidity and
mortality, both of which can be reduced by prompt surgical fixation of the
fracture and early, effective rehabilitation. This section outlines the
structures and processes required to expedite early surgery and achieve
high quality rehabilitation.
The Department of Health has suggested the following targets for
patients with hip fracture [9]: (i) all patients should be admitted within
4 h of arrival in the emergency department; and (ii) patients should be
operated on by an experienced clinical team within 24 h of a decision
that the patient is fit for surgery. In addition, the British Orthopaedic
Association Standards for Trauma (BOAST) guidelines [10] stipulate that
within 4 h of hospital arrival, hip fracture patients should be admitted to
an appropriate clinical ward area with nursing, orthogeriatric medicine
and surgical expertise appropriate for this often frail patient group;
further, that surgical fixation should not be delayed more than 48 h from
admission unless there are clear reversible medical conditions (see
below).
For many hospitals, achievement of these standards may require
service re-organisation, incorporating the following components.
Multidisciplinary hip fracture management group
This involves a broad collective of stakeholder personnel who meet
regularly in order to discuss and improve the quality and efficiency of hip
fracture care appropriate to a particular hospital. The group may include
trauma co-ordinators, general practitioners, community ⁄ falls assessment
4 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011
nurses, emergency staff, bed managers, orthopaedic nursing staff and
surgeons, anaesthetists, orthogeriatricians, physio- and occupational
therapists, social workers and rehabilitation services. Trauma coordinators
have a pivotal role, in reducing pre-operative delays, facilitating
interdisciplinary communication and instituting early discharge
planning.
Communication between this group and the hospital’s theatre
management group improves integration of system changes into general
theatre service provision.
Fast-track admission pathway
Most patients with hip fracture are admitted via an emergency department,
where a planned care package should be initiated promptly. The use
of a care pathway proforma focuses patient care and ensures basic quality
standards are met; a number of these exist, which can be tailored to
individual hospitals.
Continuous tracking ⁄ live data systems that regularly update patient
and logistical data may improve management by identifying patients’
location, delays in treatment and relevant clinical information, and may be
used to facilitate clinical audit and business planning.
Trauma lists
Protected trauma lists, separate from general emergency operating lists,
improve the efficiency of trauma service provision. These should be
provided daily, including weekends and bank holidays, and be staffed by
appropriately experienced senior medical and theatre staff. Unless life or
limb-threatening trauma intervenes, the Working Party suggests that hip
fracture surgery is prioritised within operating lists, overriding the
particular subspecialist interest of the senior surgeon assigned to the list.
Multidisciplinary trauma meetings
Daily multidisciplinary trauma meetings, convened before the start of
operating lists, offer excellent opportunities to communicate issues
relating to recent admissions and to plan operative lists and equipment
required for the day ⁄ next day, as well as providing regular teaching and
feedback. Trauma meetings may involve the same staff as above, including
their trainees. Members of the trauma team may change on a daily basis,
so handover of information is a key element. Communication of clinical
information should always involve accurate documentation in patients’
notes in addition to verbal handover.
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Consultant-delivered service
Older patients with hip fracture experience some of the worst clinical
outcomes among the hospital population. It is not acceptable for these
patients to be anaesthetised by inappropriately experienced trainees.
Ideally, such patients should be anaesthetised by a consultant or
specialist with similar clinical experience. Furthermore, a core group of
consultants with relevant experience of anaesthetising unwell, older
patients should provide the vast majority of the service, rather than
randomly-allocated consultants; one consultant ⁄ specialist should assume
overall clinical leadership for a hip fracture anaesthesia service.
Routine allocation of supernumerary trainee anaesthetists to wholeday
lists allows for greater continuity of care including pre-operative
preparation, postoperative review and interdisciplinary communication, as
well as providing training opportunities relating to orthogeriatric anaesthesia
and regional ⁄ nerve blockade.
Similarly, patients should be operated on by an appropriately
experienced surgeon, in order to minimise operative time and surgical
outcomes (e.g. blood loss, and rate of dislocation ⁄ re-operation).
Operating department
Ideally, all trauma operations should be performed in a specific ‘trauma
theatre’, large enough to allow access for an image intensifier, traction
table, and surgical equipment. Clean air systems, incorporating High
Efficiency Particulate Air Filter (HEPA) and laminar air flow, reduce the
risk of airborne infection. Theatre temperature should be maintained at
20–23 °C and humidity at 50–60%, to reduce the risk of peri-operative
hypothermia.
The minimum theatre team should consist of an operating department
practitioner, two scrub practitioners and a circulator. The theatre
team leader must be experienced in both femoral reconstruction and
replacement procedures, and scrub allocation should take account of the
patient’s health and potential complications previously identified at the
start-of-list team brief. Specialist education is crucial to building a
functional team.
The allocation of a dedicated radiographer per trauma theatre reduces
intra-operative delays.
Stock levels of surgical implants and consumables should anticipate
expected patient numbers, and instrumentation needs should take into
account processing time.
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Pre-operative management
Initial management
Hip fractures are painful, particularly on movement. Ambulance transfer
to hospital enables immobilisation and the administration of opioid
analgesia, intravenous fluid therapy and patient warming strategies.
A number of hospitals have successfully introduced ‘fast-track’ triage
systems that allow early clinical recognition of hip fracture (hip pain;
inability to weight-bear; shortened, externally rotated leg on affected
side) with early radiography and diagnosis, enabling rapid ward
admission, from where further medical input and investigations are
carried out.
Close attention should be continued towards analgesia, intravenous
fluid therapy, warming and pressure care during patients’ stay in the
emergency department, particularly if ward admission is delayed beyond
4h.
Early fracture fixation provides the most effective analgesia. In the
interim, a formalised analgesia protocol should be followed. Pain scores, at
rest and on movement, should be recorded before and after the
administration of analgesia. Other scoring systems may be used to assess
pain relief in patients with cognitive dysfunction [11]. Simple analgesics,
such as paracetamol, should routinely be prescribed on a regular basis,
unless contraindicated [12]. Approximately 40% of patients presenting
with hip fracture have at least moderate renal dysfunction (estimated
glomerular filtration rate < 60 ml.min )1 .1.73m )2 ) on admission. Opioids
should be used with caution until urea and electrolyte biochemistry results
have been reviewed, and non-steroidal anti-inflammatory analgesia is
relatively contraindicated [13].
Single-shot ⁄ continuous nerve blocks (femoral ⁄ fascia iliaca [14]) may
be successfully administered by appropriately trained emergency department,
orthopaedic and anaesthetic medical staff [15].
Pre-operative assessment
Traditionally, the pre-operative management of patients with hip fracture
has been by junior orthopaedic staff, with the role of geriatricians limited
to postoperative rehabilitation planning and social placement on discharge
from hospital. More recently, it has become apparent that the increasing
number of elderly, frail patients presenting with hip (and other fragility)
fractures may benefit from earlier, more intensive orthogeriatric input
(Table 1).
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Table 1 Benefits of early, intensive orthogeriatric input into management
of patients with hip fracture.
• Early identification of patients at increased risk of peri-operative morbidity
and mortality.
• Appropriate additional investigation, indicated by patients’ co-morbidities.
• ‘Pre-optimisation’ of less fit patients before surgery.
• Early rehabilitation and discharge planning.
• Improved interdisciplinary communication between orthogeriatricians, surgeons
and anaesthetists, reducing avoidable admission-to-operation delays.
Pre-operative assessment by the anaesthetist is mandatory, allowing
planning of anaesthetic technique, assessment and communication of perioperative
risk, and pre-optimisation. In order to avoid cancellation on the
day of surgery, a number of hospitals have developed specific information
leaflets for the benefit of orthogeriatricians and orthopaedic surgeons,
identifying particular concerns of relevance to the anaesthetist.
Co-morbidities
The preponderance of elderly patients has been noted above. Approximately
70% of patients will be of ASA physical status 3–4 [6, 7]: 35% have
one co-morbidity; 17% have two; and 7% have three or more [16]. The
most common co-morbidities are cardiovascular disease (35%), respiratory
disease (14%), cerebrovascular disease (13%), diabetes (9%), malignancy
(8%) and treated renal disease (3%).
Recently, a summative scoring system, the Nottingham Hip Fracture
Score (Appendix 1) [17], has been developed to predict postoperative
mortality according to the number of co-morbidities and other factors
(age, male sex, malignancy, pre-operative cognitive function, place of
residence and anaemia), and provides the anaesthetist with information
about outcome that may be discussed with the patient or their relatives.
In addition to assessment of the major systems, the anaesthetist
should also assess the patient with regard to: musculoskeletal abnormalities
(osteoarthritis, kyphoscoliosis, fixed flexion deformities); skin condition
and pressure areas; dentition; and hearing aids.
Polypharmacy
The over-60s consume 60% of the drugs prescribed in the UK; 20% of
people aged over 70 take more than five medications [3]. Polypharmacy
increases the likelihood of adverse drug reactions, which may be
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compounded by the limited physiological reserve of this population, and
of which 80% are potentially avoidable [18]. A current medication list
should be reviewed carefully for inappropriate dosing and prescribing, and
potential pharmacokinetic and pharmacodynamic interactions.
Routine pre-operative investigations
Full blood count and urea and electrolyte analyses are required routinely
before surgery. Coagulation studies and chest radiography are required
only if clinically indicated.
Full blood count. Pre-operative anaemia occurs in approximately 40% of
patients, and can result from fracture-related haemorrhage, haemodilution,
poor nutrition and ⁄ or chronic disease. Haemorrhage and
haemodilution may result in a fall in peri-operative haemoglobin
concentration (Hb) equivalent to approximately 2.5 g.dl )1 . Therefore,
patients who are anaemic pre-operatively are likely to be very anaemic
postoperatively, risking myocardial and cerebral ischaemia. It is has been
suggested that older patients require a higher blood transfusion trigger
than is generally used for patients undergoing elective surgery [19], to
the extent that pre-operative transfusion should be considered if Hb is
< 9 g.dl )1 , or Hb is < 10 g.dl )1 with a history of ischaemic heart disease.
If Hb is 10–12 g.dl )1 , two units of blood should be crossmatched. If Hb
is within normal limits, a grouped sample is sufficient. Revision surgery
or periprosthetic fractures incur greater blood loss and require preoperative
crossmatching according to local guidelines. Cell salvage
should be considered for such procedures. After transfusion, repeat Hb
analysis (formal full blood count or point-of-care) is strongly recommended.
Leucocytosis and neutrophilia are common (45% and 60%, respectively)
at presentation, but may be a reactive response to trauma rather
than indicative of infection. Leukocytosis > 17 · 10 9 .l )1 may indicate
infection (commonly of the chest or urine).
A platelet count of 50–80 · 10 9 .l )1 is a relative contraindication to
neuraxial anaesthesia [20]. A platelet count is below 50 · 10 9 .l )1 will
normally require pre-operative platelet transfusion.
Urea and electrolytes. Hypokalaemia is associated with new onset, rapid
ventricular rate atrial fibrillation (AF) peri-operatively. Hyperkalaemia
may indicate rhabdomyolysis if the patient was immobilised and unable to
call for help after falling.
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Hyponatraemia on admission to hospital is common (17%), and may
indicate infection or result from medication (particularly thiazide
diuretics).
Electrocardiogram (ECG). This is required in all elderly patients with hip
fracture.
Chest radiograph. Routine chest radiographs on admission are not
necessary, but may be useful in patients with newly diagnosed heart failure
or pneumonia.
Special cases
A number of clinical situations merit specific comment since they are
commonly encountered in this group of patients.
Alcohol dependence. Alcohol dependence is common, under-diagnosed
and a risk factor for falls [21]. Patients are at risk of significant perioperative
morbidity.
Atrial fibrillation. All patients in AF should have a ventricular rate
< 100.min )1 . Factors that may lead to new or fast AF include
hypokalaemia and hypomagnesaemia, hypovolaemia, sepsis, pain and
hypoxaemia. If treatment of these is ineffective, acute ventricular rate
control may be achieved using beta-blockers (metoprolol) or verapamil
[22].
Anticoagulation. A third of patients presenting with hip fracture take
aspirin regularly. There is a risk of significant bleeding if aspirin is taken in
combination with other thromboprophylactic medication. Aspirin may be
withheld during inpatient stay, unless indicated for unstable angina or
recent ⁄ frequent transient ischaemic attacks. About 4% of patients take
clopidogrel, which inhibits platelet function, and this should alert the
anaesthetist to myocardial ischaemia or cardiac stents. Clopidogrel is
generally not stopped on admission, especially in patients with drugeluting
coronary stents. Surgery should not be delayed, nor platelets
administered prophylactically, but marginally greater blood loss should be
expected. Novel antiplatelet therapies include prasugrel, eptifibatide,
abciximab and tirofiban.
Warfarin is taken by approximately 5% of patients presenting with hip
fracture. Hospital guidelines concerning the peri-operative management of
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patients taking warfarin should be followed; in general, the International
Normalised Ratio (INR) should be < 2 for surgery and < 1.5 for neuraxial
anaesthesia. Small amounts of vitamin K may be used to ‘reverse’ the
effects of warfarin; supplemental peri-operative anticoagulation with
heparins is usually indicated. Prothrombin complex concentrates rapidly
reverse the effects of warfarin but are expensive and rarely indicated.
Warfarin should be recommenced 24 h after surgery, although some
departments recommence it later on the day of surgery.
The advice of haematologists should be sought if in doubt about the
peri-operative management of patients on chronic anticoagulant therapy.
Regular anticoagulant medication requires that the anaesthetist balance
the attendant risks of neuraxial and lumbosacral plexus blockade (ie
haemorrhage and neuropraxia) against the benefits of these procedures for
the elderly.
Chest infection. Pre-operative chest infection requires prompt antibiotic
therapy, along with supplemental oxygen, intravenous fluids and
physiotherapy. Expedited surgery under regional anaesthesia is preferred,
enabling early mobilisation, analgesia and improved co-operation with
postoperative physiotherapy.
Diabetes. Approximately 9% of patients with hip fracture are diabetic.
Hospital guidelines concerning the peri-operative management of diabetic
patients should be followed. Hyperglycaemia is not a reason to delay
surgery unless the patient is ketotic and ⁄ or dehydrated.
Dialysis. Dialysed patients may develop renal bone disease and anaemia.
Although surgery is normally tailored around the patient’s dialysis, urgent
surgery may necessitate heparin-free dialysis.
Heart murmur. Unrecognised calcific aortic stenosis is an important
cause of anaesthesia-related mortality. There is considerable debate
concerning the postponement of surgery pending echocardiography, but
a majority of clinicians favour proceeding to surgery with modification of
their technique towards general anaesthesia and invasive blood pressure
monitoring, with the proviso that patients should undergo echocardiography
in the early postoperative period.
Echocardiography may be indicated: (i) to establish left ventricular
function if the patient is breathless at rest or on low level exertion; or (ii) to
investigate the severity of an ejection systolic murmur heard in the aortic
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area, particularly if significant aortic stenosis is suggested by two or more
of: a history of angina on exertion; unexplained syncope or near syncope; a
slow rising pulse; an absent second heart sound; or left ventricular
hypertrophy on the ECG without hypertension (although clinical signs of
aortic stenosis can be difficult to elicit [23]).
Implantable cardioverter defribrillators (ICD) and pacemakers. Increasingly,
ICDs are implanted to try and prevent sudden cardiac death from
dangerous cardiac arrhythmias; they may also have a pacemaker function.
As with pacemakers, there is a risk both of unipolar diathermy’s delivering
an arrhythmogenic shock to the myocardium, and of peri-operative failure
of the device. Early pre-operative consultation with a cardiologist is
required, both to establish the type of device and to develop a plan for
intra-operative management of patients.
Pre-operative optimisation
All acute hospitals should develop a specific protocol for the resuscitation
of patients with hip fracture, with particular regard to: monitoring
(pulse oximetry, respiratory rate, ECG, non-invasive blood pressure
measurement, core temperature and static ⁄ dynamic pain scores);
cannulation and intravenous fluid therapy; analgesia; thermoregulation;
and pressure care. These protocols may be commenced during ambulance
transfer, but are mandatory once the patient has been admitted to
the hospital.
Subsequently, important co-morbidities should be recognised and
treated without unnecessarily delaying surgery, in order to minimise
that patient’s specific risks of surgery and anaesthesia. This is a
multidisciplinary task, involving input from and communication between
orthogeriatricians, anaesthetists, surgeons, nursing staff and physiotherapists.
Timing of surgery
Ideally, surgery should be performed within 48 h of hospital admission
after hip fracture [2, 9], with a new target of 36 h having been introduced
in England and Wales in April, 2010. Currently, 80% of hospitals achieve a
mean admission to operation time of less than 48 h [6].
Meta-analyses [24, 25] indicate that delaying surgery beyond 48 h
from admission is associated with prolonged inpatient stay, increased
morbidity (pressure sores, pneumonia, thromboembolic complications)
and increased mortality (if delay is prolonged).
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There is no evidence to suggest that outcome is improved by delaying
surgery to allow pre-operative physiological stabilisation. However, the
benefits of expedited surgery must be balanced against the risks of certain
untreated conditions (Table 2).
Ethical considerations
A number of ethical considerations arise in the treatment of elderly
patients with hip fracture.
Consent and mental capacity
Approximately 25% of patients with hip fracture have moderate or
severe cognitive impairment, and a further 15–25% have mild cognitive
impairment. In order for patients to consent to, or refuse, surgical
repair of hip fracture, they must be able to do so voluntarily, based on
a decision made on information about the procedure presented to
them. The patient must have capacity to make a decision; that is,
he ⁄ she must be able to understand the information, remember it and
use it to reach a decision. In this age group, the ability to assimilate
information and communicate decisions may be impaired by poor
vision, hearing or speech, and steps should be taken to overcome these
problems.
If the patient lacks capacity, then treatment may be provided
according to the Mental Capacity Act 2005 [26] (MCA) (in Scotland,
the Adults with Incapacity (Scotland) Act 2000). Essentially, it remains the
Table 2 Reasons for delaying surgery for hip fracture that the Working
Party considers acceptable and unacceptable.
Acceptable
• Haemoglobin concentration < 8 g.dl )1 .
• Plasma sodium concentration < 120 or
> 150 mmol.l )1 and potassium
concentration < 2.8 or > 6.0 mmol.l )1 .
• Uncontrolled diabetes.
• Uncontrolled or acute onset
left ventricular failure.
• Correctable cardiac arrhythmia with a
ventricular rate > 120 .min )1 .
• Chest infection with sepsis.
• Reversible coagulopathy.
Unacceptable
• Lack of facilities or theatre space.
• Awaiting echocardiography.
• Unavailable surgical expertise.
• Minor electrolyte abnormalities.
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doctors’ decision to administer treatment that is deemed to be both
necessary and in the patient’s best interests; doctors should be prepared to
justify their decisions to treat ⁄ deny ⁄ withdraw treatment to the courts if
necessary. Decisions must not be biased by reference to the patient’s age.
Doctors must consult relatives about treatment decisions, and should seek
to ascertain whether the patient had previously written an advanced
directive, or appointed a Lasting Power of Attorney. The Courts may be
consulted if there is uncertainty about a patient’s management or if there
is dispute between clinical staff and relatives.
Rationing of healthcare
Implicit in the anti-discriminatory tenor of both the MCA and the Human
Rights Act 1998 is the requirement to provide equal access to, and
administration of, medical treatment (for example, high dependency unit
(HDU) care) to all patients, regardless of age and infirmity. This is at odds
with common law, which appears to support the rationing of services
within the NHS, and the issue remains unresolved in law. Doctors are not
obliged to deliver treatment that they consider to be futile or not in the
patient’s best interests.
Do not attempt resuscitation (DNAR) decisions
A joint statement from the British Medical Association, the Resuscitation
Council (UK) and the Royal College of Nursing provides the framework
under which DNAR decisions are made and ratified [27].
Do not attempt resuscitation decisions are increasingly prevalent
among the patient population with hip fracture, and may proscribe
cardiopulmonary resuscitation in the event of arrest. Although DNAR
decisions are presumed not to apply during surgery and anaesthesia,
resuscitation may not be in the patient’s best interests, or even desired by
the patient. The AAGBI has recognised these potential difficulties, and
issued guidance [28].
Discussions about DNAR should precede surgery, and anaesthetists
must take steps to make themselves aware of the outcome of these
discussions.
Intra-operative management
Surgical considerations
A number of hip fracture classification systems exist. Generally, 50% of
fractures are intracapsular, the remainder extracapsular (Fig. 2).
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Intracapsular fractures
Intracapsular fractures include subcapital, transcervical and basicervical
fractures, and may be displaced or undisplaced. Blood loss from an
intracapsular fracture at the time of injury is minimal because of the poor
vascular supply at the fracture site and tamponade effected by the capsule.
Occasionally, undisplaced fractures may be treated conservatively, but
there is a 30–50% risk of subsequent displacement. Current preference is
for all undisplaced intracapsular fracture to be treated by internal fixation
with multiple screws or a sliding hip screw.
Untreated, disruption to the capsular blood supply of the head of the
femur by a displaced intracapsular fracture can lead to avascular necrosis
of the bone, resulting in a painful hip of limited function. Therefore,
surgical treatment involves hemiarthroplasty; even then, intracapsular
fracture is associated with longer-term arthritis, and increasingly, total hip
arthroplasty is preferred for younger patients.
Compared to uncemented arthroplasty, cemented arthroplasty
improves hip function and is associated with lower residual pain
postoperatively.
Figure 2 Common sites of proximal femoral fractures. Arrows show the
insertion of the joint capsule.
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Extracapsular fractures
These include inter- and subtrochanteric fractures, and can be further
divided into groups related to the degree of comminution.
Blood loss from cancelleous bone is greater, such that the total blood
loss from an extracapsular fracture may exceed one litre; the greater the
degree of comminution and the larger the bone fragments, the greater the
blood loss. In addition, greater periosteal disruption causes extracapsular
fractures to be considerably more painful than an intracapsular fracture.
Extracapsular fractures can be treated conservatively, healing after 6–
8 weeks of traction and bed rest, but such management is associated with
increased morbidity and mortality, and a considerably reduced chance of
the patient returning home.
Invariably, extracapsular fractures are fixed surgically, using either a
sliding hip screw (intertrochanteric fractures) or less commonly, a
proximal femoral intramedullary nail (subtrochanteric fractures).
Anaesthetic considerations
Regional anaesthesia for hip fracture surgery requires blockade of the
lateral cutaneous nerve of the thigh and femoral, obturator, sciatic and
lower subcostal nerves, and can only be reliably achieved in the conscious
patient with neuraxial blockade. General anaesthesia requires additional
administration of postoperative analgesia, most commonly in the form of
peripheral nerve blockade. Poor analgesia in the immediate postoperative
period increases morbidity.
There is a minimal evidence base for determining the optimal
anaesthetic technique for patients undergoing hip fracture surgery.
Consequently, anaesthetists tend to adhere to a technique with which they
are familiar, roughly half administering neuraxial anaesthesia and the
remainder general anaesthesia. Furthermore, the wide range of drugs and
dosages used obscures determination of the best technique using audit data.
Based on a 2004 Cochrane systematic review of anaesthesia for hip
fracture surgery [29], that suggested that regional anaesthesia may
reduce the incidence of postoperative confusion, the Scottish Intercollegiate
Guidelines Network has produced the only recommendation
concerning choice of anaesthetic technique, namely that ‘Spinal ⁄
epidural anaesthesia should be considered for all patients undergoing
hip fracture repair, unless contraindicated.’ [1]. Until such time as
evidence is published that confirms regional anaesthesia is superior
to general anaesthesia or vice versa, the Working Party endorses
this recommendation. This endorsement is supported by a recent
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meta-analysis suggesting that regional anaesthesia ‘is the technique of
choice (although) the limited evidence available do(es) not permit a
definitive conclusion to be drawn with regard to mortality or other
outcomes’ [30].
Of greater importance, whichever technique is used, is that anaesthesia
is sympathetic to the limited physiological reserve and co-morbidities
of older patients [31].
The Working Party does not support the administration of opioid
analgesics as the sole adjunct to anaesthesia for this patient group, due to
the relatively greater risk of respiratory depression and postoperative
confusion. Peripheral nerve blockade should always be considered,
therefore, as an adjunct to spinal or general anaesthesia, to extend the
period of postoperative non-opioid analgesia.
Neuraxial anaesthesia
The Working Party recommends that either spinal anaesthesia or
general anaesthesia is administered, as simultaneous administration
is associated with precipitous falls in intra-operative blood pressure
[32].
Postoperative epidural analgesia (including combined spinal-epidural
anaesthesia) provides good postoperative analgesia, but may limit early
mobilisation after surgery, and for this reason is less commonly used in the
UK.
Spinal (subarachnoid) anaesthesia is commonly used, with or without
sedation. Conceptually, spinal anaesthesia for hip fracture fixation in
elderly patients should be viewed distinctly from spinal anaesthesia for
caesarean section in younger patients. Lower doses of intrathecal
bupivacaine (< 10 mg) appear to reduce associated hypotension [32,
33]. Attempted lateralisation of subarachnoid anaesthesia using hyperbaric
bupivacaine with the patient positioned laterally (with the fractured hip
inferior) may ameliorate hypotension. Co-administration of intrathecal
opioids prolongs postoperative analgesia; fentanyl is preferred to
morphine or diamorphine, which are associated with greater respiratory
and cognitive depression [34].
Sedation may be provided, but should be used cautiously in the very
elderly. Midazolam and propofol are commonly used. Ketamine may be
used, theoretically to counteract hypotension, but may be associated with
postoperative confusion.
Supplemental oxygen should always be provided during spinal
anaesthesia.
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General anaesthesia
Reduced doses of intravenous induction agents should be administered.
Inhalational induction is well tolerated by the elderly and allows for
maintenance of spontaneous ventilation. There remains debate about
whether mechanical ventilation is preferred to spontaneous ventilation.
Paralysis and tracheal intubation are associated with greater physiological
derangement than spontaneous ventilation, but proponents argue that
mechanicalventilationreducestheriskofperi-operativeaspirationandallows
greater control of arterial carbon dioxide levels. Intra-operative hypoxaemia
is common, and higher inspired oxygen concentrations may be required.
Peripheral nerve blockade
Blockade of the femoral, obturator and lateral cutaneous nerve of the thigh
may be sufficient for peri-operative analgesia. The most reliable method of
blocking all three is the psoas compartment block, although this risks a
degree of neuraxial blockade and formation of a deep haematoma in
recently anticoagulated patients.
Anterior approaches (femoral nerve ⁄ fascia iliaca block) do not
reliably block all three nerves, but reduce postoperative analgesia
requirements, and are more amenable to ultrasound-guided placement
and continuous catheter infusions postoperatively [15].
Wound infiltration with local anaesthetic is insufficiently analgesic.
High volume, low concentration pericapsular ⁄ periosteal injection of local
anaesthetic agents has not been assessed.
Pre- or postoperative peripheral nerve blockade may be used to
supplement either general or spinal anaesthesia.
Monitoring
Minimum standards for monitoring include the continual presence of the
anaesthetist, pulse oximetry, capnography, ECG and non-invasive blood
pressure monitoring [35]. Core temperature monitoring should be used
routinely. Point-of-care Hb analysers (e.g. Hemocue, or similar) should be
used routinely at the end of surgery to assess the degree of anaemia and
guide blood transfusion.
Given the high incidence of significant co-morbidities in this
population, there should be a low threshold for considering further
monitoring equipment, which may include:
• Invasive blood pressure monitoring [36], particularly for patients with
limited left ventricular function or valvular heart disease.
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• Central venous pressure (CVP) monitoring, for patients with limited left
ventricular function or undergoing revision ⁄ periprosthetic fracture
surgery.
• Cardiac output monitoring. Transoesophageal Doppler guided fluid
therapy may reduce hospital stay in patients undergoing general
anaesthesia for hip fracture surgery. Transthoracic Doppler probes are
becoming available for use in sedated or awake patients. Dilution
techniques (e.g. LiDCO) are increasingly accurate, and may be used in
conjunction with invasive blood pressure monitoring.
• Bispectral index (BIS) monitors may be used to optimise the depth of
anaesthesia and avoid potential cardiovascular depression. Initial BIS
levels may be abnormally low in alcoholic patients and patients with
dementia.
• Cerebral oxygen saturation [37]. The homeostatic regulation of cerebral
blood flow is poor in older patients, and depressed further by
anaesthesia. Detection of reduced cerebral oxygen saturation may be
associated with reduced postoperative cognitive dysfunction.
Supplemental pain relief
Regular paracetamol administration should continue throughout the perioperative
period. Non-steroidal anti-inflammatory drugs should be used
with extreme caution in hip fracture patients, and are contraindicated
in those with renal dysfunction. Similarly, opioids (and tramadol) should
be used with caution in patients with renal dysfunction: oral opioids
should be avoided, and both dose and frequency of intravenous opioids
should be reduced (e.g. halved). Codeine should not be administered, as it
is constipating, emetic and associated with peri-operative cognitive
dysfunction.
Thromboprophylaxis
Venogram and ventilation ⁄ perfusion studies have shown a prevalence of
37% for deep vein thrombosis (DVT) and 6% for PE (pulmonary
embolism) [38], although clinical symptoms are only seen in 1–3% of
DVTs and 0.5–3% of PEs in patients with hip fracture. Fondaparinux or
low molecular weight heparins are commonly prescribed and may
impact on the anaesthetic technique: low molecular weight heparin
should be administered between 18:00 and 20:00 to minimise the risk of
bleeding related to neuraxial anaesthesia during hip surgery on daytime
trauma lists. Thromboembolism stockings or intermittent compression
devices should be employed intra-operatively, in addition to ensuring the
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patient remains warm and well-hydrated. Expedited surgery and
mobilisation, and regional anaesthesia, may reduce the risk of DVT
further.
Antibiotics
Antibiotics should be administered within one hour of skin incision.
Hospital antibiotic protocols should be followed.
Pressure care
Older patients are particularly susceptible to pressure damage. Patients
should be positioned sympathetically during surgery, to avoid the
development of pressure sores and ⁄ or neuropraxia. Excessive flexion
and internal rotation of the non-operative hip should be resisted during
dynamic hip screw insertion.
The skin of older patients is thin and liable to be damaged by minimal
trauma. Care should be taken when removing dressings or diathermy
plates, and when moving the patient.
Thermoregulation
Older patients are susceptible to intra-operative hypothermia, particularly
during longer procedures [39]. Active warming strategies should always be
employed and continued postoperatively.
Intravenous fluids
Optimised peri-operative fluid management reduces morbidity and
hospital stay [40]. Many patients become hypovolaemic before surgery,
and pre-operative fluid therapy should be prescribed routinely. Cardiac
output-guided fluid administration appears to reduce hospital stay and
improve outcome [41].
Bone cement implantation syndrome (BCIS)
This is characterised by hypoxia, hypotension, or both, and ⁄ or unexpected
loss of consciousness, around the time of cementation, prosthesis
insertion, reduction of the joint or, occasionally, limb tourniquet deflation
in a patient undergoing cemented bone surgery [42]. The incidence in hip
fracture surgery is uncertain. Several mechanisms may contribute to a
multimodal aetiology, including fat ⁄ platelet ⁄ fibrin ⁄ marrow emboli and
stimulated release of vasoactive mediators. The risk of BCIS may be
reduced by good surgical technique (including medullary lavage, good
20 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011
haemostasis before cement insertion, use of a cement gun to enable
retrograde cement insertion, venting of the femur, minimising the length
of the prosthesis and minimising the force applied to it during insertion)
and good anaesthetic technique (including increasing the inspired oxygen
concentration at the time of cementation, avoiding intravascular volume
depletion, and using additional haemodynamic monitoring in high-risk
patients).
The treatment of BCIS includes delivery of 100% oxygen, fluid
resuscitation (guided by CVP measurement) and vasoactive ⁄ inotropic
support.
Postoperative management
Patients with hip fracture remain at relatively high risk of complications in
the early postoperative phase, and may require a prolonged period of
monitoring in the anaesthetic recovery unit or, less commonly, the
HDU ⁄ ICU. There is recognition that some patients may not be nursed in
the most appropriate place following hip fracture surgery. The Working
Party recommends that hip fracture patients should receive ward care with
a nurse:patient ratio of 1:4, with regular input from physicians specialised
in medicine for the elderly [4].
Analgesia
Peripheral nerve blockade is rarely effective beyond the first postoperative
night. Analgesia requirements vary considerably after fracture fixation,
particularly during remobilisation. Regular paracetamol administration
should continue [11], augmented by carefully prescribed opioid analgesia,
as indicated. Pain evaluation should be included as part of routine
postoperative nursing observations.
Oxygen
Older patients are at risk of postoperative hypoxia, and supplemental
oxygen should be administered postoperatively for at least 24 h. Oxygenation
and respiratory function improve with mobilisation.
Fluid balance
Hypovolaemia is common. Early oral fluid intake should be encouraged,
rather than routine prescription of intravenous fluids. Urinary catheters
should be removed as soon as possible, to reduce the attendant risk of
urinary tract infection.
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Anaesthesia 2011
Griffiths et al. | Guidelines: proximal hip fractures
Postoperative cognitive dysfunction ⁄ acute confusional state
This is common (25%) in patients with hip fracture, interrupting routine
management and rehabilitation. Treatment involves multimodal optimisation
of postoperative care requiring adequate analgesia, nutrition,
hydration, electrolyte balance, appropriate medication, bowel habit and
mobilisation, in conjunction with identifying and treating complications
such as chest infection, silent myocardial ischaemia and urinary tract
infection [43]. Drugs such as haloperidol or lorazepam should only be
used to control symptoms in the short term. Cyclizine should be used with
caution in older persons, due to its antimuscarinic side effects.
Nutrition
Up to 60% of patients with hip fracture are clinically malnourished on
admission to hospital. The calorie and protein density of hospital food is
often poor, and mortality (and possibly length of stay) may be reduced
through the administration of nutritional supplementation and employment
of dietetic assistants [44, 45].
Rehabilitation
The rehabilitation process constitutes the majority of a patient’s
inpatient stay after hip fracture, and continues for some time after
discharge.
Rehabilitation is ideally co-ordinated by orthogeriatricians, and is
aimed at providing a patient-centred package of care that attempts to
return the patient to levels of activity and residence similar to their prefracture
status. To this end, patients usually require input from
physiotherapists, occupational therapists, social workers, nursing staff
and their own relatives. Secondary prevention of falls and osteoporosis
should be actively considered in the early postoperative period, as
subsequent fragility fracture or periprosthetic fracture is associated with a
particularly poor prognosis.
Anaesthetists may become involved in secondary surgical management
(e.g. wound debridement, prosthesis revision) or in the provision of
longer-term analgesia or HDU facilities.
Printed information describing the typical care pathways for hip
fracture patients should be available for patients, carers and relatives.
Outcomes
Outcomes vary considerably in the UK.
22 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011
Mortality
Mortality after hip fracture has remained relatively unchanged for the last
two decades. Currently, 8.4% of patients die within 30 days of surgery [6].
However, it has been suggested that up to half of postoperative deaths are
potentially preventable [46]. Thirty-day mortality is increased for older,
sicker, male patients. Up to 15–30% of patients die within a year of
surgery.
Length of acute inpatient stay
This is between eight and 30 days, with a mean of 16 days [6].
Discharge destination
Only 44% of patients admitted from home are discharged back to their
own homes within 30 days of surgery. A further 22% are discharged to a
residential or nursing home, and discharge may become prolonged in
waiting for admission to these facilities.
Audit and research
Cochrane reviews have consistently recognised the relative dearth of
evidence on which to base best practice guidance with regards to the
clinical management of patients presenting with hip fracture. Consequently,
practice varies widely across the country, as several audits have
shown [6, 7], resulting in wide variations in patient outcome.
Clinical audit is fundamental to the process of improving the quality
of patient care. Local audit enables physicians both to identify specific
areas of care that could be improved, and to assess performance
longitudinally. National audit enables hospitals to compare performance
against other hospitals, and identify specific paragons of practice that may
they might adopt. A number of audit tools are available for anaesthetists:
Hip Fracture Perioperative Network (HFPN)
This is an NHS-sponsored network developed under the auspices of the
Age Anaesthesia Association, with the aim of improving evidence-based
(anaesthetic) care for patients with hip fracture in the UK. The HFPN
website [47] includes freely available database and annual report templates
that anaesthetists may use to audit hip fracture care in their own hospitals,
as well as ideas for research, specimen patient information leaflets, preoperative
care information for junior surgeons, and hip fracture care
pathway proformas.
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Anaesthesia 2011
Griffiths et al. | Guidelines: proximal hip fractures
National Hip Fracture Database (NHFD)
The NHFD is a collaboration between the British Orthopaedic Association
and the British Geriatrics Society, with the main aim ‘to focus attention on
hip fracture both locally and nationally, benchmark its care across the
country, and use continuous comparative data to create a drive for sustained
improvements in clinical standards and cost effectiveness’ [48]. All eligible
hospitals in the UK (except Scotland) are registered, with regular
contributions of data from over 75% of eligible hospitals, concerning in
excess of 130 000 patients (2011). The NHFD has recently begun to collect
data about anaesthetic methods used for hip fracture surgery.
Patient information
The provision of good quality information for patients is a key component
of the consent process, and is fundamental to good practice as detailed by
the General Medical Council [49] and AAGBI [50].
The Working Party recommends that each department produce a
written information leaflet or booklet. It is essential that patients and
relatives are involved in the process. Typically, such information would
include basic surgical information about the injury with more detailed
information the anaesthetic considerations. Anaesthetic options, including
intended benefits and risks, should be explained clearly. An alternative to
an anaesthetic information leaflet might be a more comprehensive
document developed with multidisciplinary input from nurses, surgeons,
physiotherapist, occupational therapists, etc. The Working Party recommends
that, where possible, information should be evidence-based.
A specimen patient information sheet is freely available from the
HFPN website [47], and may be edited to apply to the hip fracture care
pathway of specific hospitals.
Appendix 2 lists areas where information for patients can be found.
Training
The elderly patient with a proximal femoral fracture offers multiple
opportunities to learn and demonstrate specific core outcomes, knowledge
and skills within ‘units of training’ set out in the Royal College of
Anaesthetists’ 2010 curriculum [51].
The Working Party recommends that basic level trainees (CT1-2)
participate in the multidisciplinary peri-operative care of patients with hip
fracture (e.g. through participation in orthogeriatric and acute pain ward
rounds, and pre-operative assessment), as well as receiving training in the
24 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011
theory of intra-operative care of the elderly and practical experience of
relevant nerve block and regional anaesthetic techniques.
Intermediate level trainees (ST3-4) should be encouraged to become
more independent in patient assessment, and should aim to manage the
moderate- to high-risk patient with indirect local support only.
Higher level trainees (ST5-7) should be encouraged to undertake
independent trauma list planning, prioritisation and management, with
senior advice. This will, undoubtabley, reveal numerous potential
management, teamwork and leadership opportunities; all essential
domains of Common Competencies of Medical Practice. The trainee
may also develop roles in teaching medical students and more junior
trainees.
Advanced training ⁄ fellowship posts (ST6-7) undertaken in hospitals,
for example specialising in regional anaesthesia or anaesthesia for the
elderly, may provide the potential for a trainee for develop a specific
interest in the peri-operative care of older trauma patients. Higher level
trainees should be encouraged to participate in audit and research
involving patients with hip fracture.
Acknowledgement
The Working Party acknowledges the assistance of Prof. Opinder Sahota
and Dr Iain Moppett, Queen’s Medical Centre, Nottingham.
Competing interests
RG and SW have advised both the National Institute for Health and
Clinical Excellence (during development of Clinical Guideline 124 (The
management of hip fracture in adults)) and the NHFD, and are
respectively, Lead Clinician and Research Co-ordinator for the HFPN.
MJP has received honoraria from a number of commercial companies for
giving lectures on different aspects of hip fracture treatment and advising
on hip fracture treatments, and he has received royalties from BBraun Ltd
related to the design and development of an implant used for the internal
fixation of intracapsular hip fractures.
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25. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip
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26. White SM, Baldwin TJ. The Mental Capacity Act, 2005. Implications for anaesthesia and
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perioperative period. May, 2009. http://www.aagbi.org/publications/guidelines/
docs/dnar_09.pdf (accessed 30 ⁄ 08 ⁄ 2011).
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30. Luger TJ, Kammerlander C, Gosch M, et al. Neuroaxial versus general anaesthesia in
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31. Association of Anaesthetists of Great Britain and Ireland. Anaesthesia and perioperative
care of the elderly. December 2001. http://www.aagbi.org/publications/
guidelines/docs/careelderly01.pdf (accessed 30 ⁄ 08 ⁄ 2011).
32. Wood R, White SM. Anaesthesia for 1131 patients undergoing proximal femoral
fracture repair: effects on blood pressure, fluid administration and perioperative
anaemia. Anaesthesia 2011; 66: 1017–22.
33. Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G. Minidose bupivacainefentanyl
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34. Hindle A. Intrathecal opioids in the management of acute postoperative pain.
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http://www.aagbi.org/publications/guidelines/docs/standardsofmonitoring07.pdf
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40. Price JD, Sear JJW, Venn RRM. Perioperative fluid volume optimization following
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41. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and
length of hospital stay after repair of proximal femoral fracture: randomised
controlled trial. British Medical Journal 1997; 315: 909–12.
42. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation
syndrome. British Journal of Anaesthesia 2009; 102: 12–22.
43. Björkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D.
Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention
study. Acta Anaesthesiologica Scandinavica 2010; 54: 678–88.
44. Duncan DG, Beck SJ, Hood K, Johansen A. Using dietetic assistants to improve the
outcome of hip fracture: a randomised controlled trial of nutritional support in an
acute trauma ward. Age and Aging 2006; 35: 148–53.
45. Foss NB, Jensen PS, Kehlet H. Risk factors for insufficient perioperative oral nutrition
after hip fracture surgery within a multi-modal rehabilitation programme. Age and
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46. Foss N, Kehlet H. Mortality analysis in hip fracture patients: implications for design of
future outcome trials. British Journal of Anaesthesia 2005; 94: 24–9.
47. The Hip Fracture Perioperative Network. http://www.networks.nhs.uk/hipfractureanaesthesia
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Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011
52. Wiles MD, Moran CG, Sahota O, Moppett IK. Nottingham Hip Fracture Score as a
predictor of one year mortality in patients undergoing surgical repair of fractured neck
of femur. British Journal of Anaesthesia 2011; 106: 501–4.
Appendix 1
Nottingham Hip Fracture Score
A score out of ten is derived by adding weighted scores for eight criteria
(a). The total score may then be used to predict the risk of a patient dying
within 30 days of hip fracture surgery (b), a figure that may be used to
stratify patient-specific surgical risk during the process of consent, and in
order to identify patients who may benefit from more intensive levels of
peri-operative care. The score may also be used to predict 1-year
postoperative mortality [52].
(a) Derivation of score.
Variable
Points
Age 66–85 years 3
Age 86 ‡ older 4
Male 1
Haemoglobin concentration £ 10 g.dl )1 on admission to hospital 1
Abbreviated mental test score £ 6 ⁄ 10 on admission to hospital 1
Living in an institution 1
More than one co-morbidity 1
Active malignancy within last 20 years 1
(b) Predicted 30-day mortality.
Score
Predicted 30-day postoperative mortality
0 0
1 1%
2 2%
3 4%
4 6%
5 10%
6 15%
7 23%
8 22%
9 45%
10 57%
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Griffiths et al. | Guidelines: proximal hip fractures
Appendix 2
Resources for patients and relatives
There is excellent guidance, with examples, available on how to develop
and produce information leaflets from the following:
• Royal College of Anaesthetists (http://www.rcoa.ac.uk/index.asp?PageID=69):
You and your anaesthetic; Anaesthesia explained.
• British Orthopaedic Association (http://www.boa.ac.uk/en/patientinformation/olderhip):
Guidance for older patients with hip fractures.
• NHS Brand Guidelines (http://www.nhsidentity.nhs.uk/tools-and-resources/patient-information):
Patient information: a general resource
for producing written information for patients.
30 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

The Royal College of
Anaesthetists
The Association of
Anaesthetists of Great
Britain and Ireland
The Good Anaesthetist
Standards of Practice for Career Grade Anaesthetists
February 2010

The Royal College
of Anaesthetists
The Association of
Anaesthetists of
Great Britain and
Ireland
The Good Anaesthetist
Standards of Practice for Career Grade Anaesthetists
Prepared by the Joint Committee on Good Practice
ISBN: 978-1-900936-00-2
Published February 2010 by the Royal College of Anaesthetists.
Design and layout by the Royal College of Anaesthetists.
This publication will be reviewed in 2011.
© The Royal College of Anaesthetists 2010
All rights reserved. No part of this framework may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording or any
information storage or retrieval system without prior permission of the Royal College of
Anaesthetists.
Whilst the Royal College of Anaesthetists has endeavoured to ensure that the document is
as current as possible at the time it was published, it can take no responsibility for matters
arising from circumstances which may have changed, or information which may become
available subsequently.
All enquiries in regard to this document should be addressed to:
Professional Standards Directorate
The Royal College of Anaesthetists
Churchill House
35 Red Lion Square
London WC1R 4SG
email: standards@rcoa.ac.uk
Page 1

Contents ❚
Foreword 4
Introduction 5
Notes on terminology 6
Related guidelines and sources of information 7
Domain A: knowledge, skills and performance
Attribute 1: maintain your professional performance 8
Attribute 2: apply knowledge and experience to practice 10
Attribute 3: keep clear, accurate and legible records 12
Domain B: safety and quality
Attribute 4: put into effect systems to protect patients and improve care 14
Attribute 5: respond to risks to safety 16
Attribute 6: protect patients and colleagues from any risk posed by your health 18
Domain C: communication, partnership and teamwork
Attribute 7: communicate effectively 20
Attribute 8: work constructively with colleagues and delegate effectively 22
Attribute 9: establish and maintain partnerships with patients 24
Domain D: maintaining trust
Attribute 10: show respect for patients 26
Attribute 11: treat patients and colleagues fairly and without discrimination 28
Attribute 12: act with honesty and integrity 30
Prepared by the Joint Committee on Good Practice | Page 3

Foreword ❚
This document represents the distillation of many previous publications related to the standards
of practice expected of clinicians delivering anaesthesia. These standards have been mapped
to the generic standards in the Framework for Appraisal and Assessment published by the
General Medical Council (GMC) in 2008. In this document they defined four domains and three
attributes in each domain. There are then standards within each attribute, 75 in all, which every
doctor with a licence to practise must meet.
Our specialty standards must, and indeed do, map to all of these 75 generic standards but
also include those that effectively define the current practice of anaesthesia. They have been
ratified by the Joint Committee on Good Practice (JCGP) of the Royal College of Anaesthetists
(RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) and will be regularly
reviewed and updated as necessary.
It is these specialty specific standards that we have submitted to the GMC and which will
underpin all aspects of revalidation for anaesthetists. At first glance they appear daunting, but
in practice they simply describe activities we all do, and which are usually reviewed in annual
appraisal. It is worth taking some time to compare what information we each have to support
our claim to meet these standards (usually in our appraisal documents) and therefore identify
where we might be sensible to gather more supporting information (or ‘evidence’) before our
next appraisal.
Acknowledgements
We are extremely grateful to the many individuals who have contributed their time in preparing
the original document and those who assisted in the revisions for this new document. In
particular, we wish to thank Professor David Hatch and Dr Maria Rollin in their role as primary
authors; Mr Charlie McLaughlan (Director of Professional Standards), Mr Don Liu (Revalidation
Project Manager), Dr Judith Hulf CBE (Revalidation Lead, Academy of Medical Royal Colleges),
Dr Kirstyn Shaw (Revalidation Manager, Academy of Medical Royal Colleges) for their input; and,
finally, Councils for both the RCoA and AAGBI, the JCGP and the RCoA Patient Liaison Group for
their help in assisting with the revisions.
Professor C Dodds
RCoA Revalidation Lead
February 2010
Page 4 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Introduction ❚
The Good Anaesthetist has been compiled to set standards for career grade anaesthetists working
in hospital settings within and/or outside of the NHS. It provides a structured framework detailing
the minimum standards that anaesthetists are expected to meet. In particular, the framework can
be used to reflect on practice and identify knowledge areas, skills and attitudes for professional
development. The Good Anaesthetist also underpins the revalidation process for the specialty. It
maps a number of generic and specialty standards to the 12 attributes, as set out in the GMC
Framework for Appraisal and Assessment (2008), which anaesthetists are required to demonstrate
they are continuing to meet through supporting information and during annual appraisal.
The Good Anaesthetist is also intended for use by patients, to provide an informed understanding
of the standards that can be reasonably expected from a competent career grade anaesthetist.
The list of standards is not intended to be exhaustive, but to indicate the range of knowledge,
skills and attitudes in the pattern of practice expected of a career grade anaesthetist. The
standards that are generic to all doctors are drawn principally from Good Medical Practice (2006)
and can be found in the GMC Framework for Appraisal and Assessment. These generic standards
have been incorporated into The Good Anaesthetist and have been supplemented by standards
agreed by the JCGP of the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists
of Great Britain and Ireland (AAGBI). The vast majority listed have been defined as the essential
minimum standards. Anaesthetists who repeatedly fail to conform to the minimum standards
without good and sufficient reason may place their licence to practise at risk during the
revalidation process.
Within each attribute we have grouped the standards according to a shared identifiable
characteristic, i.e. a knowledge, skill, attitude or function area. No one individual standard
should be given a greater degree of importance, including the standard at the beginning of
each group. The groups are a practical way to help anaesthetists approach revalidation in an
organised and focused manner. Anaesthetists will be required to collect supporting information
in each attribute and consideration of standards, when grouped together according to a shared
characteristic, will provide focus for this activity.
Good practice in anaesthesia is dependent not only on the knowledge levels, skills and attitudes
of the individual but also on co-operation from organisations – in particular, in the provision of
adequate resources and time. All anaesthetists should bring to the attention of their employing
organisations any deficiency in resources which impacts on meeting the standards listed in The
Good Anaesthetist and which subsequently influence the quality of medical care and patient safety.
Prepared by the Joint Committee on Good Practice | Page 5

Notes on terminology ❚
The standards listed in The Good Anaesthetist are derived from Good Medical Practice (2006) and
from the work carried out by the JCGP. In Good Medical Practice the terms ‘you must’ and ‘you
should’ are used and the same convention is applied throughout The Good Anaesthetist.
■ ■
■ ■
■ ■
‘An anaesthetist must’ – is used for an overriding duty or principle.
‘An anaesthetist should’ – is used when providing an explanation of how that overriding duty
is to be met.
‘An anaesthetist should’ – is also used where a duty or principle will not apply in all situations
or circumstances, or where there are factors outside your control that affect whether you can
comply with the guidance.
‘Ensure’ is used where anaesthetists must do all that is within their control to make sure that the
event takes place.
Page 6 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Related guidelines and sources of information ❚
We have provided references to other guidance to illustrate how the standards in The Good
Anaesthetist can be interpreted and applied in practice. References are placed within the
appropriate attribute, although many of the guidelines cited cover a number of issues and are
applicable to several attributes.
For the sake of brevity we have not cited the following high level good practice guidelines
because they are applicable to all 12 attributes. It is therefore worth referring to the following:
The General Medical Council
››
Good medical practice, 2006.
The Royal College of Anaesthetists and The Association of Anaesthetists of
Great Britain and Ireland
››
Good practice: a guide for departments of anaesthesia, critical care and pain
management (3rd edition), 2006.
The Royal College of Anaesthetists
››
Guidelines for the provision of anaesthetic services (3rd edition), 2009.
The Royal College of Anaesthetists and The Pain Society
››
Pain management services: good practice, 2003.
The guidelines referenced in The Good Anaesthetist have been developed by the GMC, RCoA
or AAGBI. We have only listed those which are currently active. There are a number of other
guidance documents produced by professional bodies including the specialist societies, which
may be relevant to your job plan and professional practice. These guidelines should be referred
to as they may also illustrate how the standards in The Good Anaesthetist can be applied. The Good
Anaesthetist will be made available online as a web based resource. As we develop this area of
work we will include links to the full text of all relevant guidance documents as they are published.
Prepared by the Joint Committee on Good Practice | Page 7

Domain A: knowledge, skills and performance
Attribute 1: maintain your professional performance
Standards
➣➣
An anaesthetist must maintain knowledge of the law and other regulation relevant to
their practice.
❏❏
An anaesthetist must adhere to the laws and codes of practice relevant to their work.
➣➣
An anaesthetist must keep knowledge and skills up to date.
❏❏
An anaesthetist should regularly update relevant knowledge and skills in relation
to clinical practice to comply with core, higher and advanced level requirements of
continuing professional development (CPD).
❏❏
An anaesthetist should regularly update relevant knowledge and skills in relation to
wider clinical practice.
❏❏
An anaesthetist should learn and practise new improved techniques for patient
wellbeing and safety.
➣➣
An anaesthetist must participate in professional development and educational
activities.
❏❏
An anaesthetist should formulate a personal development plan.
❏❏
An anaesthetist should attend hospital and departmental educational meetings.
❏❏
An anaesthetist should seek opportunities to learn from colleagues locally and
elsewhere.
❏❏
An anaesthetist should retain records of CPD activities to support the revalidation
process.
❏❏
An anaesthetist must be truthful in recording CPD activities.
➣➣
An anaesthetist must take part in regular and systematic audit.
❏❏
An anaesthetist should participate actively in departmental or hospital audit meetings
on a regular basis.
❏❏
An anaesthetist should reflect upon and evaluate personal practice at regular intervals.
Page 8 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain A: knowledge, skills and performance
Attribute 1: maintain your professional performance
Explanatory notes
Maintaining professional performance is both a necessary and continuous process due to medical,
scientific and technological advances and changes in patient expectations. Realisation of these
advances and meeting of those expectations by the profession as a whole, in the day to day practice of
anaesthesia, pain medicine and intensive care, are dependent on individual doctors keeping up to date
with new knowledge and skills and applying them locally and nationally. Individual commitment to
this process requires planned and regular participation in the core, higher and advanced level areas of
continuing professional development (CPD), and also regular review of clinical practice against current
best practice and defined evaluation criteria.
An important aspect of keeping up to date is knowledge of current legal, regulatory and professional
codes which influence clinical and professional practice, e.g. controlled drug provision.
Related guidelines and sources of information
The General Medical Council
››
Guidance on CPD online (accessed 23 November 2009) www.gmc-uk.org/education.
The Royal College of Anaesthetists
››
Continuing professional development guidelines (2nd edition), 2010 (in press).
››
Raising the standard: a compendium of audit recipes (2nd edition), 2006.
Prepared by the Joint Committee on Good Practice | Page 9

Domain A: knowledge, skills and performance
Attribute 2: apply knowledge and experience to practice
Standards
➣➣
In providing care an anaesthetist must recognise and work within the limits of their
competence.
❏❏
When a problem arises outside their area of competence an anaesthetist must seek help
from a suitable colleague.
❏❏
An anaesthetist must act promptly and appropriately when anaesthetic complications
arise and be familiar with the operation of resuscitation equipment and current
resuscitation guidelines.
❏❏
An anaesthetist must take urgent appropriate action if a patient has suffered harm
through misadventure or for any other reason.
❏❏
An anaesthetist must use safe, regularly maintained equipment which has been checked
before use, and use equipment and techniques with which he or she is familiar.
➣➣
An anaesthetist must adequately assess the patient’s condition.
❏❏
An anaesthetist must assess the patient before anaesthesia and devise an appropriate
plan of anaesthetic management.
➣➣
An anaesthetist must provide or arrange advice, investigations or treatment where
necessary.
❏❏
An anaesthetist must prescribe drugs or treatment, including repeat prescriptions, safely
and appropriately.
❏❏
An anaesthetist must take steps to alleviate pain and distress whether or not a cure may
be possible.
❏❏
An anaesthetist must provide effective treatments based on the best available evidence.
❏❏
An anaesthetist should consider appropriate local or nationally agreed guidelines when
planning an anaesthetic.
❏❏
An anaesthetist must consult colleagues, or refer patients to colleagues, when this is in
the patient’s best interest.
➣➣
If they are involved in teaching, an anaesthetist must apply the skills, attitudes and
practice of a competent teacher/trainer.
❏❏
An anaesthetist should support the College Tutor in the teaching and clinical supervision
of anaesthetic trainees.
❏❏
An anaesthetist should participate actively in the professional development of trainees.
❏❏
An anaesthetist should participate in the assessment of trainees, having undertaken the
necessary training.
❏❏
An anaesthetist should contribute to the teaching of medical and other students.
❏❏
An anaesthetist should adopt a multidisciplinary approach to learning and teaching.
❏❏
An anaesthetist should help to foster a culture of lifelong learning.
Page 10 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain A: knowledge, skills and performance
Attribute 2: apply knowledge and experience to practice
Explanatory notes
Patients rely on anaesthetists to utilise and apply their expert knowledge and experience when making
professional judgements, dealing with complex situations and solving clinical problems. However, on
the other hand, given the rate of scientific and technological advances in medicine the majority of
patients do not expect anaesthetists to be the fountain of all knowledge. In return for this recognition,
anaesthetists must work within the limits of their competence; and where appropriate consult or seek
advice from other sources or refer patients to colleagues, including those from other specialties, who
do have the necessary experience and expertise.
An environment where patient care prospers is one where all members of the healthcare team can
learn from one another. Anaesthetists must therefore share their knowledge, skills and expertise by
engaging in the education, training and professional development of colleagues. This educational role
also includes undertaking reliable and honest formative assessment of students and trainees; providing
constructive feedback to them as appropriate.
Related guidelines and sources of information
The General Medical Council
››
Good practice in prescribing medicines: supplementary guidance, 2008.
››
Withholding and withdrawing life-prolonging treatments: good practice in decision making, 2006.
The Royal College of Anaesthetists
››
Cardiopulmonary resuscitation: standards for clinical practice and training, 2004.
››
Good practice in the management of continuous epidural analgesia in the hospital setting, 2004.
››
Local anaesthesia for intraocular surgery, 2001.
The Association of Anaesthetists of Great Britain and Ireland
››
Checking anaesthetic equipment (3rd edition), 2004.
››
Day surgery (2nd edition), 2005.
››
Do not attempt resuscitation (DNAR) decisions in the peri-operative period, 2009.
››
Guidelines for the management of a malignant hyperthermia crisis, 2007.
››
Peri-operative management of the morbidly obese patient, 2007.
››
Pre-hospital anaesthesia. AAGBI safety guideline, 2009.
››
Pre-operative assessment: the role of the anaesthetist, 2001.
››
Safe management of anaesthetic related equipment, 2009.
››
Suspected anaphylactic reactions associated with anaesthesia (4th edition). AAGBI safety guideline, 2009.
Prepared by the Joint Committee on Good Practice | Page 11

Domain A: knowledge, skills and performance
Attribute 3: keep clear, accurate and legible records
Standards
➣➣
In providing care an anaesthetist must keep clear, accurate and legible records.
❏❏
An anaesthetist should enter their name and GMC number on the anaesthetic record
sheet, in addition to the name of the patient and their details; non-consultants should
record the name of their consultant supervisor.
❏❏
An anaesthetist should only use recognised abbreviations in keeping clear and legible
records.
➣➣
In providing care an anaesthetist must make records at the same time as the events
they are recording or as soon as possible afterwards.
❏❏
An anaesthetist should ensure that the anaesthetic record sheet or hospital notes are up
to date as soon as practicable after the management of complications which have arisen
unexpectedly.
❏❏
An anaesthetist should make an accurate, legible, contemporaneous record of the timing
and doses of drugs and fluids administered such that a colleague could take over the
administration of the anaesthetic if necessary.
❏❏
An anaesthetist should ensure that the results of physiological monitoring of the patient
are recorded at appropriate intervals.
➣➣
An anaesthetist must record clinical findings, decisions, information given to patients,
drugs prescribed and other information or treatment.
❏❏
An anaesthetist should make a written record of the pre-operative assessment and
discussion, including any specific consent for regional anaesthesia or other procedures
when necessary.
❏❏
An anaesthetist should complete an entry in the hospital incident reporting system
following a critical incident.
Page 12 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain A: knowledge, skills and performance
Attribute 3: keep clear, accurate and legible records
Explanatory notes
The basic premise for keeping good quality medical records in anaesthesia, pain medicine and intensive
care is to facilitate communication amongst colleagues, and ensure the effective and safe continuation
of care of patients at different times and by different team members. It is therefore particularly
important that critical incidents, complications and unexpected events are accurately documented.
A secondary, but important, premise is that records (provided patients have been informed and they
do not object) are an important resource when it comes to auditing areas of anaesthesia care and
reviewing cases for educational purposes.
Related guidelines and sources of information
The Association of Anaesthetists of Great Britain and Ireland
››
Information management: guidance for anaesthetists, 2008.
Prepared by the Joint Committee on Good Practice | Page 13

Domain B: safety and quality
Attribute 4: put into effect systems to protect patients and improve care
Standards
➣➣
An anaesthetist must respond constructively to the outcome of audit, appraisals and
performance reviews or assessments.
❏❏
An anaesthetist must participate in the annual appraisal process.
➣➣
An anaesthetist must take part in systems of quality assurance and quality
improvement.
❏❏
An anaesthetist should co-operate with internal and external reviews.
➣➣
An anaesthetist must comply with risk management and clinical governance
procedures.
❏❏
An anaesthetist should participate in relevant national reporting schemes.
❏❏
An anaesthetist must cooperate with legitimate requests for information from
organisations monitoring public health.
➣➣
An anaesthetist must provide information for confidential enquiries and significant
event reporting.
❏❏
An anaesthetist must report suspected adverse drug reactions.
➣➣
An anaesthetist must ensure arrangements are made for the continuing care of the
patient where necessary.
❏❏
An anaesthetist should ensure that on-call teams have a range of skills sufficient to
manage any reasonable predictable clinical eventuality.
❏❏
An anaesthetist must write clear instructions for post-operative care including pain relief,
oxygen therapy and fluid management as necessary.
❏❏
An anaesthetist must ensure that there is continuous supervision of a patient receiving
anaesthesia. If in exceptional circumstances you are required to leave the theatre, you
must ensure that the patient is supervised by another anaesthetist or appropriately
trained assistant following a handover in accordance with AAGBI guidelines.*
❏❏
An anaesthetist must ensure that recovering patients are observed on a one-to-one
basis by an anaesthetist, recovery nurse or other properly trained member of staff
in accordance with AAGBI guidelines** until they have regained airway control and
cardiovascular stability and are able to communicate.
Page 14 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain B: safety and quality
Attribute 4: put into effect systems to protect patients and improve care
Explanatory notes
Anaesthetists have a duty of care in ensuring patient safety at all times. This duty applies at both
systems and individual patient care levels. Taking part in data collection exercises and reporting
significant events and complications are vital in developing an organisational culture whereby issues
that could potentially affect patient safety can be systematically identified. The duty of care extends,
whether you are on or off duty, to making sure that competent members of staff are involved in the
provision of safe and continuous care of patients. Patient safety, including measures to foresee and
prevent any adverse incidents that may arise, should be given due consideration in any service or
performance review, including the annual appraisal.
Related guidelines and sources of information
The General Medical Council
››
Raising concerns about patient safety, 2008.
The Royal College of Anaesthetists
››
Syringe labelling in critical care areas, 2004.
The Association of Anaesthetists of Great Britain and Ireland
››
Controlled drugs in perioperative care, 2006.
››
Immediate postanaesthetic recovery, 2002.**
››
Interhospital transfer. AAGBI safety guideline, 2009.
››
Provision of anaesthetic services in magnetic resonance units, 2002.
››
Recommendations for standards of monitoring during anaesthesia and recovery (4th edition), 2007.*
››
Recommendations for the safe transfer of patients with brain injury, 2006.
››
Theatre efficiency: safety, quality of care and optimal use of resources, 2003.
Prepared by the Joint Committee on Good Practice | Page 15

Domain B: safety and quality
Attribute 5: respond to risks to safety
Standards
➣➣
An anaesthetist must report risks in the healthcare environment to their employing or
contracting bodies.
❏❏
An anaesthetist should respond promptly to risks posed by patients.
❏❏
An anaesthetist must follow infection control procedures and regulations.
❏❏
An anaesthetist must safeguard and protect the health and well being of vulnerable
people, including children and the elderly and those with learning disabilities.
➣➣
An anaesthetist must take action where there is evidence that a colleague’s conduct,
performance or health may be putting patients at risk.
❏❏
An anaesthetist should be able to recognise when a colleague may be putting patients
at risk because of poor performance, misconduct or health reasons.
❏❏
An anaesthetist should listen impartially to medical, nursing and other colleagues when
they express concerns about a fellow anaesthetist, and discuss such concerns only in an
appropriate forum.
❏❏
An anaesthetist must take action and inform the clinical director or other responsible
person if necessary when a colleague may be putting patients at risk, and keep a written
record of the action taken.
Page 16 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain B: safety and quality
Attribute 5: respond to risks to safety
Explanatory notes
Risks to patient safety can come from several, sometimes unexpected, sources. Responsibilities in
regard to occupational health and safety laws apply to all employees in an organisation. However, there
are some risks that only a doctor, with their expertise and experience, will be able to recognise. Risk to
patient safety may stem from a poorly performing doctor in your team. If this risk could potentially or
does already affect patient safety, depending on seriousness, appropriate action must be taken in line
with local Trust and national procedures. The poorly performing doctor may be a close colleague or a
senior member of the clinical team, but your overriding duty is to take appropriate steps if there is a risk
to patient safety. Poor performance may be due to ill health; another reason to take appropriate action,
in helping a fellow colleague.
Related guidelines and sources of information
The General Medical Council
››
0–18 years: guidance for all doctors, 2007.
››
Raising concerns about patient safety, 2008.
The Royal College of Anaesthetists
››
Child protection and the anaesthetist: safeguarding children in the operating theatre –
intercollegiate document, 2007.
The Association of Anaesthetists of Great Britain and Ireland
››
Anaesthesia and peri-operative care of the elderly, 2001.
››
Infection control in anaesthesia (2nd edition). AAGBI safety guideline, 2008.
Prepared by the Joint Committee on Good Practice | Page 17

Domain B: safety and quality
Attribute 6: protect patients and colleagues from any risk posed by your health
Standards
➣➣
An anaesthetist should make arrangements for accessing independent medical advice
when necessary.
❏❏
An anaesthetist must seek advice and help from a suitably qualified professional in
accordance with GMC guidance if you know that you may have a serious condition
which either could affect your performance or is transmissible to patients.
❏❏
An anaesthetist should access professional counselling, advice, support and help services
if they are suffering from any mental health problem, including addiction, which could
potentially affect their professional judgement or performance.
➣➣
An anaesthetist must make arrangements to protect patients and colleagues from their
own health or other problem.
❏❏
An anaesthetist should be immunised against common serious communicable diseases
where vaccines are available.
❏❏
An anaesthetist should hand over duties to a colleague if judgement or ability is
temporarily impaired due to stress, tiredness or illness.
❏❏
An anaesthetist must not work under the influence of alcohol or drugs.
❏❏
An anaesthetist should take reasonable steps to stay healthy.
Page 18 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain B: safety and quality
Attribute 6: protect patients and colleagues from any risk posed by your health
Explanatory notes
Looking after patients should not distract an anaesthetist from looking after their own physical and
mental health. A healthy anaesthetist is one who can contribute fully to a team and, in turn, the
effective provision of medical care. Patients have a right to expect safe treatment. This expectation
extends to doctors whose health poses no risk in their professional relationships with patients. You
must seek formal advice if you think your own health is putting patients at risk or you feel it is limiting
your ability as a doctor to function effectively. Dependence on alcohol or drugs falls into this category,
as do stress and fatigue.
Related guidelines and sources of information
The Association of Anaesthetists of Great Britain and Ireland
››
Fatigue and anaesthetists, 2004.
››
Welfare resource pack, 2008.
Prepared by the Joint Committee on Good Practice | Page 19

Domain C: communication, partnership and teamwork
Attribute 7: communicate effectively
Standards
➣➣
An anaesthetist must communicate clearly and effectively with colleagues within and
outside the team.
❏❏
An anaesthetist must pass on information to colleagues involved in, or taking over, the
care of your patient.
❏❏
An anaesthetist should communicate directly with senior and specialist medical
colleagues when appropriate.
❏❏
An anaesthetist should communicate effectively with all members of the team to ensure
resources are used to best effect for the delivery of patient care.
❏❏
An anaesthetist should explain to assistants and other staff what your requirements are
likely to be in advance of inducing anaesthesia.
➣➣
An anaesthetist must visit and explain to patients and/or involved parties after surgery
when something has gone wrong.
❏❏
An anaesthetist should meet with close relatives by appointment when asked to do so to
discuss when things have gone wrong.
❏❏
An anaesthetist must be considerate to those close to the patient.
❏❏
An anaesthetist should ensure that a witness is present when explaining what went
wrong with a patient and/or involved parties, and that the incident and patient visit are
both adequately documented in the clinical records.
➣➣
An anaesthetist must keep patients informed about the progress of their care.
❏❏
An anaesthetist must listen to patients and respect their views about their health.
❏❏
An anaesthetist must give patients the information they need in order to make decisions
about their care in a way they can understand.
❏❏
An anaesthetist should encourage questions when possible and allow time to listen
to the concerns of patients, guardians or parents before and, where possible, after an
anaesthetic or therapeutic procedure.
❏❏
An anaesthetist must respond to patients’ questions.
❏❏
An anaesthetist must answer questions openly and honestly.
Page 20 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain C: communication, partnership and teamwork
Attribute 7: communicate effectively
Explanatory notes
Effective provision of care in anaesthesia, pain medicine and intensive care requires anaesthetists
to utilise a number of communication skills. Listening, questioning and providing instructions to
colleagues are just some of the skills that are necessary within a functioning multidisciplinary setting.
Non-verbal forms of communication are just as important as verbal ones.
Patients are very much seen as partners and contributors in the provision of their own healthcare.
Whether they can effectively contribute to this partnership is dependent on information provided by
their doctor in ways that can be easily understood. Again, this is very much dependent on a doctor’s
communication skills. Mistakes, as in any other area of life, can occur in medical practice. When a
mistake has been made, whether a complaint has followed or not, an informed and appropriate
explanation must be given to the patient or a close family member.
Related guidelines and sources of information
The Association of Anaesthetists of Great Britain and Ireland
››
Catastrophes in anaesthetic practice: dealing with the aftermath, 2005.
Prepared by the Joint Committee on Good Practice | Page 21

Domain C: communication, partnership and teamwork
Attribute 8: work constructively with colleagues and delegate effectively
Standards
➣➣
An anaesthetist must treat colleagues fairly and with respect.
❏❏
An anaesthetist should respect the skills and contributions of other members of the
anaesthetic, medical and nursing team.
❏❏
An anaesthetist should encourage multidisciplinary team working.
❏❏
An anaesthetist should ensure that the work content of job plans and on-call rotas is
fairly distributed among colleagues.
➣➣
An anaesthetist must support colleagues who have problems with their performance,
conduct or health.
❏❏
An anaesthetist should always be willing to advise and help colleagues.
❏❏
An anaesthetist should support colleagues undergoing rehabilitation after their illness or
returning to work after a period of absence for any reason.
➣➣
An anaesthetist should act as a positive role model for colleagues.
❏❏
An anaesthetist should provide appropriate professional support and encouragement for
trainees, staff and associate specialist grade (SAS) doctors and other anaesthetists under
their supervision.
❏❏
An anaesthetist should attend hospital promptly when requested and only leave when
appropriate to do so.
❏❏
An anaesthetist should be prepared to work flexibly within the department.
❏❏
An anaesthetist should ensure that they are aware of being placed on a roster to cover
emergency operating lists and on-call duties.
❏❏
An anaesthetist must make sure that when on-call they can easily be contacted.
❏❏
An anaesthetist should arrange annual, professional and study leave in advance in
accordance with local departmental policy.
➣➣
An anaesthetist must ensure that colleagues to whom they delegate have appropriate
qualifications and experience.
❏ ❏ An anaesthetist with a management role should confirm that the on-call staff work
within their competencies.
Page 22 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain C: communication, partnership and teamwork
Attribute 8: work constructively with colleagues and delegate effectively
Explanatory notes
Anaesthetists usually function as members of departments and multidisciplinary teams in order to
provide safe and effective care to patients. Developing good relationships with colleagues is important,
as well as understanding and respecting their professionalism, roles and views. Anaesthetists are
commonly leaders of clinical teams and should therefore ensure that ineffective team working does not
compromise patient care. Displaying the behaviours and attitudes of a positive role model is often the
first step in achieving this.
Related guidelines and sources of information
The General Medical Council
››
Management for doctors, 2006.
The Association of Anaesthetists of Great Britain and Ireland
››
The anaesthesia team (2nd edition), 2005.
››
Consultant trainee relationships – a guide for consultants, 2001.
››
Guidance on the 2003 (new) contract and job planning for consultant anaesthetists, 2005.
››
Guidance on the supervision of non-consultant anaesthetists, 2008.
Prepared by the Joint Committee on Good Practice | Page 23

Domain C: communication, partnership and teamwork
Attribute 9: establish and maintain partnerships with patients
Standards
➣➣
An anaesthetist should encourage patients to take an interest in their health and take
action to improve and maintain it.
❏❏
An anaesthetist must support patients in caring for themselves.
❏❏
An anaesthetist should engage in the education of patients and the wider public.
❏❏
An anaesthetist should promote the specialty of anaesthesia in the wider public interest.
➣➣
An anaesthetist must be satisfied that they have consent or other valid authority before
they undertake any examination or investigation, provide treatment or involve patients
in teaching or research.
❏❏
An anaesthetist should ensure that patients have understood the nature and purpose of
any proposed treatment or investigation and any significant risk or side effects associated
with it, enabling them to make an informed choice of anaesthetic technique by giving
clear explanation of the advantages and disadvantages of the options available, using
terms that a patient can understand and relate to when giving consent.
❏❏
An anaesthetist must abide with local research ethics committee and multicentre
research ethics committee guidelines when carrying out research.
Page 24 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain C: communication, partnership and teamwork
Attribute 9: establish and maintain partnerships with patients
Explanatory notes
It has been recognised that good professional relationships with patients is fundamental to the practice
of medicine. Establishing a partnership, which is built on trust, will allow an anaesthetist to influence
the patient’s approach and attitude to their treatment and care over time. Trust is gained through an
anaesthetist’s professionalism, which covers not only their knowledge and clinical skills but also their
ability to empathise with, understand and respect the views and feelings of patients. This is a process
and the same consideration must also be given when obtaining patient consent. It is not just a signing
of an appropriate consent form but involves listening to a patient’s concerns and anxieties, answering
their questions and providing information in a way they can understand. Having an anaesthetic, an
admission to critical care or the requirement for pain medicine are often parts of medical care about
which patients are most anxious.
Related guidelines and sources of information
The General Medical Council
››
Consent: patients and doctors making decisions together, 2008.
››
Maintaining boundaries: supplementary guidance, 2006.
››
Making and using visual and audio recordings of patients: guidance for doctors, 2002.
››
Research: the role and responsibility of doctors, 2002.
The Association of Anaesthetists of Great Britain and Ireland
››
Consent for anaesthesia (2nd edition), 2004.
Prepared by the Joint Committee on Good Practice | Page 25

Domain D: maintaining trust
Attribute 10: show respect for patients
Standards
➣➣
An anaesthetist must implement and comply with systems to protect patient
confidentiality.
❏❏
An anaesthetist must maintain patient confidentiality at all times.
➣➣
An anaesthetist must be polite, considerate and honest and respect patients’ dignity
and privacy.
❏❏
An anaesthetist should promote trust with patients through courteous behaviour,
honest discussions and respect for their right to privacy and dignity, whether conscious
or unconscious.
❏❏
An anaesthetist must treat each patient fairly and as an individual.
Page 26 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain D: maintaining trust
Attribute 10: show respect for patients
Explanatory notes
Politeness, consideration, honesty and respect are recognised social norms in any professional working
environment. Showing respect to patients includes respecting their privacy. Without assurances about
privacy, patients may be reluctant to seek help from doctors or part with the necessary information so that
doctors can provide safe and effective care. Patient confidentiality is therefore a duty for all doctors but it
is not an absolute. Information can or should be disclosed in certain circumstances, e.g. to satisfy a legal
requirement, and under certain conditions, as stipulated by the latest GMC guidance on confidentiality.
Related guidelines and sources of information
The General Medical Council
››
Confidentiality, 2009.
››
Maintaining boundaries: supplementary guidance, 2006.
››
Personal beliefs and medical practice: supplementary guidance, 2008.
Prepared by the Joint Committee on Good Practice | Page 27

Domain D: maintaining trust
Attribute 11: treat patients and colleagues fairly and without discrimination
Standards
➣➣
An anaesthetist must be honest and objective when appraising or assessing colleagues
and when writing references.
❏❏
An anaesthetist must not exaggerate competence or fail to mention significant
weaknesses in a reference.
❏❏
An anaesthetist should be honest and open in relations with colleagues.
❏❏
An anaesthetist should provide references, reports or signed documents within a
reasonable time.
❏❏
An anaesthetist should ensure that an applicant is aware that a reservation would be
expressed when writing a reference for him or her.
➣➣
An anaesthetist must respond promptly and fully to complaints.
❏❏
An anaesthetist should, if appropriate, give an apology to the patient and their relatives
and explain in understandable terms what occurred when an untoward incident took
place.
❏❏
An anaesthetist should respond constructively to any complaints received and cooperate
with any relevant complaints procedures or formal inquiry into the treatment of
a patient.
➣➣
An anaesthetist must provide care on the basis of the patient’s needs and the likely
effect of treatment.
❏❏
An anaesthetist must act in the patient’s interest at all times.
❏❏
An anaesthetist must not allow their personal prejudice to affect the treatment or
management of a patient under their care.
❏❏
An anaesthetist should consider the clinical needs of the patient and the professional
needs of colleagues when planning a clinical session.
Page 28 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain D: maintaining trust
Attribute 11: treat patients and colleagues fairly and without discrimination
Explanatory notes
Engaging with your colleagues fairly and without discrimination, irrespective of their gender, age, race,
sexuality, economic status, lifestyle, culture and religious or political belief, is essential when working
as part of a team. The reverse of this is your right to work without being subject to discrimination.
Consideration of a colleague’s competence and performance must be based on honest and objective
decisions and judgements. Honesty and objectivity must also be applied in your professional
relationships with patients. Best practice involves the recognition and acknowledgement of different
needs in helping patients access medical care on an equal basis.
Complaints must also be managed fairly and without discrimination. Not all complaints by patients
are a result of a mistake; but complaints have risen in recent years due in part to general expectations
increasing and tolerances decreasing. If justified, an anaesthetist should respond promptly and
appropriately to any complaint.
Related guidelines and sources of information
The General Medical Council
››
Personal beliefs and medical practice: supplementary guidance, 2008.
››
Withholding and withdrawing life-prolonging treatments: good practice in decision making, 2006.
››
Writing references: supplementary guidance, 2007.
The Association of Anaesthetists of Great Britain and Ireland
››
Consultant trainee relationships – a guide for consultants, 2001.
››
Management of anaesthesia for Jehovah’s Witnesses (2nd edition), 2005.
Prepared by the Joint Committee on Good Practice | Page 29

Domain D: maintaining trust
Attribute 12: act with honesty and integrity
Standards
➣➣
An anaesthetist must ensure that they have adequate indemnity or insurance cover for
their practice.
➣➣
An anaesthetist must be honest in financial and commercial dealings.
❏❏
An anaesthetist must inform patients about any fees and charges before starting
treatment.
❏❏
An anaesthetist must ensure any published information about their services is factual
and verifiable.
❏❏
An anaesthetist should not undertake private practice or any other commitment which
would prevent them from fulfilling rostered clinical NHS duties.
➣➣
An anaesthetist must be honest in any formal statement or report, whether written or
oral, making clear the limits of your knowledge or competence.
Page 30 | The Good Anaesthetist | Standards of Practice for Career Grade Anaesthetists

Domain D: maintaining trust
Attribute 12: act with honesty and integrity
Explanatory notes
Honesty and integrity form the cornerstone of medical professionalism. Divergence away from these
virtues, regardless of where an anaesthetist may be working (e.g. the NHS or private healthcare sector),
risks diminishing the trust placed in anaesthetists and the profession by patients, colleagues and the
public. In providing information about yourself, your services and others, honesty is reflected by the
accuracy and verifiability of that information. Fulfilling contractual and professional obligations to their
employer and patients will demonstrate the integrity of an anaesthetist.
Related guidelines and sources of information
The General Medical Council
››
Acting as an expert witness: supplementary guidance, 2008.
››
Conflicts of interest: supplementary guidance, 2008.
››
Reporting criminal and regulatory proceedings within and outside the UK:
supplementary guidance, 2008.
››
Taking up and ending appointments: supplementary guidance for doctors, 2008.
››
Writing references: supplementary guidance, 2007.
The Association of Anaesthetists of Great Britain and Ireland
››
Guidance on the 2003 (new) contract and job planning for consultant anaesthetists, 2005.
››
Independent practice, 2008.
››
Voluntary code of practice for billing private patients, 2008.
Prepared by the Joint Committee on Good Practice | Page 31

The Royal College of Anaesthetists
Churchill House | 35 Red Lion Square | London WC1R 4SG
020 7092 1500 www.rcoa.ac.uk info@rcoa.ac.uk
Design and layout by The Royal College of Anaesthetists
The Association of Anaesthetists of Great
Britain and Ireland
21 Portland Place | London W1B 1PY
020 7631 1650 www.aagbi.org info@aagbi.org

The Royal College of
Anaesthetists
The Association of
Anaesthetists of Great
Britain and Ireland
Good Practice
A guide for departments of anaesthesia,
critical care and pain management
Third edition
2006

The Royal College of
Anaesthetists
The Association of Anaesthetists
of Great Britain and Ireland
Prepared by the Joint Committee on Good Practice
Association of Anaesthetists of Great Britain and Ireland
Professor M Harmer (Chairman)
Dr J Chestnut
Dr I Wilson
Dr D Saunders (Sick Doctors Scheme)
Royal College of Anaesthetists
Sir Peter Simpson
Dr A-M Rollin
Dr J Curran
Dr A Lim
Professor D J Hatch (Professional Standards Advisor)
Mrs A Murray (Patient Liaison Group)
Mr C McLaughlan (Professional Standards Director)
Regional Adviser
Dr J Clarke
Lead Postgraduate Dean
Professor S Field
National Clinical Assessment Service
Professor A Scotland
British Pain Society
Dr B Collett
Intensive Care Society
Professor M Mythen

The Royal College of Anaesthetists
Churchill House 35 Red Lion Square London WC1R 4SG
tel: 020 7092 1500 fax: 020 7092 1730
email: info@roca.ac.uk web: www.rcoa.ac.uk
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place London W1B 1PY
tel: 020 7631 1650 fax: 020 7631 4352
email: info@aagbi.org web: www.aagbi.org
Design and layout by The Royal College of Anaesthetists
© Royal College of Anaesthetists and Association of
Anaesthetists of Great Britain and Ireland.
This Guidance may, however, be freely reproduced for
teaching purposes.
October 2006.
The document will be reviewed in 2009.

Contents
Foreword 5
Summary 6
Chapters
1 Introduction and background 7
2 The ethical framework 15
3 Duty of care for anaesthetists 18
4 Professional and clinical guidelines 21
5 Audit: setting, monitoring and reviewing standards 22
6 Continuing professional development 27
7 Record keeping 30
8 Leadership, management and administration 33
9 The poorly performing anaesthetist 37
References 44
Bibliography of current guidance from 46
central organisations
Appendix 1: core topics 49

Good Practice Guide 2006
Foreword
All doctors practising anaesthesia, critical care and pain management have a primary duty to
provide the best care of patients that they can, whether they practise as consultants, nonconsultant
career grade doctors or trainees, and whether in the National Health Service or
in the independent sector.
The stimulus for the first edition (1998) of this document Good Practice – A Guide for
Departments of Anaesthesia came from a meeting convened in April 1997 by the Chief
Medical Officer (England), Sir Kenneth Calman, at which all acute clinical services were urged
to produce benchmarks of good practice for their specialty.
The Royal College of Anaesthetists (the College) and the Association of Anaesthetists of
Great Britain and Ireland (the Association) set up a joint working party to address this issue.
The working party’s remit was:
❚
❚
❚
to collate current agreed guidelines and standards which specify good practice
to consider how these guidelines and standards could be applied at individual
departmental and national level to ensure patient safety
to offer guidance on the identification and management of poorly performing anaesthetists.
The first edition of the Good Practice document brought together advice, recommendations
and information which reviewed the basis of good practice in anaesthesia, critical care and pain
management. It also summarised the methods by which the medical profession was regulated
and gave guidance to anaesthetists and anaesthetic departments about how departments
could set, maintain and monitor standards of good practice within a changing environment.
The importance of corporate ownership of standards within a department and local regulation
of good practice was emphasised. The document set down as requested the benchmarks
for anaesthetic practice in the context of the many changes which marked the end of the last
Millennium. It was welcomed in both anaesthetic and wider medical circles.
Subsequently, the Association and the College set up a Joint Committee on Good Practice to
develop and advise on some of the themes in the Good Practice document. Many of the
initiatives of the late 1990s have evolved to such an extent that it became clear that the Good
Practice document would require regular review and updating. Such occurred in 2002 with
updating of regulatory issues and reflection of best current practice.
This, the third edition of the Good Practice Guide, is the result of further review and updating
of the previous documents to provide appropriate and current advice on the various aspects
that constitute good practice. Further guidance pertaining to pain management is under
development by the British Pain Society.
We, the Presidents of the Royal College of Anaesthetists and the Association of Anaesthetists
of Great Britain and Ireland, commend this guidance to all involved in anaesthesia, critical
care and pain management.
Dr David Whitaker,
President, Association of Anaesthetists
of Great Britain and Ireland
Dr Judith Hulf,
President,
Royal College of Anaesthetists

Good Practice Guide 2006
Summary
The way in which medicine is practised and the social and political environment in which doctors’
work have changed dramatically in recent years. Recent developments in the provision of NHS
care within the independent sector have again raised concerns over standards of practice.
From early in 2007 anaesthetists and patients will increasingly encounter the new nonmedically
qualified member of the anaesthesia team – the anaesthesia practitioner (AP).
Three phases of recruitment and training are under way for APs in partnership with hospitals
and universities in England, Scotland and Northern Ireland. The Phase 1 students will
qualify to practise on successful completion of 27 months of training and shortly after the
publication of this document. Working under the direct supervision of an anaesthetist, the
AP will be initially indemnified under local arrangements; however, following a period on a
voluntary register held by the College, all aspects of registration for the AP will be taken on
by a national regulator, most likely to be the Health Professions Council. The AP programme,
initiated by the Department of Health (DH) and endorsed by the College and the Association,
is the only one in the United Kingdom (UK) which has been formally accepted by patients and
anaesthetists as safe and appropriate.
Anaesthetists in the UK have an excellent record of adapting to these changes while
maintaining very high standards of patient care. However, concerns have been expressed
by Government, public bodies and the media about the continuing ability of doctors to
regulate themselves. These concerns will only be allayed as doctors demonstrate clearly
their ability to maintain high standards throughout the NHS. Indeed, quality of care has
become the centrepiece of the Government’s approach, though at the same time there is
now acknowledgement that chronic underfunding has contributed to many of the problems
in the NHS. There is a major challenge to ensure that, as funding improves, standards are
maintained and best use is made of such funding.
This third edition of Good Practice – A guide for departments of anaesthesia, critical
care and pain management, updates information and sets out the standards which the
Association of Anaesthetists and the Royal College of Anaesthetists believe should characterise
the delivery of anaesthetic services. It is vital that departments of anaesthesia and individual
anaesthetists continue to provide a high quality service and care for patients. It is the wish
of the Councils of the College and the Association that departments audit their practice and
delivery of anaesthetic services against the benchmarks in this Good Practice document.
Where departments do so, standards of practice will be maintained, anaesthetists will
continue to develop their knowledge and skills and the likelihood of poor practice will be
greatly reduced.

Good Practice Guide 2006
Chapter 1: Introduction and background
The organisational changes in medicine and in the way it is practised continue at an
alarming rate. Against a background of raised public expectations of both the National
Health Service and of individual doctors, and in a climate of blame and litigation, the
problems within medical practice seem to have increased rather than receded. At
the very least, the changes and recommendations initiated in 1998 have reinforced a
greater awareness among all doctors of the wide responsibilities they carry for their
patients, and the demands on them to demonstrate that their knowledge, skills and
attitudes are being continually updated and critically assessed.
1.1 Contemporary issues 1–5
Recent years have not only seen major changes in medicine due to scientific advances
and technological developments but also changes in the social context within which
doctors work. In the latter half of the 20th Century, the culture of paternalism on the
one hand and deference on the other, rightly, largely disappeared. The population
in general and patients in particular have become better informed about health
matters and decisions about their healthcare. Doctors have accepted that they and
their patients are partners and they now practise in this climate of better patient
knowledge and of co-operation. Simultaneously, time medical practice takes place
within a political and economic framework over which the medical profession has little
control, but in which it is expected by both politicians and patients to make the system
work efficiently and effectively.
Increasingly in the last few years, doubts have been expressed about the ability of
the medical profession to set and maintain standards of practice and to deal with
those whose knowledge, skills and attitudes are deficient. Every case of alleged poor
performance, whether in clinical practice, professional conduct or personal ethics,
serves to reinforce that perceived view. Despite the many changes in management
and the systems in which doctors work, professionally led regulation of the medical
profession is still accepted as the ultimate method for dealing with matters of poor
performance, though deficiencies in the robustness of this have been challenged by
Dame Janet Smith in her report of the Shipman Enquiry. The basis for this system is that
medicine involves knowledge, skills and attitudes which those without a medical training
or specific training cannot adequately evaluate and regulate. On the other hand, the
importance of the perspective provided by a strong non-medical input is now widely
recognised. The maintenance of professionally led regulation can only be expected
to remain extant if the overall performance of doctors is seen and agreed to be of a
consistently acceptable standard and if the profession deals promptly and effectively
with those of its membership who fall below such a standard. It is right, therefore, that
Government, the DH, the profession, the media and the public should continue to take
steps to ensure the reinforcement of the regulatory process.

Good Practice Guide 2006
The key questions are:
How do doctors set standards?
How do doctors maintain standards?
How are these standards revised when necessary?
How does the profession ensure compliance with these standards?
How does the profession publicly demonstrate this is taking place?
This Guide for anaesthetists and departments of anaesthesia, critical care and
pain management addresses these questions within the framework of the General
Medical Council’s document Good Medical Practice. 6 The relevant paragraphs
from the document are indicated in italics.
Throughout this document, the terms ‘anaesthetist’ and ‘anaesthetic practice’
are used to refer to all anaesthetists involved in clinical anaesthesia and
perioperative care, in critical care, in acute and chronic pain management, and
in obstetric care.
1.2 The traditional system of regulation
Since the Medical Act of 1858 which set up the General Medical Council (GMC), a
complex set of arrangements has developed for professional regulation. These
consist of:
The General Medical Council (GMC)
The Postgraduate Medical Education Board (PMETB)
The Medical Royal Colleges and their Faculties
National professional organisations
Contracts of employment
The GMC sets the framework within which UK medical schools undertake basic medical
training. It is required to include on the Medical Register all whom the universities
deem qualified. From the outset the GMC has had powers to remove from the Register
those whom it finds guilty of serious professional misconduct and subsequently to
restrict, supervise or suspend the practice of doctors whose health or performance
may place patients at risk.
PMETB sets the generic principles, standards and outcomes, onto which individual
specialties map their training and assessment programmes. Standards of practice
within the medical specialties are regulated by the Royal Colleges in so far as they set
up training programmes and examinations under PMETB, establish the requirements
for the recognition of training departments and lay down criteria for appointment to
consultant posts. Hitherto, their regulatory powers have been confined to training and
have not included the activities of consultants. This is gradually changing, especially
in the areas of continuing education and professional development and increasingly
in the development of criteria for revalidation.

Good Practice Guide 2006
A further part of setting and maintaining standards is the ‘guidance’ which the
Colleges and professional associations issue about clinical care and the safe provision
of services. The Association has been particularly active in this field over the past
two decades and has issued guidance on a wide range of subjects. While these
documents are without statutory authority they have, together with guidance from
the College and other groups, and with the support of the body of the specialty,
become the benchmarks by which doctors involved in anaesthesia are expected to
practise. They also set out the requirements which purchasers and providers need
to meet to enable anaesthetists to deliver high quality services. These activities
of the College, the Association and other specialist bodies are supported by their
educational programmes.
In addition to all these initiatives, doctors are subject to a range of legislation and
to their contracts of employment with the accompanying disciplinary procedures.
Individual Trusts are required to work under NHS employment guidelines, which
include all aspects of their clinical duties, including local performance assessment.
They are also influenced by the activities of the civil courts and by the demands of
their own defence societies.
During the early 1990s, in response to increasing concerns about the profession’s ability
to set and monitor standards and demonstrate that they were adhered to, the profession
initiated further regulatory developments. In 1995, there was a national conference on
the core values of medicine 7 and the Royal Colleges also introduced continuing medical
education for consultants. If individuals failed to meet the prescribed targets, they
might no longer be able to teach and supervise trainees. If a department failed to meet
them, recognition for training would be at risk. Requirements for continuing medical
education for non-consultant career grades were also introduced. In April 2000, the
Royal College of Anaesthetists issued a revised scheme for Continuing Professional
Development (CPD). The College believes it is a professional necessity for all career
grade anaesthetists to take part in CPD. This includes those who are full-time or parttime,
those who are locum anaesthetists, those engaged wholly in independent practice
and those affiliated to non-UK Colleges or Faculties.
The organisation of programmes of CPD is expected to make a major contribution
to the standards of practice. In addition, the College incorporated into CPD the list
of core topics; these are topics in which an individual specialist working in a typical
hospital and participating in the emergency on-call rota should have up-to-date
knowledge and proficiency.
The GMC and PMETB together have a statutory responsibility to co-ordinate all phases
of medical education, a responsibility which in the past it has discharged in relation
to undergraduate and postgraduate education up until entry into the career grades.
In future it will also, through its CPD board working in close collaboration with the
Medical Royal Colleges and others, co-ordinate CPD for all career grade doctors. It
is clearly essential that CPD schemes meet the criteria required for revalidation. This
attests to the importance with which these activities are regarded.

10 Good Practice Guide 2006
1.3 Recent developments in regulation
1.3.1 The General Medical Council
1.3.1.1 Medical Act 1995
In July 1997, the GMC’s new procedures for assessing the performance of doctors
under the 1995 Medical (Professional Performance) Act, 8 came into force. These
procedures enable the GMC to assess formally a doctor’s clinical and professional
performance, including tests of knowledge and skills where there is reason to believe
that these may be seriously deficient.
The GMC has powers to require doctors to undergo further training, to restrict their
practice or to suspend them from practice, initially for a limited period but indefinitely
if deficiencies are not remedied. The boundaries between these procedures and the
NHS complaints and disciplinary procedures and the criteria for referral to the GMC
are set out in the GMC document, Maintaining Good Medical Practice. 9
1.3.1.2 Revalidation
The GMC has also initiated changes which will result in all doctors having to undergo a
process of revalidation, in order to maintain their licence to practise. Although this was
planned to commence in 2004, its start has been delayed pending a review by the CMO,
following publication of the Shipman report. The appraisal system will form the basis of
the process for most doctors and there will also be a major lay input into the assessment of
doctors for revalidation. Individual specialties will have a major involvement in setting the
standards by which doctors are judged. It seems likely that several different elements will
contribute to the process including regular satisfactory appraisals which must incorporate
the development and fulfilment of a personal development plan and verified evidence of
personal performance, which will vary between specialties. This could include personal
audit, multi-professional feedback (360 o ) or evidence from hospital performance figures.
The final element will be a positive sign-off by the employer that there are no causes for
concern. The Academy of Medical Royal Colleges has been working to try to develop
systems which will be equable across specialties and throughout the whole country.
1.3.2 Government 10
The governmental initiatives outlined below refer to England. Equivalent bodies
are present or are being set up in Scotland, Wales and Northern Ireland.
1.3.2.1 White Paper
The White Paper, The New NHS, 10 published in December 1997, made it clear that
practitioners must accept responsibility for developing and maintaining standards within
their local NHS organisations. Self-regulation was strengthened and extended into the
local clinical community. Chief executives are now held accountable for the quality of
the services provided by their Trust. Through clinical governance and the appraisal
system, chief executives have been provided with the tools whereby they should be able
to encourage medical practitioners to keep their skills up to date and should have an
early warning of impending problems and the means to rectify them. The quality of local
clinical services is now overseen by the Healthcare Commission with statutory powers to
ensure that local systems are in place to monitor and improve quality.

Good Practice Guide 2006 11
1.3.2.2 The National Clinical Assessment Service (NCAS) (formerly Authority) 11
In April 2001, the National Clinical Assessment Authority (NCAA) was established and
represents part of the Government’s commitment to quality assurance in the health
service. In April 2005, following the Arm’s Length Bodies Review, the NCAA became
part of the National Patient Safety Agency (NPSA), changing its name to the National
Clinical Assessment Service (NCAS).
NCAS provides a service to NHS organisations and organisations that provide healthcare
services to the NHS, as well as to doctors and dentists themselves, aimed at helping
them tackle performance problems at an early stage, earlier than is current practice.
One of its key aims is to help avoid the inappropriate use of suspension or exclusion,
which was so often the case in the past, causing great damage to services and to doctors
themselves. Concerns about a doctor’s performance should be tackled locally and
problems hopefully resolved. If not, doctors can be referred to NCAS which can provide
a range of advice, support and assessment services which are aimed at recommending
how to proceed. It may suggest a range of possible options, for example, that the doctor
should return to work, should have a period of retraining organised and implemented
through the postgraduate dean, or perhaps should be referred to the GMC. It will be
the responsibility of the Health Authority or Trust to implement any recommendations.
NCAS now has more than five years of experience in this work, and evaluation of its work
has shown evidence of earlier resolution of even complex and challenging cases and
of substantial reductions in inappropriate use of suspension and exclusion. Evaluation
reports are available from the NCAS website at: www.ncas.npsa.nhs.uk or directly from
them by email: ncas@ncas.npsa.nhs.uk.
The College has been working closely with the Association of Anaesthetists and NCAS
to develop a portfolio of documents to advise over issues of poor performance. This
has been achieved under the umbrella of the Joint Committee on Good Practice. It is
hoped that, wherever possible, NCAS and the Joint Committee can work together so
that, effectively, there is a single point of contact for all concerns. It is often difficult
to discover initially whether the perceived problems are with the system, an individual
or a group of clinicians. The documents available include advice to Trusts, advice
to College/NCAS visitors and advice on retraining, and, for individual referral, the
confidential ‘sick doctor’ scheme still operates.
The Government expects the profession to deliver a uniformly high standard of practice
throughout the NHS and will continue to look to individual healthcare professionals to
be responsible for the quality of their clinical practice.
1.3.2.3 The National Patient Safety Agency (NPSA) 12
The NPSA was established in September 2001 with the remit to identify errors in the process
of patient care and enable such errors to be reduced in a blame free environment. In this
regard the College Critical Incident Reporting System has been adopted in full with minor
modifications for use by the agency. The results obtained from this anonymous reporting
will be collected from all NHS hospitals and will be used to reduce risks to patients.

12 Good Practice Guide 2006
1.3.3 The Academy of Medical Royal Colleges (AoMRC)
The Academy of Medical Royal Colleges is a common forum for College representatives
to meet to discuss items of mutual interest and from which a common voice can be
formulated to negotiate with Government, the GMC and other bodies. It does not
devalue the status of the individual Colleges but allows a stronger position to be
adopted in areas of common interest.
1.3.4 The Postgraduate Medical Education and Training Board (PMETB)
PMETB is a regulatory authority which has replaced both the Specialist Training Authority
(STA) and the Joint Committee for Postgraduate Training in General Practice (JCPTGP). It
is independent of the Department of Health and answers to the Secretary of State. It
launched in September 2005 and is charged with quality assuring all aspects of medical
education, training and assessment, ensuring that programmes and curricula are fit for
purpose, and appropriately validated. It will be responsible for delivering all aspects
of Modernising Medical Careers, though responsibility for Foundation training, and
particularly the first pre-registration year, will be shared with the GMC.
1.3.5 The British Medical Association (BMA)
The BMA represents the whole medical profession, is the interface between doctors,
their employers and the public and can exercise an overview of the different specialties.
It takes on board the terms and conditions of service and speaks for the profession
in discussions of remuneration and in disputes, and in how the NHS can best provide
a comprehensive service for all patients.
1.4 Local standard setting and regulation 13
The culture in which doctors work is still often not conducive to the admission of deficiencies,
which tend to be regarded as a sign of weakness, and ignored or covered up. There are
gaps between central guidance, regulation and the individual doctor. The introduction of
annual appraisal from April 2001, as a contractual obligation, has emphasised the need for
the regular and constructive review of the way in which the employee is keeping up to date
with the developments in theoretical knowledge, with the preservation of practical skills and
with the retention of appropriate attitudes. It is expected that the appraisal process will be
informed from a number of sources, representative of all the areas in which the individual
doctor works, including the private sector. Appraisal is designed to be a constructive nonconfrontational
developmental process. As well as the responsibility of individual doctors
for their own professional development, it is also necessary for the sense of corporate
responsibility to be further developed within departments. This need is highlighted by the
changes which have taken place in the way in which medicine has been practised during
the past decade, the main features of which are as follows.
1.4.1 Team working
It has become unusual for doctors to work as isolated individuals; in hospital practice,
they are usually members of departments which provide a service. This has long been
the model in anaesthesia. On a different level, doctors also function as members of
multidisciplinary healthcare teams. While they are commonly the leaders of clinical
teams, their ability to care for patients depends vitally on the skills of other doctors

Good Practice Guide 2006 13
and healthcare professionals. In such cases, the details of an individual anaesthetist’s
practice may be little known to colleagues in the same department.
1.4.2 Continuity of care
Doctors have increasing concerns about the quality of their lives apart from their
work. This has been particularly reflected in the reduction in working hours of
trainees. Consultants, while theoretically having continuous responsibility for patients
under their care, frequently hand this over to an on-call colleague at night and at
weekends. This issue is dealt with in more detail in Chapter 3.
1.4.3 Management
The NHS has a complex management system which often defines the limits of what
doctors can do. Many clinicians are involved in healthcare management as clinical
leads, clinical directors and medical directors. It is important that those undertaking
these roles are properly trained and resourced in terms of time free from other
clinical responsibilities.
1.4.4 Complaints
When a patient complains it is because of dissatisfaction with some aspect of their
care which may range from an administrative error to dissatisfaction with their clinical
management. At the same time, expectations have increased and patients’ tolerances
have decreased. Not all mistakes result in a complaint and not all complaints are
because of a mistake. The management of complaints must focus firstly on complaints
avoidance by ensuring that systems are in place so that problems are minimised.
The Clinical Negligence Scheme for Trusts (CNST) 14 allows Trusts to target areas of
repeated adverse events. Complaints are often multifaceted but good communication
with patients will often defuse potentially difficult situations and minimise the causes
for complaint. For this to develop in a constructive manner there is need for a culture
of openness. Where local action fails to resolve a complaint then an independent
review panel can be convened. Complaints are now a fact of working life and the best
way to minimise their impact is to deal with them quickly, fairly and openly.
These changes have major implications for the organisation of medical work and the
provision of patient care. They also emphasise the need for local, corporate regulation.
The former President of the GMC, Sir Donald Irvine, has summarised professional
regulation and standard setting in the following way:
Figure 1 Routes of accountability
Individual doctors Clinical team National bodies
➠
Personal standards
➠
➠
Local collective standards
➠
➠
National professional
standards
➠
Self-assessment Local audit External review

14 Good Practice Guide 2006
The key to the effective working of these arrangements is to be found at a local level.
Anaesthetists are used to working as members of a department, and teamworking
is usually accepted from an early stage of an anaesthetist’s career. The
corporate standards and ethos of departments of anaesthesia, critical care and pain
management provide the most effective way of ensuring high standards of patient
care, preventing any decline in an individual’s performance and recognising when a
deterioration occurs.
Several requirements are essential for departments to work in this way. These include:
❚
❚
❚
an effective and constructive system of appraisal
an agreed system of continuing medical education and professional development
methods of dealing sensitively and effectively with those anaesthetists whose
clinical and professional standards fall below an acceptable level.
At a national level, there are a series of initiatives to allow for the development of
national standards and monitoring of such standards. Figure 2 gives a diagrammatic
summary of some of the mechanisms involved in the setting, delivery and monitoring
of these standards. The National Institute for Health and Clinical Excellence and
the different National Service Frameworks are designed to give national standards
of service. Professional Self-Regulation and Clinical Governance allied to Life Long
Learning are designed to give dependable local delivery. In England the process
is monitored by the Healthcare Commission, the National Performance Framework
and National Patient and Users Surveys. Equivalent bodies and procedures are
operational or planned in Scotland, Wales and Northern Ireland.
Figure 2 Standards – setting, delivering, monitoring
➠
National Institute for Health and
Clinical Excellence
National Service Frameworks
➠
Clear standards of service
➠
Professional Self-Regulation
Clinical Governance
Life Long Learning
➠
Dependable local delivery
➠
Healthcare Commission
National Performance Framework
National Patient and Users Surveys
➠
Monitored standards
The Association and the College believe that where anaesthetists corporately take the
responsibility in the light of agreed advice for setting local standards and complying
with them there will be:
❚
❚
❚
a high level of professional satisfaction within departments
continuously rising standards of perioperative care for patients
considerable influence exerted throughout the hospital.

Good Practice Guide 2006 15
6, 15–18
Chapter 2: The ethical framework
The apparently straightforward relationship of mutual Trust and respect between
doctors and patients has been complicated by changes, summarised in the
introduction, which have taken place in both medicine and society in recent years.
Various groups and individuals have developed an ethical framework which sets out
what is required of doctors if they are to merit and retain the Trust of patients and
the public. The ethical framework within which anaesthetists should practise may be
summarised under four main headings:
❚
❚
❚
❚
Professional competence.
Professional relationships with patients and colleagues.
Public duties.
Probity.
2.1 Professional competence
In providing care you must recognise and work within the limits of your
competence.
A doctor’s first duty is to work for the benefit of patients. This requires a detailed,
up-to-date knowledge of the particular area in which the doctor works together with
proficiency in the skills which practice in that area requires. The time has passed
when the basic medical undergraduate training and subsequent specialist training
equipped those in anaesthesia, critical care and pain management with the knowledge
and skills for a career-long practice of high standard. The rate at which advances are
made in all aspects of the care of patients is so great that every anaesthetist needs to
be involved in a programme of continuing education and training at local and national
level. With such a rapid rate of change, anaesthetists will develop particular areas of
expertise which should be available to colleagues within a department.
However, while the benefits of modern peri-operative care are obvious, most
anaesthetic procedures carry some risk of harm to patients. Audit of both individual
practice and the service provided by a department is essential if these risks are to be
minimised and benefits maximised.
2.2 Professional relationships
2.2.1 With patients 19–20
Patients must be able to trust doctors with their lives and health.
Having an anaesthetic, an admission to critical care or the requirement for pain
management are often parts of the peri-operative care about which patients are the
most anxious. The degree of trust and confidence patients have in their anaesthetist
is crucially dependent on the relationship the anaesthetist establishes with them.
Courtesy is the essential prerequisite. It is also important to give a clear explanation
of what the anaesthetic and peri-operative care involve in language which the patients

16 Good Practice Guide 2006
can understand. Patients’ concerns and anxieties should be listened to, their questions
answered and information should be given to enable them to face the operative and
peri-operative care with confidence. The anaesthetist should also ensure that the
patient understands and has signed the appropriate consent form for the procedure
to be undertaken. Often written information can be helpful, particularly for same day
admissions and day case surgery where the pre-operative visit by the anaesthetist
may of necessity be brief. 21 A collection of leaflets on anaesthesia and anaesthetic
risk are available from the College for this purpose. Care by the anaesthetist should
never be prejudiced by a patient’s gender, age, culture, background, education, race
or life style. Interpreters should be available and consideration should be given to the
production of appropriate translated written material. It is not best practice to rely on
the patient’s family for interpreting facilities.
Patients in pain management clinics may also display a variety of concerns and emotions.
Empathetic handling of these patients is essential for a mutually successful outcome.
Chaperones should be routinely available for outpatient consultations and examinations.
If a mistake is made or a complication occurs during the course of a patient’s perioperative
care which affects outcome or may have implications for a future anaesthetic, it must
be discussed openly and honestly with the patient and where appropriate with relatives.
This discussion should be recorded in the patient’s notes.
2.2.2 With colleagues
Para 41: Most doctors work in teams with colleagues from other professions.
You must:
❚
❚
respect the skills and contributions of your colleagues
communicate effectively with colleagues within and outside the team.
Anaesthetists working in the NHS necessarily work as members of departments of
anaesthesia, critical care and pain management. In the provision of peri-operative care,
obstetrics, critical care and pain management they work with other doctors and health
professionals. The ability to work harmoniously in departments and teams is essential if
patients are to be cared for properly. Anaesthetists will often take the lead in decision making,
and robust debate within departments and with other groups is an essential component
in providing a high quality anaesthetic service. However, there is no place in modern
departments of anaesthesia for individuals who pursue their clinical practice and style of
personal conduct irrespective of the views and wishes of their colleagues. Professional
independence is important and variety is healthy, both in clinical practice and personal
style, but the limits of acceptable behaviour must be recognised by all concerned.
2.3 Public duties
Like other doctors, anaesthetists practise in a service with limited resources. While
these resources could be significantly increased if there was the political will to do so,
there is still debate whether it is possible to fund from public sources all that medicine
can do. As members of society, therefore, anaesthetists have a duty to see that public

Good Practice Guide 2006 17
2.4 Probity
funds are used responsibly. If this is to be reconciled with the duty to bring benefit to
individual patients, anaesthetists must base their clinical practice on the best available
evidence and run their departments efficiently.
If factors in the working environment are threatening the safety of patients,
anaesthetists have an ethical duty to take appropriate action. This may mean declining
to provide certain types of anaesthetic care, critical care and pain management until
the deficiencies have been rectified.
As responsible members of society, doctors should be honest in their financial
dealings, in their approach to patients and in all matters involved with their work, their
teaching responsibilities and in research. An anaesthetist’s contract of employment
and job plan set out the contractual obligation to the employer. Failure to meet these
obligations is a disciplinary offence.
While, in employment terms, NHS and independent practice are separate, in professional
terms they are often closely related. Anaesthetists are largely dependent on surgeons
for their access to independent practice and the possibility exists for this relationship
to compromise an anaesthetist’s independence. One way of preventing this is by NHS
anaesthetists organising themselves in clinical groupings to optimise patient care and
auditing their independent sector work in the same way that they audit their NHS work.
2.5 Research
2.6 Health
Research is vital in improving care for present and future patients. Doctors involved in
research have an ethical duty to show respect for human life and people’s autonomy.
It is essential that there is a partnership between the participants and the healthcare
team, based on trust. There must be respect for the patients’ and volunteers’ rights
to make decisions about their involvement, their privacy and dignity, and at all times
they must be treated with politeness and consideration. 22
The GMC 6 has issued guidance to doctors on what measures to take to protect
themselves and others, including patients, from infection by serious communicable
diseases such as hepatitis B. 23
It includes guidance on what to do if a healthcare worker suffers a needlestick injury,
and how to implement appropriate infection control measures. Those involved
in ‘exposure prone procedures’ may have to modify their professional practice.
Anaesthetists, however, are seldom involved in these procedures, described by the DH
as ‘those where the risk that injury to the healthcare worker could result in exposure
of the patient’s open tissues to the blood of the healthcare worker’.
It is equally important for departments and Trusts to have in place mechanisms to
support colleagues during periods of illness or following a clinical catastrophe. 24

18 Good Practice Guide 2006
Chapter 3: Duty of care for anaesthetists
The nature of anaesthetic practice means that most anaesthetists have a varying work
pattern with duties performed in several sites within both the public and independent
sectors. This diversity of activity means that an anaesthetist may be involved in
the care of patients in a variety of sites for a variety of durations. Concerns have
been raised as to the responsibility of the anaesthetist in the on going care that has
followed the anaesthetic intervention.
It is important to remember that, just like any other doctor, an anaesthetist has a
recognised ‘duty of care’ to patients. The term ‘duty of care’ is a legal phrase defining
whether a doctor (or other healthcare worker) can be held to be responsible for the care
of an individual patient. However, it may be more helpful to try to look at the issue more
from the GMC’s approach to doctors’ responsibilities than from a legal one.
Levels of responsibility vary. At times an anaesthetist will:
a
b
have a responsibility to be physically present with the patient, such as whilst
administering a general anaesthetic. If in exceptional circumstances the
anaesthetist has to leave the patient they must delegate responsibility to another
appropriate person in line with GMC guidance on delegation: 6
Para 54: ‘When you delegate care or treatment you must be satisfied
that the person to whom you delegate has the qualifications, experience,
knowledge and skills to provide the care or treatment involved. You
must always pass on enough information about the patient and
the treatment they need. You will still be responsible for the overall
management of the patient.’’
share responsibility with other healthcare professionals, being available for advice and
help such as during the postoperative recovery period. The nature and intensity of such
help will vary from the immediate postoperative recovery period until the end of the
‘episode of care’, whenever that happens to be. The GMC also gives guidance on this:
Para 41: ‘Healthcare is increasingly provided by multi-disciplinary
teams. Working in teams does not change your personal accountability
for your professional conduct and the care you provide’.
Para 50: ‘Sharing information with other healthcare professionals is
important for safe and effective patient care.’
c be asked to provide care when not on duty. Anaesthetists also have a responsibility
to ensure that satisfactory arrangements for the delivery of care are in place to
cover periods when they are not available. In the NHS, this is usually assured by
the ‘on-call’ system and other local departmental arrangements, but this is not
always the case in the independent sector. In the past surgeons have fallen foul of
the GMC for not making proper arrangements to deal with emergency postoperative
complications arising when they are not available; there is no theoretical reason why
anaesthetists should be treated differently.

Good Practice Guide 2006 19
Para 48: ‘You must be satisfied that, when you are off duty, suitable
arrangements have been made for your patients’ medical care. These
arrangements should include effective hand-over procedures involving
clear communication with healthcare colleagues.’
The GMC guidelines cited above are of necessity written in generic terms and include
the concept of ‘an episode of care’ without defining the precise meaning of the term.
For a surgeon or a physician, that ‘episode of care’ might reasonably relate to a
period of time in hospital or a specific consultation. The situation for anaesthetists
is less clear as the ‘episode of care’ could be interpreted as ranging from just the
period of anaesthesia, through to the complete duration of hospital confinement. For
anaesthetists practising invasive pain management, the ‘period of care’ could even
extend to include the complete period of treatment (possibly lasting years).
Notwithstanding the fundamental principles of a ‘duty of care’ but to provide some
clarification of the situation, the following are suggestions to quantify the term ‘episode of
care’ within the variability of activities undertaken by anaesthetists. They are constructed
on the basis of the extent of any intervention or the duration of action of medications
administered in the course of anaesthesia and postoperative management.
1
2
Outpatient consultation (including pre-assessment)
The episode of care ends when the patient leaves the consulting room. In
the case of repeated consultations such as for chronic pain management, the
cessation of a particular episode of care does not mean that there is not an on
going general duty of care to the patient particularly if a course of treatment has
followed that consultation.
Day case surgery
For the majority of day case surgical patients, the episode of care lasts from
the initial pre-operative visit on the day of surgery through to discharge from
hospital. Should the patient require admission as a result of an anaesthetic
incident, the episode of care shall extend until the patient has fully recovered
from the effects of that incident or the care of the patient has been transferred
to another person. Should admission be as a consequence of the surgical
procedure, the episode of care for the anaesthetist will cease as for a standard
in-patient (see below).
3 Inpatient anaesthesia
There is a wide range of anaesthetic involvement in patients admitted for a
variety of surgical procedures. For all cases, the principle should be that the
episode of care extends from the initial pre-operative visit through to the
cessation of the effect of drugs administered during and immediately following
the anaesthetic. In the case of opioid analgesic drugs administered as part of
the anaesthetic, the episode of care related to that drug shall cease with the
administration of subsequent analgesic medication (i.e. it has worn off). In the
case of local or regional anaesthesia, the episode of care shall end with the
recovery of normal sensation and muscle power.

20 Good Practice Guide 2006
4
The postoperative prescription of drugs does not in itself imply a continuing
‘episode of care’ as long as there is a clear line of responsibility for the care of
the patient relevant to drugs prescribed (e.g. for patient-controlled analgesia,
there is a protocol involving follow up by an acute pain service, or equivalent).
Use of neuraxial blockade for postoperative analgesia
The principle should be that the duty of care shall continue until such time as
the effect of the intervention ceases. In the case of intrathecally-administered
opioids, that would be the need for additional analgesic medication. For epidural
analgesia, the episode of care would cease with the removal of the epidural and
the recovery of normal sensation and motor power.
5 Implanted drug-delivery systems
These may be used for chronic pain management. In this instance, the
‘implanting’ physician retains responsibility until the device is removed. This
implies a long-term responsibility but the care can be shared with others (on-call
availability for any problems) or transferred to others (transfer of care back to
the original referring physician).
In the case of any complication of anaesthesia or analgesia, the anaesthetist shall
retain responsibility for the patient until such time as that care is transferred to
someone else.
In the event of circumstances preventing the anaesthetist from being available throughout
an episode of care (e.g. booked annual leave on the day following major surgery and
use of epidural analgesia), it is the duty of the anaesthetist to ensure that appropriate
support and monitoring are available for the patient. This may be in the form of transfer
of care to a colleague or through a mechanism such as an acute pain service.
The anaesthetist does not have a requirement to provide care beyond the end of the
‘episode of care’ but it would be seen as good practice to retain an interest in the on
going progress of any patient with whom there has been professional involvement.

Good Practice Guide 2006 21
Chapter 4: Professional and clinical
guidelines
Over the last 20 years, guidelines published by the College, the Association and other
specialist organisations have played a key part in developing and maintaining high
standards of anaesthetic care in the UK. Modern peri-operative care is complex; it is
provided by many different anaesthetists working with other doctors and healthcare
professionals. Wards are increasingly busy and are often short of staff, and staff of all
disciplines looking after patients change frequently during each 24-hour period. There
is, therefore, very considerable potential for mistakes to be made.
It is widely accepted that the practice of individual anaesthetists may vary where
evidence supports a range of different techniques. However, under certain
circumstances and in those areas where the patient is not being immediately and
personally supervised by the anaesthetist, such as in the recovery room, high
standards of care are more likely to be maintained if there are agreed guidelines
within a department and hospital. Where such guidelines have been agreed by
members of a department, they should normally be adhered to.
Guidelines are particularly appropriate where:
A problem is life threatening:
For example – management of the difficult airway
– cardiopulmonary resuscitation
– management of massive bleeding
– acute hypersensitivity (anaphylaxis)
A problem is unusual:
For example – abnormal haemoglobins
– malignant hyperthermia
A problem is routine but is managed by different people in different
wards and departments:
For example – blood ordering schedule
– postoperative pain relief
– day case anaesthesia
– peri-operative management of diabetes
– endocarditis prophylaxis
– pre-operative investigation
– pre-operative starvation
In many areas national guidelines are available which may need to be amended
according to local circumstances. In other areas, notably in the way particular
services are provided, local guidelines are often necessary. These should be based
on available evidence and audited, reviewed and revised regularly.

22 Good Practice Guide 2006
Chapter 5: Audit: setting, monitoring and
reviewing standards
Para 14: ‘You must work with colleagues and patients to maintain and
improve the quality of your work and promote patient safety. In particular
you must:
❚
❚
❚
❚
❚
❚
❚
❚
maintain a folder of information and evidence, drawn from your
medical practice
reflect regularly on your standards of medical practice in accordance
with GMC guidance on licensing and revalidation
take part in regular and systematic audit
take part in systems of quality assurance and quality improvement
respond constructively to the outcome of audit, appraisals and
performance reviews, undertaking further training where necessary
help to resolve uncertainties about the effects of treatment
contribute to confidential enquiries and adverse event recognition and
reporting, to help reduce risk to patients
report suspected adverse drug reactions in accordance with the relevant
reporting scheme.’
Clinical audit is a quality improvement process which seeks to improve patient care and
outcomes through systematic review against explicit criteria leading to implementation
of change if required. 25 It is a key component of clinical governance. Regular
review by departments of anaesthesia of what anaesthetists do and how they do it
is essential for maintaining high standards of practice. Audit became a contractual
obligation for doctors in the early 1990s. The GMC considers it to be part of good
practice. 6 The Government White Paper, The New NHS, 26 places great emphasis
on clinical governance and ‘measuring progress’ in six areas: health improvement;
fair access to services; effective delivery of appropriate healthcare; efficiency; the
experience of patients and their carers; and health outcomes of NHS care. The White
Paper also puts in place clear alternative regulatory mechanisms which will be used if
the profession fails to regulate itself effectively. At the time of publication, the review
Good Doctors, Safer Patients was still in consultation.
In order to assist departments in developing appropriate audit programmes, the
College has produced an anaesthetic audit recipe book, Raising the Standard. 27
This document, which is regularly updated, should act as a catalyst to promote local
departmental audit. It describes a list of audits which should be undertaken in all
branches of anaesthetic, critical care and pain management practice. Clearly, all audits
cannot be undertaken simultaneously nor is the list intended to be prescriptive.

Good Practice Guide 2006 23
5.1 Local audit
Audit which is properly conducted plays an important part in:
❚
❚
❚
improving patient care
improving the provision of anaesthetic services
continuing medical education.
Traditionally, audit is considered under three headings – the structure, process and
outcome of care. The key to effective audit is the audit cycle (Figure 3) whereby
information and data are collected, analysed and reviewed; changes are agreed and
standards set; the changes are implemented and after a period of time the cycle is
repeated. As the process continues, each cycle aspires to a higher level of care.
Figure 3 The audit cycle
Collect information and data
Implement change
Analyse and review
Different routes into the cycle include:
Agree change and set standards
❚
❚
❚
❚
❚
individual case reports of mortality and morbidity
reviews of critical incidents
perceptions of patients and other healthcare workers about the anaesthetic service
complaints about the anaesthetic service
formal reviews of areas of clinical practice and service provision.
All the above should feed into a departmental audit programme.
5.2 The audit programme
The audit programme of an anaesthetic department should follow a regular pattern
and the following is recommended:
Monthly
Two to three times a year
Annually
Review of deaths, complications,
unexpected outcomes (e.g. unplanned
admission to ICU or HDU), critical incidents
Joint audits with other departments, e.g.
surgeons, obstetricians, paediatricians
Review of anaesthetic record keeping
Every two to three years
Review of local guidelines
In addition, departments should review practice against national guidelines as they
are published and thereafter every two to three years. It is also good practice for

24 Good Practice Guide 2006
individual anaesthetists to undertake on going personal audits of particular aspects
of their own work.
Departments should keep written summaries of audit meetings as reference
documents for subsequent reviews.
The College has developed national audit projects within anaesthesia. These will
provide valuable data (first results published in the BJA in September 2005) and also
provide benchmarks against which a department can compare itself.
Nationally, the specialty of anaesthesia has a long record of effective audit in the
Confidential Enquiries into Maternal Deaths (now the Confidential Enquiry
into Maternal and Child Health), National Confidential Enquiry into Patient
Outcome and Death and Scottish Audit of Surgical Mortality. Both the College
and the Association encourage anaesthetic departments to contribute to national
reporting systems and also implement recommendations which follow review of
critical incidents.
5.3 Critical incidents 28–31
The College definition of a critical incident is ‘an event which led to harm or could have
led to harm if it had been allowed to progress’. It should be preventable by a change
of practice. The College has defined two ways of grading critical incidents based on
outcome and the degree of preventability.
5.3.1 Outcome
❚ No effect.
❚
❚
❚
❚
❚
Transient abnormality unnoticed by the patient, e.g. laryngospasm.
Transient abnormality with full recovery, e.g. headache.
Potentially permanent but not disabling damage, e.g. chipped tooth.
Potentially permanent disabling damage, e.g. stroke.
Death.
5.3.2 Preventability
❚ Probably preventable within current resources, e.g. failure to perform a preoperative
machine check.
❚
❚
❚
❚
Probably preventable with reasonable extra resources, e.g. failure to detect
oesophageal intubation (which could be obviated by capnography).
Possibly preventable within current resources, e.g. pneumothorax during
insertion of a central venous line, which might be prevented by better teaching/
supervision.
Possibly preventable with reasonable extra resources, e.g. inability to replace
unwell anaesthetist because of inadequate staffing which might be prevented by
more cover.
Not obviously preventable by any change in practice, e.g. idiosyncratic drug reaction.

Good Practice Guide 2006 25
Each department should have a critical incident co-ordinator whose job it is to
receive reports, discuss them confidentially with the reporter and ensure accuracy of
reporting. Incidents should be well documented in the patient’s notes and reviewed
at a department’s audit meeting.
While errors are an integral part of everyday life, an error during the giving of an
anaesthetic may have serious implications for both the patient and the anaesthetist.
Understanding the causes of error is an important way of preventing it from occurring
again. Critical analysis of errors has been successfully applied in the aviation industry
and has resulted in changes in equipment, recruitment and training policies. This
approach has been successfully adapted to anaesthesia.
Anaesthetists are part of a complex system of patient care, and deficiencies in that
system may contribute to untoward events during anaesthesia. 32 Under Health and
Safety Legislation 33 there is a requirement to report certain events to the Health
and Safety Executive for review. The Act places upon all staff an obligation to report
clinical and non-clinical incidents which are likely to have a bearing on the quality,
safety or efficiency of care provided.
Two principal reporting systems should be used. Firstly, the Royal College of
Anaesthetists in collaboration with the NPSA have distributed a reporting database
to all departments which should be used for all events. From this, reports can be
printed for use at department morbidity and mortality meetings. The NPSA was
created to implement a mandatory reporting system to detect and learn from data on
adverse incidents. The emphasis is on learning and development and not on blame. 34
Secondly, many Trusts use a Trust reporting system which should be used additionally
for events which have caused harm to the patient, staff or to the reputation of the
Trust. Trusts should be encouraged to endorse the use of both systems, as they
should complement each other. It is sensible practice for a Trust to have a common
reporting system with reports being collated by a risk manager.
Many anaesthetists have taken on the role of clinical governance lead within their
Trust or department. It is suggested that this role be clearly defined in their job plan
and that adequate time and resource be allocated. 35
5.4 Confidentiality 19
The maintenance of confidentiality about complications and critical incidents within
the specialty is essential if both national reporting and local audit are to be honest
and comprehensive and anonymity assured. Nevertheless, all anaesthetists have
a responsibility to monitor the structure, process and outcome of the care which
their department provides. Where patterns of poor care emerge or where specific
events have implications for the Trust, they have a duty to share that information with
other clinicians, healthcare workers and managers. Where actual harm has occurred,
patients must always be informed as soon as possible.

26 Good Practice Guide 2006
5.5 Audit of critical care services
Comprehensive Critical Care 36 published by the Department of Health in 2000
recommended that ‘a data collecting culture promoting an evidence base must be
recognised as an integral part of the delivery of critical care and an essential part of
the Trust’s clinical governance and risk management programme’. Clinicians should,
therefore, insist that sufficient clerical and administrative support is provided for
data collection in critical care and high dependency units. They should also ensure
that their Trust provides details of activity employing the Augmented Care Period
(ACP) dataset to the DH for incorporation in hospital episode statistics. Auditing and
assessing activity are essential in service planning at Trust level to meet clinical needs
as well as nationally to inform future development.
Clinical outcome between critical care units is particularly difficult to compare in
view of the varying case mix and severity of illness of the patients involved. It is
recommended, therefore, that all units are involved in a system of national comparative
audit such as the Intensive Care National Audit and Research Centre (ICNARC) or
its Scottish equivalent. This not only requires an efficient system of data collection
and enthusiasm from the doctors and nurses involved to ensure data accuracy and
completeness, but also a willingness to examine variations in performance from the
nationally predicted norms and initiate any change in practice that may be required
for improvement.
Regular clinical reviews and morbidity and mortality meetings should be undertaken
involving all staff in the unit including medical, nursing, paramedical and other
support staff in addition to multidisciplinary involvement of referring clinicians. The
number and process of transfers of critically ill patients outwith the critical care unit
either within hospital or between hospitals should be audited and any critical incidents
recorded and acted upon. This requires not only co-operation between Trusts within
the established critical care networks, but also review at a national level.
5.6 Audit of pain management services
Both acute and chronic pain management services should conduct regular audit and
critical incident discussion involving all staff members. Patient involvement with service
audit is important. Internal audit is essential to monitor service effectiveness, efficiency
and deficits and allows services to discuss treatment options fully with patients. Interhospital
audit allows ‘benchmarking’ against other pain management services and
can be a valuable learning tool. Recommended topics for pain management audit are
included in Raising the Standard. 27

Good Practice Guide 2006 27
Chapter 6: Continuing professional
development (CPD) 37
Para 12: ‘You must keep your knowledge and skills up-to-date throughout
your working life.’
Para 16: ‘If you are involved in teaching, you must develop the skills, attitudes
and practices of a competent teacher.’
CPD is a requirement of good medical practice and an integral part of the
maintenance of professional standards. It embraces both theoretical knowledge
and the acquisition and development of skills needed in the fields of communication,
teaching, management and clinical duties.
CPD is an essential part of the life of all doctors, and is required for appraisal,
clinical governance and revalidation. The exact amount and type of CPD activity are
a matter for the individual but must be sufficient to satisfy personal and regulatory
requirements. A review of CPD activity should be an integral part of the anaesthetist’s
annual appraisal within the Trust; that review requires not only an accurate record but
some indication of the benefit of specific activities. A complete record of CPD activity
is an integral part of the process of revalidation by the GMC.
Maintenance of CPD is also required by the College for recognition as a teacher of
trainee anaesthetists: it follows that a department cannot be approved for training
unless a majority of consultant anaesthetists in that department are up to date with
their CPD requirements. The College no longer seeks details of specific CPD but
assumes successful annual appraisal to be evidence of appropriate activity.
CPD must be cost effective and undertaken by all grades of medical staff including
non-consultant career grades.
6.1 Funding for CPD
Because CPD is a mandatory requirement for appraisal and in the long run revalidation,
it follows that employers, Trusts or otherwise, should ensure that adequate funding is
available for this purpose. If for some reason it is not available, then pressure must
be applied through the management structure, by the professional bodies both within
and without the Trust to correct shortfalls in educational and study leave budgets.
6.2 Finding time for CPD
CPD should largely take place during normal working hours. For anaesthetists
this may cause considerable problems. Internal CPD, such as departmental audit
meetings, may require the cancellation of operating lists but the inevitable requests
for exceptions to attendance must be resisted and genuine emergency work provides
the only valid reason for absence. Joint meetings with surgical groups can help solve
this dilemma. External CPD may also lead to cancellation of clinical activities and,
while this is regrettable, unfortunately it may sometimes be necessary.

28 Good Practice Guide 2006
6.3 Monitoring of CPD
Personal records must be kept of all CPD activity. It is necessary to obtain a certificate
of attendance when attending any external courses or meetings, and organisers of
meetings which are approved for CPD purposes are required to provide a certificate
of attendance for each attendee. Proof of attendance at meetings such as internal
audit meetings and journal clubs should also be maintained in the form of CPD diary
records/photocopies of departmental diaries or attendance registers.
Deficiencies of individuals, or within a department, should be acknowledged so that
attempts can be made to fill or correct them. A list of skills available to train others
should also be recorded.
6.4 Directed CPD
Usually, anaesthetists decide for themselves what type of CPD to undertake. However, at
each annual appraisal, the appraiser may suggest other forms of CPD in order to train
the anaesthetist for new clinical or management activities required for the organisation.
This should be welcomed. At the same time, at each annual appraisal, the anaesthetist
should raise with the appraiser any area of CPD that they believe is required in order to
fill deficiencies in areas within the individual’s current scheduled duties.
6.5 Range of activities
CPD embraces a large range of useful activities including:
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visiting other hospitals or centres of excellence
learning or improving management skills
improving teaching ability
use of anaesthetic simulators
interactive learning.
In the revised 2005 College CPD document (see: www.rcoa.ac.uk/docs/CPD_
guidelines.pdf), attention was drawn to the great benefit of spending sessions with
consultant colleagues. The anaesthetists undertaking this should be rostered as
supernumeraries for such sessions.
6.6 Limitations to CPD
It is unreasonable to expect all consultants to be able to anaesthetise all patients
presented to them throughout their career, be they on a routine operating list or as an
emergency. It is essential that individuals know their own professional limitations, and
act within them. Within an anaesthetic department, it is essential that all necessary
skills are present, and that a system is in place so that they can be deployed at the
time and place required. The clinical director must ensure that the corporate CPD of
the department achieves these targets. An individual, however senior, must never be
reluctant to ask for help nor should a colleague refuse to provide it.

Good Practice Guide 2006 29
However, when anaesthetists are rostered to cover emergency duties, it is essential
that they undertake CPD appropriate to cover every type of emergency likely to be
encountered on that particular roster. In order to assist this, the College CPD revised
system incorporates a list of core topics.
6.7 Core topics
The expanded list of ‘core topics’ in anaesthesia (Appendix 1) is based upon the
original list agreed by the Union of European Medical Specialists (UEMS) in 1998.
Each topic is divided into clinical challenges, knowledge and skills.
These are topics that an individual specialist working in a typical hospital and
participating in the emergency on-call rota should have up-to-date knowledge of and
proficiency in, but may be modified in the light of their individual responsibilities.

30 Good Practice Guide 2006
Chapter 7: Record keeping
Para 3 (f): ‘In providing care you must keep clear, accurate and legible
records, reporting the relevant clinical findings, the decisions made, the
information given to patients, and any drugs prescribed or other investigation
or treatment.’ 6
The King’s Fund Organisation Audit Hospital Accreditation Programme has set a
standard for health records in its Organisational Standards criteria, 38 which states:
‘There is an accurate health record which enables the patient to receive
effective continuing care, enables the healthcare team to communicate
effectively, allows another doctor or professional members of staff to assume
care of the patient at any time, enables the patient to be identified without
risk or error, facilitates the collection of data for research, education and
audit and can be used in legal proceedings.’
If this standard of record keeping is not maintained and professional requirements are
not being met, patients, and possibly staff, are put at risk. It cannot be emphasised too
strongly that in medico-legal cases the outcome is often dependent on the anaesthetic
record. An untidy, illegible, scantily completed chart may be taken as indirect evidence
of shoddy or inattentive care. 39 Furthermore, the examination of medical records
forms part of the GMC’s fitness to practise procedures (see Chapter 9). The record
must be such that if another doctor were required to take over the case, this record
would allow systematic and ready access to all the information required.
7.1 The content of the anaesthetic record
There is no standard anaesthetic record in the UK. However, in recent years both the
Association and the College have set out what they regard as the minimum data set
for an anaesthetic record. 40 The GMC uses this information for assessment purposes
in what it considers to be essential recorded information. While the format of the
anaesthetic record is a matter for local preference, the record should contain:
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basic data entry: names of surgeon(s) and anaesthetist(s), date, operation.
Where the anaesthetist is a trainee or SAS grade doctor, the name of the
supervising consultant should be recorded (see 8.2.4 for level of supervision)
patient identification: name, date of birth, gender, hospital number
pre-operative assessment: relevant history, physical examination, drugs,
allergies, ASA grade
anaesthetic technique: induction and maintenance technique, including
anaesthetic agents used, recorded in detail
intravenous drugs administered: clear record of pre-operative and intraoperative
drugs given, doses and time of administration

Good Practice Guide 2006 31
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equipment monitoring: record of anaesthetic machine and circuit check, relevant
equipment monitoring such as FiO 2
(always) and pressure alarms
patient monitoring used: this should be in accordance with the recommendations
of the Association of Anaesthetists 41
physiological variables recorded: time based chart recordings of relevant
parameters including pre-induction values
frequency of record of physiological variables: frequent recording from induction
depending on patient stability, but not less frequently than every ten minutes for
pulse, blood pressure, oxygen saturation and end-tidal carbon dioxide
fluid balance: evidence of venous cannulation; record of fluids administered;
blood loss where relevant
postoperative pain relief: clear and appropriate postoperative analgesic orders
other postoperative instructions: oxygen therapy, immediate postoperative fluids
and monitoring to Association standards. 42
Any discussions the anaesthetist has with the patient or a responsible adult acting
for the patient about anaesthetic techniques, risks, special procedures etc should be
documented either on the anaesthetic records or in the body of the clinical notes.
A printed record of each anaesthetic should be included in the patient’s case notes,
wherever practicable.
In addition:
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❚
it is particularly important that critical incidents and complications are accurately
documented
where it is necessary for a case to be handed over from one anaesthetist to
another, this should be noted, as should decisions shared with other clinicians
and staff
if a patient is unexpectedly admitted to ICU or HDU the reasons for doing so
should be recorded.
7.2 Other uses for anaesthetic records
Computerised records provide detailed information about both individual and
departmental practice. However, they are most valuable for auditing specific areas of
anaesthetic care. Records are also a useful tool of personal audit particularly when
used with three or four colleagues for case-based discussions.
Patients’ notes, including the anaesthetic record, are confidential documents and the
GMC, therefore, requires that patients’ consent to disclosure of information for research,
teaching and audit must be obtained unless the data have been effectively anonymised. 19

32 Good Practice Guide 2006
7.3 Critical care
Critical care practice requires a full assessment of each patient at least once per
24- hours. This should be documented in full, including abnormal results, changes
in treatment and reasons for them, and forward plans. Results should be charted in
such a way that trends can be easily identified.
Current trainee work patterns often result in patient care changing hands several
times a day. Accordingly, it is vital that medical notes record each change in care
and the reasons for it. They should include procedures performed, discussions with
relatives, outcomes of investigations and decisions to reduce or withdraw support.
The aim is for transparent documentation which allows any other doctor to take over
the patient’s care at any point.
7.4 Pain management
7.4.1 Outpatient
As in all other out patient clinics, comprehensive records must be kept, detailing history,
examination, investigations, treatment and outcomes. Copies of correspondence to
general practitioners, consultants and other health professionals should be retained
within the hospital notes.
Discussions about treatment options and potential side effects should be documented,
along with a record of consent, if required.
7.4.2 Inpatient
7.4.2.1 Acute pain management
There should be a record of the management of acute pain, including pain assessments
and treatment, in the hospital notes. These are necessary to foster continuity of care.
7.4.2.2 Chronic and cancer pain
Detailed clinical notes should be made in the patient’s clinical record when the pain
management service is involved in managing in-patients with chronic pain or cancer
pain. The pain service should ensure that colleagues are kept informed when patient
care is being shared.
Further to this document, an additional publication is being produced in conjunction
with The British Pain Society regarding chronic pain management.

Good Practice Guide 2006 33
Chapter 8: Leadership, management and
administration
Para 42: ‘If you are responsible for leading a team, you must follow the
guidance in Management for Doctors.’ 43
A department of anaesthesia, critical care and pain management should provide
a clinical service of high quality within a defined budget and, where appropriate,
training facilities to the standard required by the College. While good administrative
arrangements are necessary within a department, the key to achieving these is
effective and efficient leadership. This should be provided by a designated head of
service who is responsible for all the activities of the department.
8.1 Head of department
In many Trusts this is the clinical director. However, in some Trusts, the department
of anaesthesia is part of another directorate and the clinical director is not an
anaesthetist. Under these circumstances it is necessary to have an anaesthetist who
takes responsibility for all aspects of the anaesthetic service. He/she may be the lead
clinician in anaesthesia, the head of service or the chairman of the department. In
this guidance, the term ‘clinical director’ refers to the designated anaesthetist with
management responsibility for all the activities in which the department of anaesthesia
is engaged. To encourage efficient rostering and use of resources it is recommended
that the department of anaesthesia, critical care and pain management should have
management responsibility for operating departments, 39 intensive care and pain relief
services, though it is recognised that there are other models which work satisfactorily.
The clinical director is appointed by, and is accountable to, the chief executive for the
management of the anaesthetic service. However, the director cannot function without
the support of consultant and other colleagues and must therefore be acceptable
to them. Some years of consultant experience are usually necessary before being
appointed to such a post. In some hospitals there has been a tendency to appoint
clinical directors primarily because of their management capability, but it is the qualities
of good leadership which are essential. These are fundamentally the ability to provide
direction and generate trust. Giving support, guidance, inspiration and confidence to
colleagues is the foundation upon which the success of a department is built.
8.2 Role within the department of anaesthesia
8.2.1 Staff management
The clinical director must ensure that there is an equitable distribution of work within
the department with efficient rostering to meet all the activities which it undertakes.
This includes the proper management of annual, study and professional leave.
All consultants are required to have a job plan specifying their contractual obligations,
which should be reviewed and agreed annually. This is a good opportunity, along

34 Good Practice Guide 2006
with preparation for appraisal, for consultants to assess their own programmes and
workloads, professional development and needs, the overall work of the department,
their role within it and the resources available to them and their department, 44 Nonconsultant
career grade anaesthetists should also have clearly defined programmes
of work. 45 As for consultant staff, adequate arrangements must be in place for their
continuing medical education and professional development.
While the day-to-day responsibility for trainees rests with the College tutor, the
quality of the clinical work which they undertake is the responsibility of the clinical
director. The clinical director also has responsibility for all other staff within the
directorate, although they will normally be managed by the appropriate business or
nurse manager.
Close liaison between the College tutor and the clinical director is needed to ensure
that the training requirements of the College are met. A mentoring system between
consultants and trainees is strongly recommended. 46 This promotes support for and
communication with trainees.
Poor performance among anaesthetists is fortunately rare. Nevertheless, the
clinical director has a duty to promote high standards, identify poor performance in
colleagues and take whatever action is necessary to protect patients from harm. This
is discussed in detail in Chapter 9 of this Guidance.
8.2.2 Budgets
The operational control of the directorate’s finances normally will be within the
remit of the business manager. However, the clinical director has a responsibility to
ensure that the anaesthetic service is adequately resourced for the commitments it
undertakes but keeps within the agreed budget allocated to it.
8.2.3 Communication
Good communications within the directorate are essential if it is to run efficiently and if
all staff are to feel involved in the department and content in their work. Without good
communications misunderstandings easily arise and inaccurate perceptions quickly
take root. Informal discussions, regular, minuted meetings, letters, memoranda,
notice boards and emails form an essential communications network. It should be
recognised that emails are disclosable documents and that if emails are sent outside
of the NHS system, then this method of communication is not secure and should not
be used for patient information. Time given to communication pays considerable
dividends in getting things done with the support of colleagues, particularly if it is
backed up by a personal concern for people’s welfare.
In a directorate which manages the operating theatres, clear lines of communication
with surgeons and theatre staff are necessary. A theatre users’ group/committee is
a useful forum by which this can be achieved.

Good Practice Guide 2006 35
Anaesthetists who hold out-patient clinics should communicate effectively with the
patient’s general practitioner and the referring doctor (if this is not the GP). It is now
recommended that letters should normally also be copied to the patient.
8.2.4 Guidelines
The College and the Association consider it necessary that, for some areas of the
anaesthetic service and clinical practice, departments should have clear guidelines.
These should be issued during the induction of every newly appointed anaesthetist to
the anaesthetic department. Guidelines should state explicitly how the supervision of
trainees and SASGs is implemented.* The clinical director should ensure that agreed
guidelines are complied with and regularly reviewed. This is part of the audit cycle
which is a key feature of a successful department. 21
8.2.5 Delegation
The work of a modern anaesthetic department is complex. Effectiveness and
efficiency are enhanced when named anaesthetists, with appropriate experience and
skills, have responsibility for particular areas for which they are accountable to the
clinical director.
Examples are:
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rostering and management of leave
equipment
audit
continuing medical education and professional development
training
specialist services including critical care, obstetrics, paediatrics, acute pain and
chronic pain
clinical governance.
8.2.6 Contract discussions
The clinical director or Lead Clinician should undertake contract negotiations with health
service commissioners for anaesthetic, critical care and pain management services.
8.3 Role outside the department of anaesthesia
The clinical director of anaesthesia has a key part to play in the overall running of a
Trust, in determining and implementing policy, and should be a member of the Trust’s
operational board. Anaesthetists work in many different departments of a hospital
and are therefore well placed to have an overview of the opportunities and problems
within it. Good working relationships with other clinical directors are needed if the
anaesthetic department is to work well throughout a hospital.
*The principles of supervision are defined in: The CCT in Anaesthesia I: General Principles. A manual for
trainees and trainers (www.rcoa.ac.uk/docs/CCTpti.pdf).

36 Good Practice Guide 2006
It is self-evident that while the work undertaken by anaesthetists – both in nature
and volume – is mostly generated by other clinicians, anaesthetists do have a major
contribution to make to the successful accomplishment of that work. 47 Purchasers,
therefore, need to understand the full nature and range of functions that a modern
anaesthetic service can offer to patients, how it operates and the constraints within
which it operates.
8.4 Support 48–49
Clinical directors need both time and support to do the job. They should have a
separate contract for this part of their work with an agreed job description. Adequate
sessional time must be made available. Individual Trusts may make specific financial
arrangements with clinical directors but it is not recommended that a clinical director
should have a full programme of clinical work.
Clinical directors should be supported by and work closely with business and nurse
managers as well as have ready access to specialist managers in such areas as
finance and personnel. They must also be provided with adequate personal and
secretarial assistance and information technology facilities.

Good Practice Guide 2006 37
Chapter 9: The poorly performing
anaesthetist
Para 43: ‘You must protect patients from risk of harm posed by another
colleague’s conduct, performance or health.’
In its guidance to doctors on Good Medical Practice the GMC sets out the standards
of performance it expects from medical practitioners. These include the provision
of good clinical care for patients, maintaining a proper professional relationship
with patients and working constructively within medical and multidisciplinary teams.
Evidence of departure from the standards described under these general headings
may be used to support a complaint to the GMC of impaired fitness to practise. Every
doctor when aware of bad practice by another doctor, especially where this may lead
to harm to patients, has a duty to take appropriate action.
The management of the poorly performing anaesthetist is governed by a complex set
of arrangements. It is also a very sensitive issue and there is considerable scope for
the problem to be mishandled. This Chapter therefore summarises:
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❚
methods within departments of anaesthesia for preventing the performance of its
members from falling below an acceptable standard
objectives in managing the poorly performing anaesthetist
the terms used in Department of Health and GMC documents.
It also provides guidance on how clinical directors should proceed in the event of
concerns arising about an anaesthetist’s performance.
Concerns about a doctor’s conduct or capability can come to light in a wide variety of
ways, for example:
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concerns expressed by other clinical or non-clinical staff
review of performance against job plans
concerns raised at appraisal
clinical governance or clinical audit
complaints by patients or relatives
information from regulatory bodies
litigation following allegations of negligence
information from the police or coroner.
If inadequate performance has been suspected or detected it can be dealt with at
three different levels:

38 Good Practice Guide 2006
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❚
❚
Locally where it is apparent that some improvement in skills, knowledge or
behaviour is required, the clinical director may recommend that further training
or other action is required and this may be arranged by the local department.
Where more serious concerns are evident regarding a doctor’s performance,
the Trust (in England, Wales and Northern Ireland) should contact the National
Clinical Assessment Service (NCAS) at the earliest opportunity. The number
of doctors who have been suspended from work for long periods is a cause
for concern, and the issue was investigated in detail by the National Audit
Office. 50 (The phrase ‘exclusion from work’ is now used to avoid confusion with
‘suspension’ of the right to practise which may be imposed by the GMC). Trusts
are now required to discuss the case fully with the chief executive, medical
director, Director/Head of Human Resources, NCAS and other interested parties
(such as the police where there are serious criminal allegations) whenever
exclusion is being considered. 51
Where a very serious problem has occurred, a doctor may be immediately
excluded and referred directly to the GMC. In these cases the above parties must
discuss the case at the earliest opportunity following the exclusion.
9.1 Prevention of poor performance
The aim of clinical governance, which is now widely implemented in the NHS, is to
secure better quality care, and observance of its key principles should help in the
maintenance of professional standards. 52
Although designed to support improvements in practice, the introduction of a
mandatory system of annual appraisal within the NHS should help to identify poorly
performing individuals at an early stage. Appraisal, a formative process in which both
appraiser and appraised agree a professional development plan based on identified
and agreed areas of need, should be seen as quite different from assessment, in
which identified strengths and weaknesses may have implications for an individual’s
career. Although assessments are important elements of the RITA process for trainees,
they will not be used for non-training grades until the time comes for the five-yearly
revalidation of their medical registration. However, if potentially serious performance
issues arise in the appraisal process, the appraisal should be suspended whilst the
appraising doctor ensures that they are addressed urgently, especially if they pose a
threat to patient safety.
The culture within an anaesthetic department is central in maintaining high standards
of anaesthetic practice. Where little attention is paid to efficient running of the
department, record keeping, agreement on clinical guidelines, audit and local and
central programmes of continuing education, standards are likely to fall. The local
implementation of the recommendations already made in this Good Practice Guide will
go a long way to maintain the standards of performance of individual anaesthetists.
The recommendations provide the framework set by the Association and the College
within which anaesthetists are expected to practise and hence the benchmarks by
which they may be assessed. Anaesthetists should concentrate on maintaining

Good Practice Guide 2006 39
overall standards within their department and take appropriate steps to prevent any
individual’s performance from becoming seriously deficient. However, anaesthetists in
general and clinical directors in particular also need to understand the procedures to
be followed if seriously deficient performance in a colleague is suspected.
9.2 Objectives in managing the poorly performing anaesthetist
Identifying and managing the poorly performing anaesthetist is always difficult. The
person concerned will be a colleague, and often a friend, sometimes of long standing.
It is not easy to view the situation objectively and it helps, therefore, to have clear
objectives. Fundamentally there are always three:
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9.3 Terminology
To protect patients from harm. This is the primary objective which must always
be uppermost.
To ensure that the anaesthetist is treated justly. Procedures should be fair and open.
To provide opportunities for the anaesthetist to improve their performance. 53
A poorly performing anaesthetist is one whose performance is outside the accepted
limits of practice. Within these limits an anaesthetist may adopt practices which
are different from those of other departmental colleagues provided that there is a
reasonable body of anaesthetists who would practise in a similar way.
9.3.1 Department of Health terminology
In its publications Supporting doctors, protecting patients 54 and Assuring the
Quality of Medical Practice, 55 the Government indicated its intention to introduce
a new approach to the way in which poor clinical performance is dealt with in the
NHS, complementing the reforms proposed by the GMC, Medical Royal Colleges and
other professional bodies. It proposed a change from the traditional approach using
disciplinary solutions applied late in the day to one that attempts to identify problems
early so that doctors can be helped by educational measures.
In December 2003 the Department of Health issued the document High Professional
Standards in the Modern NHS; a framework for the initial handling of
concerns about doctors and dentists in the NHS, under cover of HSC 2003/012.
This framework has now been completed. 51 All NHS bodies were required by 1 June
2005 to implement the framework, and it has been agreed with Monitor that it should
be issued to NHS Foundation Trusts as advice. The framework replaces the previous
disciplinary procedures for doctors as set out in circular HC(90)9 as well as the
‘three wise men’ panels provided for in HC(82)13. It abolishes the right of appeal
to the Secretary of State held by certain doctors under Para 190 of the Terms and
Conditions of Service.
The framework, which has been drafted in close association with NHS Employers
and the NCAS and agreed with the British Medical Association and the British Dental
Association, consists of five parts:

40 Good Practice Guide 2006
Part I: Action when a concern arises
Part II: Restriction of practice and exclusion
Part III: Conduct hearings and disciplinary matters
Part IV: Procedures for dealing with issues of capability
Part V: Handling concerns about a practitioner’s health
The key changes are that:
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the distinction between personal and professional misconduct is abolished.
Doctors and dentists employed in the NHS will be disciplined for misconduct
under the same locally based procedures as any other staff member
there is a single process for handling capability issues about the practitioner’s
professional competence closely tied in with the work of the NCAS
health issues are routinely dealt with through the occupational health service
the employing Trust is squarely responsible for the disciplining of its medical and
dental staff – not outsiders
there is scope to bring in expert advice for panels considering capability issues
the capability panel will be handled by an independent chair
the same disciplinary procedures will apply to all doctors and dentists employed
in the NHS.
Where there are concerns about a doctor’s clinical performance that cannot be
resolved locally, the employer will refer the doctor to NCAS. This may initiate an
assessment of the doctor’s clinical performance and give advice on any action to be
taken. It is, however, an advisory body, and the employer will remain responsible for
dealing with the problem, either by local resolution in accordance with the framework
or by referral to the GMC.
9.3.2 GMC terminology 56
The law governing the way in which the GMC handles complaints about doctors
changed on 1 November 2004.
Under the new procedures, complaints about doctors no longer follow separate
streams for health, performance and conduct. Instead, the GMC looks at the doctor’s
fitness to practise in the round, assesses whether it is impaired, and determines if any
impairment requires action on the doctor’s registration.
For anaesthetists this encompasses the whole spectrum of peri-operative care, critical
care and pain management which they are trained to provide. Failure in one area may
be regarded as evidence of poor performance, as would failure to seek help from a
colleague if an anaesthetist’s knowledge and skill were inadequate for the level of
care required for a given patient. In practice, repeated patterns of poor performance
rather than a single episode are more likely to lead to concern.

Good Practice Guide 2006 41
Fitness to practise may be impaired by reason of misconduct, criminal conviction or caution,
determination by another regulatory body, deficient performance or ill health. When
dealing with performance or health issues, the GMC tries to identify areas where remedial
action such as retraining or medical treatment is possible, whilst protecting patients from
harm. It is also well known, for example, that the practice of anaesthesia is very stressful
and there is continuing concern about the suicide rate among anaesthetists.
The GMC has power to impose conditions on a doctor’s registration, to suspend it
or to erase the doctor from the register. In future, only doctors with a licence will
be allowed to practise clinically, and apart from erasure the above sanctions will be
applied to the licence rather than to registration. Under the new regulations the
GMC also has the power to issue a warning where a doctor’s fitness to practise is
not impaired but there has been a significant departure from the principles set out in
Good Medical Practice. Warnings will be disclosed to the doctor’s employer and
any enquirer for a period of five years.
9.4 Which procedure should be followed?
Most performance, health and conduct problems in doctors are best handled locally,
using the Trust’s agreed procedures. This is the responsibility of a Trust’s medical
director. Clinical directors must ensure that appropriate informal and formal procedures
are in place within a directorate to monitor the quality of clinical practice and discuss
any performance issues with the medical director at the earliest possible stage. In cases
involving trainees, responsibility will be shared with the postgraduate dean.
The procedure to be followed depends on the nature of the concerns about the
poorly performing anaesthetist.
9.4.1 Local procedures to be followed within a Trust
9.4.1.1 Concerns which are initially non-specific and where patients
may or may not be immediately at risk
Gather discreetly as much information as possible. Ignore hearsay evidence and
try to establish the facts. Anyone making an allegation against a colleague must
be prepared to support it in writing. It is almost always helpful to consult trusted,
senior colleagues before deciding how to proceed. If concerns appear to be wellfounded
but not serious, it may be sufficient for one or two colleagues to bring them
informally to the doctor’s attention, together with appropriate advice. If the concerns
are serious, or if the anaesthetist has no insight into the problem, he/she should be
informed that the clinical director must be involved at an early stage. This enables
the clinical director to see the issues in perspective and for a range of options to be
considered about how best to proceed. It may also be helpful later should the clinical
director be criticised by the anaesthetist concerned or by other colleagues.
Advice can also be obtained from the College and the Association. clinical directors
may find the Association’s document on Stress in Anaesthetists particularly helpful. 57
The details of the Association’s Sick Doctor Scheme are also set out in this publication.
The GMC has an advisory service for medical directors.

42 Good Practice Guide 2006
9.4.1.2 Concerns where patients are clearly at risk or informal discussions
have failed to resolve issues under the previous section (9.4.1.1)
The clinical director and medical director should be contacted urgently. NCAS should
also be contacted, especially when exclusion is being considered.
The medical director, who is responsible for deciding which particular procedure should
be followed, may wish to seek help from the Association and the College in providing
impartial advice. The clinical director, however, may be asked to be the investigating
officer. This is appropriate as the clinical director is thoroughly familiar with accepted
standards of practice and the day-to-day running of the department of anaesthesia and
understands how anaesthesia is practised locally. The clinical director’s responsibility
is to provide the medical director with the facts and such information and advice as are
required for the medical director to decide how to proceed.
9.4.2 Procedures outside a Trust
9.4.2.1 National Clinical Assessment Service (formerly Authority) (NCAS)
NCAS (formerly Authority) was established to improve arrangements for dealing with
the poor clinical performance of doctors, and its advisory and assessment services
are aimed at enabling NHS Trusts in England, Wales and Northern Ireland to handle
cases quickly and fairly, reducing the need to use disciplinary procedures to resolve
problems. A similar scheme is being developed in Scotland. It has helped to avoid
formal or informal suspension, including the so-called ‘gardening leave’ in 85% of
cases referred to it where this was being considered by the Trust.
A Trust in England can seek advice from NCAS about a doctor whom it thinks is poorly
performing at any stage in the handling of the case. NCAS has developed a staged
approach to the services it provides NHS Trusts and practitioners. This involves:
❚
❚
❚
❚
immediate telephoned advice, available 24 hours
advice, then detailed supported local case management
advice, then detailed NCAS clinical performance assessment
support with planning and implementing recommendations arising from assessment.
9.4.2.2 Ombudsman
Where the issues are not clear or where there is doubt as to the case to be answered,
referral can be made to the NHS Ombudsman for assistance in resolving the problem.
9.4.2.3 Referral to the GMC
The criteria for referral to the GMC’s Fitness to Practise procedures include:
❚
❚
❚
where local action by the Trust, with or without advice from NCAS, would be
impractical or has been tried but has failed to resolve the problem
where local action has resolved the immediate local issue but the matter has
wider implications
where the problems are so serious that immediate referral to the GMC is clearly
required regardless of whether or not local action may also be appropriate.

Good Practice Guide 2006 43
Referral should be considered if the anaesthetist fails to display appropriate insight into
the problems, has left the district but may have taken those problems to another area of
the country or has moved exclusively into private practice. In particular the GMC may be
the only body able to take effective action where serious problems arise in relation to a
doctor working as a transient locum or working solely in non-NHS practice.
Performance and health issues are unlikely to require immediate referral to the GMC
if the anaesthetist has insight into the problem and is willing to co-operate with local
initiatives to help resolve the concerns.
Finally, remember in any investigation into a colleague’s performance:
❚
❚
keep records of everything: conversations, telephone calls, meetings and
interviews. These may be needed at a later stage
do not jump to conclusions about the outcome of the investigation. Patient and
persistent investigation to establish the facts and openness with the colleague
concerned are the only ways to protect patients, maintain standards and act justly.
It is very difficult to maintain confidentiality during an investigation of a colleague’s
performance. Inevitably, rumours spread and colleagues worry about what is
happening. It is important, therefore, to keep colleagues informed in general terms
only but at the same time keeping confidential the details of the enquiry until it has
been completed.

44 Good Practice Guide 2006
References
1 Klein R. The state of the profession: the politics of the double bed. BMJ 1990;301:700–702.
2 Stacey M. The GMC and professional accountability. Pub Pol and Admin 1989;4:12–27.
3 Rosenthal MM. The incompetent doctor: behind closed doors. Open University Press, Buckingham 1995.
4 Smith R. Profile of the GMC: the day of judgement comes closer. BMJ 1989;298:1241–1244.
5 Lock S. Regulating doctors. BMJ 1989;299:137–138.
6 Good Medical Practice. GMC, London 2006.
7 Core Values Conference. Core values for the medical profession in the 21st century. BMA, London 1995.
8 Performance Procedures. GMC, London 1997.
9 Maintaining Good Medical Practice. GMC, London 1998.
10 The new NHS. DH, Stationery Office, London 1997.
11 The National Clinical Assessment Authority, London 2001 (www.ncaa.nhs.uk).
12 The National Patient Safety Agency (Establishment and Constitution) Order. Statutory Instrument No:1743, London 2001.
13 Irvine D. The performance of doctors II: Maintaining good practice, protecting patients from poor performance.
BMJ 1997;314:1613–1615.
14 National Health Service (Clinical Negligence Scheme) Regulations. CNST 1996.
15 Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Third edition. OUP, Oxford 1989.
16 Berwick DM. Medical associations: guilds or leaders? BMJ 1997;314:1564.
17 Calman K. The profession of medicine. BMJ 1994;309:1140–1143.
18 Smith R. Medicine’s core values. BMJ 1994;309:1247–1248.
19 Seeking patients’ consent: the ethical considerations. GMC, London 1998.
20 Confidentiality: Protecting and Providing Information. GMC, London 2000.
21 Anaesthesia under examination. The Audit Commission. Audit Commission Publications, Abingdon 1997:92.
22 Research: The role and responsibilities of doctors. GMC, London 2002.
23 Hepatitis B infected Healthcare Workers. Health Service Circular HSC 2000/020.
24 Catastrophies in Anaesthetic Practice. AAGBI, London 2005.
25 Principles for Best Practice in Clinical Audit. NPSA, Radcliffe Medical Press 2002 (also available via www.nelh.nhs.uk).
26 The New NHS. DH, Stationery Office 1997:63–67.
27 Raising the Standard: A compendium of audit recipes for continuous quality improvement in anaesthesia. Second
edition. RCoA, London 2006.
28 Craig J, Wilson ME. A survey of anaesthetic misadventures. Anaesthesia 1981;36:933–936.
29 Kumar V. An analysis of critical incidents in a teaching department for quality assurance: a survey of mishaps during
anaesthesia. Anaesthesia 1988;33:879–883.
30 Williamson JA, Webb RK, Pryor GL. Anaesthesia safety and the critical incident technique. Australia Clinical
Review 1985;6:57–61.
31 Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anaesthesia management:
considerations for prevention and detection. Anesthesiology 1984;60:34–42.
32 Runciman WB et al. The Australian Incident Monitoring Study. System failure: an analysis of 2000 incident reports.
Anaesth Intensive Care 1993:21:684–695.
33 Health and Safety at Work Act. Risks and Diseases of Dangerous Occurrences Regulations (RIDDOR). HSE 1974.
34 The National Patient Safety Agency (www.npsa.nhs.uk).
35 A Practical Handbook for Improving Clinical Audit – NHS Clinical Governance Support Team, March 2005.
36 Comprehensive Critical Care planning and managing critical care capacities. DH, London 2000 (www.doh.gov.
uk/compcritcare/planning.htm).
37 The Doctor as a Teacher. GMC, London 1999.
38 Standard of Records. The King’s Fund Organisation Audit.
39 Utting JE. Pitfalls in anaesthetic practice. BJA 1987;59:888–890.
40 New guidelines for anaesthetic records. RCoA Newsletter 1996;27:8–9.
41 Recommendations for Standards of Monitoring during Anaesthesia and Recovery. AAGBI, London 2000.

Good Practice Guide 2006 45
42 Efficiency of Theatre Services. AAGBI, London 1989.
43 Management for doctors: guidance from the General Medical Council. GMC, London 2006.
44 Guidance on Contracts and Workloads for Consultant Anaesthetists. AAGBI, London 1997.
45 Non-Consultant Career Grade Anaesthetists. AAGBI, London 1998.
46 Consultant trainee relationships. A guide for consultants. AAGBI, London 2001.
47 Anaesthesia under examination. The Audit Commission. Audit Commission Publications, Abingdon 1997:4–7.
48 Anaesthesia under examination. The Audit Commission. Audit Commission Publications, Abingdon 1997:91–104.
49 Departments of Anaesthesia: secretariat and accommodation. AAGBI, London 1992.
50 The Management of Suspensions of Clinical Staff in NHS Hospital and Ambulance Trusts in England. The National
Audit Office. The Stationery Office, London 2003.
51 Maintaining High Professional Standards in the Modern NHS. DH, 2005.
52 Achieving Improvements through Clinical Governance: a progress report on implementation by NHS Trusts. The
National Audit Office. The Stationery Office, London 2003.
53 When things go wrong. Practical steps for dealing with the problem doctor, version 1. Association of Trust
medical directors. Cheadle 1997.
54 Supporting Doctors, Protecting Patients. Consultation Paper on recognising and dealing with poor clinical
performance of doctors in the NHS in England. DH, London 2000 (www.gov.uk/pub/docs/doh/cmodev.pdf).
55 Assuring the Quality of Medical Practice: Implementing Supporting Doctors, Protecting Patients. DH, London 2001.
56 Referring a doctor to the GMC: a guide for individual doctors, medical directors and clinical governance managers.
GMC, London 2004.
57 Stress in Anaesthetists. AAGBI, London 1997.

46 Good Practice Guide 2006
Bibliography of current guidance from
central organisations
General documents
Department of Health
A First Class Service: Quality in the New NHS. Wetherby, 1998.
An Organisation with a Memory. Report of an Expert Group on Learning from adverse events
in the NHS chaired by the Chief Medical Officer, 2000.
Building a safer NHS for patients. Implementing an organisation with a memory, 2001.
Maintaining high professional standards in the modern NHS: Doctors’ and dentists’ disciplinary
framework, 2005.
Modernising Medical Careers, 2004.
Quality in the new NHS (HSC1999/154), 1999.
Supporting Doctors, Protecting Patients. The Stationary Office, London 1999.
The New NHS. Modern, Dependable, 1997.
The NHS Plan: a Plan for Investment, a Platform for Reform, 2000.
General Medical Council
Good Medical Practice, 2006.
Management in Healthcare – the Role of Doctors, 1999.
Research: The Role and Responsibilities of Doctors, 2002.
Serious Communicable Diseases, 1997.
The Doctor as a Teacher, 1999.
The anaesthetist’s working environment
Association of Anaesthetists of Great Britain and Ireland
Anaesthetic Related Equipment. Purchase, maintenance and replacement, 1994.
Controlled Drugs in Perioperative Care, 2006.
Department of Anaesthesia: Secretariat and Accommodation, 1992 (currently under revision).
Drug and Alcohol Abuse Amongst Anaesthetists: Guidance on Identification and Management, 2000.
Guidance on Contracts and Workload for Consultant Anaesthetists, 2005.
Infection Control in Anaesthesia, 2002.
Theatre Efficiency, 2003.
Joint Committee on Good Practice (RCoA & AAGBI)
Departmental Portfolio, 2002.
Good Practice – a guide for departments of anaesthesia, critical care and pain
management (third edition).
Guide for Appraisal, 2000.
Personal Folder Supplement to Form 3 of the NHS Appraisal Folder, 2002.
Royal College of Anaesthetists
Information for patients – Risks associated with having an Anaesthetic, 2005.
Raising the Standard: A compendium of audit recipes for continuous quality improvement in
anaesthesia. Second edition, 2006.
Raising the Standard: Information for Patients, 2003.

Good Practice Guide 2006 47
Provision of services
Association of Anaesthetists of Great Britain and Ireland
Anaesthesia in Great Britain and Ireland: a physician only service, 1996.
Anaesthetists and Non-acute Pain Management (jointly with the RCoA and British Pain Society), 1993.
Day Case Surgery, 2005.
Immediate Post Anaesthetic Recovery, 2002.
Non-Consultant Career Grade Anaesthetists, 1998 (under revision).
OAA/AAGBI Guidelines for Obstetric Anaesthesia Services, 2005.
Provision of Anaesthetic Services in Magnetic Resonance Units, 2002.
Provision of Pain Services, 1997.
Risk Management, 1998.
Surgery and General Anaesthesia in General Practice Premises, 1995.
The Role of the Anaesthetist in the Emergency Service, 1991.
Intensive Care Society
Allied Health Professional and Healthcare Scientists Critical Care Staffing Guidance, 2003.
Standards for Intensive Care Units, 1997.
Royal College of Anaesthetists
Guidance on the Provision of Anaesthetic Services, 1999–2006.
Guidance on the Provision of Paediatric Anaesthetic Services, 2004.
Pain after Surgery (jointly with RCS England), 1990.
Pain Management Services – Good Practice, 2003.
Royal College of Surgeons of England
Day Case Surgery, 1992.
Clinical practice
Association of Anaesthetists of Great Britain and Ireland
Anaesthesia and Anaesthetists: Information for Patients and their Relatives, 1997.
Anaesthesia and Peri-operative Care of the Elderly, 2001.
Blood Transfusion and the Anaesthetist – Blood Component Therapy, 2005.
Catastrophies in Anaesthetic Practice, 2005.
Checking Anaesthetic Equipment (3), 2004.
Consent for Anaesthesia (2), 2006.
Day Case Surgery, 2005.
Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting
(with RCoA and others), 2004.
HIV and other Blood Borne Viruses, 1992 & 1996.
Immediate Post Anaesthetic Recovery, 2002.
Recommendations for Standards of Monitoring during Anaesthesia and Recovery (3), 2000.
Recommendations for the Transfer of Patients with Acute Head Injuries to Neurosurgical Units, 1996.
Suspected Anaphylactic Reactions Associated with Anaesthesia (3), 2003.
General Medical Council
Confidentiality: Protecting and Providing Information, 2004.
Seeking Patients’ Consent: The Ethical Considerations, 1998.
Withdrawing and Withholding Life-prolonging Treatments – Good Practice in Decision Making, 2002.

48 Good Practice Guide 2006
Intensive Care Society
Guidelines for Adult Organ Donation, 2004.
Guidelines for the Transport of the Critically Ill Adult, 2002.
Point of Care Testing in Critical Care, 2004.
The Process of Consent within the Intensive Care Unit.
Royal College of Anaesthetists
Cardiopulmonary Resuscitation: Standards for Clinical Practice and Training (joint
statement with Royal College of Physicians of London, Intensive Care Society
and Resuscitation Council), 2004.
General Anaesthesia, Sedation and Resuscitation in Dentistry (jointly with
Faculty of Dental Surgery), 1991.
Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting
(with AAGBI and others), 2004.
Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures in
Adults (Report of an Intercollegiate Working Party of the Academy of Medical
Royal Colleges), 2001.
Local Anaesthesia for Intraocular Surgery, 2001.
Recommendations on Anaesthetic Records. RCoA Newsletter 1996;27:8–9.
Standards and Guidelines for General Anaesthesia for Dentistry, 1999.
Royal College of Surgeons of England
Sedation by non-anaesthetists, 1993.
Working relationships
Association of Anaesthetists of Great Britain and Ireland
Consultant trainee relationships – a guide for consultants, 2001.
Fatigue and Anaesthetists, 2004.
Management of Anaesthesia for Jehovah’s Witnesses, 2005.
Preoperative Assessment – The role of the Anaesthetist, 2001.
Stress in Anaesthesia, 1997.
The Anaesthesia Team, 2005.
General Medical Council
Management in Healthcare: the Role of Doctors, 1999.
Continuing education and professional development
Association of Anaesthetists of Great Britain and Ireland
Guidance on the 2003 (New) Contract and Job Planning for Consultant Anaesthetists, 2005.
Department of Health
Learning for Delivery: Making connections between post qualification learning/continuing
professional development and service planning, 2004.
Royal College of Anaesthetists
CPD Guidelines, 2005.
Guidance on Appraisal for Anaesthetists, 2000.
Personal Development Planning for the NCCG Anaesthetist, 2003.
Role of Non-Medical Staff in the Delivery of Anaesthesia Services, 2002.

Good Practice Guide 2006 49
Appendix 1: core topics
Airways
Clinical challenges
1 Anticipated or predicted difficult airway (cervical spondylosis, micrognathia, dental abscess patient).
2
3
4
5
6
7
8
9
Unexpected difficult airway (normal airway assessment, difficulty first revealed at attempt at
intubation).
Failed intubation – this will include the use of airway adjuncts to through cricothyroid puncture
techniques.
Foreign body in the airway.
Management of a patient for elective tracheostomy (e.g. major head and neck surgery, patients in ITU).
Management of a patient for emergency tracheostomy (trauma, acute upper airway obstruction).
Surgery for emergency conditions affecting the upper airway – bleeding, infection, tumour etc.
Shared airway management – types of devices available, how to use them.
Safe extubation and management of unanticipated airway obstruction in the recovery period.
Knowledge
1 Knowledge of anatomy of upper and lower airways.
2
3
4
5
6
7
Advances in understanding of physiology of airway obstruction.
Methods of assessment of likely difficulty in airway management.
Airway adjunct devices available (and their relative strengths and weaknesses).
Difficult airway strategies and protocols.
Failed intubation algorithms.
Causes and management of postoperative airway obstruction.
Skills
1 Use of airway adjuncts.
2
3
Advanced techniques, especially fibreoptic intubation.
Practice in the use of failed intubation algorithms including surgical airway access.
Emergency and major surgery
Clinical challenges
1 Major trauma – multiple systems (principles of ATLS for non-ATLS card carrying members).
2
3
4
5
Chest trauma for the non-cardiothoracic anaesthetist. Blunt chest trauma (as part of major trauma
and as an isolated event).
Leaking and ruptured abdominal aortic aneurysm.
Critically ill patient from ITU going to theatre.
Perforated viscus in the medically compromised patient (e.g. elderly patient with ischaemic heart
disease and perforated caecum or sigmoid).
6 Maintenance of body homeostasis during prolonged surgical procedures.

50 Good Practice Guide 2006
Knowledge
1 Developments and advances in the overall management of these patients – better understanding of the
role of temperature control, fluid management, intra-operative renal support, permissive hypotension.
2
3
4
5
6
7
8
Principles of management of the physiological insults from the disease processes.
Principles of massive blood transfusion.
Advances in surgical management and the implications for the anaesthetist.
Chest drain management principles – insertion, transport etc.
Advances in management of techniques such as one-lung ventilation.
The role of the relevant non-technical skills, e.g. limitations on human performance and the
techniques to help compensate for this.
Principles surrounding choice of monitoring techniques.
Skills
1 Application of ATLS principles (rather than obtaining ATLS certification).
2
3
4
5
Chest Drain Management skills where relevant.
Management of one lung ventilation.
Non-technical skills – opportunity to apply the knowledge.
Insertion and use of invasive and non-invasive monitoring.
Fluid management
Clinical challenges
1 Major haemorrhage.
2
3
4
5
Major fluid loss (burns, sequestration).
Blood transfusion policies.
Diagnosis and management of coagulopathies.
Advances in oxygen carrying substances/blood substitutes.
Knowledge
1 Advances in understanding of physiology of fluid therapy – types of fluids, aggressive vs
non-aggressive therapy etc.
2
3
4
5
6
7
Principles of massive blood replacement.
Principles of fluid therapy for major burns.
Practice from recognised expert centres, e.g. organisation of major haemorrhage packs.
Coagulopathy – monitoring of coagulopathy, role of different type of factor replacements, relevant
risks of infection etc.
Advances in new fluid therapies.
Awareness of relevant guidelines, e.g. SIGN.
Skills
1 Use of associated equipment, e.g. rapid infusing and warning devices, bedside measurement devices.

Good Practice Guide 2006 51
Intensive care medicine
Clinical challenges
1 Current uses of inotropes and other vaso-active drugs.
2
3
4
5
Methods of ventilation for different types of pulmonary disorder.
Management of the septic patient.
Multi-organ failure.
Discontinuation of treatment and organ donation.
Knowledge
1 Update on pathophysiology of relevant condition, e.g. sepsis, multi-organ failure etc.
2
3
4
5
6
7
Update on cardiovascular pharmacology – specific drugs including relative indications and
contra-indications.
Update on renal support and implications for peri-operative management.
Update on antimicrobial therapy.
Update on respiratory support – types of ventilation, weaning etc.
Severity scoring and assessment of brain function.
Procedures for organ donation.
Skills
1 Familiarisation with ventilators and infusion devices.
Invasive monitoring
Clinical challenges
1 Inserting the devices (what devices are currently available).
2
3
Using the information from the devices.
Trouble-shooting problems.
Knowledge
1 The current position on the relevant indications and contra-indications.
2
3
4
What devices are available along with their relative advantages and disadvantages.
How to deal with common problems.
Knowledge of current guidelines (NICE).
Skills
1 The use of ultrasonic location devices.
2
3
Setting up the devices (anaesthetists who do not routinely use such devices in elective work may be
using them in very ill emergency patients and not be familiar with how to configure monitors etc).
Techniques for challenging cases, e.g. approaches other than internal jugular and subclavian.
Major trauma
Clinical challenges
1 The role of the anaesthetist in major incidents (general principles of triage, immediate care etc).
2
3
Current practices in individual major trauma cases. Available techniques, indications for use
etc. (pelvic fracture fixation, diagnosis and management of blunt abdominal trauma in cases of
suspected bleeding, e.g. ruptured spleen).
The patient with a head injury and/or other potential life-threatening injuries.
4 Anaesthesia for investigation of the major trauma patient (CT scanning).

52 Good Practice Guide 2006
Knowledge
1 Advanced Life Support & Advanced Trauma Life Support principles.
2
3
4
5
Updates on advances in surgical management, e.g. pelvic fractures, gun shot wounds.
Updates in the management of the head injured patient.
Updates in the management of the patient with spinal column and spinal cord injury.
Major incident management, including triage and the role of the anaesthetist.
Skills
1 The key skills for ALS and ATLS.
Obstetrics
Clinical challenges
1 Non-obstetric surgery for the parturient.
2
3
4
5
6
7
8
9
Resuscitation of the parturient. For those covering obstetric rotas but not practising regularly.
General anaesthesia for emergency Caesarean section.
Regional anaesthesia for emergency Caesarean section.
Management of major haemorrhage (ante-partum, intra-partum or post partum) and
coagulopathies.
Neonatal resuscitation.
Analgesia and anaesthesia for labour and delivery.
Difficult or failed intubation.
Post dural puncture headache.
Knowledge
1 Update on current management of the parturient.
2
3
4
5
6
7
Update on eclampsia and pre-eclampsia.
Update on pharmacology in relation to the parturient and foetus.
Principles of management of mothers with cardiac disease.
Management of major haemorrhage and coagulopathy.
Failed intubation protocols for obstetric practice.
Management of post dural puncture headache.
Skills
1 Basic Neonatal Life Support for those with an emergency obstetric commitment – the needs will vary
depending on local resources.
2
Those providing emergency rota cover should also be familiar with the equipment available and
relevant for emergencies – infusion systems, invasive monitoring equipment etc.
Occasional emergencies
Clinical challenges
1 Serious medical conditions (endocrine, neurological, cardiorespiratory).
2
3
4
Accidental injuries (drowning, burns).
Anaphylaxis.
Advanced Life Support (adults).
5 Paediatric Life Support.

Good Practice Guide 2006 53
Knowledge
1 Updates in treatment and management of the various medical conditions.
2
3
Update on treatment of drowning and burns.
Familiarisation with current protocols for emergency conditions.
Skills
1 Ability to apply the relevant protocols.
2
Those skills necessary for the relevant protocols.
Paediatrics
Clinical challenges
1 Resuscitation of the neonate.
2
3
4
Management of paediatric emergencies that may present at A&E (upper airway problems, trauma,
acute infections with major cardiorespiratory components).
Transfer of sick children.
Provision of analgesia.
Knowledge
1 Updates in current management principles.
2
3
4
5
Current equipment and its indications and contra-indications.
Principles of fluid balance in children.
Management options for pain.
Principles of stabilisation and transfer.
Skills
1 Relevant airway skills and use of airway adjuncts.
2
Current approaches to cardiovascular access and stability.
Pain management
Clinical challenges
1 Management of the adult postoperative patient.
2
3
4
5
Management of the patient with acute pain pre-operatively.
Management of acute pain from non-surgical causes (fractured ribs, pancreatitis, acute myocardial
infarction, sickle cell etc).
Trouble shooting of problems with regional block (unilateral block, missed segment etc).
Management of patients with chronic pain conditions.
Knowledge
1 Update in physiology of pain and pharmacology of relevant drugs.
2
3
4
5
Update in non-pharmacological methods.
Update in management strategies for specific conditions.
Challenges and how to deal with them.
Current protocols and guidelines for managing infusion devices, PCA, epidural infusions etc.
Skills
1 The ability to use the relevant equipment.
2
(The ability to site regional blocks is dealt with in regional techniques below).
3 Ability to apply relevant protocols.

54 Good Practice Guide 2006
Postoperative complications
Clinical challenges
1 The patient who cannot breathe adequately postoperatively.
2
3
4
The patient who is bleeding and requires to go back to theatre.
Recognition and management of complications in the early postoperative period (airway obstruction,
shivering, nausea and vomiting, pain).
Sudden collapse from cardiovascular event.
Knowledge
1 Factors causing reduced respiratory capacity.
2
3
4
5
6
Investigation of patient who cannot breathe adequately.
Principles of fluid and blood therapy (see fluid management).
Options for management of shivering, PONV and pain.
Management of airway problems (see airways section above, knowledge 7).
Update of theoretical knowledge of causes of sudden collapse and resuscitation.
Skills
1 Maintenance of appropriate level of resuscitation skills.
Regional techniques
Clinical challenges
1 Identification and management of problems (intra-operative unilateral block, missed segment etc),
hypotension, total spinal block, extensive block.
2
3
4
Identification and management of local anaesthetic toxicity.
Management of non-obstetric patient with dural puncture headache (post spinal or post epidural).
Neurological damage.
Knowledge
1 Relevant anatomy of blocks.
2
3
4
5
Update on pharmacology of local anaesthetic drugs.
Indications and contra-indications.
Management of complications of local anaesthetic blocks.
Investigation of neurological damage.
Skills
1 Ability to perform blocks.
2
Ability to use relevant equipment (nerve location devices, infusion pumps etc).
Transfer of the critically ill patient
Clinical challenges
1 Critically ill patients to ITU in other centres.
2
3
4
Transfer of head injured patients.
Transfer of burned patients.
Stabilisation of child prior to transfer.
5 Air transfer.

Good Practice Guide 2006 55
Knowledge
1 Update of impact on pathophysiology of transfer.
2
3
4
5
The logistical and practical aspects – what equipment to have available, what drugs to take etc.
The challenges presented by different groups – the burned patient, the head injured patient, the
patient in single or multiple organ failure being taken to ITU.
Familiarisation with existing protocols.
Additional problems of air transfer.
Skills
1 Most of the challenges are organisational, which includes familiarity with the relevant equipment in
addition to the key non-technical skills.

NOTES

Design and layout by The Royal College of Anaesthetists

Reducing the risk from cemented
hemiarthroplasty for hip fracture 2015
Published by
The Association of Anaesthetists of Great Britain & Ireland
British Orthopaedic Association
British Geriatric Society
February 2015

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Safety guideline:
reducing the risk from cemented hemiarthroplasty for hip fracture 2015.
Anaesthesia 2015, 70, pages 623–626.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13036/full
© The Association of Anaesthetists of Great Britain & Ireland

Guidelines
Safety guideline: reducing the risk from
cemented hemiarthroplasty for hip fracture
2015
Association of Anaesthetists of Great Britain and
Ireland
British Orthopaedic Association
British Geriatric Society
Membership of the Working Party: R. Griffiths, S. M. White,
I. K. Moppett, M. J. Parker, 1
T. J. S. Chesser, 1 M. L. Costa, 1 A. Johansen, 2 H. Wilson 2 and
A. J. Timperley
1 British Orthopaedic Association
2 British Geriatric Society
Summary
Concise guidelines are presented for the preparation and conduct of
anaesthesia and surgery in patients undergoing cemented hemiarthroplasty
for hip fracture. The Working Party specifically considered recent
This is an open access article under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly
cited, the use is non-commercial and no modifications or adaptations
are made.
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
1

publications highlighting complications occurring during the peri-operative
period [1, 2]. The advice presented is based on previously published
advice and clinical studies.
....................................................................................................
This is a consensus document produced by expert members of a Working
Party established by the Association of Anaesthetists of Great Britain and
Ireland, with representatives from the British Orthopaedic Association
and British Geriatric Society. It has been seen and approved by the
elected Boards/Councils/Committees of all three organisations.
All AAGBI guidelines are reviewed to ensure relevance/accuracy and are
updated or archived when necessary. Date of review: 2020.
Accepted: 13 February 2015
• What other guideline statements are available on this topic?
The National Patient Safety Agency (NPSA) issued an alert in 2009,
about the use of bone cement during hip arthroplasty [3]. Specialtyfocused
advice has been published by both anaesthetists [4] and
surgeons [5].
•
Why was this guideline developed?
The Anaesthesia Sprint Audit of Practice (ASAP) [1] collected prospective
information on bone cement implantation syndrome (BCIS)
[6]. The audit revealed evidence of cardiovascular compromise in
some patients undergoing cemented hemiarthroplasty for hip fracture.
•
How does this statement differ from existing guidelines?
This document has been a collaborative effort by anaesthetists, surgeons
and orthogeriatricians. It highlights the need for joint decision
making, teamworking and attention to detail during the peri-operative
period.
•
Why does this statement differ from existing guidelines?
This is the first multidisciplinary clinical guidance on peri-operative
management of this clinical problem.
Recommendations
There should be a three-stage process to reduce the incidence of problems
in patients undergoing cemented hemiarthroplasty for hip fracture:
1. Identification of patients at high risk of cardiorespiratory compromise:
2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

a) Increasing age;
b) Significant cardiopulmonary disease;
c) Diuretics;
d) Male sex.
2. Preparation of team(s) and identification of roles in case of severe
reaction:
a) Pre-operative multidisciplinary discussion when appropriate;
b) Pre-list briefing and World Health Organization Safe Surgery
checklist ‘time-out’.
3. Specific intra-operative roles:
a) Surgeon:
Inform the anaesthetist that you are about to insert cement;
Thoroughly wash and dry the femoral canal;
•
Apply cement in retrograde fashion using the cement gun
with a suction catheter and intramedullary plug in the femoral
shaft;
•
Avoid vigorous pressurisation of cement in patients judged
to be at risk of cardiovascular compromise (see below).
b) Anaesthetist:
Ensure adequate resuscitation pre- and intra-operatively;
• Confirm to surgeon that you are aware that he/she is about
to prepare/apply cement;
•
Maintain vigilance for signs of cardiorespiratory compromise.
Use either an arterial line or non-invasive automated
blood pressure monitoring set on the ‘stat’ mode during/
shortly after application of cement. Early warning of cardiovascular
collapse may be heralded by a drop in systolic
pressure. During general anaesthetic, a sudden drop in endtidal
pCO 2 may indicate right heart failure and/or catastrophic
reduction in cardiac output;
• Aim for a systolic blood pressure within 20% of pre-induction
value;
• Prepare vasopressors in case of cardiovascular collapse.
Introduction
This guidance is aimed at clinicians involved in the intra-operative management
of patients undergoing cemented arthroplasty. The guidance
does not include the consenting process, or the choice of surgical intervention,
which is covered in existing national guidelines [7], although
the Working Party acknowledges that these are vital parts of the process
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
3

y which patients undergo such surgery, and that the usual requirements
for individualised treatment and supplying patients with appropriate
information must apply.
Bone cement implantation syndrome
Surgical instrumentation of the femoral canal has been associated with significant
cardiovascular compromise [1, 5]. This phenomenon can occur
with any such surgery, especially procedures that breach the femoral canal,
such as intramedullary nailing and cemented and uncemented hip
implants, but the risk has been particularly highlighted in frail patients
undergoing cemented hemiarthroplasty following hip fracture.
During surgery, significant cardiovascular compromise can occur
during preparation of the femoral canal, during insertion of the cement
(if used for fixation) and/or prosthesis, and when the hip is reduced [6].
Compared with uncemented prostheses, the use of cemented prostheses
for hip fracture surgery increases the likelihood of pain-free mobility
after surgery [8], reduces the risk of re-operation and is associated with
a lower mortality rate at 30 days [8–11]. However, an adverse cardiovascular
event has been associated with cemented hemiarthroplasty and this
is sometimes referred to as ‘bone cement implantation syndrome’
(BCIS) [6].
Adverse cardiovascular events occur in approximately 20% of hip
fracture operations in which a cemented prosthesis is used [1, 2]. The
severity of the reaction is indicated in Table 1.
Certain patient factors are associated with an increased risk of
severe cardiovascular events during cemented hemiarthroplasty, in particular
increasing age, male sex, significant cardiopulmonary disease and
use of diuretic medication [2, 11]. These factors are also associated with
increased 30-day mortality, though the magnitude of the association is
far greater for BCIS itself [2].
Table 1 Incidence of adverse effects during arthroplasty using a cemented
prosthesis [1, 2].
Grade 1
Arterial saturation < 94% or > 20% fall in
~20%
systolic blood pressure
Grade 2
Arterial saturation < 88% or hypotension
~3%
> 40% fall in systolic blood
pressure or loss of consciousness
Grade 3 Cardiopulmonary resuscitation required ~1%
4 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Administrative and human factor aspects
In patients with the above risk factors, discussion between surgeons, anaesthetists
and orthogeriatricians should consider how best to minimise
the early peri-operative risks of mortality and morbidity, given the
known benefits of surgical intervention [10]. Surgeons and anaesthetists
can also modify peri-operative practice both to reduce the risk of cardiovascular
events and to improve outcome in the event of such an
Table 2 Specific intra-operative surgical and anaesthetic roles for reducing
the incidence and management of BCIS.
Conduct of surgery
Conduct of
anaesthesia
Ask the anaesthetist to confirm that he/she has
heard your instruction to the theatre team that
you are about to prepare the femoral canal for
cement and prosthesis insertion
Carefully prepare, wash and dry the femoral canal.
Use of a pressurised lavage system is
recommended to clean the endosteal bone of
fat and marrow contents
Use a distal suction catheter on top of an
intramedullary plug. Insert the cement from a
gun in retrograde fashion on top of the plug
and pull the catheter out as soon as it is
blocked with cement.
Do not use excessive manual pressurisation or
pressurisation devices in patients at higher risk
of cardiovascular events (see above for risk factors)
Ensure that the patient is adequately hydrated before
induction of and during anaesthesia
Maintain vigilance for possible cardiovascular events
once the femoral head is removed and the surgeon
has verbally indicated his/her intent to instrument
the femoral canal
Confirm to the surgeon that you are aware of
preparation of the femoral canal for cement and
prosthesis insertion
Aim to maintain the systolic blood pressure within
20% of pre-induction values throughout surgery,
using vasopressors and/or fluids. Invasive blood
pressure monitoring is indicated for patients at
higher risk
Be ready to give vasopressors, e.g. metaraminol/
adrenaline in case of cardiovascular collapse
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
5

event (Table 2) [11]. All hip fracture surgery should be undertaken or
directly supervised by appropriately experienced anaesthetists and surgeons
and on planned trauma lists [7].
All members of the theatre team should be aware of the problems
associated with femoral instrumentation and the use of cemented prostheses.
The potential for adverse events should be identified for each patient
as part of both the pre-list briefing before starting a theatre list and at the
World Health Organization Safe Surgery checklist ‘time-out’ immediately
before surgery. In the event of a severe reaction or cardiopulmonary arrest,
theatre staff should be aware of their defined roles in resuscitating the
patient, as described in the Coventry ‘cement curfew’ and modified
according to individual hospital operating procedures [12].
References
1. National Hip Fracture Database. Anaesthesia Sprint Audit of Practice, 2014.
https://www.rcplondon.ac.uk/sites/default/files/national_hip_fracture_database_
anaesthesia_sprint_audit_of_practice_asap.pdf (accessed 19/12/2014).
2. Olsen F, Kotyra M, Houltz E, Ricksten SE. Bone cement implantation syndrome in
cemented hemiarthroplasty for femoral neck fracture: incidence, risk factors, and
effect on outcome. British Journal of Anaesthesia 2014; 113: 800–6.
3. National Patient Safety Agency. Mitigating surgical risk in patients undergoing hip
arthroplasty for fractures of the proximal femur, 2009. http://www.nrls.npsa.nhs.uk/
alerts/?entryid45=59867 (accessed 19/12/2014).
4. Safe Anaesthesia Liaison Group. Patient Safety Update, 1 October 2011 to 31
December 2011. http://www.rcoa.ac.uk/system/files/CSQ-PS-PSU-DEC2011.pdf
(accessed 19/12/2014).
5. Timperley AJ, Whitehouse SL. Mitigating surgical risk in patients undergoing hip
arthroplasty for fractures of the proximal femur. Journal of Bone and Joint Surgery
[British] 2009; 91-B: 851–4.
6. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome.
British Journal of Anaesthesia 2009; 103: 12–22.
7. National Institute for Health and Care Excellence. Hip fracture: the management of
hip fracture in adults, 2011. www.nice.org.uk/guidance/cg124 (accessed 19/12/
2014).
8. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone
cement) for proximal femoral fractures in adults. Cochrane Database of Systematic
Reviews 2010; 6: CD001706.
9. Yli-Kyyny T, Sund R, Hein€anen M, Venesmaa P, Kr€oger H. Cemented or uncemented
hemiarthroplasty for the treatment of femoral neck fractures? Acta Orthopaedica
2014; 85: 49–53.
10. Costain DJ, Whitehouse SL, Pratt NL, Graves SE, Ryan P, Crawford RW. Perioperative
mortality after hemiarthroplasty fixation method. A study based on the Australian
Orthopaedic Association National Joint Replacement Registry. Acta Orthopaedica
2011; 82: 275–81.
6 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

11. Griffiths R, Parker M. Bone cement implantation syndrome and proximal femoral
fracture. British Journal of Anaesthesia 2015; 114: 6–7.
12. Scrase A, Horwood G, Sandys S. Coventry, ‘‘Cement Curfew’’: team training for
crisis. Anaesthesia News 2014; 327: 8–9.
© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland
7

The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
Website: www.aagbi.org
British Orthopaedic Association
35-43 Lincoln’s Inn Fields, London, WC2A 3PE
Tel: 020 7405 6507
Website: www.boa.ac.uk
British Geriatric Society
Marjory Warren House, 31 St John’s Square
London, EC1M 4DN
Tel: 020 7608 1369
Website: www.bgs.org.uk

UK National Core Competencies for Post-anaesthesia Care 2013
Immediate Post-anaesthesia Recovery 2013 supplement

CONTENTS
Glossary of terms 3
Introduction 5
Competency 1 Communication 7
Competency 2 Professional development 9
Competency 3 Clinical leadership 10
Competency 4 Clinical governance 11
Competency 5 Assessment and management of the airway 13
Competency 6 Assessment and management of breathing 16
Competency 7 Assessment and management of the circulation 17
Competency 8 Assessment of level of consciousness 18
Competency 9 Monitoring during recovery 19
Competency 10 Intravenous access and fluid balance 21
Competency 11 Applied knowledge of pharmacology in peri-operative care 22
Competency 12 Management of postoperative pain, nausea and vomiting 24
Competency 13 Recovery emergencies 26
Competency 14 Post surgical care 29
Appendix 1 31
2

GLOSSARY OF TERMS
AAGBI
AIMS
AVPU
BARNA
BVM
CODP
CPAP
CPD
DVT
ECG
GCS
HDU
HPC
ICU
LMA
MH
NCEPOD
NES
NIBP
NMC
NPSA
ODP
PACU
Association of Anaesthetists of Great Britain and Ireland
Anaesthetic Incident Monitoring Study
Alert, Verbal, Pain Unresponsive scoring system for conscious level
British Anaesthetic and Recovery Nurses Association
Bag, valve, mask ventilation
College of Operating Department Practitioners
Continuous positive airway pressure
Continuing professional development
Deep vein thrombosis
Electrocardiogram
Glasgow Coma Scale
High dependency unit
Health Professionals Council
Intensive care unit
Laryngeal mask airway
Malignant hyperpyrexia
National Confidential Enquiry into Patient Outcome and Death
NHS Education Scotland
Non-invasive blood pressure
Nursing and Midwifery Council
National Patient Safety Agency
Operating department practitioner
Post-anaesthesia care unit
3

PCA
pCO2
PDP
PONV
PPE
QIS
RAE
RCN
RCS
SaO2
SPSP
ETT
Patient controlled analgesia
Partial pressure of carbon dioxide
Personal development plan
Postoperative nausea and vomiting
Personal protective equipment
NHS Quality Improvement Scotland
Ring/Adair/Elwyn endotracheal tubes
Royal College of Nursing
Royal College of Surgeons
Oxygen saturation
Scottish Patient Safety Programme
Tracheal tube
4

INTRODUCTION
The provision of safe care during recovery from anaesthesia and surgery relies heavily on investment in the education and training of post-anaesthesia care
unit (PACU) staff. Maintenance of standards requires continual update such as resuscitation skills, application of new techniques and advances in pain
management. PACU staff are specialists and often play a key role in the education of others, including other theatre staff, ward-based nurses, midwives and
trainee doctors. All PACU staff should receive training, tailored to meet the needs of the individual and the local service but meet the national standards
defined in this document.
The concept of recovery rooms was first discussed and documented in the late 19 th century as anaesthesia was evolving. The importance of specialist
nursing care for postoperative patients was recognised [1]. A study during the 1940s in the United States recommended the continuing development of the
recovery room as being an essential part of the post-anaesthesia care pathway. This study highlighted, amongst other factors, airway obstruction as a key
factor contributing to potentially preventable postoperative deaths [2].
Dramatic advances in anaesthesia and surgery over the last 150 years have contributed significantly to the fall in morbidity and mortality. Nonetheless deaths
still occur during the recovery phase of postoperative care. The National Confidential Enquiry into Peri-operative Outcome and Death (NCEPOD) addressed
this issue in its 2001 report Changing the way we operate [3] and stated “Immediately after surgery all patients not returning to a special care area (e.g. ICU or
HDU) need to be nursed by those trained and practised in the postoperative recovery area. If there are separate arrangements for staffing the operating
theatre out of hours, these must include the provision of specialised recovery staff.”
A review of recovery room critical incidents was published by the Anaesthetic Incident Monitoring Study in 2002 [4] that detailed the proportion and type of
incidents encountered in recovery rooms in Australia and the United States and called for ongoing education and quality assurance programmes to be
developed to reduce these events.
A report released by NHS Quality Improvement Scotland (2003) demonstrated that not all staff who recover patients postoperatively are fully trained to the
required standard and that much of the recovery training was on an ad hoc and informal basis raising particular concerns in remote locations such as
remotely located operating theatres and the radiology departments [5].
Basic training for PACU starts with achievement of entry-level competence during nursing or operating department practitioner (ODP) training programmes of
learning. This individual requires supervision and mentoring until he/she has acquired the competencies to care safely and successfully for a patient in the
PACU. Thereafter they are expected to maintain, develop and enhance their practice through practical experience, further learning and continuing
professional development. They will be expected to populate and maintain a lifelong portfolio of experience during their training and working life. Registered
practitioners with current experience of working in the PACU are able to have prior qualifications and experience recognised.
The competencies required by PACU staff are both professional and clinical. The professional components are:
• Communication
• Professional development
• Clinical leadership
• Clinical governance
5

The clinical components are:
• Assessment and management of the airway
• Assessment and management of breathing
• Assessment and management of the circulation
• Assessment of consciousness
• Monitoring during the immediate postoperative phase
• Intravenous access and fluid balance
• Applied knowledge of pharmacology in peri-operative care
• Management of postoperative pain,
• Management of postoperative nausea and vomiting (PONV)
• Management of surgical and anaesthetic emergencies
In specialised areas of surgery, such as paediatrics and obstetrics, additional specific competencies are required.
This document uses work previously published by Quality Assuring Continuing Professional Development and by NHS Education Scotland. The three
relevant documents are A Route to Enhanced Competence in Perioperative Practice for Operating Department Practitioners and Nurses. (NHS
Education for Scotland. A Route to Enhanced Competence in Perioperative Practice for Operating Department Practitioners and Nurses. Edinburgh:
NES, 2002.)
Core Competencies for Anaesthetic Assistants 2011 http://www.nes.scot.nhs.uk/media/4239/anaesthetic_core_competencies_2011.pdf and
Portfolio of Core Competencies for Anaesthetic Assistants 2012 http://www.nes.scot.nhs.uk/media/1410332/nesd0050_smaad_portfolio_2012.pdf
This document has been modified following consultation with other stakeholders across Great Britain and Ireland (see appendix 1). All standards and
recommendations described in this document should be applied to all recovery areas where anaesthesia is administered including obstetric, cardiology,
radiology, dental and mental health units as well as community hospitals.
References
1. Radford M. Recovery nursing services: An evolution. British Journal of Perioperative Nursing 2003; 13:155-8,160-1.
2. Hatfield A, Tronson M. The Complete Recovery Room Book, 4 th edition. New York: Oxford University Press, 2009.
3. NCEPOD. Changing the Way we Operate. www.ncepod.org.uk/pdf/2001/01full.pdf (accessed 18/10/12).
4. Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;
57: 1060-66.
5. Healthcare Improvement Scotland. National Overview September 2005, Anaesthesia – Care Before, During and After Anaesthesia.
http://www.healthcareimprovementscotland.org/idoc.ashx?docid=b19010c9-13fc-4f4a-be49-916919990246&version=-1 (accessed 18/10/12).
6. Association of Great Britain and Ireland. Immediate Post-anaesthesia Recovery 2013. Anaesthesia 2013; 68: 288-97.
6

COMPETENCY 1: COMMUNICATION
Competency 1 Knowledge and skills Suggested indicators
1.1 Apply effective communication skills in
order to promote clinically effective patient
care.
Understands and applies principles of good
communication with patients, carers and
peri-operative team members.
Assess, plan, implement and evaluate
individualised care using a recognised nursing
framework in collaboration with all members of
the multidisciplinary team.
1.2 Establish and maintain effective,
professional relationships with patients, carers
and staff in all disciplines.
Provides accurate, concise and relevant verbal
and written information related to peri-operative
patient care.
Alerts appropriate members of the
multidisciplinary team to changes in patientʼs
condition.
Acquires knowledge of Guidelines for records
and record keeping (Nursing and Midwifery
Council (NMC), 2004) and Standards of
conduct, performance and ethics (Health
Professionals Council (HPC), 2003).
Demonstrates use of information technology
including computers and data management
skills.
Uses appropriate listening and responding
skills to develop relationships with patients,
carers and staff.
Interpret an anaesthetic chart that includes
pre-operative assessment and intraoperative
observations of vital signs and documentation
of fluids and drugs administered.
Communicate changes in patientʼs
observations appropriately.
Treat patients in a non-judgmental manner,
maintaining their dignity at all times.
Demonstrate concern and respect for patients
and carers.
7

Articulates role within peri-operative
team Demonstrates knowledge of
teamwork strategies related to the perioperative
environment.
Use effective communication strategies with
patients, anaesthetists and surgeons.
1.3 Apply the principles of good communication
to promote trust and confidence.
Educates and informs patients and carers
attending the PACU.
Complies with local and national policies and
protocols regarding record keeping.
Keeps accurate and comprehensive records.
Recognise patientʼs feelings of vulnerability.
Provide reassurance, comfort and appropriate
physical and psychological support.
Maintain patient records completely and
accurately.
1.4 Admission of patient to PACU. Understands admission protocol for PACU.
Describes preparation of PACU for receiving a
patient into the unit.
Identifies patients not suitable for admission to
PACU.
Safely admit patient to PACU including
mandatory documentation.
Start discharge planning of patient to
appropriate area.
1.5 Discharge of patient from PACU. Understands discharge criteria for the unit.
Explains significance of each criterion for
patients well being.
Understands the process for discharge from
PACU to trained staff accepting the patient into
their care.
Identify patient fit for discharge and meeting
agreed discharge criteria.
Ensure completion of relevant documentation.
Handover care to appropriately trained staff
maintaining patient dignity including full
documentation of the process.
8

COMPETENCY 2: PROFESSIONAL DEVELOPMENT
Competency 2 Knowledge and skills Suggested indicators
2.1 Demonstrate personal continuing
professional development (CPD) in recovery
skills.
2.2 Contribute to the continuing professional
development needs of the multidisciplinary
team.
2.3 Contribute and promote an environment
that encourages CPD.
Keeps a professional portfolio of learning and
experience gained.
Recognises own limitations, identifies
professional development needs and develops
a personal development plan (PDP).
Uses appropriate resources and reflective
practice to enhance knowledge and skills.
Demonstrates personal accountability for
ensuring own clinical competence.
Contributes to peri-operative teaching
programmes by promoting clinically effective
practice.
Supports and assesses learners.
Offers clinical supervision to others as
appropriate.
Participates in performance appraisal
programmes.
Develops and delivers teaching appropriate to
the PACU environment.
Demonstrates ability to develop and access
learning resources.
Maintain a personal portfolio.
Undertake appraisal and document evidence of
achievements.
9

COMPETENCY 3: CLINICAL LEADERSHIP
Competency 3 Knowledge and skills Suggested indicators
3.1 Demonstrate leadership skills in order to
enhance patient care.
3.2 Support and promote clinical effectiveness
by developing an evidence-based approach to
postoperative care.
Develops autonomy in own role within the
recovery room.
Makes effective clinical decisions and manages
resources.
Shows evidence of research awareness.
Adapts clinical practice in light of current
research.
Motivates and supports others in developing
evidence-based practice.
10

COMPETENCY 4: CLINICAL GOVERNANCE
Competency 4 Knowledge and skills Suggested indicators
4.1 Identify and manage risks and
hazards.
4.2 Understand how to recognise a
critical incident or near miss and follow
local and national reporting
mechanisms.
4.3 Participate and contribute to a
quality assurance strategy.
Understands the principles, issues
and factors relating to risk
management.
Uses knowledge appropriately to
eliminate or reduce these risks.
Understands critical incidents, their
definition, actions required including a
worked example.
Aware of local and national critical
incident reporting policies.
Uses knowledge of national and local
measures of quality assurance to
develop and participate in high
quality peer review audit.
Apply manual handling techniques appropriately using available
aids. Attend regular updates.
Demonstrate safe management of clinical waste, sharps, drugs
and chemicals.
Use personal protective equipment (PPE) and be aware of
infection control principles.
Comply with national and local guidance on single-use items and
medical device decontamination.
Report and feedback on critical incidents.
Complete local critical incident forms satisfactorily.
Critical incidents that may occur include:
Acute or sub-acute airway obstruction
Cardiopulmonary arrest
Need for cardiovascular support (inotropes, vasoconstrictors,
anti-arrhythmics)
Inadequate reversal of neuromuscular blocking drugs
Need for urgent review of patient by anaesthetist.
Need for ventilatory support (CPAP, tracheal intubation,
lung ventilation)
Severe pain that is difficult to control Unduly prolonged stay
in PACU (>2 h) Significant hypothermia (

4.4 Demonstrate and promote the
delivery of recovery care within a
professional, ethical and legal
framework.
4.5 Demonstrate personal and
professional accountability in relation
to the role of recovery of the
postoperative patient.
Discusses and applies the principles
of ethical, legal and professional
issues affecting patient care,
ensuring appropriate documentation
that follows national and local
directives. Understands the
importance of confidentiality.
Applies the principles of
accountability to the care of the
patient following surgery. Practises
within the limitations of personal
scope of practice and, where
appropriate seeks guidance and
support from colleagues when
exposed to new or unfamiliar
procedures or situations.
Awareness of concept of:
informed consent in adults and children
legal issues relating to patients with learning disabilities or mental
health difficulties
patient groups including Jehovahʼs Witnesses and advance patient
directives.
Adhere to the NMC and HPC codes of conduct.
http://www.aagbi.org/sites/default/files/Jehovah%27s%20Witnesse
s_0.pdf
Take on appropriate responsibility.
Show recognition of own limitations with reflection on
performance.
12

COMPETENCY 5: ASSESSMENT AND MANAGEMENT OF THE AIRWAY
Competency 5 Knowledge and skills Suggested indicators
5.1 Apply knowledge of the anatomy and
physiology of the upper airway
tomanagement of the airway in the PACU.
5.2 Can maintain an airway during emergence
from anaesthesia.
Understands those aspects of the anatomy of
the upper airway which are relevant to airway
management including physiological changes
to the airway postoperatively as a
consequence of anaesthesia and surgery.
Can recognise signs of upper airway
obstruction or compromised airway using the
ʻlook, listen and feelʼ approach.
Can perform simple manoeuvres to establish
a clear airway:
effective head tilt chin lift
jaw-thrust
oropharyngeal suction
insertion of an appropriate oropharyngeal
or nasopharyngeal airway.
Describe the anatomy and physiology of the
upper airway.
Discuss the physiological changes caused by
anaesthesia and surgery.
Discuss oxygen requirements in the immediate
postoperative period.
Describe signs of partial and complete airway
obstruction.
Demonstrate manoeuvres to clear the airway
on a patient or manikin as described in
immediate life support (ILS) course
curriculum.
5.2a Assist in maintaining an airway during
bag and mask ventilation.
Can hold a face mask in position, ensuring a
gas-tight seal, or perform manual intermittent
positive pressure ventilation (IPPV).
Can identify suitable breathing systems.
Can describe features of self-inflating bag and
demonstrate its use.
Demonstrate ability to perform either role in
two-person bag and mask ventilation as
described in the immediate life support (ILS)
course curriculum.
Demonstrate bag-valve-mask (BVM)
technique for ventilatory support using an
Ambu self- inflating bag or similar.
Explain need of proficiency in this skill in the
theatre suite, PACU and during intra-hospital
patient transfer.
13

5.3 Understands features of oxygen delivery
equipment.
Demonstrates familiarity with and use of
face masks: (types, design features, including
fixed and variable performance designs).
nasal cannulae
nebulisers
breathing circuits including T-pieces
piped gases and oxygen flowmeters
oxygen cylinders.
Choose an oxygen delivery system appropriate
for a particular patient.
Explain rationale behind choice.
5.4 Can set up and assist the anaesthetist with
emergency intubation of the trachea.
Sets up intubation equipment tray / trolley. Able
to test the equipment.
Can select appropriate tracheal tube (TT).
Positions the patient appropriately and assists
the anaesthetist with routine intubation of the
trachea.
Assist in elective intubation of patient or
manikin.
Calculate TT size (diameters and lengths)
using standard formulae.
Explain morbidity associated with use of
incorrect tube size.
5.5 Ability to select appropriate airway
equipment for use in an emergency.
Demonstrates detailed knowledge of
emergency airway equipment, including salient
features of each and their use.
Demonstrates detailed knowledge of laryngeal
mask airway (LMA), TT and other methods of
securing the airway.
Describe indications for use of straight and
curved bladed laryngoscopes, specialised
laryngoscopes, forceps, bougies and
introducers.
Describe indications for the use of
LMA
intubating LMA
TT (including double lumen, RAE and
microlaryngeal tubes)
cricothyroidotomy and tracheostomy.
14

5.6 Demonstrate ability to place a LMA
in an adult patient.
5.7 Awareness of risks and complications of
removing an airway.
Ability to assess when it is safe to do so.
5.8 Ability to prepare and check appropriate
suction equipment.
Demonstrates LMA placement in an adult
patient equating to ILS course standard. (PACU
staff need to be proficient in using an LMA in an
emergency).
Objectively assesses patientʼs neuromuscular
function.
Prepares and positions patient for removal of
airway devices.
Appropriate airway management following
removal.
Demonstrates knowledge of types of suction
catheters and their appropriate use.
Site an LMA in a manikin.
Demonstrate appropriate management for
removal of airway devices.
Describe the range of suction equipment
available. Demonstrate the assembly and use
of appropriate equipment.
5.9 Ability to prepare and check appropriate
airway equipment.
Demonstrates knowledge of oxygen
administration devices and masks.
Describe the range of airway equipment
available. Demonstrate the assembly and
correct use of appropriate devices.
15

COMPETENCY 6: ASSESSMENT AND MANAGEMENT OF BREATHING
Competency 6 Knowledge and skills Suggested indicators
6.1 Can apply knowledge of the anatomy and
physiology of the respiratory system to
assessing the adequacy of breathing in
patients in the PACU.
6.2 Can apply knowledge of effects of
pharmacology of anaesthetic agents and of
surgery upon the respiratory system.
Understands those aspects of the anatomy and
physiology of the respiratory system in
controlling breathing.
Understands effects of anaesthesia and
surgery on respiration.
Understands the effects of anaesthesia and
surgery on respiratory function.
6.3 Can assess respiration. Describes postoperative patterns of respiration.
Describe the signs of obstructed breathing.
Can describe, identify and use equipment used
for assessing the respiratory system.
Describe the anatomy and physiology of the
respiratory system.
Discuss the physiological changes caused by
anaesthesia and surgery and the changes in
oxygen requirements in the immediate
postoperative period.
Describe the signs and symptoms of
inadequate reversal of neuromuscular blockade
and central respiratory depression. See
competency 11.
Describe the mechanism of inspiration and
expiration and factors controlling respiration.
Assess the airway, chest movement,
respiratory rate, rhythm and colour.
Accurately measure respiratory rate.
Can identify use of accessory muscles and
presence of tracheal tug.
Demonstrate safe use of pulse oximeters and
stethoscopes.
6.4 Can identify patients with pre-existing
respiratory disease.
Recognises patients with pre-existing
respiratory disease and the effects of surgery
and anaesthesia.
Identify and demonstrate appropriate
management of patients with respiratory
insufficiency.
6.5 Can identify patients at risk of postoperative
hypoxia and manage appropriately.
Can identify signs and symptoms of hypoxia,
respiratory depression and impending
respiratory failure.
Understands the use of appropriate monitoring
equipment.
Describe hypoxia and cyanosis. Uses
Use pulse oximetry and capnography
appropriately.
16

COMPETENCY 7: ASSESSMENT AND MANAGEMENT OF THE CIRCULATION
Competency 7 Knowledge and skills Suggested indicators
7.1 Can apply knowledge of the anatomy and
physiology of the cardiovascular system to
manage cardiopulmonary circulation in the
PACU.
7.2 Can measure arterial pressure in
postoperative patients and recognise
deviations from the norm.
7.3 Understand use of intravenous fluids to
support the circulation.
7.4 Understands the use of vasoactive drugs
to treat heart rate and arterial pressure in the
PACU.
Understands those aspects of the anatomical
and physiological changes to the
cardiovascular system postoperatively as a
consequence of anaesthesia and surgery.
Measures arterial pressure and assess
peripheral perfusion.
Understands the importance of autoregulation
and factors that affect it.
Describes signs of circulatory abnormalities.
Can perform manoeuvres to support circulation
appropriately.
Demonstrates knowledge about:
intravenous infusion sets
fluid bags
pressure bags and infusors
fluid warmers.
Knows where the drugs are located.
Understands methods of administration of:
atropine
glycopyrronium
metaraminol
ephedrine
adrenaline
GTN.
Describe the anatomy and physiology of the
cardiovascular system.
Discuss the physiological changes caused by
anaesthesia and surgery.
Describe common circulatory problems
encountered in the immediate postoperative
period.
Demonstrate ability to measure and interpret
arterial pressure in the postoperative period
and communicate with relevant staff.
Demonstrate appropriate management to
optimise circulation.
Demonstrate manoeuvres to correct circulation
such as elevation of legs, Trendelenberg and
reverse Trendelenberg.
Explain use of appropriate fluids for different
patient groups.
Explain rationale of choice of fluids.
Demonstrate appropriate management of
patients requiring fluid resuscitation.
See competency 10.
Identify and describes preparation and
indication for each drug according to local drug
protocols.
17

COMPETENCY 8: ASSESSMENT OF LEVEL OF CONSCIOUSNESS
Competency 8 Knowledge and skills Suggested indicators
8.1 Can assess conscious level in the
postoperative patient and take appropriate
action.
Can use appropriate assessment tools.
Understands the effects of anaesthesia and
surgery on the level of consciousness.
Understands locally and nationally used
assessment tools for conscious level e.g. the
Glasgow Coma Scale (GCS) and Alert, Verbal,
Pain, Unresponsive (AVPU) scores.
Describe the relevant physiology of the central
nervous system.
Discuss the changes caused to the levels of
consciousness by anaesthesia and surgery and
describe common problems encountered in the
immediate postoperative period.
Uses appropriate assessment tools to
measure, record and interpret return to
consciousness of the postoperative patient.
18

COMPETENCY 9: MONITORING DURING RECOVERY
Competency 9 Knowledge and skills Suggested indicators
9.1 Can undertake full patient assessment on
admission to the PACU and in the immediate
postoperative period.
9.2 Demonstrate knowledge of monitoring
equipment used in PACU including normal
parameters and need for interventions when
outside these parameters.
9.2a Can establish routine monitoring.
Understands physiological consequences of
surgery and anaesthesia.
Able to use and identify abnormalities using:
Pulse oximeters including indications for
arterial blood gas sampling.
Capnographs including significance of
end-tidal CO2 values.
Invasive arterial pressure lines including
recognition and management of hyperand
hypotension.
ECG including basic interpretation of rate,
rhythm and ischaemia. Understands
indications for performing a 12 lead EGC.
Temperature probes and warming
devices.
Recognises signs and symptoms of
adequate neuromuscular function.
Urine output as an indicator of renal
function.
Able to assess wound drainage and
surgical procedure.
Demonstrate ability to assess airway,
breathing, circulation, conscious level, drug
therapy, dressings, drains and fluid balance.
Set up routine monitoring of SpO2, NIBP,
ECG and temperature.
Demonstrate ability to establish
capnography measurement, use nerve
stimulator and urimeter appropriately.
Perform 12-lead ECG and document
accurately.
Measure temperature using appropriate
equipment and take appropriate action to
maintain normothermia.
Use a urimeter.
Record wound drainage accurately. Change
drain bottles. Troubleshoot and manage
wound drainage systems.
19

9.3 Perform charting of physiological data and
describes patientʼs clinical status appropriately
to the anaesthetist and other staff members.
Understand the significance of trends.
9.4 Uses available near-patient testing as a
monitoring tool.
Can measure haemoglobin (Hb) and blood
glucose concentrations and describe risks
associated with abnormal values.
9.5 Can assist during establishment of central
venous and invasive arterial pressure
monitoring.
9.6 Able to record and interpret data from
invasive central venous and arterial monitors,
identifying values outside normal parameters.
Can set up a pressure transducer and take
blood samples from central venous and arterial
lines.
Able to chart monitor values using standard
symbols.
Recognises adverse trends which indicate risk.
Identifies common artefacts.
Describes patientʼs clinical status to the
anaesthetist. Able to alert staff to adverse
monitoring trends pre-empting development of
life-threatening emergencies.
Able to use near-patient testing for Hb and
blood glucose and describe risks associated
with abnormal values.
Shows knowledge of normal parameters and
actions to be taken when values are abnormal.
Understands relevance in paediatric patients.
Can calibrate near-patient testing machines
(using manufacturersʼ guidelines).
Able to prepare the necessary equipment.
Assists in positioning and supporting the
patient, skin preparation and helping to prevent
accidental movement during the procedure.
Shows knowledge of complications and risk
factors.
Able to recognise complications and act
appropriately.
Understands indications for invasive
monitoring.
Able to set up, attach and calibrate
pressure transducers and maintain
patency of lines. Able to take blood
samples from these lines.
Accurately monitor and record physiological
parameters.
Describe the appropriate course of action for
abnormal trends and adverse events.
Able to use Situation, Background,
Assessment, Recommendation (SBAR)
methodology to communicate with appropriate
professional colleagues.
Attain certification of competency for all nearpatient
testing equipment in use.
Describe the process and discuss the principle
risks.
Monitor and record physiological data
accurately.
Describe appropriate course of action
for adverse readings or abnormal
trends.
20

COMPETENCY 10: INTRAVENOUS ACCESS AND FLUID BALANCE
Competency 10 Knowledge and skills Suggested indicators
10.1. Can set up intravenous infusion equipment. Able to set up intravenous infusions, including
fluid-warming devices, pressure bags,
volumetric infusers and volumetric pumps.
Undertake training on equipment used
locally.
10.2 Understand basic principles and participates
in postoperative fluid management.
10.3 Knowledge of equipment associated with
transfusion of blood and blood products.
10.4 Understands the principles involved in safe
administration of crystalloids, colloids, blood and
blood products.
Understands postoperative fluid maintenance
Demonstrates ability to accurately record fluid
balance including fluid intake and losses.
Understands use of equipment for
administration and warming of blood and
blood products.
Understands clinical aspects of blood and blood
products administration including safety checks
and documentation.
Able to recognise and manage an adverse
reaction to transfusions.
Accurately monitor and record fluid balance.
Recommend appropriate measures in the
event of adverse readings and trends.
Ensure acquisition of current Better Blood
Transfusion competency.
Familiar with indications for transfusion of
Crystalloids
Colloids
concentrated red cells
platelets
fresh
frozen
plasma
cryoprecipitae salvaged red cells.
See competency 7.3.
10.5 Knowledge of safe placement and use of
nasogastric tubes.
Aware of local protocols regarding safe
administration of blood products.
Understands the rationale of use of salvaged
blood and the workings of cell-savers.
Understands the indications for the use of
nasogastric tubes and checks for accurate
placement.
http://www.aagbi.org/sites/default/files/red_cell_
08.pdf
http://www.aagbi.org/sites/default/files/cell%20_s
alvage_2009_amended.pdf
Demonstrates appropriate management of
nasogastric tubes and confirmation of
accurate placement.
21

COMPETENCY 11: APPLIED KNOWLEDGE OF PHARMACOLOGY IN PERIOPERATIVE CARE
Competency 11 Knowledge and skills Suggested indicators
11.1 Can calculate appropriate doses and
concentrations in clinical use.
11.2 Understands the clinical indications,
location, preparation, and labelling of drugs
relevant to the PACU.
Able to calculate doses and concentrations in
clinical use (as per local policy).
Prepares drugs for administration during
emergencies.
Familiar with safe practice and local policies.
Aware of clinical indications, complications,
side effects and clinical preparation of
following drugs as well as their labelling and
storage location within the PACU including
local Standard Operating Procedures for
Controlled Drugs:
antacids
inotropes
pressor agents
vasodilators
antiarrhythmics anticoagulants
bronchodilators
steroids
antibiotics
antiemetics
intravenous induction agents
anticholinergics
sedatives and their antagonists
non-steroidal analgesics
opioids and their antagonists
suxamethonium
non-depolarising neuromuscular
blocking agents and reversal agents
respiratory stimulants
local anaesthetic agents
Attain local course certification.
Describe local intravenous drug administration
policies.
22

11.3 Can set up patient-controlled analgesia
(PCA) equipment and other infusion devices.
11.4 Can set up equipment to deliver nebulised
drugs.
Understands the principles of PCA including
knowledge of PCA pumps and safety features.
Demonstrates knowledge of opioid
pharmacology.
Understands local protocols, standard
operating procedures and monitoring.
Understands the principles of epidural
administration of local anaesthetics and
opioids.
Demonstrates knowledge of pharmacology of
local anaesthetics and opioids (see
competency 11.2).
Demonstrates knowledge of pumps used for
continuous epidural analgesia infusions in line
with local protocols and monitoring.
Understands the principles of nebulised drug
administration.
Demonstrates knowledge of pharmacology of
nebulised drugs.
Understands local protocols and monitoring of
patients on nebulised drugs.
Set up a PCA pump according to local
protocols.
Monitor patient appropriately.
Attain certificate of competency in use of locally
provided PCA pumps.
Set up an epidural infusion according to local
protocols.
Monitor patients appropriately.
Attain certification of competency in use of
epidural pumps in local use.
Set up a nebuliser to deliver drugs.
23

COMPETENCY 12: MANAGEMENT OF POSTOPERATIVE PAIN, NAUSEA AND VOMITING
Competency 12 Knowledge and skills Suggested indicators
12.1 Assess and manage postoperative pain. Can describe pain pathways including
physiology of pain transmission.
Use pain scoring tool and knowledge of pain
physiology to select appropriate techniques for
pain management.
12.2 Can match prescribed analgesia to
patientʼs pain score.
Understands how the following analgesic
techniques can modify transmission of pain
sensation:
opioids
paracetamol
nonsteroidal analgesics
local anaesthetics.
Select and deliver appropriate prescription to
achieve adequate analgesia before discharge
from the PACU.
12.3 Management of side effects of analgesics. Understands side effects and complications of
the following analgesic techniques:
opioids
paracetamol
nonsteroidal analgesics
local anaesthetics.
Recognise side effects and complications
associated with administration of analgesics.
Act promptly and appropriately to minimise
morbidity.
Administer naloxone according to local
protocols.
Explain dermatome chart and the significance
of levels of neuraxial block.
Explain local protocols for management of local
anaesthetic toxicity (see competency 13.9).
24

12.4 Can manage patients with central
neuraxial and peripheral nerve block.
Understands indications, side effects,
complications and rationale for:
spinal anaesthesia
epidural analgesia
regional nerve blockade.
Is aware of specialist nursing care needed for
patients in these groups.
Explain structure and function of the spinal
column.
Explain signs and symptoms of:
dural puncture headache
high spinal block
migration of epidural catheter.
Measure sensory and motor blockade and
record extent of block using a dermatome chart.
Administers epidural top-ups in accordance
with local protocols.
12.5 Can assess PONV. Demonstrates knowledge of the physiology and
pathophysiology of PONV Including knowledge
of risk factors.
Assess and manage PONV using local
protocols and multi-modal therapy.
25

COMPETENCY 13: RECOVERY EMERGENCIES
Competency 13 Knowledge and skills Suggested indicators
13.1 Knows how to contact
anaesthetic, surgical and other
appropriate staff for assistance.
Is aware of the importance of calling
for urgent help when needed.
Well versed with local
communication protocols for
contacting appropriate clinicians.
Explain mechanisms in place to contact appropriate members of staff for
assistance.
13.2 Can perform ILS. Demonstrates knowledge of ILS.
Understands local protocols for
access and use of defibrillators
and support.
Attain current certification of attendance of locally approved ILS course –
Ref: ILS Resuscitation Council (UK).
13.3 Recognises significant
cardiac dysrhythmias.
13.4 Understands principles of
managing the shocked patient.
13.4a Recognises and
understands principles of
managing anaphylaxis.
Understands the aetiology,
relevance, and management of
significant cardiac dysrhythmias.
Understands types and grades of
shock, their significance, and
principles of management.
Demonstrate knowledge of
anaphylactic shock management
guidelines published by the
AAGBI.
http://www.aagbi.org/sites/default/files/anaphylaxis_2009_0.pdf
http://www.aagbi.org/sites/default/files/ana_web_laminate_final.pdf
26

13.5 Recognises pathophysiology
of malignant hyperthermia (MH)
including management of patient
with proven MH susceptibility.
13.6 Recognises and
understands principles of
managing suxamethonium
apnoea.
13.7 Can implement local
protocol for management of
sudden life-threatening
haemorrhage.
13.8 Can describe detailed
management of patient with latex
allergy.
Demonstrate knowledge of MH
management guidelines published
by the AAGBI.
Can prepare dantrolene in an
emergency situation.
Understands causes of
suxamethonium apnoea, its
significance and principles of
management.
Understands local protocol for
management of sudden lifethreatening
haemorrhage including
use of rapid infusors / warmers
where available.
Understands pathophysiology and
clinical management of latex allergy
including use of local protocols.
http://www.aagbi.org/sites/default/files/MH%20guideline%20for%20web%2
0v2.pdf
http://www.aagbi.org/sites/default/files/MH%20task%20allocations%20for%
20web.pdf
http://www.aagbi.org/sites/default/files/MH%20recommended%20contents
%20for%20web.pdf
Participate in local simulation using date-expired dantrolene.
Set up pressure infusors for rapid infusion of fluids.
Explain major blood transfusion protocols.
Explain rationale and use of tourniquets and pressure dressings to reduce
blood loss.
Identify latex allergy patient and explain risk factors.
Source and prepare equipment and environment safe for use in patients
with latex allergy.
13.9 Can describe detailed
management of patient with local
anaesthetic toxicity.
Demonstrates knowledge of
severe local anaesthetic toxicity
management published by the
AAGBI.
Be aware of location of Intralipid.
http://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf
http://www.aagbi.org/sites/default/files/la_toxicity_notes_2010_0.pdf
27

13.10 Short term management of
a patient requiring unexpected
ventilation in the PACU.
13.11 Understand appropriate
specialty specific complications,
side effects and principles of
management.
Understands the indications for
short-term postoperative
ventilation.
Demonstrates knowledge of local
protocols including documentation
and relevant nursing interventions
in these patients.
Fat embolism
Pulmonary embolism
Amniotic fluid embolism
Glycine induced
hyponatraemia
Orthopaedic cement
Unstable cervical spine.
Prepare a recovery bay, ventilator and essential equipment for
postoperative ventilation.
Describe local protocols for the care of a ventilated patient in the PACU.
Seek appropriate support from other clinical staff as appropriate.
Explain local protocols for these complications.
28

COMPETENCY 14: POST SURGICAL CARE
Competency 14 Knowledge and skills Suggested indicators
14.1 Thromboembolic
prophylaxis.
14.2 Management of
normothermia.
14.3 Management of the
diabetic patient.
Demonstrate knowledge of risk
factors and current local
prophylaxis regimens and
understand clinical reasons for
variance.
Understands importance of
normothermia and indications for
intra-operative hypothermia and
postoperative management.
Understands importance of
normoglycaemia and use of
insulin infusion pumps. Able to
determine blood glucose levels
using near-testing equipment.
Adherence to current thromboembolic prophylaxis regimens.
Use of available equipment to promote normothermia and hypothermia
where clinically appropriate.
Maintenance of normoglycaemia in diabetic patients with appropriate
intervention of clinicians to maintain normoglycaemia. Institute therapy to
maintain normoglycaemia in diabetic patients using appropriate, protocols,
equipment and clinical guidance.
14.4 Surgical site inspection. Ability to assess the operative site
including dressings for
complications.
Communicate effectively between theatre teams and PACU staff with
regard to surgical site and dressing complications. Establish parameters
for surgical interventions.
14.5 Orthopaedic and other
stabilising casts.
Recognises poor circulation
secondary to oedema or failing
circulation.
Explain clinical signs and symptoms of complications associated with the
use of plasters, casts and splints.
14.6 Circulatory observations. Observes peripheral circulation and
pulses.
Explain use of ultrasound Doppler and appropriate charting to
demonstrate adequate peripheral circulation and demonstrate an
understanding of the limitations of Doppler assessment.
29

14.7 Urinary catheters and
bladder irrigation systems.
Accurately documents urinary
output and demonstrate
understanding of bladder irrigation
systems with knowledge of
including issues associated with
poor output.
14.8 Wound drainage. Accurately records wound drainage
and understands the principles of
reinfusion systems.
Demonstrates understanding of
individual patient parameters where
surgical intervention may be
appropriate.
Accurately document urine output.
Use bladder irrigation systems and indicate clearly need for surgical
intervention.
Explain factors requiring intervention while monitoring wound drains.
14.9 Specialist dressings. Demonstrate knowledge of
surgical specific dressings.
14.10 Surgery specific care. Demonstrate knowledge of
surgical specific care required
by individual patient.
30

APPENDIX 1
Stakeholder groups consulted were:
Association for Perioperative Practice
British Anaesthetic and Recovery Nurses Association
College of Operating Department Practitioners
Royal College of Nursing
Royal College of Surgeons
31

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

INDEPENDENT PRACTICE
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
www.aagbi.org
April 2008

Members of the Working Party
Dr W Harrop-Griffiths (Chairman) Honorary Secretary, AAGBI
Dr D K Whitaker
Dr D Bogod
Dr M Wee
Dr D Dickson
Dr S McDevitt
Dr N Denny
Dr M Ward
Dr J Carter
President, AAGBI
Editor-in-Chief, Anaesthesia
Vice President, AAGBI
Council Member, AAGBI
Council Member, AAGBI
Council Member, AAGBI
Former Vice President, AAGBI
Former Vice President, AAGBI
Ex Officio
Dr I Wilson
Dr I Johnston
Dr R Birks
Dr L Gemmell
Honorary Treasurer, AAGBI
Honorary Membership Secretary, AAGBI
President Elect, AAGBI
Honorary Secretary Elect, AAGBI

Contents
Key Points 2
Introduction 3
Good Practice 5
Getting started in Independent Practice 9
Billing issues in Private Practice 13
Indemnity for Independent Practice 14
Independent Medicolegal Practice 16
Independent Practice in Pain Medicine 20
Independent Practice in Intensive Care 22
Chambers and Group Practice 26
Resources and Useful Contacts 29
1

Key Points
• Independent practice should only be conducted by fully trained and
suitably experienced doctors. The minimum requirements include
a registerable medical degree, FRCA or equivalent, a certificate of
completion of training or equivalent, and entry in the appropriate
specialist register of the General Medical Council.
• Maintenance of the highest possible standards of ethics, medical
care and clinical governance is mandatory in the performance of
independent practice, as it is for NHS practice.
• Consultants with NHS contracts must take every possible step to ensure
that their private practice does not adversely impact on their NHS
duties.
• Consultants should only practise in hospitals in which they have been
given practising privileges or admitting rights.
• Consultants conducting private practice should have appropriate
medical indemnity.
• Consultants should keep clear and accurate records of their private
practice activities.
• Groups or partnerships of consultants should be established under
legally acceptable agreements.
2

Introduction
Information about independent practice is not commonly available and yet
it is often the subject of questions asked by members. The purpose of this
booklet is to provide a background to independent practice in Great Britain
& Ireland and to provide advice and guidance for those consultants involved
in private practice.
Before the start of the National Health Service in 1948, independent practice
was the main source of income for anaesthetists in this country. With the
advent of the NHS, a number of provident societies merged to form the
British United Provident Association (BUPA) to preserve freedom of choice in
healthcare and to help patients afford choice in terms of where, when and by
whom they were treated. BUPA had some 80% of the insurance market in the
1950s, and private practice represented about 6% of acute medical activity,
largely concentrated in the major metropolitan centres. At this time, insurers
provided patients with a single combined benefit towards both anaesthetist’s
and surgeon’s fees, and it was not until 1975 that, following successful
representations by the AAGBI, this was divided into separate surgical and
anaesthetic benefits.
In 1975, the health minister Barbara Castle closed all pay beds in NHS
hospitals, and this resulted in a major expansion of independent hospital
facilities, rapidly doubling the number of private beds. BUPA purchased its
first group of hospitals, and US businesses invested heavily to establish what
is now the largest hospital provider (BMI/Netcare) and other hospital groups.
This considerably improved the quantity and quality of private facilities
available. The current size of the UK private healthcare market is around £4
billion, with 7.5 million insured patients (12.7% of the population). About 2.8
million patients are insured by BUPA, who now have 41% of the insurance
market. About 19% of the market is self-pay.
As with any activity, there are pros and cons to independent practice.
The advantages include additional income, more clinical freedom and an
opportunity to develop closer relationships with colleagues and patients. The
disadvantages include the additional time spent in practice, out-of-hours and
antisocial working, and a need for flexibility. Consultants may also need to
be on call for their private patients and will work more often on their own.
Anyone doing private practice will be required to pay a higher medical
3

indemnity subscription, have more complicated accounts and must make sure
that their private work does not conflict with their NHS contract.
The main purpose of private practice is the income that it generates. No
consideration of private practice is complete without a clear description of
the difference between benefits and fees.
Benefits are what insurance companies pay out on behalf of patients according
to the terms of their policy contract with them.
Fees are what consultants charge patients for their professional services.
These two terms should never be confused, and they should not be used
interchangeably. Most private medical insurers (PMIs) make their benefit
schedules available to consultants. Some, such as the Western Provident
Association (WPA), make their schedule publicly available (http://www.wpa.
org.uk). A small number of PMIs do not publish their benefit schedules. The
AAGBI is of the view that all PMIs should make their benefit tables public.
No organisation can set consultants’ private practice fees. If any membership
organisation such as the AAGBI were to attempt to set fees, it would attract
unwelcome interest from the Office of Fair Trading (OFT). It is for the
individual consultants to determine their own fees themselves.
Anyone considering conducting private practice should consider the matter
fully before embarking on it. Although it provides financial and other rewards,
it demands the very highest ethical, clinical and financial standards. Private
practice income is difficult to estimate accurately over time, and the private
practitioner must always put clinical governance and cooperation with
colleagues ahead of financial gain.
4

Good Practice
Doctors should treat their private patients to the same clinical standards
that they treat their NHS patients and vice versa. Therefore, all the guidance
documents and recommendations that set standards of care for NHS patients
should be presumed to be valid for private patients. Guidance documents
for anaesthesia are issued by the Royal College of Anaesthetists (RCoA), the
AAGBI, the British Medical Association (BMA) and the General Medical
Council (GMC). The Healthcare Commission (HCC) has responsibility
for setting and assessing standards in the private sector as well as in the
NHS. The National Institute for Health and Clinical Excellence (NICE) also
produces recommendations, most of which are directly relevant to the private
sector. The websites of all these bodies are given in the Resources Section.
The anaesthetist in private practice should be well versed in all relevant
publication and national guidelines. Active membership of subspecialty
societies is strongly recommended in order to maintain current knowledge in
the areas of practice conducted in both public and private sectors.
Practising anaesthesia in private hospitals commonly involves working in
isolation, often being the only anaesthetist in an operating theatre suite or in the
whole hospital. The qualifications necessary for appointment to a substantive
NHS Consultant Anaesthetist should be considered those necessary to provide
private anaesthetic care: a registerable medical degree; FRCA or equivalent
qualification as judged by the RCoA; a Certificate of Completion of Training
(CCT) or equivalent; entry as an anaesthetist in the Specialist Register of the
GMC. Some private hospitals only award practising privileges to doctors
who hold or who have held a substantive consultant appointment in an NHS
hospital; others consider this not to be necessary.
Anaesthetists who do private work should be appraised to standards similar
to those pertaining in the NHS. If the anaesthetist holds an NHS contract,
appraisal should prove easy to arrange. If the anaesthetist practises only in
the private sector, he or she should make arrangements to be appraised by
a suitably trained and certified colleague. The anaesthetist should maintain
appropriate Continuing Professional Development training in subspecialties
practised in the private sector and should be prepared to prove this to the
appropriate authorities.
5

Anaesthetists practising in the private sector should adhere and conform to
appropriate Clinical Governance requirements as determined by the private
hospitals and agreed by the Medical Advisory Committees of these hospitals.
Anaesthetists should only practise in private hospitals in which they have been
awarded Admitting Rights or Practising Privileges. They should conform to the
regulations and guidelines adopted by the private hospital. The private hospital
has the responsibility for ensuring that the Medical Advisory Committee has
approved these regulations and guidelines, and that all anaesthetists are
informed of the regulations and guidelines relevant to them. The hospital
should make the anaesthetist aware of its disciplinary procedures. There have
been instances of private hospitals demanding that consultants make all the
details of their annual appraisal available. The AAGBI believes that the details
of an anaesthetist’s appraisal documentation are confidential, but that it is
reasonable for a hospital to be given written confirmation that an anaesthetist
has successfully undergone an appraisal process.
An anaesthetist should not undertake cases in the private sector for which he
or she is not appropriately trained, experienced and in ongoing practice. This
usually means that an anaesthetist who has an NHS appointment will have a
similar clinical portfolio in both sectors. Anaesthetists should keep a logbook
of cases done in the private sector and should be prepared to provide the
information contained therein to appropriate supervising bodies.
The anaesthetist has an ongoing clinical responsibility to a private patient
that continues into the postoperative period. However, this responsibility
has limits, and we suggest that the anaesthetist makes the limits clear to the
surgeon and other healthcare professionals involved in the patient’s care.
Such limits may be:
• Until postoperative high dependency or intensive care is no longer
needed or is handed over to an intensivist or another anaesthetist.
• For patients not requiring intensive or high dependency care, the limits
of the anaesthetist’s care may be when the patient is:
- Awake and discharged from the recovery room
- Physiologically stable and satisfactory
- Free from significant postoperative pain, nausea and vomiting
- Not receiving intravenous opioid treatment, e.g. patient-controlled
analgesia
6

- Not receiving neuraxial or peripheral local anaesthetic infusions
- Free from the short-term effects of peripheral or neuraxial
nerve blocks
Any care provided by an anaesthetist beyond these limits may be separately
chargeable if the patient has been warned of this before treatment. It is
reasonable to expect an anaesthetist to be available for a private patient for
the period during which the early and predictable complications of surgery
may occur. However, we suggest that this period should not normally exceed
24 – 48 h and should certainly cease at the discharge of the patient from
hospital.
For anaesthetists who work in both the NHS and the private sector, there will
be times at which the demands of these two practices will seem to clash. The
New Consultant Contract is specific about the conduct expected of an NHS
consultant with regard to private practice. A copy of the contract and specific
guidance can be found on the BMA website. The following general points are
worthy of consideration:
• Private practice should not normally be conducted in contracted NHS
hours but may on occasion be acceptable provided it causes minimal
disruption and has the support of both colleagues and managers.
• Scheduled private practice should not normally be undertaken when
on call for NHS patients. However, if the private practice is performed
in the consultant’s base NHS hospital, this may be acceptable to
colleagues and managers.
• The BMA Code of Conduct for Private Practice states that “There
will be circumstances in which consultants may reasonably provide
emergency treatment for private patients during time when they are
scheduled to be working or are on call for the NHS. Consultants should
make alternative arrangements to provide cover where emergency
work of this kind regularly impacts on NHS commitments”. If one of
your existing private patients unexpectedly develops a complication
that requires the urgent presence of an anaesthetist, it is therefore
acceptable to leave NHS duties or to delay them provided adequate
cover is given for those NHS patients under your care. Under these
uncommon circumstances it might be acceptable to delay the start of
7

an elective list; it would not be acceptable to abandon an NHS patient
in an operating theatre or recovery room unless a suitable colleague is
willing and able to take over care.
Good practice in the private sector involves treating all patients to the highest
standards while maintaining appropriate skills and knowledge. Patients
in both the NHS and private sector are entitled to high standards of care
provided by competent professionals.
8

Getting started in Independent Practice
Before embarking on independent practice, it is important to get advice from
a chartered accountant about your tax situation and to get advice from one of
your colleagues who is an experienced independent practitioner. If you have
joined a group practice, then the best person to ask may be the person who
runs the group.
Admitting rights
Before you can work in a private hospital, you will need to obtain what
are variously known as admitting rights or practising privileges. All private
hospitals should have a Medical Advisory Committee (MAC) that comprises
consultants of all subspecialties, one of whom will be the chairman. The
senior manager of the hospital should grant practising privileges to consultants
who meet the standards set by the MAC. Practising privileges are not awarded
by right; some hospitals may refuse to award them even to consultants who
meet the criteria set by the MAC. The private hospital will provide you with
the necessary application forms on request. It may be a good idea to make an
appointment to meet with the senior manager of the hospital before seeking
practising privileges. Take advice on this from a colleague who already
works in the hospital. The hospital’s requirements for the award of practising
privileges are likely to include:
• A curriculum vitae
• Documentary evidence of relevant qualifications and completion of
subspecialty training
• A current and valid GMC certificate
• Proof of membership of a medical defence organisation (MDO)
• Evidence of hepatitis B immunit
• Proof of recent successful appraisal
• A Criminal Records Bureau (CRB) Enhancement Disclosure or the
following documents that will allow the hospital to acquire one:
o A completed CRB application form
o A passport, driving licence and recent utility bill confirming
home address
9

Some of these documents will need to be updated annually, and you
should expect the hospital to ask for ongoing evidence that you fulfil their
requirements for the maintenance of practising privileges.
Registration with PMIs
Before a PMI will pay you directly for treating their customers, you will need
to register with them. This may involve providing copies of documents that
will satisfy the PMI that you are suitably qualified to provide medical care to
their customers. A list of the larger PMIs along with their contact details is
provided in the Resources Section.
Accountants
All consultants conducting private practice should seek and heed advice from
an accountant with experience in private medical practice. Accountants will
provide invaluable advice on billing, banking, taxation and expenses. They
will also be very helpful when planning pensions and eventual retirement from
both NHS and private practice. The fee that an accountant charges for work
done that relates to private medical practice is a tax-deductible expense.
Billing
The keeping of accurate records is the key to efficient billing. You should keep
a record of the following for every patient you treat:
• Name
• Address
• Telephone numbers
• Date of birth
• Insurance details (PMI, registration number, authorisation number)
• Date of procedure
• The hospital at which the procedure was performed
• Surgeon (if any)
• Procedures performed (both narrative and OPCS codes)
• Any unusual occurrences or circumstances
10

A logbook or database that contains this information will obviously contain
confidential information. Electronic records come under the terms of the
Data Protection Act, and appropriate registration and data protection are
required. A secure backup of all data should be kept. Many consultants
starting in private practice choose to do their own billing and to keep their
own accounts. The consultant should keep precise and careful records of
the date and amount billed, and the date and amount received. Commercial
software packages are available that will facilitate this process. However,
as practice volumes in increase, many opt to pay others to do their billing
and financial record-keeping. An increasing number of commercial billing
services are available. Consultants working in a partnership or group practice
often directly employ someone to do the billing or have an established
arrangement with a commercial billing service. Consultants whose wives,
husbands or partners have no income or whose earnings are less than the
threshold for higher-rate income tax may benefit financially from paying their
partners to do the billing.
Setting fees
Each consultant should determine his or her own fees. Agreeing with a group
of local consultants to charge the same fee as other group members can
be considered anti-competitive and should be avoided unless the group is
trading as a partnership with an established legal identity. If there is doubt
about the trading status of a group of anaesthetists, expert legal advice should
be sought.
Banking
Take advice from your accountant on how to manage your bank accounts.
Most consultants who conduct private practice maintain a separate bank
account that is wholly dedicated to their private practice. You should keep a
full and accurate record of all payments into this account and all payments
made from it.
Tax
Never forget that you will have to pay tax on the money that you have earned,
so take advice from your accountant. Many wise anaesthetists ring-fence 40%
of their private practice income in a separate account so that they always have
the money available to pay the tax when a demand arrives on the doorstep.
11

Investigations by the Inland Revenue
Every year, a number of doctors is investigated by the Inland Revenue. Most
are chosen at random, some are chosen because they have drawn attention to
themselves in some way. A tax investigation is time-consuming and costly for
the individual concerned. It is possible to take out an annual insurance policy
to cover the costs of an investigation; consultants should consider taking out
this sort of insurance.
12

Billing issues in Private Practice
The publication of this guideline document coincides with that of the “AAGBI
Voluntary Code of Practice for Billing Private Patients”, to which the reader
should refer for advice on billing in independent practice.
It is illegal for the AAGBI or any other professional body to set medical fees.
However, the individual anaesthetist is free to set his or her fees according to a
variety of factors that he or she may feel are pertinent. These might include:
• The time taken to provide the service, including pre-operative, intraoperative
and postoperative care
• The training, qualifications and experience necessary to provide
medical care safely
• The complexity of the medical care provided
• The rarity of the anaesthetic skills necessary to provide safe and
effective care.
• The risk to the patient of the procedures being performed
• The time of day and day of the week that the service is provided and
the degree of surgical urgency
• The risk to the anaesthetist of providing the service
Anaesthetists should review their fees on an annual basis.
There are occasionally problems when privately insured patients are admitted
to NHS hospitals with medical conditions requiring emergency surgery.
Most of these patients are entitled to be treated by the NHS without charges
being made. Some patients in these circumstances choose to be treated on
a private basis. In general, PMIs will not pay benefits to anaesthetists under
these circumstances unless the patient signs a declaration that they wish to
be treated privately. If the patient is incapable of expressing such a wish or
signing such a form but his or her next of kin requests private treatment, the
next of kin should sign a declaration waiving NHS treatment and requesting
private treatment. Such declarations should be acquired before treatment is
given.
13

Indemnity for Independent Practice
Under NHS indemnity, NHS bodies take direct responsibility for costs and
damages arising from clinical negligence in which employers are vicariously
liable for the acts and omissions of their healthcare professional staff, including
locums whether “internal” or provided by an external agency. An anaesthetist
employed by one Trust working in another Trust as part of a formal agreement
between the Trusts is also covered by NHS indemnity. A consultant
undertaking contracted NHS work in a private hospital would also normally
be covered by the NHS Litigation Authority (NHSLA). NHS indemnity does not
cover the defence of staff involved in disciplinary proceedings conducted by
statutory bodies like the GMC, police investigations arising from professional
practice or Good Samaritan acts. Clinical negligence means actual or alleged
negligence or breach of duty in connection with the provision of clinical
services. A Good Samaritan act is the provision of clinical services related to
a clinical emergency, accident or disaster when the anaesthetist is not present
in his or her professional capacity but as a bystander. NHS indemnity does not
normally extend to private practice, whether conducted in the independent
sector or in NHS hospitals.
It is therefore essential for all anaesthetists, especially those undertaking private
practice, to be a member of a medical defence organisation (MDO) or have
some other form of appropriate insurance cover. This indemnity will cover
clinical negligence claims, complaints procedures, Good Samaritan acts,
advice on legal and ethical dilemmas arising from professional practice, GMC
enquiries, disciplinary procedures, inquests and fatal accident enquiries, and
police investigations arising from professional practice. Absence of protection
will leave the anaesthetist exposed in the event of a claim, and this may lead
to professional and financial ruin.
In the UK, there are three main MDOs – the Medical Defence Union (MDU),
the Medical Protection Society (MPS) and the Medical and Dental Defence
Union of Scotland (MDDUS). All three organisations are mutual companies
and they do not have legally binding contracts with their subscribers. Their
benefits are discretionary on the decision of their boards. In choosing suitable
cover, one should carefully consider not just the actual costs but also the
detail of the benefits and services offered by the company. The subscriptions
for the above three medical organisations are based on a scale according to
specialty and private income, excluding income from medicolegal work and
14

taking into account legitimate private practice expenses. It is also important
to note that, in the event of a claim, the MDO will require documentary proof
that the full subscription had been paid for indemnity cover. Subscriptions to
MDOs are allowable expenses against private practice earnings.
Policies with commercial companies are on a ‘claims made’ basis. This means
that the insured doctor is only covered for claims arising from incidents
which both occur and are reported whilst the policy is in force. When the
policy expires, so does the cover unless a run-off payment is made. The
mutual organisations offer ‘occurrence or incident-based’ schemes that
give protection for claims arising from incidents that occurred during the
subscription period no matter when they are reported, even if it is many
years after that subscription had ceased. These provide ongoing protection at
retirement or death – the latter prevents one’s estate being liable for claims.
The MDU introduced a version of ‘claims made’ membership in 1992, known
as contemporary, which offered lower subscriptions, particularly in the first
five years. The cover for this policy ceases unless a run-off payment is made
and this is equivalent to approximately one year’s normal premium. When a
doctor switches to another organisation or company, his or her previous risk
is usually covered by the new organisation or company. It is wise to get this
confirmed in writing from the new organisation or company.
It is not possible to cover all aspects of indemnity in the NHS or private
practice in the limited confines of this guidance and some aspects are
complex. Readers are advised to consult the relevant defence organisations
for further information pertaining to their personal circumstances from the
web addresses given in the Resources Section.
15

Independent Medicolegal Practice
Medicolegal work can be divided into personal injury and negligence. The
former entails examining clients who are making claims for injuries that they
have sustained outside the medical arena, often occupational in nature, e.g.
repetitive strain injury or back pain, or following an accident, e.g. whiplash
or nerve damage leading to a chronic regional pain syndrome. While much
of this work is performed by orthopaedic colleagues, it can provide a useful
source of income for the chronic pain specialist, who will often encounter
patients in need of a report in the course of their daily duties.
However, this section of the guidance is about clinical negligence work and
the role of the medicolegal expert. There are some misconceptions about
medicolegal experts, so let’s deal with these first.
You have to be old to be an expert. No, in fact any consultant anaesthetist
is, almost by definition, an expert in anaesthesia, although not necessarily an
expert in all branches of anaesthesia – it is unwise to stray outside those areas
of practice that you encounter on a regular basis. An expert has to be able
to: derive a likely sequence of events from a bundle of documents, largely
clinical records; explain those events in terms that an intelligent layman
can understand; decide (often by reference to the literature) whether the
standard of care contained in those events would be regarded as acceptable
practice by a reasonable body of his or her peers; write all of this down in a
logical, accessible manner; and – very rarely – hold his or her own in what
many regard as the ultimate viva voce, the conference with Counsel or an
appearance in the witness box. Yes, your qualifications and expertise will be
compared to those of the expert retained by the other side, but this is a very
minor issue; the calm, honest, modest and well-prepared expert will always
come over well.
Experts sell their souls to the lawyers. This is completely untrue. Expert
witnesses have always been meant to be impartial and, whichever side has
instructed them, their report should be neutral. This has, in the past, been more
honoured in the breach than in the observance, but recent guidance from the
Department of Constitutional Affairs, in the form of the Civil Procedure Rules
means that the expert’s duty to the Court has been formalised, and the days
of the so-called ‘hired gun’ are well and truly over. Modern experts should
16

eschew being labelled as ‘claimant’ or ‘defence’ practitioners. Indeed, recent
reforms mean that they might even be instructed jointly by both sides.
Do I want to do it?
Expert witness work has some distinct advantages. You are not beholden to
surgeons for independent income, and the bulk of the work can be done from
the comfort of your own home. The research needed to produce a report
can be enlightening and educational in its own right. The rewards can be
substantial, although you will be fortunate indeed to achieve an hourly rate
that matches that of independent clinical practice.
However, it is not an easy option. Deadlines are rarely flexible and recent
reforms have made them tighter than ever. There can be no short-cuts in
writing a report; flaws are very quickly and publicly shown up if the case
gets to Court. Reports are very rarely unchallenged, even by the team that has
instructed you, so if you find it difficult to accept criticism, this is not a job
for you. Good organisational skills are essential, especially as your practice
expands, and you will need a well-ordered and persistent billing service. And,
of course, medicolegal practitioners can get into very hot water indeed if they
are perceived as having stepped outside their field of expertise.
So how do I get started?
Word of mouth remains the best way to get your first instructions. Somewhere
near you is an expert in anaesthesia with more work than he or she can
handle. Ask them if you can help out, or offer to write a draft report on
a simple case so that they can get an idea of your abilities. Solicitors are
looking for someone who can deliver a sensible, logical, readable report that
addresses the key issues, who can do it on time, and who will not overstate
the strengths of the case only to retract later when under pressure.
In the past, most experts have learned on the job, but this is far from ideal,
and there are now courses that the aspiring practitioner can attend. Action
Against Medical Accidents (AvMA) have transformed over the years from an
aggressive pressure group into a powerful and respectable training and policysetting
organisation. Details of courses, including ‘Getting Started as a Clinical
Negligence Expert’, can be found on their website. Other commercial bodies
offer similar courses and even the chance to stand up and be cross-examined
in a court hired for the day, although the costs can be rather prohibitive.
17

Moving on
There are also organisations out there that act as forums for medicolegal
practitioners and represent their interests, such as the Academy of Experts
and the Expert Witness Institute. These bodies provide useful advice to
their members, and membership – which requires references from solicitors
and/or barristers – is an indication to instructing solicitors that you know
what you are doing. They represent a useful next step to advancing your
medicolegal career, although very few solicitors will instruct you on the basis
of membership of one of these organisations alone. AvMA holds a register of
practitioners that does appear to be widely used by claimant solicitors looking
for an expert. Inclusion is out of the expert’s control but seems to be based
on a good history of producing high quality reports. The Resources Section
contains website addresses for the organisations mentioned above.
As timeframes for conducting cases and costs are being forced down by the
courts, solicitors are looking more avidly for fast turn-around times and low
costs when selecting experts. A fixed-price preliminary report is now often
the first recourse for the solicitor who wants a quick opinion as to whether
a case has merit, and this approach has been sanctioned by the courts and
professional bodies. The ability to provide a two = to three-page report
within two weeks of receipt of records often leads to further instruction in the
same and other cases, although this does need careful organisation and time
management.
A final word of caution
As with every other area of medical practice, there are great pressures to
reduce the amount of money that doctors can earn as experts. The Legal
Services Commission (formerly the Legal Aid Board) has stated that expert
fees should be capped at levels that are far below the sort of rates currently
charged, and are actively in consultation to achieve this end. At the same
time, there is a drive towards improving quality by introducing accreditation,
through a process that is still far from clear.
You will, of course, have taken out professional liability insurance with
one of the MDOs for your clinical practice, but be aware that this does not
necessarily provide cover for medicolegal work. You can fall foul of doctors
whom you have unfairly castigated in a report, of patients who feel that you
have not been sufficiently supportive of their claim, or of lawyers who are
18

dissatisfied with the service you provided. Medicolegal insurance is available
from all the major MDOs and costs very little – make sure you are covered!
It is tempting to take on every case that comes through your door – after all,
it is flattering to have your opinion sought. However, always ask yourself the
following questions before agreeing to help:
• Can I deliver within the requested time-frame?
• Is this within my area of expertise?
• Do I have any conflict of interests, e.g. close friendship or professional
relationship with any of the doctors involved?
• Can I take on the extra work that will inevitably arise through requests
for clarification, further comments, responses to challenges from the
other side, conferences with Counsel, and Court appearances?
19

Independent Practice in Pain Medicine
Independent practice in Pain Medicine should only be undertaken by those
with the appropriate training and experience. In most cases this will mean
that the consultant holds or has held a substantive NHS consultant post that
includes regular work in this subspecialty.
Standards of practice
There should be no difference in the standard of care provided to NHS or
private patients. Similarly, clinical pain medicine decision-making and casemix
should be similar for an individual consultant in both public and private
sectors. The only exception to this would be differences in care relating to the
time available to consult with the patient, the limitations of waiting lists and
the form of therapies funded by the NHS and PMIs.
Clinic facilities
Clinics should be held in an environment in which access to adequate and
appropriate support facilities is available. This should include adequate
facilities for consultation and examination of patients, chaperone facilities,
resuscitation equipment and access to appropriate clinical investigations.
Facilities for more complex investigations and scans should be available but
not necessarily present on site.
Interventions
If any form of intervention is undertaken, suitable sterile conditions, equipment
and nursing support should be available, along with recovery facilities if
sedation or anaesthesia is given. Major interventions may demand operating
theatre facilities, trained nurses and radiological facilities. Patients should
follow a defined and documented pathway of pre-operative assessment,
informed consent, procedure, recovery, ward care and discharge.
Mode of practice
When practising in pain medicine, the anaesthetist’s mode of practice more
resembles that of a surgeon than an anaesthetist. A pain specialist will need to
arrange for outpatient consultation facilities to be made available by a private
hospital or he or she may rent private consulting rooms. Referrals will come
from General Practitioners (GPs), consultant colleagues, physiotherapists,
osteopaths or chiropractors. When the referral does not come from a GP, it
is good practice to notify the patient’s GP and to ensure that the GP is fully
20

informed about the progress of the treatment. A pain specialist may well have
to invest in secretarial and administrative support.
On-call cover
A consultant will need to be on call and available for their own patients
throughout any hospital admission. They will also need to provide some form
of availability at other times for their patients who are undergoing treatment.
It is advisable to arrange cross-cover with one or more colleagues in the same
specialty. This allows adequate cover for patients during holidays and other
absences.
Multidisciplinary work
Although it is less usual for pain consultants in private practice to run
multidisciplinary clinics, referral pathways to the relevant allied health
professionals such as physiotherapists, occupational therapists, psychologists
and pharmacists should be available in order to provide appropriate standards
of care.
Fees
Fees should be set in accordance with the advice set out in the section on
“Billing issues” above. Most PMIs provide schedules of benefit maxima for
pain therapy procedures.
Indemnity
Consultants undertaking independent practice in pain medicine will require
full indemnity from their MDO, which should be informed of the exact nature
of the consultant’s practice, i.e. the relative proportions of the consultant’s
income that are sourced from pain management and from purely anaesthetic
practice.
21

Independent Practice in Intensive Care
Responsibility for patients admitted to an Intensive Care Unit (ICU)
When a private patient requires admission to an ICU, their medical management
should become the responsibility of one clinician who should be a recognised
intensivist. A recognised intensivist is a clinician with appropriate training
and experience who holds or has held a substantive consultant’s post that
includes clinical responsibilities for patients in intensive care. This clinician
should be the only consultant to charge the patient for their services. Only if
the intensivist requests another consultant, e.g. a cardiologist, to attend the
patient should any other consultant charge be made.
Postoperative intensive care as a ‘routine’ part of anaesthesia
Many major surgical procedures are followed by a short and predictable
stay in an ICU, e.g. cardiac bypass or aortic aneurysm surgery. In these
circumstances, and if the patient’s postoperative treatment and course are
uncomplicated, it is common practice for the anaesthetist who has managed
the patient before and during surgery to be responsible for the patient while
in the ICU. The fee charged by the consultant anaesthetist should include
this routine ICU care. However, if intensive care extends beyond this routine
postoperative period, usually taken to be a period of no more than 24 h,
responsibility for the patient’s ongoing care should become the responsibility
of an intensivist, who should be able to make separate charges for the patient’s
care. If the anaesthetist providing the anaesthetic care is also an intensivist, he
or she can make additional charges after the first 24 h in the ICU provided the
patient has been given appropriate warning that this may happen.
Unexpected postoperative ICU admission
In the event of a private patient unexpectedly requiring postoperative ICU
management, the patient’s medical management should be handed over to
an intensivist, who will make appropriate charges.
Standard of care
The same standard of care should be provided to patients in the ICUs of
both independent and NHS hospitals. Equipment and beds should comply
with existing national standards. Adequate numbers of intensive care trained
nursing staff must be available to manage the required patient dependency.
Junior medical staff with intensive care training, including airway management
22

skills and resuscitation, must be immediately available. An on-call consultant
intensivist without other responsibilities should be available at all times.
Transfer of patients from independent hospitals to NHS ICUs
Many independent hospitals do not have adequate Level 3 ICU facilities, and
patients may therefore need to be transferred to an appropriate NHS hospital.
The independent hospital should have in place a contractual agreement with
a neighbouring NHS ICU to provide transfer of a sick private patient to the
NHS ICU or, if full, provide transfer to an ICU where a bed is available.
Patients may elect either to continue to be fee-paying or to become an NHS
patient if they are entitled to receive free NHS care. If the patient is too sick
to make a decision, then they remain a private patient in an NHS hospital
until such time as they are competent to express their preference. Under these
circumstances, some PMIs will try to claim that, if the patient is entitled to
NHS care, they will no longer provide cover after such a transfer. Patients,
or their next of kin, should be told that this is not usually the case and they
should be advised to contact their relative’s PMI to seek confirmation of
continued private patient status.
If no retrieval contract has been agreed, it remains the responsibility of the
independent hospital to undertake the transfer of the patient. Such transfers
must be prearranged in accordance with Intensive Care Society guidelines,
with the availability of appropriate monitoring and equipment. Accompanying
medical and nursing staff should have suitable training and experience in
transporting critically ill patients.
Charging for ICU services
Some elements of ICU management may be charged as individual procedures.
For example, the procedure of percutaneous tracheostomy requires both an
operator (intensivist) and an anaesthetist, and both may submit accounts for
the procedure. Most ICU management is a combination of procedures, ward
rounds, therapy adjustments and waiting for these adjustments to work, and
availability. This work may be charged as an hourly rate for actual attendance
or as a daily rate taking on-call availability into account. A fixed daily charge
for each patient covering all procedures may be more practical for billing
purposes, and more acceptable to PMIs. As for anaesthetic fees, the actual
rate charged is up to the individual, but in calculating the rate it may be
helpful to consider the degree of expertise required and the length of training
undertaken to become an intensivist.
23

Accurate records of procedures undertaken and time spent treating patients
should be kept, in case submitted accounts are questioned either by the
patients or their healthcare insurance companies.
Charging for ward consultations
Requests for consultation for possible ICU admission should be charged at the
rate of a complex outpatient referral, and may be repeated over consecutive
days if indicated. Intensivists may also oversee a patient’s management in the
first few days after discharge from ICU, and may charge for this at a suitable
daily attendance rate.
Charging for patient transfers
If a patient is transferred from an independent hospital to a hospital with
ICU facilities, the accompanying consultant anaesthetist or intensivist may
charge for their services. This may most appropriately be at an hourly rate to
include stabilising the patient for transfer, and the time taken to perform the
handover.
“Fixed cost” cases and intensive care
Many independent hospitals offer “Fixed cost” packages for uninsured
patients. Hospitals offering such packages should have made arrangements in
advance to cover unexpected complications, including unanticipated critical
care requirements and transfer to NHS facilities. Such arrangements may
include a contingency fund to cover additional medical and hospital fees, or
an increased payment for each case to cover such complications.
The 2003 Consultant Contract
Under the terms of the new consultant contract, independent practice should
not be undertaken during NHS time except with the explicit permission of
the employing NHS hospital management. It is not considered permissible to
be paid twice for the same event. This is a problem for intensivists who may
be asked to take over the management of private patients during their normal
NHS duties.
The agreement between the BMA and the Department of Health relating
to the new consultant contract allows for some independent practice to be
undertaken alongside a consultant’s scheduled NHS duties at the discretion of
their NHS employers. This may be taken to cover the situation where an NHS
Intensive Care Unit contains the occasional private patient.
24

Otherwise, the options are:
• Invoice the patient for the intensive care services provided and then
pay the fee directly to the hospital. This may cause problems with tax
records.
• Invoice the patient, keep the fee, then reimburse the hospital in time
spent looking after patients.
• If the work is undertaken outside of contracted NHS time as defined
in the individual’s job plan, it is acceptable to invoice the patient and
keep the fee.
• Arrange either for a colleague to undertake the management of
the patient, or for this colleague to cover the intensivist’s NHS
responsibilities in order to avoid such a conflict of interest.
• Formalise an agreement with Trust management that allows intensivists
to charge for the management of private patients on the basis they are
a source of additional income to NHS hospitals and as such a suitable
mutually agreeable solution should be possible between clinicians and
management.
25

Chambers and Group Practice
For anaesthetists, the prospect of practice in the independent sector may be
a lonely one, as for many their introduction to private practice soon after
appointment to consultant status is as a single-handed practitioner. Many
will find that an established group practice already exists and if their job plan
makes them attractive to the established group or they express an interest in
becoming part of the group, an invitation to join might be forthcoming soon
after appointment. Within the specialties such as anaesthesia, radiology and
pathology, group practice is particularly attractive as a result of the usually
discrete episodes of direct patient responsibility.
The advantages of group practice
Sharing:
Maximising:
Practice costs and expenses
Practice accommodation and secretarial assistance
Administrative responsibilities
Practice cover and on-call
Specialty expertise, i.e. not everyone in the group
needs to be able to cover all specialties
Income
Free and off-call time
Strength in negotiating with private hospitals,
Treatment Centres and PMIs
The disadvantages of group practice
Loss of:
Practice and professional autonomy
Income, if your personal practice becomes very busy
or only involves high-value procedures
Tax advantage of paying a low-earning partner for
secretarial services.
For an increasing number of anaesthetists, the concept of group practice
has of late been particularly attractive, and it is important to understand
the terminolgy in use. Group practices generally fall into one of two types:
chambers or partnerships.
26

Chambers
This title has been borrowed from the legal profession in the UK. Here,
following completion of his or her training, a new barrister must find a seat or
“tenancy” in a set of chambers. Chambers are groups of barristers, and tend
to comprise between 20 and 60 barristers. The term can equally be used to
describe any group of professionals who choose to work together and who
share rent and facilities such as the service of secretaries and other support
staff. Most chambers offer a system whereby the members contribute to these
common expenses by paying a percentage of their gross income. However,
there is no profit-sharing as in a partnership (see below), and individual
members of the group keep the fees they themselves earn beyond what they
have to pay towards the chambers expenses.
Partnerships
This title has a much more significant legal meaning under UK law whereby
a partnership is a type of business entity in which partners share the profits
or losses of the business undertaking in which they have all invested. The
shares may be equal (equity partnership) or may be fractional, based upon the
seniority or some other factor that varies only by the consent of all partners. A
true partnership must have a legally drafted partnership agreement signed by
all partners and there should be regular partnership meetings.
Generally, partners have an obligation of strict liability to third parties injured
by the partnership. Partners may have joint liability or joint and several
liability depending upon circumstances. The liability of limited partners is
limited to their investment in the partnership, hence the term Limited Liability
Partnership. Without a legally drafted partnership agreement, the group acting
as a partnership will be regarded in law as a “sham” partnership and will not
benefit from the legal advantages of a real partnership, such as the ability for
all partners to charge the same fee without an accusation of price fixing.
The key to the success of a partneship rests in a sense of mutual trust between
partners so that there is a feeling that the work is genuinely being shared
equally. One important element in achieving this feeling is the important
part played by the partnership manager who allocates work according
to the agreed partnership rules laid down in the agreement. Partnership
administration can be largely left to the salaried partnership manager who
acts under the immediate direction of the elected partnership chairperson.
Larger partnerships may also choose to appoint a partnership secretary and a
27

treasurer, but the arrangements of the partnership executive are matters to be
decided by the members of the partnership with professional advice from their
nominated legal and financial advisors.
Since partners are jointly responsible for third party damage, one important
item that must be agreed at the onset is the individuals’ responsibility for
medical indemnity insurance, which should ideally be made an absolute
obligation for continued membership of the partnership. Some partnerships
take on the responsibility of payment on behalf of the individuals to avoid
any inadvertent lapses.
28

Resources and useful contacts
Medical Defence Union
Medical and Dental Defence Union of Scotland
Medical Protection Society
www.the-mdu.com
www.mddus.org.uk
www.mps.org.uk
Academy of Experts
Action Against Medical Accidents
Association of Anaesthetists of Great Britain & Ireland
Criminal Records Bureau
Department of Constitutional Affairs
Expert Witness Institute
General Medical Council
Healthcare Commission
Intensive Care Society
Legal Services Commission
National Institute for Health and Clinical Excellence
National Patient Safety Agency
NHS Litigation Authority
Office of Fair Trading
Royal College of Anaesthetists
Small Claims Court
The British Pain Society
UK Department of Health
www.academy-experts.org
www.avma.org.uk
www.aagbi.org
www.crb.gov.uk
www.dca.gov.uk
www.ewi.org.uk
www.gmc-uk.org
www.healthcarecommission.org.uk
www.ics.ac.uk
http://www.legalservices.gov.uk
www.nice.org.uk
www.npsa.nhs.uk
www.nhsla.com
www.oft.gov.uk
www.rcoa.ac.uk
www.hmcourts-service.gov.uk
www.britishpainsociety.org
www.dh.gov.uk
AXA PPP
BCWA
BUPA
CIGNA
Norwich Union
Standard Life
WPA
www.axappphealthcare.co.uk
www.bcwa.co.uk
www.bupa.co.uk
www.cigna.co.uk
www.norwichunion.com/health
www.standardlifehealthcare.co.uk
www.wpa.org.uk
29

30

31

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

AAGBI SAFETY GUIDELINE
Infection Control in Anaesthesia
2
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
E-mail: info@aagbi.org Website: www.aagbi.org
October 2008

Membership of the Working Party
Dr Leslie Gemmell
Dr Richard Birks
Dr Patrick Radford
Professor Don Jeffries CBE
Dr Geoffrey Ridgway
Mr Douglas McIvor
Chairman, Honorary Secretary Elect
President Elect
Royal College of Anaesthetists
Emeritus Professor of Virology, University of London
Consultant Microbiologist
Medicines and Healthcare Products Regulatory Authority
Ex officio
Dr David Whitaker
Dr William Harrop-Griffiths
Dr Iain Wilson
Dr Ian Johnston
Dr David Bogod
President
Honorary Secretary
Honorary Treasurer
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia
This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please
use the following reference:
Anaesthesia 2008, 63; 1027-36

Anaesthesia, 2008, 63, pages 1027–1036
doi:10.1111/j.1365-2044.2008.05657.x
.....................................................................................................................................................................................................................
GUIDELINES
Infection Control in Anaesthesia
Association of Anaesthetists of Great Britain and Ireland
Membership of the Working Party: Gemmell L, Chair; Birks R, President Elect; Radford P, Royal
College of Anaesthetists representative; Jeffries D, National Institute for Health and Clinical
Excellence; Ridgway G, consultant microbiologist; McIvor D, Medicines and Healthcare Products
Regulatory Authority; Executive Officers of AAGBI, ex officio
This is a consensus document produced by expert members of a Working Party established by the Association of
Anaesthetists of Great Britain and Ireland (AAGBI). It updates and replaces previous guidance published in
2002.
1.0. Summary
(1) A named consultant in each department of anaesthesia
should liaise with Trust Infection Control
Teams and Occupational Health Departments to
ensure that relevant specialist standards are established
and monitored in all areas of anaesthetic
practice.
(2) Precautions against the transmission of infection
between patient and anaesthetist or between patients
should be a routine part of anaesthetic practice.
In particular, anaesthetists must ensure that hand
hygiene becomes an indispensable part of their
clinical culture.
(3) Anaesthetists must comply with local theatre infection
control policies including the safe use and disposal of
sharps.
(4) Anaesthetic equipment is a potential vector for
transmission of disease. Policies should be documented
to ensure that nationally recommended
decontamination practices are followed and audited
for all reusable anaesthetic equipment.
(5) Single use equipment should be utilised where
appropriate but a sterile supplies department (SSD)
should process reusable items.
(6) An effective, new bacterial ⁄ viral breathing circuit
filter should be used for every patient and a local
policy developed for the re-use of breathing circuits
in line with manufacturer’s instructions. The AAGBI
recommends that anaesthetic departments should
consider changing anaesthetic circuits on a daily basis
in line with daily cleaning protocols.
(7) Appropriate infection control precautions should be
established for each anaesthetic procedure, to include
maximal barrier precautions for the insertion of central
venous catheters, spinal and epidural procedures and
any invasive procedures in high risk patients.
2.0. Introduction
The Association of Anaesthetists of Great Britain and
Ireland (AAGBI) published guidelines in 2002 on problems
relating to infection control in anaesthetic practice.
In addition to AAGBI Officers and Council members,
representation included the Royal College of Anaesthetists
and the Medicines and Healthcare Products Regulatory
Authority (MHRA). This is an updated version of
that guidance document.
Healthcare organisations now have a legal responsibility
to implement changes to reduce healthcare associated
infections (HCAIs). The Health Act 2006 provided the
Healthcare Commission with statutory powers to enforce
compliance with the Code of Practice for the Prevention
and Control of Healthcare Associated Infection (The
Code). The Code provides a framework for NHS Bodies
to plan and implement structures and systems aimed at
prevention of HCAIs. The Code sets out criteria that
mandate NHS bodies, including Acute Trusts, and which
ensure that patients are cared for in a clean environment.
Anaesthetists should be in the forefront of ensuring
that their patients are cared for in the safest possible
environment. Further advice can be obtained from the
Department of Health (DOH) website http://www.
clean-safe-care.nhs.uk.
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3.0. General principles
Healthcare providers have responsibilities under the
Health and Safety at Work Act 1974; offences against
the Act are covered by Criminal Law. The Control of
Substances Hazardous to Health (COSHH) Regulations 1999
have been considered part of the Health and Safety at Work
Act; the Act ensures that Trusts are responsible for the
health and safety of their employees and others (including
visitors and patients), and the control and management of
the risk of infection. As part of the Health Act 2006, the
Department of Health (DOH) released the Code of Practice
for the Prevention and Control of Healthcare Associated
Infections [1].
Trust Chief Executives are accountable for ensuring
that care delivered within each Trust meets relevant
standards. Trusts should have Infection Control Committees
and Infection Control Teams responsible for
preparing policies and monitoring compliance with
appropriate standards. A microbiologist should be designated
to provide advice on microbiological aspects of
decontamination and sterilisation. The AAGBI Working
Party recommends that a named consultant in each
Department of Anaesthesia should liaise with the Infection
Control Team and the Occupational Health Department
to ensure that relevant standards are established and
monitored in all areas of anaesthetic practice.
The environment
Hospital environmental hygiene encompasses a wide
range of routine activities that are important in the
prevention of HCAI. The hospital must be visibly clean
and acceptable to patients, visitors and staff. Statutory
requirements must be met in relation to safe disposal of
clinical waste, laundry and linen. Bed occupancy should
ensure enough time between patient admissions to ensure
adequate cleaning and decontamination of the patient
area.
The Code of Practice enshrines in law the duty of
Trusts to maintain a clean and appropriate environment
for patients including the fabric of the building and related
structures. Operating theatres and associated areas should
be designed and maintained to the standards defined
in Health Building Note 26, Facilities for Surgical Procedures
published in 2004. Microbiological commissioning and
monitoring of operating theatre suites should adhere to
national recommendations.
Standard precautions
Anaesthetists will be involved in the care of patients who
may harbour potentially pathogenic organisms, which
may not be obvious or readily identifiable. Precautions
aimed at preventing the transmission of organisms
between patient and anaesthetist or between patients
must be a routine part of anaesthetic practice.
The AAGBI recommends the use of Standard Precautions,
which incorporate additional safeguards for specific
procedures and patients, including single-use gloves, fluid
resistant masks with a transparent face shield and gowns
[2]. Precautions are recommended for all patients regardless
of their diagnosis or presumed infectious status and
must be implemented when there is a possibility of
contact with:
1 Blood.
2 All other body fluids.
3 Non-intact skin.
4 Mucous membranes.
Preventative measures should be based on the likelihood
of an infectious agent being present, the nature of
the agent and the possibility of dispersion, e.g. splashing.
A standard set of precautions should be established for
every invasive procedure (see below) with additional risk
assessment of each patient to determine extra and specific
precautions that may be appropriate.
Hand hygiene
Anaesthetists must ensure that good hand hygiene becomes
an indispensable part of their clinical culture
Hand-mediated transmission is the major contributing
factor to infection associated with healthcare [3]. Effective
hand decontamination immediately before every episode
of direct patient contact will result in a significant
reduction in the transfer of potential pathogens and a
decrease in the incidence of preventable HCAI [4].
Despite consistent advice, staff often neglect hand hygiene
when caring for patients.
At the start of every session, and when visibly soiled or
potentially contaminated, hands must be washed with
liquid soap and water. When there is no soiling, the
Hand Hygiene Liaison Group advocates that staff should
use an antimicrobial hand rub between patients or
activities [5] as this is effective and quicker. It is vital to
ensure that the whole hand and fingers (particularly the
tips), are exposed to the hand rub. Antimicrobial hand
rub is not effective in preventing cross infection with
Clostridium difficile.
Trusts must ensure that sinks, soap and antimicrobial
hand rubs are conveniently placed to encourage regular
use. Watches and jewellery (including dress rings
and wrist adornments) must be removed at the beginning
of each clinical session, before regular hand decontamination
begins. Cuts and abrasions must be covered with
waterproof dressings, which must be changed as appropriate.
Staff with dermatitis, psoriasis or other skin
conditions should consult with the Occupational Health
Department for further advice.
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The Code of Practice states that policies should be
directly tied to the clinical governance framework and
regularly reviewed under a system of audit, revision and
update.
Gloves
It is important to undertake a risk assessment regarding
the safe use of gloves. Although they may offer some
protection against inoculation with blood-borne viruses,
incorrect use of gloves could actually spread infection
between patients.
Sterile gloves must be worn for invasive procedures and
contact with sterile sites. Non-sterile examination gloves
must be worn for contact with mucous membranes, nonintact
skin and all activities that carry a risk of exposure to
blood, body fluids, secretions and excretions. All blood
and body fluids, substances, secretions and excretions may
be considered to be potentially infective regardless of the
perceived risk of the source.
Gloves must be worn as single-use items. They should
be put on immediately before an episode of patient
contact and removed as soon as the activity is completed,
and before contact with fomites, including curtains, pens,
clinical notes, keyboards and telephones. Gloves should
be changed between patients and between different
procedures on the same patient. Gloves must be disposed
of as clinical waste and hands should be washed or
decontaminated following the removal of gloves. It has
been demonstrated that 98% of anaesthetists’ contact with
patients’ blood could be prevented by routine use of
gloves [6].
Gloves of an acceptable quality must be available in all
clinical areas. Latex-free gloves must be available for use
for staff or patients who have an allergy or sensitivity to
rubber gloves.
Facemasks
The use of facemasks to decrease the incidence of
postoperative wound infection has been questioned
[7, 8]. However, masks with a face shield should be
worn when there is a risk of blood, body fluids, secretions
and excretions splashing into the face and eyes. Masks
must also be worn by anaesthetists when carrying out a
sterile procedure under full aseptic conditions (see later).
If worn, masks should not be taken down to speak and
should be changed if they become damp or contaminated.
Masks must only be handled by the ties. Correctly fitting
facemasks may also give some protection to the anaesthetist
against inhaling infected droplets from the respiratory
tracts of patients with infectious respiratory
diseases.
The Working Party is aware that the wearing of masks
remains an area of contention in many Trusts and
conflicting evidence may be cited [9, 10]. In view of
the continuing controversy about the wearing of masks,
the Working Party suggests that local protocols should be
agreed about their use in hospitals.
Theatre caps
Theatre personnel in most UK operating theatres wear
disposable headgear although there is little evidence for
the effectiveness of this practice except for scrub staff in
close proximity to the operating field [11]. However,
theatre caps should be worn in laminar flow theatres
during prosthetic implant operations, and it is the
Working Party’s view that their general use should
continue.
Theatre suits and gowns
The skin of staff working in the operating theatre is a
major source of bacteria that have the potential for being
dispersed into the air. Clean theatre suits should be
available for all staff in theatre. Full body, fluid-repellent
gowns should be worn where there is a risk of extensive
splashing of blood, body fluids, secretions and excretions.
Sterile gowns should be worn when invasive procedures
are undertaken. Disposable plastic aprons are often worn
on wards in situations where there is a risk of physical
soiling of clothing in order to prevent transmission of
infection between patients.
Contaminated clothing should be changed and safely
discarded into an appropriate receptacle at the earliest
opportunity.
There is little evidence to show that wearing surgical
attire outside the theatre and returning to the theatre
without changing increases surgical wound infection
rates. With the widespread move to admission on the
day of surgery, the times when anaesthetists will have to
leave theatre have increased and repeated changing will
impact on theatre efficiency. Local policies must be
developed and reflect the necessity for ‘theatre discipline’
and allay perceived concerns of patients and visitors. Local
policies should be agreed between all theatre users and
Trusts must ensure adequate provision of appropriate
clothing. The DoH guidance on Uniforms and Workwear
[12] also recognises that there is little evidence that
work clothes pose a significant hazard in terms of
increased infection rates.
Shoes and overshoes
Special footwear should be worn in the operating
department and cleaned if contaminated or after every
use. Trusts should ensure that a system for cleaning
theatre footwear is in place in each theatre suite. Plastic
overshoes may increase bacterial contamination of floors
[13] and, in addition, hands become contaminated when
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overshoes are put on or removed. Their use is not
recommended.
Movement within the theatre complex
To reduce airborne contamination, general traffic in and
out of the operating theatre itself should be kept to a
minimum. Doors should be kept closed to ensure the
efficiency of the ventilation system.
Moving patients on their beds into the operating
theatre may increase the bacterial count on floors, but it is
claimed that this is of little significance if bed linen is
changed before transfer [14]. All used linen must be
handled safely to minimise the risk of contamination of
the environment and staff. Used bed linen must be
handled with care to reduce the release of small fomite
particles into the air – bed linen should be ‘bagged’ by the
bed or patient trolley. The use of separate trolleys from
ward to transfer area and transfer area to table has not
been shown to have benefit [15] although this practice
continues in many operating areas.
If entering the operating theatre itself, visitors should
change into theatre suits and wear designated footwear.
Order of patients
There should be a written hospital policy requiring
accurate printed theatre lists to be available prior to the
scheduled date. ‘Dirty cases’, i.e. patients likely to disperse
microbes of particular risk to other patients, should be
identified before surgery and theatre staff should be
notified. These patients should be scheduled last on an
operating list to minimise risk. Where this is not possible,
the Hospital Infection Society (HIS) advises that a
plenum-ventilated operating theatre should require a
minimum of 15 min before proceeding to the next case
after a ‘dirty’ operation [16].
The most probable routes for transmission of infection
between successive patients are airborne or on items and
surfaces that have been in contact with the patient.
Appropriate cleaning of the operating theatres between
all patients should be undertaken. Whenever there is
visible contamination with blood or other body materials,
the area must be disinfected with sodium hypochlorite
(according to local protocols) and then cleaned with
detergent and water. Floors of the operating room should
be disinfected at the end of each session.
Safe use and disposal of sharps
Accidental injury has long been recognised as an occupational
hazard in the healthcare setting. Accidental
inoculation with infected blood, however small in
amount, presents a significant risk to anaesthetists.
In the UK, 16% of occupational injuries occurring
in hospitals are attributed to sharps injuries. These are
predominantly caused by needles and are associated
mainly with venepuncture, administration of intravenous
drugs and recapping of needles. These should be
preventable by adhering to national guidelines and agreed
standards [17]:
• Sharps must not be transferred between personnel and
handling should be kept to a minimum.
• Needles must not be bent or broken prior to use or
disposal.
• Needles and syringes must not be disassembled by hand
prior to disposal.
• Needles should not be recapped or resheathed.
• Used sharps must be discarded into an approved sharps
container at the point of use.
• The sharps container should be sealed and disposed of
safely by incineration when about two-thirds full or in
use for more than four weeks, whichever is sooner.
Sharps containers must comply with BS 7320:1990 –
‘Specification for sharps’.
• Blunt aspirating needles should be used for drawing up
drugs.
• Needle protection devices may reduce needlestick
injuries but require further evaluation before widespread
use can be advised.
Preventing contamination of drugs
Drugs and fluids require safe handling by anaesthetists,
who should follow local protocols for preparation and
administration to prevent contamination.
Syringes and needles are sterile, single-use items and,
after entry or connection to a patient’s vascular system
or attachment to infusions, a syringe and needle should
be considered contaminated and used only for that
patient. A syringe must not be used for multiple
patients even if the needle is changed. Before use,
prepared syringes and needles should be stored in a
clean container and syringes capped to avoid contamination.
After use or at the end of the anaesthetic, all
used syringes with needles should be discarded into an
approved sharps container.
Care must be taken when drawing up drugs. Single use
ampoules should be discarded after the required amount
of drug is drawn up and not re-used for subsequent
patients. Ampoules can be kept for identification purposes
and discarded at the end of the list. Multiple-use ampoules
are not recommended.
All infusions, administration sets or items in contact
with the vascular system or other sterile body compartments
are for single-patient use. An aseptic technique
should be used when preparing infusions and breaks ⁄ taps
in lines should be kept to a minimum. Injection ports
should be maintained with a sterile technique, kept free
of blood and covered with a cap when not in use.
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Connections and injection ports in intravenous lines
should be kept to a minimum. Three-way taps should be
avoided if practicable. Needle-free Luer injection devices
should be used to cover exposed female Luer injection
ports. These are easily cleaned before and after drug
administration, do not harbour blood in crevices and also
reduce the need for needles, resulting in a reduction of
needlestick injuries.
infection. ‘Guidance on Decontamination’ prepared by
the MHRA and DoH provides guidelines for the safe
reprocessing of medical devices [19, 20]. It is recommended
that each department identifies a designated
consultant who, in conjunction with the appropriate
bodies in their Trust, will develop specific guidelines for
anaesthetic practice which satisfy national recommendations
and that these practices are audited on a regular basis.
4.0. Anaesthetic equipment and infection
control
Items of anaesthetic equipment may become contaminated
either by direct contact with patients, indirectly via
splashing, by secretions or from handling by staff.
Contamination is not always visible and all used pieces
of equipment must be assumed to be contaminated and
disposed of or, if reusable, undergo a process of decontamination.
The Code of Practice has specific requirements
for the decontamination of surgical equipment
and other equipment used in patient care. There is a need
to designate a person who is responsible for ensuring
equipment cleanliness.
Single-use equipment
Where appropriate, single-use disposable equipment will
remove the difficulties of re-use and decontamination
procedures. The use of such equipment is to be encouraged.
However, there are problems of cost, storage and
disposal of single-patient use devices, and for some
equipment there is no feasible disposable alternative.
The balance between single-use items and re-usable
equipment will require local determination based on an
assessment of patient safety, the available facilities and cost.
Packaging should not be removed until the point of use for
infection control, identification, traceability in the case of
a manufacturer’s recall, and safety.
A multidisciplinary research team at the University of
Nottingham has carried out a study investigating the use
and re-use of single-use devices in English NHS operating
theatres. The published paper clarified some of the issues
around single-use devices such as single-use equipment
that must be immediately discarded after use, e.g. suction
catheters, and some that may be re-used in the same
patient in the same episode, e.g. disposable laryngoscope
blades [18].
Decontamination
Decontamination is a combination of processes including
cleaning, disinfection and ⁄ or sterilisation used to make a
re-usable item safe to be handled by staff and safe for
further use on patients. Effective decontamination of
re-usable devices is essential in reducing the risk of
Decontamination processes
Cleaning – removal of foreign material from an item.
This usually involves washing with a detergent to remove
contamination followed by rinsing and drying. All
organic debris, e.g. blood, tissue or body fluids, must be
removed before disinfection or sterilisation, as its presence
will inhibit disinfectant or sterilant from contacting
microbial cells. Cleaning before sterilisation is of the
utmost importance in the effectiveness of decontamination
procedures in reducing the risk of transmission of
prions.
Low Level Disinfection – kills most vegetative bacteria
(except TB and endospores), some fungi and some viruses
using disinfectants such as sodium hypochlorite, 70%
alcohol and chlorhexidine.
High Level Disinfection – kills vegetative bacteria (not
all endospores), fungi and viruses. With sufficient contact
time (often several hours), these high level disinfectants
may produce sterilisation, e.g. the use of aldehydes,
peracetic acid and chlorine dioxide.
Sterilisation – A process used to render an object free
from viable micro-organisms, including all bacteria,
spores, fungi and viruses, with techniques such as
autoclaving (but see prions later).
Risk assessment
The choice of equipment and ⁄ or the level of cleanliness
⁄ disinfection ⁄ sterility required of re-usable items may
be assessed against the risk posed to patients of transmission
of infection during any procedure in which the
equipment is employed. It has been proposed by the
MHRA Microbiology Advisory Committee that three
levels should be considered:
1 High Risk – the device will penetrate skin or
mucous membranes, enter the vascular system or a
sterile space – these devices require sterilisation.
2 Intermediate Risk – the device will be in contact
with intact mucous membranes or may become
contaminated with readily transmissible organisms –
these devices require high level disinfection or
sterilisation.
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3 Low Risk – the device contacts intact skin or does not
contact patient directly – these devices require low
level disinfection or cleaning.
Infection control policy
Anaesthetic face masks
Although normally in contact with intact skin, these
items are frequently contaminated by secretions from
patients and have been implicated in causing crossinfection
[21]; local disinfection is not normally effective
. These items should be single-use items or should
be sterilised between patients by an audited Sterile
Supplies Department in accordance with the manufacturer’s
instructions.
Airways and tubes
Oral airways, nasal airways and tracheal tubes should be
of single-use type since they readily become contaminated
with transmissible organisms [22] and blood [23].
Ideally, supraglottic airways should be of the singlepatient
use type but the re-usable design is in common
use and many anaesthetists perceive it as being less
traumatic. Therefore, a supraglottic airway designed for
repeated use should be sterilised (in an audited SSD) no
more often than the manufacturer recommends. A
supraglottic airway used for tonsillectomy or adenoidectomy
should not be used again (see section on Prion
Diseases). The AAGBI recommends single-use supraglottic
airways.
Catheter mounts – angle pieces
It is recommended that these items are single-patient use
type.
Anaesthetic breathing systems
The AAGBI has previously recommended that ‘an
appropriate filter should be placed between the patient
and the breathing circuit (a new filter for each patient)’.
Although it appears that pleated hydrophobic filters
have a better filtration performance than most electrostatic
filters, the clinical relevance of this has yet to be
established [24, 25]. The MHRA have also warned of the
difficulty in assessing the performance of breathing filters
in MDA ⁄ 2004 ⁄ 013.
Until 2001 manufacturers of disposable anaesthetic
breathing circuits supplied these as non-reusable items. In
practice, most UK departments of anaesthesia used these
circuits for more than one patient or for more than one
operating session in conjunction with the use of a new
filter for each patient. In 2006, the MHRA re-emphasised
in Devices Bulletin DB 2006(04) the clinical and legal
implications of re-use of devices labelled for single use and
the AAGBI firmly supports their recommendations.
Therefore, departments may follow the manufacturer’s
recommendations for use for up to 7 days. However, to
ensure consistency in the infection control process, the
Working Party recommends that circuits are disposed of
when the anaesthetic machine and monitors are cleaned
(see below). The AAGBI recommends that anaesthetic
circuits are routinely changed on a daily basis. If
visibly contaminated or used for highly infectious cases,
e.g. tuberculosis, the circuits should be changed between
patients and safely discarded. No attempt should be made
to reprocess these items.
Anaesthetic machines
Routine daily sterilisation or disinfection of internal
components of the anaesthetic machine is not necessary if
a bacterial ⁄ viral filter is used between patient and circuit.
However, manufacturers’ cleaning and maintenance policies
should be followed, and bellows, unidirectional
valves and carbon dioxide absorbers should be cleaned
and disinfected periodically. All the surfaces of anaesthetic
machines and monitors should be cleaned on a daily basis
with an appropriate disinfectant or immediately if visibly
contaminated.
Laryngoscopes
As with anaesthetic facemasks, laryngoscopes are known
to become contaminated during use. Current practices
for decontamination and disinfection between
patients are frequently ineffective, leaving residual
contamination that has been implicated as a source of
cross-infection [26, 27]. Blades are also regularly
contaminated with blood [28], indicating penetration
of mucous membranes, which places these items into a
high-risk category. Proper cleaning of laryngoscope
blades is of great importance before decontamination
⁄ sterilisation, particularly of residue around light
sources or articulated sections. New purchases should
be of a design that is easy to clean. Although repeated
autoclaving may affect the function of laryngoscopes
[29], the Working Party recommends that re-usable
laryngoscope blades should be sterilised by an audited
SSD between patients, following the manufacturers’
instructions. Plastic sheaths may be used to cover blades
and handles to reduce contamination but it has been
noted, especially with blade covers, that these have
created difficulties during tracheal intubation.
There are an increasing number of inexpensive, singleuse
laryngoscope blades and handles of improving design
available, and their use is to be encouraged. The choice of
blade must be dictated by Departments of Anaesthesia.
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Traditional blades should be available at all times in case
difficulty is encountered.
Laryngoscope handles also become contaminated with
micro-organisms and blood during use, and they should
be washed ⁄ disinfected and, if suitable, sterilised by SSDs
after every use. The knurled handles of laryngoscopes
cannot be cleaned reliably manually if covered in blood or
body fluids.
Anaesthetists should show great care when handling
laryngoscopes: wear gloves during intubation and place
used instruments in a designated receptacle to prevent
contamination of surfaces, pillows and drapes.
Fibreoptic bronchoscopes
These are expensive items which cannot be autoclaved.
Decontamination is dependent on sufficient contact time
with high level disinfectants and it is particularly important
that the washing and cleaning process removes all
tissue residues from the lumens. Decontamination is best
achieved with an automated system. National guidelines
for care of these instruments have been provided by the
MDA, now the MHRA, DoH and NHS Estates [18, 30,
31, and 32].
With the uncertainty of the future implications of
variant Creutzfeld Jakob Disease (CJD), these items
should have a unique identifier which should be recorded
at every use to permit future tracing.
Bougies
Re-use of these items has been associated with crossinfection
[33]. Manufacturers recommend that a gum
elastic bougie may be disinfected up to five times between
patients and stored in a sealed packet. It is preferable that
alternative single-use intubation aids are employed when
possible.
Surfaces
The surfaces of anaesthetic machines and monitoring
equipment, especially those areas which are likely to
have been touched by the gloved hand that has been in
contact with blood or secretions, should be regarded as
contaminated and should be cleaned at the earliest
opportunity, probably between patients. Local policies
should be in place to ensure that all equipment that
touches intact skin, or does not ordinarily touch the
patient at all, is cleaned with a detergent at the end
of the day or whenever visibly contaminated. This
includes non-invasive blood pressure cuffs and tubing,
pulse oximeter probes and cables, stethoscopes,
electrocardiographic cables, blood warmers etc., and
the exterior of anaesthetic machines and monitors.
Items such as temperature probes should be for single
patient use.
Oxygen masks and tubing
Single-patient use products should be used.
Resuscitation equipment
Single-patient use equipment should be kept in a sealed
package or should be resterilised between patients
according to the manufacturer’s instructions. All training
equipment should be handled similarly.
5.0. Prion diseases
Transmissible Spongiform Encephalopathies (TSEs) are a
group of illnesses in which there is progressive neurological
degeneration associated with characteristic pathological
changes. TSEs are caused by abnormal prions,
which are infectious proteins. Microscopic traces of
tissue often remain on surgical instruments after washing
and autoclaving or disinfecting and any prion protein in
these traces could still transmit the disease if inoculated
into another patient. However, successive washing after
use reduces the concentration so that, after about 10
decontamination cycles, infectivity becomes negligible
[34].
Variant Creutzfeldt-Jakob disease (vCJD) is a TSE
caused by the same prion protein that causes Bovine
Spongiform Encephalopathy (BSE) in cattle. After an
incubation period of several years, the disease shows itself
as a progressive degeneration of the brain leading to
death. It is similar to sporadic CJD, which has been spread
by neurosurgical instruments, dura mater grafts and
pituitary extracts. However, while sporadic CJD prion
protein is to be found only in brain, spinal cord and
posterior eye, the prion protein of vCJD can also be
found in lymph nodes, appendix and tonsils. Prion
protein becomes detectable in tissues in the later period
of incubation and is present in higher concentrations once
the disease becomes manifest [34]. Advice on the
detection and prevention of prion diseases is available
from the Advisory Committee on Dangerous Pathogens
(ACDP), the Spongiform Encephalopathy Advisory
Committee (SEAC) and the National Institute for Health
and Clinical Excellence [35]. The CJD Incidents Panel
Advice advises on the prevention of transmission of CJD
in specific cases [36, 37].
Tonsillectomy and adenoidectomy
Lymphoid tissue, including that of the adenoid and tonsil,
is of ‘medium infectivity’ for vCJD and it is possible that a
patient undergoing surgery could be incubating this
disease. Surgeons routinely operate with traceable reusable
instruments in accord with latest national advice,
since single-use instruments were associated with excessive
bleeding and risks of CJD transfer are low [38].
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Tracheal tubes, supraglottic airways and oral airways
should be destroyed after use for these operations as they
can be contaminated by infectious tissue and batch
cleaning may cause transfer of protein from one device
to another [39].
Theoretically, a laryngoscope blade used at the end of
surgery or for emergency re-intubation could become
contaminated. However, the Working Party’s estimate is
that the risk is extremely small and probably less than
those posed by the use of a disposable laryngoscope for
what could be a difficult laryngoscopy. Therefore, the
recommendation is that single-use laryngoscopes are
not mandatory in anaesthesia for tonsil and adenoid
surgery. Those purchasing laryngoscopes with single-use
blades (and other single-use devices) have a responsibility
to ensure that the performance of the instruments is at
least as good as that of the standard reusable alternatives.
Anaesthetic management of cases of CJD
This advice covers known cases, suspected cases and those
who are at risk of developing CJD. Isolation is not
needed. Standard (‘universal’) precautions are essential.
Blood and other samples should be labelled ‘Biohazard’.
Invasive procedures such as central venous cannulation
and spinal anaesthesia mandate the use of full aseptic
procedures, including mask and eye protection. The area
around where invasive procedures are performed should
be clear enough to allow easy mopping of spillages. High
infectivity tissues are those in the brain, spinal cord and
posterior eye; medium risk tissues for CJD are those in the
anterior eye and olfactory epithelium – any needles or
probes used by anaesthetists near these tissues will be
disposable. In vCJD, lymphoid tissue is also classed as
having medium infectivity. In these circumstances, it is
advisable that any laryngoscope used after the tonsil has
been operated on or any bronchoscope used for biopsy on
patients in this group should be treated as potentially
contaminated. These instruments should either be
destroyed (easily done with single-use laryngoscopes) or
should be quarantined pending advice. Such advice can
be obtained from the CJD Incidents Panel.
Transmission of vCJD by transfusion of blood
and blood products
Although only three cases have been discovered, this is
the only route of transfer of vCJD as yet shown to be
from medical interventions. The National Blood Transfusion
Service repeatedly updates its procedures so as to
reduce the tiny risk of transfer of prions, viruses and
bacteria [40]. Procedures include leucodepletion and
sourcing most plasma products from outside the UK.
Anaesthetists can further decrease the risk by minimising
the use of blood and blood products.
Summary: how to reduce the risk of transmission
of prion disease
1 Adherence to the same universal precautions as for
other potential infections.
2 Minimising the use of transfusion of blood and blood
products.
3 Use of SSD decontamination and sterilisation with
tracing for all reusable equipment.
4 Ensuring that any instrument that contacts the brain,
spinal cord or dura is destroyed afterwards.
5 The employment of single-use equipment when this is
as reliable and safe as the re-usable alternatives.
6 Destroying or quarantining instruments used on cases
who may have CJD and for those known to be at risk.
7 Ensuring that all airway devices used during tonsillectomy
and adenoidectomy are discarded after use.
6.0. Infection control precautions for
anaesthetic procedures
Carrying out procedures in an operating theatre does not
pose a lower risk of infection than other hospital locations
and the risk of infection depends on the procedure and on
the level of barrier protection rather than the surrounding
environment [41].
Maximal barrier precautions
Maximal barrier precautions involve full hand washing,
the wearing of sterile gloves and gown, a cap, mask and
the use of a large sterile drape [42]. The skin entry site
should be cleaned with an alcoholic chlorhexidine
gluconate solution or alcoholic povidone-iodine solution
[43]. The antiseptic should be allowed to dry before
proceeding.
Certain invasive anaesthetic procedures require this
optimum aseptic technique:
• Insertion of central venous catheters.
• Spinal, epidural and caudal procedures.
The Working Party is aware that many anaesthetists do
not employ this level of asepsis for ‘one-shot’ spinals or
epidurals but believes that, when central neural spaces are
penetrated, full aseptic precautions are required.
Comprehensive guidelines have been prepared for
insertion and maintenance of central venous catheters
[44] and are commended to all anaesthetists. The use of
care bundles has been advocated by IHI (Institute of
Health Improvement) to reduce catheter related bacteraemias.
Originally developed in the USA, Care Bundles
is an approach that systematically appraises clinical
processes. It is based on measuring the actual provision
of therapeutic interventions according to standards,
informed by evidence, which local clinicians set themselves
[45].
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Other barrier precautions
Certain invasive procedures do not require full barrier
precautions as above but nevertheless demand appropriate
aseptic techniques. Such precautions involve the wearing
of sterile gloves and use of small drapes, although similar
attention is required to hand washing and skin preparation.
These procedures include:
• Peripheral regional blocks.
• Arterial line insertion.
Peripheral venepuncture or intramuscular injection in
low-risk patients will involve handwashing, non-sterile
gloves and skin preparation with propyl alcohol. Peripheral
intravenous catheters are a significant source of
nosocomial bacteraemias and care is required.
High-risk patients
Certain patients may be especially vulnerable to infection,
e.g. the immunocompromised, or offer particularly high
risk of transmitting infection, e.g. tuberculosis and HIV.
For the immunocompromised, maximal barrier precautions
are required for all invasive procedures and similarly,
where there is a high infection risk, staff should concentrate
not only on preventing cross-infection between
patients but in protecting themselves by ensuring compliance
with all precautions.
7.0. References
1 DoH The Health Act 2006. Code of Practice for the Prevention
and Control of Health Care Associated Infections.
2 National Association of Theatre Nurses. Universal Precautions
and Infection Control in the Peri-Operative Setting. Harrogate:
NATN, 1997.
3 Stone SP, Teare L, Cookson BD. The evidence for hand
hygiene. Lancet 2001; 357: 479–80.
4 Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a
hospital wide programme to improve compliance with hand
hygiene. Lancet 2000; 356: 1307–12.
5 Teare L, Cookson B, Stone S. Hand hygiene. British Medical
Journal 2001; 323: 411–12.
6 Kristensen M, Sloth E, Jensen TK. Relationship
between anaesthetiprocedure and contact of anesthesia
personnel with patient body fluids. Anesthesiology 1990; 73:
619–24.
7 Orr NW. Is a mask necessary in the operating theatre? Annals
of the Royal College of Surgeons of England 1981; 63: 390–2.
8 Mitchell NJ, Hunt S. Surgical face masks in modern
operating rooms – a costly and unnecessary ritual? Journal of
Hospital Infection 1991; 18: 239–42.
9 McLure HA, Tallboys CA, Yentis SM, Azadian BS. Surgical
face masks and downward disposal of bacteria. Anaesthesia
1998; 53: 624–6.
10 Philips BJ, Ferguson S, Armstrong P, Anderson P, Anderson
FM, Wildsmith JAW. Surgical face masks are effective in
reducing bacterial contamination caused by dispersal from
the upper airway. British Journal of Anaesthesia 1992; 69:
407–8.
11 Humphreys H, Russell AJ, Marshall RJ, Ricketts VE, Reeves
DS. The effect of surgical theatre headgear on bacterial counts.
Journal of Hospital Infection 1991; 19: 175–80.
12 DoH Uniforms and Workwear. An Evidence Base for
Developing Local Policy, Department of Health, 2007.
13 Humphreys H, Marshall RJ, Ricketts UE, Russell AJ,
Reeves DG. Theatre overshoes do not reduce operating
theatre floor bacterial counts. Journal of Hospital Infection 1991;
17: 117–23.
14 Litsky BY, Litksy W. Bacterial shedding during bedstripping
of reusable and disposable linens as detected by the
high volume air sampler. Health Laboratory Science 1971; 8:
29–34.
15 Lewis DA, Weymond G, Nokes CM, et al. A bacteriological
study of the effect on the environment of using a one or two
trolley system in theatre. Journal of Hospital Infection 1990; 15:
35–53.
16 Hospital Infection Society: Behaviours and Rituals in the
Operating Theatre – A Report from the Hospital Infection Society
Working Group on Infection Control in Operating Theatres.
Hospital Infection Society, 2002.
17 Health Service Advisory Committee. Safe disposal of clinical
waste. Sheffield HSE, 1999; 68.
18 Rowley E, Dingwall R. The use of single-use devices in
anaesthesia: balancing the risks to patient safety. Anaesthesia
2007; 62: 569–74.
19 Sterilisation, disinfection and cleaning of medical equipment.
Guidance on decontamination from the Microbiology
Advisory Committee to Department of Health Medical
Devices Agency MDA. London 2002, 2005, 2006.
20 NHS Decontamination Programme. Department of Health
(UK). http://www.dh.gov.uk/en/Managingyourorganisation/
Leadershipandmanagement/Healthcareenvironment/
NHSDecontaminationProgramme/index.htm (accessed 15
July 2008).
21 MacCallum FO, Noble WC. Disinfection of anaesthetic face
masks. Anaesthesia 1960; 15: 307.
22 Miller DH, Youkhana I, Karunaratne WU, Pearce A. Presence
of protein deposits on cleaned re-usable anaesthetic equipment.
Anaesthesia 2001; 56: 1069–72.
23 Chrisco JA, Devane G. A descriptive study of blood in the
mouth following routine oral endotracheal intubation.
Journal of American Association of Nurse Anesthetists 1992; 60:
379–83.
24 Wilkes AR. Breathing system filters. British Journal of
Anaesthesia. CEPD Review. 2002; 2: 151–4.
25 Wilkes AR, Benbough JE, Speight SE, Harmer M.
The bacterial and viral filtration performance of breathing
system filters. Anaesthesia 2002; 55: 458–65.
26 Ballin MS, McCluskey A, Maxwell S, Spilsbury S.
Contamination of laryngoscopes. Anaesthesia 1999; 54:
1115–6.
27 Esler MD, Baines LC, Wilkinson DJ, Langford RM.
Decontamination of laryngoscopes: a survey of national
practice. Anaesthesia 1999; 54: 587–92.
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.....................................................................................................................................................................................................................
28 Phillips RA, Monaghan WP. Incidence of visible and
occult blood on laryngoscope blades and handles. Journal
of American Association of Nurse Anesthetists 1997; 65: 241–6.
29 Bucx MJ, Veldman DJ, Beenhakker MM, Koster R. The
effect of steam sterilisation at 134°C on light intensity
provided by fibrelight Macintosh laryngoscopes. Anaesthesia
1999; 54: 875–8.
30 Device Bulletin DB2002 (05) Decontamination of
Endoscopes. London: MDA, 2002.
31 Transmissible spongiform encephalopathy agents: safe
working and the prevention of infection, annex F
(Decontamination of endoscopes, amended 2005). Advisory
Committee of Dangerous Pathogens and Spongiform
Encephalopathy Advisory Committee. http://www.
advisorybodies.doh.gov.uk/acdp/tseguidance/index.htm
(accessed 15 July 2008).
32 HTM 2030, Washer Disinfectors. London: NHS Estates, 1997.
The Stationary Office.
33 Jerwood DC, Mortiboy D. Disinfection of gum elastic
bougies. Anaesthesia 1995; 50: 376.
34 Transmissible spongiform encephalopathy agents. safe
working and the prevention of infection. Guidance from the
(updated website): http://www.advisorybodies.doh.gov.uk/
acdp/tseguidance/index.htm (accessed 15 July 2008).
35 Patient safety and the reduction of risk of transmission of
Creutzfeldt-Jakob disease (CJD) via interventional procedures.
National Institute for Health and Clinical Excellence
interventional procedure guidance 196, available via the
NICE website: http://www.nice.org.uk (accessed 15 July
2008).
36 Health Protection Agency CJD Panel: information and
advice. http://www.hpa.org.uk/infections/topics_az/cjd/
incidents_panel.htm (accessed 15 July 2008).
37 CJD Incidents Panel Fifth Annual Report to the
Advisory Committee on Dangerous Pathogens on Transmissible
Spongiform Encephalopathies (2006): website as
above.
38 Re-introduction of Re-usable instruments for tonsil surgery.
Press release from the UK Department of Health, 14
December 2001.
39 Richards E, Brimacombe J, Laupau W, Keller C. Protein
cross-contamination during batch cleaning and autoclaving
of the ProSeal TM laryngeal mask airway. Anaesthesia 2006;
61: 431–3.
40 Current information from the UK and Scottish blood
transfusion services. http://www.blood.co.uk/hospitals/
library and http://www.scotblood.co.uk (accessed 15 July
2008).
41 Pearson ML Hospital Infection Control Practices Advisory
Committee. Guidelines for prevention of intravascular
device related infections. Infection Control and Hospital
Epidemiology 1994; 15, 227–30.
42 Fletcher SJ, Bodenham AR. Catheter-related sepsis:
an overview. British Journal of Intensive Care 1999; 9: 74–80.
43 Maki DG, Ringer M, Alvacado CJ. Prospective
randomised trial of providone-iodine, alcohol, and
chlorhexidine for prevention of infection associated with
central venous and arterial catheters. Lancet 1991; 338:
339–43.
44 Pratt RJ, Pellowe C, Loveday HP, et al. The Epic Project –
Guidelines for preventing infections associated with the
insertion and maintenance of central venous catheters. Journal
of Hospital Infection 2001; 47: (Suppl) S47–67.
45 Implement the central line bundle. http://www.ihi.org/
IHI/Topics/CriticalCare/IntensiveCare/Changes/
ImplementtheCentralLineBundle (accessed 15 July 2008).
Ó 2008 The Authors
1036 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland

21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 76314352
E-mail: info@aagbi.org
Website: www.aagbi.org

AAGBI SAFETY GUIDELINE
Interhospital Transfer
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org
February 2009

MEMBERSHIP OF THE WORKING PARTY
Dr D Goldhill
Dr L Gemmell
Dr D Lutman
Dr S McDevitt
Dr M Parris
Dr C Waldmann
Dr C Dodds
Chairman, Consultant Anaesthetist,
Royal National Orthopaedic Hospital
Honorary Secretary Elect, AAGBI
Consultant Anaesthetist, Great
Ormond St Hospital
Council Member, AAGBI
Group of Anaesthetists in Training
Consultant Anaesthetist, Royal
Berkshire Hospital
Royal College of Anaesthetists
Ex-Officio
Dr D K Whitaker
Dr R J S Birks
Dr I H Wilson
Dr A W Harrop-Griffiths
Dr I G Johnston
Dr D G Bogod
President
President Elect
Honorary Treasurer
Honorary Secretary
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia
© Copyright of the Association of Anaesthetists of Great Britain and Ireland.
No part of this book may be reproduced without the written permission of the AAGBI.

CONTENTS
Section 1 Recommendations ..............................................................2
Section 2
Section 3
Section 4
Section 5
Section 6
Section 7
Section 8
Section 9
Background..........................................................................3
Introduction.........................................................................4
The decision to transfer........................................................5
Stabilisation before transfer..................................................7
Accompanying the patient...................................................8
Monitoring, drugs and equipment......................................10
The ambulance..................................................................11
Documentation and handover............................................13
Appendix ..........................................................................................14
References ..........................................................................................15
1

Section 1
Recommendations
1. Transfer can be safely accomplished even in extremely ill patients.
Those involved in transfers have the responsibility for ensuring that
everything necessary is done to achieve this.
2. The need for transfers between hospitals is likely to increase. Transfers
for non-clinical reasons should only take place in exceptional
circumstances and ideally only during daylight hours.
3. The decision to transfer must involve a senior and experienced
clinician.
4. Hospitals should form transfer networks to coordinate and manage
clinically indicated transfers.
5. Networks should take responsibility for ensuring that arrangements can
be made for accepting transfers to an agreed protocol with minimal
administrative delays.
6. Protocols, documentation and equipment for transfers should be
standardised within networks.
7. All doctors and other personnel undertaking transfers should have the
appropriate competencies, qualifications and experience. It is highly
desirable that this should include attendance at a suitable transfer
course.
8. A professional, dedicated transfer service has many advantages and is
the preferred method of transferring suitable patients.
9. Hospitals must ensure that suitable transfer equipment is provided.
10. Hospitals must ensure that they have robust arrangements to ensure that
sending personnel on a transfer does not jeopardise other work within
the hospital.
11. Hospitals must ensure that employees sent on transfers have adequate
insurance cover and are made aware of the terms and limitations of this
cover.
12. Arrangements must be in place to ensure that personnel and equipment
can safely and promptly return to base after the transfer.
13. Details of every transfer must be recorded and subject to regular audit
and review.
2

Section 2
Background
The AAGBI Council decided to commission a Working Party to produce
guidelines in the usual format of the Association to provide instruction and
help to those arranging transfers and those involved with the actual transfer of
the patients between hospitals.
A large number of interhospital transfers already take place and the number
is likely to increase. Anaesthetists are commonly involved in transferring
the sickest of these patients. This has the potential to affect an Anaesthetic
Department’s budget and ability to maintain a service and on-call rotas.
This document addresses transfers between hospitals, not within a hospital.
However, the principles for the safe movement of patients are also applicable
to transport within a hospital.
3

Section 3
Introduction
In 1997 it was estimated that over 11,000 critically ill patients were transferred
between intensive care units in the UK [1]. The majority of transfers are for
appropriate clinical reasons for patients requiring care not available in the
referring hospital. Such specialist care includes neuroscience, paediatrics,
burns, spinal injury, etc. There is a limited number of paediatric and neonatal
centres with high-level critical care support. Transfer of critically ill children
must be a consideration in any hospital with an emergency department. Many
transfers are undertaken for non-clinical reasons commonly related to the
relative lack of critical care beds. It is government policy that these transfers
should be as few as possible and contained within critical care transfer
groups [2]. A relatively small percentage of patients transferred between
hospitals involve repatriations of patients previously transferred. Patients may
be transferred from the emergency department, critical care units, operating
theatres, wards or other areas of the hospital. Transfers often occur outside of
normal working hours and take place at short notice [3]. During the transfer
the patient is in a noisy, difficult and potentially dangerous environment and
the transferring medical team is operating independently. All hospitals that
may be involved in transfers must ensure that the appropriate personnel,
equipment, training and support are available. In the past, inexperienced
doctors with inadequate training, supervision and equipment carried out
many of the transfers [1,3-5]. Although the situation has improved, in many
regions of the country there are still significant limitations in the process of
arranging and carrying out a transfer.
This booklet should be read in conjunction with ‘Recommendations for the
Safe Transfer of Patients with Brain Injury’ published by the Association of
Anaesthetists in 2006 (http://www.aagbi.org/publications/guidelines/docs/
braininjury.pdf). Other guidelines have been published including those from
the Intensive Care Society ([6] available from www.ics.ac.uk). This booklet
is not intended to be an in-depth document on transfer but should be read in
conjunction with these and other guidelines.
4

Section 4
The decision to transfer
It is essential that a systematic approach is taken to the process of patient
transfer; starting with the decision to transfer, through the pre-transfer
stabilisation, and then the management of the transfer itself. This will
encompass all the stages including skilled evaluation, communication,
documentation, monitoring and treatment, handover and return to base.
Education and preparation are central to any safe transfer.
The decision to transfer must not be taken lightly. It has the potential to expose
the patient and transferring staff to additional risk, requires trained personnel,
specialised equipment and a vehicle, and may result in additional expense
and worry for carers and relatives. A senior doctor, normally a consultant,
should therefore be involved in making this decision. Documentation of the
decision should include the name of the doctor making the decision with their
grade and contact details, and the date and time at which the decision was
made. Reasons for the decision should be given including whether it is for
clinical or non-clinical reasons.
Once the decision is made a hospital and medical team must agree to take
the patient. In much of the United Kingdom critical care transfer groups have
been established with a role of co-ordinating and facilitating transfers within
a network. If a critical care bed is required, direct consultant-to-consultant
contact is often the best way to make arrangements. In the appropriate
circumstances and for the right patient many intensive care units are able
to accommodate patients at short notice. However, the further away the
referring hospital and the more tenuous the links, the less responsibility the
accepting hospital is likely to feel. We would therefore strongly advise groups
of hospitals to form networks to facilitate and organise transfers.
Most of the country is covered by bed bureaux such as the Emergency
Bed Service (EBS). They contact critical care units on a regular basis and
are able to provide some indication of the availability of beds. They do
not take responsibility for arranging the transfer and it is still necessary to
negotiate directly with individual units. Once a critical care unit has agreed
to accept a patient it is necessary for the patient’s medical team to arrange
for the appropriate medical speciality in the receiving hospital to take overall
responsibility for the patient during their admission to that hospital.
5

This process may require many telephone calls and take several hours [7].
Streamlining this process should be a responsibility for a transfer network.
The process of arranging the transfer must be documented including the
name, grade and contact details of those making the arrangements both at the
referring and receiving centres, the date and time of calls made and details of
any advice received.
A limited number of retrieval services able to perform transfers exist in the UK,
mainly covering paediatric patients. A professional, dedicated transfer service
has many advantages and is the preferred method of transferring suitable
patients. Networks should aim to fund and develop such teams. Members of
these teams have the training and competencies to undertake transfers; such
teams have appropriate equipment and can work with the ambulance service,
hospitals and other interested parties on protocols and guidelines. They also
ensure that transfers can be safely achieved without compromising the work
of the transferring hospital.
Although these services are extremely welcome they cannot be relied upon
to provide a service at short notice and at all times [8-10]. Every hospital that
may transfer patients must have suitable arrangements in place for providing
transfers. Most transfers are in an ambulance by road. There is an increasing
number of transfers in rotary and fixed wing aircraft. Air transfers confer
additional hazards and expense and require further training [11,12].
6

Section 5
Stabilisation before transfer
Although transfers are potentially associated with additional risk to patients
[13-15], they can be safely accomplished even in extremely ill patients [16-
18]. Generally, a transfer should not be undertaken until the patient has
been resuscitated and stabilised. All hospitals involved in transfers must
ensure that they have appropriate arrangements in place for this. It may be
several hours after the decision to transfer before the transfer can take place.
It may be necessary to secure the airway, and many patients will require
a tracheal tube or tracheostomy with appropriate end-tidal carbon dioxide
monitoring. Appropriate venous access must be in place and monitoring
instituted. Continuous invasive blood pressure measurement is the best
technique for monitoring blood pressure during the transfer of ill patients.
Treatment should not be delayed while waiting for the transfer. The accepting
hospital may be able to provide advice on the immediate management in
specialised situations. A ‘scoop and run’ philosophy is only appropriate on
rare occasions when the urgency of the situation and the need for definitive
treatment will limit the time available for stabilisation before transfer. For
example, transfer of a patient with a leaking aortic aneurysm to a vascular
centre may be time-critical. Even in these situations the transfer should not
begin until essential management and monitoring has been undertaken. It
is good practice to establish the patient on the transport ventilator and other
equipment for a period of time before they are moved.
7

Section 6
Accompanying the patient
A critically ill patient should be accompanied by a minimum of two
attendants. The precise requirement for accompanying personnel will depend
upon the clinical circumstances in each case. The level of a patient’s critical
care dependency provides a guide to the personnel who should accompany
them [19]. A senior doctor, normally a consultant, should take the decision
on who should accompany the patient. Before departure the senior individual
undertaking the transfer should be satisfied with the state of the patient and
all other aspects associated with the transfer. Many patients do not need
anaesthetic support during interhospital transfer.
These patients include:
• patients who are not likely to need airway or ventilatory support
• patients for whom attempting cardiopulmonary resuscitation would
be inappropriate
• patients being transferred for acute definitive management for whom
anaesthesia support will not affect their outcome
Levels of patients’ critical care needs as a guide to transfer requirements.
The decision should be made by a senior doctor [19]
Level 0:
Patients whose needs can be met through normal ward care in an acute
hospital should not usually need to be accompanied by a doctor, nurse or
paramedic.
Level 1:
At risk of their condition deteriorating, or those recently relocated from higher
levels of care and whose needs can be met on an acute ward with additional
advice and support from the critical care team will require a paramedic
ambulance crew and may require a nurse, paramedic and/or medical escort.
Level 2:
Requiring more detailed observation or intervention including support for a
single failing organ system or post-operative care and those stepping down
from higher levels of care must be escorted by competent, trained and
experienced personnel, usually a doctor and a nurse or paramedic.
8

Level 3:
Patients requiring advanced respiratory support alone or basic respiratory
support together with support of at least two organ systems. This level
includes all complex patients requiring support for multi-organ failure. These
patients must be escorted by competent, trained and experienced personnel,
usually a doctor and a nurse or paramedic.
When the request for anaesthetic care during transfer exceeds the Department
of Anaesthesia’s ability to do this safely, decisions about priority and relative
risk may have to be taken. Although the patient would benefit from anaesthesia
management, the issue may be one of either delaying transfer until resources
are available or sending the patient without an accompanying anaesthetist
but with another doctor. Anaesthetic Departments should use interhospital
transfers to provide doctors with training and experience under the direct
supervision of an experienced transfer team.
All individuals involved in the transport of critically ill patients should be
suitably competent, trained and experienced. A competency-based training
curriculum is being developed by the Royal College of Anaesthetists. There
are generic training courses available but consideration should be given to the
development of local Trust and Network training and simulation programmes.
Good communication skills are essential. Each Trust should have a designated
consultant who is responsible for secondary transfers, guideline production
and training and audit.
While safety is of paramount importance during transfer, there is always a
remote possibility of an ambulance being involved in an accident resulting in
death or serious injury to staff. The insurance situation in these circumstances
is complex. It is essential that all members of staff who might be involved
in transporting patients and their employers ensure that adequate financial
arrangements are in place for themselves and their dependents in the event of
an accident and that they are made aware of the terms and limitations of this
cover. In addition, the AAGBI has negotiated insurance for all their members
involved in the transport of critically ill patients. Details of the appropriate
insurance schemes and the cover benefit of membership are available from
the AAGBI (www.aagbi.org). The AAGBI also recommends that doctors
involved with the transfer of patients are members of a medical defence
organisation.
9

Section 7
Monitoring, drugs and equipment
Patients with level 1, 2 or 3 critical care needs will require monitoring during
the transfer. Monitoring needs to be established and secure before the transfer
is started. This may require the insertion of central venous lines, arterial lines
and equipment for measuring cardiac output, as well as end-tidal carbon
dioxide monitoring.
The personnel involved in the transfer should ensure that they have adequate
supplies of the necessary drugs. These may include sedatives, analgesics,
muscle relaxants, and inotropes. Many of these drugs are best prepared
beforehand in pre-filled syringes. The patient should be established on the
medication to be used during the transfer before the transfer commences.
As much of the equipment as possible should be mounted at or below the
level of the patient. In particular, large arrays of vertical drip stands should be
avoided. This allows unhindered access to the patient and improves stability of
the patient trolley. All equipment should be robust, durable and lightweight.
Electrical equipment must be designed to function on battery when not
plugged into the mains. Additional batteries should be carried in case of
power failure. Portable monitors should have a clear illuminated display and
be capable of displaying ECG, arterial oxygen saturation, non-invasive blood
pressure, two invasive pressures, capnography and temperature. Non-invasive
blood pressure may rapidly deplete battery power and is unreliable when
there is external movement and vibration. Alarms should be visible as well
as audible in view of the loud background noise levels.
Portable mechanical ventilators should have, as a minimum, disconnection
and high pressure alarms, the ability to supply positive end expiratory pressure
and variable inspired oxygen concentration, inspiratory : expiratory ratio,
respiratory rate and tidal volume. In addition, the ability to provide pressurecontrolled
ventilation, pressure support and continuous positive airway
pressure is desirable. Additional equipment for maintaining and securing the
airway, intravenous access, etc should also be available.
Ideally, all equipment within a Critical Care Network should be standardised
to enable the seamless transfer of patients without, for example, interruption of
drug therapy or monitoring due to incompatibility of leads and transducers.
10

Section 8
The ambulance
The European Committee for Standardisation has published specifications for
ambulances. Private transport services may use Type C mobile ICU vehicles.
These will have 240V AC power, a secure critical care trolley and carry a
ventilator and syringe drivers. It is more usual to request an ambulance from
the local ambulance service to perform the transfer. This is a likely to be a
Type B or equivalent vehicle that has 12V electric sockets, oxygen supply and
limited monitoring and other equipment.
Before transfer it is essential to ascertain what needs to be taken with the
patient to support the transfer. The oxygen supply and battery operated
equipment must be more than sufficient for the anticipated duration of the
transfer. Unless a transfer service is used, everything except the oxygen
supply usually has to be supplied by the transferring hospital. Hospitals
involved in transfers must ensure that the appropriate equipment is available
for likely transfers at all times.
The standard ambulance trolley is ill-suited to patient transfers. Ideally, it
should be able to carry all the equipment including oxygen supply, a ventilator,
syringe drivers, suction and backup batteries. These items should be placed
below the patient, and the trolley should be secured within the ambulance to
allow free access to all sides with a fixation capable of withstanding up to 10
G in all directions. It is not acceptable to place items on the patient’s trolley
or on shelves within the vehicle. Gravity feed drips are unreliable in moving
vehicles. Sufficient syringe or infusion pumps are required to enable essential
fluids and drugs to be delivered. Pumps should preferably be mounted below
the level of the patient and infusion sets fitted with anti-siphon devices.
Portable warm-air devices for maintaining the patient’s temperature can be
useful and can also be mounted on the patient’s trolley.
A major issue relating to safety during transport is the speed of travel. For
the majority of cases high-speed travel is not necessary and the safety of all
passengers and other road users is paramount. Medical personnel present
may offer advice as to the patient’s clinical condition and the speed of travel
but they should be aware of the requirements of the Road Traffic Act in such
cases. The decision to use blue lights and sirens rests with the ambulance
driver. The goal is to facilitate a smooth and rapid transfer with the minimum
acceleration and deceleration. A police escort may be required through
11

heavily congested areas, but not all police authorities provide this service.
Staff should remain seated at all times and wear the seat belts provided. If,
despite meticulous preparation, unforeseen clinical emergencies arise and
the patient requires intervention, this should not be attempted in a moving
ambulance. The vehicle should be stopped appropriately in a safe place and
the patient attended to. Where staff may be required to move outside the
vehicle, high visibility clothing must be worn. On safety issues all staff in the
vehicle must obey the instructions of the crew.
Air transport should be considered for longer journeys where road access is
difficult or when, for other reasons, it may be quicker. Perceived speed of
air transport must be balanced against organisational delays and inter-vehicle
transfers at either end of the journey. Helicopters vary in size, capacity and
range. They generally provide a less comfortable, more cramped environment
than a road ambulance or pressurised fixed wing aircraft. In addition, they are
expensive and have a poorer safety record.
The transport of patients by air presents medical escorts with many problems
unique to this mode of travel. Staff involved in aeromedical transport must
have both a high level of expertise, specialist knowledge and practical training.
Staff without appropriate training should not undertake aeromedical transfers.
Minimum requirements include safety training, evacuation procedures for the
aircraft and basic on-board communication skills (particularly for helicopters).
However, more advanced training in aeromedical transport medicine is
desirable. Training should also address the special physical, physiological
and psychological stresses that are important when flying as well as provide
a detailed knowledge of how medical conditions can be affected by this
environment and the necessary precautions needed to facilitate safe transfer.
12

Section 9
Documentation and handover
Clear records should be maintained at all stages. This is a legal requirement
and should include details of the patient’s condition, reason for transfer,
names of referring and accepting consultants, clinical status prior to transfer
and details of vital signs, clinical events and therapy given during transport.
Standard documentation should be developed across networks and be
used for both intra-hospital and interhospital transport. The clinical record
should briefly summarise the patient’s clinical status before, during and after
transport, including relevant medical conditions, environmental factors and
therapy given. This should include a core data set for audit purposes and the
transport team should be able to retain a duplicate. There should be a process
to investigate specific problems, including delays in transportation.
Clear information should be given to the transport team before departure about
the location of the receiving area for the formal handover of the patient. On
arrival at the receiving hospital, there should be a formal handover between
the transport team and the receiving medical and nursing staff who will
assume responsibility for the patient’s care. Handover should include a verbal
and written account of the patient’s history, vital signs, therapy and significant
clinical events during transport. X-rays, scans and other investigation results
should be described and handed over to receiving staff.
After handover, the transport team is relieved of the duty of care to the patient,
who is now in the medical care of the receiving hospital. This is an important
part of the transfer of care and the status of the patient should be formally
noted by the receiving team. It should be noted that the ambulance crew
or air crew may not always be able to return the transfer team whence they
came. The transfer team should be prepared to return home by taxi or other
appropriate means and therefore thought should be given to clothing, the
amount of equipment to be carried and the means of payment for the return
journey.
13

APPENDIX
1 Departure checklist
Do attendants have adequate competencies, experience, knowledge
of case, clothing, insurance?
Appropriate equipment and drugs?
Batteries checked?
Sufficient oxygen?
Trolley available?
Ambulance service aware or ready?
Bed confirmed? Exact location?
Case notes, X ray films, results, blood collected?
Transfer chart prepared?
Portable phone charged?
Contact numbers known?
Money or cards for emergencies?
Estimated time of arrival notified?
Return arrangements checked?
Relatives informed?
Patient stable, fully investigated?
Monitoring attached and working?
Drugs, pumps, lines rationalised and secured?
Adequate sedation?
Still stable after transfer to mobile equipment?
Anything missed?
14

References
1. Mackenzie PA, Smith EA, Wallace PG. Transfer of adults between
intensive care units in the United Kingdom: postal survey. British
Medical Journal 1997; 314: 1455-6.
2. Department of Health. Comprehensive Critical Care. a review of adult
critical care services. 2000. London, Department of Health.
3. Gray A, Gill S, Airey M, Williams R. Descriptive epidemiology of adult
critical care transfers from the emergency department. Emergency
Medicine Journal 2003; 20: 242-6.
4. Jameson PP, Lawler PG. Transfer of critically ill patients in the Northern
region. Anaesthesia 2000; 55: 489.
5. Spencer C, Watkinson P, McCluskey A. Training and assessment
of competency of trainees in the transfer of critically ill patients.
Anaesthesia 2004; 59: 1248-9.
6. Guidelines for the transport of the critically ill adult. 2002. London,
The Intensive Care Society.
7. Duke GJ, Green JV. Outcome of critically ill patients undergoing
interhospital transfer. The Medical Journal of Australia 2001; 174: 122-
5.
8. Vos GD, Nissen AC, Nieman FH et al. Comparison of interhospital
pediatric intensive care transport accompanied by a referring
specialist or a specialist retrieval team. Intensive Care Medicine 2004;
30: 302-8.
9. Bellingan G, Olivier T, Batson S, Webb A. Comparison of a specialist
retrieval team with current United Kingdom practice for the transport
of critically ill patients. Intensive Care Medicine 2000; 26: 740-4.
10. Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do
specialist transport personnel improve hospital outcome in critically ill
patients transferred to higher centers? A systematic review. Journal of
Critical Care 2006; 21: 8-17.
11. Diaz MA, Hendey GW, Bivins HG. When is the helicopter faster? A
comparison of helicopter and ground ambulance transport times. The
Journal of Trauma 2005; 58: 148-53.
12. Dewhurst AT, Farrar D, Walker C, Mason P, Beven P, Goldstone JC.
Medical repatriation via fixed-wing air ambulance: a review of patient
characteristics and adverse events. Anaesthesia 2001; 56: 882-7.
15

13. Bercault N, Wolf M, Runge I, Fleury JC, Boulain T. Intrahospital
transport of critically ill ventilated patients: a risk factor for ventilatorassociated
pneumonia--a matched cohort study. Critical Care Medicine
2005; 33: 2471-8.
14. Fan E, Macdonald RD, Adhikari NK et al. Outcomes of interfacility
critical care adult patient transport: a systematic review. Critical Care
2005; 10: R6.
15. Waydhas C. Intrahospital transport of critically ill patients. Critical Care
1999; 3: R83-R89.
16. Gebremichael M, Borg U, Habashi NM et al. Interhospital transport of
the extremely ill patient: the mobile intensive care unit. Critical Care
Medicine 2000; 28: 79-85.
17. Penner GE, Brabson TA, Bunk C. Are interfacility ground transports
of patients utilizing intra-aortic balloon pumps safe? Prehospital
Emergency Care 2001; 5: 395-8.
18. Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe long-distance
interhospital ground transfer of critically ill patients with acute severe
unstable respiratory and circulatory failure. Intensive Care Medicine
2002; 28: 1122-5.
19. The Intensive Care Society. Levels of critical care for adult patients.
2002. London, The Intensive Care Society.
16

17

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Management of
Anaesthesia for
Jehovah’s Witnesses
2nd edition
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org
November 2005

Members of the Working Party
Dr Mike E Ward
Dr John Dick
Dr Stephanie Greenwell
Dr Ellen O’Sullivan
Dr Ranjit Verma
Dr David K Whitaker
Chairman of the working party
Group of Anaesthetists in Training
Vice-President
Council Member
Council Member
Immediate Past Honorary Secretary
Ex Officio
Prof Mike Harmer
Dr Peter G M Wallace
Dr Richard Birks
Prof W Alastair Chambers
Dr Diana Dickson
Dr David Bogod
President
Immediate Past President
Honorary Treasurer
Honorary Secretary
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia
The Working Party would like to acknowledge the helpful advice of
Mr Bertie Leigh of Hempsons Solicitors and Geraldine Hickey of
McCann Fitzgerald Solicitors (Ireland)
1

2

Recommendations
1. Wherever possible, consultant staff (anaesthetists and surgeons)
should be directly involved throughout the care of Jehovah’s Witness
patients.
2. Departments of Anaesthesia should review their procedure for being
alerted at an early stage of the scheduling of Jehovah’s Witness patients
for elective surgery.
3. Departments should keep a regularly updated list of those senior
members prepared to care for followers of the Jehovah’s Witness
faith.
4. In an emergency, an anaesthetist is obliged to care for a patient in
accordance with the patient’s wishes.
5. Properly executed Advance Directives must be respected and special
Jehovah’s Witness consent forms should be widely available for use as
required.
6. All Jehovah’s Witnesses must be consulted individually, whenever
possible, to ascertain what treatments they will accept.
7. Discussions with individual Jehovah’s Witness patients should be fully
documented and their acceptance or rejection of treatments recorded
and witnessed.
8. In the case of children, local procedures for application to the High
Court for a ‘Specific Issue Order’ should be reviewed and available for
reference.
9. In Scotland. In the case of children, local procedures for application to
the Court of Session or appropriate Sheriff Court should be reviewed
and available for reference.
10. In Ireland. In the case of children, application to District Court for
child to be placed under Emergency Care Order should be reviewed
and available for reference.
11. A ‘Specific Issue Order’ or equivalent should only be applied for when
it is felt to be entirely necessary to save the child in an elective or semielective
situation.
12. In a life-threatening emergency in a child unable to give competent
consent, all life-saving treatment should be given, irrespective of the
parents’ wishes.
3

SECTION 1
1. Introduction
1.1 The first edition of this guidance [1] was published in March 1999 and
was received by the members of both the Association of Anaesthetists
of Great Britain and Ireland (the Association) and the Watch Tower Bible
and Tract Society of Britain (the official organisation for British Jehovah’s
Witnesses) with some acclaim.
1.2 Since then there has been a continuing debate surrounding the ethical and
practical consequences of consent for medicine as well as developments
in the areas of ‘Oxygen Therapeutics’, blood transfusion medicine and
alternative blood sparing technologies.
1.3 In his Report for 2003 entitled On the State of Public Health, the UK
Department of Health’s Chief Medical Officer, Professor Liam Donaldson,
stated that he believed too many unnecessary blood transfusions were
being given in England [2]. He added, “The gift of blood is too often
squandered by unnecessary and inappropriate use”, and expressed
concern at the fall in the donor pool (down by one fifth in 4 years). He
further suggested that transfusion is unnecessary unless the haemoglobin
falls below 7 g/dl, and proposed that only consultants, and not junior
staff, should be allowed to order blood and blood products.
1.4 The management of Jehovah’s Witness patients was briefly reviewed in
the Royal College of Anaesthetists’ publication Continuing Education in
Anaesthesia, Critical Care & Pain[3].
1.5 This present report has been prepared by the Association and advises
on the anaesthetic management of patients belonging to the Jehovah’s
Witness faith.
4

SECTION 2
2. Beliefs and their Implications for the Anaesthetist
2.1 Every competent adult patient is entitled to refuse to consent to medical
treatment for good reason, bad reason or no reason. No opinion should
be attributed to a patient simply because they are a member of a religious
or political group. In this guide we seek to describe the views held by
most mainstream Elders of the community of Jehovah’s Witnesses in the
hope that this will assist anaesthetists in advising and treating individual
Jehovah’s Witness patients. However, there is no substitute for seeking the
views of the individual patient who happens to be a Jehovah’s Witness at
the time when decisions have to be made. Doctors must be aware at all
times that all patients are entitled to change their minds and that the only
thing that matters is what treatment the patient wishes to have at the time
when the decision has to be taken.
2.2 It is estimated that there are nearly 6.5 million Jehovah’s Witnesses in 235
countries worldwide and about 150, 000 in Great Britain and Ireland.
2.3 Recent knowledge of the risk of transmission of disease and other
complications of blood transfusion have in many cases been cited as
further support for the Jehovah’s Witnesses’ refusal to accept blood
transfusion. Increasing awareness of this risk generally by the medical
profession has altered views on the need for transfusion and altered our
perception of the problems occurring as a result of acute unexpected
blood loss.
2.4 The Jehovah’s Witness movement is some 120 years old, having been
founded in North Eastern United States of America. It is an actively
proselytising Christian organisation that originally had objections to other
medical treatments such as vaccinations and inoculations, although these
are now largely accepted. In 1945, the Watch Tower Bible and Tract
Society (the name of the group’s legal publishing entity) promulgated
the views that adherents to the faith should not receive allogenic blood.
Some adherents of the faith choose to extend this prohibition to include
blood products. The explanation for these beliefs is their interpretation
of Genesis 9:3, 4, Leviticus 17:11, 12 and Acts 15:28, 29 (Appendix
1), all of which describe the prohibition of the consumption of blood.
The established Jehovah’s Witnesses’ interpretation of this is that an
individual’s life is represented by their blood. The prohibition of blood
transfusion is a deeply held core value and is a sign of respect for the
sanctity of life.
5

2.5 It may be helpful to regard these rules under the following two
headings:
2.5.1 Treatment generally regarded as unacceptable by Jehovah’s
Witnesses:
• Transfusion of whole blood, packed red cells, white cells, plasma
(FFP), and platelets
• Preoperative autologous blood collection and storage for later
reinfusion (pre-deposit)
2.5.2 Matters that Jehovah’s Witnesses recognise as being of personal
choice:
Each Witness decides whether he/she wishes to accept the
following as a matter of individual choice. It is therefore important
to discuss with each patient whether or not these are acceptable.
• Blood salvage (intra and post-operative), haemodilution,
haemodialysis, and cardiac bypass
• Blood ‘fractions’ of plasma or cellular components (eg albumin,
immunoglobulins, clotting factors)
• Whilst haemoglobin based oxygen carrying solutions are not
yet licensed in the UK, they may soon be available and may be
acceptable to some Jehovah’s Witness patients.
• Transplantation, including solid organ, bone, tissue etc
• Epidural blood patch (see below)
2.6 It should be remembered that no absolute rules regarding blood
products exist. Some Witnesses are willing to accept the use of plasma
protein fraction (PPF) or components such as albumin, immunoglobulins
and haemophilic preparations, when asked individually. Other clinical
interventions may also need to be dealt with on a personal basis. Organ
transplantation, for example, is not specifically forbidden for Jehovah’s
Witnesses, and each individual is expected to reach his or her own
decision.
2.7 Cardiac bypass may be accepted provided the pump is primed with nonblood
fluids and blood is not stored in the process. Auto transfusion is
acceptable to many Jehovah’s Witnesses. Jehovah’s Witnesses will not
accept pre-operative collection, storage and later re-infusion of blood.
2.8 The use of an epidural blood patch may be acceptable to some Jehovah’s
Witnesses [4].
6

2.9 Administration of blood to a competent patient, against their will and
in conflict with their genuinely held beliefs, has been likened by the
Witnesses to rape. It will not result in expulsion from the community if it
was carried out against the expressed wishes of the patient but may have
as deep a psychological effect as forceful sexual interference.
2.10 Because of the variability between individual beliefs, it is common for a
Witness patient to wish to consult with the Elders of the community for
help in reaching a decision regarding accepting blood-product related
medical treatment. Most active communities (in 42 key locations in
Great Britain and Ireland, generally based in the major cities) maintain
a committee of Elders, known as the ‘Hospital Liaison Committee for
Jehovah Witnesses’, which can be contacted and whose telephone
numbers are generally lodged with the local hospital switchboards served
by the committee. Appendix 2 gives the main contact numbers for the
national central committees.
2.11 The local Hospital Liaison Committee can also act as a local resource for
information regarding the beliefs and practices of Jehovah’s Witnesses.
They are generally aware of up to date research and clinical practice in
the area of bloodless surgery and have access to a great deal of reference
material and information.
2.12 Hospital Liaison Committees also hold a schedule of clinicians experienced
in treating patients in accordance with the wishes of Jehovah’s Witnesses.
These clinicians may be prepared to give advice if consulted or even
accept transfer of the patient’s care.
2.13 The Working Party suggests that departments of anaesthesia have
available a list of anaesthetists willing to manage such patients.
7

SECTION 3
3. The legal position in respect of anaesthesia and consent
3.1 Jehovah’s Witnesses are generally well informed, both about their legal
position and the options for treatment. Any competent adult is entitled
to accept surgery but also specifically to exclude certain aspects of
management, such as the administration of a blood transfusion. The
recent recommendations from the Department of Health in respect
of consent forms provide for the inclusion of a box for the patient to
complete, and this may contain specific exclusions from the consent.
Most practising Jehovah’s Witnesses will carry with them an Advance
Directive document. Appendix 3 gives the full wording of a typical
directive which specifically states that “in the event of emergency
treatment including general anaesthesia and surgery….” it forbids the
administration of blood or blood components. The advance directive
goes on to state “my express refusal of blood is absolute and is not to be
overridden in any circumstances”. It is important to realise that individual
Jehovah’s Witnesses may have different views, and the doctor’s obligation
is to respect the wishes of the individual patient.
3.2 It is the view of this Working Party that such an advance medical
directive by a competent adult, if properly signed and witnessed, must
be respected unless there is evidence that the patient has changed their
view since the directive was executed.
3.3 The Working Party strongly recommends that the views held by each
Jehovah’s Witness patient should be ascertained to find out which aspects
of treatment are acceptable and which are not.
3.4 To administer blood to a patient who has steadfastly refused to accept it
by either the provision of an advance directive or by its exclusion in a
consent form is unlawful and ethically unacceptable. It may also lead to
referral to the General Medical Council, criminal and/or civil proceedings
[5].
3.5 In the management of an unconscious patient whose status as a Jehovah’s
Witness may be unknown, the doctor caring for the patient will be
expected to perform to the best of his ability, and this may include the
administration of blood transfusion. However, there may be opinions put
forward by relatives or associates of the patient suggesting that the patient
would not accept a blood transfusion even if that resulted in death. Such
relatives should be invited to produce evidence of the patient’s status as
8

a Jehovah’s Witness. It is not uncommon for Jehovah’s Witnesses to lodge
a copy of their advance directives with their General Practitioner, who
should be contacted.
3.6 Children of Jehovah’s Witnesses below the age of 16 years may cause
particular difficulty. The wellbeing of the child is overriding and, if the
parents refuse to give permission for blood transfusion, it may be necessary
to apply for a ‘Specific Issue Order’ via the High Court in order legally
to administer the blood transfusion (see below and Appendix 4 for the
procedure to follow). It is important, however, before this serious step is
taken, that two doctors of consultant status should make an unambiguous
clear and signed entry in the clinical record that blood transfusion is
essential, or likely to become so, to save life or prevent serious permanent
harm. In the event that a court order is sought, it is essential [5] that the
parents be given the opportunity to be properly represented and are kept
fully informed of the practitioners’ intention to apply for the order.
In Scotland such an application for a ‘Specific Issue Order’ is made to
the Court under Section 11 of the Children (Scotland) Act 1995
In Ireland an application is made for an Emergency Care Order to the
District Court under Section 12 or 13 of the Child care Act 1991
In the case of young people over 12 years who are capable of understanding
the issues, the anaesthetist may be able to rely upon their consent (see
Section 5).
The management of a child of a Jehovah’s Witness in an emergency
situation who is likely to succumb without the immediate administration
of blood is viewed in law in a different light. In this situation, application
to the courts will be too time-consuming and the blood should be
transfused without consulting the court. The courts are likely to uphold
the decision of the doctors who give blood.
Most hospitals provide a special Jehovah’s Witness consent form but, if
that is not forthcoming, the Hospital Liaison Committee of the Jehovah’s
Witnesses has a suitable form available (See Appendix 3). It may also be
advisable to make a separate clear entry in the patient’s clinical notes
to the effect that the patient has refused the administration of blood or
blood products under any circumstances. However the extent of the
prohibition should be clearly set out, because of the range of opinions
identified in paragraph 2.5 above.
9

SECTION 4
4. Clinical Management
4.1 Preoperative
4.1.1 It is essential that surgeons who are aware that an elective patient
is a Jehovah’s Witness should alert the anaesthetic department as
soon as possible in order to ensure that a consultant anaesthetist
is prepared to manage the patient’s care. Early warning of any
potential intervention that could lead to the need for blood or
blood products is also advisable.
4.1.2 Anaesthetists have the right to refuse to anaesthetise an individual
in an elective situation but should attempt to refer the case to a
suitably qualified colleague prepared to undertake it. The surgeon
should be informed as soon as possible if any difficulty ensues. In
an emergency, the anaesthetist is obliged to provide care and must
respect the patient’s competently expressed views.
4.1.3 Major procedures can be carried out in stages in order to limit
acute blood loss, and the choice of operative technique may also
influence outcome; for example bilateral procedures could be
performed in two unilateral stages.
4.1.4 Increasingly, obstetric or major lower limb procedures may be
performed under local or regional anaesthesia alone and, in this
situation, some patients may change their mind when confronted
with the need for a blood transfusion as a life saving measure. Any
change in the patient’s views at this point should be regarded as a
modification in the scope of consent and should be witnessed. A
contemporaneous entry should be made in the patient’s anaesthesia
and clinical record. Whether or not a patient who has received
sedation will be competent to vary the consent which they have
previously given will depend upon the facts of the case. Broadly
speaking the law holds that a patient has capacity to consent to
treatment if they are capable of receiving advice from a doctor, of
understanding that advice, of balancing the issues in their mind and
uttering their wishes. They do not need to be able to give a full and
detailed discourse on the finer points of religion or pharmacology
that may be involved in their decision, simply to decide whether
or not they want to have the blood or blood products in question.
Where a patient has consented to receive blood which the doctor
10

elieved was immediately necessary in order to save their life, if
the Court accepts that that belief is reasonably held it should not
criticise the doctor for acting upon the consent of the patient.
4.1.5 The introduction of an antenatal alert of the anticipated delivery
of a child to a Jehovah’s Witness mother can also be beneficial so
that appropriate senior staff will be available. This arrangement
should apply to booking of delivery dates by both obstetricians
and midwives.
4.1.6 Full pre-operative investigations and consultations with the patient
should take place as early as possible in order to ascertain the
degree of limitation on intra-operative management.
4.1.7 At the pre-operative visit it is very important to take the
opportunity to see the patient without relatives or members of the
local community who may influence and impede full and frank
discussion of the acceptability of certain forms of treatment. At
this stage, treatments that are regarded as acceptable should be
established and the patient and staff made fully aware of the risks
of refusal of blood or blood products. Agreed procedures and
unacceptable treatments should be entered into the clinical notes
and signed as a record and witnessed by the patient. Such entries
should be both dated and timed.
At the patient’s request, family members or members of the Hospital
Liaison Committee for Jehovah’s Witnesses may be part of these
discussions. Their prime role should be to avoid confrontation and
assist understanding on both sides.
These family or Hospital Liaison Committee members may
however hold stronger views than those of the patient and, with
the patient’s agreement, they should be excluded if their presence
is detrimental to the patient’s peace of mind and mental comfort.
4.1.8 Pre-operative anaemia should be investigated and treated. The
use of recombinant erythropoetin to improve haemoglobin levels
has been documented but is a slow treatment that might not be
clinically justified or cost effective. It may be beneficial, however, to
improve the iron stores by pre-administration of iron supplements.
Discussion of an individual case with a haematologist could be
beneficial.
11

4.2 Intra-operative Management
4.2.1 Consideration should be given, before surgery, to one or more of
a number of techniques to reduce intra-operative blood loss, such
as: careful positioning to avoid venous congestion, hypotensive
anaesthesia, use of tourniquets where appropriate, meticulous
haemostasis, use of vasoconstrictors and haemodilution.
4.2.2 A ‘cell saver’ system may be acceptable to the Jehovah’s Witness
and can be used in certain operations where blood loss is unlikely
to result in blood contamination. Nevertheless, discussions of the
use of a cell saver should be carried out with the patient to assess
acceptability.
4.2.3 A number of drugs have been used in an effort to reduce fibrinolysis,
increase coagulability and reduce blood loss; eg tranexamic acid
and aprotinin [6].
4.3 Postoperative Care
4.3.1 Postoperative blood loss should be carefully monitored and
accurately recorded. Simple manoeuvres (e.g. direct compression)
or early surgical intervention (e.g. re-exploration) may reduce
overall blood loss.
4.3.2 In some peripheral orthopaedic surgery, such as total knee
replacement, postoperative wound drainage of blood can be
reinfused, using special filter-drainage systems.
4.3.3 In the event of massive blood loss it may be necessary to consider
elective ventilation to enhance oxygen delivery [7].
4.3.4 Active cooling in the postoperative period has also been described
to reduce oxygen consumption and increase dissolved oxygen
carriage, but this technique is not widely accepted [8].
4.3.5 Hyperbaric oxygen therapy has been described in the management
of anaemia following severe blood loss. Swift reversal of hypoxia is
possible but the technique has limited application. Nevertheless,
referral for hyperbaric therapy may be considered if an appropriate
facility is available [9].
12

5. Paediatric Considerations
5.1 Young adults of sound mind aged 16–18 years have a statutory right
in England and Wales to consent to procedures on their own account
and there is no legal requirement to obtain additional consent from a
parent or guardian. The patient’s consent takes precedence over parental
objections. Parents may give lawful consent to a young adult unable to
consent in their own right, because of decreased consciousness.
In Scotland, young persons aged 16 or over have an exclusive right to
determine their own medical treatment. The parent has no right to consent
or interfere; similarly, recourse to the Courts would not be available.
In Ireland a person is considered adult for the purposes of consent to
medical treatment at the age of 16 and there is no legal requirement to
obtain additional consent from parent or guardian (Section 23 of the
Non-Fatal Offences against the Person Act 1997).
5.2 In England and Wales children younger than 16 years may be
competent to give their own consent if they demonstrate a clear grasp
of the proposed treatment and the risks, benefits or consequences of
acceptance or rejection of a proposed treatment. This is referred to as
‘Gillick-competence’. However, this is likely only to apply to children
above the age of 12 years, but could for more minor procedures apply
much younger.
A situation could be envisaged where a child under the age of 16 years,
of Jehovah’s Witness parents, were to consent to an elective blood
transfusion in the face of parental opposition. Consent in this situation
would be sound provided that the child could show evidence of ‘Gillick
competence’.
5.3 Although children aged 16–18 years are capable of consenting to any
medical procedure, so that consent of another person is not necessary,
the law expressly states that this does not invalidate the right of others to
consent on their behalf. If the patient is in an acute emergency situation it
will be lawful for an anaesthetist to proceed on the basis of the consent of
either parent. Where time permits, the court should be asked to resolve
the position.
In Scotland, a young person aged 16 or over can only be treated against
their wishes in cases where the young person has some mental incapacity,
in which case a parent or agency could aquire rights by being appointed
as guardian.
13

In Ireland the issue of the “mature minor” has not been judicially
considered and it is unclear whether young people under the age of 16
are permitted to give consent and whether the Irish Courts would adopt a
principle of competence similar ‘Gillick’. Similarly it is not clear whether
the Irish Courts would accept that minors are capable of refusing medical
treatment. The Irish judiciary are reluctant to intervene to overrule parental
decisions and will do so only in exceptional cases. However each case
must be judged on its merits and where there are life threatening issues
the Courts may favour the personal rights of the child over family and
parental considerations.
In an unreported case in March 2003 the Gardai were called to to a
hospital after the parents of a two-year-old boy refused to allow him a
blood transfusion on religious grounds. The Gardai made an application
under the Child Care Act and the transfusion proceeded. In another case
the High Court ordered that a child be made a Ward of Court to enable
her to be treated with blood products. In this case the five-month-old
baby girl required life saving open heart surgery. [10]
5.4 Consent to give blood products in the face of opposition by both child
and parents is illustrated by a case involving a 14-year-old burns victim
[11]. Both the child and the parents, with strongly held beliefs, refused
a transfusion required to manage severe burn injuries. It was found by
the Family Court, following the opinion of an expert in child psychiatry,
that these beliefs were founded upon the context of her own family
experience alone and that there was a distinction between a view of that
kind and the constructive formulation of an opinion which occurred with
adult experience.
While it was accepted that the patient’s opinions were firmly held, they
were necessarily based upon a limited understanding of matters and that
she was not in possession of all the details which it would be right and
appropriate to have in mind when making such a decision. The Official
Solicitor was appointed to act as ‘guardian ad litem’ and consent to give
blood products was granted.
5.5 This point was further discussed in the High Court in England in 2003
[12] where it was found to be in the best interests of a Jehovah’s Witness
patient (nearly 17 years old) to receive blood products where the risk
to life was immediately threatening and there was no other form of
treatment available. A useful Case Study is available to further explore
this point [13].
14

5.6 On 1st April 2001 under the provisions of the Criminal Justice and Court
Services Act, the Children and Family Court Advisory and Support
Service – (CAFCASS) was set up. This is a national Non-Departmental
Public Body for England and Wales that safeguards and promotes the
welfare of children involved in family court proceedings. It is accountable
to Parliament through the Department for Education and Skills. CAFCASS
is independent of the courts, social services, education and health
authorities and all similar agencies. It brings together the services
previously provided by:
• The Family Court Welfare Service
• The Guardian ad Litem Services
• The Children’s Division of the Official Solicitor.
15

6. Consequences of Bloodless Anaesthesia and Surgery
6.1 Financial Consequences
6.1.1 Cost of care
Special equipment for, and additional theatre time spent in the
conservation of blood carries an increased cost to the hospital.
Depending on the specialty and complexity of the surgery, theatre
time costs between £7 and £15 a minute [14].
Maintaining a patient with a low haemoglobin level following
surgery without transfusion may also carry an additional cost in
days spent in HDU or ITU. National figures indicate that each
additional day spent in an HDU bed costs £543 and in an ITU bed
£1266 [15]. Occupation of these beds also further denies access
of an already scarce resource to other patients in need of higher
dependency and intensive care.
Access to hyperbaric oxygen facilities is limited to only 30 sites
in the UK and session costs vary. There is an additional cost of
transfer of the patient to these centres.
6.1.2 Costs of Cell Saver
The cost of blood salvage machinery varies. Prices range from
£5,000 to £14,000, with the price of disposables ranging between
£70 and £100.
6.1.3 Savings in Costs of Blood
The price of a unit of blood has risen dramatically in the last
decade, especially since leucodepletion has been added to the
preparation process. The current national price of a unit of packed
cells is around £132, a unit of FFP around £35 and a unit of platelets
around £217 [16].
6.2 Consequences of avoidance of blood transfusion errors and
disease
Incorrect blood components transfused (or “wrong blood”) account for
75% of all reports to the Serious Hazards of Transfusion working group
(SHOT) in 2003. The risk of death from an acute haemolytic reaction
is quoted as 0.67 per million units (British Committee for Standards in
Haematology guidelines, http://www.bcshguidelines.com). The rates of
transfusion-transmitted infections are estimated to be 1 in several million
16

transfusions for HIV, 1 in 30 million for Hep C, and 1 in 1 million for Hep
B. (Data from the SHOT annual report for 2003, published July 2004).
The transmission rate for vCJD is unknown. There have been two reports
to date of possible vCJD transmission secondary to blood transfusions
from donors who subsequently developed vCJD [17].
6.3 Use of Erythropoetin And Recombinant Factor VIIa
6.3.1 Erythropoetin
The acceptance of either of the two erythropoetin products
currently available in Britain does not raise any religious issues for
patients who are Jehovah’s Witnesses.
6.3.1.1 Autologous blood pre-donation
Erythropoetin is licensed for autologous blood predonation
in the UK and Ireland and should be commenced four
weeks before to surgery. However, Jehovah’s Witnesses
do not accept autologous predonation.
6.3.1.2 Increasing haemoglobin levels preoperatively
The use of erythropoetin to boost haemoglobin levels
before surgery may be considered. However this is
an unlicensed use of erythropoetin in Ireland and the
UK. The exact dose required has not been established
and the patient would require careful monitoring.
Erythropoetins will not be indicated in patients with
history of cardiovascular or ischaemic heart disease,
unstable angina or at risk of venothromboembolism.
6.3.1.3 Post-operative use of erythropoetin in Jehovah’s Witness
patients
Erythropoetin is not licenced for post-operative use in
any patient group, although it has been successfully used
to treat acute anaemia [18].
6.3.2 Recombinant Factor VIIa (rFVIIa)
rFVIIa is indicated for the treatment of bleeding episodes in patients with
haemophilia A or B, with inhibitors to Factors VIII or IX. It has also been
used in cases of refractory thrombocytopenia, and there have been a
number of case reports of its successful use in Jehovah’s Witness patients
particularly after cardiac surgery [19]. rFVIIa has also been used to
correct the coagulation and platelet defects in Jehovah’s Witness patients
with cirrhosis to allow invasive procedures to be performed [20].
17

6.4 Other considerations
6.4.1 Stress and Anxiety for Anaesthetists and Surgeons
It is well recognised that both surgeons and anaesthetists regard
any limitation on their clinical freedom to be stressful, and this
added stress is likely to be even greater when the consequences
of the limitation may result in an otherwise avoidable death.
This should be clearly and calmly explained to the patient, their
relatives or representatives so that all parties are clear as to the
consequence of their expressed wishes.
A clinician may refuse to participate in an elective procedure if he
feels that the patient’s request is unreasonable or inappropriate in
his hands (para 4.1.2). This freedom of action is not present in an
emergency when a practitioner may find himself participating in a
procedure against his will and with compromised clinical freedom.
Departments of both anaesthesia and surgery should have a
procedure to deal with this situation, such as the maintainance
of a register of clinicians who are prepared to be involved in
procedures within the limitations imposed by Jehovah’s Witness
patients.
6.4.2 Ethical Dilemmas
Working within restrictions imposed by Jehovah’s Witness
patients can result in diversion of hospital resources from other
patients who have a medically indicated need for them. Examples
are significant periods in ITU or HDU, the use of a hyperbaric
chamber or temporary dialysis.
6.4.3 Effects on Other Patients
Excessive resources, including the extra time necessary to complete
bloodless surgery safely, used by these special patients in order to
satisfy their religious beliefs may result in a lack of resources being
available to other patients.
6.4.4 Effects on Members of Hospital Staff
The ripple effect on other members of the theatre teams and ward
staff may also be profound. Full briefing of ALL members of the
expanded team can avoid feelings of frustration and anger which
may be directed at the patient, their relatives or representatives.
Ideally this should be done before surgery so that all support can
be provided to the patient and staff as required.
18

Counselling may be required for the anaesthetic and surgical
team who may feel that, whilst adhering to the patient’s expressed
wishes, they have been unable to provide an optimal level of care
that has resulted in a significant morbidity or even death during
their care.
19

7. Conclusion
7.1 The Association of Anaesthetist of Great Britain and Ireland remains
firmly of the view that all patients are entitled to take individual decisions
about matters respecting their treatment which are important to them. It
is the doctor’s duty to advise the patient clearly about their professional
assessment of the patient’s needs and it is the patient’s right to decide
what should be done to his or her body. Once the patient’s views have
been clearly articulated they should be recorded and respected. This
is based squarely on a respect for the patient’s right of autonomy and
to decide what is done with and to their body. Any wilful flouting of a
patient’s clearly recorded wishes in this fashion will be a serious matter
which may expose the transgressor to punishment in the GMC and is
liable as an offence against the criminal law.
The Association has some sympathy with the anxieties and frustration
experienced by anaesthetists asked to practice what they may feel to
be suboptimal care. Nevertheless it is our view that a full explanation
by both sides to the other of their needs, concerns and the potential
consequences of their actions should help to mitigate these stressors.
Discussion between the parties is a tenet of the Consent process.
7.2 As the recent paper [3] in the Royal College of Anaesthetist’s Continuing
Medical Education Journal states “Many of the techniques developed
for use in Jehovah’s Witness patients will become standard practice in
years to come in an effort to conserve blood stocks and reduce the need
for transfusion”. Our experience in this area of anaesthetic practice may
have positive developments which can be extended to other areas.
20

References
1. Management of Anaesthesia for Jehovah’s Witnesses, AAGBI March
1999
2. Annual Report of the Chief Medical Officer – 2003 On the State of the
Public Health.
www.publications.doh.gov.uk/cmo/annualreport2003/index.htm
3. Milligan LJ and Ballamy MC, Anaesthesia and critical care of Jehovah’s
Witnesses. Continuing Education in Anaesthesia, Critical Care & Pain
2004; 4: 35-39
4. Bearb ME and Pennant 1987. Epidural Blood Patch in a Jehovah’s Witness
Anesthesia and Analgesia 1987; 66: 1052
5. ReT All England Law Reports 1992; 4:647-70.
6. Royston D. Blood-sparing Drugs: Aprotinin, Tranexamic Acid, and
Epsilon-Aminocaproic Acid. In International Anesthesiology Clinics 1995;
Vol 33:155-79.
7. Ashley E. Anaesthesia for Jehovah’s Witnesses. British Journal of Hospital
Medicine 1997; Vol 58:375-380.
8. Baker CE, Kelly GD and Perkins GD. BJA 1998; Vol 81: 256-259.
9. P. L. McLoughlin, T. M. Cope and J. C. Harrison Hyperbaric oxygen
therapy in the management of severe acute anaemia in a Jehovah’s
Witness Anaesthesia 1999; 54, 891-895
10. Personal Communication Geraldine Hickey of McCann FitzGerald
Solicitors Ireland
11. Blood Transfusion Refusal – Best interests of minor Jehovah Witness.
Medical Litigation 1998; 8-9 [Re L (A Minor) (FamD: The President, June
10, 1998 10 Pages].
12. Re P (Minor) [2003] EWHC 2327
13. http://www.ethics-network.org.uk/Cases/previous/process.htm
14. Personal Communicational Northumbria Health Care NHS Trust
21

15. NHS Reference Costs 2003 and National Tariff 2004, Department of
Health, 2004
16. Personal Communication from the National Blood Service, and
https://www.blood.co.uk/
17. Llewelyn CA et al. Possible transmission of variant Creutzfeldt-Jakob
disease by blood transfusion. The Lancet 2004; 363: 417-421.
18. Atabek U, Alvarez R, Pello MJ, Alexander JB, Camishion RC, Curry
C, Spence RK. Erythropoetin accelerates hematocrit recovery in postsurgical
anemia. Am Surg. 1995; 61(1):74-7.
19. Tanaka, Kenichi A. M.D.; Waly, Amr A. M.D. +; Cooper, William A.
M.D.; Levy, Jerrold H. M.D. Treatment of Excessive Bleeding in Jehovah’s
Witness Patients after Cardiac Surgery with Recombinant Factor VIIa
(NovoSeven(R)). Anesthesiology 2003; 98 :(6), 1513-5.
20. Papatheodoridis G.V.; Chung S.; Keshav S.; Pasi J.; Burroughs A.K.
Correction of both prothrombin time and primary haemostasis
by recombinant factor VII during therapeutic alcohol injection of
hepatocellular cancer in liver cirrhosis. Journal of Hepatology, 1999; 31:
(4),747-750.
22

Appendix 1
The Holy Bible – Authorised King James Version
Genesis Chapter 9, Verses 3–4
3. Every moving thing that liveth shall be meat for you; even as the green
herb have I given you all things.
4. But flesh with the life thereof, which is the blood thereof, shall ye not
eat.
Leviticus Chapter 17, Verses 11–12
11. For the life of the flesh is in the blood: and I have given it to you upon the
altar to make an atonement for your souls: for it is the blood that maketh
an atonement for the soul.
12. Therefore I said unto the children of Israel, No soul of you shall eat blood,
neither shall any stranger that sojourneth among you eat blood.
Acts Chapter 15, Verse 28–29
28. For it seemed good to the Holy Ghost, and to us, to lay upon you no
greater burden than these necessary things;
29. That ye abstain from meats offered to idols, and from blood, and from
things strangled, and from fornication: from which if ye keep yourselves,
ye shall do well. Fare ye well.
23

Appendix 2
Hospital Liaison Committees – Contact Numbers
Hospital Information Services
IBSA House, The Ridgeway, London, NW7 1RN
020 8906 2211
his@uk.jw.org
Belfast Ken McGuire 07801 632151 ken.mcguire@belfasthlc.co.uk
Birmingham Roy Jackson 07889 648508 roy@jw-hlc.org
Cardiff David Newman 07860 794807 d.newman@swwales-hlc.org.uk
Dublin Mark Scully 00 353 87 1209019 mark.scully@hlc.ie
Glasgow Harry Crawford 07711 367409 harry@hlcglasgow.co.uk
London North Brian Brooks 07931 714369 brian.brooks@hlcln.org.uk
London South Peter Foster 07947 046330 pf1@london.com
24

Appendix 3
Full Wording of suggested “Jehovah’s Witness Consent/Release”
GENERAL CONSENT FORM EXCLUDING
BLOOD TRANSFUSION
Your Trust or Authority:
Patient Information...........................................................................................
Patient’s Surname ............................................................................................
Other Name (s)............... Hospital Unit Number....... Date of Birth....................
DOCTOR – (this part to be completed by Registered Medical Practitioner)
NATURE OF OPERATION, INVESTIGATION OR TREATMENT:
I confirm that I have explained the operation investigation or treatment, and such
appropriate options as are available and the type of anaesthetic, if any (general/
regional/sedation) proposed, to the patient in terms which in my judgment are
suited to the understanding of the person named below. I further confirm that I
have emphasised my clinical judgment of the potential risks to the patient and/
or person who nonetheless understood and imposed the limitation expressed
below.
I acknowledge that this limited consent will not be over-ridden unless revoked
or modified.
Signature.......................................... Date.................................
Name of Registered Medical Practitioner...........................................................
PATIENT (this part to be completed by the patient)
I...............................................................................................................................(name)
Confirm that I have read the words above and have consented to undergo
the above named procedure. I confirm that the doctor named on this form
has explained to me the nature and purpose of the procedure and the type of
25

anaesthetic that he proposes to use, that I have consented to undergo both. I have
also agreed to his using non- blood volume expanders and pharmaceuticals that
control haemorrhage and/or stimulate the production of red blood cells. I also
consent to his using other drugs routinely used in the course of an anaesthetic.
However, I have told the doctor that I am one of Jehovah‘s Witnesses with firm
religious convictions. With full realization of the implications of this position and
knowledge that it may pose additional risks to my health or life, I have decided
to impose the following further restrictions on what the doctors may do in the
course of the operation. I do so exercising my own choice. I expressly withhold
my consent to the following:
1. Allogenic blood;
2. Primary blood components including
a. red cells
b. white cells
c. plasma
d. platelets
3. Any sample of my blood being used for cross-matching.
4. I also object to the following: (please insert any other restrictions that you
wish to impose):
I understand that I am free to delete any of the words which appear above in
order to modify these restrictions.
I understand that this limitation of consent will remain in force and bind all those
treating me unless and until I expressly revoke it.
I understand that the procedure may not be done by the doctor who is treating me
so far and that the express limitation of my consent to this procedure described
above will be regarded as absolute by all the doctors who treat me, and will not
be overridden in any circumstances by a purported consent of a relative or other
person or body unless I have identified them to the hospital and appointed them
in writing with authority to act as my proxy.
I understand that such refusal will be regarded as remaining in force and binding
upon those who care for me even though I may be unconscious or affected
by medication or medical condition rendering me incapable of expressing my
wishes and that doctors treating me will continue to be bound by my refusal
even though they may believe that the treatment is immediately necessary in
order to save my life.
26

I further consent to any other procedure that may be immediately necessary to
save my life or health, but I attach the same restrictions I have described above
to the performance of that procedure.
I further understand that details of my treatment and any consequences resulting
will not be disclosed to any other person without my express consent or that of
my authorised proxy unless required by law.
Signature............................... Dated ..............................................
Witnessed by.........................
Of..........................................
Dated..............................................
27

Appendix 4
Simplified Procedure for Application to Courts for a ‘Specific Issue Order’
1. Child and parents refuse consent to treatment. Doctors believe treatment
must be given, in the best interests of the child. This would not be an
emergency situation – if it is, the doctor should act in the best interests of
the child, having taken a second opinion, and record his actions carefully
in the medical records.
2. Doctors seek advice from their Trust Legal Department or Chief Executive
who in turn seeks solicitors’ advice. Parents should be kept informed and
invited to case conferences.
3. If solicitors advise proceeding, they will involve CAFCASS whose function
is to represent the interests of minors or others who are ‘incompetent’.
A member of the CAFCASS staff, or a solicitor appointed by them, will
probably wish to see the parents and the child, to discuss the situation.
CAFCASS may then instruct solicitors and counsel to act on the child’s
behalf.
4. The Trust applies to the High Court (in Scotland the Court of Session or
Sheriff Court) for an order giving consent to the proposed treatment. The
terms of the proposed order should be discussed in advance with the
CAFCASS representative.
5. A hearing might be held in public, but with the names of the family,
the hospital and the doctors directly involved kept confidential, when
the doctor(s) recommending treatment would give evidence, based on
a previously prepared affidavit. The Court will wish the doctor to state
the reasons for the recommended treatment, together with other options
considered and the reasons for discarding those options. Independent
expert advice may also be required. CAFCASS may call their own
experts to give evidence. The parents may wish to have separate legal
representation.
6. The Court may grant the order and may impose further conditions. The
Court’s paramount consideration will be the welfare of the child.
7. The Trust and the doctors then consider how best to proceed in
accordance with the Court’s ruling.
8. The Trust may be required to pay a proportion of the legal costs of
CAFCASS, as well as its own.
28

Procedure for cases
involving children
under 18
See sections 3.6, 3.7
& Appendix 4
Parents refuse consent for
essential transfusion for immediate
or anticipated need even after
careful and complete counselling
If child capable of giving
consent and does so,
respect his wishes
If life threatening,
take second opinion,
administer life-saving
transfusion, document
fully and inform Legal
Dept/Manager
If non-emergency, approach Trust Legal
Dept/Duty Manager to seek advice
from Trusts Solicitors. Keep parents
informed of intentions
Trust’s solicitors contact CAFCASS
who will probably interview
parents, child & medical staff
CAFCASS will act on the
child’s behalf
Trust applies to High Court (in Scotland
the Court or Sheriff Court) for Order giving
consent for proposed treatment
Public Hearing (Court will be asked to rule that names of family,
hospital and doctors remain confidential). Doctors give evidence
of need & lack of alternatives. CAFCASS will represent the child.
The Parents may be heard and have legal representation.
Court may grant order and may impose other conditions.
Court’s paramount consideration will be child’s best interest
Trust’s doctors proceed according to
Court ruling.
NB Trust may be required to pay part of
costs of CAFCASS
29

21 Portland Place, London W1B 1PY
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Designed and produced by Cox Design Ltd

AAGBI Safety Guideline
Management of Severe Local Anaesthetic Toxicity
1
Recognition
2
Immediate
management
3
Treatment
Signs of severe toxicity:
• Sudden alteration in mental status, severe agitation or loss of consciousness,
with or without tonic-clonic convulsions
• Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and
ventricular tachyarrhythmias may all occur
• Local anaesthetic (LA) toxicity may occur some time after an initial injection
• Stop injecting the LA
• Call for help
• Maintain the airway and, if necessary, secure it with a tracheal tube
• Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may
help by increasing plasma pH in the presence of metabolic acidosis)
• Confirm or establish intravenous access
• Control seizures: give a benzodiazepine, thiopental or propofol in small
incremental doses
• Assess cardiovascular status throughout
• Consider drawing blood for analysis, but do not delay definitive treatment to do
this
In circulatory arrest
• Start cardiopulmonary resuscitation
(CPR) using standard protocols
• Manage arrhythmias using the
same protocols, recognising that
arrhythmias may be very refractory to
treatment
• Consider the use of cardiopulmonary
bypass if available
Without circulatory arrest
Use conventional therapies to treat:
• hypotension,
• bradycardia,
• tachyarrhythmia
Give intravenous
lipid emulsion
(following the regimen overleaf)
• Continue CPR throughout treatment
with lipid emulsion
• Recovery from LA-induced cardiac
arrest may take >1 h
• Propofol is not a suitable substitute
for lipid emulsion
• Lidocaine should not be used as an
anti-arrhythmic therapy
Consider intravenous
lipid emulsion
(following the regimen overleaf)
• Propofol is not a suitable substitute
for lipid emulsion
• Lidocaine should not be used as an
anti-arrhythmic therapy
4
Follow-up
• Arrange safe transfer to a clinical area with appropriate equipment and suitable
staff until sustained recovery is achieved
• Exclude pancreatitis by regular clinical review, including daily amylase or lipase
assays for two days
• Report cases as follows:
in the United Kingdom to the National Patient Safety Agency
(via www.npsa.nhs.uk)
in the Republic of Ireland to the Irish Medicines Board (via www.imb.ie)
If Lipid has been given, please also report its use to the international registry at
www.lipidregistry.org. Details may also be posted at www.lipidrescue.org
Your nearest bag of Lipid Emulsion is kept
This guideline is not a standard of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan
must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options available.
© The Association of Anaesthetists of Great Britain & Ireland 2010

Immediately
Give an initial intravenous bolus
injection of 20% lipid emulsion
1.5 ml.kg –1 over 1 min
and
Start an intravenous infusion of 20%
lipid emulsion at 15 ml.kg –1 .h –1
after 5 min
Give a maximum of two repeat
boluses (same dose) if:
• cardiovascular stability has not
been restored or
• an adequate circulation
deteriorates
Leave 5 min between boluses
A maximum of three boluses can be
given (including the initial bolus)
and
Continue infusion at same rate, but:
Double the rate to 30 ml.kg –1 .h –1 at
any time after 5 min, if:
• cardiovascular stability has not been
restored or
• an adequate circulation deteriorates
Continue infusion until stable and
adequate circulation restored or
maximum dose of lipid emulsion given
Do not exceed a maximum cumulative dose of 12 ml.kg –1
An approximate dose regimen for a 70-kg patient would be as follows:
Immediately
Give an initial intravenous bolus
injection of 20% lipid emulsion
100 ml over 1 min
and
Start an intravenous infusion of 20%
lipid emulsion at 1000 ml.h –1
after 5 min
Give a maximum of two repeat
boluses of 100 ml
and
Continue infusion at same rate
but double rate to 2000 ml.h –1 if
indicated at any time
Do not exceed a maximum cumulative dose of 840 ml
This AAGBI Safety Guideline was produced by a Working Party that comprised:
Grant Cave, Will Harrop-Griffiths (Chair), Martyn Harvey, Tim Meek, John Picard, Tim Short and Guy Weinberg.
This Safety Guideline is endorsed by the Australian and New Zealand College of Anaesthetists (ANZCA).
© The Association of Anaesthetists of Great Britain & Ireland 2010

Anaesthesia 2016, 71, 352
Corrections
In [1], the Figure 2 legend should be amended from:
Figure 2 Ultrasound screen captures of block administration, with needle advanced cranio-caudally. 1 ribs, 2 serratus anterior
muscle, 3 intercostal muscle, 4 local anaesthetic.
to:
Figure 2 Ultrasound screen captures of block administration, with needle advanced cranio-caudally. 1 paraspinal muscles,
2 local anaesthetic, 3 intercostal muscles, 4 ribs.
Reference
1. Roue C, Wallaert M, Kacha M, Havet E. Intercostal/paraspinal nerve block for thoracic surgery. Anaesthesia 2015; 71: 112–3.
doi:10.1111/anae.13383
In the Guidelines [1] by Harrop-Griffiths et al., the notes to accompany Table 2 stated that there was one death in a
patient who underwent lumbar plexus block. This was incorrect, and should read:
“The one death in this series was that of a patient on clopidogrel who underwent a lumbar sympathetic
block...”
Reference
1. Harrop-Griffiths W, Cook T, Gill H, Hill D, Ingram M, Makris M, Malhotra S, Nicholls B, Popat M, Swales H, Wood P (Working Party). The
Association of Anaesthetists of Great Britain & Ireland & The Obstetric Anaesthetists’ Association Regional Anaesthesia UK. Regional anaesthesia
and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–72.
doi:10.1111/anae.13380
352 © 2016 The Association of Anaesthetists of Great Britain and Ireland

AAGBI: Consent for anaesthesia 2017
Published by
The Association of Anaesthetists of Great Britain & Ireland
21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650 Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org January 2017

This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. AAGBI: Consent for anaesthesia 2017. Anaesthesia 2017; 72: 93-105.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13762/full

Anaesthesia 2017
Guidelines
doi:10.1111/anae.13762
AAGBI: Consent for anaesthesia 2017
Association of Anaesthetists of Great Britain and Ireland
S. M. Yentis, 1 A. J. Hartle, 2 I. R. Barker, 3 P. Barker, 4 D. G. Bogod, 5 T. H. Clutton-Brock, 6 A. Ruck
Keene, 7 S. Leifer, 8 A. Naughton 9 and E. Plunkett 10
1 Consultant Anaesthetist, Chelsea and Westminster Hospital, London and Honorary Reader, Imperial College
London, UK; Vice-President, AAGBI (Working Party Chair from July 2015)
2 Consultant Anaesthetist, Imperial College Healthcare NHS Trust, London, UK; President, AAGBI (to Sept 2016;
Working Party Chair to July 2015)
3 Specialist Registrar in Anaesthesia, Imperial rotation, London, UK (present position: Consultant Anaesthetist,
Imperial College Healthcare NHS Trust, London, UK)
4 Consultant Anaesthetist, Norfolk and Norwich University Hospitals, Norwich, UK; member, AAGBI Board of Directors
5 Consultant Anaesthetist, Nottingham University Hospitals NHS Trust, Nottingham, UK
6 Reader, University of Birmingham, Birmingham, UK; Council member, Royal College of Anaesthetists (to Feb. 2016)
7 Barrister, 39 Essex Chambers, London; Honorary Research Lecturer University of Manchester, UK; Visiting Research
Fellow, King’s College London, UK
8 Specialist Registrar in Anaesthesia, Manchester rotation, Manchester, UK; member, AAGBI Group of Anaesthetists in
Training (GAT) Committee
9 Lay member, AAGBI Board of Directors
10 Specialist Registrar in Anaesthesia, Birmingham School of Anaesthesia, Birmingham, UK; member, AAGBI GAT
Committee
Summary
Previous guidelines on consent for anaesthesia were issued by the Association of Anaesthetists of Great Britain and
Ireland in 1999 and revised in 2006. The following guidelines have been produced in response to the changing ethical
and legal background against which anaesthetists, and also intensivists and pain specialists, currently work, while
retaining the key principles of respect for patients’ autonomy and the need to provide adequate information.
The main points of difference between the relevant legal frameworks in England and Wales and Scotland, Northern
Ireland and the Republic of Ireland are also highlighted.
.................................................................................................................................................................
Correspondence to: S. M. Yentis.
E-mail: s.yentis@imperial.ac.uk
Accepted: 22 October 2016
Keywords: anaesthesia; assessment; consent; medicolegal; pre-operative
This is a consensus document produced by expert members of a Working Party established by the Association of
Anaesthetists of Great Britain and Ireland. It has been seen and approved by the AAGBI Board of Directors. Date of
review: 2022.
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Anaesthesia 2017 Yentis et al. | AAGBI: Consent for anaesthesia 2017
• What other guidelines are available on this topic?
Previous guidance was published by the Association
of Anaesthetists of Great Britain and Ireland
(AAGBI) in 1999 [1] and this was revised in 2006
[2]. Guidance on consent to examination and treatment
was published by the General Medical Council
(GMC) in 2008 [3] and the Department of
Health (DoH) in 2009 [4]. The British Medical
Association and Law Society have published
guidance on the assessment of mental capacity in
2015 [5].
• Why was this guideline developed?
There have been a number of changes in the ethical
and legal context around delivery of healthcare
since the last AAGBI guidance, in particular new
case law and increasing emphasis on consumerism
and patient-centred care.
• How and why does this statement differ from existing
guidelines?
The previous AAGBI guidance has been updated
and input received from intensivists and pain
specialists as well as anaesthetists. In addition,
some guidance is offered for the increasingly different
systems in the devolved nations and in Ireland.
Recommendations
(The legal frameworks for decision-making in relation
to those lacking capacity in Scotland, Northern Ireland
and the Republic of Ireland are not the same as that
in England and Wales, although the guiding principles
are largely the same. The body of this guidance is
based on the law as it applies in England and Wales; a
comparative table is provided at the end to highlight
the main differences (Appendix 1, Supporting Information)).
1 Information about anaesthesia and its associated
risks should be provided to patients as early as
possible, preferably in the form of an evidencebased
online resource or leaflet that the patient
can keep for future reference. Those undergoing
elective surgery should be provided with information
before admission, preferably at pre-assessment
or at the time of booking, but the duty remains
on the anaesthetist to ensure that the information
is understood.
2 Immediately before induction of anaesthesia, for
example in the anaesthetic room, is not an acceptable
time to provide elective patients with new
information other than in exceptional circumstances.
3 The amount and the nature of information that
should be provided to the patient should be determined
by the question: ‘What would this particular
patient regard as relevant when coming to a
decision about which of the available options to
accept?’
4 At the end of an explanation about a procedure,
patients should be asked whether they have any
questions; any such questions should be addressed
fully and details recorded.
5 Anaesthetists should record details of the elements
of a discussion in the patient record, noting the
risks, benefits and alternatives (including no treatment)
that were explained.
6 A separate consent form, signed by the patient, is
not required for anaesthetic procedures that are
done to facilitate another treatment.
7 Consent is an ongoing process, not a single event,
and may require repeated discussion and/or confirmation,
with documentation at every stage.
8 For a course of treatment (e.g. for chronic pain),
consent to continue should be confirmed and documented
before each individual component, and
any changes to risks, benefits or alternatives discussed
fully.
9 If patients insist they do not want to know about
the risks of a procedure (including anaesthesia),
the consequences of this should be explained; this
discussion should be recorded in writing and the
patient given the opportunity to change his/her
mind. Patients should understand that there may
be risks but should not have a detailed explanation
forced upon them if unwilling.
10 The Mental Capacity Act 2005 (MCA) [6] confirms
that adults should be presumed to have
capacity to consent to medical treatment. If there
are reasonable grounds for concluding otherwise,
these must be documented. The MCA places a
duty upon all those concerned with care to make
efforts to reverse or minimise temporary incapacity
to enable patients to make their own decisions
2 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Yentis et al. | AAGBI: Consent for anaesthesia 2017 Anaesthesia 2017
and, where it is not possible to do so, to treat
patients lacking capacity in their best interests.
Adults may make an advance decision to refuse
treatment or appoint a proxy to decide upon their
behalf using a lasting power of attorney (LPA). A
valid and applicable advance decision or a decision
of a validly appointed health and welfare LPA is legally
binding, as is the decision of a court-appointed
deputy with the appropriate powers.
11 Anaesthetists should be aware of the different
frameworks that apply in relation to consent (and
who can consent on behalf of the patient) with
respect to patients aged 16 and 17 and those
under 16.
12 When planning to allow trainees or others to use
an opportunity presented by a clinical encounter
for training in practical procedures, the anaesthetist
should make every effort to minimise risk
and maximise benefits, and should consider alternative
ways of achieving the same end. Specific
consent for such procedures may or may not be
required depending on the circumstances.
A set of ‘frequently asked questions’ (FAQs) (relating
to England and Wales and Northern Ireland, with
a version adapted for Scotland and a note relating to
the Republic of Ireland) is also provided in Appendix 2,
Supporting Information.
Introduction
The need for consent before treatment is firmly
embedded in modern healthcare. These guidelines –
the third produced by the Association of Anaesthetists
of Great Britain and Ireland (AAGBI) – draw upon
previous versions [1, 2] and other guidance [3–5] in
the context of the particular roles of anaesthetists,
intensivists and pain specialists in providing clinical
care, against a backdrop of evolving legal and ethical
frameworks in which they work. In light of the different
legal frameworks that now apply in the devolved
nations and in the Republic of Ireland, the body of
this guidance limits itself to the legal framework that
applies in England and Wales (although the guiding
principles are largely the same). A table highlights the
key differences in the legal frameworks in Scotland,
Northern Ireland and the Republic of Ireland
(Appendix 1, Supporting Information). (n.b. the word
‘treatment’ is used in this document to indicate both
treatment in the usual sense, that is, something used
to ‘treat’ (alleviate) something, and also an anaesthetic
intervention such as general/regional anaesthesia, etc).
The importance of consent
Ethical aspects
Clinicians have an ethical obligation to respect
patients’ autonomy – that is, their right to be involved
in decisions that affect them. In medicine, this is
reflected in the requirement to obtain consent for
treatment, which can only be valid if adequate information
is supplied and the patient has the capacity to
understand it and make a balanced decision, free from
coercion [7]. Patients may change their minds and
withdraw consent at any time, so long as these conditions
still apply.
The need to respect autonomy sometimes conflicts
with other obligations, such as the principle of beneficence
(doing good). For example, patients may decline
life-saving treatment, and this decision must be
respected if they have capacity.
Professional aspects
Respect for autonomy and the need for consent is
emphasised in professional guidance as being central
to the doctor–patient relationship. The GMC’s guidance
in 2008 confirmed that doctors should tell their
patients what the latter wanted to know, not what the
doctors thought they should know [3].
Patients also have an interest in knowing what is
going to happen to them and what they should expect
during a course of treatment or other medical encounter.
It is a professional obligation to explain such
things to patients, to give them the opportunity to ask
questions and to provide honest answers.
Legal aspects
The legal requirements for valid consent reflect the ethical
ones: it must be given voluntarily by an appropriately
informed patient, who has the capacity to exercise a
choice – even if this choice appears irrational. Pain, illness
and premedication do not necessarily make a
patient incapable of consenting to treatment [7].
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 3

Anaesthesia 2017 Yentis et al. | AAGBI: Consent for anaesthesia 2017
Touching a patient without consent or approaching
him/her with a needle, irrespective of outcome,
may lead to a claim of assault or battery. Far more
common, although, is a claim of negligence after a
complication has occurred, on the basis that had a
warning been given, the patient would not have agreed
to the treatment and the complication would not have
occurred [8]. Case law suggests that a doctor might
still be found negligent even if the patient would have
undergone the treatment had he/she been warned [9,
10], reflecting the importance that the law accords to
the duty to respect patients’ autonomy. In addition,
Articles 3, 8 and/or 9 of the European Convention on
Human Rights might feasibly be invoked if consent is
not sought from patients before treatment [10, 11].
The treating doctor is responsible for ensuring that
the patient has consented to the treatment. For
patients referred for investigations requiring anaesthesia,
for example MRI, consent for the investigation
should be sought by the referring doctor or local radiologist,
while consent for anaesthesia should be sought
by the anaesthetist providing anaesthesia.
For many decades, legal decisions concerning consent
have been based on the Bolam principle [12], that
is, whether the doctor seeking consent did so (i.e.
provided enough information) in accordance with a
responsible body of clinical opinion. The courts subsequently
stressed that such a clinical opinion must be
rational and stand up to logical analysis [13]. Recent case
law (Montgomery v Lanarkshire Health Board) has confirmed
that the Bolam principle no longer applies in
matters of consent, and that a doctor needs to provide all
‘material risks’ to a patient, with materiality defined as:
“... whether a reasonable person in the patient’s position
would be likely to attach significance to the risk, or the
doctor should reasonably be aware that the particular
patient would be likely to attach significance to it” [10] –
thus bringing the law in line with previous professional
guidance from the GMC in 2008 [3, 14]. There are only
three exceptions to this rule: i) the patient has expressed
a fixed desire not to know the risks; ii) discussion of the
risks would pose a serious threat (beyond merely causing
distress) to the patient (e.g. suicide); and iii) in ‘circumstances
of necessity’ where urgent treatment is needed
but the patient lacks capacity, and where the treatment
that is being delivered is in his/her best interests.
Patients must be informed of alternative treatments,
the risks associated with them and the option
of not receiving treatment; not doing so may invalidate
consent and result in a negligence claim [10, 15].
Capacity, best interests and
voluntariness
Capacity
The MCA provides the legal framework in England
and Wales for protecting and supporting people whose
capacity may be impaired [6]. It reinforces that capacity
should be assumed unless proven otherwise (Section
1(2)), sets out how to make decisions where a
person does not (despite being supported) have the
capacity to make his/her own decisions (Sections 1(5)
and (4)) and introduced several new roles, bodies and
powers (see Table 1).
Those over 16 years have the legal capacity to
consent to a medical procedure if they are able to
understand, retain, use and weigh the relevant information,
and communicate their decision [3, 6, 16]. In
most instances, it is for the person treating the patient
to decide whether the patient has the capacity or not.
Assumptions relating to capacity based on age,
Table 1 Summary of the Mental Capacity Act (2005)’s
main features and provisions [6].
Statutory
principles
Roles/institutions
created
Other
A person must be assumed to have
capacity unless proved otherwise
A person must be given all practicable
help to make his/her own decision
before being treated as lacking capacity
A person must not be treated as lacking
capacity merely because he/she makes
an unwise decision
An intervention or decision made on
behalf of a person lacking capacity
must be in his/her best interests.
The intervention or decision made on
behalf of a person lacking capacity
must cause the least restriction of
his/her rights and freedom of action to
achieve the stated purpose
Court of Protection
Lasting power of attorney
Independent Mental Capacity Advocates
Deputies
Advance decisions to refuse treatment
confirmed in law
Applies to anyone over 16 years old
4 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Yentis et al. | AAGBI: Consent for anaesthesia 2017 Anaesthesia 2017
appearance or behaviour must not be made [3, 17],
and nor should they be made about a patient’s capacity
to make decisions on the basis of a particular condition,
for instance a learning disability. Furthermore,
patients cannot be treated as lacking capacity to consent
to or refuse medical procedures unless all practicable
steps to support them to do so have been taken
without success [6].
The decision made by the patient does not have to
be sensible, rational or well considered. Furthermore, a
patient should not be treated as being unable to make a
decision merely because the decision that he/she makes
is one that appears unwise to the treating professionals
[6]. However, a highly irrational decision that is based
on a persistent misinterpretation of the information
presented may indicate that the patient does not, in
fact, have the capacity to make the decision within the
meaning of the MCA (in practice, determining incapacity
on the grounds of irrationality is fraught with difficulty;
in such a situation, legal advice should be
sought). Under the MCA, the patient’s inability to
make the decision must be because of an impairment of
or disturbance in the functioning of their mind or
brain, in the absence of which he/she has the capacity
no matter how impaired his/her reasoning process is.
(See also Voluntariness, below, in relation to concerns
that a patient’s decisions may be made under duress).
Refusal of treatment by an adult with capacity is
legally binding, even if refusal is likely to result in the
patient’s death [18]. The position in relation to 16-
and 17-year-olds is addressed below.
Capacity is issue-specific: patients may have capacity
to consent to simple procedures but not complex
ones [19, 20].
A lack of decision-making capacity may be the
predictable result of a condition (e.g. Alzheimer’s disease,
Huntingdon’s dementia), the temporary result of
an event (e.g. unconsciousness following intoxication,
head injury or during general anaesthesia), or the permanent
result of an event (e.g. perinatal brain damage
or persistent vegetative state).
Mental illness may impair a patient’s capacity to
provide valid consent for treatment. However, a person
receiving treatment for mental illness (even if he/she is
detained under the Mental Health Act 1983 (MHA))
should not be assumed to be incapable of providing
valid consent for medical, surgical or dental treatment.
The consent of a patient detained under the MHA is
not required for any medical treatment of the patient’s
mental disorder if that treatment is being given under
the provisions of Part 4 of the MHA. However, the
patient’s consent, or a second opinion, is required
before the administration of electroconvulsive therapy
(ECT), which also cannot be given where the patient
has made an advance decision refusing ECT, or a
health and welfare attorney or court-appointed deputy
refuses the treatment. When the patient is not capable
of consenting, or refuses treatment, ECT can be given
in an emergency if the authorised practitioner certifies
the patient’s lack of capacity or refusal, and that the
treatment is likely to alleviate or prevent deterioration
in the patient’s condition. Licence to treat in this way
in an emergency would also extend to the use of general
anaesthesia for administering ECT [21].
Best interests
If a patient lacks capacity, practitioners must make a
clear record of the grounds on which they have
reached this decision, the treatment that will be undertaken,
and how this treatment will be in the patient’s
best interests. The courts have made clear that ‘best
interests’ for these purposes involve consideration of
the patient’s ‘welfare in the widest sense, not just medical
but social and psychological; they must consider the
nature of the medical treatment in question, what it
involves and its prospects of success; they must consider
what the outcome of that treatment for the patient is
likely to be; they must try and put themselves in the
place of the individual patient and ask what his attitude
to the treatment is or would be likely to be; and
they must consult others who are looking after him or
interested in his welfare, in particular for their view of
what his attitude would be’ [22]. The process of best
interests decision-making is designed to ensure that
the decision that is made is right for the patient ‘as an
individual human being’, which may or may not
accord with the decision that appears wise to the treating
professionals [22, 23]. The MCA stresses that family
members (and where appropriate, other persons
close to the patient) must be consulted when considering
patients’ best interests [6], but failure to do so
should not compromise care in an emergency. If a
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 5

Anaesthesia 2017 Yentis et al. | AAGBI: Consent for anaesthesia 2017
patient lacking capacity is to undergo serious medical
treatment (defined in the context of a fine balance
between risks and benefits, or of the ‘serious consequences’
that may arise) but no family members or
close friends are available, consultation with an Independent
Mental Capacity Advocate should be sought,
under Sections 35-37 of the MCA [6].
Patients who are aware that they are likely to lose
capacity to make decisions, either temporarily or permanently,
may choose to prepare an ‘advance decision’
(often known as ‘advance directive’ or ‘living will’),
stating which treatments they would refuse in the
event that their treating team consider them indicated
(see below).
A patient may also have made an LPA. This is a
legal document that allows patients to appoint another
person(s) to make decisions on his/her behalf in the case
of incapacity. Two types of LPA exist (health/welfare
and property/financial affairs), and they must be registered
with the Office of the Public Guardian for them to
have effect (this process may take up to several weeks; if
needed more urgently an application may have to made
to the Court of Protection). Only an attorney under a
health and welfare LPA can have any power to make
decisions in relation to medical treatment, and an attorney
has no power to refuse life-sustaining treatment
unless the document contains specific provision to that
effect (a health and welfare deputy can never have the
power to refuse life-sustaining treatment). Enduring
powers of attorney (EPA), which can no longer be made
but many of which are still used, could only give the
attorney power to make decisions in relation to property
and financial affairs; an attorney under an EPA can
therefore never make healthcare decisions on behalf of a
patient. In some circumstances, a patient lacking capacity
to make decisions may have a court-appointed deputy,
who may (depending on the terms of their
appointment) have powers to make some healthcare
decisions, but will never have the power to refuse lifesustaining
treatment.
Voluntariness
For a decision by an individual to be valid, it must
have been taken voluntarily, that is, without coercion
[3, 7]. In general, it is good practice for the clinician
who is seeking consent to indicate whether he/she
favours one therapeutic option over another, but the
imbalance of power and influence in the doctor–patient
relationship means that the vulnerable patient
may feel coerced by the doctor’s enthusiasm. Anaesthetists
seeking consent should be aware of this and
not allow their preferences to override the patient’s
autonomy [4].
Coercion can occur when patients are influenced
by the beliefs or preferences of friends or relatives.
This is more likely to arise where a child with capacity
is accompanied by a parent, in areas where both parties
have a major stake in the outcome, such as obstetrics,
or in certain cultures. Where such a situation is
suspected, anaesthetists should seek to speak to the
patient away from a potentially coercive influence.
Legal advice should be sought where anaesthetists are
not clear whether a patient’s inability to make decisions
about his/her medical treatment is down to an
impairment or disturbance in the functioning of his/
her mind or brain, or the duress to which he/she may
be being subjected by family members or friends [7].
Such situations must be handled very carefully, particularly
if English is not the first language of any participant.
A ‘whole team’ approach is always best, but is
essential in obstetric and/or paediatric cases, with early
consultant involvement.
Information and the consent process
Information about anaesthesia and related procedures
is not exclusively provided by anaesthetists, but the
anaesthetist caring for the patient is responsible for the
discussion with the patient regarding that procedure.
This can be delegated to someone else, providing that
the person is suitably trained and qualified with adequate
knowledge of what is planned, including an
understanding of the risks. He/she must also act in
accordance with the GMC’s guidance [3].
Timing
Information about anaesthesia and its associated risks
should be provided to patients as early as possible, preferably
in the form of an evidence-based online resource or
leaflet that the patient can keep for future reference (see
e.g. http://www.labourpains.com/UI/Content/Content.as
px?ID=5; http://www.aagbi.org/news/information-public/
information-about-anaesthesia-adults). Those undergoing
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Yentis et al. | AAGBI: Consent for anaesthesia 2017 Anaesthesia 2017
elective surgery should be provided with information
before admission, preferably at pre-assessment or the time
of booking, but the duty remains on the anaesthetist to
ensure that the information is understood. This is particularly
important for patients admitted on the day of surgery
– increasingly the norm in modern surgical practice –
where the opportunity for prolonged discussion is limited.
Patients should be informed that they will meet the anaesthetist
before their operation, so that further queries and
discussions can take place before finally consenting to
anaesthesia. Consent can only be valid if the patient is sufficiently
informed and understands the broad nature of
the procedure [4, 24, 25].
The anaesthetist must be satisfied that patients
have been given sufficient time to come to a considered
view after they have been provided with relevant
information about their treatment, and have had the
opportunity for adequate discussion, even if admitted
on the same day as surgery. The time required for this
will depend on the patient and the nature of the procedure.
Immediately before induction of anaesthesia,
for example in the anaesthetic room, is not an acceptable
time to provide elective patients with new information
other than in exceptional circumstances. The
importance of allowing sufficient time for the consenting
process is illustrated by a recent case in which it
was held to be unacceptable to inform a patient who
had specifically arranged to have surgery performed by
a particular surgeon, as she was about to enter the
operating theatre, that her surgery would be performed
by a different surgeon, since there was insufficient
time for her to make an informed and free
decision [26].
Standards for provision of information
Sufficient time must be allowed for the process of consent
to take place during the pre-operative visit.
The amount and the nature of information that
should be disclosed to the patient should as far as possible
be determined by the question: ‘What would this
particular patient regard as relevant when coming to a
decision about which – if any – of the available
options to accept?’ [4].
Individual anaesthetists and departments may wish
to use nationally available written information or to
produce their own (e.g. see http://www.rcoa.ac.uk/docu
ment-store/you-and-your-anaesthetic; https://www.rcoa.
ac.uk/node/428; http://www.labourpains.com/UI/Con
tent/Content.aspx?ID=5). Written information should
be available in languages commonly read by local
patients. Braille and large-print versions should be
available for situations where impaired vision is likely
(e.g. information about local anaesthesia for cataract
surgery). Translators or readers must be available for
those patients unable to read the written information
provided. If the patient does not speak English then
consent must take place with the use of an interpreter,
and must not rely on family members or friends to
translate, ensuring the accuracy of the information
provided and reducing any coercive influence.
Information may only be withheld if providing it
would pose a serious threat to a patient’s health, not
just because the anaesthetist feels it may make a
patient anxious or deter him/her from undergoing a
beneficial procedure. Conversely, any information that
might lead a patient to cancel or defer a procedure
should be considered significant. If patients insist they
do not want to know about anaesthesia or a procedure,
the consequences of not understanding the procedure/
anaesthesia should be explained, particularly as it may
mean their consent is not valid. This discussion should
be recorded and the patient provided with the opportunity
to change his/her mind. Basic information about
the nature of the procedure should always be provided;
however, detailed information should not be forced
upon patients who have repeatedly indicated that they
do not want to hear it [27].
In broad terms, patients must understand to what
they are consenting. Therefore, anaesthetists should tell
the patient: i) what procedures are intended, and why;
ii) what the significant, foreseeable risks of these procedures
are, and their consequences; and iii) what the
alternatives are, including having no treatment. When
deciding how much information to provide, anaesthetists
must consider the relevance of information
from their judgement of the patient’s perspective, and
mention significant hazards. A broad summary of what
should be included in most cases is provided in
Table 2, although the information given should always
be according to what a particular patient wants to
know and the likelihood of outcomes in that specific
case, given the patient’s medical history, the nature of
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Anaesthesia 2017 Yentis et al. | AAGBI: Consent for anaesthesia 2017
Table 2 Broad summary of information appropriate for patients during the consenting process (n.b. the anaesthetist
should be guided by what each particular patient wants to know, rather than a proforma list, and with consideration
of what the incidence of risks might be in that patient).
Common components
of anaesthetic technique
Specific aspects related to
procedure or condition
Common/significant
side-effects
Serious side-effects
Fasting; administration and effects of premedication; transfer from ward to anaesthetic room;
cannula insertion; non-invasive monitoring; induction of general and/or local anaesthetic;
monitoring throughout surgery by the anaesthetist; intra-operative drugs/fluids; intra-operative
discomfort/awareness of the procedure/surroundings, etc, if awake/sedated; transfer to recovery
area; return to ward; postoperative analgesia/anti-emetics/fluids; techniques of a sensitive nature,
e.g. insertion of an analgesic suppository
Alternative techniques where appropriate, including if one technique fails (e.g. general anaesthesia
for caesarean section as an alternative to regional anaesthesia, or if the latter is inadequate)
Invasive monitoring and associated risks; recovery in a critical care environment; sedation;
intubation/tracheotomy
Nausea and vomiting; sore throat; damage to teeth/lips; cognitive dysfunction; numbness/
weakness/return of pain after local anaesthetic techniques; suxamethonium pains; post-dural
puncture headache
Nerve/eye damage; awareness during anaesthesia; death
the surgery and its urgency. It is the anaesthetist’s
responsibility to make reasonable efforts to judge what
would be particularly significant risks or complications
to his/her patient, for example the risk of vocal cord
damage from general anaesthesia if the patient is a
professional singer. Where possible, estimates of the
incidence of risks should be given and the discussion
recorded (see below).
All patients should be given the opportunity to ask
questions and honest answers should be provided. The
courts have emphasised the importance of medical professionals’
recognising that they are engaged in a dialogue
with the patients they are treating, and tailoring
that dialogue to the needs of the individual patient [10].
Many questions relate to the operation itself. The
anaesthetist should not provide information about the
surgical procedure beyond his/her capability.
Documentation
As in previous versions of this guidance, the Working
Party’s view continues to be that a signed consent
form is not necessary for anaesthetic procedures that
are done to facilitate another treatment, since it is the
process of consent itself that is important; a signed
form is evidence that a consent process has been
undertaken but does nothing to validate or invalidate
the consent. Furthermore, the anaesthetic can be considered
a component of another treatment (e.g. anaesthesia
for surgery) or as part of a larger and interrelated
process (e.g. epidural pain relief for childbirth),
rather than a treatment in itself (see FAQs, Appendix 2,
Supporting Information).
Whether consent is oral or written, it is essential
for anaesthetists to document clearly both a patient’s
agreement to the intervention and the discussions that
led up to that agreement, including the patient’s questions
and the responses given. This can be done on a
standard consent form, on the anaesthetic record or
separately in the patient’s notes. Anaesthetic departments
may wish to design anaesthetic records to document
the discussions and agreement to specific modes
of anaesthesia and interventions. A proforma may be
useful – but as a guide to the conversation, not as a
checklist to be ticked off without recording further
detail. Documentation is particularly important where
a patient wishes to reverse a previously documented
decision, or circumstances when the patient’s decision
goes against the anaesthetist’s advice, for example if a
patient wishes to convert to general anaesthesia during
apparently effective regional anaesthesia, or alternatively
to continue with regional anaesthesia despite
suboptimal anaesthesia in the view of the anaesthetist.
Sometimes, the anaesthetic procedure is the primary
therapeutic intervention. Examples include invasive procedures
for the treatment of chronic pain, epidural
blood patch for the treatment of post-dural puncture
headache or placement of a central line for chemotherapy
or parenteral nutrition. In these circumstances, and
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especially when the procedure is carried out in the operating
theatre complex, many Trusts insist that a DoH
consent form be completed and signed by the patient as
evidence that consent has been given, and the Working
Party’s advice is that local procedures should be followed.
For a course of treatment (e.g. repeated nerve
blocks), consent to continue should be confirmed before
each individual component, with any changes to the
risks, benefits or alternatives discussed fully [28].
Qualified consent
Some patients, for religious or other personal reasons,
may qualify their general consent to treatment by
refusing specific aspects of that treatment. Doctors
must respect these wishes as far as possible.
Jehovah’s Witnesses, for example, may differ in
their interpretations of the acceptability of blood transfusions.
Most Jehovah’s Witnesses will refuse homologous
blood transfusion; however, some will accept
autologous or cell-salvaged blood. Cardiopulmonary
bypass with non-haematogenous primes and organ
transplantation are usually regarded as acceptable [29].
If a patient gives qualified consent, a record should
be made in the hospital notes indicating that the patient
has been informed of the likely consequences of this
decision, together with the reasons why such a treatment
was proposed in the first instance. If the patient remains
adamant, attention should be drawn to the clause on the
consent form that specifies the patient’s right to list procedures
for which consent is not agreed. The doctor
should also make a note of the precise nature of the
restriction that has been imposed by the patient and the
explanation of risks that took place.
Qualified consent does not remove a patient’s right
to reasonable and proper care, including provision of all
other forms of treatment that are appropriate in the circumstances.
If an individual anaesthetist does not feel
capable of providing proper care consistent with the
patient’s wishes, then he/she can refuse to treat the
patient, provided that no additional harm is likely to
result from that refusal, and make reasonable attempts
to find a different anaesthetist who is willing to treat the
patient. However, in an emergency when treatment is
immediately necessary, the anaesthetist should attempt
to comply with the wishes of a patient who has capacity.
Advance decisions (‘advance
directives’, ‘living wills’) and ‘Do not
attempt resuscitation’ decisions
Adult patients with capacity who anticipate future
incapacity through illness may indicate their preferences
for future treatment by completing an advance
decision, to take effect if they do not have the capacity
to consent to or refuse specific medical treatments. For
example, patients may indicate that they do not wish
to undergo life-saving surgery if they suffer from
dementia when they are older. Many Jehovah’s Witnesses
carry with them an advance decision forbidding
the administration of blood or blood components.
Although an advance decision to refuse routine
treatment does not have to be in writing, one to refuse
life-sustaining treatment must be in writing, must be
witnessed, and must make clear that it is to apply to
the treatment even if life is at risk [6]. An advance
decision that is valid and applicable to the treatment
in question is legally binding [6]. Wherever possible,
anaesthetists should check whether a patient has made
a relevant advance decision to refuse treatment.
When a situation falls fully within the terms of the
advance decision, clinicians should respect the terms
unless there is good evidence that the patient did not
have capacity to make the advance decision, or that
the patient has changed his/her mind since signing it
[31].
Advance decisions cannot authorise doctors to do
anything outside the law, or compel them to carry out
a specific form of treatment, for example continue lifesustaining
treatment that is not in a patient’s best
interests, or provide a treatment the primary intention
of which is to hasten death [22].
‘Do not attempt resuscitation’ (DNAR) decisions
are not advance decisions. Consideration as to the
likely appropriateness of resuscitation must, however,
be based wherever possible on discussion with the
patient (or, where the patient is unable to take part in
the discussion, those close to the patient). Further
guidance on DNAR decisions is available elsewhere
[27]. The Working Party is aware of current work
being done to produce similar guidance encompassing
wider emergency treatment, beyond DNAR alone
(Recommended Summary Plan for Emergency Care
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Anaesthesia 2017 Yentis et al. | AAGBI: Consent for anaesthesia 2017
and Treatment (previously Emergency Care and Treatment
Plan); see https://www.resus.org.uk/consultations/
respect/).
Special circumstances
Obstetrics
Drugs, fatigue, pain or anxiety may compromise the
capacity of an adult parturient, but do not necessarily
lead to incapacity unless the degree of compromise is
severe.
Labour is the wrong time to burden women with
excessive information. Every obstetric unit must provide,
in early pregnancy, advice about pain relief and
anaesthesia during labour and delivery [32]. An anaesthetist
must be involved in preparing this information
and approve the final version. Any patient who wishes
to discuss techniques with an anaesthetist must be able
to do so. Nevertheless, the patient must still be provided
with appropriate information at the time of the
procedure, the details of which must be documented.
Birth plans often include references to analgesia
and anaesthesia. If a woman loses capacity during
labour, the birth plan should be treated as representing
an advance decision, and any documented refusal of
therapy must be respected. However, a presumption of
capacity remains in these circumstances. Therefore,
women who have capacity and who request epidural
analgesia during labour, despite recording a refusal in
their birth plan, must have their request respected, and
the decision documented as above.
In law, a pregnant woman with capacity can refuse
any treatment for any reason, even if this puts the
unborn child at risk of harm or death. An emergency
court order to authorise treatment may be requested
in such circumstances, but will only be granted if the
court concludes that the woman lacks the relevant
decision-making capacity and that the treatment is in
her best interests.
In general, 16- and 17-year-old parturients are to
be regarded as adults from the point of view of making
decisions about interventions, and children younger
than this may be considered as having capacity depending
upon the circumstances (see below). Units should
therefore have guidelines in place to ensure that these
patients receive age-appropriate information and advice
and access to an anaesthetist if needed.
Critical care
The principles of consent for patients receiving critical
care are the same as in the general population; however,
many will lack capacity because of their underlying
condition or essential therapy (e.g. sedation).
Chronic pain
Anaesthetic interventions for patients with chronic
pain are often primary in nature – that is, the intervention
is intended to be therapeutic, rather than facilitating
a more definitive procedure to take place.
When this is the case, written, signed consent on conclusion
of the consent process is recommended, and is
often a Trust requirement. Guidance is available from
the Faculty of Pain Medicine at the Royal College of
Anaesthetists for specialists performing specific interventional
procedures (see http://www.rcoa.ac.uk/faculty-of-pain-medicine/guidelines).
16- and 17-year-olds
In England and Wales, 16- and 17-year-olds (often
referred to as ‘young people’) are covered by the MCA
and are presumed to have the capacity to consent to
treatment, including the administration of an anaesthetic,
as if they were adults. Where a capable young
person has given consent, it is not then necessary to
obtain consent from his/her parent or guardian. Consent
can also be given by those with parental responsibility
(see https://www.gov.uk/parental-rights-responsi
bilities/who-has-parental-responsibility; https://e-justice.
europa.eu/content_parental_responsibility-302-IE-en.do?
clang=en) for the young person, whether or not he/she
lacks capacity. The closer the young person is to the
age of maturity and the more that he/she objects to
the proposed treatment (especially if it is invasive or
serious), the more cautious healthcare professionals
should be about relying upon the consent of a person
with parental responsibility; rather, consideration
should be given to applying to court. The court can
override the refusal of treatment of a capable young
person if he/she is likely to suffer irreversible harm as
a result of his/her refusal.
Children
Children (for these purposes, those under the age of
16) are not presumed to have capacity to consent to
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Yentis et al. | AAGBI: Consent for anaesthesia 2017 Anaesthesia 2017
treatment, unless the doctor decides that the child ‘has
sufficient intelligence and understanding to appreciate
fully what is proposed’ (i.e. ‘Gillick competence’ [20]).
The degree of understanding they will need to show
will vary depending upon the nature of the procedure
and the severity of the condition being treated. A capable
child should understand the treatment and its
effects, and the consequence of non-treatment. If
capacity fluctuates, the child should be considered as
lacking capacity. Capable children should be encouraged
to inform their parents about treatment, but the
doctor must still respect their right to confidentiality
and a refusal to permit disclosure to the parents.
Consent may be provided for children lacking
capacity by a person with parental responsibility, provided
the treatment for which the consent is given is in
the child’s best interests. Usually, parents (or those with
parental responsibility) will make the decision, although
they themselves must be capable of making the decision
and it must be made in the child’s best interests. Either
parent may give consent; but other family members cannot
give consent on behalf of the parents. If there is disagreement
between the parents, the courts may limit the
power of one parent to refuse treatment that is in the
best interests of the child. If both parents refuse, an
application may be made to the court to overrule the
parents. Where a Gillick competent child refuses treatment,
healthcare professionals can, in principle, rely
upon the consent of a person with parental responsibility,
but they should always consider whether it is necessary
to obtain the authority of the court.
In life-threatening situations, parental authorisation
should be obtained if possible and, in default, application
should be made to the court if necessary. Whatever
happens, the best interests of the child must be put first
and treatment that is immediately essential to safeguard
the child’s life or health should not be denied in the
absence of parental authorisation, even if there is no
time to get court authority (although it should be noted
that it is usually possible to find a judge within an hour).
Individual judgment must be exercised in determining
the degree of restraint that is acceptable to achieve induction
of anaesthesia in an uncooperative child, even
when the parents appear to consent to have the child
restrained. When faced with a child who is uncontrollable
for whatever reason, the anaesthetist should
consider ceasing treatment, giving an appropriate explanation
to the parent or representative, and arranging necessary
future treatment for the child.
Research and audit
The need for participants’ consent and for review by an
independent Research Ethics Committee is no different
in anaesthetic and related research to that in any other
area of medical research, and anaesthetists are referred
to the copious guidelines and regulations that already
exist (e.g. at http://www.hra.nhs.uk/research-community/).
Particular considerations apply in relation to
patients who do not have the capacity to consent to participation
in research studies; in such cases, a relative or
other person may be appointed as a ‘consultee’ to advise
researchers as to the patient’s preferences, and patients
may be recruited into emergency research without prior
consent if specific criteria are met [33].
Learning/maintaining practical skills
Although practical procedures can be rehearsed and
practised on manikins – and, to a lesser extent, volunteers
– most learning and maintaining of practical
skills occurs during patients’ care (unlike research, in
which the process is usually extra to care).
It may be difficult to define what constitutes a single
‘procedure’ since most can be separated into several
components. In addition, practitioners learn from every
procedure they do. It is therefore impossible to seek
patients’ consent for every aspect of every ‘procedure’
in which there may be a learning component. The
Working Party endorses the following approach [34]:
• The risks and benefits of each procedure and its
components, both to the patient concerned and to
society in general, must be considered.
• The harms should be minimised as much as possible,
for example by close supervision, prior practice
on manikins, etc.
• The benefits should be maximised as much as possible,
for example by close supervision, and targeting
skills to practitioners most likely to use them in
the future.
• Alternatives should be considered, for example
other ways of learning/maintaining skills, other
techniques.
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In some cases, for example an anaesthetist inexperienced
in fibreoptic orotracheal intubation wishing to
learn the technique unsupervised during general anaesthesia,
patients’ specific consent should be sought since
there may be additional risks from inexperienced use
and there are limited benefits to the patient. In other
cases, for example an experienced endoscopist using
the fibrescope as part of his/her routine technique,
specific consent would not be required since the risks
have been minimised and the benefits maximised, and
the technique constitutes part of the general procedure
of ‘orotracheal intubation’ (so long as the associated
risks remain equivalent to or less than the alternatives).
However, if a particular patient wishes to discuss
intubation, for example if he/she is especially
concerned about damage to teeth or sore throat, the
anaesthetist should provide more details, as for any
other aspect of anaesthesia – upholding the principle
that disclosure of information should be flexible
according to what the individual patient wants to
know. It should also be remembered that patients have
the right to know who is doing what to them, and
how qualified they are [3, 34]. This right is not diminished
by the fact that they may be under the influence
of anaesthesia at the time of the intervention.
The same principles apply to supervision of others:
the supervising anaesthetists should include trainees’
and their own experience as part of their assessment
of overall risks and benefits, including the need to
minimise the former and maximise the latter, as
described above.
Sometimes anaesthetists are approached by medical
students and paramedical staff wishing to learn/
maintain skills, for example in airway management.
Such individuals are not only less skilled than anaesthetists
but also not medically qualified, making the
risk/benefit assessment even more important. The
Department of Health’s guidance states that patients’
specific consent is not required for procedures done
by students if such procedures are part of patients’
normal care. However, the Working Party considers
that this depends on the student’s competence and
the risks involved. For example, while it would be
acceptable for a novice to hold a facemask under
supervision without specific consent, since the risks
are minimal, tracheal intubation is more invasive and
requires a greater level of competence before the
patient’s specific consent is no longer required. In
particular, the Working Party strongly opposes the
practice whereby students or paramedics move
between anaesthetic rooms to ‘do’ intubations, with
no consideration of these issues.
The above approach is equally applicable to
patients who lack capacity to give consent, so long as
it is concluded that specific consent would not be
required. If the patient may lack capacity to give specific
consent to a procedure, the same considerations set
out above under Capacity, best interests and voluntariness
should be applied. There is no necessary bar to a
student carrying out such a procedure but particular
care will need to be taken by those supervising them.
Acknowledgements
The Working Party is grateful to Dr Chris Danbury,
Legal and Ethical Policy Unit, Faculty of Intensive
Care Medicine/Intensive Care Society (FICM/ICS), and
Dr R. Searle, Faculty of Pain Medicine, Royal College
of Anaesthetists, for comments. We are also grateful
to: Mr Colin McKay, Chief Executive, Mental Welfare
Commission for Scotland, Mr Michael Graham, Cleaver
Fulton Rankin Solicitors, Belfast, and Dr Ciaran
Craven, Merchants Quay Chambers, Dublin, for drafting
Appendix 1; to Dr D. Ray, Consultant in Anaesthesia
and Critical Care, Royal Infirmary of Edinburgh
and Honorary Clinical Senior Lecturer, University of
Edinburgh, Mr C. McKay, Chief Executive, Mental
Welfare Commission for Scotland, and Mrs N. Shippin,
Legal Adviser and Director, Central Legal Office,
NHS National Services Scotland, for adapting the Scottish
version of Appendix 2; and to Drs Peter Maguire,
Tim Bennett and Aidan Cullen, Consultant Anaesthetists,
Daisy Hill Hospital, Newry, Northern Ireland,
for comments and suggestions relating to Northern
Ireland.
Competing interests
SMY, AH, DGB and THCB have provided expert witness
reports for the court on the instructions of both
claimants and defendants, and/or HM Coroner. SMY
was a member of the working group that wrote the
GMC’s guidance on consent [6]. AH is his Trust’s
Lead Clinician for the MCA, and has written and
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Yentis et al. | AAGBI: Consent for anaesthesia 2017 Anaesthesia 2017
broadcast on issues related to capacity and consent.
ARK regularly acts in proceedings before the Court of
Protection involving the MCA, and has acted in proceedings
on the instructions of the FICM/ICS. He is
on the FICM/ICS Legal and Ethical Policy Unit, and
has provided assistance to the Resuscitation Council
(UK)/British Medical Association/ Royal College of
Nursing on their Guidance on Decisions relating to
Cardiopulmonary Resuscitation [27].
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(plus new statement
2015 https://www.resus.org.uk/dnacpr/decisionsrelating-to-cpr-new-statement/)
(accessed 20/10/2016).
28. Bartley v Studd [1995] Medical Law Monitor 2(8) 1.
29. Association of Anaesthetists of Great Britain and Ireland. Management
of anaesthesia for Jehovah’s Witnesses, 2nd edn. London:
AAGBI, 1999. https://www.aagbi.org/sites/default/files/
Jehovah’s%20Witnesses_0.pdf (accessed 20/10/2016). OR new
AAGBI guidelines on blood transfusion if ready (due 2016) &
appropriate.
30. HE v A Hospital NHS Trust [2003] EWHC 1017 (Fam).
31. Obstetric Anaesthetists’ Association & Association of Anaesthetists
of Great Britain and Ireland. OAA/AAGBI Guidelines
for obstetric anaesthetic services 2013. London: AAGBI, 2013.
https://www.aagbi.org/sites/default/files/obstetric_anaesth
etic_services_2013.pdf (accessed 20/10/2016).
32. Health Research Authority. Adults unable to consent for themselves.
http://www.hra.nhs.uk/resources/before-you-apply/
consent-and-participation/adults-unable-to-consent-for-themsel
ves/ (accessed 20/10/2016).
33. Yentis SM. The use of patients for learning and maintaining
practical skills. Journal of the Royal Society of Medicine 2005;
98: 299–302.
34. General Medical Council. Good Medical Practice. London: GMC,
2013. http://www.gmc-uk.org/guidance/good_medical_practice.asp
(accessed 20/10/2016).
Supporting Information
Additional Supporting Information may be found in
the online version of this article:
Appendix S1. Summary of the main differences in
the legal framework for decision-making in relation to
those lacking capacity in England and Wales and those
in Scotland, Northern Ireland and the Republic of Ireland.
Appendix S2a. Frequently asked questions regarding
consent (England and Wales and Northern Ireland).
Appendix S2b. Frequently asked questions regarding
consent (Scotland).
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 13

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Management of a Patient with Suspected
Anaphylaxis During Anaesthesia
SAFETY DRILL
(Revised 2009)
Immediate management
∙∙
∙∙
∙∙
∙∙
∙∙
∙∙
∙∙
Use the ABC approach (Airway, Breathing, and Circulation). Team-working enables several tasks to be
accomplished simultaneously.
Remove all potential causative agents and maintain anaesthesia, if necessary, with an inhalational agent.
CALL FOR HELP and note the time.
Maintain the airway and administer oxygen 100%. Intubate the trachea if necessary and ventilate the lungs
with oxygen.
Elevate the patient’s legs if there is hypotension.
If appropriate, start cardiopulmonary resuscitation immediately according to Advanced Life Support
Guidelines.
Give adrenaline i.v.
◦◦
Adult dose: 50 µg (0.5 ml of 1:10 000 solution).
◦◦
Child dose: 1.0 µg.kg -1 (0.1 ml.kg -1 1:100 000 solution).
∙∙
∙∙
Several doses may be required if there is severe hypotension or bronchospasm. If several doses of
adrenaline are required, consider starting an intravenous infusion of adrenaline.
Give saline 0.9% or lactated Ringer’s solution at a high rate via an intravenous cannula of an appropriate
gauge (large volumes may be required).
◦◦
Adult: 500 - 1 000 ml
◦◦
Child: 20 ml.kg -1
∙∙
Plan transfer of the patient to an appropriate Critical Care area.
CONTINUED OVERLEAF
© The Association of Anaesthetists of Great Britain & Ireland 2009

Secondary management
∙∙
Give chlorphenamine i.v. Adult: 10 mg
Child 6 - 12 years: 5 mg
Child 6 months - 6 years: 2.5 mg
Child

The use of blood components
and their alternatives 2016
Published by
The Association of Anaesthetists of Great Britain & Ireland
July 2016

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. AAGBI
guidelines: the use of blood components and their alternatives 2016
Anaesthesia 2016; 71: 829-842.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13489/full

Guidelines
AAGBI guidelines: the use of blood
components and their alternatives 2016
A. A. Klein, 1 P. Arnold, 2 R. M. Bingham, 3 K. Brohi, 4 R. Clark, 5
R. Collis, 6 R. Gill, 7 W. McSporran, 8 P. Moor, 9 R. Rao Baikady, 10
T. Richards, 11 S. Shinde, 12 S. Stanworth 13 and T. S. Walsh 14
1 Consultant, Department of Anaesthesia and Intensive Care, Papworth
Hospital, Cambridge, UK and Chair, AAGBI Working Party
2 Consultant, Department of Paediatric Anaesthesia, Alder Hey
Children’s Hospital, Honorary Lecturer, University of Liverpool,
Liverpool, UK
3 Consultant, Department of Paediatric Anaesthesia, Great Ormond
Street Hospital for Children, London, UK
4 Professor, Centre for Trauma Sciences, Barts Health NHS Trust and
Queen Mary University of London, London, UK
5 Specialist Trainee, Department of Anaesthesia, Glasgow Royal
Infirmary, Glasgow, UK and Group of Anaesthetists in Training
6 Consultant, Department of Anaesthesia, University Hospital of Wales,
Cardiff, UK and Obstetric Anaesthetists’ Association
7 Consultant, Department of Anaesthesia, University Hospital Southampton,
UK, Royal College of Anaesthetists and Association of Cardiothoracic
Anaesthetists
8 Transfusion Practitioner, The Royal Marsden Hospital, London, UK
9 Consultant, Department of Anaesthesia, Derriford Hospital, Plymouth,
UK and Defence Anaesthesia representative
10 Consultant, Department of Anaesthesia, The Royal Marsden Hospital,
London, UK
11 Professor, Division of Surgery and Interventional Science, University College
Hospital, London, UK and Royal College of Surgeons
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.

Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
12 Consultant, Department of Anaesthesia, Southmead Hospital, Bristol,
UK and Honorary Secretary, AAGBI
13 Consultant, Department of Haematology, Oxford Radcliffe Hospitals,
Oxford, UK, and NHS Blood and Transplant
14 Professor, Department of Anaesthetics, Critical Care and Pain
Medicine, Edinburgh University, Edinburgh, UK
Summary
Blood transfusion can be life-saving. Anaesthetists regularly request and
administer blood components to their patients. All anaesthetists must be
familiar with indications and appropriate use of blood and blood components
and their alternatives, but close liaison with haematology specialists
and their local blood sciences laboratory is encouraged.
Considerable changes in approaches to optimal use of blood components,
together with the use of alternative products, have become apparent
over the past decade, leading to a need to update previous
guidelines and adapt them for the use of anaesthetists working throughout
the hospital system.
....................................................................................................
Endorsed by the Royal College of Anaesthetists and the Network for
Advancement of Transfusion Alternatives (NATA).
Keywords: anaemia and coagulation, blood crossmatch, FFP indications,
major haemorrhage, transfusion
Accepted: 11 March 2016
Recommendations
1 All patients should have their haemoglobin concentration (Hb)
measured before listing for major elective surgery.
2 Patients who are anaemic by the World Health Organization definition
(Hb men < 130 g.l
1 , women < 120 g.l
1 ) should be investigated
before elective surgery and treated appropriately, and elective
non-urgent surgery other than caesarean section should be delayed.
3 Where blood transfusion is anticipated, this and alternatives to
transfusion should be discussed with the patient before surgery, and
this should be documented.
2 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
4 Red blood cells should be transfused one unit at a time, and the
patient’s Hb should be checked before each unit transfused, unless
there is ongoing bleeding or a large deficit that needs correcting.
5 The use of intra-operative cell salvage and tranexamic acid administration
should be considered in all non-obstetric patients where blood
loss > 500 ml is possible and in traumatic and obstetric major haemorrhage.
6 Blood components should be prescribed for small children by volume
rather than number of units.
7 Every institution should have a massive transfusion protocol which is
regularly audited and reviewed.
8 Group O red cells for transfusion should be readily available in the
clinical area, in case haemorrhage is life-threatening. Group-specific
red cells should be available within a very short time
(15–20 min) of the laboratory receiving correctly-labelled samples
and being informed of the emergency requirement for blood.
9 During major haemorrhage due to trauma and obstetrics, consideration
should be given to transfusing red cells and FFP in preference
to other intravenous fluid.
10 Patients who continue to actively bleed should be monitored by pointof-care
and/or regular laboratory tests for coagulation, fibrinogen and
platelet counts or function, and a guide for transfusion should be FFP if
INR > 1.5, cryoprecipitate if fibrinogen < 1.5 g.l
1 and platelets if platelet
count < 75 9 10 9 .l
1 .
What other guidelines are available on this topic?
A number of other guidelines are available, some of which are quite recent,
but none cover the breadth of UK anaesthetic practice (Appendix 1).
Why was this guideline developed?
There is a need for a relevant up-to-date clinical guidance for practising
UK anaesthetists, critical care staff and those from other specialities and
backgrounds, based on evidence where possible and with a focus on
safety.
How and why does this publication differ from
existing guidelines?
This is an updated guideline that also brings three previous AAGBI
guidelines together (blood component therapy, 2005; massive haemorrhage,
2010; and red cell transfusion, 2008).
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland 3

Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Introduction
Transfusion medicine is changing rapidly in response to new developments.
Considerable changes in approaches to transfusion, together with
the use of alternative agents, have become apparent over the past decade.
Blood transfusion can be life-saving, but this is a scarce and costly
resource. There is increased focus on appropriate transfusion practice to
ensure quality of service provision, and transfusion has been proposed
as a quality indicator in surgical care. Blood transfusion usage remains
high, particularly in trauma, obstetrics, critical care and cardiovascular
surgery.
Anaesthetists are frequently involved in transfusion decisions, the
administration of blood and blood components and as part of the team
managing any major haemorrhage. However, the use of allogeneic blood
components has serious implications and warrants careful consideration
[1]. As a consequence, there has recently been an expansion of interest
in safeguarding and checklists, blood conservation, preservation techniques,
coagulation profiling and the use of haemostatic agents. Appropriate
use of blood components in patient care is of utmost importance.
Several recent major research publications that have looked at transfusion
practice were aimed at patient safety, outcomes and individualised
care, including: use of restrictive transfusion protocols; adjuvant
therapies; substitution of blood components with pooled factor concentrates;
and use of point-of-care (POC) testing to target specific component
use (see http://onlinelibrary.wiley.com/doi/10.1111/anae.2014.70.
issue-s1/issuetoc).
It is essential that our practice of blood transfusion is safe and
based on current, scientific, evidence-based knowledge. A multidisciplinary
approach that aims to benefit patients by the reduction in inappropriate
transfusions is paramount. This working party aims to
formalise guidance on the clinical indications and risks of transfusion,
blood conservation and the transfusion process.
Patient blood management
Patient blood management is a patient-based approach aimed at reducing
the utilisation of blood transfusion and improving the patient’s clinical
outcome and safety, and focuses on the optimisation of three factors
peri-operatively: patient, surgical and anaesthetic. It has been recommended
as a standard of care in the UK National Health Service [2]. It
focuses on three ‘pillars’ of care in surgical patients: detection and
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
Table 1 Patient blood management – measures that should be taken in
patients who are expected to bleed during surgery.
Pre-operative
-Pre-operative Hb should be measured, recorded and optimised as
required
-Elective surgery should be postponed in patients with untreated anaemia
-Review and consider stopping antiplatelet and anticoagulant medication
seven days before surgery
-Consider minimally invasive or laparoscopic surgical technique
-Point-of-care testing should be available with appropriate training.
Intra-operative
-Position patient carefully to maintain venous drainage
-Use patient warming to maintain temperature > 36°
-Consider cell salvage if blood loss > 500 ml anticipated
-Consider giving tranexamic acid 1 g if blood loss > 500 ml anticipated
-Apply restrictive transfusion threshold (Hb 70–80 g.l
1 depending on
patient characteristics and haemodynamics)
-Consider use of topical haemostatic agents.
Postoperative
-Maintain oxygen delivery, targeting oxygen saturation levels > 95%
-Single unit blood transfusion policy – re-assess Hb concentration and
clinical need between units
-Postoperative drains or cell salvage.
treatment of peri-operative anaemia; reduction of peri-operative blood
loss; and harnessing and optimising the patient-specific physiological
reserve of anaemia [3] (Table 1).
Anaemia
Pre-operative anaemia is common, occurring in up to a third of patients
before surgery, and associated with worse outcomes. All patients should
have their Hb checked before listing for surgery. Patients who are anaemic
(Hb in men < 130 g.l
1 , women < 120 g.l
1 ) should be investigated
and the cause treated appropriately [4]. Patient pathways and pre-assessment
clinics should be established to allow timely and appropriate management,
and elective surgery should be delayed if required [5].
Cell salvage
The use of cell salvage should be considered for high- or medium-risk
surgery in non-obstetric adult patients where blood loss > 500 ml is
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
likely, and in obstetric major haemorrhage. In patients with malignancy
or obstetric haemorrhage, a leucocyte filter must be used. Bacterial contamination
of the surgical field remains a contra-indication. Cell salvage
may also be continued in the postoperative period [6].
Other aspects of patient blood management are discussed throughout
these guidelines.
Process for transfusion
Administering the wrong blood type in error (with the risk of ABO
incompatibility) is the most serious outcome of blood transfusion. Most
of these incidents are due to the failure of the final identity checks carried
out between the patient (at the patient’s side) and the blood to be
transfused. All members of staff involved in the administration of a
blood component must be trained and competency-assessed as per local
policy. Local policy will also stipulate if this is a one- or two-person
bedside check, with each person performing the check independently
[7]. Red cell transfusions must be completed within 4 h of removal from
the blood fridge. All prescriptions for transfusion must be documented
in the patient record, either on the anaesthetic chart or on the drug/
fluid prescription chart. Local policy for confirmation of the transfusion
must be followed – it is a legal requirement that 100% of blood components
must be traceable [8]. Where blood transfusion is anticipated, this
should be discussed with the patient before surgery and valid consent to
receive transfusion should be documented [9]. Patients should be
informed that they have received blood or blood components before discharge
from hospital as they will otherwise be unaware; they should also
be informed that this removes them from the donor pool. It is also
important that the patient’s general practitioner is informed.
The following guidance is for a manual checking process at the bedside;
the preferred system is an electronic transfusion management system.
-The patient must be positively identified. All patients receiving blood
components should be wearing an identification wristband containing
four core identifiers – first name, last name, date of birth and patient
identification number.
-Immediately before the transfusion, check the component next to the
patient, against the prescription.
-Check the four core identifiers on the compatibility label attached to
the blood component with the identification attached to the patient. If
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
there are any discrepancies, do not proceed and call the transfusion
laboratory.
-Check that the compatibility label attached to the blood component
has the same blood group and 14-digit component donation number
(or batch number for coagulation factors) as the sticker on the blood
component.
-Visually check the blood component for any leakage, discolouration or
presence of any clots or clumps.
-Check the expiry date and time.
Transfusing an unidentified patient
All hospitals should have a clear local policy for transfusion of patients
whose identity is unknown. In emergency situations or where the
patient cannot immediately be identified, the patient should still have
identification attached stating unknown male or female and a unique
identification number. The blood sample sent to the transfusion laboratory
should contain these exact details.
In the event that the patient’s identity becomes known, new identification
must be attached to the patient and a new transfusion sample
collected and fully labelled with the known patient’s details.
Monitoring for adverse events or reactions during transfusions
Clinical observations should include heart rate, blood pressure, temperature
and respiratory rate, as per local guidelines (national guidelines
define a minimum of pre-transfusion, at the end of transfusion and 15
min after transfusion). If there are any signs of a transfusion reaction,
such as tachycardia, rash, breathlessness, hypotension or fever, stop the
transfusion and contact the laboratory immediately [10]. Management
may include the administration of antihistamine or steroid drugs, or
intramuscular/intravenous adrenaline if life-threatening [11]. Diagnosis
of a transfusion reaction during ongoing haemorrhage may be difficult,
but if concern arises, the documentation should be double-checked for
administration errors and further analyses performed as per local protocols.
Transferring blood with a patient
Blood components should be transferred with patients at high risk of
requiring transfusion en route or immediately on arrival. There should
be effective communication between the blood transfusion laboratories
involved, according to regional policy. Blood components must be
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
transported in a storage box suitable to maintain their integrity, along
with accompanying paperwork, and careful handover is required. When
the patient arrives at their destination, the receiving transfusion laboratory
should be immediately informed that blood was transported. The
patient should be issued with a new identity wristband, a new sample
taken for cross-match and more blood issued; until this is available,
blood transferred with the patient may be administered if required.
Red blood cell transfusion
Red blood cell (RBC) transfusion is potentially life-saving for the treatment
of blood loss (Major haemorrhage – see next section). In patients
who do not have active bleeding and in normovolaemic patients, the Hb
should be measured before and after every unit of RBC transfused. Nearpatient
measurement of Hb may be particularly useful, but laboratory
measurement remains the gold standard. Haemoglobin concentration is
dependent on both red cell mass and plasma volume; it may fall due to
haemodilution due to intravenous fluid administration. In the bleeding
patient, haemoglobin concentration may remain falsely elevated despite
significant blood loss due to inadequate fluid resuscitation.
Other potential indications for RBC transfusion are clinical signs
and biochemical markers of inadequate oxygen delivery, such as elevated
blood lactate concentration, a low Ph and low central or mixed venous
oxygen saturation.
Optimum haemoglobin transfusion trigger
Recent publications comparing more liberal transfusion strategies (typical
transfusion trigger Hb 90–100 g.l
1 ) with more restrictive strategies
(typical transfusion trigger Hb 70–80 g.l
1 ) did not show any difference
in patient outcomes [12, 13]. Therefore, a general Hb threshold of
70 g.l
1 should apply as a guide for red cell transfusion. Uncertainty
remains for patients with ischaemic heart disease, including acute coronary
syndrome and after cardiac surgery [14], and higher thresholds
(80 g.l
1 ) may be more appropriate in such circumstances.
Major haemorrhage
Major haemorrhage is variously defined as loss of more than one blood
volume within 24 h (around 70 ml.kg 1 , > 5 l in a 70 kg adult); 50%
of total blood volume lost in < 3 h; or bleeding in excess of
150 ml.min 1 . A pragmatic clinically-based definition is bleeding which
leads to a systolic blood pressure of less than 90 mm Hg or a heart
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
rate of more than 110 beats.min 1 . Major haemorrhage is a significant
cause of mortality and morbidity in the peri-operative setting. Appropriate
and effective management integrates multiple factors, including:
recognition; communication; timely delivery of blood products; and
application of definitive modalities of treatment (surgery and interventional
radiology) [15].
Major haemorrhage protocol
Policies should be defined in an institutional major haemorrhage protocol.
Activation of a protocol should result in the immediate release and
administration of blood components for initial resuscitation, without
prior approval from a haematologist. Such protocols perform best when
specific to clinical areas such as the emergency department or the labour
ward, and are designed to include robust and clearly understood activation
and communication from bedside to laboratory. Their activation
should also mobilise other resources, such as additional (senior) staff
including portering, blood warmers, pressure infusers and cell salvage
devices [16].
A clear mechanism for the escalation of a team response and for
identifying individuals with sufficient seniority and experience to undertake
the key roles of team leader (senior anaesthetist) and co-ordinator
is essential to the process, as is enabling a single point of contact with
the laboratory and other support services.
Initial resuscitation
Most major haemorrhage packs will contain four units of RBCs and
four units of FFP (equivalent to 15–20 ml.kg 1 in a standard adult);
platelet concentrate may also be provided. Administration should be via
wide-bore intravenous access, or intra-osseous access until the former
can be obtained.
Group O red cells should be readily available and transfused if
haemorrhage is life-threatening. It is essential to give group O Rh-negative
red cells to children and women of childbearing potential, but
group O Rh-positive red cells may be used in adult men.
Group-specific red cells should be rapidly made available (within
15–20 min) by the laboratory after receiving a correctly labelled blood
group sample and being informed of the emergency requirement for
blood. Emergency Group O red cells should continue to be provided
where timely and safe issue of group-specific red cells is not possible.
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Haemostatic resuscitation
This describes the process of restoring and sustaining normal tissue perfusion
with the emphasis on preservation of effective clotting. Coagulopathy
is associated with haemorrhage (consumption) and transfusion
of blood products (dilution), as well as mechanism of injury in trauma;
this may exacerbate the haemorrhage and resultant morbidity. Point-ofcare
or laboratory testing should be used to guide management.
During resuscitation, the following should be prevented/treated:
hypothermia; acidosis; hypocalcaemia (aim for ionised calcium
> 1.0 mmol.l
1 ); and hyperkalaemia.
Special situations
Critical care
Anaemia is prevalent during critical illness. In addition to blood loss and
sampling, haemodilution and impaired erythropoiesis may be important
contributors [17]. Patients with anaemia demonstrate biochemical abnormalities
similar to those with chronic inflammatory diseases.
Although biochemical markers of tissue hypoxia, notably blood
lactate concentration, are frequently elevated, evidence does not support
increasing oxygen delivery with RBC transfusion when the Hb is
> 70 g.l
1 , unless the patient has cardiac disease [18].
One important group of patients admitted to ICU are patients with
haematological malignancies. Overall, patients with cancer form one of
the larger groups of recipients of blood components. However, unlike
other patient groups, the anaemia in patients with haematological malignancies
reflects an underlying bone marrow failure, and therefore, it is
unclear to what extent findings from the majority of randomised trials
conducted in surgery or general critical care can be extrapolated to cancer,
although the same broad principles of restrictive use of red cells commonly
apply (70–80 g.l
1 for red cell transfusion).
Obstetrics
Estimating blood loss at delivery is notoriously difficult, and every effort
should be made to directly measure abnormal bleeding across all settings
in the delivery suite [19]. Early recognition of bleeding by changing
bed linen and pads immediately after delivery and systematically
weighing new blood-soaked pads correlates with the fall in Hb concentration
and improves outcome.
As soon as abnormal bleeding is recognised, > 500 ml after a vaginal
delivery and > 1000 ml after a caesarean delivery, the obstetrician,
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
anaesthetist and senior midwife should attend the mother. Blood should
be taken for full blood count (Hb), clotting studies, group and screen,
and a venous blood gas for rapid Hb measurement and lactate
(> 2 mmol.l
1 is an indicator of shock). Cell salvage is recommended if
abnormal bleeding occurs during caesarean section, and a leucocyte filter
should be used for autotransfusion of processed blood.
Severe early consumptive coagulopathy is associated with abruption,
amniotic fluid embolus and severe bleeding with pre-eclampsia. Early
use of FFP before RBC may be required.
Postpartum haemorrhage associated with atony or trauma is unlikely
to be associated with haemostatic impairment unless the diagnosis is
delayed. Protocol-led use of blood products will lead to overtransfusion of
FFP in the majority of cases [20]. If coagulation tests are not known, then
FFP should be withheld until four units of RBC have been given. If no
coagulation results are available and bleeding is ongoing, then, after four
units of RBC, four units of FFP should be infused and 1:1 ratio of RBC–
FFP transfusion maintained until the results of haemostatic tests are
known. Point-of-care (POC) testing is recommended in this setting [21].
Hypofibrinogenaemia, below normal levels for pregnancy, predicts
the risks of ongoing postpartum haemorrhage. The normal plasma fibrinogen
concentration in pregnancy is 4–6 g.l
1 , and a laboratory Clauss
fibrinogen of < 3 and especially < 2 g.l
1 , with ongoing bleeding, is associated
with progression to major obstetric bleeding [22]. Fibrinogen
replacement with cryoprecipitate or fibrinogen concentrate should be considered
in these circumstances, if there is bleeding.
Monitoring of haemostatic function in obstetric haemorrhage is particularly
important; laboratory testing is often too slow during obstetric
haemorrhage, and therefore, POC testing is preferred. Tests should include
plasma fibrinogen concentration or POC equivalent [21]. With ongoing
bleeding, any abnormalities should be treated, as this indicates significant
haemostatic impairment in the obstetric patient. Platelet transfusions are
rarely required and should only be given once the platelet count is known.
Tranexamic acid reduces total blood loss and should be given if
postpartum haemorrhage is severe (> 500 ml after a vaginal delivery
and > 1000 ml after a caesarean delivery), at an initial dose of 1 g.
Paediatrics
There is little direct evidence to guide the use of blood products in children,
and generally the guidance intended for adults can be safely
applied to children with some modifications (specifically in transfusion
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
volumes). ‘Restrictive’ approaches to transfusion are appropriate for
almost all children older than 3 months of age. Higher transfusion
thresholds are often applied to neonates and children with congenital
heart disease. Although thresholds are not clearly defined, there is evidence
that quantities of transfusion can be reduced in these patients by
applying moderately restrictive thresholds for transfusion without
adverse effect on outcome [23, 24]. Neonates should receive components
specified for neonatal use, including cytomegalovirus-negative blood
products.
The volume of blood to be administered requires modification
depending on the size of the patient. It is recommended that blood in
children should be prescribed in volume rather than number of units.
In practice, sensible rounding to the nearest unit will be more efficient.
• A transfusion of 10 ml.kg 1 of RBC should increase Hb by approximately
20 g.l
1 .
• Cryoprecipitate should be given in a dose of 5–10 ml.kg 1 .
• Platelets should be given in a dose of 10–20 ml.kg 1 .
• Fresh frozen plasma may be given in doses of 10–15 ml.kg 1 .
Tranexamic acid can be used in children: a loading dose of 15 mg.kg 1
followed by infusion 2 mg.kg 1 .h 1 should be used in trauma [25].
With technical refinements, cell salvage can be useful in children,
even if the absolute volume of blood loss is less than 500 ml [26].
Major haemorrhage is rare in children outside of highly specialist
areas of practice. The guidance suggested for adults can be generally
applied, though requires an awareness of the size of the child and the
clinical context of the bleeding. Blood volume of a child is estimated at
70 ml.kg 1 but may be as high as 100 ml.kg 1 in newborns. Devices for
vascular access and rapid administration of blood should be appropriate
for the size of the child and rate of blood loss. Children are at particular
risk of electrolyte imbalance and hypothermia during rapid administration
of blood products.
Trauma
During active bleeding, follow the principles of damage control resuscitation:
Early haemorrhage control
Ensure clinical treatment is constantly directed towards haemorrhage
control. Use temporary haemostatic devices (pressure, tourniquets, etc.)
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
followed as soon as practically possible by surgery or interventional
radiological control of haemorrhage.
Permissive hypotension
Do not try to normalise blood pressure during active haemorrhage.
Maintain a minimum acceptable preload and blood pressure with volume
resuscitation alone; this may need to be modified in the presence
of trauma in head and spinal injuries. The use of vasopressors should
be avoided during active haemorrhage.
Avoid crystalloid and colloid administration
During uncontrolled haemorrhage, avoid clear fluids for volume resuscitation
unless there is profound hypotension and no imminent availability
of blood products.
Target trauma-induced coagulopathy
Deliver blood products empirically at first, and use laboratory or pointof-care
tests of coagulation to guide therapy as soon as available [27].
Give tranexamic acid 1 g immediately, but avoid if more than 3 h
after injury, unless there is ongoing evidence of hyperfibrinolysis (as
suggested by POC testing).
Whilst haemorrhage is being controlled, administration of RBC and
FFP in a ratio of 1:1 should be used to replace fluid volume [28]. Consider
the administration of cryoprecipitate (two pools) and platelets (one
adult therapeutic dose) until test results are available and bleeding is
controlled. Once control is achieved, blood components should be
administered as guided by testing at the earliest opportunity (see Monitoring
section, blood components).
Cardiac surgery
Anaemic patients have an increased risk of mortality and complications
following cardiac surgery [29]. Elective cardiac surgery should not be
undertaken in an anaemic patient without prior investigation and treatment
as considered necessary.
Viscoelastic testing is recommended to guide transfusion [30]. The
use of local transfusion protocols guided by point-of-care testing may
lead to appropriate transfusion with reduced costs. The evidence base
for the efficacy of fresh frozen plasma is minimal and of poor quality
[31].
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
The effect of cardiopulmonary bypass on platelet function may
make the use of a higher platelet count (> 75 9 10 -9 .l
1 ) necessary after
bypass.
There is no clear evidence of the benefit of platelet function analysis
except in those patients who have taken PY12 receptor inhibitors such
as clopidogrel within 5 days of surgery [32].
Monitoring
Laboratory testing
Traditional tests such as APTT and PT/INR have been standardised for
the monitoring of anticoagulants and are designed to diagnose and
manage factor deficiencies such as haemophilia. Standardisation within
laboratories has made the results very reliable.
The PT and APTT were not designed to monitor coagulation deficiencies
during haemorrhage and suggested INR and APTT ratios or
triggers, which are widely quoted to guide coagulation product replacement,
are based on small historic studies that have little relevance today.
Slow turnaround time also means that the results do not reflect the
dynamic clinical situation during ongoing haemorrhage [33].
Point-of-care testing
Point-of-care testing has a shorter turnaround time and represents a
more global and therefore more relevant reflection of coagulation status
[34]. Point-of-care testing is increasingly popular for general and
cardiac surgery, trauma units, intensive care and obstetrics. Point-ofcare
testing for Hb concentration is commonly used, such as blood
gas analysis or the HemoCue â (€Angelholm, Sweden), which both correlate
well with laboratory measurements [35]. The activated clotting
time (ACT) is also well validated and should be used routinely whenever
heparin is administered, particularly in cardiac and vascular
surgery.
Targeted blood component therapy based on POC testing has been
shown to be safe and effective, and to decrease blood product usage.
However, there are currently no studies that show improved patient outcome
compared with standard treatment [32].
At the current time, there are two commercially available semi-automated
viscoelastic machines that use similar technology: thromboelastometry
(ROTEM, TEM International, Munich, Germany) and
thromboelastography (TEG, Haemonetics Corp, Braintree, MA, USA).
One manufacturer cannot be recommended above the other.
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
There are no universal algorithms across the specialities, and local
protocols are required based on institutional procedures. There is limited
interchangeability between TEG and ROTEM, and development
and validation of separate treatment algorithms for the two devices are
required [36].
There are concerns about standardisation of both assays with poor
quality control and assurance and a wide variation in results between
centres [37]. It is good practice to pair coagulation samples and send a
second sample for laboratory-based analysis.
Drugs
An increasing number of patients take either anticoagulants or antiplatelet
agents. All patients require careful pre-operative medication optimisation
before surgery. The management of drugs related to antithrombotic therapy
in the peri-operative setting is a common problem, balancing bleeding
risk with thrombosis.
Patients at high risk (> 10% risk of thrombotic events per year)
of thrombosis should be considered for bridging anticoagulation, or
in the following circumstances:
-venous thromboembolic event within the last 3 months, or
-prosthetic (mechanical) heart valve
Bridging anticoagulation usually consists of low molecular weight heparin.
The dose and type of the low molecular weight heparin depends on the
patient’s weight, timing of surgery, type of procedure and thrombotic risks.
Warfarin (Vitamin K antagonist)
The international normalised ratio (INR) is used to monitor the effectiveness
of warfarin. In most situations, INR is maintained between 2.0
and 2.5.
The peri-operative management of warfarin is summarised in
Table 2. In patients with atrial fibrillation on warfarin, routine use of
bridging anticoagulation with low molecular weight heparin before surgery
is not recommended.
For emergency reversal of warfarin, prothrombin complex concentrate
(PCC) 50 IU.kg 1 is recommended. Intravenous vitamin K
(10 mg) may also be given, but this may preclude re-warfarinisation
for a number of days. Fresh frozen plasma is an alternative if PCC
is not available [37], but should not be used as elective prophylaxis
in patients taking warfarin.
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Table 2 Peri-operative optimisation of warfarin anticoagulation for
major surgery. Bridging with LMWH required for high-risk patients,
patients who suffered recent thromboembolic events or patients with
mechanical prosthetic heart valves.
Day 5 Days 4, 3, 2 Day 1 Surgery Postoperative
Last dose of
warfarin.
Treatment dose LMWH
(consider Vitamin K if
INR > 2.5
Half treatment
dose LMWH
Omit
LMWH.
Check
INR
Prophylactic
LMWH until
warfarin is
commenced.
INR, international normalised ratio; LMWH, low molecular weight heparin.
Novel oral anticoagulants
Novel oral anticoagulants have more predictable pharmacodynamics and
a faster onset of action with a shorter half-life than warfarin. There are
currently three drugs on the market; these are increasingly used for
management of patients with atrial fibrillation; after stroke and transient
ischaemic attacks; and prophylaxis/management of venous thromboembolism
[38].
Their half-life varies, especially in the presence of renal impairment.
Currently, there are no specific routine coagulation tests to determine
their effectiveness. Regarding antidotes, the United States Food and
Drug Administration and the European Commission have recently
approved the first of these, idarucizumab (Praxbind, Boehringer Ingelheim
International, Ingelheim am Rhein, Germany), for the emergency
reversal of dabigatran; other antidotes are currently undergoing clinical
trials.
Dabigatran is a direct thrombin inhibitor. Half-life depends on
extent of renal impairment (normally 48–72 h). For major elective surgery,
neuraxial blockade and in patients with renal dysfunction, the drug
should be stopped 5 days before surgery. For others, it can be stopped
3 days before surgery.
Rivaroxaban and apixaban are direct factor Xa inhibitors. Half-life
is 5–13 h and is less dependent on renal function. For major elective
surgery, neuraxial blockade and in patients with renal dysfunction, the
drug should be stopped 3 days before surgery, otherwise stop 24–48 h
before surgery.
If surgery is urgent, consider PCC 50 IU.kg 1 , correct other abnormal
coagulation tests and check platelets. Bridging anticoagulation is not
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
required except in patients with recent (< 3 months) history of pulmonary
embolism or deep venous thrombosis.
Antiplatelet drugs
These drugs cause irreversible inhibition of platelets; replenishment of
platelets occurs at a rate of 10–15% per day. The restoration of normal
platelet function depends on the individual drug and dosage.
Aspirin inhibits the production of thromboxane. It should be continued
for most procedures until the day before surgery. In patients at
low risk of cardiovascular events having major surgery and those undergoing
high-risk procedures such as intracranial surgery, aspirin should
be discontinued 5 days before the procedure.
Clopidogrel is an oral, thienopyridine-class antiplatelet agent, and
the active metabolites circulate for up to 18 h after the last dose. Clopidogrel
should be stopped 7 days before surgery unless point-of-care testing
is used to check platelet function.
The drugs prasugrel and ticlopidine are also thienopyridine-class
antiplatelet drugs similar to clopidogrel. The same recommendations as
for clopidogrel apply to the above drugs.
Antiplatelet drugs and non-cardiac surgery in patients with
coronary stents
The management of these drugs in patients with coronary stents in situ
depends on the type of stent, time after the coronary event and surgery
type (major vs minor). Communication with the cardiology team is key.
Elective surgery should be postponed for at least 4–6 weeks after
bare metal stent implantation and 6 months after drug-eluting stent
implantation. Aspirin may be continued during the peri-operative
period except in closed space surgery such as intracranial and spinal
surgery.
For emergency surgery, management depends on the antiplatelet
agent and when the last dose was taken. Platelet transfusion should be
reserved as an additional measure for critical bleeding.
Drugs that decrease blood loss
Tranexamic acid is a synthetic derivative of the amino acid lysine that
inhibits plasminogen activation, thus preventing impairment of fibrinolysis.
In the last few years, there is increased evidence that its use may reduce
bleeding in trauma, cardiac surgery and other major surgery. Seizures have
been reported when high doses are given, but there is little evidence of
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
other side effects [39]. Dose is variable, but 1 g bolus is recommended,
and an additional infusion of 500 mg.h 1 may also be considered [40].
Aprotinin is a serine protease inhibitor antifibrinolytic which acts
by inactivating free plasmin. The drug was withdrawn from the market
in 2007 due to safety issues with increased incidence of renal impairment
and anaphylactic reactions. Recently, regulators have licensed the
drug only for myocardial revascularisation (coronary artery bypass surgery)
[41].
Blood components
Before administration of any blood component, the patient’s details
should be checked against those on the bag (see red blood cell transfusion
section). Blood components have specific storage and expiry times.
Every effort must be made to avoid wastage.
In haematological malignancy, the clinical team must be consulted
before administering blood components because of the need for specific
requirements. The transfusion threshold may be different to non-haematological
patients. A small number of patients require transfusion with
irradiated blood components to prevent them developing transfusionassociated
graftversus-host
disease (TA-GVHD), which is rare, but usually fatal. Patients
with the following conditions require irradiated blood: congenital immunodeficiency
states, for example Di-George’s syndrome; allogeneic bone marrow
transplant recipients and donors; autologous bone marrow-transplanted
patients; Hodgkin’s lymphoma; purine analogue therapy including new
agents clofarabine and bendamustine; and patients who receive antithymocyte
globulin (anti-CD52) therapy (alemtuzumab) [42].
Fresh frozen plasma
Fresh frozen plasma is leucodepleted plasma rapidly frozen to below
25 °C to maintain the integrity of labile coagulation factors. The use
of FFP has increased significantly in the past few years [38]. Given that
anti-HNA and anti-HLA antibodies occur at higher frequency in multiparous
women, implementation of male-only plasma in component therapy
began in the UK in 2003, and this has reduced the incidence of
transfusion-related acute lung injury (TRALI) [43].
Fresh frozen plasma can be thawed using a dry oven (10 min),
microwave (2–3 min) or in a water bath (20 min). Thawed FFP can be
used for up to 24 h as long as it is stored at 4 °C. This time has
recently been extended to 5 days when stored at 4 °C for use in major
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
haemorrhage associated with trauma. Once out of the fridge, it must be
used within 30 min, and once thawed, it should never be refrozen.
Approximate volume per bag is 300 ml.
Fresh frozen plasma contains all the factors of the soluble
coagulation system, including the labile factors V and VIII to a varying
degree. The fibrinogen content of four units of FFP is approximately
2 g, compared with approximately 4 g fibrinogen in two pools of
cryoprecipitate.
Fresh frozen plasma should be the same group as the patient. If the
blood group is unknown, group AB FFP is preferred, as it does not contain
any anti-A or anti-B. If group O FFP is given to non-group O children,
it should be high-titre (HT) negative. The recommended
therapeutic dose is 15 ml.kg 1 .
To reduce the risk of variant Creutzfeldt–Jakob disease, FFP for use
in all those born in 1996 or later is sourced outside of the UK and has
undergone viral inactivation (either with methylene blue or solvent
detergent treatment).
Indications for FFP use include the following:
• replacement of coagulation factors during major haemorrhage, particularly
trauma and obstetrics;
acute disseminated intravascular coagulation (DIC) with bleeding;
• in patients who are actively bleeding and whose INR is > 1.5 (or
POC equivalent);
• immediate reversal of warfarin-induced haemorrhage when PCC is not
available (PCC is the first choice);
• thrombocytopenic purpura usually with plasmapheresis preferably
using pathogen-inactivated FFP; and
• replacement of coagulation factors when specific factors are not
available (uncommon).
There is a very limited role for FFP in the management of (mild–
moderate) coagulation abnormalities frequently seen in many nonbleeding
critically ill patients before invasive procedures. Fresh frozen
plasma is not recommended for routine use in patients with cirrhosis/
liver disease unless significant coagulopathy is identified, as again current
understanding indicates that isolated abnormalities of the PT or
APPT do not reflect a ‘balanced haemostasis’. Fresh frozen plasma
should not be used simply as routine circulatory volume replacement.
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Cryoprecipitate
Cryoprecipitate is also a leucodepleted plasma product containing concentrated
factor VIII, von Willebrand factor, fibrinogen, factor XIII and
fibronectin, produced by further processing of FFP. It is stored
at 25 °C; once thawed for administration, it can be kept at ambient
temperature for 4 h, and should not be kept in the fridge again [42].
In the UK, it is mainly available as pooled bags of five units, 100–
200 ml per bag. It is also available as one unit of 20–40 ml. Each single unit
has 400–450 mg of fibrinogen, and pools of five units contain at least 2 g.
The adult dose is two pools; transfuse using a standard blood giving
set with a 170- to 200-lm filter.
Indications for cryoprecipitate include the following:
• hypofibrinogenaemia due to major haemorrhage and massive transfusion.
There is increased use of cryoprecipitate in major trauma,
obstetric haemorrhage
and cardiac surgical bleeding. During major haemorrhage,
fibrinogen should be maintained > 1.5 g.l
1 , except in active obstetric
haemorrhage where fibrinogen should be maintained > 2 g.l
1 ;
combined liver and renal failure with bleeding;
bleeding associated with thrombolytic therapy;
• disseminated intravascular coagulation with fibrinogen < 1.0 g.l 1 ;
and
• advanced liver disease, to maintain fibrinogen level > 1.0 g.l 1 .
Cryoprecipitate for use in all those born in 1996 or later is made
from FFP sourced outside of the UK and has undergone viral inactivation
with methylene blue. These components are available as single units
for smaller children and pooled units for older children and young
adults.
Platelets
Platelets are either made from pooled buffy coat-derived platelets from
four whole blood donations, suspended in platelet additive solution and
the plasma of one of the four donors (who is male), or as an adult therapeutic
dose obtained from a single donor by apheresis donation. Both
can be used interchangeably; NHSBT recommends that recipients born
on or after 1st January 1996 should receive apheresis donation platelets
where possible.
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
There is increased use of platelets in the last few years. The greatest
demand is for haemato-oncology patients; platelets should not be
administered to patients with chemotherapy-induced thrombocytopenia
in the absence of bleeding, unless their platelet count is < 10 9 10 9 .l
1 .
The risk of transmission of bacterial infection (1 in 12,000) is higher
than other blood components because platelets are stored at 22 °C. This
risk is reduced by bacterial screening before release.
Platelets do not have to be the same group as the patient, but where
group O platelets are given to a non-group O child they should be selected
to be high-titre negative. D-negative children and women of childbearing
potential should receive D-negative platelets because of the small risk of
developing immune anti-D.
Platelet concentrate should be stored at 22 °C with constant gentle
agitation in an approved incubator. Platelets must not be placed in a
refrigerator. Transfusion should ideally be commenced within 30 min of
removal from the platelet storage incubator. Each pack contains 250–
350 ml; platelet count in the pack is > 2.4 9 10 10 .l
1 per adult dose,
and transfusion should lead to an increase in the patient’s platelet count
by approximately 30 9 10 9 .l
1 . The patient’s platelet count should be
repeated after transfusion.
A standard adult therapeutic dose should be infused over a period of
30 min through a standard blood administration set or platelet administration
set incorporating a 170- to 200-lm filter. Do not give through a set
that has already been used for red cells. No drugs should be added directly
to the unit of platelets.
Indications for platelets include the following:
• prevention and treatment of bleeding due to thrombocytopenia or
platelet function defects.
• If patient is actively bleeding, transfuse to a platelet count
> 75 9 10 9 1
.l
If not bleeding, the following triggers should be applied:
routine prophylactic use: 10 9 109 .l
1 ;
• prophylactic use with additional risk factors (e.g. Sepsis):
10 – 20 9 10 9 .l
1 ;
other major surgery or invasive procedures: 50 9 109 .l
1 ;
• neuraxial blockade: 50 9 109 .l
1 ; and
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
• prophylactic use in closed compartment surgery (eye, brain):
100 9 10 9 .l
1 .
In the UK, the availability of platelets is centralised and will depend
on the demand and distance from nearest blood centre. Clinicians need
to be aware of local laboratory arrangements and normal time interval
for obtaining platelets from central storage.
Special blood components
Prothrombin complex concentrate
Prothrombin complex concentrate (in the UK) comes as four-factor
concentrate containing factors II, VII, IX and X, with protein S, C and
heparin. It can be rapidly reconstituted providing a high concentration
of these four clotting factors in a small volume. It is indicated in
acquired factor deficiency and for urgent reversal of warfarin. There is
limited evidence for use in any other setting.
Fibrinogen concentrate
There has been considerable interest in fibrinogen concentrate. It is
widely used in mainland Europe in the management of bleeding following
surgery or trauma. Recent trials in cardiac surgery have not shown
any benefit from its use. It is only licensed for use in congenital
hypofibrinogenaemia in the UK.
Recombinant factor viia
Licensed for use in haemophiliacs with inhibitors. It is the most potent
thrombin generator available at present. Late use in the exsanguinating
patient is almost always associated with no benefit, a high risk of mortality
and thrombotic complications. Following cardiac surgery, it has
been shown to reduce re-operation rates and transfusion in the bleeding
patient. However, its use may increase the risk of thrombotic complications
and its use except under haematological direction cannot be recommended
[44].
Acknowledgements
AK is the Editor-in-Chief of Anaesthesia, and has received research
funding and honoraria from Pharmacosmos and CSL Behring. RB has
received educational support from Pharmacosmos. RG has received honoraria
from CSL Behring and Octapharma. TR has received research
funding and honoraria from Vifor Pharma and Pharmacosmos. RC has
22 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
received research funding from CSL Behring and TEM International.
No other conflicts of interest declared.
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39. Sharma V, Katznelson R, Jerath A, et al. The association between tranexamic acid
and convulsive seizures after cardiac surgery: a multivariate analysis in 11 529
patients. Anaesthesia 2014; 69: 124–30.
40. Hunt BJ. The current place of tranexamic acid in the management of bleeding.
Anaesthesia 2015; 70: 50–e18.
41. Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice.
British Journal of Anaesthesia 2013; 111: 549–63.
42. Challis M, Marrin C, Vaughan RS, Goringe A. Who requires irradiated blood products?
Anaesthesia 2011; 66: 620–1.
43. Hart S, Cserti-Gazdewich CM, McCluskey SA. Red cell transfusion and the immune
system. Anaesthesia 2015; 70: 38–e16.
44. Gill R, Herbertson M, Vuylsteke A, et al. Safety and efficacy of recombinant activated
factor VII: a randomized placebo-controlled trial in the setting of bleeding
after cardiac surgery. Circulation 2009; 120: 21–7.
Appendix 1
Other available guidelines.
National Institute for Health and Care Excellence (NICE) 2015
(http://www.nice.org.uk/guidance/indevelopment/gid-CGWAVE0663?)
British Committee for Standards in Haematology, 2012-15
(http://www.bcshguidelines.com/4_haematology_guidelines.html?Dtype=
Transfusion&dpage=0&sspage=0&ipage=0#gl)
Practice Guidelines for Peri-operative Blood Management – American
Society of Anesthesiologists (http://anesthesiology.pubs.asahq.org/
article.aspx?Articleid=2088825)
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Management of severe perioperative bleeding – Guidelines from
the European Society of Anaesthesiology (2013) (http://anest-rean.lt/wpcontent/uploads/2013/05/Management_of_severe_perioperative_bleeding_.
2.pdf)
Network for the Advancement of Patient Blood Management,
Haemostasis and Thrombosis
(NATA) (http://www.nataonline.com)
National Blood Authority Australia PBM Guidelines (http://
www.blood.gov.au/pbm-guidelines)
26 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

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The use of blood components
and their alternatives 2016
Published by
The Association of Anaesthetists of Great Britain & Ireland
July 2016

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. AAGBI
guidelines: the use of blood components and their alternatives 2016
Anaesthesia 2016; 71: 829-842.
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.13489/full

Guidelines
AAGBI guidelines: the use of blood
components and their alternatives 2016
A. A. Klein, 1 P. Arnold, 2 R. M. Bingham, 3 K. Brohi, 4 R. Clark, 5
R. Collis, 6 R. Gill, 7 W. McSporran, 8 P. Moor, 9 R. Rao Baikady, 10
T. Richards, 11 S. Shinde, 12 S. Stanworth 13 and T. S. Walsh 14
1 Consultant, Department of Anaesthesia and Intensive Care, Papworth
Hospital, Cambridge, UK and Chair, AAGBI Working Party
2 Consultant, Department of Paediatric Anaesthesia, Alder Hey
Children’s Hospital, Honorary Lecturer, University of Liverpool,
Liverpool, UK
3 Consultant, Department of Paediatric Anaesthesia, Great Ormond
Street Hospital for Children, London, UK
4 Professor, Centre for Trauma Sciences, Barts Health NHS Trust and
Queen Mary University of London, London, UK
5 Specialist Trainee, Department of Anaesthesia, Glasgow Royal
Infirmary, Glasgow, UK and Group of Anaesthetists in Training
6 Consultant, Department of Anaesthesia, University Hospital of Wales,
Cardiff, UK and Obstetric Anaesthetists’ Association
7 Consultant, Department of Anaesthesia, University Hospital Southampton,
UK, Royal College of Anaesthetists and Association of Cardiothoracic
Anaesthetists
8 Transfusion Practitioner, The Royal Marsden Hospital, London, UK
9 Consultant, Department of Anaesthesia, Derriford Hospital, Plymouth,
UK and Defence Anaesthesia representative
10 Consultant, Department of Anaesthesia, The Royal Marsden Hospital,
London, UK
11 Professor, Division of Surgery and Interventional Science, University College
Hospital, London, UK and Royal College of Surgeons
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.

Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
12 Consultant, Department of Anaesthesia, Southmead Hospital, Bristol,
UK and Honorary Secretary, AAGBI
13 Consultant, Department of Haematology, Oxford Radcliffe Hospitals,
Oxford, UK, and NHS Blood and Transplant
14 Professor, Department of Anaesthetics, Critical Care and Pain
Medicine, Edinburgh University, Edinburgh, UK
Summary
Blood transfusion can be life-saving. Anaesthetists regularly request and
administer blood components to their patients. All anaesthetists must be
familiar with indications and appropriate use of blood and blood components
and their alternatives, but close liaison with haematology specialists
and their local blood sciences laboratory is encouraged.
Considerable changes in approaches to optimal use of blood components,
together with the use of alternative products, have become apparent
over the past decade, leading to a need to update previous
guidelines and adapt them for the use of anaesthetists working throughout
the hospital system.
....................................................................................................
Endorsed by the Royal College of Anaesthetists and the Network for
Advancement of Transfusion Alternatives (NATA).
Keywords: anaemia and coagulation, blood crossmatch, FFP indications,
major haemorrhage, transfusion
Accepted: 11 March 2016
Recommendations
1 All patients should have their haemoglobin concentration (Hb)
measured before listing for major elective surgery.
2 Patients who are anaemic by the World Health Organization definition
(Hb men < 130 g.l
1 , women < 120 g.l
1 ) should be investigated
before elective surgery and treated appropriately, and elective
non-urgent surgery other than caesarean section should be delayed.
3 Where blood transfusion is anticipated, this and alternatives to
transfusion should be discussed with the patient before surgery, and
this should be documented.
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
4 Red blood cells should be transfused one unit at a time, and the
patient’s Hb should be checked before each unit transfused, unless
there is ongoing bleeding or a large deficit that needs correcting.
5 The use of intra-operative cell salvage and tranexamic acid administration
should be considered in all non-obstetric patients where blood
loss > 500 ml is possible and in traumatic and obstetric major haemorrhage.
6 Blood components should be prescribed for small children by volume
rather than number of units.
7 Every institution should have a massive transfusion protocol which is
regularly audited and reviewed.
8 Group O red cells for transfusion should be readily available in the
clinical area, in case haemorrhage is life-threatening. Group-specific
red cells should be available within a very short time
(15–20 min) of the laboratory receiving correctly-labelled samples
and being informed of the emergency requirement for blood.
9 During major haemorrhage due to trauma and obstetrics, consideration
should be given to transfusing red cells and FFP in preference
to other intravenous fluid.
10 Patients who continue to actively bleed should be monitored by pointof-care
and/or regular laboratory tests for coagulation, fibrinogen and
platelet counts or function, and a guide for transfusion should be FFP if
INR > 1.5, cryoprecipitate if fibrinogen < 1.5 g.l
1 and platelets if platelet
count < 75 9 10 9 .l
1 .
What other guidelines are available on this topic?
A number of other guidelines are available, some of which are quite recent,
but none cover the breadth of UK anaesthetic practice (Appendix 1).
Why was this guideline developed?
There is a need for a relevant up-to-date clinical guidance for practising
UK anaesthetists, critical care staff and those from other specialities and
backgrounds, based on evidence where possible and with a focus on
safety.
How and why does this publication differ from
existing guidelines?
This is an updated guideline that also brings three previous AAGBI
guidelines together (blood component therapy, 2005; massive haemorrhage,
2010; and red cell transfusion, 2008).
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Introduction
Transfusion medicine is changing rapidly in response to new developments.
Considerable changes in approaches to transfusion, together with
the use of alternative agents, have become apparent over the past decade.
Blood transfusion can be life-saving, but this is a scarce and costly
resource. There is increased focus on appropriate transfusion practice to
ensure quality of service provision, and transfusion has been proposed
as a quality indicator in surgical care. Blood transfusion usage remains
high, particularly in trauma, obstetrics, critical care and cardiovascular
surgery.
Anaesthetists are frequently involved in transfusion decisions, the
administration of blood and blood components and as part of the team
managing any major haemorrhage. However, the use of allogeneic blood
components has serious implications and warrants careful consideration
[1]. As a consequence, there has recently been an expansion of interest
in safeguarding and checklists, blood conservation, preservation techniques,
coagulation profiling and the use of haemostatic agents. Appropriate
use of blood components in patient care is of utmost importance.
Several recent major research publications that have looked at transfusion
practice were aimed at patient safety, outcomes and individualised
care, including: use of restrictive transfusion protocols; adjuvant
therapies; substitution of blood components with pooled factor concentrates;
and use of point-of-care (POC) testing to target specific component
use (see http://onlinelibrary.wiley.com/doi/10.1111/anae.2014.70.
issue-s1/issuetoc).
It is essential that our practice of blood transfusion is safe and
based on current, scientific, evidence-based knowledge. A multidisciplinary
approach that aims to benefit patients by the reduction in inappropriate
transfusions is paramount. This working party aims to
formalise guidance on the clinical indications and risks of transfusion,
blood conservation and the transfusion process.
Patient blood management
Patient blood management is a patient-based approach aimed at reducing
the utilisation of blood transfusion and improving the patient’s clinical
outcome and safety, and focuses on the optimisation of three factors
peri-operatively: patient, surgical and anaesthetic. It has been recommended
as a standard of care in the UK National Health Service [2]. It
focuses on three ‘pillars’ of care in surgical patients: detection and
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
Table 1 Patient blood management – measures that should be taken in
patients who are expected to bleed during surgery.
Pre-operative
-Pre-operative Hb should be measured, recorded and optimised as
required
-Elective surgery should be postponed in patients with untreated anaemia
-Review and consider stopping antiplatelet and anticoagulant medication
seven days before surgery
-Consider minimally invasive or laparoscopic surgical technique
-Point-of-care testing should be available with appropriate training.
Intra-operative
-Position patient carefully to maintain venous drainage
-Use patient warming to maintain temperature > 36°
-Consider cell salvage if blood loss > 500 ml anticipated
-Consider giving tranexamic acid 1 g if blood loss > 500 ml anticipated
-Apply restrictive transfusion threshold (Hb 70–80 g.l
1 depending on
patient characteristics and haemodynamics)
-Consider use of topical haemostatic agents.
Postoperative
-Maintain oxygen delivery, targeting oxygen saturation levels > 95%
-Single unit blood transfusion policy – re-assess Hb concentration and
clinical need between units
-Postoperative drains or cell salvage.
treatment of peri-operative anaemia; reduction of peri-operative blood
loss; and harnessing and optimising the patient-specific physiological
reserve of anaemia [3] (Table 1).
Anaemia
Pre-operative anaemia is common, occurring in up to a third of patients
before surgery, and associated with worse outcomes. All patients should
have their Hb checked before listing for surgery. Patients who are anaemic
(Hb in men < 130 g.l
1 , women < 120 g.l
1 ) should be investigated
and the cause treated appropriately [4]. Patient pathways and pre-assessment
clinics should be established to allow timely and appropriate management,
and elective surgery should be delayed if required [5].
Cell salvage
The use of cell salvage should be considered for high- or medium-risk
surgery in non-obstetric adult patients where blood loss > 500 ml is
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
likely, and in obstetric major haemorrhage. In patients with malignancy
or obstetric haemorrhage, a leucocyte filter must be used. Bacterial contamination
of the surgical field remains a contra-indication. Cell salvage
may also be continued in the postoperative period [6].
Other aspects of patient blood management are discussed throughout
these guidelines.
Process for transfusion
Administering the wrong blood type in error (with the risk of ABO
incompatibility) is the most serious outcome of blood transfusion. Most
of these incidents are due to the failure of the final identity checks carried
out between the patient (at the patient’s side) and the blood to be
transfused. All members of staff involved in the administration of a
blood component must be trained and competency-assessed as per local
policy. Local policy will also stipulate if this is a one- or two-person
bedside check, with each person performing the check independently
[7]. Red cell transfusions must be completed within 4 h of removal from
the blood fridge. All prescriptions for transfusion must be documented
in the patient record, either on the anaesthetic chart or on the drug/
fluid prescription chart. Local policy for confirmation of the transfusion
must be followed – it is a legal requirement that 100% of blood components
must be traceable [8]. Where blood transfusion is anticipated, this
should be discussed with the patient before surgery and valid consent to
receive transfusion should be documented [9]. Patients should be
informed that they have received blood or blood components before discharge
from hospital as they will otherwise be unaware; they should also
be informed that this removes them from the donor pool. It is also
important that the patient’s general practitioner is informed.
The following guidance is for a manual checking process at the bedside;
the preferred system is an electronic transfusion management system.
-The patient must be positively identified. All patients receiving blood
components should be wearing an identification wristband containing
four core identifiers – first name, last name, date of birth and patient
identification number.
-Immediately before the transfusion, check the component next to the
patient, against the prescription.
-Check the four core identifiers on the compatibility label attached to
the blood component with the identification attached to the patient. If
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
there are any discrepancies, do not proceed and call the transfusion
laboratory.
-Check that the compatibility label attached to the blood component
has the same blood group and 14-digit component donation number
(or batch number for coagulation factors) as the sticker on the blood
component.
-Visually check the blood component for any leakage, discolouration or
presence of any clots or clumps.
-Check the expiry date and time.
Transfusing an unidentified patient
All hospitals should have a clear local policy for transfusion of patients
whose identity is unknown. In emergency situations or where the
patient cannot immediately be identified, the patient should still have
identification attached stating unknown male or female and a unique
identification number. The blood sample sent to the transfusion laboratory
should contain these exact details.
In the event that the patient’s identity becomes known, new identification
must be attached to the patient and a new transfusion sample
collected and fully labelled with the known patient’s details.
Monitoring for adverse events or reactions during transfusions
Clinical observations should include heart rate, blood pressure, temperature
and respiratory rate, as per local guidelines (national guidelines
define a minimum of pre-transfusion, at the end of transfusion and 15
min after transfusion). If there are any signs of a transfusion reaction,
such as tachycardia, rash, breathlessness, hypotension or fever, stop the
transfusion and contact the laboratory immediately [10]. Management
may include the administration of antihistamine or steroid drugs, or
intramuscular/intravenous adrenaline if life-threatening [11]. Diagnosis
of a transfusion reaction during ongoing haemorrhage may be difficult,
but if concern arises, the documentation should be double-checked for
administration errors and further analyses performed as per local protocols.
Transferring blood with a patient
Blood components should be transferred with patients at high risk of
requiring transfusion en route or immediately on arrival. There should
be effective communication between the blood transfusion laboratories
involved, according to regional policy. Blood components must be
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
transported in a storage box suitable to maintain their integrity, along
with accompanying paperwork, and careful handover is required. When
the patient arrives at their destination, the receiving transfusion laboratory
should be immediately informed that blood was transported. The
patient should be issued with a new identity wristband, a new sample
taken for cross-match and more blood issued; until this is available,
blood transferred with the patient may be administered if required.
Red blood cell transfusion
Red blood cell (RBC) transfusion is potentially life-saving for the treatment
of blood loss (Major haemorrhage – see next section). In patients
who do not have active bleeding and in normovolaemic patients, the Hb
should be measured before and after every unit of RBC transfused. Nearpatient
measurement of Hb may be particularly useful, but laboratory
measurement remains the gold standard. Haemoglobin concentration is
dependent on both red cell mass and plasma volume; it may fall due to
haemodilution due to intravenous fluid administration. In the bleeding
patient, haemoglobin concentration may remain falsely elevated despite
significant blood loss due to inadequate fluid resuscitation.
Other potential indications for RBC transfusion are clinical signs
and biochemical markers of inadequate oxygen delivery, such as elevated
blood lactate concentration, a low Ph and low central or mixed venous
oxygen saturation.
Optimum haemoglobin transfusion trigger
Recent publications comparing more liberal transfusion strategies (typical
transfusion trigger Hb 90–100 g.l
1 ) with more restrictive strategies
(typical transfusion trigger Hb 70–80 g.l
1 ) did not show any difference
in patient outcomes [12, 13]. Therefore, a general Hb threshold of
70 g.l
1 should apply as a guide for red cell transfusion. Uncertainty
remains for patients with ischaemic heart disease, including acute coronary
syndrome and after cardiac surgery [14], and higher thresholds
(80 g.l
1 ) may be more appropriate in such circumstances.
Major haemorrhage
Major haemorrhage is variously defined as loss of more than one blood
volume within 24 h (around 70 ml.kg 1 , > 5 l in a 70 kg adult); 50%
of total blood volume lost in < 3 h; or bleeding in excess of
150 ml.min 1 . A pragmatic clinically-based definition is bleeding which
leads to a systolic blood pressure of less than 90 mm Hg or a heart
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
rate of more than 110 beats.min 1 . Major haemorrhage is a significant
cause of mortality and morbidity in the peri-operative setting. Appropriate
and effective management integrates multiple factors, including:
recognition; communication; timely delivery of blood products; and
application of definitive modalities of treatment (surgery and interventional
radiology) [15].
Major haemorrhage protocol
Policies should be defined in an institutional major haemorrhage protocol.
Activation of a protocol should result in the immediate release and
administration of blood components for initial resuscitation, without
prior approval from a haematologist. Such protocols perform best when
specific to clinical areas such as the emergency department or the labour
ward, and are designed to include robust and clearly understood activation
and communication from bedside to laboratory. Their activation
should also mobilise other resources, such as additional (senior) staff
including portering, blood warmers, pressure infusers and cell salvage
devices [16].
A clear mechanism for the escalation of a team response and for
identifying individuals with sufficient seniority and experience to undertake
the key roles of team leader (senior anaesthetist) and co-ordinator
is essential to the process, as is enabling a single point of contact with
the laboratory and other support services.
Initial resuscitation
Most major haemorrhage packs will contain four units of RBCs and
four units of FFP (equivalent to 15–20 ml.kg 1 in a standard adult);
platelet concentrate may also be provided. Administration should be via
wide-bore intravenous access, or intra-osseous access until the former
can be obtained.
Group O red cells should be readily available and transfused if
haemorrhage is life-threatening. It is essential to give group O Rh-negative
red cells to children and women of childbearing potential, but
group O Rh-positive red cells may be used in adult men.
Group-specific red cells should be rapidly made available (within
15–20 min) by the laboratory after receiving a correctly labelled blood
group sample and being informed of the emergency requirement for
blood. Emergency Group O red cells should continue to be provided
where timely and safe issue of group-specific red cells is not possible.
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Haemostatic resuscitation
This describes the process of restoring and sustaining normal tissue perfusion
with the emphasis on preservation of effective clotting. Coagulopathy
is associated with haemorrhage (consumption) and transfusion
of blood products (dilution), as well as mechanism of injury in trauma;
this may exacerbate the haemorrhage and resultant morbidity. Point-ofcare
or laboratory testing should be used to guide management.
During resuscitation, the following should be prevented/treated:
hypothermia; acidosis; hypocalcaemia (aim for ionised calcium
> 1.0 mmol.l
1 ); and hyperkalaemia.
Special situations
Critical care
Anaemia is prevalent during critical illness. In addition to blood loss and
sampling, haemodilution and impaired erythropoiesis may be important
contributors [17]. Patients with anaemia demonstrate biochemical abnormalities
similar to those with chronic inflammatory diseases.
Although biochemical markers of tissue hypoxia, notably blood
lactate concentration, are frequently elevated, evidence does not support
increasing oxygen delivery with RBC transfusion when the Hb is
> 70 g.l
1 , unless the patient has cardiac disease [18].
One important group of patients admitted to ICU are patients with
haematological malignancies. Overall, patients with cancer form one of
the larger groups of recipients of blood components. However, unlike
other patient groups, the anaemia in patients with haematological malignancies
reflects an underlying bone marrow failure, and therefore, it is
unclear to what extent findings from the majority of randomised trials
conducted in surgery or general critical care can be extrapolated to cancer,
although the same broad principles of restrictive use of red cells commonly
apply (70–80 g.l
1 for red cell transfusion).
Obstetrics
Estimating blood loss at delivery is notoriously difficult, and every effort
should be made to directly measure abnormal bleeding across all settings
in the delivery suite [19]. Early recognition of bleeding by changing
bed linen and pads immediately after delivery and systematically
weighing new blood-soaked pads correlates with the fall in Hb concentration
and improves outcome.
As soon as abnormal bleeding is recognised, > 500 ml after a vaginal
delivery and > 1000 ml after a caesarean delivery, the obstetrician,
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
anaesthetist and senior midwife should attend the mother. Blood should
be taken for full blood count (Hb), clotting studies, group and screen,
and a venous blood gas for rapid Hb measurement and lactate
(> 2 mmol.l
1 is an indicator of shock). Cell salvage is recommended if
abnormal bleeding occurs during caesarean section, and a leucocyte filter
should be used for autotransfusion of processed blood.
Severe early consumptive coagulopathy is associated with abruption,
amniotic fluid embolus and severe bleeding with pre-eclampsia. Early
use of FFP before RBC may be required.
Postpartum haemorrhage associated with atony or trauma is unlikely
to be associated with haemostatic impairment unless the diagnosis is
delayed. Protocol-led use of blood products will lead to overtransfusion of
FFP in the majority of cases [20]. If coagulation tests are not known, then
FFP should be withheld until four units of RBC have been given. If no
coagulation results are available and bleeding is ongoing, then, after four
units of RBC, four units of FFP should be infused and 1:1 ratio of RBC–
FFP transfusion maintained until the results of haemostatic tests are
known. Point-of-care (POC) testing is recommended in this setting [21].
Hypofibrinogenaemia, below normal levels for pregnancy, predicts
the risks of ongoing postpartum haemorrhage. The normal plasma fibrinogen
concentration in pregnancy is 4–6 g.l
1 , and a laboratory Clauss
fibrinogen of < 3 and especially < 2 g.l
1 , with ongoing bleeding, is associated
with progression to major obstetric bleeding [22]. Fibrinogen
replacement with cryoprecipitate or fibrinogen concentrate should be considered
in these circumstances, if there is bleeding.
Monitoring of haemostatic function in obstetric haemorrhage is particularly
important; laboratory testing is often too slow during obstetric
haemorrhage, and therefore, POC testing is preferred. Tests should include
plasma fibrinogen concentration or POC equivalent [21]. With ongoing
bleeding, any abnormalities should be treated, as this indicates significant
haemostatic impairment in the obstetric patient. Platelet transfusions are
rarely required and should only be given once the platelet count is known.
Tranexamic acid reduces total blood loss and should be given if
postpartum haemorrhage is severe (> 500 ml after a vaginal delivery
and > 1000 ml after a caesarean delivery), at an initial dose of 1 g.
Paediatrics
There is little direct evidence to guide the use of blood products in children,
and generally the guidance intended for adults can be safely
applied to children with some modifications (specifically in transfusion
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
volumes). ‘Restrictive’ approaches to transfusion are appropriate for
almost all children older than 3 months of age. Higher transfusion
thresholds are often applied to neonates and children with congenital
heart disease. Although thresholds are not clearly defined, there is evidence
that quantities of transfusion can be reduced in these patients by
applying moderately restrictive thresholds for transfusion without
adverse effect on outcome [23, 24]. Neonates should receive components
specified for neonatal use, including cytomegalovirus-negative blood
products.
The volume of blood to be administered requires modification
depending on the size of the patient. It is recommended that blood in
children should be prescribed in volume rather than number of units.
In practice, sensible rounding to the nearest unit will be more efficient.
• A transfusion of 10 ml.kg 1 of RBC should increase Hb by approximately
20 g.l
1 .
• Cryoprecipitate should be given in a dose of 5–10 ml.kg 1 .
• Platelets should be given in a dose of 10–20 ml.kg 1 .
• Fresh frozen plasma may be given in doses of 10–15 ml.kg 1 .
Tranexamic acid can be used in children: a loading dose of 15 mg.kg 1
followed by infusion 2 mg.kg 1 .h 1 should be used in trauma [25].
With technical refinements, cell salvage can be useful in children,
even if the absolute volume of blood loss is less than 500 ml [26].
Major haemorrhage is rare in children outside of highly specialist
areas of practice. The guidance suggested for adults can be generally
applied, though requires an awareness of the size of the child and the
clinical context of the bleeding. Blood volume of a child is estimated at
70 ml.kg 1 but may be as high as 100 ml.kg 1 in newborns. Devices for
vascular access and rapid administration of blood should be appropriate
for the size of the child and rate of blood loss. Children are at particular
risk of electrolyte imbalance and hypothermia during rapid administration
of blood products.
Trauma
During active bleeding, follow the principles of damage control resuscitation:
Early haemorrhage control
Ensure clinical treatment is constantly directed towards haemorrhage
control. Use temporary haemostatic devices (pressure, tourniquets, etc.)
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
followed as soon as practically possible by surgery or interventional
radiological control of haemorrhage.
Permissive hypotension
Do not try to normalise blood pressure during active haemorrhage.
Maintain a minimum acceptable preload and blood pressure with volume
resuscitation alone; this may need to be modified in the presence
of trauma in head and spinal injuries. The use of vasopressors should
be avoided during active haemorrhage.
Avoid crystalloid and colloid administration
During uncontrolled haemorrhage, avoid clear fluids for volume resuscitation
unless there is profound hypotension and no imminent availability
of blood products.
Target trauma-induced coagulopathy
Deliver blood products empirically at first, and use laboratory or pointof-care
tests of coagulation to guide therapy as soon as available [27].
Give tranexamic acid 1 g immediately, but avoid if more than 3 h
after injury, unless there is ongoing evidence of hyperfibrinolysis (as
suggested by POC testing).
Whilst haemorrhage is being controlled, administration of RBC and
FFP in a ratio of 1:1 should be used to replace fluid volume [28]. Consider
the administration of cryoprecipitate (two pools) and platelets (one
adult therapeutic dose) until test results are available and bleeding is
controlled. Once control is achieved, blood components should be
administered as guided by testing at the earliest opportunity (see Monitoring
section, blood components).
Cardiac surgery
Anaemic patients have an increased risk of mortality and complications
following cardiac surgery [29]. Elective cardiac surgery should not be
undertaken in an anaemic patient without prior investigation and treatment
as considered necessary.
Viscoelastic testing is recommended to guide transfusion [30]. The
use of local transfusion protocols guided by point-of-care testing may
lead to appropriate transfusion with reduced costs. The evidence base
for the efficacy of fresh frozen plasma is minimal and of poor quality
[31].
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
The effect of cardiopulmonary bypass on platelet function may
make the use of a higher platelet count (> 75 9 10 -9 .l
1 ) necessary after
bypass.
There is no clear evidence of the benefit of platelet function analysis
except in those patients who have taken PY12 receptor inhibitors such
as clopidogrel within 5 days of surgery [32].
Monitoring
Laboratory testing
Traditional tests such as APTT and PT/INR have been standardised for
the monitoring of anticoagulants and are designed to diagnose and
manage factor deficiencies such as haemophilia. Standardisation within
laboratories has made the results very reliable.
The PT and APTT were not designed to monitor coagulation deficiencies
during haemorrhage and suggested INR and APTT ratios or
triggers, which are widely quoted to guide coagulation product replacement,
are based on small historic studies that have little relevance today.
Slow turnaround time also means that the results do not reflect the
dynamic clinical situation during ongoing haemorrhage [33].
Point-of-care testing
Point-of-care testing has a shorter turnaround time and represents a
more global and therefore more relevant reflection of coagulation status
[34]. Point-of-care testing is increasingly popular for general and
cardiac surgery, trauma units, intensive care and obstetrics. Point-ofcare
testing for Hb concentration is commonly used, such as blood
gas analysis or the HemoCue â (€Angelholm, Sweden), which both correlate
well with laboratory measurements [35]. The activated clotting
time (ACT) is also well validated and should be used routinely whenever
heparin is administered, particularly in cardiac and vascular
surgery.
Targeted blood component therapy based on POC testing has been
shown to be safe and effective, and to decrease blood product usage.
However, there are currently no studies that show improved patient outcome
compared with standard treatment [32].
At the current time, there are two commercially available semi-automated
viscoelastic machines that use similar technology: thromboelastometry
(ROTEM, TEM International, Munich, Germany) and
thromboelastography (TEG, Haemonetics Corp, Braintree, MA, USA).
One manufacturer cannot be recommended above the other.
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
There are no universal algorithms across the specialities, and local
protocols are required based on institutional procedures. There is limited
interchangeability between TEG and ROTEM, and development
and validation of separate treatment algorithms for the two devices are
required [36].
There are concerns about standardisation of both assays with poor
quality control and assurance and a wide variation in results between
centres [37]. It is good practice to pair coagulation samples and send a
second sample for laboratory-based analysis.
Drugs
An increasing number of patients take either anticoagulants or antiplatelet
agents. All patients require careful pre-operative medication optimisation
before surgery. The management of drugs related to antithrombotic therapy
in the peri-operative setting is a common problem, balancing bleeding
risk with thrombosis.
Patients at high risk (> 10% risk of thrombotic events per year)
of thrombosis should be considered for bridging anticoagulation, or
in the following circumstances:
-venous thromboembolic event within the last 3 months, or
-prosthetic (mechanical) heart valve
Bridging anticoagulation usually consists of low molecular weight heparin.
The dose and type of the low molecular weight heparin depends on the
patient’s weight, timing of surgery, type of procedure and thrombotic risks.
Warfarin (Vitamin K antagonist)
The international normalised ratio (INR) is used to monitor the effectiveness
of warfarin. In most situations, INR is maintained between 2.0
and 2.5.
The peri-operative management of warfarin is summarised in
Table 2. In patients with atrial fibrillation on warfarin, routine use of
bridging anticoagulation with low molecular weight heparin before surgery
is not recommended.
For emergency reversal of warfarin, prothrombin complex concentrate
(PCC) 50 IU.kg 1 is recommended. Intravenous vitamin K
(10 mg) may also be given, but this may preclude re-warfarinisation
for a number of days. Fresh frozen plasma is an alternative if PCC
is not available [37], but should not be used as elective prophylaxis
in patients taking warfarin.
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Table 2 Peri-operative optimisation of warfarin anticoagulation for
major surgery. Bridging with LMWH required for high-risk patients,
patients who suffered recent thromboembolic events or patients with
mechanical prosthetic heart valves.
Day 5 Days 4, 3, 2 Day 1 Surgery Postoperative
Last dose of
warfarin.
Treatment dose LMWH
(consider Vitamin K if
INR > 2.5
Half treatment
dose LMWH
Omit
LMWH.
Check
INR
Prophylactic
LMWH until
warfarin is
commenced.
INR, international normalised ratio; LMWH, low molecular weight heparin.
Novel oral anticoagulants
Novel oral anticoagulants have more predictable pharmacodynamics and
a faster onset of action with a shorter half-life than warfarin. There are
currently three drugs on the market; these are increasingly used for
management of patients with atrial fibrillation; after stroke and transient
ischaemic attacks; and prophylaxis/management of venous thromboembolism
[38].
Their half-life varies, especially in the presence of renal impairment.
Currently, there are no specific routine coagulation tests to determine
their effectiveness. Regarding antidotes, the United States Food and
Drug Administration and the European Commission have recently
approved the first of these, idarucizumab (Praxbind, Boehringer Ingelheim
International, Ingelheim am Rhein, Germany), for the emergency
reversal of dabigatran; other antidotes are currently undergoing clinical
trials.
Dabigatran is a direct thrombin inhibitor. Half-life depends on
extent of renal impairment (normally 48–72 h). For major elective surgery,
neuraxial blockade and in patients with renal dysfunction, the drug
should be stopped 5 days before surgery. For others, it can be stopped
3 days before surgery.
Rivaroxaban and apixaban are direct factor Xa inhibitors. Half-life
is 5–13 h and is less dependent on renal function. For major elective
surgery, neuraxial blockade and in patients with renal dysfunction, the
drug should be stopped 3 days before surgery, otherwise stop 24–48 h
before surgery.
If surgery is urgent, consider PCC 50 IU.kg 1 , correct other abnormal
coagulation tests and check platelets. Bridging anticoagulation is not
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
required except in patients with recent (< 3 months) history of pulmonary
embolism or deep venous thrombosis.
Antiplatelet drugs
These drugs cause irreversible inhibition of platelets; replenishment of
platelets occurs at a rate of 10–15% per day. The restoration of normal
platelet function depends on the individual drug and dosage.
Aspirin inhibits the production of thromboxane. It should be continued
for most procedures until the day before surgery. In patients at
low risk of cardiovascular events having major surgery and those undergoing
high-risk procedures such as intracranial surgery, aspirin should
be discontinued 5 days before the procedure.
Clopidogrel is an oral, thienopyridine-class antiplatelet agent, and
the active metabolites circulate for up to 18 h after the last dose. Clopidogrel
should be stopped 7 days before surgery unless point-of-care testing
is used to check platelet function.
The drugs prasugrel and ticlopidine are also thienopyridine-class
antiplatelet drugs similar to clopidogrel. The same recommendations as
for clopidogrel apply to the above drugs.
Antiplatelet drugs and non-cardiac surgery in patients with
coronary stents
The management of these drugs in patients with coronary stents in situ
depends on the type of stent, time after the coronary event and surgery
type (major vs minor). Communication with the cardiology team is key.
Elective surgery should be postponed for at least 4–6 weeks after
bare metal stent implantation and 6 months after drug-eluting stent
implantation. Aspirin may be continued during the peri-operative
period except in closed space surgery such as intracranial and spinal
surgery.
For emergency surgery, management depends on the antiplatelet
agent and when the last dose was taken. Platelet transfusion should be
reserved as an additional measure for critical bleeding.
Drugs that decrease blood loss
Tranexamic acid is a synthetic derivative of the amino acid lysine that
inhibits plasminogen activation, thus preventing impairment of fibrinolysis.
In the last few years, there is increased evidence that its use may reduce
bleeding in trauma, cardiac surgery and other major surgery. Seizures have
been reported when high doses are given, but there is little evidence of
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
other side effects [39]. Dose is variable, but 1 g bolus is recommended,
and an additional infusion of 500 mg.h 1 may also be considered [40].
Aprotinin is a serine protease inhibitor antifibrinolytic which acts
by inactivating free plasmin. The drug was withdrawn from the market
in 2007 due to safety issues with increased incidence of renal impairment
and anaphylactic reactions. Recently, regulators have licensed the
drug only for myocardial revascularisation (coronary artery bypass surgery)
[41].
Blood components
Before administration of any blood component, the patient’s details
should be checked against those on the bag (see red blood cell transfusion
section). Blood components have specific storage and expiry times.
Every effort must be made to avoid wastage.
In haematological malignancy, the clinical team must be consulted
before administering blood components because of the need for specific
requirements. The transfusion threshold may be different to non-haematological
patients. A small number of patients require transfusion with
irradiated blood components to prevent them developing transfusionassociated
graftversus-host
disease (TA-GVHD), which is rare, but usually fatal. Patients
with the following conditions require irradiated blood: congenital immunodeficiency
states, for example Di-George’s syndrome; allogeneic bone marrow
transplant recipients and donors; autologous bone marrow-transplanted
patients; Hodgkin’s lymphoma; purine analogue therapy including new
agents clofarabine and bendamustine; and patients who receive antithymocyte
globulin (anti-CD52) therapy (alemtuzumab) [42].
Fresh frozen plasma
Fresh frozen plasma is leucodepleted plasma rapidly frozen to below
25 °C to maintain the integrity of labile coagulation factors. The use
of FFP has increased significantly in the past few years [38]. Given that
anti-HNA and anti-HLA antibodies occur at higher frequency in multiparous
women, implementation of male-only plasma in component therapy
began in the UK in 2003, and this has reduced the incidence of
transfusion-related acute lung injury (TRALI) [43].
Fresh frozen plasma can be thawed using a dry oven (10 min),
microwave (2–3 min) or in a water bath (20 min). Thawed FFP can be
used for up to 24 h as long as it is stored at 4 °C. This time has
recently been extended to 5 days when stored at 4 °C for use in major
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
haemorrhage associated with trauma. Once out of the fridge, it must be
used within 30 min, and once thawed, it should never be refrozen.
Approximate volume per bag is 300 ml.
Fresh frozen plasma contains all the factors of the soluble
coagulation system, including the labile factors V and VIII to a varying
degree. The fibrinogen content of four units of FFP is approximately
2 g, compared with approximately 4 g fibrinogen in two pools of
cryoprecipitate.
Fresh frozen plasma should be the same group as the patient. If the
blood group is unknown, group AB FFP is preferred, as it does not contain
any anti-A or anti-B. If group O FFP is given to non-group O children,
it should be high-titre (HT) negative. The recommended
therapeutic dose is 15 ml.kg 1 .
To reduce the risk of variant Creutzfeldt–Jakob disease, FFP for use
in all those born in 1996 or later is sourced outside of the UK and has
undergone viral inactivation (either with methylene blue or solvent
detergent treatment).
Indications for FFP use include the following:
• replacement of coagulation factors during major haemorrhage, particularly
trauma and obstetrics;
acute disseminated intravascular coagulation (DIC) with bleeding;
• in patients who are actively bleeding and whose INR is > 1.5 (or
POC equivalent);
• immediate reversal of warfarin-induced haemorrhage when PCC is not
available (PCC is the first choice);
• thrombocytopenic purpura usually with plasmapheresis preferably
using pathogen-inactivated FFP; and
• replacement of coagulation factors when specific factors are not
available (uncommon).
There is a very limited role for FFP in the management of (mild–
moderate) coagulation abnormalities frequently seen in many nonbleeding
critically ill patients before invasive procedures. Fresh frozen
plasma is not recommended for routine use in patients with cirrhosis/
liver disease unless significant coagulopathy is identified, as again current
understanding indicates that isolated abnormalities of the PT or
APPT do not reflect a ‘balanced haemostasis’. Fresh frozen plasma
should not be used simply as routine circulatory volume replacement.
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Cryoprecipitate
Cryoprecipitate is also a leucodepleted plasma product containing concentrated
factor VIII, von Willebrand factor, fibrinogen, factor XIII and
fibronectin, produced by further processing of FFP. It is stored
at 25 °C; once thawed for administration, it can be kept at ambient
temperature for 4 h, and should not be kept in the fridge again [42].
In the UK, it is mainly available as pooled bags of five units, 100–
200 ml per bag. It is also available as one unit of 20–40 ml. Each single unit
has 400–450 mg of fibrinogen, and pools of five units contain at least 2 g.
The adult dose is two pools; transfuse using a standard blood giving
set with a 170- to 200-lm filter.
Indications for cryoprecipitate include the following:
• hypofibrinogenaemia due to major haemorrhage and massive transfusion.
There is increased use of cryoprecipitate in major trauma,
obstetric haemorrhage
and cardiac surgical bleeding. During major haemorrhage,
fibrinogen should be maintained > 1.5 g.l
1 , except in active obstetric
haemorrhage where fibrinogen should be maintained > 2 g.l
1 ;
combined liver and renal failure with bleeding;
bleeding associated with thrombolytic therapy;
• disseminated intravascular coagulation with fibrinogen < 1.0 g.l 1 ;
and
• advanced liver disease, to maintain fibrinogen level > 1.0 g.l 1 .
Cryoprecipitate for use in all those born in 1996 or later is made
from FFP sourced outside of the UK and has undergone viral inactivation
with methylene blue. These components are available as single units
for smaller children and pooled units for older children and young
adults.
Platelets
Platelets are either made from pooled buffy coat-derived platelets from
four whole blood donations, suspended in platelet additive solution and
the plasma of one of the four donors (who is male), or as an adult therapeutic
dose obtained from a single donor by apheresis donation. Both
can be used interchangeably; NHSBT recommends that recipients born
on or after 1st January 1996 should receive apheresis donation platelets
where possible.
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Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
There is increased use of platelets in the last few years. The greatest
demand is for haemato-oncology patients; platelets should not be
administered to patients with chemotherapy-induced thrombocytopenia
in the absence of bleeding, unless their platelet count is < 10 9 10 9 .l
1 .
The risk of transmission of bacterial infection (1 in 12,000) is higher
than other blood components because platelets are stored at 22 °C. This
risk is reduced by bacterial screening before release.
Platelets do not have to be the same group as the patient, but where
group O platelets are given to a non-group O child they should be selected
to be high-titre negative. D-negative children and women of childbearing
potential should receive D-negative platelets because of the small risk of
developing immune anti-D.
Platelet concentrate should be stored at 22 °C with constant gentle
agitation in an approved incubator. Platelets must not be placed in a
refrigerator. Transfusion should ideally be commenced within 30 min of
removal from the platelet storage incubator. Each pack contains 250–
350 ml; platelet count in the pack is > 2.4 9 10 10 .l
1 per adult dose,
and transfusion should lead to an increase in the patient’s platelet count
by approximately 30 9 10 9 .l
1 . The patient’s platelet count should be
repeated after transfusion.
A standard adult therapeutic dose should be infused over a period of
30 min through a standard blood administration set or platelet administration
set incorporating a 170- to 200-lm filter. Do not give through a set
that has already been used for red cells. No drugs should be added directly
to the unit of platelets.
Indications for platelets include the following:
• prevention and treatment of bleeding due to thrombocytopenia or
platelet function defects.
• If patient is actively bleeding, transfuse to a platelet count
> 75 9 10 9 1
.l
If not bleeding, the following triggers should be applied:
routine prophylactic use: 10 9 109 .l
1 ;
• prophylactic use with additional risk factors (e.g. Sepsis):
10 – 20 9 10 9 .l
1 ;
other major surgery or invasive procedures: 50 9 109 .l
1 ;
• neuraxial blockade: 50 9 109 .l
1 ; and
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Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
• prophylactic use in closed compartment surgery (eye, brain):
100 9 10 9 .l
1 .
In the UK, the availability of platelets is centralised and will depend
on the demand and distance from nearest blood centre. Clinicians need
to be aware of local laboratory arrangements and normal time interval
for obtaining platelets from central storage.
Special blood components
Prothrombin complex concentrate
Prothrombin complex concentrate (in the UK) comes as four-factor
concentrate containing factors II, VII, IX and X, with protein S, C and
heparin. It can be rapidly reconstituted providing a high concentration
of these four clotting factors in a small volume. It is indicated in
acquired factor deficiency and for urgent reversal of warfarin. There is
limited evidence for use in any other setting.
Fibrinogen concentrate
There has been considerable interest in fibrinogen concentrate. It is
widely used in mainland Europe in the management of bleeding following
surgery or trauma. Recent trials in cardiac surgery have not shown
any benefit from its use. It is only licensed for use in congenital
hypofibrinogenaemia in the UK.
Recombinant factor viia
Licensed for use in haemophiliacs with inhibitors. It is the most potent
thrombin generator available at present. Late use in the exsanguinating
patient is almost always associated with no benefit, a high risk of mortality
and thrombotic complications. Following cardiac surgery, it has
been shown to reduce re-operation rates and transfusion in the bleeding
patient. However, its use may increase the risk of thrombotic complications
and its use except under haematological direction cannot be recommended
[44].
Acknowledgements
AK is the Editor-in-Chief of Anaesthesia, and has received research
funding and honoraria from Pharmacosmos and CSL Behring. RB has
received educational support from Pharmacosmos. RG has received honoraria
from CSL Behring and Octapharma. TR has received research
funding and honoraria from Vifor Pharma and Pharmacosmos. RC has
22 © 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland

Klein et al. | AAGBI blood transfusion guidelines 2016 Anaesthesia 2016
received research funding from CSL Behring and TEM International.
No other conflicts of interest declared.
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Appendix 1
Other available guidelines.
National Institute for Health and Care Excellence (NICE) 2015
(http://www.nice.org.uk/guidance/indevelopment/gid-CGWAVE0663?)
British Committee for Standards in Haematology, 2012-15
(http://www.bcshguidelines.com/4_haematology_guidelines.html?Dtype=
Transfusion&dpage=0&sspage=0&ipage=0#gl)
Practice Guidelines for Peri-operative Blood Management – American
Society of Anesthesiologists (http://anesthesiology.pubs.asahq.org/
article.aspx?Articleid=2088825)
© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd
on behalf of Association of Anaesthetists of Great Britain and Ireland 25

Anaesthesia 2016 Klein et al. | AAGBI blood transfusion guidelines 2016
Management of severe perioperative bleeding – Guidelines from
the European Society of Anaesthesiology (2013) (http://anest-rean.lt/wpcontent/uploads/2013/05/Management_of_severe_perioperative_bleeding_.
2.pdf)
Network for the Advancement of Patient Blood Management,
Haemostasis and Thrombosis
(NATA) (http://www.nataonline.com)
National Blood Authority Australia PBM Guidelines (http://
www.blood.gov.au/pbm-guidelines)
26 © 2016 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
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

The Anaesthesia Team
3
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org May 2010

Membership of the working party
(details correct at the start of the working party process)
Dr R J S Birks
Dr V R Alladi
Ms J Angell
Dr R Broomhead
Prof W A Chambers*
Dr R Griffiths
Prof C M Kumar
Dr I H Wilson
Chairman and AAGBI President
Council Member, AAGBI
PA(A) Representative, RCoA
GAT representative
Vice President, AAGBI
Council Member, AAGBI
Council Member, RCoA
Honorary Treasurer, AAGBI
This guideline has been seen and approved by the Council of the
AAGBI.
The working party acknowledges the assistance of Ms Diane Gilmour (AfPP),
Mr Bill Kilvington (CODP) and Dr David Whitaker (AAGBI Immediate Past
President).
*Prof Chambers is chair of the PA(A) project steering group run by NHS
Education for Scotland.
1

Contents
1. Recommendations 3
2. Introduction 4
3. Organisation and management 5
4. Pre-operative assessment 7
5. The operating department 8
6. Recovery post-anaesthetic care unit (PACU) 14
7. Postoperative pain management 16
References 18
To be reviewed by 2015.
© Copyright of the Association of Great Britain & Ireland. No part of this
book may be reproduced without the written permission of the AAGBI.
2

1. Recommendations
Comprehensive peri-operative care can only be provided by an anaesthesia
team led by consultant anaesthetists. All members of the team must be
trained to nationally agreed standards.
Effective pre-operative assessment of patients for anaesthesia and surgery is
vital in the modern setting. It reduces cancellations, promotes efficient bed
usage and can allay patients’ anxieties. It does not replace the need for the
anaesthetist’s pre-operative visit.
Anaesthetists must have dedicated qualified assistance wherever anaesthesia
is administered, whether in the operating department, the obstetric unit or
any other area.
Recovery (post-anaesthetic care unit) areas must have sufficient numbers of
trained staff available throughout all operating hours. If operating occurs
over the whole of a 24-hour period, the PACU area must be open for the
whole 24 hours.
All acute hospitals providing inpatient surgical services must have an acute
pain team led by a consultant anaesthetist.
The AAGBI supports the concept of common training schemes for operating
department staff that share objectives and lead to the development of
common working practices, pay, conditions and career opportunities.
Close monitoring of the development of the physicians’ assistant (anaesthesia)
role, with particular reference to maintenance of standards, will continue.
Only those who have trained and qualified within a recognised UK
programme should practice in the role.
The AAGBI believes the recommendations in this document should apply to
all nations of the UK.
3

2. Introduction
It is now over 20 years since the Association of Anaesthetists of Great Britain
& Ireland (AAGBI) made recommendations on assistance for anaesthetists.
This was the first development of the anaesthesia team concept. The
team approach has continued to develop even in the five years since this
document was last published.
Anaesthetists increasingly work with non-medical personnel in all aspects
of patient care. These relationships within the team are described in this
document. In the context of this document, the term ‘anaesthetist’ includes
all grades: consultants, SAS grades, specialist doctors and trainees unless
specified.
Pre-operative assessment clinics are now a feature of most hospitals and
trusts. These must be effective and efficient if they are to improve the safety
and quality of patient care.
As this publication goes to press, most trusts/hospitals have put into place the
surgical checking procedures pioneered by the World Health Organization
and endorsed by the National Patient Safety Agency (NPSA), the AAGBI
and others. This should be a routine team discipline afforded to all
patients undergoing surgery and emphasises the importance of teamwork.
Anaesthetic aspects are described in this publication.
Devolution of nations within the UK has led to different emphasis in different
areas of practice and has sometimes hindered the development of uniform
national standards, particularly in the field of assistance for anaesthetists. We
believe uniform standards should be the goal.
The role of physicians’ assistants (anaesthesia) (PA(A)s) is commented upon in
this publication. It is not clear to what extent and how the role of the PA(A)
will develop.
4

3. Organisation and management
Organisation of comprehensive anaesthetic services requires considerable
knowledge, effort and expertise.
Each acute hospital facility should have a designated head of anaesthesia
services responsible for all activities in which anaesthetists are engaged. This
individual will usually be the clinical director and should have managerial
and budgetary control of the service. In some hospitals, the clinical director
of anaesthesia may be responsible for the whole of the operating services.
In some, the department of anaesthesia is part of another directorate. If
this is the case, it is necessary to have an identified lead anaesthetist to
take responsibility for all aspects of the anaesthesia service. For the sake of
simplicity this publication refers to this individual as the clinical director.
Whatever the wider directorate structure, the budget for anaesthesia services
should be controlled by anaesthetists.
The clinical director’s role
The clinical director is responsible to the chief executive for the safety of the
local service. He/she must ensure that the recommended national standards
of staffing and facilities are in place to provide a high quality anaesthesia
service throughout the peri-operative period and in all areas where
anaesthesia is performed.
Sufficient resources must be committed to recruiting and training staff and
to encourage continued professional development to ensure successful
revalidation. The clinical director must be provided with management
support, usually in the form of a business manager and clinical service
manager, as well as having sufficient contracted time to undertake his/
her duties. In addition to management responsibilities, the clinical director
must offer support, guidance and encouragement to all members of the
department. Recognition of the importance of the training responsibility of
the NHS is essential.
The role of other consultants
The clinical director will usually delegate some operational aspects of the
anaesthesia team. It is often helpful to have a lead consultant to provide
medical supervision in specialist areas such as day surgery, obstetric
anaesthesia, training (the College tutor), safety and postoperative pain
control. A rota co-ordinator, who has a good knowledge of the local service
and skill-mix of anaesthetists should be appointed and supported in the role.
5

The role of the clinical service manager
Non-medical staff involved in the anaesthesia team are normally managed
by a senior operating department practitioner (ODP) or a senior nurse,
responsible to a clinical service manager.
Modern anaesthesia services are complex and the clinical service
manager will usually work closely with other departments or managers.
Responsibilities of the senior manager will include:
• Careful co-ordination of pre-operative assessment that requires
communication with surgeons, the medical records department,
outpatient clinics and all related departments; the individual leading this
service should work closely with a lead anaesthetist,
• Maintaining adequate staffing with trained anaesthesia assistants in the
operating department,
• An appropriately staffed PACU,
• Ensuring an adequate skill-mix of staff is available 24 hours a day, 7 days
a week. There may be advantages in rotating trained staff with common
skills between theatres, PACU and high dependency and intensive
care units depending on local circumstances,
• An acute pain service that should be a routine part of the anaesthesia
team and adequately staffed by trained nurses working with an
anaesthesia lead,
• Regular audit of all components of the anaesthesia service, not
only for the efficient use of resources, but also for clinical quality and
safety.
There is therefore a need for close communication with all users of the
service. A multidisciplinary theatre users’ committee is often useful for
ensuring common goals, co-operation and motivation across specialties.
A theatre governance group should review all clinical incidents and safety
guidance and ensure patient safety is seen as a priority by the hospital.
6

4. Pre-operative assessment
Assessment before anaesthesia is the responsibility of the anaesthetist.
However, pre-operative assessment before the date of surgery achieves
several desirable objectives. It ensures that patients are prima facie fit for
anaesthesia and surgery, and that all likely investigations will be completed
and available at the time of admission. It thus minimises the disruption
caused by late cancellation or postponement and their adverse effects
on theatre utilisation and bed occupancy, not to mention the distress and
inconvenience to patients and their relatives or carers. It enhances efficiency
and ensures a higher level of overall patient care. It also gives an opportunity
for patients to express concerns they may have about anaesthesia and
surgery.
Good practice dictates that all patients should be seen by an anaesthetist
before undergoing an operation that requires the services of an anaesthetist.
Ideally, this should be the doctor who is to give the anaesthetic. Although it
is the anaesthetist who is responsible for deciding whether a patient is fit for
anaesthesia, other professional groups may be involved in the pre-operative
assessment process.
Pre-operative assessment is now commonly carried out by a specially trained
multidisciplinary team led by, and with access to, a consultant anaesthetist,
in the pre-operative assessment clinic. In the clinic, nursing, ODP and other
trained staff play an essential role when, by working to agreed protocols, they
screen and assess patients for fitness for anaesthesia and surgery [1].
It is important to be clear about the boundaries between the remit of the
pre-anaesthesia assessment team and the responsibilities of the anaesthetist.
The AAGBI feels that it is inappropriate for a non-anaesthetist to promise a
particular type of premedication, anaesthetic technique or postoperative pain
management and that the decision to proceed (with anaesthesia) cannot be
delegated. It is essential, in all but a dire emergency, that the anaesthetising
anaesthetist should see patients pre-operatively in a quiet ward, theatre
reception area or theatre admissions unit rather than in a busy operating
theatre.
It is not within the remit of this document to go into the details of the
running of pre-operative assessment clinics. This is addressed in the AAGBI
publication on pre-operative assessment (2010) [1].
7

5. The operating department
Management
The operating department must have a manager who is responsible for
ensuring an efficient and effective service. This individual will be responsible
for ensuring the provision of adequately trained staff and ongoing audit of
activity, whatever the local directorate structure. Proper use of resources
and optimum throughput of patients depends on maintaining good
communication between anaesthetists, surgeons and operating department
staff.
World Health Organization (WHO) Surgical Safety Checklist [2]
In 2008 the WHO produced a core set of standards for the peri-operative
period within the operating department. The NPSA has endorsed these
standards and issued guidance on how they should be implemented. An
executive and clinical lead is appointed to implement the surgical safety
checklist within each organisation where surgery is performed.
The checklist is completed for each patient who undergoes any surgical
procedure; this includes those done under local anaesthesia.
An accurate record, either paper or electronic, confirming that the checklist
is complete must be entered into the clinical notes by a registered member of
the team; this could be a surgeon, anaesthetist, nurse or ODP.
The whole process is designed to reduce the mistakes or omissions that occur
during surgical procedures by improving team communication. A briefing
and debriefing with all theatre staff should occur at the beginning and end
of the list. For individual patients we describe the rest of the process with
particular reference to anaesthesia.
Sign in
This is performed before induction of anaesthesia. The anaesthetic
equipment must be formally checked in accord with AAGBI machine check
guidelines (currently under review) [3]. There must be written verification
of this process. Patient monitoring should be attached in compliance with
the AAGBI guideline [4].The anaesthesia team should confirm the ‘sign
in’ checks before induction of anaesthesia. They include patient identity,
surgical site marking, medication, allergies, airway and risk of blood loss.
When the patient is unable to confirm the necessary information, this can be
provided by carers or significant others.
8

Time out
This procedure should be completed before the start of the surgical
intervention. All members of the operating department team must introduce
themselves to each other, unless already known. The surgeon, anaesthetist
and registered practitioners verbally confirm the identity of the patient, the
site of surgery and the procedure. At this stage any anticipated adverse events
should be discussed. In particular, the anaesthesia team may wish to highlight
any patient co-morbidities. The anaesthetist should pay particular attention
to monitoring the patient throughout surgery, maintaining normothermia and
ensuring that there are no issues with any of the equipment used by the team.
The anaesthesia team must pay particular attention to the site of surgery
when regional blocks are being performed.
Sign out
This takes place before any member of the team leaves the operating
theatre at the end of each case. Of particular concern to the whole theatre
team is the checking of swabs and accurate measurement of fluid loss, key
concerns for the patient in the recovery period. The postoperative recovery
and management plan should be discussed and information relayed to the
recovery practitioner.
The WHO checklist is new (as of May 2010) to most units and may be
subject to local/minor modification as time progresses.
NB. In Scotland the process is slightly different. Briefing and de-briefing are as
above. Then in three parts:
i. Sending for the patient: name, procedure and ward check,
ii. Surgical pause: before the commencement of anaesthesia the
anaesthetist and assistant, surgeon operating, and theatre team member
check name, date of birth, armband, consent, allergies,
thromboprophylaxis, antibiotics and staff competencies,
iii. End of procedure: swab and instrument count.
9

Assistance for the anaesthetist
Trained assistance for the anaesthetist must be provided wherever anaesthesia
is provided.
The safe administration of anaesthesia cannot be carried out single handedly;
competent and exclusive assistance is necessary at all times.
The clinical director must insist on adequate resources to employ, train and
develop sufficient numbers of assistants to ensure a safe anaesthesia service
in accordance with good practice.
If appropriate basic resources are not available, the clinical director should
limit clinical practice so that safe, quality-based patient care is ensured.
Anaesthetic room
The anaesthetist and trained assistant are joined in some units by a third
member of staff to help with any untoward emergency, obese patients, carers
in the anaesthetic room, and so on. In any event, a third person should
be available in close proximity to the anaesthetic room to help with any
unforeseen problem.
The AAGBI recommends that a trained anaesthesia assistant should always
be immediately available and present during anaesthesia. Only in extreme
emergencies, as judged by the anaesthetist, should anaesthetic intervention
proceed without a trained assistant, e.g. acute unforeseen airway/bleeding
problems.
The role of the anaesthesia assistant
The current trend is towards multi-skilling where most professionals in the
operating department are able to perform many tasks including assisting
the anaesthetist, assisting the surgeon, working in the recovery area and
undertaking administrative duties. However, patterns of work must ensure
that skills are maintained. Staff assigned to the role of anaesthetic assistant
should not have any other duties that would prevent them from providing
dedicated assistance to the anaesthetist during anaesthesia.
Training
Assistance for the anaesthetist may be provided by ODPs or adequately
trained, registered nurses. Whatever the background, the training for all
anaesthesia assistants must comply fully with national standards. Employment
of staff without a qualification that complies with national standards is
not acceptable. Learners are accepted for formal training as anaesthesia
10

assistants, but they must be supervised at all times by a registered practitioner.
There should be a programme of continuing professional development and
training for all anaesthesia assistants.
Operating Department Practitioners (ODPs)
There are now 27 universities and colleges providing qualifications for ODPs;
these are based in England, Wales and Scotland. ODPs must have completed
an approved programme that confers eligibility to apply for registration with
the Health Professions Council (HPC). Currently for an ODP to enter the
HPC register they must complete a two-year Diploma HE, although a degree
programme is under development.
ODPs became a statutorily regulated profession (within the HPC) in October
2004. There are almost 10,000 ODPs registered with the HPC.
Nurses
Qualified nurses are already registered professionals but require additional
training before taking on the duties of an anaesthesia assistant. In England
until 2002, the recognised national qualification of competency for nurses
as anaesthesia assistants was the English National Board qualification (ENB
182).
Universities now provide postgraduate nurse training and have developed
theatre courses to replace the ENB 182. At most universities these comprise
three core modules and three optional modules, including anaesthesia.
There are no standard competencies and the courses may differ in length
and content. The AAGBI would like to see the development of nationally
recognised competencies for nurses assisting the anaesthetist. However,
the courses led by local universities are in the main of a high standard and
have some national guidance. A nurse should not assist an anaesthetist until
successful completion of such a course.
Qualified nurses can still train as ODPs, either through the NVQ route (until
2008) or by APL (accreditation of prior learning) with a university ODP
provider. They cannot complete an award that entitles them to the title of
ODP unless they complete the full Dip HE in ODP award.
In Scotland, nurses assisting anaesthetists now have to achieve a series of
competencies devised by NHS Education Scotland. The courses to achieve
these competencies are administered by individual hospitals.
11

Professional associations
Continuing education and support is offered by three organisations: the
College of Operating Department Practitioners (CODP), the Association for
Perioperative Practice (AfPP) and the British Association of Anaesthetic &
Recovery Nurses (BARNA).
Physicians’ Assistants (Anaesthesia) – PA(A)s [5]
The AAGBI has previously stated that the highest standards of anaesthesia
can only be achieved by a physician-only service. However, in response
to a potential workforce crisis in 2002 the Royal College of Anaesthetists
(RCoA) and Department of Health reported on the potential for development
of a non-medical role as part of a consultant-led anaesthesia team to
enhance flexibility and service provision whilst maintaining the highest
standards of safety. [6] The AAGBI engaged with the pilot project run by
the Modernisation Agency to ensure that the model developed would work
effectively in NHS practice.
The AAGBI believes that the workforce concerns envisaged in 2002 have
not yet materialised but recognises that the full impact of the EWTD and
increasingly consultant-based service provision has yet to be determined.
Numbers of trained PA(A)s are low and numbers employed in the future will
be determined by local departments and their staffing needs. The AAGBI
would like to reiterate that all PA(A)s are required to practice within the
guidelines of the RCoA/AAGBI (available on both websites), and consultants
working with them should ensure that they are supported to the required
standard.
In 2009 there were around 70 trained PA(A)s nationally (

the establishment of a Managed Voluntary Register. Formal registration is
currently being sought with the Health Professions Council.
Whether in the NHS or private sector, two PA(A)s to one consultant
anaesthetist should remain the maximum, and PA(A)s working in this
way should each have their own qualified assistance. There is as yet no
equivalence for those wishing to enter the PA(A) profession from abroad. The
AAGBI does not recommend employing PA(A)s who have not trained in the
UK programme.
It should again be emphasised that at the end of their initial training
PA(A)s are not qualified to undertake regional, obstetric or paediatric
anaesthesia, or be involved in initial airway management of the acutely ill or
injured, as described in the AAGBI/RCoA standards document. [9]
As before, the situation will be monitored continuously by the AAGBI.
13

6. Recovery post-anaesthetic care unit
(PACU)
The AAGBI published guidance on the required facilities for the safe recovery
from anaesthesia in 2002 [10]. (This guidance is being reviewed and the
revised edition will be published in 2010). There is, however, a need to
re-emphasise the principles outlined in that report and to emphasise the
recommendations on staffing and training.
The responsibility of anaesthetists for the care of their patients extends into
the postoperative period and includes the management of postoperative pain
and postoperative nausea and vomiting (PONV). Emergence from anaesthesia
is potentially hazardous and patients require close observation until recovery
is complete. Care must be transferred to staff who have been specially trained
in recovery procedures and reached prescribed competencies. Currently
these are often locally devised but the AAGBI is working to promote the
development of national competencies. All recovery staff should have
achieved their recognised local competencies.
While patients remain in the PACU there must always be a suitably trained
anaesthetist (and surgeon) immediately available within the hospital.
Close collaboration between the anaesthetist and the surgeon is particularly
important at this time so that clear instructions are given to recovery staff.
Transfer to recovery area
The anaesthetist should be satisfied that the recovery staff are competent to
take responsibility for the patient before care is transferred. No fewer than
two staff should be present when there is a patient in the PACU who does not
fulfil the criteria for discharge to the ward [10]. If this level of staffing cannot
be assured, the anaesthetist should stay with the patient until satisfied that the
patient is fit to return to the ward.
Recommendations on the transfer of the patient from the operating theatre to
the PACU are outlined in the AAGBI’s publication referred to above [10].
Immediate recovery
Continuous individual observation of each patient is required on a oneto-one
basis until the patient is able to maintain their own airway. The
recovery staff, therefore, must not have any other duties at this time. Failure
to provide adequate care for patients during this period of vulnerability,
14

in which the possibility of serious complications is well recognised, may
prove catastrophic for the patient and could result in serious medico-legal
consequences for the hospital. In hospitals with an emergency surgical
service, appropriately staffed recovery facilities must be available throughout
the 24 hours.
A post-anaesthesia care plan should be implemented for each patient which
includes monitoring to ensure satisfactory cardiorespiratory function, fluid,
pain and PONV management, and the administration of other drugs to
agreed protocols. These have been the subject of previous advice [4]. Careful
records must be maintained (increasingly in electronic form) and recovery
staff must be able to interpret the information and initiate appropriate action
where necessary. Staff must also be able to assess the suitability of transfer of
patients to the next level of care.
Dedicated recovery staff must be trained in immediate and advanced
resuscitation techniques.
Discharge
The patient should remain in a suitably equipped PACU until all the criteria
for discharge have been met. Discharge must be based on a carefully
worded protocol or on the personal instructions of the anaesthetist.
Recommendations on the criteria for discharge from the recovery area have
been published previously and are currently being reviewed [10].
Management
The optimal management structure for the PACU should be influenced by the
directorate of anaesthesia. There must be clear lines of communication with
other relevant directorates and departments.
Training and qualifications
All staff who work in the recovery area should have received appropriate
training and have achieved recognised competencies. The core skills
required are summarised in our published work [10].
Personnel who are in training may work in PACUs but must be supervised
by trained staff. Staffing levels should not be depleted to fill deficits in other
areas of the hospital, although rotation between staff within the operating
department should be encouraged to maintain skills. All staff must have
access to further professional development and there should be appropriate
study leave.
15

7. Postoperative pain management
Background
All hospitals performing major surgery should have a multidisciplinary
acute pain team with an anaesthetist in overall charge (the majority having
a sessional commitment by a consultant to acute pain) and a senior nurse
running the service on a day-to-day basis, following predefined protocols.
In 1997, an Audit Commission report [11] recommended more effective
collaboration between the anaesthetist, surgeon and nurses.
A high quality acute pain management service should include identifying the
patient’s individual requirements on admission and then ‘tracking’ the patient
from the surgical ward, through recovery, critical care if appropriate and back
to the ward.
The acute pain team
Potential members of an acute pain team include:
• A consultant anaesthetist(s) with sessional commitments to the team,
• Trainee anaesthetists, as part of the on-call team and as part of their
modular training in pain management,
• SAS and specialist doctors in anaesthesia,
• A nurse team to manage the day to day follow-up of patients made up
of specialist nurse/nurse practitioners who have had specific training in
the management of acute pain,
• Nurses in training,
• ODPs,
• A pharmacist,
• A physiotherapist,
• Secretarial and audit department support.
Consultant responsibility
It is important that postoperative pain be controlled immediately on recovery
from anaesthesia. The pain team must therefore be involved from an early
stage with PACU staff and the consultant responsible for the pain service has
an obvious role in PACU and other critical care areas. This role will involve
the design and implementation of pain management protocols and the
education and training of staff.
Roles of non-medical personnel
A lead nurse should be responsible for running the service on a day-to-day
16

asis within the limits defined by protocols. The lead nurse is responsible
for liaison between PACU, critical care areas and the wards, troubleshooting
problems and referring problem patients to medical staff. They also have
an important role in education. Potential additional roles for the acute pain
team are the placing of intravenous cannulae, administering appropriate
drugs intravenously and topping up epidurals. The appropriateness of the
delegation of any of these tasks is obviously influenced by the location in
which they were used, with different roles being appropriate in the HDU,
recovery and general ward.
The pharmacy has a role in the provision of drugs for the acute pain team. It
should also be involved in maintaining the range of drugs required for the
service, the evaluation of new drugs and education. This important role is
enhanced by nominating a specific pharmacist to the team.
An important aim of postoperative analgesia is restoration of function and this
can be assessed by the ward physiotherapist who should be involved with
the acute pain team and may be a source of secondary referrals.
Standards of practice
The majority of pain services are delivered on the basis of protocols that have
been drawn up by consultation between anaesthetists, surgeons and staff
from PACU and general wards. Because there are local differences in both
the role of nurses and the extent of their remit, there will be variations in the
protocols between hospitals. The pain team should be responsible for the
implementation of a system to introduce, disseminate and review protocols
for all grades of staff caring for postoperative patients and for continuing audit
of the service.
Educational implications
The educational implications are two-fold: education of the team members
and education by the team members.
Anaesthetists must play a major role in educating the members of the acute
pain team, in collaboration with the lead nurse. Appropriate aspects of
training should also be addressed by other members of the team.
17

References
1. The Association of Anaesthetists of Great Britain and Ireland. Pre-
Operative Assessment and Patient Preparation - The role of the
Anaesthetist 2. London: AAGBI, 2010.
2. World Health Organization. Surgical Safety Checklist. Switzerland:
WHO, 2009.
3. The Association of Anaesthetists of Great Britain and Ireland. Checking
Anaesthetic Related Equipment 3. London: AAGBI, 2004 (currently
being reviewed).
4. The Association of Anaesthetists of Great Britain and Ireland.
Recommendations for Standards of Monitoring During Anaesthesia and
Recovery 3. London: AAGBI, 2000 (revised in 2007).
5. The Royal College of Anaesthetists. Physicians Assistants (Anaesthesia)
[PA(A)]. http://www.rcoa.ac.uk/index.asp?PageID=761(accessed
23/02/2010.)
6. The Royal College of Anaesthetists. The Role of Non-Medical Staff in
the Delivery of Anaesthesia Services. London: RCoA, 2002.
7. The Royal College of Anaesthetists. Bulletin of the Royal College of
Anaesthetists; 50. London: RCoA, 2008.
8. The Royal College of Anaesthetists and The Royal College of
Ophthalmologists. Local Anaesthesia for Intraocular Surgery. London:
RCoA, 2001.
9. The Association of Anaesthetists and The Royal College of Anaesthetists.
Physicians’ Assistants (Anaesthesia) - PA(A)s - supervision and limitation
of scope of practice. http://www.rcoa.ac.uk/docs/PA(A)_JointStatement.
pdf (accessed 26.02.10).
10. The Association of Anaesthetists of Great Britain and Ireland.
Immediate Postanaesthetic Recovery. London: AAGBI, 2002 (currently
being reviewed).
11. Department of Health. Briefing Anaesthesia under Examination Audit
Commission Report. Oxford: DoH, 1997.
18

19

20

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

AAGBI SAFETY GUIDELINE
Suspected Anaphylactic Reactions
Associated with Anaesthesia
4
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org July 2009

This guideline was originally published in Anaesthesia. If
you wish to refer to this guideline, please use the following
reference:
Association of Anaesthetists of Great Britain and Ireland.
Suspected anaphylactic reactions associated with anaesthesia.
Anaesthesia 2009; 64: pages 199-211
This guideline can be viewed online via the following URL:
http://www3.interscience.wiley.com/cgi-bin/fulltext/121583621/
PDFSTART

GUIDELINES
Suspected Anaphylactic Reactions
Associated with Anaesthesia
Association of Anaesthetists of Great Britain and Ireland
Membership of the Working Party: N J N Harper, Chairman;
T Dixon; P Dugué; D M Edgar; A Fay; H C Gooi; R Herriot;
P Hopkins; J M Hunter; R Mirakian; R S H Pumphrey;
S L Seneviratne; A F Walls; P Williams; J A Wildsmith; P Wood.
Ex Officio: A S Nasser 1 , R K Powell 1 , R Mirakhur 2 , J Soar 3 ,
Executive Officers, AAGBI
1 British Society for Allergy and Clinical Immunology
2 Royal College of Anaesthetists
3 Resuscitation Council UK
This is a consensus document produced by expert members of a Working Party
established by the Association of Anaesthetists of Great Britain and Ireland
(AAGBI). It updates and replaces previous guidance published in 2003.
Summary
(1) The AAGBI has published guidance on management of anaphylaxis
during anaesthesia in 1990, 1995 and 2003. This 2008 update was
necessary to disseminate new information.
(2) Death or permanent disability from anaphylaxis in anaesthesia may be
avoidable if the reaction is recognised early and managed optimally.
(3) Recognition of anaphylaxis during anaesthesia is usually delayed
because key features such as hypotension and bronchospasm more
commonly have a different cause.
Re-use of this article is permitted in accordance with the Creative Commons Deed,
Attribution 2.5, which does not permit commercial exploitation.
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(4) Initial management of anaphylaxis should follow the ABC approach.
Adrenaline (epinephrine) is the most effective drug in anaphylaxis and
should be given as early as possible.
(5) If anaphylaxis is suspected during anaesthesia, it is the anaesthetist’s
responsibility to ensure the patient is referred for investigation.
(6) Serum mast cell tryptase levels may help the retrospective diagnosis of
anaphylaxis: appropriate blood samples should be sent for analysis.
(7) Specialist (allergist) knowledge is needed to interpret investigations for
anaesthetic anaphylaxis, including sensitivity and specificity of each
test used. Specialist (anaesthetist) knowledge is needed to recognise
possible non-allergic causes for the ‘reaction’. Optimal investigation
of suspected reactions is therefore more likely with the collaboration
of both specialties.
(8) Details of specialist centres for the investigation of suspected
anaphylaxis during anaesthesia may be found on the AAGBI website
http://www.aagbi.org.
(9) Cases of anaphylaxis occurring during anaesthesia should be reported
to the Medicines Control Agency and the AAGBI National
Anaesthetic Anaphylaxis Database. Reports are more valuable if the
diagnosis is recorded following specialist investigation of the reaction.
(10) This guidance recommends that all Departments of Anaesthesia
should identify a Consultant Anaesthetist who is Clinical Lead for
anaesthetic anaphylaxis.
Introduction
The AAGBI published its first guidelines on suspected anaphylactic reactions
in 1990. Subsequent revisions were published in 1995 and 2003. The current
guidelines incorporate advice from a large number of clinical immunologists,
allergists and anaesthetists throughout the UK. In common with the 1995 and
the 2003 editions, this report is published jointly with the British Society for
Allergy and Clinical Immunology (BSACI).
This document is intended to be concordant with, and complementary
to, the 2007 Scandinavian Clinical Practice Guidelines, the 2008 Resuscitation
Council UK guidelines and the BSACI guidelines: Investigation of
suspected anaphylaxis during anaesthesia.
These guidelines apply only to suspected anaphylactic reactions associated
with anaesthesia and it is presupposed that the patient is in the care of a
trained anaesthetist.
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Objectives
(1) To clarify the definitions used in allergy and anaphylaxis.
(2) To review the epidemiology of anaesthesia-related anaphylaxis.
(3) To provide advice on the recognition of anaesthetic anaphylaxis.
(4) To make recommendations on the immediate management and initial
investigation of suspected anaesthetic anaphylaxis.
(5) To make recommendations concerning the further investigation of
suspected anaesthetic anaphylaxis.
(6) To assist anaesthetists in obtaining access to a specialist centre for
comprehensive investigation of suspected anaesthetic anaphylaxis.
(7) To assist anaesthetists to provide appropriate information to the
specialist centre.
(8) To make recommendations about the reporting and collection of data
on anaesthetic anaphylaxis in Great Britain and Ireland.
Definitions
The term ‘anaphylaxis’ has been used for all types of acute life-threatening
illness triggered by abnormal sensitivity (hypersensitivity) to a trigger agent,
and for apparently spontaneous attacks with similar features (idiopathic
anaphylaxis). This has made it difficult to define. The EAACI Nomenclature
Committee proposed the following broad definition [1]:
Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity
reaction.
Minor, localised or non-systemic reactions are outside the definition of
anaphylaxis. Anaphylaxis may be divided into ‘allergic anaphylaxis’ and
‘non-allergic anaphylaxis’. The clinical features of allergic anaphylaxis
and non-allergic anaphylaxis may be identical. The EAACI committee
proposed the term ‘allergic anaphylaxis’ should be used only when the
reaction is mediated by an immunological mechanism (such as IgE, IgG, or
complement activation by immune complexes). An anaphylactic reaction
mediated by IgE antibodies, such as to amoxicillin, is referred to as ‘IgEmediated
allergic anaphylaxis’.
The term ‘anaphylactoid’ reaction had been introduced for non-
IgE-mediated anaphylactic reactions but the EAACI committee has
recommended this term should no longer be used. This proposal has not
been universally accepted. An authoritative recent American practice
parameter [2] states: ‘Anaphylaxis is defined … as a condition caused by an
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IgE-mediated reaction [2]. Anaphylactoid reactions are defined as those
reactions that produce the same clinical picture as anaphylaxis but are not IgE
mediated.’ In these guidelines we will follow the European (EAACI)
nomenclature.
Anaphylaxis is not a homogeneous process: the pathways, mediators,
time course and response to treatment depend on the trigger agent, its route
and rate of administration, the nature of the patient’s hypersensitivity and
the state of health of the patient, including incidental pathology such as
respiratory or cardiovascular disease and the effects of concomitant
medication such as b-blockers and ACE inhibitors. Although anaphylaxis
commonly involves respiratory, cutaneous and circulatory changes, variations
such as shock with gastrointestinal disturbance or shock alone are
possible. Alternatively, reactions may be fatal without significant shock
except as the terminal event following respiratory arrest [3]. Angioedema
and urticaria may be features of anaphylaxis but commonly result from
mechanisms other than anaphylaxis.
Intravascular volume redistribution is an important component of
anaphylactic shock. Cardiac output may be decreased as a result of reduced
coronary artery perfusion pressure as well as impaired venous return. Local
release of mediators may cause coronary artery spasm and there may be
features of acute left or right ventricular failure. Myocardial ischaemia with
ECG changes is expected within minutes of anaphylactic shock becoming
severe.
Asphyxia may be due to upper airway occlusion caused by angioedema,
or bronchospasm with mucus plugging of the lower airways; the latter most
commonly occurs in patients taking daily treatment for asthma. Both these
processes may occur simultaneously in patients reacting to foods, latex,
b-lactam antibiotics or aspirin.
Anaphylaxis usually resolves in 2–8 h but secondary pathology arising
from the reaction or its treatment may prolong this. Resolution is complete
except when cerebral hypoxia at the peak of the reaction has caused
significant brain damage, or when disordered clotting leads to bleeding.
Acknowledgements
The involvement of the British Society for Allergy and Clinical Immunology
and the Clinical Immunology and Allergy section of the British
Society for Immunology is gratefully acknowledged. In addition, the
working party wishes to acknowledge the assistance of the following:
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Sr Alex Farragher Specialist Immunology Nurse
Mr Chris Hirst AAGBI Anaphylaxis website designer
Dr David Noble
Dr Martin Shields
References
1 Johansson SGO, Bieber T, Dahl R, et al. Revised nomenclature for allergy for
global use: Report of the Nomenclature Review Committee of the World
Allergy Organization, October 2003. Journal of Allergy and Clinical Immunology
2004; 113: 832–6.
2 Joint Task Force on Practice Parameters. The diagnosis and management
of anaphylaxis: an updated practice parameter. Journal of Allergy and Clinical
Immunology 2005; 115: S483–523.
3 Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal
reactions. Clinical and Experimental Allergy 2000; 30: 1144–50.
Epidemiology
Geographical variation
Most reports on anaesthesia-related anaphylaxis originate from France,
Australia, New Zealand and the United Kingdom. Other case series have
been described from Scandinavia and the USA. The true incidence and
their associated morbidity and mortality remain poorly defined. Both the
accuracy and completeness of reporting is not optimal.
10% of anaesthesia-related reactions reported to the UK Medicines
Control Agency (MCA) were fatal. These data should be interpreted with
caution because it is likely that many less-severe reactions are not reported
[1]. Reactions that are accepted as side-effects of certain drugs, for instance,
histaminergic reactions due to atracurium and mivacurium, may be underreported.
During a time period of over 6 years only 361 reactions were
reported to the MCA. In a 2-year period 789 reactions were reported in
France in a comparable population where there is a well-established culture
of reporting anaesthesia-related reactions [2].
Based on studies in Australia and France, the incidence of anaphylaxis
during anaesthesia has been estimated at between 1 in 10 000 and 20 000
[3, 4]. The true incidence of anaphylaxis during anaesthesia in the UK is
not known. By extrapolating the French and Australian data to the UK, it is
estimated that there are approximately 500 severe reactions in the UK each
year. Anaphylactic reactions are more common when drugs are given
intravenously.
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In one large study an immune basis was demonstrated in two-thirds of
patients investigated for anaphylaxis [2]: the remainder comprised nonallergic
anaphylaxis and mechanisms other than anaphylaxis. The tests
currently available for the diagnosis of anaesthetic anaphylaxis are imperfect.
Skin tests and blood tests have limited sensitivity and specificity and their
positive and negative predictive value varies between drugs.
Patient characteristics (age, sex, ethnicity, smoking etc)
Neuromuscular blocking drugs and latex appear to cause anaphylaxis more
commonly in female patients. There appears to be a connection between
smoking and antibiotic anaphylaxis, possibly because smokers may become
sensitised by exposure to repeated courses of antibiotics for respiratory tract
infections. Individuals with a history of atopy, asthma or allergy to some
foods appear to be at increased risk of latex allergy but not anaphylaxis to
neuromuscular blocking drugs or antibiotics [2, 5]. Anaphylaxis associated
with radiographic contrast media appears to be associated with atopy [6].
Patients with asthma or taking b-blocking drugs may suffer a more severe
reaction. Some of these reactions may be refractory to conventional
therapy.
Possible environmental sensitising agents
The prevalence of anaphylactic reactions to neuromuscular blocking agents
(NMBAs) is reported to be at least six times more frequent in some
countries [7, 8]: it is considerably more common in Norway than in
Sweden. Quaternary ammonium ions (QAI) are proposed to be the
allergenic epitopes in NMBAs. Common environmental chemicals such as
toothpastes, washing detergents, shampoos, and cough medicines share
these allergenic epitopes with the NMBAs [8]. Numerous possibilities exist
for a predisposed individual to become sensitised to QAIs and thus be at risk
of developing anaphylaxis to NMBAs during anaesthesia. In a recent
Scandinavian survey, use of certain cough medicines was found to be the
only significant difference in environmental chemical exposure [8]. In
Norway, but not Sweden, cough syrups containing pholcodine are available
without prescription. IgE-antibodies to pholcodine were seen in 6% of a
general population (blood donors) in Norway but not in Sweden (0%).
Muscle relaxants
Approximately 60% of cases of anaesthesia-related anaphylaxis are thought
on the basis of skin tests to be due to neuromuscular blocking agents.
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Mivacurium and atracurium are associated with non-allergic anaphylaxis in
which release of mediators (notably histamine) from mast cells exactly
imitates allergic anaphylaxis. Cisatracurium, although sharing a benzylisoquinolinium
structure, is not associated with non-allergic anaphylaxis,
although several cases of allergic anaphylaxis have been reported. It is
generally accepted that succinylcholine is the NMBA most likely to
be associated with allergic anaphylaxis, although rocuronium has been
implicated in a similar number of cases in France.
The prevalence of sensitisation to NMBAs in the community is higher
than the incidence of reactions would suggest. In one study, approaching
10% of the general population exhibited skin reactivity to NMBAs, an
incidence that far exceeds the incidence of anaphylaxis on administration of
these drugs during anaesthesia [9]. A previous history of specific drug
exposure is not necessary, particularly for neuromuscular blocking drugs. A
history of previous exposure is found in fewer than 50% of patients who are
allergic to neuromuscular blocking drugs. Conversely, an uneventful
exposure may sensitise an individual to subsequent administration of the
drug.
Cross-sensitivity between different NMBAs is relatively common,
probably because they share a quaternary ammonium epitope. If anaphylaxis
to an NMBA is suspected, the patient should undergo skin prick
testing with all the NMBAs in current use. If a patient demonstrates a
positive skin prick test (SPT) to an NMBA, the patient should be warned
against future exposure to all NMBAs if possible. If it is mandatory to use an
NMBA during anaesthesia in the future, it would seem appropriate to
permit the use of an NMBA which has a negative skin test, accepting that a
negative skin test does not guarantee that anaphylaxis will not occur.
The apparent excess of cases of anaphylaxis to rocuronium in some
countries should be interpreted with caution until much more data have
been collected. Large sample sizes are needed to estimate the true incidence:
if the true incidence is 1 in 5000, a sample size of 7 million would be
needed to have a 95% chance of being within 5% of the true value [10].
There is a need for further epidemiological studies.
Latex
Latex hypersensitivity is the second most common cause of anaesthesiarelated
anaphylaxis in many studies (up to 20% of cases). However, the
incidence of anaphylaxis to latex is considerably less than would be
suggested by the prevalence of positive skin tests or positive IgE tests. It
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appears that the incidence may be waning, at least in some countries;
possibly as a result of a change or decline in the use of latex gloves. Certain
patient groups are more susceptible to latex anaphylaxis (see Appendix II).
Antibiotics
Approximately 15% of anaesthesia-related anaphylactic episodes are due to
antibiotics. This proportion has increased in recent years and may merely
mirror increased exposure to antibiotics in the community [2, 11]. The
pre-operative history is important. Although only a minority of patients
who report allergy to antibiotics have a true allergy, the consequence
of anaphylaxis to intravenous antibiotics may be catastrophic, and selfreporting
should be taken seriously. Skin testing is only approximately 60%
predictive of clinical hypersensitivity. Penicillins and cephalosporins which
share the b-lactam ring are responsible for approximately 70% of antibioticinduced
anaphylaxis. Many antibiotics possess a b-lactam ring:
• Benzylpenicillin, phenoxymethylpenicillin
• Flucloxacillin, temocillin
• Amoxicillin, ampicillin, co-amoxiclav
• Co-fluampicil
• Piperacillin, ticarcillin,
• Pivmecillinam HCl
• Cephalosporins
• Aztreonam
• Ertapenem, imipenem with cilastatin, meropenem
The structure of the side chains attached to the b-lactam ring is also
important in determining the response of the immune system. First
generation cephalosporins and cefamandole share a similar side chain with
penicillin and amoxicillin. A recent meta-analysis suggested that patients
who are allergic to penicillin or amoxicillin have a higher incidence of
allergic reactions to first generation cephalosporins and cefamandole, but
not other cephalosporins [12]. The issue is complicated because the
classification of cephalosporins relates to their antimicrobial activity rather
than their chemical structure.
First generation cephalosporins
• Cefalexin (cephalexin)*
• Cephaloridine
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• Cephalothin
• Cefazolin
• Cefradine (cephradine)*
• Cefadroxil*
Second generation cephalosporins
• Cefaclor*
• Cefamandole
• Cefuroxime*
Third generation cephalosporins
• Cefixime*
• Cefotaxime*
• Cefpodoxime*
• Ceftazidime*
• Ceftriaxone*
Fourth generation cephalosporins
• Cefepime
• Cefpirome
*Listed in the British National Formulary.
Local anaesthetics
Anaphylactic reactions to local anaesthetic drugs are very uncommon. Local
anaesthetic esters are more likely than amides to provoke a Type lV allergic
reaction. Preservatives such as methyl-paraben or metabisulphites may be
responsible in some cases. It has been suggested that inadvertent intravascular
injection of a local anaesthetic or the systemic absorption of adrenaline
may be responsible for many of the reported reactions. Reactions occurring
in the dental chair may also be associated with idiopathic angioedema or
latex allergy.
Opioids
Opioids are an uncommon cause of anaesthesia-related anaphylaxis.
Diagnosis is difficult and the true incidence is unknown. Morphine,
pethidine and codeine are well-known to cause non-specific histamine
release which precludes diagnostic skin testing. The diagnosis of opioid
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anaphylaxis often rests on a careful history and the exclusion of other
possibilities. Challenge testing may be appropriate in some cases but may be
performed only in specialist centres.
Anaesthetic induction agents
Anaphylaxis to propofol is very uncommon. The antigenic determinant
may be the isopropyl groups. It has been stated that patients with egg allergy
or soy allergy should avoid propofol but there is no strongly-supportive
evidence. It has been suggested that propofol anaphylaxis is more likely if
lignocaine is added to reduce pain on injection: there is no evidence to
support this suggestion. Anaphylaxis to thiopental has become extremely
uncommon, probably reflecting the decline in its use. A small number of
cases of midazolam anaphylaxis have been reported.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Several mechanisms may be responsible for reactions to NSAIDs.
Inhibition of the PGE 2 pathway leads to excessive leukotriene synthesis
and subsequent mediator release, causing urticaria or bronchospasm. IgEmediated
reactions may also occur in relation to some NSAIDs. Fatal
anaphylaxis has been described after oral administration of NSAIDs.
Halogenated volatile anaesthetics
There are no published reports of anaphylaxis to halogenated volatile
anaesthetics. The rare fulminant form of hepatitis associated with halothane
has an immune basis which is unrelated to anaphylaxis.
Colloids
Intravenous colloids are responsible for approximately 4% of all perioperative
anaphylactic reactions. In one study, gelatin solutions were
responsible for 95% of the intravenous colloid reactions. It has been stated
that the incidence may be greater with the urea-linked gelatins compared with
the modified fluid gelatins. Intravenous gelatin solutions should be avoided in
patients with a history of allergy to gelatin-containing vaccines. Anaphylaxis
to intravenous dextrans has been reported, with an incidence similar to the
modified fluid gelatins. Anaphylaxis to hydroxyethyl-starch is rare.
Antiseptics and disinfectants
Reactions to chlorhexidine have come into greater prominence in recent
years. There appears to be a significant difference in incidence between
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countries [13]. Reactions range from contact dermatitis to life-threatening
anaphylaxis. Anaphylaxis has occurred when chlorhexidine was used as an
antiseptic for urological and gynaecological procedures as well as insertion
of central venous and epidural catheters. The chlorhexidine coating of
certain central venous catheters has been implicated in such reactions. It is
prudent to allow skin disinfectant to completely dry before beginning an
invasive procedure. Anaphylaxis to polyvinylpyrrholidine as povidoneiodine
or as an excipient for oral medicines occurs but is rare.
Miscellaneous agents
Many agents to which patients may be exposed during anaesthesia may be
associated with anaphylaxis, including aprotinin, protamine, heparins,
radiological contrast material, dyes and oxytocin. Anaphylaxis to glycopyrronium
and neostigmine may occur very rarely.
References
1 Axon AD, Hunter JM. Editorial III: Anaphylaxis and anaesthesia – all clear now?
British Journal of Anaesthesia 2004; 93: 501–4.
2 Mertes PM, Laxenaire MC, Alla F. Anaphylactic anaphylactoid reactions
occurring during anaesthesia in France in 1999–2000. Anesthesiology 2003; 99:
536–45.
3 Fisher MM, Baldo BA. The incidence and clinical features of anaphylactic
reactions during anesthesia in Australia. Annales Francaises d’Anesthesie et de
Reanimation 1993; 12: 97–104.
4 Laxenaire MC. Epidemiology of anesthetic anaphylactoid reactions. Fourth
multicenter survey (July 1994-December 1996). Annales Francaises d’Anesthesie et
de Reanimation 1999; 18: 796–809.
5 Laxenaire MC, Mertes PM. Anaphylaxis during anaesthesia. Results of a
two-year survey in France. British Journal of Anaesthesia 2001; 87: 549–58.
6 Lang DM, Alpern MB, Visintainer PF, Smith ST. Increased risk for anaphylactoid
reaction from contrast media in patients on beta-adrenergic blockers or
with asthma. Annals of Internal Medicine 1991; 115: 270–6.
7 Laake JH, Rottingen JA. Rocuronium and anaphylaxis – a statistical challenge.
Acta Anaesthesiologica Scandinavica 2001; 45: 1196–203.
8 Florvaag E, Johansson SG, Oman H, et al. Prevalence of IgE antibodies to morphine.
Relation to the high and low incidences of NMBA anaphylaxis in Norway
and Sweden, respectively. Acta Anaesthesiologica Scandinavica 2005; 49: 437–44.
9 Porri F, Lemiere C, Birnbaum J, et al. Prevalence of muscle relaxant sensitivity
in a general population: implications for a preoperative screening. Clinical and
Experimental Allergy 1999; 29: 72–5.
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10 Fisher M, Baldo BA. Anaphylaxis during anaesthesia: current aspects of diagnosis
and prevention. European Journal of Anaesthesiology 1994; 11: 263–84.
11 Moss J. Allergy to anesthetics. Anesthesiology 2003; 99: 521–3.
12 Pichichero ME, Casey JR. Safe use of selected cephalosporins in penicillinallergic
patients: a meta-analysis. Otolaryngology-Head and Neck Surgery 2007; 136:
340–7.
13 Garvey LH, Roed-Petersen J, Menne T, Husum B. Danish Anaesthesia
Allergy Centre – preliminary results. Acta Anaesthesiologica Scandinavica 2001; 45:
1204–9.
Recognition and clinical diagnosis of anaphylaxis
In a closely monitored patient such as during anaesthesia, when a fall in
blood pressure, change in heart rate or difficulty with ventilation are
noticed, anaphylaxis is so rarely the cause that inevitably treatment is given
for another diagnosis before anaphylaxis is recognised; the response to this
treatment has commonly delayed or even prevented recognition of the true
cause. It is therefore probable that many grade I and II acute allergic
reactions to anaesthetic drugs are missed. Conversely, a cause other than
allergic anaphylaxis seems more likely in around one-third of the patients
referred to specialist centres for investigation of suspected anaphylaxis
during anaesthesia.
Previous history
Any clue that appropriately raises anticipation of anaphylaxis will be helpful.
A previous history of reaction to anaesthetic drugs, antibiotics, other drugs,
chlorhexidine or latex should obviously lead to appropriate avoidance.
Because it is always possible the wrong trigger factor was identified, the
exact details of exposure leading to any previous reaction should be sought
during the pre-operative assessment. Cross-reactivity between non-anaesthetic
drugs such as pholcodine or environmental chemicals containing
quaternary ammonium groups such as cosmetics and detergents has been
proposed as the source of sensitivity to opioids and muscle relaxants: a
history of cutaneous sensitivity to cosmetics or rashes from cough medicines
should raise caution.
Anaphylaxis to amoxicillin and cephalosporins is commonest in asthmatic
smokers who have had multiple courses of these antibiotics without
reacting: the symptoms of anaphylaxis in such a patient are likely to be
initially misinterpreted (quite reasonably) as those expected from anaesthesia
in an asthmatic smoker.
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Clinical features
Although anaesthesia-related anaphylaxis usually results from intravenous
drug administration, administration by other routes, for example cutaneous,
mucosal ⁄ vesical peritoneal, intra-articular or intramuscular may be responsible.
Clinical features include hypotension, tachycardia or bradycardia;
cutaneous flushing, rash or urticaria; bronchospasm; hypoxia; angioedema
and cardiac arrest. If an adverse event such as hypotension or bronchospasm
occurs during anaesthesia it is appropriate to suspect anaphylaxis unless
there exists a significantly more likely cause.
Tachycardia is not invariable: bradycardia is seen in approximately 10%
of patients with allergic anaphylaxis during anaesthesia. Hypotension is the
sole clinical feature in approximately 10% of patients and is likely to be
exaggerated in patients undergoing anaesthesia with neuraxial blockade.
Widespread flushing or urticaria is seen in the majority of patients but the
absence of cutaneous signs does not exclude anaphylaxis. Bronchospasm
may be more common in patients with pre-existing asthma.
Clinical features
Allergic
anaphylaxis
(n = 518), n (%)
Non-allergic
anaphylaxis
(n = 271), n (%)
Cardiovascular 387 (74.7) 92 (33.9)
Arterial hypotension 90 (17.3) 50 (18.4)
Cardiovascular collapse 264 (50.8) 30 (11.1)
Bradycardia 7 (1.3) 2 (0.7)
Cardiac arrest 31 (5.9) –
Bronchospasm 207 (39.8) 52 (19.2)
Cutaneous signs 374 (71.9) 254 (93.7)
Angioedema 64 (12.3) 21 (7.7)
Clinical features of allergic anaphylaxis and non-allergic anaphylaxis occurring during
anaesthesia in France between 1st Jan 1999 and 31st Dec 2000. Mertes PM et al. Anesthesiology
2003; 99: 536–45.
The clinical features usually occur within a few minutes but may be
delayed by up to an hour. Substances to which the clinical reaction may be
delayed include latex, antibiotics, intravenous colloids and Cidex OPA
(used to disinfect surgical instruments). However, an immediate response
does not exonerate these substances. The clinical features of anaphylaxis
to neuromuscular blocking agents usually develop rapidly. Deflation of a
surgical tourniquet may induce anaphylaxis if the allergen has been
sequestered in the limb.
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Immediate management
These management guidelines presuppose that the patient is in the care of an
appropriately-trained anaesthetist and full resuscitation facilities and appropriate vital
signs monitors are available.
There is a wide spectrum of severity and combinations of clinical
features. Although management should be tailored to the individual patient,
there is consensus that adrenaline should be given as early as possible. In
addition to having alpha-agonist activity, adrenaline is a valuable betaagonist
which is inotropic and a bronchodilator, and reduces further
mediator release.
Other causes of hypotension or difficulty in ventilation should be
excluded, for example a misplaced tracheal tube or equipment failure.
Immediate management
1 Use the ABC approach (Airway, Breathing, Circulation). Teamworking
enables several tasks to be accomplished simultaneously.
2 Remove all potential causative agents (including IV colloids, latex and
chlorhexidine) and maintain anaesthesia, if necessary, with an inhalational
agent.
3 Call for help and note the time.
4 Maintain the airway and administer oxygen 100%. Intubate the trachea if
necessary and ventilate the lungs with oxygen.
5 Elevate the patient’s legs if there is hypotension.
6 If appropriate, start cardiopulmonary resuscitation immediately according
to Advanced Life Support Guidelines.
7 Administer adrenaline intravenously. An initial dose of 50 lg (0.5 ml of
1 : 10 000 solution) is appropriate (adult dose). Several doses may be
required if there is severe hypotension or bronchospasm.
8 If several doses of adrenaline are required, consider starting an intravenous
infusion of adrenaline (adrenaline has a short half-life).
9 Administer saline 0.9% or lactated Ringer’s solution at a high rate via an
intravenous cannula of an appropriate gauge (large volumes may be
required).
Secondary management
1 Administer chlorphenamine 10 mg IV (adult dose).
2 Administer hydrocortisone 200 mg IV (adult dose).
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3 If the blood pressure does not recover despite an adrenaline infusion,
consider the administration of an alternative intravenous vasopressor
according to the training and experience of the anaesthetist, for example
metaraminol.
4 Treat persistent bronchospasm with an intravenous infusion of salbutamol.
If a suitable breathing-system connector is available, a metered-dose
inhaler may be appropriate. Consider giving intravenous aminophylline
or magnesium sulphate.
5 Arrange transfer of the patient to an appropriate Critical Care area.
6 Take blood samples (5–10 ml clotted blood) for Mast Cell Tryptase as
follows:
a Initial sample as soon as feasible after resuscitation has started – do not
delay resuscitation to take the sample.
b Second sample at 1–2 h after the start of symptoms.
c Third sample either at 24 h or in convalescence (for example in a
follow-up allergy clinic). This is a measure of baseline tryptase levels as
some individuals have a higher baseline level.
d Ensure that the samples are labelled with the time and date.
7 Liaise with the hospital laboratory (see Appendix lll: Mast cell Tryptase).
Drug doses in children
Adrenaline
Intramuscular
> 12 years: 500 lg IM (0.5 ml of a 1 : 1000 solution)
300 lg IM (0.3 ml of a 1 : 1000 solution) if the child is small
6–12 years: 300 lg IM (0.3 ml of a 1 : 1000 solution)
Up to 6 years: 150 lg IM (0.15 ml of a 1 : 1000 solution)
Intravenous
Intravenous adrenaline may be used in children in acute areas such as
operating theatres or intensive care units by those familiar with its use and if
IV access is already available. Great care should be taken to avoid dose
errors when preparing drug dilutions. Prepare a syringe containing 1 ml
of 1 : 10 000 adrenaline for each 10 kg body weight (0.1 ml.kg )1 of
1 : 10 000 adrenaline solution = 10 lg.kg )1 . Titrate to response, starting
with a dose of one-tenth of the contents of the syringe, i.e. 1 lg.kg )1 .
Often a child will respond to as little as 1 lg.kg )1 . In smaller children,
further dilution may be needed to allow dose titration (check carefully
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for decimal point and concentration errors). The intramuscular route is
preferred where there is no venous access or where establishing venous
access would cause a delay in drug administration.
Hydrocortisone
> 12 years: 200 mg IM or IV slowly
6 to 12 years: 100 mg IM or IV slowly
6 months to 6 years: 50 mg IM or IV slowly
< 6 months: 25 mg IM or IV slowly
Chlorphenamine
> 12 years: 10 mg IM or IV slowly
6 to 12 years: 5 mg IM or IV slowly
6 months to 6 years: 2.5 mg IM or IV slowly
< 6 months: 250 lg.kg )1 IM or IV slowly
Later investigations to identify the causative agent
Any patient who has a suspected anaphylactic reaction associated with
anaesthesia should be investigated fully, but investigations should not
interfere with the immediate treatment of the patient. The anaesthetist who
administered the anaesthetic or the consultant anaesthetist in charge of the
patient is responsible for ensuring that the reaction is investigated.
The patient should be referred to a specialist Allergy or Immunology
centre that has appropriate experience of investigating this type of problem.
Anaesthetic departments should identify a lead anaesthetist for anaesthetic
anaphylaxis. Referral pathways should be agreed prospectively with the appropriate
specialist centre.
Criteria for referral to a specialist centre for investigation
Patients in whom allergic or non-allergic anaphylaxis is suspected should be
referred to a specialist clinic for investigation. A patient should be referred if
there is any of the following:
1 Unexplained cardiac arrest during anaesthesia.
2 Unexplained, unexpected hypotension (for example a decrease of
mean arterial pressure of more than 30 mmHg) which requires active
treatment.
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3 Unexplained, unexpected bronchospasm, particularly if the bronchospasm
is severe, causes a significant decrease in oxygen saturation and is
relatively resistant to treatment.
4 Widespread rash, flushing or urticaria.
5 Angioedema.
A detailed analysis of events surrounding the suspected anaphylactic
reaction must be undertaken. The time of onset of the reaction in relation to
induction and other events is the most important information. All drugs and
other agents to which the patient was exposed before and during the
anaesthetic as well as their timing in relation to the reaction must be recorded.
Details sent to the specialist centre along with a letter of referral must
include:
• A legible photocopy of the anaesthetic record
• A legible photocopy of the recovery room chart
• Legible photocopies of drug charts
• A description of the reaction and time of onset in relation to induction
• Details of blood tests sent and their timing in relation to the reaction
• Contact details of the surgeon and the general practitioner
A standard referral proforma is useful (see Appendix S1 in Supporting
Information).
Tests performed at the specialist centre
Skin tests
Patients should be referred for skin testing as soon as possible after the
clinical event. Skin testing can be performed as soon as the patient has made
a full clinical recovery and the effects of any antihistamine given to treat
the reaction have fully worn off. Skin tests can provide confirmation of
sensitisation to a specific drug but must be interpreted within the clinical
context. There are a variety of techniques and several different criteria are
used for positivity [1–4] so skin testing must be performed by suitably
trained and experienced personnel.
A histamine solution and physiological saline are used as positive and
negative controls respectively. Drugs with anti-histamine activity must be
discontinued a few days before testing. There is no need to discontinue oral
or inhaled steroids.
Skin prick tests are usually done on the volar surface of the forearm. A
drop of the drug is placed on the skin and the skin pricked through the drop
with a lancet. The results are read after 15–20 min.
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Intradermal tests may be performed where skin prick tests are negative.
Although they are more sensitive, they are less specific, more difficult to
interpret and more likely to precipitate a systemic reaction. Intradermal tests
are usually performed on the forearm or back. 0.02 to 0.05 ml of a dilute
solution is injected intradermally and the results read after 20–30 min.
Both skin prick tests and intradermal tests are widely used in the diagnosis
of IgE mediated allergic reactions though the diagnostic value of a positive
test for most drugs is limited due to lack of subsequent challenge data. If the
mechanism is unknown a negative test is unreliable.
All drugs used during anaesthesia may be tested and lists of non-irritant
dilutions have been compiled for both skin prick tests and intradermal tests
[5]. Skin tests are most useful for latex, beta lactam antibiotics and NMBAs.
They are also useful for induction agents, protamine [6] and chlorhexidine.
Intradermal testing may be more reliable for propofol [2]. Skin tests are not
usually performed for opioids because false positive results are common.
However, skin prick testing appears to be informative for the synthetic
opioids fentanyl and remifentanil. Skin tests are not useful for NSAIDs,
dextrans or iodinated radiological contrast media [6] because anaphylaxis to
these agents is not usually IgE-mediated.
Patch tests are the mainstay of diagnosis for contact allergic reactions and
may be useful for diagnosing exanthematous drug rashes but are not helpful
in eliciting the cause of suspected anaphylactic reactions occurring during
anaesthesia.
References
1 Pepys J, Pepys EO, Baldo BA, Whitwam JG. Anaphylactic ⁄ anaphylactoid
reactions to anaesthetic and associated agents. Anaesthesia 1994; 49: 470–5.
2 Fisher MMcD, Bowey CJ. Intradermal compared with prick testing in the
diagnosis of anaesthetic allergy. British Journal of Anaesthesia 1997; 79: 59–63.
3 Berg CM, Heier T, Wilhelmsen V, Florvaag E. Rocuronium and cisatracuriumpositive
skin tests in non allergic volunteers: determination of drug concentration
thresholds using a dilution titration technique. Acta Anaesthesiologica Scandinavica
2003; 47: 576–82.
4 Leynadier F, Sansarricq M, Didier JM, Dry J. Prick tests in the diagnosis
of anaphylaxis to general anaesthetics. British Journal of Anaesthesia 1987; 59:
683–9.
5 Prevention of allergic risk in Anaethesia. Societe Francaise d’Anesthesie et de
Reanimation, 2001. http://www.sfar.org/allergiefr.html [accessed 8 October
2008].
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6 Fisher M, Baldo BA. Anaphylaxis during anaesthesia: current aspects of diagnosis
and prevention. European Journal of Anaesthesiology 1994; 11: 263–84.
Blood tests
Appropriate further blood investigations depend on the drug in question,
and the experience of the specialised laboratory service. Blood samples
for specific IgE tests may be taken at the time of the reaction, or soon
afterwards during that hospital admission. If the results are negative these
tests should be repeated when the patient is seen at the specialist centre in
case the initial results might be falsely negative due to possible consumption
of relevant IgE antibodies during the reaction. The most commonly used
test for allergen-specific IgE uses target allergen or drug bound onto a
three-dimensional sponge-like solid matrix or ‘CAP’ and a fluorescent
detection system. The Radio-AllergoSorbent Test (RAST) uses a radioactive
detection system: it is now rarely used but the name has persisted in
common use.
Specific IgE antibodies against succinylcholine (thiocholine ester) can be
assayed in serum but the sensitivity is relatively poor (30–60%). Tests for
serum IgE antibodies against other neuromuscular blocking drugs are not
available in the UK. Specific IgE antibodies against several antibiotics can
be assayed. These include amoxicilloyl, ampicilloyl, penicilloyl G, penicilloyl
V and cefaclor, however the diagnostic value of these tests is less well
defined. Tests for specific antibodies against latex, chlorhexidine and bovine
gelatin are available.
The presence of drug-specific IgE in serum is evidence of allergic
sensitisation in that individual and provides a possible explanation of the
mechanism and specific drug responsible for the reaction. It is not in itself
proof that the drug is responsible for the reaction. It is important to
emphasise that attribution of cause and effect is a judgement made after
considering all the clinical and laboratory information relevant to the
reaction.
Experimental tests
There is much research into ways of improving the in vitro elucidation of
anaphylaxis. In addition to tissue-bound mast cells, circulating basophils are
also involved in anaphylaxis. During anaphylaxis, proteins such as CD63
and CD203c become newly or increasingly expressed on the surface of
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basophils. These can be detected by flow cytometry which forms the basis
of experimental drug-induced basophil stimulation tests.
Appendix I
Frequently asked questions
Should I give a test dose of IV antibiotic?
No. Predictive testing would require serial challenges with increasing doses,
starting with a minuscule dose and allowing at least 30 min between each
dose. This approach is impossible within the constraints of an operating list.
Should I avoid cephalosporins in a patient who gives a history suggestive of penicillin
allergy?
Most patients who give a history of a penicillin-related rash are not allergic
to cephalosporins. However, there are now many suitable alternatives to
cephalosporins and, unless there are compelling bacteriological indications,
it would be appropriate to consider avoiding first and second generation
cephalosporins. If there is a convincing history of penicillin-related
anaphylaxis, the case for avoiding first and second generation cephalosporins
is stronger.
Should I use crystalloid or colloid in the immediate management of anaphylaxis?
There is no evidence that one is better than the other. If an IV colloid has
already been given to the patient before the appearance of clinical signs of
anaphylaxis, it should be discontinued and either replaced by crystalloid or
replaced by a colloid of a different class; e.g. replace a gelatin-based colloid
with a starch-based colloid.
Should I give an H2-blocking drug as part of the immediate management of
anaphylaxis?
There is no evidence to support the use of H2-blocking drugs in this
situation.
What should I do if a patient with a convincing history of cardio-respiratory collapse
during a previous anaesthetic presents for emergency surgery without having been
investigated for anaphylaxis?
1 Covert cardiac or respiratory disease should be sought in accordance with
normal pre-operative practice.
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2 It may be possible to exclude latex allergy by taking a detailed history
from the patient. If this is impossible, a latex-free environment should be
provided.
3 Inhalational agents are likely to be safe unless the previous collapse was
due to malignant hyperthermia.
4 If previous records are available:
a It would be appropriate to avoid all drugs given during the previous
anaesthetic before the onset of cardio-respiratory collapse, with the
exception of inhalational agents.
b If the patient received a neuromuscular blocking drug before the
collapse, then all neuromuscular blocking drugs should be avoided if
possible because cross-sensitivity is common.
5 If previous records are not available:
a It would be appropriate to avoid all neuromuscular blocking drugs if
possible (the anaesthetist will need to assess the balance of risks).
b Drugs used in local and regional anaesthesia are likely to be safe;
allergy to amide local anaesthetic drugs is extremely rare.
c It would be appropriate to avoid chlorhexidine preparations if possible;
allergy to povidone iodine is less common than allergy to chlorhexidine.
d The previous reaction may have been the result of non-allergic
anaphylaxis; it would be appropriate to avoid drugs that are known to
release histamine, for example morphine.
6 There is no evidence that pre-treatment with hydrocortisone or
histamine-blocking drugs will reduce the severity of anaphylaxis.
What should I say to a patient who wishes to be screened for anaesthetic allergy
pre-operatively?
Unless there is a history suggestive of previous anaesthetic anaphylaxis, preoperative
screening is of no value. The sensitivity and specificity of skin
tests and blood tests is relatively low. If the pretest probability is very low,
i.e. there is no positive history, neither a negative test nor a positive test is
likely to be predictive of outcome.
Should I avoid propofol in patients who are allergic to eggs, soya or nuts?
There is no published evidence indicating that propofol should be avoided
in patients who are allergic to eggs, soya or nuts. Propofol contains purified
egg phosphatide and soya-bean oil. It is likely that the manufacturing
process removes or denatures the proteins responsible for egg allergy and
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soya allergy. However, a cautious approach would seem to be appropriate
in patients with egg allergy or soya allergy.
I don’t have a specialist allergy centre nearby. Should I do my own skin-testing?
The results of skin tests are very technique-dependent and their interpretation
requires specialist training and experience.
Appendix II
Latex allergy
Latex is a natural rubber derived from the sap of a tree (Hevea brasiliensis)
found in Asia which contains several water-soluble proteins, designated
Hev b 1- Hev b 13. Patient contact with natural rubber latex (NRL) during
anaesthesia may occur via several routes including the airway, mucous
membranes, surgical wounds and parenteral injection. An anaphylactic
reaction to NRL during anaesthesia may be immediate, or may be delayed
for up to an hour. The clinical manifestations of NRL anaphylaxis during
anaesthesia tend to be less severe than anaphylaxis due to neuromuscular
blocking drugs.
Classification of latex reactions
1 Systemic reaction: a Type 1 hypersensitivity reaction involving
specific IgE to Hev proteins, mostly to Hev b 5&6. This is the most
severe but least frequent reaction and occurs in genetically predisposed
individuals. The symptoms consist of itching, swelling, rhinitis,
asthma and anaphylaxis. This allergy is life long. A proportion of
sensitized individuals also react to certain fruits cross reacting with
latex proteins.
2 Contact dermatitis: a delayed Type IV hypersensitivity reaction
consisting of an eczematous reaction starting 24–48 h after repeated
skin or mucosal contact with additives used during rubber production.
This is a T cell-mediated, non-life-threatening reaction. It may,
however, predispose the individual to a more severe systemic
reaction.
3 Clinical non-immune-mediated reaction: irritant dermatitis resulting
from a mild irritant effect of the powder in the gloves and that of
disinfectants, sweating etc. This is the most frequent reaction, is limited
to the contact area and is characterised by itching, irritation and blistering
at the side of contact.
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High risk individuals
Approximately 8% of the population is sensitized to latex but only 1.4% of
the population exhibits latex allergy. The following groups are at increased
risk:
• Patients with atopy
• Children undergoing multiple surgical procedures, such as spina bifida,
or children undergoing surgery at a very young age
• Patients with severe dermatitis of their hands
• Healthcare professionals
• Patients with allergy to fruits; most frequently banana, chestnut and
avocado
• Industrial workers using protective gear
• Occupational exposure to latex
Pre-operative assessment
A history of pre-operative symptoms suggestive of latex allergy is present in
approximately a quarter of patients who develop intra-operative NRL
anaphylaxis. A thorough history, including an occupational history, should
be part of the pre-operative assessment. It is useful to ask specifically
whether contact with balloons, condoms or latex gloves provokes itching,
rash or angioedema.
Pre-operative testing
If the clinical history is positive or equivocal, the patient should be referred
for testing before the surgical procedure and surgery should proceed only in
an emergency. In the preoperative situation, it is particularly important to
exclude IgE-mediated sensitivity. The choice of test: either a blood test for
latex-specific IgE, or skin testing may depend on local availability. Current
tests have a sensitivity of approximately 75–90%; skin prick testing may be
more sensitive than blood tests for specific IgE. It is important that skin
prick tests are performed by trained staff. It may be appropriate to proceed
to challenge testing in some patients.
Peri-operative precautions
• If NRL allergy is diagnosed pre-operatively, avoidance is mandatory.
• Care should be taken to avoid introducing additional, unrelated hazards
when latex precautions are implemented in the operating theatre.
• Latex allergy should be recorded in the case-notes and on the patient’s
wrist bracelet.
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• The surgical team and the nursing and anaesthetic support teams should
be alerted.
• There is no evidence that premedication with an anti-histamine or
steroid is useful.
• The operating theatre should be prepared the night before to avoid
the release of latex particles and the patient should be scheduled first
on the list. Evidence is limited regarding the need for this degree of
caution in operating theatres where all latex gloves are of the nonpowdered
type.
• A ‘Latex allergy’ notice should be placed on the doors to the anaesthetic
room and operating theatre.
• Staff traffic should be limited.
• Absolute use of synthetic gloves when preparing equipment and during
anaesthesia, surgery and postoperative care.
• Non-essential equipment should be removed from the vicinity of the
patient.
• The anaesthetic and surgical areas must contain only latex free products.
• Only latex-free dressings and tapes should be applied.
• Equipment in resuscitation boxes and trolleys must contain only latex
free material.
Postoperative investigation of possible latex anaphylaxis
If skin testing and specific IgE testing is negative or equivocal in the
presence of a suggestive history, it may be appropriate for the patient
to proceed to a provocation test with the finger of a latex glove. This
procedure must be performed by trained staff and resuscitation facilities
must be available. Patch testing by an expert is useful in the diagnosis of
delayed (Type lV) hypersensitivity to rubber.
Hospital Latex-Allergy Policy
It is recommended that all hospitals have a latex-allergy policy which
should address the following:
• A named clinical lead for latex allergy
• Instructions for accessing latex-allergy testing
• Latex allergy precautions in the ward and clinic settings
• Latex allergy precautions in the operating theatre environment
• Avoidance of latex sensitization in employees
• Liaison with pharmacy and equipment-procurement departments
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Further reading
Demaegd J, Soetens F, Herregods L. Latex allergy: a challenge for anesthetists. Acta
Anaesthesiologica Belgica 2006; 57: 127–135.
Mari A, Scala E, D’Ambrosio C, Breitenerder H, Wagner S. Latex allergy with a
cohort of non at risk subjects with respiratory symptoms: prevalence of latex
sensitization and assessment of diagnostic tools. International Archives of Allergy and
Immunology 2007; 143: 135–143.
Bousquet J, Flahault A, Vandemplas O, Ameille J, et al. Natural rubber latex allergy
among health care workers: a systematic review of the evidence. The Journal of
Allergy and Clinical Immunology 2006; 118: 447–54.
Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reactions
occurring during anesthesia in France in 1999-2000. Anesthesiology 2003; 99:
536–545.
Suli C, Lorini M, Mistrello G, Tedeschi A. Diagnosis of latex hypersensitivity:
comparison of different methods. European Annals of Allergy and Clinical
Immunology 2006; 38: 24–30.
Appendix III
Mast cell tryptase
1 Mast cells are found within many tissues including lung, intestine and
skin. Tryptase is a protease enzyme which acts via widespread protease
activated receptors (PARs). There are two types of tryptase; a and b,
each of which has several subtypes. Mature b-tryptase is stored in
granules in mast cells and is released during anaphylaxis by a calciumdependent
mechanism. a-tryptase is secreted constitutively by mast cells
and is the form normally found in the blood in health. a-tryptase is
elevated in systemic mastocytosis. Pro-b-tryptase is also secreted
constitutively by mast cells.
2 The normal functions of tryptase include modulation of intracellular
calcium ion and intestinal chloride ion transport in addition to
mediating relaxation of smooth muscle in vascular endothelium and
bronchial smooth muscle. In inflammation, tryptase stimulates the
release of pro-inflammatory interleukins and stimulates further tryptase
secretion by neighbouring mast cells.
3 A variety of pathways may combine to produce anaphylaxis, depending
on the trigger and the susceptibility of the patient. Typically anaphylaxis
results from mast cell activation, and typically this will cause release of
mast cell b-tryptase into the circulation.
4 Anaphylaxis may be caused by basophil or complement activation, both of
which are not associated with a rise in mast cell tryptase. A raised tryptase
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concentration is therefore a marker of anaphylaxis, but anaphylaxis does
not always cause a raised concentration. The greater the rise in concentration,
the greater the probability this was caused by an anaphylactic
reaction but a normal concentration does not disprove anaphylaxis.
5 A rise in serum tryptase simply indicates mast cell degranulation and
does not discriminate between allergic and non-allergic anaphylaxis. It
has been stated that the rise in serum tryptase concentration may be less
marked in non-allergic anaphylaxis.
6 During anaphylaxis, tryptase peaks by approximately 1 h and its half-life
in the circulation is about 2 h: the concentration therefore falls rapidly
following an anaphylactic reaction.
7 The most widely used assay for tryptase is the ImmunoCAP Ò
fluorescence enzyme immunoassay (FEIA) which measures the sum
of a and b-tryptase concentrations. A raised resting concentration is
usually due to a-tryptase, secreted constitutively by the increased
numbers of mast cells in systemic mastocytosis.
8 Although the current tryptase assay has a high specificity, its sensitivity is
relatively low and some cases of anaphylaxis may be missed.
9 The sensitivity and specificity of the tryptase assay depends on the cutoff
point that is chosen to indicate anaphylaxis. Because there is a wide
variation in the base-line plasma concentration of tryptase, the change
in tryptase concentration is more helpful than the absolute concentration
in reaching a diagnosis.
10 Intravenous fluid replacement is usually required during treatment of a
reaction. This fluid will dilute the blood and causes a fall in the
concentration of tryptase measured. This must be taken into account
when evaluating the measured concentration.
11 Following death, the circulation stops and tryptase is no longer removed
from the circulation; samples taken postmortem are helpful in evaluating
whether the terminal events were related to anaphylaxis. A raised
tryptase concentration found at autopsy has lower predictive value than
a sample taken during life. b-tryptase may be raised in trauma or
myocardial infarction.
Further reading
Fisher MM, Baldo BA. Mast cell tryptase in anaesthetic anaphylactoid reactions.
British Journal of Anaesthesia 1998; 80: 26–29.
Enrique E, Garcia-Ortega P, Sotorra O, Gaig P, Richart C. Usefulness of UniCAP
Tryptase fluoroimmunoassay in the diagnosis of anaphylaxis. Allergy 1999; 54:
602–606.
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Payne V, Kam PCA. Mast cell tryptase: a review of its physiology and clinical
significance. Anaesthesia 2004; 59: 695–703.
Brown SGA, Blackman KE, Heddle RJ. Can serum mast cell tryptase help diagnose
anaphylaxis? Emergency Medicine Australasia 2004; 16: 120–124.
Appendix IV
Useful websites
http://www.aagbi.org
The Association of Anaesthetists of Great Britain and Ireland
http://www.bsaci.org
The British Society for Allergy and Clinical Immunology
http://www.immunology.org
The British Society for Immunology
http://www.resus.org.uk
Resuscitation Council UK
http://www.eaaci.net
The European Academy of Allergology and Clinical Immunology
http://www.mhra.gov.uk
The Medicines and Healthcare products Regulatory Agency
Supporting Information
Additional Supporting information may be found in the online version of
this article:
Appendix S1 Anaesthetic Anaphylaxis Referral Form.
Please note: Wiley-Blackwell are not responsible for the content or
functionality of any Supporting materials supplied by the authors. Any
queries (other than missing material) should be directed to the
corresponding author for the article.
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21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Appendix 2a
Frequently asked questions regarding consent (n.b. relating to England and Wales). Please note:
i) When the new Mental Capacity (Northern Ireland) Act 2016 comes into force in Northern Ireland, the
relevant legal provisions in England and Wales and in Northern Ireland will be very similar; for more
information see http://www.legislation.gov.uk/nia/2016/18/contents.
ii)
iii)
For information about the implications of the new Assisted Decision-Making (Capacity) Act 2015 in the
Republic of Ireland, see
http://www.hse.ie/eng/about/Who/qualityandpatientsafety/nau/AssistedDecisionMaking/).
A separate document [Appendix 2b] relates to Scotland.
1. Can obtaining consent for anaesthesia be delegated to another healthcare professional?
It is recommended that the person who gains consent for anaesthesia from a patient is the anaesthetist who will
perform the case. However, for logistical reasons this is not always possible. The person taking consent should
always be an anaesthetist or a physician’s assistant in anaesthesia (PA(A)) who understands the risks and benefits
of the anaesthetic technique and also the alternatives. Surgeons and pre-operative assessment nurses should not
be expected to take consent from patients for general or regional anaesthesia, although this may form part of
their discussion about the procedure. Surgeons may take consent for procedures under local anaesthetic that
they are going to administer.
2. How soon before the procedure should consent be taken?
Consent is a process and not a fixed point in time. The consent process for anaesthesia begins when the
procedure necessitating anaesthesia is first discussed with the patient. At that point the mode of anaesthesia
should be mentioned and written information about anaesthesia should be provided. (For urgent or emergency
cases, provision of written information is not always practical or possible.) For elective cases, further information
can be given at the pre-operative assessment visit. If the patient is seen by an anaesthetist at this point, consent
may be taken for anaesthesia and any associated procedures. However, consent must still be confirmed on the
day of the procedure by the anaesthetist. Verification that consent has been given should be done again in the
anaesthetic room, although this should not be the place where risks, alternatives and additional procedures are
discussed.
3. For how long does consent remain valid?
Consent is event-specific and there is no defined length of time for which it remains valid. It should be taken in
advance of the procedure in question and confirmed immediately before the procedure. It may be withdrawn at
any time.
4. Do patients need to receive written information about anaesthesia and its risks?

Elective patients should be offered written information about anaesthesia and the associated risks. Patients
undergoing urgent or emergency surgery may also benefit from receiving written information although this is not
always possible in practice.
5. What steps should I take to ensure that information is understood?
Potential barriers to comprehension include: language differences; communication difficulties; poor numerical
literacy (quantifying risk); medical illiteracy (understanding medical conditions or terminology); preference for
types of learning (visual or auditory); presence of pain and/or psychological and emotional distress; and lack of
time. The consent process should involve presentation of information in a way that the patient can understand.
This may involve the use of an interpreter, patient information leaflets (translated as required), infographics,
diagrams, credible patient information websites and involvement of a family member, friend or other healthcare
professional. Sufficient time must be allowed for the process and a phased approach may be necessary, allowing
the patient time to absorb information before making a decision.
6. Which risks of anaesthesia do I need to document that I have discussed with the patient?
Ideally, all of the risks that have been discussed should be documented. Anaesthetic charts should have space for
documentation of the discussion leading to consent. Some charts employ a tick-box system as an aide memoire;
such systems can be useful but care must be taken to ensure that they are accurately completed.
7. Should I discuss a technique as a possible option even if I don’t feel I have the skills to use it, e.g. shoulder block
for shoulder surgery?
Discussion of the treatment options should in general include alternative techniques, but it would be
unreasonable to require inclusion of an exhaustive list of treatments that are not available to that patient (thus
the Montgomery ruling states that patients are entitled to decide: “which, if any, of the available forms of
treatment to undergo” and that they should be made aware of: “any material risks involved in any recommended
treatment, and of any reasonable alternative or variant treatments” [10]. The range of ‘reasonable’ anaesthetic
techniques that should be discussed will depend on the individual anaesthetist's ability to provide them and their
availability in that institution/setting, as well as the degree to which they are used in general to provide
anaesthesia for the procedure in question. Thus, for example, it would be standard modern practice to discuss
regional anaesthesia for caesarean section as the preferred option, but to include also discussion of general
anaesthesia both as a technique in its own right and as a back-up technique should regional anaesthesia fail. It is
also accepted practice to offer regional anaesthesia for other procedures, e.g. shoulder surgery, but it is not
universal practice to offer this as the preferred option in all centres, although there are anaesthetists (and units)
that might argue it should be. The Working Party accepts that opinions as to the preference for and availability of
such techniques vary, and would suggest that anaesthetists present and explain the technique that is their/their
unit's standard practice, whilst explaining that there are other techniques that are used elsewhere/by others, and
that the patient may have heard of. If the patient has strong views/preferences around the use of e.g. a regional

or another technique, to the point where he/she would even consider seeking treatment elsewhere, then this
should be discussed with patient and surgeon, along with the implications of such a course of action.
8. What level of detail of anaesthetic technique do I need to discuss with the patient?
Discussion of a treatment (or anaesthetic) should include those components that are of importance to that
patient. However, it would be unreasonable to list every drug and technique that together constitute
‘anaesthesia’, so that the patient may ‘approve’ each one; thus the Montgomery ruling states: “The doctor's duty
is not therefore fulfilled by bombarding the patient with technical information which she cannot reasonably be
expected to grasp” [10]. The broad range of information considered appropriate for discussion with patients
during the consenting process in most cases is provided in Table 2 of the consent guidance [link]; further
discussion should be guided by the patient’s wishes.
9.What level of risk requires me to inform the patient about a particular complication?
It is occasionally stated that complications with a risk < 1% do not need to be discussed with a patient. However,
what might constitute a ‘material risk’ to a particular patient does not depend on its size. The Montgomery ruling
states that: “...the assessment of whether a risk is material cannot be reduced to percentages. The significance of
a given risk is likely to reflect a variety of factors besides its magnitude: for example, the nature of the risk, the
effect which its occurrence would have upon the life of the patient, the importance to the patient of the benefits
sought to be achieved by the treatment, the alternatives available, and the risks involved in those alternatives. The
assessment is therefore fact-sensitive, and sensitive also to the characteristics of the patient” [10].
10. What should I do if a patient indicates that he/she does not wish to know about the risks of anaesthesia?
A patient who refuses to hear about the risks of anaesthesia should be given the opportunity to change his/her
mind and this may require a repeat appointment. Information should not be forced upon a patient and so if a
patient repeatedly indicates that he/she does not wish to hear about the risks of anaesthesia then the
implications of this should be explained and the details of this conversation must be documented in the notes.
11. Is a signed consent form for anaesthesia recommended?
No, a signed consent form for anaesthesia is not recommended if the anaesthesia or anaesthetic procedure is
done to facilitate another treatment (e.g. anaesthesia for surgery) or as part of a larger and inter-related process
(e.g epidural pain relief for childbirth). The statement in the Montgomery ruling, above (see FAQ 8) goes on to
state: “The doctor's duty is not therefore fulfilled by bombarding the patient…, let alone by routinely demanding
her signature on a consent form” [10].
For procedures done as primary therapeutic interventions, e.g. interventional pain procedures, local
practices/policies should be followed and this may include a written consent form.

12. If a patient signs a surgical consent form mentioning general or regional anaesthesia, do I need to discuss the
risks associated with anaesthesia with him/her?
Yes. Unless the patient has received accurate information about the anaesthetic and the risks and alternatives, it
cannot be said that he/she has given his/her consent. A signature on a form does not remove the requirement for
a discussion to take place.
13. My patient is refusing a treatment that is clearly in his/her best interests; does this mean he/she lacks
capacity?
A patient’s capacity to decide is not defined according to whether or not the patient’s decision is in what his/her
doctor believes to be his/her best interests, so if a treatment decision appears not to be sensible, rational or well
considered, it does not necessarily mean that the patient lacks capacity to make it. However, if a decision is highly
irrational and based on persistent misinterpretation it may be that the patient is suffering a mental illness, in
which case a specialist clinical opinion should be sought, since deeming incapacity on the grounds of irrationality
is unlawful.
14. Who can determine whether a patient has capacity?
In most cases, this will be the responsibility of the person providing the treatment and therefore taking consent. If
you doubt your patient’s capacity, the GMC’s Good Medial Practice guidance states that you need to seek advice
from others involved in his/her care and those close to the patient, who may have knowledge of his/her usual
abilities and methods of communication. Gaining opinions of colleagues with specialist experience, for example
neurologists, psychiatrists and speech and language therapists, is also advised. If you are still unsure about a
patient’s capacity, the GMC states that legal advice should be sought, since application to a court may be
appropriate.
15. Under what circumstances can someone else consent on a patient’s behalf?
A person can consent on behalf of another person: (i) if a healthcare proxy has been appointed through a lasting
power of attorney, and the attorney has the power to make the decision in question; (ii) if a court has appointed a
deputy with the appropriate powers; or (iii) if the patient is a child or young person, in which case his/her parents
or those with parental responsibility, local authorities or the courts may consent (although children and young
people should be involved as much as possible in decisions about their care, even when they are not able to make
decisions on their own).
16. When does an Independent Medical Capacity Advocate (IMCA) need to be consulted?
An IMCA should be consulted to assist with decision-making when a patient over 16 lacks capacity, and a
treatment is proposed that is felt by medical professionals to be in his/her best interests but there are no family
or friends to consult. The IMCA acts to represent the patient and will decide if the best interests’ framework has
been appropriately followed, but the IMCA does not make the decision him/herself. If the IMCA feels that due

process has not been followed, he/she will issue a formal challenge. More information about IMCAs can be found
at http://www.scie.org.uk/publications/imca/information/doctors.asp.
17. What if the medical teams disagree as to what is in the patient’s best interests if he/she doesn’t have
capacity?
Assessing the best interests of somebody lacking capacity requires consideration of that person’s point of view,
and what his/her decision would be under the circumstances were he/she to have capacity. Assessment of
somebody's best interests is a process rather than an event, and must take into account any evolving factors
including the urgency and seriousness of the situation. The Mental Capacity Act 2005 includes a checklist for
assessing best interests that includes: ensuring a non-judgemental, non-discriminatory approach; taking acount of
all relevant circumstances including the possibility that the person might regain capacity later; enabling the
person to participate as much as possible; considering his/her wishes, feelings, beliefs and values; and seeking the
views of others (e.g. relatives) where appropriate. No one person or group of people has the ultimate say in
determining best interests over any other, and it is feasible that different people/groups might apply the above
process and conclude that different treatment options represent the patient's best interests. If consensus cannot
be reached, then a Clinical Ethics Committee could be consulted if one exists, but the ultimate decision would rest
with the Court of Protection. An exception to this would be in the case of a valid lasting power of attorney or
court-appointed deputy, when the decision between treatment options would rest with the attorney/deputy (but
even their decisions may be referred to the Court of Protection if they are disputed). See
http://www.39essex.com/content/wp-content/uploads/2016/08/Capacity-Assessments-Guide-August-2016.pdf.
18. Is there a specified lower age limit for ‘age of consent’?
No. Under 16, the treating doctor may decide that the child has 'sufficient intelligence and understanding to
appreciate fully what is proposed'. Young persons (16- and 17-year-olds) are presumed to have the capacity to
consent.
19. Who has parental responsibility?
Mothers automatically have parental responsibility from birth. There are different conditions for whether fathers
and same-sex partners have parental responsibility in the devolved nations and Ireland (see
https://www.gov.uk/parental-rights-responsibilities/who-has-parental-responsibility and https://ejustice.europa.eu/content_parental_responsibility-302-IE-en.do?clang=en).
Other people who may have parental
responsibility are: someone who has successfully applied for it; a legally appointed guardian; a person with a
residence order for that child; the local authority designated to care for that child; or a person with an emergency
protection order for that child.
20. What resources are available to help children, young people and their parents understand about the risks of
anaesthesia?

The AAGBI in association with the Royal College of Anaesthetists and the Association of Paediatric Anaesthetists
of Great Britain and Ireland have produced a selection of leaflets and activities for this purpose as part of the
‘Anaesthesia information for children and young people’ project (see http://www.aagbi.org/news/informationpublic/information-about-anaesthesia-children-and-young-people).
21. What other resources can I use to help me with the consent process?
The AAGBI and the Royal college of Anaesthetists have also produced a series of information leaflets for adults
(see http://www.aagbi.org/news/information-public/information-about-anaesthesia-adults). Some of the other
specialist societies also have information available. In the UK, guidance is available from the GMC (see
http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp).
If your patient lacks capacity to consent and has nobody whom he/she is willing for you to consult, the
Independent Mental Capacity Advocate (IMCA) service should be used (see
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365629/making-decisionsopg606-1207.pdf).
22. What should I do if a patient has given consent for a particular anaesthetic technique and the situation
changes and I think an alternative is indicated? (e.g. a laparoscopic procedure is changed to an open procedure
and regional analgesia is now indicated.)
If the patient has not consented to a particular technique before induction of anaesthesia, then any alternatives
must be in the patient’s best interests. The risks and benefits to that patient must be carefully considered, along
with any preferences expressed during the pre-operative discussion. Ideally, possible changes in circumstance,
e.g. the risk of conversion of laparoscopic cholecystectomy to open, should be anticipated and discussed preoperatively.
23. If the anaesthetist responsible for the case changes, does the consent process need to be repeated?
The anaesthetist caring for the patient is the one responsible for the discussions with that patient regarding that
procedure. If you are satisfied that consent was appropriately taken by someone suitably qualified and trained,
then it is acceptable to continue without repeating the consent process – though it would be good practice to
introduce yourself and confirm consent.
24. Do I need to seek specific consent for an arterial line or central venous catheter?
If this is an intended or likely procedure as part of a patient’s care then it should be discussed with the patient,
along with a discussion of any significant risks and consequences. If the need arises unexpectedly once the patient
is anaesthetised, any additional procedures must be in the patient’s best interests. The decision to perform such
procedures must be recorded in the patients’ notes.
n.b. all websites accessed on 20/10/2016. References refer to those in the main article document.

Appendix 2b
Frequently asked questions regarding consent (n.b. relating to Scotland). (A separate document [Appendix 2a]
relates to England and Wales, and Northern Ireland. For information about the implications of the new Assisted
Decision-Making (Capacity) Act 2015 in the Republic of Ireland, see
http://www.hse.ie/eng/about/Who/qualityandpatientsafety/nau/AssistedDecisionMaking/).
1. Can obtaining consent for anaesthesia be delegated to another healthcare professional?
It is recommended that the person who gains consent for anaesthesia from a patient is the anaesthetist who will
perform the case. However, for logistical reasons this is not always possible. The person taking consent should
always be an anaesthetist or a physician’s assistant in anaesthesia (PA(A)) who understands the risks and benefits
of the anaesthetic technique and also the alternatives. Surgeons and pre-operative assessment nurses should not
be expected to take consent from patients for general or regional anaesthesia, although this may form part of
their discussion about the procedure. Surgeons may take consent for procedures under local anaesthetic that
they are going to administer.
2. How soon before the procedure should consent be taken?
Consent is a process and not a fixed point in time. The consent process for anaesthesia begins when the
procedure necessitating anaesthesia is first discussed with the patient. At that point the mode of anaesthesia
should be mentioned and written information about anaesthesia should be provided. (For urgent or emergency
cases, provision of written information is not always practical or possible.) For elective cases, further information
can be given at the pre-operative assessment visit. If the patient is seen by an anaesthetist at this point, consent
may be taken for anaesthesia and any associated procedures. However, consent must still be confirmed on the
day of the procedure by the anaesthetist. Verification that consent has been given should be done again in the
anaesthetic room, although this should not be the place where risks, alternatives and additional procedures are
discussed.
3. For how long does consent remain valid?
Consent is event-specific and there is no defined length of time for which it remains valid. It should be taken in
advance of the procedure in question and confirmed immediately before the procedure. It may be withdrawn at
any time.
4. Do patients need to receive written information about anaesthesia and its risks?
Elective patients should be offered written information about anaesthesia and the associated risks. Patients
undergoing urgent or emergency surgery may also benefit from receiving written information although this is not
always possible in practice.

5. What steps should I take to ensure that information is understood?
Potential barriers to comprehension include: language differences; communication difficulties; poor numerical
literacy (quantifying risk); medical illiteracy (understanding medical conditions or terminology); preference for
types of learning (visual or auditory); presence of pain and/or psychological and emotional distress; and lack of
time. The consent process should involve presentation of information in a way that the patient can understand.
This may involve the use of an interpreter, patient information leaflets (translated as required), infographics,
diagrams, credible patient information websites and involvement of a family member, friend or other healthcare
professional. Sufficient time must be allowed for the process and a phased approach may be necessary, allowing
the patient time to absorb information before making a decision.
6. Which risks of anaesthesia do I need to document that I have discussed with the patient?
Ideally, all of the risks that have been discussed should be documented. Anaesthetic charts should have space for
documentation of the discussion leading to consent. Some charts employ a tick-box system as an aide memoire;
such systems can be useful but care must be taken to ensure that they are accurately completed.
7. Should I discuss a technique as a possible option even if I don’t feel I have the skills to use it, e.g. shoulder block
for shoulder surgery?
Discussion of the treatment options should in general include alternative techniques, but it would be
unreasonable to require inclusion of an exhaustive list of treatments that are not available to that patient (thus
the Montgomery ruling states that patients are entitled to decide: “which, if any, of the available forms of
treatment to undergo” and that they should be made aware of: “any material risks involved in any recommended
treatment, and of any reasonable alternative or variant treatments” [10]. The range of ‘reasonable’ anaesthetic
techniques that should be discussed will depend on the individual anaesthetist's ability to provide them and their
availability in that institution/setting, as well as the degree to which they are used in general to provide
anaesthesia for the procedure in question. Thus, for example, it would be standard modern practice to discuss
regional anaesthesia for caesarean section as the preferred option, but to include also discussion of general
anaesthesia both as a technique in its own right and as a back-up technique should regional anaesthesia fail. It is
also accepted practice to offer regional anaesthesia for other procedures, e.g. shoulder surgery, but it is not
universal practice to offer this as the preferred option in all centres, although there are anaesthetists (and units)
that might argue it should be. The Working Party accepts that opinions as to the preference for and availability of
such techniques vary, and would suggest that anaesthetists present and explain the technique that is their/their
unit's standard practice, whilst explaining that there are other techniques that are used elsewhere/by others, and
that the patient may have heard of. If the patient has strong views/preferences around the use of e.g. a regional
or another technique, to the point where he/she would even consider seeking treatment elsewhere, then this
should be discussed with patient and surgeon, along with the implications of such a course of action.

8. What level of detail of anaesthetic technique do I need to discuss with the patient?
Discussion of a treatment (or anaesthetic) should include those components that are of importance to that
patient. However, it would be unreasonable to list every drug and technique that together constitute
‘anaesthesia’, so that the patient may ‘approve’ each one; thus the Montgomery ruling states: “The doctor's duty
is not therefore fulfilled by bombarding the patient with technical information which she cannot reasonably be
expected to grasp” [10]. The broad range of information considered appropriate for discussion with patients
during the consenting process in most cases is provided in Table 2 of the consent guidance [link];further
discussion should be guided by the patient’s wishes.
9. What level of risk requires me to inform the patient about a particular complication?
It is occasionally stated that complications with a risk < 1% do not need to be discussed with a patient. However,
what might constitute a ‘material risk’ to a particular patient does not depend on its size. The Montgomery ruling
states that: “...the assessment of whether a risk is material cannot be reduced to percentages. The significance of
a given risk is likely to reflect a variety of factors besides its magnitude: for example, the nature of the risk, the
effect which its occurrence would have upon the life of the patient, the importance to the patient of the benefits
sought to be achieved by the treatment, the alternatives available, and the risks involved in those alternatives. The
assessment is therefore fact-sensitive, and sensitive also to the characteristics of the patient” [10].
10. What should I do if a patient indicates that he/she does not wish to know about the risks of anaesthesia?
A patient who refuses to hear about the risks of anaesthesia should be given the opportunity to change his/her
mind and this may require a repeat appointment. Information should not be forced upon a patient and so if a
patient repeatedly indicates that he/she does not wish to hear about the risks of anaesthesia then the
implications of this should be explained and the details of this conversation must be documented in the notes.
11. Is a signed consent form for anaesthesia recommended?
No, a signed consent form for anaesthesia is not recommended if the anaesthesia or anaesthetic procedure is
done to facilitate another treatment (e.g. anaesthesia for surgery) or as part of a larger and inter-related process
(e.g epidural pain relief for childbirth). The statement in the Montgomery ruling, above (see FAQ 8) goes on to
state: “The doctor's duty is not therefore fulfilled by bombarding the patient…, let alone by routinely demanding
her signature on a consent form” [10].
For procedures done as primary therapeutic interventions, e.g. interventional pain procedures, local
practices/policies should be followed and this may include a written consent form.
12. If a patient signs a surgical consent form mentioning general or regional anaesthesia, do I need to discuss the
risks associated with anaesthesia with him/her?

Yes. Unless the patient has received accurate information about the anaesthetic and the risks and alternatives, it
cannot be said that he/she has given his/her consent. A signature on a form does not remove the requirement for
a discussion to take place.
13. My patient is refusing a treatment that he/she clearly needs; does this mean he/she lacks capacity?
A patient’s capacity to decide is not defined according to whether or not the patient’s decision is what his/her
doctor believes that he/she needs, so if a treatment decision appears not to be sensible, rational or well
considered, it does not necessarily mean that the patient lacks capacity to make it. However, if a decision is highly
irrational and based on persistent misinterpretation it may be that the patient is suffering a mental illness, in
which case a specialist clinical opinion should be sought, since deeming incapacity on the grounds of irrationality
is unlawful.
14. Who can determine whether a patient has capacity?
In most cases, this will be the responsibility of the person providing the treatment and therefore taking consent. If
you doubt your patient’s capacity, the GMC’s Good Medial Practice guidance states that you need to seek advice
from others involved in his/her care and those close to the patient, who may have knowledge of his/her usual
abilities and methods of communication. Gaining opinions of colleagues with specialist experience, for example
neurologists, psychiatrists and speech and language therapists, is also advised. If you are still unsure about a
patient’s capacity, the GMC states that legal advice should be sought, since application to a court may be
appropriate.
15. How do I proceed if the patient does not have capacity to consent to the treatment?
Part 5 of the Adults with Incapacity (Scotland) Act 2000 (‘the AWI Act’) sets out the procedures to be followed. In
most cases, the treating doctor grants a certificate (a ‘section 47 certificate’) confirming his/her opinion that the
patient is incapable of making a decision in relation to the treatment in question, and setting out the treatment
being authorised under the certificate. Assessing the appropriate treatment for somebody lacking capacity
requires consideration of that person’s point of view, and what his/her decision would be under the
circumstances, were he/she to have capacity. Assessment of the treatment that somebody needs is a process
rather than an event, and must take into account any evolving factors including the urgency and seriousness of
the situation. The AWI Act aims to protect people who lack capacity to make particular decisions, but also
supports their involvement in making decisions about their own lives as far as they are able to do so. The
principles to be followed include: considering the benefit of the procedure or treatment to the person; using the
option that restricts the person’s freedom as little as possible; taking the person’s past and present wishes into
account; consulting with relevant others including primary carers, nearest relative, named person, attorney or
guardian (if there is one); and encouraging the person to use existing skills and develop new skills.
16. What if the medical teams disagree as to what treatment the patient needs if he/she does not have capacity?

It is feasible that different people/groups might apply the above process and conclude that different treatment
options are needed. Ultimately, the responsibility rests with the doctor granting the section 47 certificate,
although attempts should be made to reach a consensus among the clinical team, and to consult others (e.g. a
Clinical Ethics Committee if one exists). If there is serious concern about the decision, formal authorisation from
the sheriff court could be obtained by applying for an intervention order under the AWI Act.
17. Under what circumstances can someone else consent on a patient’s behalf?
A person can consent on behalf of another adult: (i) if the patient has appointed a welfare attorney, it has been
confirmed the patient lacks capacity, and the welfare attorney has the power to make the decision in question; (ii)
if the sheriff court has appointed a welfare guardian with the appropriate powers; or (iii) if the patient is a child or
young person, in which case his/her parents or those with parental responsibility, local authorities or the courts
may consent (although children and young people should be involved as much as possible in decisions about their
care, even when they are not able to make decisions on their own).
18. What if the welfare attorney or welfare guardian disagrees with the treating doctor?
Guardians or attorneys cannot demand a treatment that the treating doctor does not believe is clinically justified.
But if they have the appropriate power, they can withhold consent to medical treatment. In such cases, if
agreement cannot be reached, the medical practitioner can seek an independent opinion under s50 of the AWI
Act from a medical practitioner nominated by the Mental Welfare Commission. The nominated medical
practitioner can override the refusal of the attorney or guardian. Ultimately, any interested party can appeal to
the Court of Session for a final decision.
19. Is there a specified lower age limit for ‘age of consent’?
No. A child under 16 may give consent where the treating doctor believes that he/she is capable of understanding
the nature and the possible consequences of the procedure or treatment proposed. Young persons aged 16 or
more are presumed to have the capacity to consent.
20. Who has parental responsibility?
Mothers automatically have parental responsibilities and rights – only a court order can take any of these away. A
father also has these responsibilities and rights but only if:
• he was married to the child’s mother at the time of (or since) the child’s conception, or
• he has been given the responsibilities and rights by a court order, or
• he has made and registered together with the mother, a Parental Responsibilities and Rights Agreement.
The Family Law (Scotland) Act 2006 states that when the birth is registered by both parents and the father’s name
is on the child’s birth certificate, full and equal parental responsibilities and rights are given. This applies only
from May 2006 and is not retrospective.

The position in same-sex relationships is more complicated. When a woman is a parent by virtue of
section 42 of the Human Fertilisation and Embryology Act (HFEA) 2008, i.e. when she is in a civil partnership with
the child’s mother, she will automatically have parental responsibilities and rights. If a woman is the child’s
second female parent by virtue of section 43 of HFEA 2008, i.e. when the mother has agreed that she should be
the child’s second parent and she is registered as such, she will automatically have parental responsibilities and
rights. Where none of these principles applies, there are two ways that a father or the child’s second female
parent can obtain these responsibilities and rights:
• by agreement with the mother (if the mother has not been deprived of some or all of her parental
responsibilities and rights). This agreement must stipulate the date upon which the father or second
female parent is to acquire the responsibilities and rights, and the agreement must be in a prescribed
form and registered in the Books of Council and Session.
• by applying to the Sheriff Court or Court of Session under the Children (Scotland) Act 1995.
The provisions apply only where the child has been conceived as a result of assisted reproduction. If the child is
conceived as a result of sexual intercourse, the civil partner or female cohabitant will not be the child’s parent
though she may accept that child as a child of the family.
Other people who may have parental responsibility are: someone who has successfully applied for it; a
legally appointed guardian; a person with a residence order for that child; the local authority designated to care
for that child; or a person with an emergency protection order for that child.
21. What resources are available to help children, young people and their parents understand about the risks of
anaesthesia?
The AAGBI in association with the Royal College of Anaesthetists and the Association of Paediatric Anaesthetists
of Great Britain and Ireland have produced a selection of leaflets and activities for this purpose as part of the
‘Anaesthesia information for children and young people’ project (see http://www.aagbi.org/news/informationpublic/information-about-anaesthesia-children-and-young-people).
22. What other resources can I use to help me with the consent process?
The AAGBI and the Royal college of Anaesthetists have also produced a series of information leaflets for adults
(see http://www.aagbi.org/news/information-public/information-about-anaesthesia-adults). Some of the other
specialist societies also have information available. In the UK, guidance is available from the GMC (see
http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp). Sources of further advice,
include the AWI Code of Practice on part 5 (see http://www.gov.scot/Publications/2010/10/20153801/0), the
Mental Welfare Commission guidance on Consent to Treatment (see
http://www.mwcscot.org.uk/media/51774/Consent%20to%20Treatment.pdf), and on the use of the AWI in
General Hospitals (see http://www.mwcscot.org.uk/media/340709/awi_in_general_hospitals_final_2.pdf).

23. What should I do if a patient has given consent for a particular anaesthetic technique and the situation
changes and I think an alternative is indicated? (e.g. a laparoscopic procedure is changed to an open procedure
and regional analgesia is now indicated.)
If the patient has not consented to a particular technique before induction of anaesthesia, then the risks and
benefits to that patient of any alternatives must be carefully considered, along with any preferences expressed
during the pre-operative discussion. Ideally, possible changes in circumstance, e.g. the risk of conversion of
laparoscopic cholecystectomy to open, should be anticipated and discussed pre-operatively.
24. If the anaesthetist responsible for the case changes, does the consent process need to be repeated?
The anaesthetist caring for the patient is the one responsible for the discussions with that patient regarding that
procedure. If you are satisfied that consent was appropriately taken by someone suitably qualified and trained,
then it is acceptable to continue without repeating the consent process – though it would be good practice to
introduce yourself and confirm consent.
25. Do I need to seek specific consent for an arterial line or central venous catheter?
If this is an intended or likely procedure as part of a patient’s care then it should be discussed with the patient,
along with a discussion of any significant risks and consequences. If the need arises unexpectedly once the patient
is anaesthetised, the decision to perform any additional procedures must be recorded in the patients’ notes.
n.b. all websites accessed on 20/10/2016. References refer to those in the main article document. See main
article document for acknowledgements.

AAGBI SAFETY GUIDELINE
Arterial line blood sampling: preventing
hypoglycaemic brain injury
Published by
The Association of Anaesthetists of Great Britain & Ireland
September 2014

This guideline was originally published in Anaesthesia. If you wish to refer
to this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Arterial line blood
sampling: preventing hypoglycaemic brain injury 2014. Anaesthesia 2014,
69: pages 380–385
This guideline can be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.12536/abstract
© The Association of Anaesthetists of Great Britain & Ireland

Guidelines
Arterial line blood sampling: preventing
hypoglycaemic brain injury 2014
The Association of Anaesthetists of Great Britain
and Ireland
Membership of the Working Party: T. E. Woodcock, T. M. Cook,
K. J. Gupta and A. Hartle
Summary
Drawing samples from an indwelling arterial line is the method of
choice for frequent blood analysis in adult critical care areas. Sodium
chloride 0.9% is the recommended flush solution for maintaining the
patency of arterial catheters, but it is easy to confuse with glucose-containing
bags on rapid visual examination. The unintentional use of a
glucose-containing solution has resulted in artefactually high glucose
concentrations in blood samples drawn from the arterial line, leading to
insulin administration causing hypoglycaemia and fatal neuroglycopenic
brain injury. Recent data show that it remains a common error for
incorrect fluids to be administered as arterial line flush infusions.
Adherence to the National Patient Safety Agency’s 2008 Rapid Response
Report on this topic may not be enough to prevent such errors. This
guideline makes detailed recommendations on the prescription, checking
and administration of arterial line infusions in adult practice. We also
make recommendations about storage, arterial pressure monitoring and
sampling systems and techniques. Finally, we make recommendations
about glucose monitoring and insulin administration. It is intended that
adherence to these guidelines will reduce the frequency of sample
© 2014 The Association of Anaesthetists of Great Britain and Ireland 1
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contamination errors in arterial line use and capture events, when they
do occur, before they cause patient harm.
....................................................................................................
This is a consensus document produced by expert members of a Sprint
Working Party established by the Association of Anaesthetists of Great
Britain and Ireland (AAGBI). It has been seen and approved by the
AAGBI Board.
Accepted: 5 November 2013
• What other guideline statements are available on this topic?
In July 2008, a National Patient Safety Agency (NPSA) Rapid Response
Report was released [1], highlighting examples of patient harm resulting
from glucose-containing flush infusions contaminating blood samples
drawn from arterial lines [2, 3]. Subsequently, it was reported to
the Safe Anaesthesia Liaison Group in 2011 that the NPSA had
received 169 further incident reports, featuring 31 glucose monitoring
errors (personal communication, Prof. D. Cousins, NHS England).
The Medicines and Healthcare products Regulatory Authority
(MHRA) issued a Drug Safety Update on the issue in 2012 [4].
•
Why was this guideline developed?
Experiment and experience show that compliance with the procedures
required in the NPSA’s 2008 Rapid Response Report, even with good
sampling technique using a simple open arterial line system, is not sufficient
to prevent injury or death arising from sample contamination
error. In a series of 102 cases where a glucose-containing solution was
incorrectly infused, sample contamination error occurred in 30 (personal
communication, Prof. D. Cousins, NHS England). Recent data
show that using incorrect arterial line fluid infusions is a common
error, with an average of one such event reported to the National
Reporting and Learning System every week [5]. More than 30% of
intensive care units have reported recent arterial line errors, with a further
30% reporting errors from operating theatres or the emergency
department [5]. In one case, neuroglycopenia contributed to the
patient’s death [6].
•
How and why does this statement differ from existing guidelines?
The Working Party identified three error-prone processes that can
lead to iatrogenic hypoglycaemia. Our recommendations are
2 © 2014 The Association of Anaesthetists of Great Britain and Ireland

designed to address each of these processes and reduce the likelihood
of active errors and latent risks leading to patient harm [7]. The
error-prone processes are:
• use of arterial flush solution (prescription, dispensing, checking
and administration)
• blood sampling technique for glucose concentration measurement
• administration of insulin to treat apparent hyperglycaemia.
•
For each error-prone procedure, the Working Party systematically
considered whether it was possible or practicable to: eliminate the
procedure; apply safeguard technology; use warning or alarm systems;
specify training requirements for practitioners; and protect the
patient from the consequences of occasional error.
The evidence that informs these guidelines mostly concerns arterial
blood sampling in adult patients. Our recommendations can also be
applied to venous cannulae that are flushed and used for blood sampling.
There may be additional considerations for paediatric practice
that are outside our remit.
Basic knowledge for all practitioners
‘Dextrose’ and ‘glucose’ are interchangeable biological terms for dextrorotatory
glucose (C 6 H 12 O 6 ). Figure 1 illustrates the arrangement of
‘open’ and ‘closed’ systems for maintaining patency and drawing blood
samples from flushed vascular access systems. The open system has a
single three-way tap, close to the vascular catheter, that is used for both
removing residual flush solution and obtaining the blood sample. The
volume of residual fluid between the sampling point and the bloodstream
is referred to as the dead space. To prevent contamination of a
blood sample with flush solution, it has been recommended that 39
dead space volume be withdrawn and discarded (or saved for return to
the circulation) before a sample is taken [8]. However, bench-top experiments
have shown that significant glucose contamination of the blood
sample occurs even with 59 dead space removal when using an open
arterial line sampling system with a glucose 5% flush solution [9]. A
solution of glucose 5% contains approximately 280 mmol.l
1 , hence
contamination of a 1-ml blood sample with just 0.03 ml flush solution
would conceal true hypoglycaemia or make a normal sample hyperglycaemic,
potentially leading to inappropriate insulin therapy. Erroneous
administration of glucose 10% or 20% would result in even greater
© 2014 The Association of Anaesthetists of Great Britain and Ireland 3

Figure 1 Open and closed systems for sampling from arterial lines. The syringe indicated is for removal of dead
space volume and the red arrow indicates the sample drawing point.
4 © 2014 The Association of Anaesthetists of Great Britain and Ireland

contamination. With sodium chloride 0.9% flush, only gross sample
contamination (e.g. due to incorrect sampling technique) will cause dangerous
sampling errors. Contamination of a sample with heparinised
saline also leads to artefactually increased phosphate concentrations.
Erratic or highly varying sequential test results should heighten the suspicion
of blood sample contamination error.
The closed system has a port for removal of dead space beyond a
separate sampling point and, if used as intended by its designers, effectively
eliminates the risk of significant contamination of the sample [9].
Moreover, it reduces the risk of bacteraemia and minimises wastage of
blood because the withdrawn flush and blood can be returned to the
circulation without opening the system.
Nervous tissue is not able to sustain functional or basal metabolic
activity during hypoglycaemia, and prolonged neural glucose deprivation
(neuroglycopenia) leads to permanent or fatal neural injury. Hypoglycaemia
reduces conscious level and causes sympathetically mediated symptoms
of anxiety, tachycardia, tachypnoea, pupillary dilation and
sweating. Beta-blocker therapy blunts some of these symptoms. Hypoglycaemia
is difficult to diagnose clinically in patients with an altered
level of consciousness and in those treated with exogenous catecholamines.
In these patients, practitioners should therefore check for hypoglycaemia
in the presence of a new increase in heart rate or respiratory
rate, sweating, convulsions, pupillary changes, or a fall in conscious
level. Continuous electroencephalography has the potential to detect
neuroglycopenia in monitored patients [10]. Fatal neuroglycopenic brain
injury can occur within two hours of the onset of hypoglycaemia [2].
Neuroglycopenia is therefore not reliably prevented by routine checking
of glucose levels (e.g. once per nursing shift) with blood from an alternative
site.
Sodium chloride 0.9% with glucose 5% has been recommended as
an intravenous fluid for use in paediatric practice [11]. Figure 2 illustrates
how this fluid is particularly easy to confuse with sodium chloride
0.9%. Currently, at least twelve other fluids containing combinations of
sodium chloride, glucose and potassium exist for use in a variety of clinical
circumstances. They all carry increased risk of misidentification,
accidental use as arterial line flush solution and glucose contamination
of blood samples.
Peripheral glucose testing by pricking a finger or ear lobe may be inaccurate
in patients with poor peripheral perfusion, on vasopressor therapy,
or with severe peripheral oedema [12]. Continuous intravascular glucose
© 2014 The Association of Anaesthetists of Great Britain and Ireland 5

(a)
(b)
Figure 2 Appearance of sodium chloride 0.9% and glucose 5% fluid bag
(a) when placed inside a pressure bag and (b) when removed, showing
the ease of confusion with plain sodium chloride. Reproduced from [6],
with permission.
monitoring is under development for introduction into clinical practice
[13, 14], but until that technique is established, it is necessary to draw
frequent blood samples for glucose analysis to guide insulin therapy in
critically ill patients.
Recommendations
The Working Party’s recommendations apply to any clinical areas where
blood is sampled from arterial access devices and includes critical care
areas, operating theatres and emergency departments.
Policy and training
Hospitals must raise awareness among relevant staff of the serious
patient harm that can result from arterial line sample contamination
errors and must have a policy that defines local procedures for arterial
line use, including prescribing, administering and monitoring flush
solutions and blood sampling technique.
Policies about the prescribing, administering and monitoring of
intravenous infusions and policies about intravenous insulin therapy
6 © 2014 The Association of Anaesthetists of Great Britain and Ireland

should be cross-referenced to the arterial line and blood sampling
policy.
All staff involved in the insertion of, management of, or sampling
from, arterial lines must be appropriately trained and competent to deliver
the standards set out in the policy, and performance against these
standards should be regularly audited.
Fluids for flush infusions
Sodium chloride 0.9%, with or without heparin, should be the only solution
to be used for arterial line infusion and flushing. Blood sampling
from a cannula lumen that carries other solutions is not recommended.
Identifying arterial lines
Arterial infusion lines must be clearly identifiable. Labels and colour differentiation
are appropriate measures to achieve this.
Fluid stock and storage
In clinical areas that use arterial lines, bags of sodium chloride 0.9% for
use as arterial line flush should be stored away from fluids for intravenous
use. Bags should be stored in a suitable receptacle and not scattered
across a shelf.
Only those fluid solutions in regular use should be stored in a
clinical area. For example, sodium chloride 0.9% with glucose 5%,
which is recommended for use in paediatric practice, should not be
stored in clinical areas where paediatric practice is unusual. If practicality
dictates that such solutions must be stored, an additional risk
assessment and management plan must be made to prevent their
erroneous use.
Prescription and setting up
An arterial line flush solution must be documented by prescription or
record of administration (e.g. anaesthetic chart) or standard operating
procedure as defined in the hospital’s arterial line policy.
The flush solution must be independently double-checked by a second
practitioner before setting up and attaching to an arterial line. Also
known as independent validation, an independent double-check of a
high-alert medication is a procedure in which two clinicians separately
check, alone and apart from each other, then compare results of each
component of prescribing, dispensing and verifying the high-alert medication
before administering it to the patient [15].
© 2014 The Association of Anaesthetists of Great Britain and Ireland 7

Pressurising devices
All pressurising devices must be designed to permit unimpaired inspection
of the contained flush infusion bag while in use. A fully transparent
front panel is strongly recommended.
Checking during use
The flush infusion bag must be independently double-checked at least
once during each nursing shift and whenever nursing care of the patient
is handed over. This double-check must include removal of the flush
bag from its pressurising device (Fig. 2).
Sampling techniques
To avoid sample contamination with flush infusions, the use of ‘closed’
arterial line sampling systems is recommended.
Where an ‘open’ system is to be used for blood sampling, inevitable
contamination must be kept to a minimum by making the dead space
volume between the sampling port and the arterial lumen as small as
practicable in the clinical situation. The syringe used for removal of
dead space volume must be readily distinguishable from the sampling
syringe. Throughout the sampling process and until the sample syringe
is removed, the sampling technique must avoid flush solution’s entering
the dead space, the sample or any three-way tap at the sampling site.
Glucose concentration thresholds
When an arterial line is used to take blood samples for measurement of
blood glucose concentrations, a value that is unexpectedly high must
trigger a medical review and a check of the blood sampling system for
possible sample contamination error. The source of the blood sample
should be checked to ensure no possibility of sample contamination. If
this is not possible, a confirmatory sample must be drawn from the
most appropriate alternative site.
Initiating and increasing insulin infusions
Before commencing an insulin infusion in a patient not previously
known to be an insulin-dependent diabetic and before increasing an
insulin infusion rate above a policy-defined threshold (e.g. 6 IU.h 1 )on
the basis of samples drawn from a flushed line, there must be a medical
review. The source of the blood sample should be checked to ensure no
possibility of sample contamination. If this is not possible, a confirmatory
sample must be drawn from the most appropriate alternative site.
8 © 2014 The Association of Anaesthetists of Great Britain and Ireland

Abnormal blood tests
A blood test that shows an unexpected abnormality or unusual variation
from previous results should prompt a check of the source of the blood
sample to ensure no possibility of sample contamination. If this is not
possible, a confirmatory sample must be drawn from the most appropriate
alternative site.
Recording trends in measured glucose levels and physiological
variables
Variations in blood chemistry and vital signs are easier to appreciate
from a graphic trend display, which may facilitate earlier detection of
hypoglycaemia. Graphic trend displays, particularly of glucose readings
and of vital signs including heart rate and respiratory rate, are recommended.
Monitoring for signs of hypoglycaemia
Hypoglycaemia should be considered and specifically checked for in any
sedated or unconscious patient receiving insulin therapy who exhibits a
new increase in heart rate or respiratory rate, or sweating, pupillary
changes or a fall in conscious level.
Incident reporting
Any incident causing potential or actual patient harm related to contamination
of blood samples obtained from an arterial line should be
reported to both local and national incident reporting systems. Any
incident causing patient harm must be disclosed to the patient or his/
her next of kin in accordance with local policy.
National monitoring of incidents
National patient safety organisations should monitor the occurrence of
incidents relating to arterial line and flush infusion errors to determine
whether further actions are needed to reduce their incidence.
Engineered solutions
Equipment manufacturers, pharmaceutical suppliers and clinicians should
engage in a collaboration to develop safer systems for the prevention of
arterial cannula clotting. Potential solutions to be considered will include:
• highly visible and easily distinguishable fluid bags for exclusive use
with arterial pressure monitoring and sampling systems.
© 2014 The Association of Anaesthetists of Great Britain and Ireland 9

• special connections between the fluid bag and the arterial pressure
monitoring and sampling system.
• integrated systems, possibly incorporating both the above solutions.
Supporting healthcare providers when errors occur
When errors occur, staff and organisations must “promise to learn and
commit to act” [16]. It is often the systems, procedures, conditions, environment
and constraints faced by healthcare providers that lead to patient
safety problems. Rather than blame individuals, trust should be placed in
the goodwill and good intentions of the staff and attention focused on
learning from (and remembering) errors [16, 17].
Acknowledgements
We are grateful to all individuals and organisations who provided comments
on the first draft of this guideline, and to the following people who
attended a Consensus Conference for Stakeholders at 21 Portland Place
on 10 October 2013: Chris Quinn (Beckton Dickson); Iswori Thakuri and
Markku Ahtiainen (British Anaesthetic and Recovery Nurses Association);
Catherine Plowright (British Association of Critical Care Nurses); Tim
Lewis (College of Operating Department Practitioners); Jane Harper
(Intensive Care Society); Caroline Wilson (Group of Anaesthetists in
Training); Archie Naughton (AAGBI Lay Representative); Desmond Watson
(Medical and Dental Defence Union of Scotland); Gary Duncum and
Hayley Bird (Smiths Medical); Sharon Maris (Teleflex); Clare Crowley
and Mark Tomlin (UK Clinical Pharmacy Association); Graham Milward
(Vygon).
Competing interests
No external funding and no competing interests declared.
References
1. National Patient Safety Agency. Infusions and sampling from arterial lines. Rapid
Response Report. NPSA/2008/RRR006. http://www.nrls.npsa.nhs.uk/resources/?
EntryId45=59891 (accessed 01/08/2013).
2. Sinha S, Jayaram R, Hargreaves CG. Fatal neuroglycopaenia after accidental use of a
glucose 5% solution in a peripheral arterial cannula flush system. Anaesthesia
2007; 62: 615–20.
3. Panchagnula U, Thomas AN. The wrong arterial line flush solution. Anaesthesia
2007; 62: 1077–8.
4. Medicines and Healthcare products Regulatory Authority. Glucose solutions: false
blood glucose readings when used to flush arterial lines, leading to incorrect insulin
10 © 2014 The Association of Anaesthetists of Great Britain and Ireland

administration and potentially fatal hypoglycaemia. Drug Safety Update 2012; 5:
A2. http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON175433
(accessed 01/08/2013).
5. Leslie R, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling
in intensive care: a threat to patient safety. Anaesthesia 2013; 68: 1114–19.
6. Gupta KJ, Cook TM. Accidental hypoglycaemia caused by an arterial flush drug error:
a case report and contributory causes analysis. Anaesthesia 2013; 68: 1178–87.
7. Reason J. Human error: models and management. British Medical Journal 2000;
320: 768–70.
8. Burnett RW, Covington AK, Fogh-Andersen N. Recommendations on whole blood
sampling, transport, and storage for simultaneous determination of pH, blood
gases, and electrolytes. International Federation of Clinical Chemistry Scientific Division.
Journal of the International Federation of Clinical Chemistry 1994; 6: 115–20.
9. Brennan KA, Eapen G, Turnbull D. Reducing the risk of fatal and disabling hypoglycaemia:
a comparison of arterial blood sampling systems. British Journal of Anaesthesia
2010; 104: 446–51.
10. Remvig LS, Elsborg R, Sejling AS, et al. Hypoglycemia-related electroencephalogram
changes are independent of gender, age, duration of diabetes, and awareness status
in type 1 diabetes. Journal of Diabetes Science and Technology 2012; 6: 1337–44.
11. National Patient Safety Agency. Reducing the risk of hyponatraemia when administering
intravenous infusions to children. Patient Safety Alert. NPSA/2007/22.
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59809 (accessed 01/08/
2013).
12. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the
management of hyperglycemia in critically ill patients. Critical Care Medicine 2012;
40: 3251–76.
13. Beier B, Musick K, Matsumoto A, Panitch A, Nauman E, Irazoqui P. Toward a continuous
intravascular glucose monitoring system. Sensors (Basel) 2011; 11: 409–24.
14. Romey M, Jovanovic L, Bevier W, Markova K, Strasma P, Zisser H. Use of an intravascular
fluorescent continuous glucose sensor in subjects with type 1 diabetes
mellitus. Journal of Diabetes Science and Technology 2012; 6: 1260–6.
15. ISMP Medication Safety Alert! Nurse Advize-ERR Volume 6 Edition 12 December 2008.
http://www.ismp.org/Newsletters/nursing/Issues/NurseAdviseERR200812.pdf
(accessed 13/10/2013).
16. National Advisory Group on the Safety of Patients in England. A promise to learn, a
commitment to act – improving the safety of patients in England. https://www.
gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Ber
wick_Report.pdf (accessed 13/10/2013).
17. Smith A. Lest we forget: learning and remembering in clinical practice. Anaesthesia
2013; 68: 1099–103.
© 2014 The Association of Anaesthetists of Great Britain and Ireland 11

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Assistance for the Anaesthetist
A Report by the Irish Standing Committee of the
Association of Anaesthetists of Great Britain & Ireland
2007
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
www.aagbi.org
October 2007

Membership of the working party
Dr Brian Pickering
Dr Ellen O’Sullivan
Dr Rory Page
Dr Anne Bergin
Dr David Honan
Dr John Kennedy
Dr J Loughrey
Dr Carlos McDowell
Dr John McAdoo
Chairman, Working Party
Convenor, Irish Standing Committee,
AAGBI
Secretary, Irish Standing Committee,
AAGBI
Member, Irish Standing Committee,
AAGBI
Member, Irish Standing Committee,
AAGBI
Member, Irish Standing Committee,
AAGBI
Member, Irish Standing Committee,
AAGBI
Co-opted, Irish Standing Committee,
AAGBI
Co-opted, President Irish College of
Anaesthetists

Table of Contents
1. Summary..............................................................................................2
2. Introduction..........................................................................................3
3. Survey of Availability of Assistance for the Anaesthetist.........................3
Setting for Anaesthetic Delivery............................................................3
Anaesthetic Assistance Availability........................................................4
Anaesthetic Assistance Rostering...........................................................4
Anaesthetic Assistance Training.............................................................5
The Future............................................................................................5
4. Detailed Recommendations..................................................................6
Setting for Anaesthetic Delivery............................................................6
Anaesthetic Assistance Availability........................................................6
Anaesthetic Assistance Rostering...........................................................7
Anaesthetic Assistance Training.............................................................7
The Future............................................................................................8
5. Appendix .............................................................................................9
6. References..........................................................................................12

Section 1-Summary
1. The availability of assistance to the anaesthetist is considered to be
of fundamental importance to the safe conduct of anaesthesia, as
recommended by the AAGBI.
2. The Irish Standing Committee considers the availability of trained
assistance to the Irish anaesthetist to be inadequate in relation to the
standards set by the AAGBI.
3. Anaesthetic assistance is most often provided by nursing staff without
a dedicated anaesthetic role.
4. Anaesthetic departments currently have little role in the rostering of
anaesthetic assistants. Communications between anaesthetic assistant
managers and anaesthetic departments are informal and may benefit
from a more structured approach
5. The absence of a nationally identifiable core competency programme
for anaesthetic assistants has led to variable practices within Irish
hospitals.
6. Off-site locations are particularly vulnerable to practice variances
and should be paid special attention when considering anaesthetic
assistance.
7. Early discussion about perceived inadequacies or potentially unsafe
practices should be encouraged.
8. Managers and fund holders should understand the role of the
anaesthetic department in identifying failures in the provision of
adequate anaesthetic assistance. Once notified of inadequacies,
anaesthetic department recommendations should be acted upon in
a timely fashion. Failure to act upon these recommendations should
be cause for the withdrawal of anaesthetic services from the affected
area.
9. The Committee recommends the development of a national core
competencies programme that will contribute to a quality improvement
in anaesthesia delivery.

Section 2-Introduction
The availability of assistance to the anaesthetist is considered to be of
fundamental importance to the safe conduct of anaesthesia 1 . The presence of
such assistance has been shown to reduce the incidence of adverse anaesthetic
events and to improve patient outcome 2 . The purpose of this review by the
Irish Standing Committee of the Association of Anaesthetists of Great Britain
and Ireland (AAGBI) is to place in context the current status of anaesthetic
assistance in Irish hospitals and to make recommendations for the future
development of this service. Our core findings are informed by the results
of our national “Survey of Availability of Assistance for the Anaesthetist”,
conducted during 2006-2007, and the resultant Committee discussions. In
addition, recent changes to Irish legislation 3 mean that there is now a statutory
requirement for the availability of trained anaesthetic assistance during
the conduct of certain procedures, e.g. electroconvulsive therapy (ECT) in
psychiatric hospitals. This is the first time that this requirement has been in
place and we are unaware of any other jurisdiction in which this is the case.
The issues raised for Irish anaesthetists are unclear at present but we believe
that this report addresses a significant information gap and may serve as a
template for future developments.
Section 3-Survey of Availability of Assistance for the
Anaesthetist
This survey was conducted during 2006-2007. The questionnaire was sent to
all accredited training departments registered with the College of Anaesthetists
RCSI. Twelve training departments responded. The key results are summarised
below. (A more detailed view of the questionnaire and of the response is
included in the Appendix).
Setting for Anaesthetic Delivery
The respondents were from a range of hospitals that, in the opinion of the
Committee, represent a cross section of settings in which anaesthesia is
conducted in Ireland. A majority of departments indicated that they regularly

provide cover for off-site locations. These included interventional radiology,
magnetic resonance imaging, computerised tomography scanning, cardiac
catheterisation, cardioversion, endoscopy and ECT.
Responses were received from a number of sub-specialty hospitals including
those that provide paediatric and obstetric services. These settings have
unique assistance requirements.
Anaesthetic Assistance Availability
The availability of trained assistance was generally poor. Only a minority
of hospitals replied that they always have a trained assistant present during
anaesthesia (25%), and most departments did not have trained assistance
available in all of the areas in which they provided anaesthetic cover (62.5%).
About half of the departments replied that they could identify recurrent
circumstances, e.g. time or location, within their hospital that resulted in lack
of adequate assistance being available. One quarter of departments could
recall an instance of error or near miss that could be directly attributed to the
non-availability of assistance for the anaesthetist.
Anaesthetic Assistance Rostering
In Ireland almost all anaesthetic assistants are nurses. As such, anaesthetic
assistants are rostered by a nurse manager in the theatre complex. The
individual manager may be a designated senior anaesthetic nurse or may be
the co-ordinating senior theatre nurse. No department surveyed has input into
the rostering of anaesthetic assistance. Anaesthetic departments are generally
unaware of the criteria employed by nurse managers when deciding who
should be rostered to provide anaesthetic assistance. Only 25% of nurses
rostered were from a dedicated pool of anaesthetic or recovery nurses. The
remainder were from the theatre pool of nurses. This situation continued outof-hours
but 25% of hospitals responded that assistance was more likely to be
drawn from a non-dedicated pool of nurses during this time.

Anaesthetic Assistance Training
There is enormous variability in the type of training that anaesthetic assistants
receive throughout Ireland. The majority of respondents were unclear as to
the exact training that their assistants had received. One hospital has its own
in-house training programme. Some assistants had been on an anaesthetic
assistant training course. Of those departments that knew what training
was provided, the majority response was that the assistants had some local
“on the job” training or exposure to anaesthesia during a theatre course.
Some departments indicated that they were involved in the development of
local training programmes but five departments responded that they had no
involvement in the training of anaesthetic assistants in their hospital.
The Future
Nearly all departments responded that the current level of anaesthetic assistance
available to Irish anaesthetists was inadequate (88%). Non-nursing assistance
for the anaesthetist would be acceptable to the majority of departments (75%)
and most felt that the College of Anaesthetists in conjunction with individual
hospitals should be at the forefront of developing future training programmes.
Many departments felt that lack of communication and interaction between
anaesthetists and those responsible for rostering of assistants was a significant
barrier to their provision. Training deficiencies were identified as another key
barrier.

Section 4-Detailed Recommendations
The following recommendations are the consensus opinion of the Irish
Standing Committee of the AAGBI.
Setting for Anaesthetic Delivery
The Committee notes that most departments provide anaesthetic cover in a
wide variety of off-site locations. It is well recognised that these environments
pose particular challenges for the anaesthetist and can be associated with
higher rates of critical or near-miss incidents. As such, the Committee
recommends that the provision of adequate assistance in these settings
should be a priority for all stakeholders. Settings that fail to provide adequate
assistance should be considered unsafe environments and departments of
anaesthesia should be supported by hospital management to ensure that any
recommendations regarding the provision of assistance in these settings are
complied with.
Anaesthetic Assistance Availability
There is an unacceptably high level of lack of assistance for the anaesthetist
and this could result in critical incidents or near misses within Irish hospitals.
The Committee is of the opinion that adequate assistance should be
immediately available at any site where an anaesthetist is expected to provide
anaesthetic cover.
Departments of anaesthesia should be supported in establishing reporting
mechanisms that identify recurrent circumstances which result in the nonprovision
of adequate assistance for the anaesthetist. Inadequacies thus
identified should be discussed at a departmental level and reported to hospital
managers as appropriate.
Hospital managers should understand the critical importance of anaesthetic
assistance and the dangers that the lack of trained and competent assistance
poses to patient safety. It is the department of anaesthesia’s responsibility to
make hospital management aware of any significant deficiencies. Service
provision should not be undertaken in circumstances in which there is a
resulting identified risk to patient safety. The department of anaesthesia

should be the recognised identifier of such risks and their recommendations
on these matters should be acted upon.
Anaesthetic Assistance Rostering
As the majority of anaesthetic assistants are currently recruited from the nursing
profession, the principle responsibility for rostering should remain with nurse
managers. Communication between relevant departments of anaesthesia
and nurse managers appears to be poor in many of the centres that replied
to our survey. There appears to be significant potential for improvement in
the communication between these key stakeholders. Early discussion about
perceived inadequacies or potentially unsafe rostering practices should be
encouraged.
The skill mix of those individuals rostered for anaesthetic assistance duties
should be discussed and agreed between nurse managers and the department
of anaesthesia. Rostering from a dedicated pool of anaesthetic assistants
is preferable to alternative arrangements. This will encourage a culture of
anaesthetic safety awareness and service development. It is recommended
that agency staff are not rostered to provide anaesthetic assistance.
Rostering arrangements should be transparent. An agreed mechanism should
be put in place to identify those areas in which anaesthetic assistance will
be required on a daily basis. The anaesthetic assistant co-ordinator should
meet with the anaesthetic co-ordinator on a daily basis to discuss service
requirements. This meeting should identify those areas that have particular
assistant requirements and it should identify those areas where no immediate
assistance is rostered. Service planning can then take place in consultation
with the duty anaesthetist rostered to provide anaesthesia.
Anaesthetic Assistance Training
The Committee notes the efforts that have been made at a local level to
introduce training programmes and the success of certain individual training
courses. However, the training of anaesthetic assistants varies widely
throughout Ireland. There are no national, identifiable core competencies
that an individual should attain before being considered a trained anaesthetic

assistant. As such there is little guidance available on who should be
considered competent to act as an anaesthetic assistant. It is the opinion of
the Committee that the lack of a national standard could contribute to errors
or near misses during the peri-operative period. This is most critical in off-site
or isolated areas.
The Future
The Committee recommends the development of a national core competencies
programme consistent with the Scottish Medical and Scientific Committee
published report “Core Competencies for the Anaesthetic Assistant” 4 as
endorsed by the AAGBI. Such a development should identify a multidisciplinary
group involving key stakeholders and should be funded as a Health Service
Executive initiative guided by the Irish Standing Committee of the AAGBI
and the College of Anaesthetists. A national training programme should be
established to train a new generation of anaesthetic assistants. Consideration
should be given to the entry into such a training program of individuals from
non-nursing backgrounds. In the Committee’s opinion, a national training
programme would result in a significant improvement in the quality of
anaesthesia delivery in the Republic of Ireland. This is consistent with the
views expressed in the Hanly Report 5 , “Teamwork in Anaesthesia” 1 and
“Response to Hanly Report” 6 previously published by the AAGBI.

Appendix
Anaesthetic Department Questionnaire
Setting for Anaesthesia Cover
Median [range]
How many beds are in your hospital? 255 [69-680]
How many ICU beds are in your hospital? 4.5 [0-26]
How many theatres do you provide cover for? 2.5 [1-10]
How many off-site locations do you provide cover for? 1 [0-4]
Availability
Is trained assistance for the anaesthetist available YES (37.5%)
in every area that anaesthesia is provided? NO (62.5%)
Is a trained assistant always present during anaesthesia? YES (25%)
NO (75%)
In what circumstances may an assistant not be available? (text entry)
Are there any recurrent circumstances (location or time of YES ( 50%)
anaesthesia) that cause your department particular difficulty? NO (50%)
In the past year, have there been any instances of error or YES (25%)
near miss that could be attributed to the non-availability NO (75%)
of assistance in your department?

Rostering
Who is responsible for the rostering of anaesthetic assistants? (text entry)
Is assistance from dedicated pool of anaesthetic/ Dedicated 25%
recovery nurses or from general pool of theatre nurses? General 75%
Is this the same at night? YES 75%
NO 25%
Do you roster agency staff to provide assistance for the YES (0%)
anaesthetist? NO (100%)
What criteria do you employ when deciding who should
be rostered to provide assistance for the anaesthetist? (text entry)
In the past year, have there been any instances of error or YES (12.5%)
near miss that could be attributed to the rostering of NO (87.5%)
assistance in your department?
Training
Specify the anaesthesia assistance training that those personnel
rostered for assistant duty have received.
10

What training does your department provide for anaesthesia
assistants? (text entry)
In the past year, have there been any instances of error or YES 12.5%
near miss that could be attributed to gaps in anaesthetic NO 87.5%
assistance training in your department?
The Future
In your opinion:
1. Is the current level of anaesthetic assistance adequate? YES 12.5%
NO 87.5%
2. Is non-nursing assistance for the anaesthetist acceptable? YES 75%
NO 25%
3. Where is the most appropriate place to base future
anaesthetic assistance training programmes?
University 12.5% College of Anaesthetists 62.5%
School of Nursing 12.5% Individual hospitals 62.5%
4. What, if any, are the barriers to providing adequate assistance for the
anaesthetist? (text entry)
11

References
1. The Anaesthesia Team, Section 5 “Assistance for the Anaesthetist”
(2005) – AAGBI guideline. http://www.aagbi.org
2. Impact of Anaesthesia Management Characteristics on Severe
Morbidity and Mortality Arbous, M Sesmu et al. Anesthesiology
2005; 102: 257-68.
3. Mental Health Act 2001, Section 59(2) “Rules Governing the Use of
ECT”- (2006) Mental Health Commission R-S59 (2)/01/2006.
4. Core Competencies for the Anaesthetic Assistant- (2006) Scottish
Medical and Scientific Committee.
5. The Hanly Report – June 2003.
6. Response to Hanly Report – (2005) Irish Standing Committee
AAGBI. http://www.aagbi.org
12

13

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
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www.aagbi.org

The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
ISSN 0959-2962 No. 349
AUGUST 2016
SPECIAL ISSUE:
Age and the
Anaesthetist
A report of a working party of the AAGBI, endorsed by the
Royal College of Anaesthetists, with a joint editorial by Andrew Hartle,
President, AAGBI and Liam Brennan, President, RCoA

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Editorial
This issue of Anaesthesia News is devoted to print publication of ‘Age and
the Anaesthetist’. Why has the AAGBI taken this unusual step? It is simply
this: the single biggest challenge facing the NHS is to respond to the vastly
increased demands of an ageing population, not just for our patients but
also for the staff on whom they depend. Quick fixes balance the books; but
recent 'bailouts' mixed cash with efficiencies so this is not sustainable long
term. As more patients live even longer, real term funding per person must
increase to maintain current service provision. Lifestyle changes and new
drugs may both extend life further; one costs little, one (inevitably) costs lots.
Commissioned and approved by the Board of the AAGBI, endorsed by
Council of the RCoA, ‘Age and the Anaesthetist’ has a distinguished
authorship led by former RCoA President Peter Hutton, whose original
idea it was. What began as a lecture has evolved through being an AAGBI
'glossy' to the comprehensive analysis of the impact of age on the individual
anaesthetist, their clinical practice, patients, retirement and the wider NHS.
What has emerged is unlike anything produced previously by either the
AAGBI or the RCoA; devoted to a single topic like a guideline, closer in size
to one of the GAT or SAS Handbooks.
This publication could not be better timed. English trainees will soon have
a new contract, although we now know it isn't one they have agreed.
Negotiations on a new English consultant contract are advanced, but a final
offer has yet to be made. Pension changes have already been introduced,
with the ageing population as one of the major drivers. More people living
longer with more comorbidities will undoubtedly put more strain on the
affordability of healthcare and healthcare workers are not immune to these
pressures.
The implications for anaesthetists of these demographic changes are not
just theoretical. We will all face clinical, personal, financial, ethical and many
other challenges. Contract and pension changes mean all consultants
starting in post today will have to work until they are at least 68 to receive
their pension in full. That extra eight years of service compared to the status
quo may be crucial in determining how those affected cope with longer
working hours, on-call, or shift work. We both (aged 51 and 56) take much
longer to recover from disturbed nights on-call, and would not relish more of
the same in ten years time (and neither may our patients!)
Anaesthetists are not age-immune. Increasing pensionable ages mean all
stakeholders must acknowledge that consultants (or SAS doctors) at 35 and
65 have different and varying mental and physical strengths (particularly
around 24/7 service) which must be intrinsic to job and career plans.
The NHS* evolves in response to the electoral cycle as much as service
needs. It now needs a long-term, sustainable strategy agreed openly by
all major political parties, or to be removed from party politics. Other areas
affecting generations (climate change, pollution, energy and water supply,
pensions) suggest it sometimes requires a disaster to effect change.
Our specialty doesn’t need to wait for a disaster; we hope ‘Age and the
Anaesthetist’ may play a major part in guiding decision-making by our
members, employers and politicians as they prepare themselves and the
NHS for whatever the future holds.
Contents
1.0: Executive Summary 04
2.0: Introduction – what is the problem? 05
3.0: Societal changes and financial issues 06
3.1: Life expectancy 06
3.2: Financial provision for retirement 07
3.3: The current conflicted situation 09
4.0: Age, physiological changes and comorbidities 10
4.1: The ageing process and its impact on
organ function 10
4.2: The role of comorbidity 12
4.3: Healthy life expectancy and survivorship
in good health 13
4.4: Summary of key factors 13
5.0: Workforce patterns and workforce issues 14
5.1: Time in employment and retirement patterns
of the general population 14
5.2: Employment patterns and the retirement
intentions of medical staff 15
5.3: Wellbeing at work: making work possible 16
5.4: The public’s expectations of older professionals 17
5.5: Other professional groups and human factors 19
6.0: Implications for the future: practical aspects
to be addressed 21
6.1: Considerations for the anaesthetist 21
6.2: Considerations for the employer 23
6.3: The role of the Government 25
6.4: The role of the public 26
Appendix 1: Working party members 26
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: anaenews@aagbi.org
Website: www.aagbi.org
Anaesthesia News
Managing Editor: Upma Misra
Editors: Phil Bewley (GAT), Nancy Redfern, Richard Griffiths, Sean Tighe,
Mike Nathanson, Rachel Collis, Felicity Platt, Gerry Keenan and Elizabeth McGrady
Address for all correspondence, advertising or submissions:
Email: anaenews@aagbi.org
Website: www.aagbi.org/publications/anaesthesia-news
Andrew Hartle
President, AAGBI
Liam Brennan
President, RCoA
Editorial Assistant: Rona Gloag
Email: anaenews@aagbi.org
Design: Chris Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Email: chris@aagbi.org
Printing: Portland Print
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*it is likely that the future will see
divergence of the taxation, funding and
political models of the NHS in England
Copyright 2016 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
Advertisements are accepted in good faith. Readers are reminded that
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Anaesthesia News cannot be held responsible in any way for the quality
Anaesthesia News August 2016 • Issue 349
or correctness of products or services offered in advertisements. 3

Age and the
Anaesthetist
1.0: Executive Summary
• The effects of ageing are inevitable, but the rates of physical
and psychological change are highly variable from person
to person. A one-size retirement strategy cannot fit all and
necessarily be compatible with patient safety. Although the
volume of data is small, there is evidence emerging that the
anaesthetist’s age per se, could be a risk factor for anaesthetic
safety.
The report of a working party of the AAGBI*
Working Party Members
Peter Hutton (Chair)
Mary Baker MBE
Carol Black DBE
Tony Giddings
Richard Griffiths (AAGBI)
William Harrop-Griffiths (RCoA)
Guy Hirst
Nancy Redfern (AAGBI)
David Shipway
*This report has been endorsed by the Royal College of Anaesthetists
For citation purposes:
Hutton P, Baker M, Black C, et al. Age and the Anaesthetist. AAGBI
Working Party Report. March 2016. Anaesthesia News 2016; 349: 3-27.
‘Every generation
Blames the one before
And all of their frustrations
Come beating on your door’
• There are considerable benefits to be obtained from reviewing
how other safety-critical industries, such as airline, nuclear
power, transport, fire-fighting, and oil extraction, have managed
the problems of the ageing employee. These have involved
considerations of hours of work, optimisation of the workplace
and competence testing.
• The NHS, as the major employer of anaesthetists, has an onus
upon it to anticipate the demographic workforce changes
that will parallel the planned increases in retirement age and
to make appropriate adjustments to the working environment,
working practices and the job plans of older workers.
• As the public ages, the proportion of patients with significant
comorbidities who require anaesthesia will increase. Older
anaesthetists will need to remain capable of managing this
population. Given the current nature of annual appraisal and
revalidation, the possibility of introducing processes to confirm
workplace competency needs to be considered.
• The public has a reasonable expectation that professional
groups will manage their practitioners to ensure they are
capable of undertaking the duties for which they are employed.
It is important that anaesthesia acts now to anticipate the
problems of the future. Leaving things to natural evolution and
chance is a too high-risk strategy to be compatible with both
patient safety and the best interests of individual anaesthetists.
• The implications of increased life expectancy and economic
projections have resulted in unprecedented pressures on the
long-term payment of state and salary-related pensions.
• There are demonstrable positive returns in wellbeing and
income from remaining in employment, but the effects of
removing a mandatory retirement age on safety-critical jobs,
such as that of an anaesthetist, have not been evaluated.
• Current retirement patterns in medicine may well reflect ‘selfselection’
in terms of an individual being able to carry out the
demands of a consultant post safely. From the best available
data, > 40% of consultants expressed an intention to retire
between 56 and 60, with a similar percentage intending to
go before 65 years. Only 3% intended to continue beyond
65 and at present the over-65s on the UK’s General Medical
Council (GMC) register represent £115 billion and is increasingly difficult to contain.
The combination of these factors and their projected costs is a huge
burden for current and future governments. The single most effective
strategy to manage the increasing costs is simply to decrease the
period for which government-funded pensions (work-related and
basic state) are paid to individuals. Since it is not possible to affect
the date of death, this has resulted in the UK Government increasing
the retirement age for both the basic state pension [4] and public
sector salary schemes, and increasing a person’s monthly financial
contributions to the latter.
These changes will impact on medical staff in two ways:
• In order to make adequate pension provision for their own future,
they may have to stay in work longer than they had intended.
• The patient population will age and present with more
comorbidities, adding greater complexity to routine surgical
procedures.
Increasing the retirement ages of medical staff in the presence
of greater patient complexity is an open-ended experiment with
considerable potential for adverse outcomes for all concerned.
It is important for those in work to understand the implications for
themselves in providing finance for their retirement while retaining a
high quality of delivery of care, and for employers to make changes
that enable older workers to remain at work.
This report on Age and the Anaesthetist looks at the various facets of
this new social and professional construct with a view to assessing
and anticipating its impact on our specialty and its practitioners. In
doing so, it not only evaluates the consequences for anaesthetists
themselves, but also touches on the implications for the wider
workplace environment and for other staff with whom we work.
Note: All references in this document can be found
with the online version of this issue
Mike and the Mechanics, 1988
www.aagbi.org/AgeandtheAnaesthetist
4 Anaesthesia News August 2016 • Issue 349 Anaesthesia
Anaesthesia
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3.0: Societal changes
and financial issues
3.1: Life expectancy
Life expectancy is defined as the average number of years of life
remaining at a particular age. It is a blunt metric that when applied to
the newborn is used to describe the average duration of life of a defined
population set. It includes many factors including infant mortality,
country, profession, gender, the supply of food, the effects of wars and
epidemics, and the diseases associated with age. Importantly, what
total life expectancy at birth does not do is to predict with any accuracy
the age at which those who have reached adulthood actually die.
It is frequently stated that over millennia, life expectancy has continued
to increase. While statistically true, this unrefined statement conceals
the causes of this trend. There are many cases in ancient history of
people living to an age which would meet current expectations.
Sophocles died aged 90 in 406 BC, and Socrates died aged 70 in
399 BC. This anomaly of the typical age at death differing from life
expectancy is clearly explained in the figure below 1 which plots the
probability of dying against age in ancient Rome.
1000 live births – the lowest rate on record. This compares with 11.1
deaths in 1981, a 62% decrease. In the last 15–20 years, there has
however, been a marked change in society’s demographics that has
been due to the increasing numbers of adults surviving into old age,
i.e. a genuine increase in life expectancy based on longevity rather than
improvements in child and maternal health. Data from the UK’s 2011
Census [5] showed that in England and Wales, 1 in 6 of the population
was aged > 65 years, whereas only 1 in 16 of the population was
aged < 5 years. The current life expectancy in the UK as people age is
shown in the table below.
Life expectancy by sex and age. National Life Tables, Office for
National Statistics, UK, 2011–2013
Current age; years
Male life
expectancy;
years
40 40.3 43.6
45 35.6 38.8
Female life
expectancy;
years
50 31.0 34.1
Probability of death
The probability of dying at a given age in the Roman Empire
It can be seen that, at birth, the infant mortality rate was over 1 in 3,
yet for those who survived birth, this rate of mortality did not return
until > 60 years of age. The death rate from 15–35 years of approximately
10% was the effect of warfare on men and maternal death in women.
Since antiquity, infant mortality has steadily decreased, and with it both
the average life expectancy at birth and the size of the population have
increased. In the UK, the infant mortality rate in England and Wales
continues to decrease; in 2011, there were just 4.2 infant deaths 2 per
55 26.6 29.5
60 22.3 25.1
65 18.3 20.8
70 14.5 16.7
75 11.2 13.0
80 8.2 9.6
85 5.8 6.8
This trend, first noted over two decades or so ago, continues. For both
mortality and disability, overall health has improved substantially in
absolute terms in the UK between 1990 and 2010. During this period,
life expectancy increased by 4.2 years [6]. Illustrative projections are
as follows:
• About one-third of babies born in 2012 in the UK are expected to
survive to celebrate their 100th birthday.
• More than 95,000 people aged 65 in 2012 are expected to
celebrate their 100th birthday in 2047.
• The total number of centenarians is projected to rise from 14,500
in 2012 to 110,000 in 2035.
• 10% of current 65-year-old males and 15% of current 65-year-old
females will become centenarians.
As the population ages and more people become economically inactive
(discussed more fully in Section 3.3), more of the burden of providing
public finance from taxation falls on the young, who are decreasing in
number. This is a major funding problem for the Government.
This trend towards an older population with a higher median age
and requiring more taxable income from the young for its support is
also true worldwide, as shown in the diagram below from the World
Health Organization [7]. In 2010, an estimated 524 million people
were aged 65 or older (8% of the world’s population). By 2050, this
number is expected to nearly triple to about 1.5 billion, representing
16% of the world’s population. Although developed countries have the
oldest population profiles, the vast majority of older people – and the
most rapidly ageing populations – are in less developed countries.
Between 2010 and 2050, the number of older people in less developed
countries is projected to increase more than 250%, compared with a
71% increase in developed countries. This raises major issues for
overseas aid policies.
3.2: Financial provision for retirement
Private pensions
The plight of those having insufficient funds to live out their life in relative
comfort was first addressed in the 18th century by the Presbyterian
Church in Scotland. Under the Law of Ann (1672), the widow and
children of a deceased minister of the Church of Scotland received
only half a year’s stipend in the year of the minister’s death. After that
they faced penury. Two ministers, Robert Wallace and Andrew Webster,
along with the Professor of Mathematics at Edinburgh, Colin Maclaurin,
decided to tackle this injustice.
In gathering data they found that there were approximately ‘930
ministers in life at all times’, of whom ‘27 died yearly’, leaving ‘280
widows living at any one time’ [8]. From annual premiums paid by
ministers, the Fund for a Provision for the Widows and Children of the
Ministers of the Church of Scotland 3 was established. The contributions
were set at a level so that, when invested, there was sufficient income
to meet the payments to the beneficiaries. This was the first actuarial
forecast to determine what contributions had to be made during one’s
working life to provide for benefits during retirement or after death.
As such, it formed the model for innumerable other ‘fully-funded’
independent schemes. The Universities Superannuation Scheme, and
most industrial company and private pensions, are structured in this
way. Many clinical academics are in the Universities Superannuation
Scheme.
As a result of the increasing longevity of new entrants, most of these
actuarially-determined private pensions are moving away from final
salary benefits (where the pension is a proportion of the final salary
determined by the number of years of contributions), to defined benefit
schemes where the returns relate to the individual’s total contributions
made and estimated years of life rather than the final salary.
1
Figure taken from the work of Parkin and presented by Harlow M, Laurence R. Growing Up and Growing Old in Ancient Rome. London: Routledge, 2002. Fig 1.1, p 9.
2
An infant death is defined as the death of a child aged less than 1 year old.
3
This grew steadily from its inception to become the general insurance and pension fund now known as Scottish Widows.
6 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 7

The pace of private pension reform has accelerated over the past
decade. The Pensions Act 2008 instructed that all employees over 22
years of age and below the state pension age 4 should be automatically
enrolled into a qualifying workplace pension scheme between 2012
and 2016. From October 2017, all private sector employers have
to contribute a minimum of 3% to an employee’s pension with the
employee contributing at least 4%.
‘Old-age’ or basic state pensions
In the UK an ‘old-age’ or basic state pension is paid from current
taxation to everybody reaching the state pension age who has made
compulsory or voluntary National Insurance contributions during the
whole or part of their working lifetime.
Publically funded pensions of this type, which aimed to provide
support during the life remaining when work was no longer possible,
were introduced (probably as a political manoeuvre to wrong-foot his
socialist opponents) by Bismarck, the Chancellor of Germany, in the
Old Age and Disability Insurance Bill of 1889. This provided a state
pension funded jointly by those in work and the state for all those
retired from work and > 70-years-old. Less than 10% of the population
lived to benefit.
In Britain at the beginning of the 20th century, the only general
support for old age was the Poor Law. None but a small number of
people received a proper pension or had made private insurance
provision. The consequent extent of poverty in the elderly resulted in
Lloyd George’s Old Age Pensions Act (1908) [9], which paid a noncontributory,
means-tested pension to each person aged over 70 from
1 January 1909. Through a series of subsequent legislative initiatives
over ensuing years, the pensionable age was set at 60 for women and
65 for men. The National Insurance Act (1946) created a universal
social insurance system based around flat-rate benefits (at the same
level for all contingencies) in return for flat-rate contributions. This still
forms the basis for the current basic state pension. On average, the
benefits from the basic state pension represent over half the incomes
of those currently retired [10].
Of great importance in state-funded pensions is the ‘support ratio’,
which is an important indicator of the pressures that demographics
pose for a state pension system. It measures how many people there
are of working age (20–64 years) relative to the number of retirement
age (over 65 years): this is effectively the ratio of the number of
economically active people in relation to those drawing benefits. Data
from the Organisation for Economic Co-operation and Development
[11] shows the following for the UK from 1950 to 2050.
Year
Support ratio
1950 7.2 to 1
1980 5.1 to 1
2010 3.5 to 1
2050 1.8 to 1
It is clear that the situation pertaining to when the welfare state started
is very different from that today, and things will get steadily worse.
Sometime before 2050, on average, two working people will be paying
the full basic state pension for one retired person.
To manage these unprecedented trends, the Pensions Act (2007)
introduced a number of changes to state pensions. The most important
was to provide for gradual increases in the state pension age for men
and women, from 65 to 68 between 2024 and 2046. The Pensions Bill
(2011) speeded up the pace of the increases of the 2007 Act: women’s
state pension age would rise to 65 by November 2018 and for both
4
This is the age determined by government at which the basic state pension will be paid.
men and women would reach 66 by 2020. The 2013/14 Pensions Bill
and the Chancellor's 2013 Autumn Statement set out a framework
within which the state pension age would be regularly reviewed in the
future. They anticipated that an increase to 68 years and, later, to 69
years would occur sooner than in previous estimates.
Public sector employment pensions
It has been the norm for many years for employees in the public sector
to be enrolled automatically in a final salary pension scheme. However,
there are no individual ‘pension pots’ with people’s names on them; the
pension contributions made over a professional lifetime are not saved
as hypothecated taxes for future use. Furthermore, even if there were
proper ‘pension pots’, the total contributions throughout life would not
meet the lifetime benefits.
The NHS (and the public sector in general) thus has an ‘unfunded’,
or ‘pay-as-you go’, scheme paid out of general taxation as part of the
cost of providing public services. In its elemental form this is essentially
a Ponzi scheme whereby younger workers pay taxes to support
those who have retired. Long-term, such a scheme only works when
the population is growing and when most retirees do not live for too
long. When there is a national financial crisis or low economic growth
combined with a simultaneous increase in beneficiaries, maintaining
these payments is a major problem for the Government.
The four largest pay-as-you-go public sector schemes [12] are:
• The Armed Forces Pension Scheme (covering the UK).
• The Principal Civil Service Pension Scheme (for England, Scotland,
Wales and some employees in Northern Ireland).
• The NHS Pension Scheme (for England and Wales).
• The Teachers’ Pension Scheme (for England and Wales).
These four schemes have accounted for over 75% of total payments
from UK public service pay-as-you-go pension schemes in recent
years. They are all of the defined benefit type, in which the pension
that a retired employee receives depends on the final salary earned
and the number of years of service. In accordance with their terms and
conditions, the schemes usually pay a lump sum when an employee
retires, followed by a regular pension until the death of the pensioner
and any eligible dependents. Combined, the schemes had 6.5 million
members at 31 March 2009, comprising 2.75 million current staff, 1.59
million previous employees who had earned pensions but were not yet
eligible to draw them, and 2.13 million pensioners, i.e. there were fewer
people contributing than there were those eligible to draw benefits.
These schemes have a major current and future funding problem. Total
payments to pensioners in the four schemes increased by 38% (a 26%
real-terms increase), in the decade from 2000 to 2010, the dominant
factor being the 23% increase in the number of pensions paid.
3.3: The current conflicted situation
Through legislation, the Government sets:
• An annual allowance for the maximum amount of pensionable
contributions that qualify for tax relief in any one year.
• A cap (the lifetime allowance) on the maximum total pension assets
an individual can hold without incurring extra tax on its benefits.
The Finance Act (2011) contained a number of changes to the tax
regime for both private and public sector funded pensions of which the
most important were:
• A decrease in the annual contributions allowance from £255,000 in
2010/11 to £50,000 from 2011/12 onwards.
• A decrease in the lifetime allowance from £1.8 million to £1.5 million
from April 2012. Any amounts in excess of the lifetime allowance
are subject to a tax charge of 25% (in addition to income tax) if the
benefits are paid as a pension, or a 55% tax charge if they are paid
as a lump sum.
For many NHS doctors (and especially those who have made additional
private pension provision), the lifetime allowance is being reached in
their late 50s or early 60s. It is calculated as 5 :
Private pension assets + NHS lump sum + (20 x the annual NHS
pension)
For a doctor with no additional private pension, retiring from an annual
salary of £100,000 per annum with 40 years’ contributions results in a
lifetime allowance of:
£150,000 (lump sum) + (20 x £50,000) = £1,150,000
The lifetime allowance was introduced in 2006 at a level of £1.5 million.
It then increased each year to 2010, when it reached a level of £1.8
million. Since 2010, there have been a number of pension reforms that
have led to the lifetime allowance being further reduced. The current
level of the lifetime allowance in the 2015–16 tax year is £1.25 million and
this will reduce further to £1 million from April 2016 6 as the Government
tries to decrease its expenditure on pension tax relief.
The financial paradox of this for doctors and other professionals (who
in relation to the general population have earnings and pension benefits
well into the upper quartile), is that whereas the Government would
like them to continue to work and contribute to the economy through
productivity and taxation (to optimise pension returns and minimise
tax contributions), they are retiring on financial grounds while still fit for
work. Some, but not all, return to work after retirement. In this situation,
once having officially retired and returned, the new contract will have no
continuation of time-accumulated benefits such as sick leave.
As a result of the progressive cost of meeting retirement benefits, public
sector schemes have recently undergone significant modifications.
Following changes for new joiners and existing members who opted to
convert in 2008, on 1 April 2015 the NHS pension scheme was modified
again [13]. The 2015 NHS Scheme is a Career Average Revalued
Earnings scheme. This is a form of defined benefit pension scheme,
which means you get a guaranteed level of benefit at retirement payable
according to a fixed formula related to totalled annual contributions.
In a Career Average Revalued Earnings scheme, your pension reflects
your pensionable pay throughout your career. The pension you earn
each year is based on actual pensionable pay in that ‘scheme year’
and is increased by a set rate linked to inflation (known as ‘revaluation’)
each year up to retirement or leaving. A ‘scheme year’ runs from 1 April
of one year to 31 March of the following year. The final pension payable
is calculated by adding together the revalued pensions earned in each
year of membership. Under these new arrangements:
• The normal pensionable age at which benefits can be taken
without reduction is the same as the state pension age at that time,
i.e. the normal NHS ‘contributory’ pensionable age will increase as
set by the future legislation that defines the state pensionable age.
At present, this means it will be 66 years for both men and women
by 2020.
• Employees can contribute until they are 75.
• Members’ contributions vary from 5% to 14.5% (increasing with
salary), and the employer pays 14%. The Government has reserved
the right to alter these figures.
• The Pensions Policy Institute estimates that reforms to the NHS
pension schemes will decrease the average value of the benefit
offered across all scheme members by more than a third [14].
• An important feature of the new scheme is that because pension
benefits are accumulated annually, it more easily allows for career
breaks and for reduced hours closer to retirement age.
In summary, the current situation is confusing. On the one hand, the
imposition of the lifetime allowance on existing final salary schemes is
encouraging earlier retirements for high earners such as consultants.
On the other hand, the future will see higher contributions, lower benefits
and an increasing age at which contributory and state pensions will be
paid. Furthermore, the application of the lifetime allowance will decrease
the appetite for making further conventional private pension provision.
It is clear that future arrangements will not match the traditional NHS
pension benefits. The age of retirement will increase and individuals
will be increasingly responsible for their own financial provision in
retirement.
Very importantly, the effect of the proposed changes on the health of
older consultants, their ability to maintain complex sophisticated skills
and their ability to care for an increasingly complex patient population
appears not to have been considered.
5
The annual pension is multiplied by 20 to calculate the ‘virtual pot’ that would be required to generate the value of the annual pension from an annuity at 5%. Since the global
financial crisis there have been very low or zero interest rates, but the multiplier has not been adjusted. If it ever were to be adjusted, the effect on tax payable on pension income
could be considerable.
6
Data from the Pensions Advisory Service. http://www.pensionsadvisoryservice.org.uk
8 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 9

4.0: Age, physiological
changes and comorbidities
4.1: The ageing process and its impact
on organ function
The ageing process
Ageing is a complex biological process that remains inadequately
understood. It is characterised by a progressive decrease in organ
reserve that increases the vulnerability of an individual to organ
dysfunction and failure. However, ageing is very unpredictable and
its effects are heterogeneous. Genetic factors interact with those of
the environment to influence both rate and extent of ageing. Twin
concordance studies suggest that 25% of ageing variation can be
accounted for by genetics, while 50% is due to environmental factors
[15–18]. While a range of environmental agents is known to play a role,
how these will affect the ageing of each exposed individual is extremely
difficult to predict. The average progress of ageing in a cohort is
predictable, but the individuals within it show large and unpredictable
variability.
Impact of ageing on organ function
Ageing may affect physical performance in three broad categories:
1. Disruption of physiological rhythms. Physiological circadian
rhythms such as sleep and endocrine axes are altered with ageing.
2. Loss of physiological complexity. Results in functional decline
of the organism by diminishing the range of available, adaptive
responses to the innumerable stressors of everyday life [19].
3. Homeostenosis. This represents the progressive loss
of physiological reserves and inability to compensate for
physiological stressors. Its most extreme manifestation is frailty.
In the frail individual, most physiological reserves are employed to
maintain basal organ function. A subsequent external challenge
may result in loss of organ function. In the frail, this typically
presents with failure of complex neurophysiological processes
such as ambulation, balance, continence and cognition. This is
shown as a conceptual graphic below [20].
The processes of ageing are diverse and, even before a state of frailty
is reached, ageing can affect physical performance. Circadian rhythm
disruption and an inability to adapt to changes in the sleep-wake cycle
may have implications for 24-hour working in advanced age [21].
Cardiovascular changes include those of anatomical and decreased
physiological variation in heart rate [22]. Both these lead to an overall
reduction in cardiovascular peak performance [23]. Similar changes
are seen across other key organ systems, e.g. ageing also affects
parameters of pulmonary function with decreases seen in the forced
expired volume in one second (FEV1) and the forced vital capacity [24].
Neurological ageing is characterised by neuronal loss and decrease in
white matter volume [25]. Changes also occur at a cellular level, with
reduction in receptor expression and neurotransmitter function [26].
These factors translate into measurable neurocognitive parameters,
including decreases in cognitive processing speed [27].
Decreased neurocognitive testing performance is seen with advancing
age in a range of cognitive domains [28], but particularly within
executive planning and function. Presbyacusis [29] and presbyopia
[30] may also affect sensory input into the ageing neurological system
[31]; this may synergistically combine with neurocognitive ageing to
affect physical performance.
The effects on the major organ systems are summarised in the table
below [32].
While physical changes are unlikely to affect the ability of an
anaesthetist to function on a day-to-day basis in the workplace, the
equivalent subtle changes in neurological, sensory and cognitive
function may be of greater significance. Also, individuals ageing even
at normal rates [33] may only rarely be exposed to stressor events of
sufficient magnitude to unmask the loss in neurophysiological reserve.
It would be bad for patient safety if such a situation arose unexpectedly
during anaesthesia.
Homeostenosis and frailty
Age related physiological changes
(adapted from Chester & Rudolph [32])
Mechanism of
change
Molecular,
structural and
organ level
changes and
systemic
effects
Blood pressure Pulse and cardiac output Respiratory Hormonal/immunological
• oxidative and
mechanical
damage to vascular
endothelium
• heightened
inflammatory
response from
cytokines, growth
factors, collagen,
elastases and
proteinases
• decreased arterial wall
pliability
• increased left
ventricular wall
thickness
• diastolic dysfunction
• increased pulse
pressure
• desensitisation of
sympathetic receptors
disrupts intracellular
signalling
• decreased baroreflexes
• delayed responses
• decreased cardiac
output and increased
resting heart rate
• maximum heart rate is
more limited with age
• increased elastases
degrade elastic tissue
and reduce compliance
with dilation of
airspaces
• altered chest wall shape
• increased work of
breathing
• altered diaphragm
shape
• decreased compliance
• air trapping with
increased residual
volumes and decreased
tidal volumes
• increased respiratory
rate compensates for
less tidal volume
• decreased T-cell function
with reduced immunity
• changes in hypothalamic
activity
• Increase in dysfunctional/
deficient hypothalamic
mineralocorticoid receptors
• increased night-time
cortisol levels
• reduced ability to maintain
body heat with less
subcutaneous fat, reduced
peripheral vasoconstriction
• dysregulated circadian
rhythm
• loss of muscle mass
10 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 11
Compensation
to stress
• reduction in
• less sympathetic • weakened respiratory • loss of heat maintenance
endogenous cellular responsiveness
muscles, less
and thermogenesis
repair capability
hinders ability of
compliant chest wall,
mechanisms with
due to damaged
cardiovascular system and increased work
heightened vulnerability to
cardiomyocytes and to adjust when
of breathing diminish
hot and cold stressors
vascular endothelium stimulated
ability to adapt to stress • lower core body
• altered intracellular • less adaptability in • less sensitivity of
temperature hinders
protein expression
heart rate is associated chemoreceptors and
ability to regulate body
• mitochondrial ageing with falls, frailty
mechanoreceptors
temperature
and changes in signal
causes decreased
transduction cascades
response to hypoxia
• loss of responsiveness
and hypercapnia
to sympathetic stimuli
Age related physiological changes (adapted from Chester & Rudolph [32])

4.2: The role of comorbidity
The relationship between comorbidity and age
Though the processes of ageing result in loss of physiological reserve,
primary organ failure and disease are not considered parts of the normal
ageing process. However, the accumulation of chronic comorbidity,
and importantly multimorbidity, is closely associated with advancing
age. Not only is the presence of comorbidity associated with increased
mortality, but so is poor health and physical function. Data reporting
the prevalence of multimorbidity have historically been scarce. A recent
landmark UK population study [34] reported that by the age of 50, half
the population had acquired at least one comorbidity, with 65% having
multimorbidity by the age of 65.
Impact of ill health and comorbidity on the ability to work
The presence or absence of comorbidity is of limited use in determining
its effect on an individual’s ability to function in the workplace. Although
reported limitation is more useful, this depends on the role fulfilled by
that individual. The application of population-wide data to a highly
selected population of anaesthetists with a very specific defined skillset
therefore has its weaknesses. However, the data sources quoted above
and immediately below describe high rates of impaired dexterity (8%),
stamina (11%) and mobility (13%) within the working population, which,
importantly, increase significantly after the age of 65. These may have
implications for anaesthetists towards the end of their working life.
Effects of physical or mental health conditions lasting > 12
months. Office for National Statistics, UK, 2013
4.3: Healthy life expectancy
and survivorship in good health
Despite the presence of significant longstanding disability and limitation
of function, life expectancy in the UK continues to increase. At the age
of 65, life expectancy ranges from 18 years for men to 20.7 years for
women. Approximately 60% of this further life expectancy will be spent
in good health, indicating that the current conventional retirement age
does not reflect impending disability and poor health status. Data from
the Office for National Statistics are shown below [36].
Projected survival, health status and disability at birth and
65 years. Derived from self-reported prevalence of limiting
longstanding illness and disability data (2009–11) and life
expectancy tables (2011–13). Office for National Statistics, UK.
Multimorbidity and age
Longstanding limiting illness and disability
Percentage of physical parameters affected by physical or mental
health, by age
Affected
parameter
Age
25–44; %
Age
45–64; %
Age
65–74; %
Age >
75; %
Sex
Healthy life expectancy at birth
Life
expectancy;
years
Healthy life
expectancy;
years
Actual
years of
‘not good’
health
Proportion
of life
spent
in good
health; %
In addition to physical health problems, mental health disorders
increase in prevalence with age. They are closely associated with
combined physical and mental comorbidity, which is present in 18%
of patients ≥ 65. Although these patients are at or above current
retirement age, this study also found that nearly two thirds of people
with combined physical and mental health comorbidity were aged <
65 years. Although multimorbidity is more prevalent in older people,
approximately half of the multimorbid population in the UK is aged
below 65. This indicates that physical and mental health problems
affect large numbers of the working-age population. These data are
similar to rates of self-reported longstanding illness and disability for
the UK population derived by the Office for National Statistics in 2013
[35].
Self-reported prevalence of longstanding illness and disability.
Office for National Statistics, UK, 2013
Age; years Male % Female % All %
24–44 19 22 21
45–64 42 42 42
Arguably, more important than knowing the prevalence of comorbidity
or multimorbidity is understanding how these conditions affect the
physical function and lifestyle of an individual. UK data from the Office
for National Statistics provides information on self-reported limiting
conditions, i.e. illnesses which require a change to life activities [35].
Self-reported prevalence of longstanding illness and disability
that limit life activities. Office for National Statistics, UK, 2013
Age; years Male % Female % All %
24–44 9 11 10
45–64 21 23 22
65–74 33 31 32
> 75 45 49 47
These data illustrate that although self-reported longstanding illness
and disability is common within the working population, increasing
from 21% (between ages 24–44) to 42% (between ages 45–64),
the limitation of life activities associated with this is significantly less
common. Only 10% of those aged 24–44 years and 22% of those aged
45–64 are limited by their condition. This increases a further 10% to
32% of those aged 65–74.
Vision 2 4 7 16
Hearing 1 4 9 21
Mobility 5 13 22 42
Dexterity 3 8 11 21
Learning,
comprehension
and
concentration
2 3 2 4
Memory 2 4 5 12
Mental health 5 6 2 2
Male 78.4 64.2 14.2 81.9
Female 82.4 66.1 16.3 80.2
Healthy life expectancy at age 65
These data pertain to the entire UK population, and therefore
Social skills and
are unlikely to be perfectly reflective of the working population of
behaviour
65–74 59 55 57
anaesthetists. They do not account for illness or disability starting in
1 1 0 0
youth in people who never reach the workplace, nor does it account for
socioeconomic status. Multimorbidity correlates closely with increasing
Other 5 6 9 7
> 75 68 70 69
social deprivation, and these data may therefore over-predict poor
health and disability in the selected population that is the subject of
this report.
12 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 13
Stamina,
breathing and
fatigue
4 11 16 25
Sex
Life
expectancy;
years
Healthy life
expectancy;
years
Actual
years of
‘not good’
health
Male 18 10.7 7.3 59.3
Female 20.7 12.1 8.6 58.6
4.4: Summary of key factors
Proportion
of life
>65 years
spent
in good
health; %
1. Ageing is a complex and heterogeneous process. Biological and
chronological ageing are not synonymous, and the course of
ageing in an individual is difficult to predict.
2. Ageing results in progressive loss of physiological reserve, which
is characterised by homeostenosis, loss of physiological variability
and disruption of native physiological rhythms.
3. Comorbidity is increasingly prevalent with advancing age. Variation
in patterns of comorbidity is seen within populations between
diverse socioeconomic groups.
4. Longstanding disability increases with age, but is significantly
prevalent in the working age population. A large proportion of
these people have limitations in their function.
5. Life expectancy in the UK is increasing, with approximately 60% of
remaining life expectancy at age 65 expected to be characterised
by self-reported good health.

5.0: Workforce patterns
and workforce issues
5.1: Time in employment and retirement
patterns of the general population
It is important to review employment trends in the general population.
As well as medical staff being part of this population and hence subject
to its characteristics, the trends also describe the population whose
health the Government will be responsible for managing with a view to
keeping them economically active.
rather than the condition itself – is by far the main predictor of leaving
work. In addition, the presence of three or more doctor-diagnosed
conditions is strongly related to cessation of work. Another key factor
that will influence the ability of the Government to modify the public
sector pension bill is the current retirement pattern. To change this
requires a massive culture shift. The current data on employment rates
are shown below.
The European Commission, in preparing for the future needs of its
ageing population, commissioned a study into the impact of chronic
disease on the retirement age in the EU. This was undertaken by the
Dutch National Institute for Public Health and the Environment and
published in 2012 [37]. At the time of their survey, the normal retirement
age across Europe varied from 57 years in Greece to 67 in Norway,
with the UK then having 60 for women and 65 for men. They concluded
the following:
• The burden of chronic diseases on Europeans of retirement age
is substantial and will increase due to population ageing and
prevailing lifestyle risks.
• Poor health has an impact on the labour participation of older
workers.
• Chronic diseases among older European workers contribute to
economic costs.
• Musculoskeletal and cardiovascular complaints were the main
causes of early retirement in the health services 7 .
One metric was emphasised as being an important vector of whether
or not people remained in employment. This was the percentage of
each age group reporting a longstanding illness or health problem;
this is shown in the figure below.
People in the EU reporting chronic health issues by age
categories in 2010 (Eurostat 8 2012)
It can be seen that between the ages of 60 and 65, the 50% rate is
passed. This does not indicate that all these people will be unfit for
work, but may mean that earlier employment may have to be modified
to accommodate a change in health status. It is a very important to
note that the review indicated that self-perception of poor health –
The EU average employment rate (%) by age category in 2011
(source: Eurostat 2012)
It is very important to note that for whatever the various causes, labour
participation decreases progressively after the age of 50.
Putting the above findings together results in these conclusions:
• When the state pensionable age is increased, as is planned in the
UK, if people continue to work, the number of older workers with
a chronic disease and activity limitations due to health problems
will also increase.
• Effective interventions will be needed to improve the work
participation of people with a chronic disease.
• The reasons for retirement will not be entirely determined by
health or the self-perception of health. Some of those retiring will
be doing so because they are economically able to, or because
they need to care for a loved one, or simply because they dislike
their work.
The crucial point is that in order to meet the Government’s planned
intentions for the normal pensionable age in the NHS pension scheme
to become equal to the state pensionable age (so as to allow retirement
without an actuarial penalty), a huge change to current retirement
patterns is required. It means that approximately three times as many
people at present in the 60–64 age group and nearly ten times as
many as are at present in the 65–69 age group would have to remain
in employment. It is highly unlikely that this will be the case and many
individuals will end up taking reduced benefits when compared with
the present retirees. Perversely, it may also encourage an increase in
attempts to retire on grounds of ill health so that the pension entitlement
is ‘made-up’ to what it would be at the state pensionable age.
7
This includes all health workers, not just medical staff.
8
Eurostat is a directorate of the European Commission responsible for the collection of data. This was the data source used to inform the 2012 RIVM report referenced in
reference 37. It can be accessed at http://www.ec.europa.eu/eurostat
5.2: Employment patterns and the
retirement intentions of medical staff
Getting data on the retirement intentions of consultant medical staff is
difficult. The most basic approach is to look at the age distribution of
doctors registered with the GMC. The current situation is shown in the
table below [38].
14 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 15
Age group
Number of doctors
≤ 25 10,715 3.9%
26–35 76,139 27.8%
36–45 80,350 29.3%
46–55 57,796 21.1%
56–65 31,672 11.6%
> 65 13,344 4.9%
No birth date 3,837 1.4%
Total 273,853 100.0%
Proportion of the
workforce
Doctors (all grades) registered with the GMC in 2016
Clearly these data must be interpreted with caution since, over time,
there has been an increasing number of doctors registered per year.
At present there are nearly 86,000 doctors on the specialist register, of
whom 11.5% are anaesthetists. The number of specialist registrants
has increased by over 50% from 2005. These will however be occupying
the earlier years in the table below. The important figure to note is that
between the decade 46–55 years to the decade 56–65 years there
is a reduction of nearly 50% in continued employment, and between
the decade 56–65 years to over 65 years there is a further nearly
60% reduction. These reductions will have a number of confounding
variables buried within them, but the decrements are so great that for
medical staff to continue in employment as the Government intends
requires a massive change in end-of-career decisions.
Accepting that there will be some specialty differences, probably the
best information to date on retirement intentions is that from a survey
undertaken by the Federation of the Royal Colleges of Physicians of
the UK in 2011 [39]. The intended ages of retirement are shown below.

These data clearly confirm the discrepancy between the retirement
intentions of the consultant workforce and the objectives of public
sector retirement policy. A total of 47% expressed an intention to retire
between 56 and 60, and a further 43% intended to retire before 65. Only
3% intended to work beyond that age. The two most common reasons
cited for wanting to retire were pressure of work and domestic reasons,
with dissatisfaction with the NHS following close behind.
Voluntary early retirements were also studied in a 2011 survey published
by the British Medical Association [40], which found that retirements
before the age of 60 had increased by 72% in the previous year. The
proportion of retiring consultants each year who took retirement early
had almost doubled from 7.3% in 2006 to 14% in 2011. If these figures
remain unchanged as retirement intentions, possibly also stimulated by
the financial problems associated with exceeding the lifetime allowance,
there is a very significant professional problem ahead that affects both
the service capability of the NHS and doctors’ personal lives.
5.3: Wellbeing at work: making
work possible
The changes to pensions regulations not only affect medical staff – they
affect all workers in the NHS. Others in doctors’ workplaces will also be
increasing in age and, in interacting with them, mutual allowances may
have to be made. As a result of this and other considerations, wellbeing
at work relates to more than just the individual: it includes their health,
colleagues, and the matrix of hours and facilities within which they carry
out their job. There is considerable financial and social loss to those
absent from work, and going to work needs to be recognised as the
healthier option. The importance of work and health in people’s lives was
explored by Dame Carol Black’s report Working for a healthier tomorrow
[41]. This review was not instigated primarily to meet the future changes
planned in pensions reform, but its findings and conclusions have
considerable impact on them. In essence, it sought to establish the
foundations for a broad consensus around a new vision for health and
work in the UK. At the heart of this vision were three principal objectives:
• Prevention of illness and promotion of health and wellbeing.
• Early intervention for those who develop a health condition.
• An improvement in the health of those out of work so that everyone
with the potential to work has the support they need to do so.
A shift in attitudes is necessary to ensure that employers and employees
recognise not only the importance of preventing ill health, but also the
key role the workplace can play in promoting health and wellbeing.
Over the past decades, the focus has been on health and safety in the
workplace – and great strides have been made in this regard - but little
was done to address positive health and wellbeing. Research specially
commissioned for the Black Report found considerable evidence that
health and wellbeing programmes produced economic benefits across
all sectors and all sizes of business; in other words, good health is good
business.
The review identified that health and wellbeing are not just medical
issues. The nature and characteristics of the jobs people do are critically
important in terms of satisfaction, reward and control. Good management
also leads to good health, wellbeing and improved performance. Line
managers have a role in identifying and supporting people with health
conditions to help them to carry on with their responsibilities or to adjust
responsibilities when necessary. In the future this could become a
critical path towards keeping all grades of older workers in the NHS in
employment. Medical staff will need to play their part in this process.
For those who develop health conditions, their roles will need to be
underpinned by changes in ideas of fitness for work. It is inappropriate
to be at work unless you have the appropriate fitness; being at work
when unwell normally impedes recovery. Employers have significant
scope to facilitate an employee’s early return from sickness absence.
Early, regular and sensitive contact with employees during sickness
absences can be a key factor in enabling an early return. Tackling
stigma around ill health and disability is key to enabling more people
with health conditions to stay in work. This is particularly true for those
with mental ill health, as many organisations fail to recognise the full
value of the contribution they can make.
Changing perceptions will also require greater public engagement
with the benefits of work to health, increasing expectations of what
makes a job good and of the support people with health conditions
should expect to enable them to remain in or return to work. A lack
of understanding about the relationship between work and a person’s
health, and the omission of this evidence from professional training,
has meant that despite best intentions, the work-related advice that
healthcare professionals give to their patients can be overly cautious
and may not be in the best interests of the patient in the long term.
Emerging evidence suggests that, for many people, early interventions
help to prevent short-term sickness absence from progressing to
long-term sickness absence and ultimately the inability to work. In a
subsequent report [42] that tackled the issue of absence from work
because of sickness, it was noted that much sickness absence and
inactivity follows common health conditions that, given the right support,
are compatible with work, although sometimes work patterns need to
change. Sickness absence in the NHS varies significantly. Sickness
absence data in the NHS are presented in terms of percentage of
working time lost, and different NHS workforces have markedly different
absence rates. Ambulance staff have the highest aggregated sickness
absence rate (6.3%) followed by healthcare assistants and other
support staff (6.21%). By contrast, nursing, midwifery and health visiting
learners had the lowest rate (1.05%) followed by medical and dental
staff (1.21%). Generally, NHS absence rates have decreased in recent
years, particularly in those job areas exhibiting above average absence.
One of the great social conundrums of our time has been revealed by
the Marmot Report [43], which was commissioned on behalf of the
Department of Health. This studied the effects of inequalities on health.
These are reflected in the NHS workplace through the wide spectrum of
people working there. There is a social gradient in health: the lower a
person’s social position, the worse his or her health. Health inequalities
result from social inequalities, so action on health inequalities requires
action across all the social determinants of health. While within England
there are nowhere near the extremes of inequalities in mortality and
morbidity seen globally, inequality is still substantial, and the Marmot
Report calls for urgent action. In England, people living in the poorest
neighbourhoods will, on average, die seven years earlier than people
living in the richest neighbourhoods. Even more disturbing, the average
difference in disability-free life expectancy is 17 years. Thus, people in
poorer areas not only die sooner, but they will also spend more of their
shorter lives with disability. The combined effect of social class and the
importance of employment (as described above in the Black Report)
can be seen in the figure below 9 .
Social class, employment and mortality rates
There is an important link between the findings of the Marmot Report
and the planned changes to state and public sector pensions in the
UK. Assuming that the late 60s is the pensionable age towards which
England is moving, > 30% will have a limiting disability when aged >
65 years. The Marmot Report concludes that if society wishes to have
a healthy population working for longer, it is essential to take action to
increase the general level of health and to flatten the social gradient.
It can therefore be inferred that alone, the planned pensions legislation
changes will probably fail to meet their intended targets. What is
required alongside these changes is a wholesale change in the way
society views health and work. For people to work longer, the workplace
needs to promote health and wellbeing and make sure that everybody
with the potential to work has the support they need to do so. The
NHS employs persons from all social classes; to enable them all to
play their part as economically active members of society, there also
needs to be attention focused on the reduction of inequalities in order
to transform illness, disability and dependency into continued good
health and social engagement through work.
5.4: The public’s expectations of older
professionals
Trust and professional regulation
The relationship between medical staff and patients is in constant
evolution and, if the media are to be believed, appears to be
moving away from ‘blind faith’ towards accountability, challenge and
measurement of competence. This is encouraged by individual doctor
performance league tables and the sort of user, infection and mortality
ratings shown on the NHS Choices website. Despite this, patient
satisfaction on an individual basis remains high and, in May 2015, >
95% of inpatients treated by NHS Trusts and Foundation Trusts would
have recommended their provider to friends or family [44]. The question
for this publication is: ‘How does the age of the medical practitioner
affect the public’s reasonable right to expect that the medical staff it
sees are competent?’
In a series of Reith Lectures entitled A Question of Trust, Onora
O’Neill examined the relationship between those receiving and those
providing professional services [45]. She argued that although at times
the relationship would break down and disappointment would result,
the essential factor in any lay-professional relationship was trust. If
there was no trust and an innate responsibility to provide good care on
trust, all the possibly recordable numerically accountable data could
not substitute for it. In her view, the need for, and acceptance of, trust
is both crucial and self-evident, and any erosion of it is to everybody’s
detriment. While trust is still possible on a person-to-person basis, the
public, Government and media nevertheless (and with good reason)
require certain groups, of whom the medical profession is one, to be
regulated within the law and to adhere to specified standards and
behaviours. The need for this is well accepted by society as a means
of containing at least the worst of professional lapses through control
of the Medical Register. More recently, with the introduction of annual
appraisal and revalidation, the GMC is now seen as not only regulating
serious offences but also managing ongoing quality control throughout
a professional lifetime. Unfortunately, although the public may see
revalidation as providing a guarantee of minimum satisfactory quality
standards, there is evidence that the process at times has considerable
gaps. People still present to the GMC who have had a series of
satisfactory annual appraisals and a few even end up subsequently
in jail. The question is: How should the public be reassured about an
older doctor’s competence?
Evidence relating age to competence
A good starting point is to review available evidence of when things
have gone wrong. Perhaps the first point to make is that whatever
correlation is being looked at with respect to underperformance or
reporting, males always outnumber females, both in absolute numbers
and proportionately. The National Clinical Assessment Service 10
has been collecting data since its inception in 2001. Referrals made
in 2009/10 (the latest data available), show patterns similar to those
observed in earlier years [46], and the incidence of referral related to
age is shown below [47]. In this diagram, H & C are specialist medical
staff working in hospitals and the community.
It can be seen that for hospital consultants, unlike general practitioners,
there is no strong correlation with age. On the other hand, in terms of
GMC referrals [48], between 2010 and 2013 for those on the specialist
register in the 30–50 year old group, the referral rate was 7.6%, as
compared with 13% for those aged > 50. These rather unrefined GMC
metrics do not give any information about the subset close to or above
the usual retirement age. In the UK, there is currently little information
on the relationship between doctors’ age and their competence,
particularly around and above the ‘normal’ retirement age.
In the USA, the situation is different because there are no equivalent
pensions similar to those of the UK public sector. Consequently,
there are greater financial drivers to keep people at work, but these
are not necessarily in the public’s best interest, and this has been a
regular topic of discussion in newspapers such as the Washington
Post [49], in which continued employment of elderly medical staff has
been questioned. It reports that 42% of physicians are > 55-years-old
and 21% are > 65-years-old – a considerable contrast with the UK.
Probably the oldest clinically practising living physician was Ephraim
Engleman, who worked until his death at the age of 104 [50] as Director
of the Rosalind Russell Medical Research Centre for Arthritis at the
University of California. At a different medical centre, the dangers of
being too respectful to age and reputation were demonstrated when a
patient bled to death during a routine cholecystectomy [51]. When the
hospital investigated this event, which was caused by a revered mentor
of several generations of surgeons, they found that for six years, junior
staff had always ordered extra blood for his laparoscopic procedures,
and the anaesthesia department always put an experienced consultant
with him because it was common knowledge that the surgical risks
were greater. The surgeon’s colleagues and the hospital were
essentially accommodating his deficiencies rather than tackling the
root of the problem.
The problem of the ageing surgeon was reviewed in some detail by
Blasier, an American orthopaedic surgeon [52], during a symposium
on clinical risk and judicial reasoning. He concluded that both
anecdotal evidence and objective testing suggest that age causes a
deterioration in physical and cognitive performance, and that surgeons
were reluctant to plan for retirement. In addition, he indicated that
conventional outcome measures are unable to detect a progression of
substandard outcomes that are unacceptable clinically but insufficient
to trigger an institutional response.
9
This is reproduced in the Marmot report and is taken from: Bethune A. Unemployment and Mortality. In Drever F and Whitehead
M (Eds.) Health inequalities: Decennial supplement. ONS Series DS no. 15. London: The Stationery Office, 1997.p 156–67.
10
Since 2013, NCAS has been an operating division of the NHS Litigation Authority.
16 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 17

The removal of an age-related retirement date in the UK
The problems in the UK are further complicated by the combination of
the pressure to work longer to meet the criteria for a full pension in the
presence of anti-age discrimination legislation. The Equality Act 2010,
and the Employment Equality (Repeal of Retirement Age Provisions)
Regulations 2011, came into force on 6 April 2011 in England, Scotland
and Wales [53]. These regularised several aspects of public and
personal life with respect to the prevention of discrimination, and from
October 2012 it was not possible for employers to require employees
to retire on the grounds of age alone. At a stroke this removed the
safety valve of being able to remove employees known or thought
to be underperforming when they reached the accepted retirement
age for their employment. If they do not want to stop work, an older
employee now has to be shown to be unable to satisfactorily undertake
the content of their job description. The situation is further complicated
because there is an onus on the employer to respond to a request to
make a change in a job description ‘in a reasonable manner’ [54], and
guidance has been issued by the Advisory Conciliation and Arbitration
Service [55]. Changes to a job description can be requested by the
employer or the employee. Case law is developing on disputes in
which these requests have not resulted in mutual agreement. It is now
established that an employee cannot demand changes to their job that
are convenient to them if they do not meet the corporate objectives of
the employer. Similarly, the employer has to make ‘reasonable’ efforts to
accommodate a request if the corporate objectives can still be achieved
if the request were granted.
The impact of the removal of the fixed retirement age has been reviewed
by the Health and Safety Executive (HSE) in relation to ‘safety critical
work’ [56]. This included occupations in the airline, nuclear power,
transport, fire-fighting and oil extraction industries. Anaesthesia is
clearly ‘safety critical work’ but no medical specialties were specifically
reviewed by the HSE. Their methodology and analysis is nevertheless
highly relevant. In summary, their key messages relevant to an older
consultant were:
• While there is evidence that cognitive and physical abilities decline
with increasing age, these do not necessarily have a negative
impact on performance at work. Studies of age have found huge
inter-individual variations in performance.
• The relationship between chronological age and performance is
neither simple nor straightforward. A number of factors including
functional capacity for work, work demands, work environment,
stress, shift work, expertise, and attitudes towards work and
retirement are relevant. There was a critical age for increasing
intolerance to night work as age progressed, but this was again
individually variable.
• It is the specific combination of demands and complexity required
by a job that makes it potentially highly demanding, as opposed to
the job title itself. Individuals are able to use different strategies to
compensate for age-related declines in performance, such as their
expertise, job knowledge, education and high motivation. However,
when job demands exceed the overall capacity of a worker, they
may no longer be able to compensate for any decline.
• There is evidence of ‘healthy worker’ effects, whereby individuals
self-select to move into less demanding jobs, or retire as their
ability to carry out a job decreases. There is also evidence of ‘safe
worker’ effects where rigorous screening standards mean that
workers lose their licence to work, e.g. pilots and offshore workers.
• There is a paucity of information about the performance of older
workers in very demanding jobs. For example, the extent of ‘healthy
worker’ effects or ‘safe worker’ effects within demanding jobs is
unknown. The extent to which these effects act as a safeguard
against safety critical outcomes is also unknown.
• More longitudinal research is required in order to investigate
decrements in performance over a working life.
The present position with regard to anaesthetists
• The relationships between patients and doctors remain very good,
with a high degree of trust. Part of this places a responsibility on
doctors both individually and collectively to ensure a high standard
of clinical practice is delivered.
• The changes in the public sector pension arrangements, coupled
with the removal of age-related compulsory retirement from
clinical practice, create a situation in which doctors who are
underperforming because of age may go undetected. Current
audits lack the sensitivity to identify subtle but significant changes
in performance, and there have been many situations in which
clinicians have been inappropriately ‘carried’ by colleagues and
institutions when they should have ceased clinical practice.
• There is no simple relationship between age and performance, and
there are huge individual variations. While there is evidence that
cognitive and physical abilities decline with increasing age, these
do not necessarily have a negative impact on performance at work.
However, there will come a point when the job demands exceed the
overall capacity of an individual worker to compensate.
• In employment outside medicine, there is evidence that individuals
self-select to move into less demanding jobs, or retire as their ability
to carry out a job decreases. The safety implications for the public
of the ability to modify the job content of an anaesthetist with age
are obvious. So also is the need to detect those without the insight
to ‘self-select’ when their workplace performance is declining.
• Although the volume of literature is small, there is however
increasing evidence that within anaesthesia, older age per se
could be an independent risk factor for safe practice. Should this
risk become established as true by continuing audit and evidence
collection, and what can be done about it, is considered in
Section 6.
5.5: Other professional groups
and human factors
Other professional groups
As acknowledged above, several ‘high-stakes’ industries (airline,
nuclear power, transport, fire-fighting and oil extraction), have taken
steps to try to ensure that their professionals are performing to proper
standards throughout their working lives and have had to modify
their processes as regulations and legislation have changed. There
are lessons to be learned from this and it is useful to take the airline
industry, which has long had age, fitness and competency barriers to
continued employment, as an example.
Historically, national aviation authorities grew up in response to the
increasing aviation activity after the Second World War, and in 1947
the International Civil Aviation Organisation was established. In 2003, a
European Aviation Safety Agency was created, but individual member
states have their own national authorities. In the UK, this body is the
Civil Aviation Authority, which works closely with the European Aviation
Safety Agency to promote the highest common standards of safety
and environmental protection.
A pilot’s competence on a specific aircraft is confirmed by the granting
of a licence by the Civil Aviation Authority. The pilot is subsequently
checked on a six-monthly basis for technical, handling and crew
resource management (equivalent to team management) competence
over a two-day period. This time is also used to refresh skills in dealing
with abnormal and emergency situations on a rotational basis, so all
possible scenarios are covered every three years. Every training pilot
is checked either by a Civil Aviation Authority inspector or a senior
examiner every three years, as well as by ad hoc standardisation
checks. In addition, all pilots have a two-yearly line check in which an
authorised training captain observes a crew operate a commercial flight.
Medical checks covering past medical events, eyesight, hearing, ECG,
lung function, haematology, biochemistry and urine are mandatory.
These have to be repeated at yearly or six-monthly intervals, depending
on the class of aircraft.
It is worthy of note that pilots generally get apprehensive about their
six-monthly competency checks in the simulators. This raised level of
anxiety can, and sometimes does, cause degraded performance levels.
Debriefing after the event usually precipitates an admission from the
pilot that the cause of the reduction in performance was as a result of
‘life stresses’ rather than cognitive degradation. In all airlines there have
been cases of performance degradation stimulated by more sinister
medical issues. It is therefore important to try to differentiate between
the causes so that retraining and remedial actions are appropriately
instigated.
Until 1 October 2006, British Airways had a maximum age for pilots
of 55 even though their Civil Aviation Authority licence allowed for a
maximum age of 60, and most other British and international airlines
had a policy of a maximum age of 60. Issues of restraint of trade and
ageism subsequently forced British Airways to fall in line with the Civil
Aviation Authority’s maximum age limit. Now, in the UK, pilots, like all
other workers, have been freed from an upper age limit by legislation,
although they still have to pass regular competency tests. The ‘effects of
age’ problem has been tackled internationally by the International Civil
Aviation Organisation. It developed the concept of an ‘incapacitation
risk’ occurring to a pilot during the cockpit on any given flight, and
made the important point that:
• Not all causes of death or fatal conditions posed an incapacitation
risk because the disease develops slowly, e.g. most malignant
disease.
• Not all incapacitations necessarily pose a risk of death, e.g. a faint
or a transient ischaemic attack.
Accidents due to simultaneous double incapacitation from physical
disease, i.e. both pilots incapacitated at the same time, are extremely
rare; none having occurred for > 40 years. European Aviation Safety
Agency aircraft design standards state that the average probability
per flight per hour of a ‘catastrophic failure’ must be ‘extremely
improbable’, with a probability per flight hour of the order of < 1 x 10 -9 .
Its presentation of this concept is shown in the figure below.
Deaths per million in UK males which impacts on the
incapacitation risk with age
It can be seen from the figure that up to age 65, the mortality rate is still
< 1% per year, which approximately equates to 1 death per 1,000,000
hours. With two pilots, the probability of both dying is (1 x 10 -6 ) x (1
x 10 -6 ), which equals (1 x 10 -12 ). This probability is 1,000 times less
than that set by the European Aviation Safety Agency 11 . Surveys on
pilot performance [57] concluded similarly to the HSE that: ‘Overall,
the scientific record has not resulted in a clear specification of the
relationship between age, cognitive function, and pilot performance’.
Further data demonstrated that although there was a measurable
reduction in performance in those aged > 60 years, it still stood
significantly above the licence requirements. It was recognised that
there was considerable individual variation but that performance up to
the age of 65 years is not now seen as an issue by the industry. As a
result of these reviews, the Civil Aviation Authority now specifies that
in two-pilot civilian passenger aircraft, pilots can be licensed up to the
age of 65 years, but either the pilot in charge or the co-pilot must be <
60 years [58].
It is clear from the measured experiences of the airline industry that
there are many similar findings to those observed anecdotally in
medicine and to the conclusions of the Health and Safety Executive
review (see ref 56 earlier). With ageing, there remains very wide
individual variation. Health has a measurable impact, there are regular
competency checks, and risk is mitigated by combining professionals
of different ages.
Human factors
Human error is known to occur during the practice of medicine, but
for > 20 years, its genesis has been known more as a problem of
psychology or engineering rather than medicine [59]. The words of
George Santayana, the Spanish philosopher – ‘Those who do not
remember the past are condemned to repeat it’ – are particularly
apposite because doctors make the same mistakes again and
again, sometimes over decades [60,61]. Command, control and
more regulation appear not to have significantly decreased failure at
the doctor-patient interface. It is surely naïve to think that if we go on
11
These calculations are based on population death rates, which are not the same as ‘incapacitation incidents’ while flying, but the methodology establishes the principle.
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prescribing the same remedies, we will get a different result. As Cicero
observed around 140 BC, ‘Any man can make mistakes, but only an
idiot persists in his error’. His view was supported over two thousand
years later by Einstein in his observations on experimental science
when he said ‘Insanity is doing the same thing over and over again,
and expecting a different result’. We need the help of better systems
and a change in organisational culture.
In other high-risk industries, research into human factors and safety
science has substantially changed the culture of organisations and
the management of risk because their leaders have realised that their
future, their jobs and their profits depend on it. The same impact of
human factors research has not yet been felt in hospitals. Perhaps
this is because consultants usually go unchallenged and, as they age,
they persist with established mental pathways. After all, accepted
practice is where the majority of errors and harm arise.
Medical experts are quick and productive, and most of the time
they get it right, but when they don’t, perhaps due to an incorrect
perception, assumption or communication, or because they are the
victims of confirmation bias, the risks are much greater than in those
of the novice who is full of self-doubt. In his book Thinking Fast and
Slow [62], Daniel Kahneman has helped us to grasp how we make
decisions and the benefits and risks of each process. Being mindful
of this science is an important safeguard in understanding what we
and others do, especially when, as experts, we make rapid, intuitive
choices that feel effortless and right. In these conditions, our normally
competent but possibly ageing brain does not invite us to pause and
consider. That step requires another team member, a ‘second brain’,
to challenge us. This is a crucial benefit of team working and of open
relationships in medicine and in management, and as we age these
become of much greater potential importance. Established consultants
are particularly vulnerable to delusions of adequacy and resistant to
change, particularly if it means unlearning a cherished habit. They may
need to be rewired.
Unlearning and relearning are complex and time-consuming
processes. Furthermore, new behaviours commonly revert to older
habits when there is distraction, stress or urgency, so there may
be a particular vulnerability for retrained doctors faced with these
conditions. It is difficult but at times necessary to change one’s habits
and what one believes; only by recognising the importance of human
factors in the workplace can this be achieved.
Human factors optimisation is about designing systems that are
resilient to unanticipated events and addressing problems by
modifying the design of the system to support people better [63]. In a
nutshell, the aim of human factors optimisation is 'modifying systems
to make it easy for people to do the right thing'. Such interventions
develop environments that are intrinsically safer than before, and
have great potential to mitigate the errors and changes associated
with ageing. For them to be introduced first requires an acceptance
that error is normal and is only a moral issue when it is known to be
avoidable or undeclared. When it occurs, it is never just one person’s
fault, it is a system failure and the primary determinant of safety is
one of organisational culture. To quote Don Berwick [64], ‘In the end,
culture will trump rules, standards and control strategies every single
time and achieving a vastly safer NHS will depend far more on major
cultural change than on a new regulatory regime’. Some in leadership
positions in healthcare have yet to understand and adopt these
principles; they think that identifying culprits is corrective. They blame
individuals alone for errors and ignore the cultural and systems factors
that are so contributive. Such leaders need help because although
they are probably doing their best they ‘don’t know what they don’t
know’. It is a risk for all of us, and especially those older members in
the workplace.
Conclusions
Medicine is not unique in having to address the continued employment
of an ageing worker who has to perform to a highly sophisticated
professional standard. Other industries have, through systematic
research and audit, found and solved problems that medicine has,
to date, really only recorded at an anecdotal level. There is much that
can be learned from them both in their approach and in their solutions.
Two things come through as constant themes. The first is that while
there is evidence that cognitive and physical abilities decline with age,
these are highly individually variable and do not necessarily prevent
continued employment at a safe level. The second is that human
factors are increasingly being recognised as vectors for error, and that
working in properly functioning teams and modifying the environment
can have very considerable safety advantages. This is particularly
relevant to ageing professionals who may warrant some special
consideration in this regard: perhaps at the end of one’s career there
should be an appreciation that a safe working environment is one with
which one is familiar.
6.0: Implications for the
future: practical aspects
to be addressed
Anaesthesia is a safety-critical occupation that in the UK has very high
standards of practice and very low levels of morbidity and mortality. It
is clear from this review that the plan to maintain more people in work
to an older age than at present, in the presence of an increasingly
complex patient population, has significant, potential safety
implications. The actual effect on patient safety cannot be calculated
in advance with any accuracy. There are four key stakeholder groups
involved, each of which has responsibility and a contribution to make
in trying to maintain the current levels of safe practice. These are:
• The anaesthetists themselves.
• The organisations that employ anaesthetists and maintain their
workplaces.
• The Government, through national and health policies.
• The public who use the health services.
The sections below try to identify the factors relevant to each of these
groups. It should be emphasised that these are rapidly developing
areas of consideration and what is written is in no way definitive in its
scope: recommendations are highly likely to change over time.
6.1: Considerations for the anaesthetist
The first and greatest commandment for anaesthetists, both
individually and as a professional group, is to accept that extending
their clinical working lives will bring problems, and that planning for
the consequences of change is essential. Although the evidence for
age-related problems is still emerging, there are clear trends.
Evidence that there is a problem
In 2012, Tessler et al. [65] reviewed a ten year period of anaesthesia
activity in British Columbia, Quebec and Ontario with respect to
the age of anaesthetist and litigation events. In general, older
anaesthesiologists tended to care for fewer patients and were involved
in less complex procedures. They found that when compared to
anaesthesiologists < 50 years of age, those > 65 had an incidence of
being involved in litigation that was 50% higher and, of those medicolegal
cases, almost twice as many had a disabled patient outcome.
In 2013, a survey of Canadian anaesthesiologists [66] reviewed the
age of those practising. It found that:
• 68% were < 54 years old.
• 22% were 55–64 years old.
• 7% were 65–74 years old.
• 3% were >75 years old.
Canada, like the UK, has anti-age discrimination legislation, and the
review discussed the personal and institutional problems that the
removal of a statutory retirement age is bringing. The problem of
ageing in the workplace has also been highlighted by the Anaesthesia
Continuing Education Committee (ACECC). Their Welfare of
Anaesthetists Special Interest Group has studied the Retirement and
Late Career Options for the older professional [67].
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These three publications incorporate and discuss several common
themes:
• There is good neurophysiological evidence that after the age
of approximately 60, processing speed (dealing with incoming
information quickly and efficiently), short-term memory, the ability
to retain new information and vigilance all decline. However, there
is great inter-individual variability and the impact of ageing on
each individual’s performance at work is different: many older
anaesthetists in good health will be able to continue to perform
well.
• Age-related physical health problems can impact on performance.
The incidence of many chronic conditions (e.g. musculoskeletal
problems and cataracts), and of acute illness (e.g. ischaemic
heart disease) increases with age, as does a decrement in visual
acuity, hearing loss and some aspects of cognitive function.
Some health problems (e.g. hypothyroidism), are not always easy
to spot and may go unrecognised by both the individual and their
colleagues until well advanced.
• Quality of sleep worsens with age and sleep becomes shorter.
Tiredness has an effect on older doctors’ performance and mood.
Being on-call can be highly disruptive to sleep, even when not
called out. There is a decrease in the capacity to adapt to shift
work with increasing age: older workers’ cognitive performance
may be more impaired during night work but they may be less
aware of their degree of impairment.
• Decreased job satisfaction, irritability, burnout, anxiety, depression
and fatigue are more common in older practitioners, and these,
combined with fear of failure and challenges to self-esteem, can
impact on the decision to retire.
• Older anaesthetists may be slower at recognising and managing
new situations, but can be quick to respond when they are not tired
and are able to draw on previous experience. Older practitioners
may rely heavily on previous experience, intuitively recognising
patterns and making ‘routinised’ automatic rapid responses to
developing situations without employing conscious analysis and
reasoning [68]. As physicians age, they are perhaps more likely
to make errors from placing undue weight on first impressions, i.e.
premature closure.
• There was complete agreement that the path towards eventual
retirement (whenever that was) needed active management.
Waiting passively for an adverse event to signal professional
failure was definitively not the way forward.
Detecting and managing underperformance
While the conclusion is that ageing anaesthetists can present problems
to themselves and their patients, and that problems with ageing
anaesthetists will become more frequent, it is far from clear what should
be done to address the situation and to protect patients. Tessler and
Shrier [65] demonstrated that older anaesthetists are more likely to
make errors in even simple cases. A frequently stated assumption then
follows that older anaesthetists should not undertake complex cases,
but where is the hard evidence for specific individuals? While it is true
that, on an individual basis, a number of practitioners choose to try
to scale down the complexity and intensity of their workload, and are
probably showing laudable insight in doing so, does this have to be
applied as a rule at a particular age?
Baxter et al.[66] suggested ways in which anaesthetists could tailor
their practice to address their individual situations, and how hospital
management could get the best from the older clinician. They concluded
that ‘a more structured approach to tapering clinical activities and
planning retirement may benefit both individuals and departments of
anaesthesia and may ultimately improve patient safety’. This proactive
methodology was echoed by the ACECC and also discussed by
Redfern and Gallagher [68]. Examples of suggested actions are:
• Progressively scaling-down activities, with a gradual move to a
shorter working week, elimination of on-call night shifts, more time
for assessment of patients with complex medical problems, help
with more complex cases, or, when appropriate, a modification in
the scope of practice to avoid predictable difficulties.
• Older individuals typically receive less feedback on their
performance, but may find it more difficult to recognise when their
skills deteriorate because they rely more on pattern recognition
than analytic cognitive processes. Doing a list with a consultant
colleague, observing and discussing each others’ practice, is
useful and can assist in overcoming potential errors.
• Always working in a theatre complex where there are other
anaesthetists readily available to advise or assist in crises,
whether with clinical issues or with personal health, is helpful. This
also overcomes the ‘incapacitation incident’ discussed in Section
5.5. Careful consideration should be given to the advisability of
working in remote sites, including those in the independent sector.
• The design of CPD and remedial training should take into account
the needs of the older workforce. Traditional, lecture-based CPD
may be less useful to the older practitioner than group activities
in which participants discuss clinical management and receive
feedback from peers [69]. Maintaining a commitment to teaching
and learning from trainees can only be good.
The big issue to be addressed is that given the impact the ageing
anaesthetist can have on patient safety, how are they to be confirmed
as being fit for purpose within their clinical job plan? Although there
are several tools used for the cognitive assessment of physicians,
these do not evaluate crisis management and may not pick up subtle
changes in performance. Workplace assessments are an obvious
possibility, but these can be fraught with numerous problems, not least
of which is the lack of accepted methodology and frequency of review.
Does the ‘assessment situation’ (either in real time or by retrospective
review of cases) replicate the ‘real thing’? What if the assessor was
once the trainee of the ageing ‘examinee’? Would inappropriate power
dynamics and oversensitivity to a person’s feelings influence the
findings and conclusions? How would one manage an unsatisfactory
outcome? Would patients deserve to be informed about any limitations
on the scope of an individual’s practice? It is however, in principle,
surely important for both the older anaesthetist and their colleagues
to regard peer observation and confirmation of competence (or
otherwise) as helpful and in patients’ interests, and not as a challenge
to their personal professionalism. This may in the future become a
professional commitment, with confirmations of competence from
observation etc. starting at five-year intervals earlier in a career but
progressing to perhaps bi-annually at greater ages. Another factor in
reducing anxiety in older workers is the minimisation of changes to
their working environment, both in terms of location, equipment and
personnel.
To overcome some of the disadvantages of workplace assessment,
simulation training has been suggested for older anaesthetists in the
pre-retirement phase of their careers. Evidence exists that knowledge
and skill sets are transferred from the simulated environment to the
clinical setting, both for procedural skills, and non-technical skills
for crisis management. However, using simulation as a summative
assessment tool might be problematic, as validity has not been tested
in this age group. Boulet and Murray [70] conclude that ‘it is not clear
how judgments of minimal competence should or could be made’.
Return to work after illness
Another problem that already exists is that of anaesthetists returning
to work from non-trivial illness (e.g. myocardial infarction, transient
ischaemic attacks and depression). Such an event is more common
in the older age group, and diseases recur. Measures that could be
put in place that would enhance patient safety with respect to older
anaesthetists in this situation could include:
• A gradual and planned return to work, at an appropriate pace to
allow stamina and confidence to re-build.
• Never working in an isolated site or alone without anaesthetists
in adjoining theatres.
• Identification of a younger buddy.
• Having known support readily available to assist in crises (clinical
events or personal health).
• Specifying appropriate clinical duties more closely.
• Considering changes (perhaps temporary) to job plans.
• Considering changes to the annual appraisal process and
combining them with a medical report of fitness for employment.
Summary
A reasonable summary of the present position is to say that:
• There will be an increase in the number of older anaesthetists in
the workplace in future, and there need to be plans in place to
manage this demographic shift.
• There is evidence emerging that some older anaesthetists may
have a reduced clinical performance that can be adverse to
patient safety.
• There is a widespread belief that older anaesthetists need
enhanced monitoring of their workplace performance.
• It would be valuable to introduce some sort of process to confirm
competence within the individual’s job plan before problems
arise.
• Annual appraisal needs to be tailored specifically to the older
practitioner so as to allow a genuine two-way interchange of
information both to optimise the anaesthetist’s job plan and to
maximise patient safety.
• Older anaesthetists need to recognise that performance
deteriorates with age, and they need to be both self-aware and
proactive in addressing concerns they have about themselves.
Individual anaesthetists have a responsibility to demonstrate
insight into the potential impacts of ageing, and to ensure that
their health remains compatible with their job requirements.
• Older anaesthetists should comply with reasonable requests
from their department with respect to their planned duties. If
changes are needed, it is vital that the clinical director ensures
the older anaesthetist understands the reasons for change, and
that their perspective is taken into account in decision-making.
• Although ageing processes are known to be individually variable,
it may be necessary for the purposes of practicality to introduce
some arbitrary age ranges or limits within or at which age-related
factors are reviewed.
For a successful outcome, there will be complementary features of
departmental policy that need to be introduced that will mirror the
responsibilities of the individual practitioner, and these are considered
in the next section. To plan a good future for patients, individual
anaesthetists and departments, older workers must be supported
and not left to form yet another ‘lost tribe’.
6.2: Considerations for the employer
In increasing the age at which NHS pensions can be withdrawn
without actuarial decrement, the Government has created an openended,
uncontrolled experiment for departments and hospitals that
have to accommodate the demographic shift in retirement age while
maintaining patient safety. In addition, if the NHS is to have enough
staff to meet ever-increasing demands, it will need to retain older
workers. As with anaesthetists themselves, the first thing departments
and hospitals have to do is to recognise the problems ahead, plan for
them and be prepared to commit resources in terms of time and cost
to maintaining safety.
General principles
A passive ‘wait and see’ and ‘hope for the best’ approach cannot be
justified on the available safety data related to ageing. Organisations
must therefore ensure that job plans, CPD and the work environment
are designed and adapted to meet the needs of older workers.
Clinical directors and departments that take a strategic approach,
with effective job planning and appropriate involvement of human
resources and occupational physicians, are likely to get the most from
their older workforce.
All employers ought to be able to trust anaesthetists to adhere to
professional standards. With more people in the future working
22 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 23

eyond the age at which they would choose to retire, there is a potential
for this trust to be broken more frequently than it is at present, since
older physicians are less likely to follow guidelines [66]. Current GMC
guidelines (Good Medical Practice Domain 2 [71]) make it clear that
there is an inherent responsibility to comply with workplace policies.
Adherence to these by medical staff is a reasonable expectation of the
employer.
Departments and Clinical Directors have a responsibility to ensure
that the working environment addresses the needs of older workers.
Equipment should be easy to see and hear. Hearing becomes
progressively less sensitive, and cataracts, glaucoma and macular
degeneration are all more common with advancing age. Beeps and
alarms need to be sufficiently flexible to cater for normal age-related
hearing loss [68], and drug labels and monitor displays should be highcontrast
and in large print [72].
When an anaesthetist has a chronic or relapsing condition, it is useful for
the Clinical Director to involve the Consultant Occupational Physician
in ensuring the individual is well enough to meet the demands of their
job, to help in redesigning job plans when needed, and to optimise
the working environment. A formal assessment of the workplace to
identify an individual’s specific needs may be helpful, e.g. provision
of appropriate seating in theatre for someone with musculoskeletal
problems.
Job plans
Individual job plans must take appropriate account of the impacts
of ageing. Over time, older anaesthetists’ work patterns will need
adjustment. Changes made should play to the individual’s strengths,
and ensure continued involvement in the department. Job satisfaction
and a sense of being valued by colleagues are important in retaining
older colleagues in the workforce. Appropriate job planning might
include daytime weekend work instead of overnight on-call, flexible
working, shorter hours, less isolated working and less demanding or
less stressful lists. A change of role might be appropriate for some,
perhaps involving pre-operative assessment clinic work, undergraduate
or postgraduate education, clinical governance or other non-clinical
roles.
Because the impact of ageing is very variable, the timing and nature
of changes to job plans will be different for different individuals. It is
therefore difficult to provide indicative age ranges at which such changes
should be considered. It is also possible that some individuals may
demand changes that suit them, but that are difficult or unreasonable
for the department to accommodate. This can produce strains that will
need to be overcome.
Irrespective of the increase in statutory retirement age (as described in
Section 5.4), the Repeal of Retirement Age Provisions Regulations 2011
came into force on 6 April 2011 in England, Scotland and Wales. One
of the consequences of this was that, from October 2012, it was not
possible for employers to require employees to retire on the grounds
of age alone. This means that an enforced retirement would have to be
a proportionate means of achieving a legitimate aim of the employer.
In practice, justifying such a retirement is likely to be difficult unless
the employer can provide evidence that there is a decline in either
intellectual or physical performance, which is linked to an increase in
age that prevents the job being done properly.
The current situation is that if a person is performing satisfactorily and
wishes to continue to work in the same post without change, they
cannot be prevented from doing so on the grounds of age alone. If
changes are desired to the job description, these can be requested
by the employer or the employee. Case law is developing on disputes
in which these requests do not result in agreement. However, it has
been established that an employee cannot demand changes to their
job which convenience them but do not meet the corporate objectives
of the employer. Similarly, the employer has to make ‘reasonable’
efforts to accommodate a request if the corporate objectives can still
be attained if the request were granted. The Department of Work and
Pensions [73], in its description of good employment practice, says:
‘Part-time or flexible working can be an important way of enabling
employees of all ages to stay in work, or return to work, while meeting
their wider personal needs. For many older employees flexible working
is a popular option as it allows them to make a gradual transition
between full-time work and retirement. 60 per cent of over 50s would
like to continue working past State Pension age, but on a part-time
basis… Flexible working options can help employers to retain skilled
and experienced staff. It can also help employers to manage the flow
of work, whether on a day to day basis or over the longer-term. Benefits
can include less downtime...or covering peak business periods’.
In summary, a person at or over retirement age has identical rights
and limitations to a younger person who requests a change to their
job description, and it is good practice for both parties to approach the
situation appreciating the objectives and views of the other.
The approach of other industries
The HSE, in its review of the management of safety critical occupations
[56], recommends surveillance for, and the development of, intervention
strategies for employers of older workers to be complemented by an
assessment tool.
The Work Ability Index [74], developed by the Swedish Institute of
Occupational Health, is an example of a validated instrument used
by occupational physicians to assess work ability during health
examinations. This questionnaire asks the employee about:
• Current work ability compared with lifetime best.
• Work ability in relation to the demands of the job.
• Number of current diseases diagnosed by a physician.
• Estimated work impairment due to diseases.
• Sick leave during the past year.
• An employee’s own prognosis of work ability two years from now.
• Mental resources.
This generates a useful matrix of information from which to discuss
future plans with a trained appraiser who understands the needs of
the older worker and the factors that influence continued enjoyment
of work. The decision to continue working or to retire is influenced by
workplace performance, personal health, job satisfaction, working
hours, financial status, pension arrangements, family commitments,
peer-retirement norms, employer attitudes and availability of work.
While not recommending this tool above others, it has had wide
usage and is validated: it is an example of how other safety critical
occupations have approached assessment. Assessment is common
in other industries and, although well-recognised for airline pilots,
analogous processes are already in place for such occupations as
miners, professional road drivers, engine drivers, oil rig workers,
sailors, air traffic controllers and nuclear power workers. ‘Why are
anaesthetists not subject to something similar?’ is a legitimate question
to ask. This will need a change of culture to one of acceptance by both
anaesthetists and employers that peer monitoring and assessment is
not a challenge to personal professionalism. Instead it is, or should
be, an essential part of professionalism, and it needs to be recognised
that this is a considerable time commitment for all concerned. To
achieve the right outcome, it needs to be done properly, not squeezed
in or fitted between existing commitments. At present, once consultant
grade is achieved, there appears to be little or no appetite from either
employee or employer to make consultant staff subject to regular
workplace scrutiny of their clinical performance.
6.3: The role of the Government
It is clear from this review that the Government has the unenviable
task of managing the increasingly complex health needs of an ageing
population whose expectations of what is possible are rising in the
presence of:
• Probable future low economic growth.
• A shortage of natural resources and energy.
• An increasing ratio of economically unproductive to productive
members of the population.
The Government is in a difficult position. It has made an understandable
start by moving towards a situation in which people provide more
for their own retirement. In making savings in public expenditure
by reducing pension costs, it has gone directly to the biggest
lever it can pull. In addition the Government is already subject to
recommendations of its own making. In 2004, the English Department
of Health [75] said that ‘the reduction of inequality in health outcomes
is a key objective, which is to be achieved through local action as well
as national planning’. In 2007, the Office of Science and Technology
[76] made it clear that ‘Health inequalities result from many interlinking
factors, of which relative poverty and socioeconomic grouping are the
main drivers. The greatest variations are seen in the elderly’.
As previously described (Section 5.3), in 2010 the Marmot Report
echoed these views. However, it is important to question whether a
reduction in inequality is politically achievable, and whether there is
an acceptable cost in achieving it. Approximately 2,700 years ago, it
was written that ‘There will always be poor people in the land’ 12 and
Aristotle 13 , who saw social differences as inevitable, said ‘The worst
form of inequality is to try to make unequal things equal’. In 2014, a
rather concerning health economics analysis by Bognar and Hirose
[77] concluded that, in a developed democracy operating within a
limited financial envelope, the pursuit of health equality may be
counterproductive to many. They asked: ‘How much overall health
should society sacrifice (i.e. in the better-off) for reducing the social
inequality in health?’ These are political rather than health questions
and the answers are not obvious. The Government’s stated policy on
health equality, although laudable, may have a major impact on the
service but not deliver the goals it intends. It is clear that the balance
between health need and health expenditure requires constant
review. It is certain that modifications to policy and solutions that limit
demand will inevitably arise. How the Government will develop those
policies that limit demand, or even if this is politically possible, is by
no means clear. Some of the most contentious measures, which are
currently not officially being considered, are:
• Allowing co-funding of care within the NHS when a patient can
afford it and wants it.
• Facilitating and encouraging ‘self-help’ by local groups on a
voluntary basis within the context of community care.
• Setting a maximum cost for any specific pathway of care, and
in particular for terminal illness. A fixed NHS Personal Maternity
Care budget has recently been suggested [78].
• Establishing a hypothecated health tax to augment health
expenditure raised from general taxation. This possibility is
receiving increasing consideration within parliament [79].
• Admitting publically that everything cannot always be delivered
to everybody on all occasions, i.e. there needs to be an ethical
policy on healthcare rationing.
Whatever approach the Government and politicians take, underlying
the whole issue of quality is the fact that clinical honesty will not be
achieved in practice without political honesty of purpose for the NHS.
Watch this space.
12
Deuteronomy 15:11 – 7th century BCE.
13
Paraphrase from Aristotle, Book VII 3.5, 1325.b.
24 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 25

6.4: The role of the public
Appendix 1: Working party members
The responsibilities of the public are more difficult to describe than
their interests. Lifelong, free at the point of service ‘cradle to grave’
healthcare has existed for over 60 years in the UK, and is now
embedded as a part of British expectation. The NHS Constitution
[80] was launched in an attempt to try to clarify what patients’ and
employees’ rights and responsibilities were. Section 3b describes
the patients’ and public’s responsibilities. These are:
• Recognise that you can make a significant contribution to your
own, and your family’s, good health and wellbeing, and take
personal responsibility for them.
• Register with a GP practice – the main point of access to NHS
care as commissioned by NHS bodies.
• Provide accurate information about your health, condition and
status.
• Keep appointments or cancel within reasonable time.
• Follow the course of treatment that you have agreed, and talk to
your clinician if you find this difficult.
• Participate in important public health programmes such as
vaccination.
• Ensure that those closest to you are aware of your wishes about
organ donation.
• Give feedback – both positive and negative – about your
experiences and the treatment and care you have received.
• Treat NHS staff and other patients with respect.
Peter Hutton (Chair)
Peter is a consultant anaesthetist with a focus on
neuroanaesthesia and trauma at the University
Hospital Birmingham, and Honorary Professor of
Anaesthesia at the University of Birmingham. He
also undertakes Medical Examiner duties. During
his career he has served on a number of national
bodies such as the GMC and from 2007–2009 was joint clinical lead
for unscheduled care for NHS London. He is a past Council Member
of the AAGBI and was formerly President of the Royal College of
Anaesthetists (2002–2003) and Chair of the Academy of Medical
Royal Colleges (2002–2004). He established and chaired a Home
Office Ethics Group to manage the ethical aspects of forensic DNA
Analysis (2008–2010), and in the recent past was the Independent
Hospital Consultant Advisor to the two Mid-Staffs inquiries. In 2014
he was appointed by the Home Office to lead a review of Forensic
Pathology services in England and Wales.
Mary Baker MBE
Tony Giddings
Tony is a retired a consultant general and vascular
surgeon who also holds a pilot’s licence. He has had
a long-term practical and research interest in surgical
organisation, performance and safe systems. A
former Council Member of the Royal College of
Surgeons, he was also President of the Association
of Surgeons of Great Britain and Ireland. He was a reviewer for the
original Mid-Staffs inquiry and a special adviser to the Parliamentary
Health Committee.
He continues to research and teach on patient safety and in promoting
a better understanding of the opportunities for improvement in health
services and the wellbeing of practitioners. Through films he has
helped to show healthcare staff their familiar world with new eyes, and
with new insights into human factors. He believes that we have much
more to do to apply what we already know to make better use of our
skills and to reduce inappropriate blame and avoidable harm.
Richard Griffiths (AAGBI)
Guy Hirst
Guy was a British Airways pilot from 1972 until
2006, during which time he flew over 18,000 hours
and was a Training Captain on DC 10 and Boeing
747-400 aircraft. In 1999 he was promoted to be a
Training Standards Captain, responsible for training,
developing and revalidating British Airways training
pilots on behalf of the Civil Aviation Authority. Guy was one of the
pioneers of the introduction of Human Factors (HF) Training into Airline
culture.
Since 2001 Guy has been running training and coaching programmes
in association with many healthcare organisations in the UK. He
has also been involved with several research projects, particularly
in the operating theatre environment. Guy is the co-founder of Risky
Business (http://www.risky-business.com) He is the Aviation Expert for
ITV news and recently appeared in a BBC Horizon programme entitled
How to Avoid Mistakes in Surgery.
Nancy Redfern (AAGBI)
These are all laudable responsibilities, but what is lacking is an open
public discussion about the quantity and content of healthcare that
can be provided across the NHS with the current funding. Many visits
to primary care and A&E departments are known to be unnecessary
and waste resources. For the NHS to be able to pursue better
methods of managing serious illness, the public will have to use
the services more sparingly, and have a better understanding of the
costs of what is provided.
Mary is a sociologist whose professional life has
been spent representing the interests of patients
and relatives, culminating as the former CEO of the
Parkinson’s Disease Society. She is the Immediate
Past President of the European Brain Council, Past
President of the European Federation of Neurological Associations, a
Consultant to the World Health Organization and Chair of the Working
Group on Parkinson’s Disease. Academic appointments include
Associate Membership of the Health Services Research Unit, University
of Oxford and Visiting Fellow within the London School of Economics
Health Centre. For her work, Mary has received Honorary Doctorates
from the Universities of Surrey and Aston. She had Honorary Fellowship
conferred by the Faculty of Pharmaceutical Medicine. In 2009 she
received the prestigious British Neuroscience Association Award
for Outstanding Contribution to British Neuroscience and for Public
Service, followed in 2014 by the Dana/EDAB Lifetime Achievement
Award for Outreach on Behalf of Brain Research.
Following postgraduate clinical training in the East
Midlands and California and undertaking a BJA
Research Fellowship and completing an MD (1995)
in Leicester, Richard was appointed to his present
post of consultant anaesthetist at Peterborough &
Stamford Hospitals in 1996. He was an examiner for
the FRCA (2003–2012) and was elected to the Council of the AAGBI
in 2008. Here he served as Honorary Secretary and is currently a Vice
President. He chaired AAGBI working parties into Proximal Femoral
Fractures and Surgery in the Elderly.
Richard has pursued a major interest in peri-operative medicine in
older adults, specifically around hip fractures. He founded the NHS Hip
Fracture Perioperative Network in 2007 and co-led the observational
study, Anaesthesia Sprint Audit of Practice (ASAP). He was awarded
the Dudley Buxton medal by the Royal College of Anaesthetists for
promoting the understanding of the science of anaesthesia in 2014.
Nancy is Honorary Membership Secretary of the
AAGBI and a Consultant Anaesthetist. Throughout
her 29 years of consultant practice, her interests have
been in education and professional development.
Following a stint as College Tutor and Programme
Director, she worked part-time as Associate Dean
managing flexible training and developing a system to support and
manage doctors who became ill. This led to work on the ‘expert
group’ of the National Clinical Assessment Service. For her Diploma
in Education she reviewed ways of managing and supporting doctors
in difficulty. As Specialty Dean Director, she managed 56 different
disciplines, contributed regularly to the Conference of Postgraduate
Medical Deans and was Lead Dean for two specialties. She established
mentoring both in the Northern Deanery and at the AAGBI, and now
reaps the benefit, using mentors to ensure she contributes in ways she
enjoys in her senior years.
Carol Black DBE
William Harrop-Griffiths (RCoA)
David Shipway
Introducing this as a social concept through public education will be
difficult but necessary. If the public does not respond to calls for better
usage, funds will inevitably dry up, and rationing without rationale will
become the norm unless there are personal funds to bridge the gap.
There is evidence that rationing is already happening internationally
[81]. With the increased use of pre-assessment clinics because of
the increased age and complexity of patients, these locations could
gradually become the places where ‘worthwhile use of resource’
decisions are taken [82]. To be able to retain the trust of the public,
discussions with patients and relatives need to be open and honest.
This again requires proper public information and education to allow
conversations to be undertaken against the background of an ethical
framework acceptable to society and supported by the Government.
Dame Carol Black is Principal of Newnham College
Cambridge, Expert Adviser on Health and Work to
the Department of Health England and to Public
Health England, and Chairman of the Nuffield Trust
for Health Policy. She is also a member of the Welsh
Government’s Bevan Commission on Health in
Wales, and Chair of the RSSB’s Health and Wellbeing Policy Group.
In November 2011 when National Director for Health and Work she
completed as Co-Chair an independent review for the UK Government
of sickness absence in Britain. The recommendations of this report
are now being put in place, with for example a national Fit for Work
Service. Professor Black is a Past President of the Royal College
of Physicians, and a past-Chair of the Academy of Medical Royal
Colleges. The Centre she established at the Royal Free Hospital in
London continues to be internationally renowned for the research and
treatment of connective tissue diseases such as scleroderma.
William is a Consultant Anaesthetist and Honorary
Clinical Senior Lecturer at Imperial College Healthcare
NHS Trust, London, UK. He graduated in 1981 from
Oxford University and St Thomas’s Hospital, London
and trained in London and Seattle. He was President
of the AAGBI from 2012–2014, and is a Council
Member of the Royal College of Anaesthetists. He is the Chair of
NHS England’s National Safety Standards for Invasive Procedures
Group, and has great enthusiasm for regional anaesthesia with
clinical interests in orthopaedic, obstetric and vascular anaesthesia.
William is an Associate Editor of the journal Regional Anesthesia &
Pain Medicine. He is fond of speaking in public, and his lectures have
often been described as ‘a victory of style over content’. He takes this
as a compliment.
David is a Consultant Physician and Gerontologist
at St Mary’s Hospital, Imperial College Healthcare
NHS Trust, London. He is an atypical geriatrician,
and subspecialises in the peri-operative care of old
and multimorbid patients undergoing surgery. David
trained at Oxford University, and completed his
postgraduate medical training in London. He undertook specialist
fellowship training in peri-operative medicine at Guy’s and St Thomas’
NHS Foundation Trust. Since his appointment at St Mary’s Hospital,
he has established a new service delivering embedded peri-operative
geriatric medical care within the department of surgery. He has
published in the field of peri-operative medicine and the implications of
the ageing population for surgical services and training. His specialist
interests are frailty and cognitive impairment in the peri-operative
setting.
26 Anaesthesia News August 2016 • Issue 349 Anaesthesia News August 2016 • Issue 349 27

15 th Anaesthesia, Pain and Critical Care Update
Friday 30 th September & Saturday 1 st October 2016
Royal Armouries, Armouries Drive, Leeds LS10 1LT
REGISTRATION
08:00 - 08:45: Registration, Coffee, Trade Stands
08:45 - 09:00: Welcome address - Dr Velu Guruswamy, Leeds, Organising Secretary
SESSION 1 (Chairs – Prof Ravi Mahajan & Dr Mahesh Shah)
09:00 - 09:25: Management of Critically unwell parturients
Dr Audrey Quinn , Middlesborough 2B06, 3B00
09:25 - 09:50: Day to day challenges in Paediatric Anaesthesia
Dr Stephanie Bew, Leeds 2D02, 3D00
09:50 - 10:15: Trauma Anaesthesia - lessons learnt & is there a fixed recipe
Dr Martin Drezner, Leeds 2A02, 3A10
10 :15 -10:30: Discussion
10:30 - 11:00: Coffee break, Trade Stands, Posters
SESSION 2 (Chairs – Prof Rajinder Mirakhur & Dr Ravi Marthi)
11:00 - 11:25: Paediatric Anaesthesia in India - remembering ‘Taare Zameen Par’
Prof (Retd) Rebecca Jacob, India 3J00
11:25 - 11:50: Patient safety first
Dr Liam Brennan, President RCoA 3I00
11:50 - 12:15: Is Medical profession under threat in UK
Dr Anthea Mowat, Deputy Chair BMA, London 3J00
12:15 - 12:30: Discussion
12:30 - 13:30: Lunch , Posters, Trade Stands
SESSION 3 A (Chairs – Dr Roop Kishen & Dr Shivkumar Singh)
13:30 - 14:45: Free paper presentation
SESSION 3B (Chairs – Dr Ranjit Verma & Dr Nalini Malarkkan)
13:30 - 13:55: Acute Brain Injury - Optimum management from DGH to Tertiary Center
Dr Tonny Veenith, QEH, Birmingham 2F01, 3F00
13:55 - 14:20: Acute pain in Chronic pain patients
Dr Barani Ganesan, Leeds 3E00
14:20 - 14:45: Why people fail in Revalidation
Ms Tista Chakravarthy- Gannon, Lead Regional Advisor, GMC, London 3J00
14:45 - 15:00: Discussion
15:00 - 15:30: Coffee, Trade Stands and Posters
SESSION 4 (Chairs – Dr Abhiram Mallick & Dr Jayavanth Kini)
15:30 - 15:55: Peri-operative Medicine
Dr Ramani Moonesinghe, London 2A06, 2A07
15:55 - 16:20: Oxygen Insufflation in Difficult Airway
Dr Anil Patel, President, DAS 1C02, 3A01
16:20 - 16:30: Discussion
SESSION 5 (Chairs – Prof Monsukh Popat & Dr Pawan Gupta)
16:30 - 17:15: Debate – This house believes consultants being resident on call
is the way forward for the NHS 3J00
Supporting the notion - Dr Simon Tomlinson, Manchester,
Against the notion - Dr Hamish McLure, Leeds
(RCOA Approved 6 CPD points)
Organsied by BAOIA. Charity Dinner with Mr Sunil Gavaskar.
Further details and registration, visit www.baoia.co.uk
Workshops on 1 st October 2016
WS 1 - Airway workshop (AW)
Dr Sonal Sonwalkar / Dr Heather Gorton
Regional Anaesthesia (RA)
Dr Sameer Bhandari / Dr Vinay Shanthi
WS 2 UL (UPPER LIMB / TRUNK)
WS 3 LL (LOWER LIMB / CNB)
WS 4 - Simulation workshop (SW)
Organiser TBC
09.00-
12.30
13.30-
16.30
WS1 WS2 WS3 WS4
AW UL - SW
AW - LL SW
Each delegate can attend 2 of 4 workshops
(RCOA Approved 6 CPD points)
EARLY BIRD
BOOKING CLOSES
26 SEPTEMBER
2016
ANNUAL
SCIENTIFIC
MEETING
2016
BOOKING NOW OPEN
Torquay 16-18 November 2016
Riviera Centre
Torquay
ABSTRACTS
SUBMISSION DEADLINE
05 SEPTEMBER
2016
• WORKSHOPS
• PRO/CON DEBATES
• EXPERT CASE DISCUSSION
• ODP SIMULATION SESSION
• ORAL PRESENTATIONS
• INDUSTRY EXHIBITION
www.das2016.co.uk
DAS_Bulletin_Ad_2016.indd 1 24/06/2016 14:18
TRAVEL GRANTS/IRC FUNDING
The International Relations Committee (IRC)
offers travel grants to anaesthetists who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that grants will not normally be considered for
attendance at congresses or meetings of learned societies.
Exceptionally, they may be granted for extension of travel
in association with such a post or meeting. Applicants
should indicate their level of experience and expected
benefits to be gained from their visits, over and above
the educational value to the applicants themselves.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email secretariat@aagbi.org
or telephone 020 7631 1650 (option 3)
Closing date: 19 September 2016
C
M
Y
CM
MY
CY
CMY
K
11 th West of England
Anaesthesia Update
11 th West of England Anaesthesia Update Conference
Based in Chalet Hotel St Christoph Austria
Talks cover a wide range of topics in anaesthesia, pain and ICM
15 CPD points RCOA
Flights from Bristol, Gatwick, Southampton and other airports nationwide
All grades of Anaesthetist from everywhere welcome.
ROYAL COLLEGE OF PHYSICIANS
16 th – 20 rd January 2017
St Christoph am Arlberg (nr St Anton), Austria
Visit: www.weauconf.com
7TH NOVEMBER 2016
LONDON
The
Preoperative
Association
NATIONAL CONFERENCE
ACCREDITED WITH 5 CEPD POINTS
TOPICS TO INCLUDE: Preoperative Optimisation in Primary Care / “Getting it right first
time” Model Hospital / Perioperative Medicines Guide / Obstructive Sleep Apnoea /
Hypertension Guidelines Update / Perioperative Medicine Curriculum / Revalidation
for Nurses / ECG Workshop / Perioperative Quality Improvement Programme
ABSTRACT FOR PRESENTATIONS OR POSTERS TO BE SUBMITTED BY 9TH SEPTEMBER 2016
Open to all healthcare professionals involved in the preoperative assessment of
the surgical patient. For full details and to book your place, please contact us:
W: WWW.PRE-OP.ORG / T: 020 7631 8896

THE ROYAL COLLEGE OF ANAESTHETISTS
CPD STUDY DAY
BELFAST
Wednesday, 28 September 2016
The Waterfront Hall, Belfast
£200 (£150 for RCoA registered trainees)
Event organiser: Dr B Darling
Lectures on the day may include:
■ Anaesthesia for bariatric surgery
■ Interventional radiology in the management of strokes
■ Pre-hospital health emergency management system
■ Fast track total knee arthroplasty
■ Analgesia for acute surgical pain
■ The GMC: working for patients
■ The GMC: working with doctors
■ How doctors cure crime
5
CPD
CREDITS
st
21Annual Scientic Meeting 2016
Friday, 4 th November 2016
Oxford Town Hall, Oxford
Improving patients’ outcomes
Sessions:
• Pain in orthopaedic patients: whose pain is it?
• Pushing the boundaries of regional anaesthesia
for orthopaedic surgery
• Working together to improve patients’ outcomes
Follow @RCoA_Events
Find us on Facebook
events@rcoa.ac.uk | 020 7092 1673 | www.rcoa.ac.uk/events
Abstract submission deadline: 23 rd September
Register at www.bsoa.org.uk
Registration fees from £ 50.
Approved by the RCoA for 5.0 CPD credits
Essentials of Anaesthesia in the
Developing World
Focused Intensive Care
Echocardiography (FICE) Course
Training the Trainers
Resuscitation Update for
Consultants
Cardiff Ultrasound Guided
Regional Anaesthesia with
Cadaveric Anatomy
Cardiff Perioperative Hands-on
Transoesophageal
Echocardiography (TOE)
Symposium
Date
15th September 2016
13th & 14th October 2016
22 November 2016
Course Full
NEW date coming in Autumn!
Dates Available are:
20-22 September 2016
15-17 November 2016
12th &13th September 2016
Course Details
A 1 day fun, interactive and informative course offering an
introduction to working in the developing world. There will be
simulation demonstrations and participants can experience
equipment used applicable to the developing world.
FICE accreditation course for the Intensive Care Society
(ICS) and British Society of Echocardiography (BSE).
A 2 day multi professional simulation course offering 10 CPD
points for those interested in Simulation Education.
A half day refresher course on managing cardiac arrest in
adults.
A 2 day practical hands-on course that course enables you to
optimize and interpret the ultrasound machine’s information
and to apply it to real-world clinical procedures.
A 3 day practical course for all specialists who wish to
perform perioperative transoesophageal echocardiography.
Symposium Course Details
A 2 day lecture based course for all specialists who wish
to gain expert knowledge of transoesophageal
echocardiography.
Courses for Clinicians
Course Fee
£100
Earlybird price by 26th Aug or £120
thereafter. (including
lunch/refreshments)
£150
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Recommendations for the Safe Transfer of
Patients with Brain Injury
2006
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 76311650 Fax 020 7631 4352
www.aagbi.org
May 2006

MEMBERSHIP OF THE WORKING PARTY
Dr PA Farling
Dr PJD Andrews
Dr S Cruickshank
Dr I Johnston
Dr B Matta
Prof DK Menon
Dr E Moss
Dr MP Parris
Dr M Power
Dr M Smith
Dr DK Whitaker
Ex Officio
Professor M Harmer
Professor WA Chambers
Dr A W Harrop-Griffiths
Dr RJS Birks
Dr IH Wilson
Dr DE Dickson
Dr D Bogod
Chairman of Working Party and Immediate
Past President Neuroanaesthesia Society of
Great Britain & Ireland
Chairman Neuro-intensive Care & Emergency
Medicine Section, European Society of Intensive
Care Medicine
Immediate Past Honorary Treasurer Neuroanaesthesia
Society of Great Britain & Ireland
Council Association of Anaesthetists of Great Britain
& Ireland
Honorary Secretary Neuroanaesthesia Society of
Great Britain & Ireland
Intensive Care Society
Royal College of Anaesthetists
Group of Anaesthetists in Training
Honorary Secretary Intensive Care Society of Ireland
President Neuroanaesthesia Society of Great Britain
& Ireland
President Elect Association of Anaesthetists of
Great Britain and Ireland
President
Honorary Secretary
Honorary Secretary Elect
Honorary Treasurer
Honorary Treasurer Elect
Honorary Membership Secretary
Editor-in-Chief Anaesthesia
The Joint Royal Colleges Ambulance Liaison Committee has endorsed this document.
Significant contributions were received from The Society of British Neurological
Surgeons and from Dr Stephen Hancock, Consultant Paediatric Intensivist.
The Association of Anaesthetists of Great Britain and Ireland wishes to record its
sincere thanks for the support and advice given by the Neuroanaesthesia Society of
Great Britain and Ireland in publication of this document.
© This document was first published in December 1996 by the Association of
Anaesthetists of Great Britain and Ireland, 9 Bedford Square London WC1B 3RA
© Copyright of the Association of Anaesthetists of Great Britain and Ireland. No part of
this book may be reproduced without the written permission of the Association of
Anaesthetists.

CONTENTS
Section I Summary and Recommendations 02
Section II Background 03
Section III Introduction 04
Section IV Organisation and Communication 05
Section V Staffing Requirements and Standards 07
Section VI Preparation for the Transfer 08
Section VII The Transfer 11
Section VIII Equipment and Drugs 13
Section IX Education and Training 15
Section X Resource Implications for Transfer of Patients 17
with Brain Injuries
References 18
Appendices 19
1

SECTION I - SUMMARY AND RECOMMENDATIONS
1. High quality transfer of patients with brain injury improves outcome.
2. There should be designated consultants in the referring hospitals and
the neuroscience units* with overall responsibility for the transfer of
patients with brain injuries.
3. Local guidelines on the transfer of patients with brain injuries
should be drawn up between the referring hospital trusts, the
neurosciences unit and the local ambulance service. These should
be consistent with established national guidelines. Details of the
transfer of responsibility for patient care should also be agreed.
4. While it is understood that transfer is often urgent thorough
resuscitation and stabilisation of the patient must be completed
before transfer to avoid complications during the journey.
5. All patients with a Glasgow Coma Scale (GCS) less than or equal to
8 requiring transfer to a neurosciences unit should be intubated and
ventilated, as should any patients with the indications detailed in
Appendix 1.
6. Patients with brain injuries should be accompanied by a doctor with
appropriate training and experience in the transfer of patients with
acute brain injury. They must have a dedicated and adequately
trained assistant. Arrangements for medical indemnity and personal
accident insurance should be in place.
7. The standard of monitoring during transport should adhere to
previously published standards.[1]
8. The transfer team must be provided with a means of communication
- a mobile telephone is suitable.
9. Education, training and audit are crucial to improving standards of
transfer.
* Throughout this document the term acute neuroscience unit is taken
to include neurology, neurosurgery, neuroanaesthesia, neurocritical
care and neuroradiology.
2

SECTION II - BACKGROUND
In 1996 the Association of Anaesthetists (AAGBI) and the
Neuroanaesthesia Society (NASGBI) published Recommendations for
the Transfer of Patients with Acute Head Injuries to Neurosurgical
U n i t s. Since 1996 a number of organisations have published
guidelines relating to transfer.[2-8] However, it was felt that it would
be beneficial to provide an up-to-date resource to be distributed to
members of the AAGBI. The National Service Framework for long term
conditions has implications for neurological patients.[9] Changes in
clinical practice, for example the development of intrava s c u l a r
treatment of subarachnoid haemorrhage,[10] will increase the number
of transfers of patients with non-traumatic brain injury. It wa s ,
therefore, considered appropriate to extend the scope of the guideline
to include all patients with acute brain injury. Ideally the transfer of
paediatric patients will be undertaken by staff experienced in the
transfer of critically ill children.
Supplementary electronic material can be obtained from many of the
sources that are detailed in the References section of this document.
3

SECTION III - INTRODUCTION
Patients with neurotrauma or other acute brain injury often receive
their initial treatment at a local hospital, which may not have a
neurosciences unit. As a result, many patients with serious brain
injuries have to be transferred urgently between hospitals by road
ambulance, or occasionally by air. In some areas Critical Care
Networks and transfer groups have been established according to
national directives.[11] While no precise time targets have been set
between injury and surgery, a maximum of 4 hours is aimed at because
it is clear that the sooner an expanding haematoma is evacuated, the
better for the patient.
Transfer of patients with brain injury is potentially hazardous if poorly
executed.[12] Patients can come to harm as a result and ultimate
neurological outcome may be adversely affected. This can be avoided
if sound principles are applied. The main causes of secondary brain
damage are raised intracranial pressure (ICP), hypotension, hypoxia,
hy p e rcarbia, cardiovascular instability and hy p e r pyrexia. Most
principles of safe transfer are common to all seriously ill patients but
there are some specific features that apply in particular to those with
acute brain injury. These principles apply equally to transfer of patients
both within and between hospitals.
These recommendations are provided for those responsible for
planning, managing and undertaking transfer of brain injured patients.
They aim to supply not only practical guidelines for ensuring safe
transfer of individual patients, but also principles of organisation to
assist in local negotiation when establishing new or improving existing
transfer arrangements.
4

SECTION IV - ORGANISATION AND
COMMUNICATION
Safe transfer of patients with brain injuries requires an effective
partnership between the referring hospitals, the neurosciences unit and
the ambulance service.
Local guidelines should be agreed between the referring hospitals and
the neurosciences unit in advance. They should be subject to regular
review and audit. The guidelines will include:
• which patients should be referred,
• when a transfer should be made,
• who is responsible for accepting the patient,
• the preparations and arrangements for the journey itself so that there
is no unnecessary delay,
• when the responsibility for the patient is transferred from the
referring to the receiving team.
Anaesthetists should be involved in agreeing local guidelines that are
consistent with established national and international guidelines.
Guidelines do not replace clinical judgement but they provide a safe
framework within which judgement can be exercised.
Every hospital to which the ambulance services take patients with
serious brain injuries must have facilities for resuscitation and
diagnosis, including 24-hour access to computerised tomography.
Appropriate staff and equipment should be available to ensure a safe
transfer to the neurosciences unit when necessary. There should be a
designated consultant within that hospital who has ove ra l l
responsibility for secondary transfers and a consultant at the
neurosciences unit who has ove rall responsibility for receiv i n g
transfers. These duties should be recognised in job plans.
Education and training are crucial to improving standards of transfer.
Appropriate resources must be provided by those who plan and
5

purchase these services. They must be available to all professionals
who share responsibility for the safety of the patient. There are obvious
advantages in having a common philosophy of care and standardised
terminology, such as those provided by the Advanced Trauma Life
Support (ATLS) system and the GCS. A modified GCS should be used
for paediatric patients.[3]
Good verbal and written communications are vital. This is especially
so at the time of referral and when a patient is handed over at the end
of the transfer. They will include precise details of where, within the
neurosciences centre, the patient is to be taken. The ambulance
service appreciate an early warning to facilitate their arrangements.
6

SECTION V - STAFFING REQUIREMENTS AND
STANDARDS
Expediency should not dictate the level of expertise available for the
transfer of patients. Critically ill patients with acute brain injuries must
be accompanied by a doctor with suitable training, skills,
competencies and experience of brain injury transfer.
It must be recognised that a trainee alone in an ambulance is working
in an unsupervised capacity. Changes in working patterns may reduce
the availability of trainees for transfers and consultant time for transfers
must be built into manpower projections. Account should be taken of
shift arrangements when deciding who should accompany the patient.
A dedicated trained assistant must be provided for the escorting doctor.
This might be an appropriately trained operating department
practitioner, nurse or paramedic.
Employers must ensure that there is appropriate medical indemnity
i n s u rance for such transfers. In addition, the Association of
Anaesthetists (AAGBI) recommends that doctors are members of
medical defence organisations. Adequate death and personal injury
insurance must also be provided for the members of the transfer team
by the employer; existing employer insurance may be inadequate and
local arrangements should be clarified. Details of appropriate
insurance schemes are available from the AAGBI (www.aagbi.org) and
such cover is a benefit of membership.
7

SECTION VI - PREPARATION FOR THE TRANSFER
Many critical care networks have reached consensus with local
ambulance providers to ensure that all Trusts have common standards
of transfer equipment. These developments are highly desirable, and
likely to result in better organisation and delivery of patient care
The decision to transfer a patient with a brain injury must be made by
senior medical staff at the referring hospital in consultation with senior
staff at the neurosciences unit, who should provide written advice on
neurosurgical management. Thorough resuscitation and stabilisation
of the patient before transfer is the key to avoiding complications
during the journey. The fundamental requirement before transfer is to
ensure satisfactory oxygen delivery. A mean blood pressure greater
than 80 mmHg (paediatric values - appendix III), PaO2 greater than 13
kPa and PaCO2 between 4.5 – 5.0 kPa should be achieved.
Monitoring should include:
pupillary size and reaction to light
ECG
pulse oximetry
invasive blood pressure
urine output by urinary catheter
capnography
central venous pressure monitoring where indicated
temperature (preferably core and peripheral)
Investigations undertaken prior to transfer should include:
arterial blood gas estimation
chest, lateral cervical spine pelvis, and other appropriate X-rays [13]
haematology FBC and coagulation screen
biochemistry blood sugar
other investigations as appropriate
blood should be cross matched if appropriate, and sent in the
transferring ambulance (not in a separate taxi)
8

A p p ropriate re s p i ra t o ry support must be established. Tra ch e a l
intubation during transfer is difficult and dangerous. All patients with
a GCS of 8 or less require intubation prior to transfer. In addition,
whatever the baseline GCS, intubation should be considered if the
GCS has fallen by 2 or more points. Intubation is essential if there is a
fall of 2 or more points in the motor score. Intubation requires
adequate sedation and muscle relaxation to avoid an increase in (ICP),
and measures to prevent aspiration of gastric contents. This will
normally involve rapid sequence induction with in-line stabilisation of
the cervical spine. After intubation, appropriate drugs should be
employed to maintain sedation, analgesia and muscle relaxation,
(preferably administered by syringe driver), while avoiding hypotension
and reduced cerebral perfusion pressure (CPP). Patients should be
ventilated with the aim of achieving a PaO2 greater than 13 kPa and a
PaCO2 of 4.5 – 5.0 kPa unless there is clinical or radiological evidence
of raised intracranial pressure when more aggressive hyperventilation
is justified (but not below 4 kPa). If hyperventilation is used the FIO2
should be increased.
Inspired oxygen should be guided by blood gas estimations before
departure. Expired carbon dioxide should be monitored continuously.
A chest drain should be inserted if a pneumothorax is present or
considered a potential problem, eg due to fractured ribs. Underwater
seals should normally be replaced by leaflet valve (Heimlich type)
drainage systems. Chest drains should not be clamped.[2] A large bore
orogastric tube should be passed and left on free drainage (not
nasogastric in case the patient has a base of skull fracture).
Intravenous volume loading should be undertaken with crystalloid or
colloid initially to maintain or restore satisfactory peripheral perfusion,
blood pressure and urine output. 5% Dextrose should be avoided and
blood products should be given as required. Hypovolaemic patients
tolerate transfer poorly and the circulating volume should be normal or
supra-normal before transfer, preferably with a haematocrit over 30%.
A central venous catheter may be useful to optimise filling pressures
and for the administration of drugs and fluids during the transfer.
9

A patient who remains hypotensive despite resuscitation must not be
transported until all possible causes of the hypotension have been
identified and the patient stabilised.
Correction of major haemorrhage takes precedence over transfer. It is
important that these measures are not omitted in an attempt to speed
transfer of the patient, as resultant complications may be impossible to
deal with once the journey has begun.
Persistent hypotension will adversely affect neurological outcome.
When other causes of hypotension have been excluded, consider the
judicious use of inotropes/vasopressors to offset the hypotensive effects
of sedative agents.
If the patient has had a seizure, loading with anticonvulsant agents
(usually phenytoin) should be considered prior to transfer. Unstable or
compound long bone fractures should have preliminary toilet and be
splinted to provide neurovascular protection and analgesia.
If the transfer team has not been involved in the initial stages they
should familiarise themselves with treatment already given and
independently assess the general status of the patient before departure.
All lines and tubes must be fixed securely and ready access to them
ensured.
The transfer team should confirm the availability of an appropriate
transfer vehicle and check the function of all equipment, including
battery charge status.[14] Oxygen requirements for the journey
including possible delays should be estimated and should include
driving gas requirements of the ventilator. A minimum reserve of
oxygen and drugs should be one hour or twice the estimated journey
time. If transfer times are unduly long, it may be necessary to arrange
for back up oxygen supplies to be made available en route if possible.
Before departure, case notes, X-rays, a referral letter and investigation
reports should be collated and any required blood or blood products
collected. The neurosciences unit should be contacted and informed of
the estimated journey time.
10

SECTION VII - THE TRANSFER
The transfer team should be relieved of all other duties, be
appropriately dressed, equipped and insured. Ideally, the transfer team
should be involved in the initial resuscitation and management of the
patient. If this is not possible, they should receive a formal hand-over
from the resuscitation team. All notes (or photocopies), X-rays, CT
scans, blood results and cross-matched blood should accompany the
patient. The duty consultant anaesthetist in the referring hospital
should be made aware of the planned transfer. All monitoring
equipment should be checked, connected to the patient and securely
mounted so that it cannot fall on to the patient during transfer or cause
injury to ambulance occupants in the event of an accident.
The patient should be transferred onto the transport trolley/stretcher,
properly secured and padded with due regard to any possible spinal
injury.[2, 15] The patient should be positioned with a 20° head up tilt.
The development of ambulance trolleys that allow this degree of tilt,
while maintaining spinal immobilisation, should be encouraged. Most
transfers will be by land ambulance but for transfers over longer
distances local protocols may include transfer by air.[16]
During transfer, patient management will be centred upon maintaining
oxygenation and adequate blood pressure and minimising rises in ICP.
Monitoring ECG, invasive blood pressure, SpO2, PECO2, temperature,
pupillary size and reaction to light, and the administration of drugs
and other infusions should be continued.
A paper record must be maintained during the transfer. This may be
aided by a dictaphone or by the electronic memory in monitors. The
development of standardised documentation is encouraged and many
critical care networks have developed local transfer documentation.
Transfers should be undertaken smoothly and not at high speed.
The transfer team should be equipped with a mobile telephone to
contact the neurosciences unit and their base hospital en route.
11

A patient who has been made physiologically stable before departure
is more likely to remain so for the duration of the transfer, although
there is still the need for constant vigilance and prompt action to deal
with complications. If, despite thorough preparation, there is a need to
perform any procedure during the transfer this should be done with the
ambulance brought to a halt.
Staff at the neurosciences unit should be available to receive a
comprehensive hand-over following which they assume responsibility
for the patient’s care. Notes, X-rays, scans and a copy of the transfer
record should be left with the receiving staff. The neurosciences unit
should be prepared to provide the transfer team with refreshments.
A protocol should be established to ensure the immediate return of the
referring team with their equipment to their hospital. Often a contract
exists with a local taxi firm for this purpose. Personal injury insurance
should also cover the return journey.
The referring team should keep a copy of the summary and transfer
record for audit purposes.
The relatives should be notified about the transfer by the referring
hospital, but they should not normally accompany the patient in the
ambulance.
12

SECTION VIII - EQUIPMENT AND DRUGS
All equipment must be serviced regularly, ch e cked daily and
rechecked immediately before any transfer. If the ambulance ventilator
is to be used then it must be checked before departure, as should the
ambulance oxygen supply and suction. It is advisable before
purchasing any new equipment to consult the ambulance service, to
ensure that it is compatible with the oxygen and power supply in their
vehicles.
The patient should receive the same standard of phy s i o l o g i c a l
monitoring during transfer as they would receive in an intensive care
unit. The transfer team must be familiar with all of the equipment and
drugs in the transfer kit and the transfer vehicle.
Essential equipment to go with the patient in the ambulance
The following equipment should be readily available, purpose
designed, dedicated for transfers and be stored in a suitable container
which should have some form of seal, which when broken, would
indicate that the equipment has been used and requires restocking and
checking:
1. Portable mechanical ventilator with airway pressure and minute
volume monitor, and disconnect alarm
2. Adequate supply of oxygen for the journey, including unforeseen
delays (see Section VI)
3. Portable battery powered multifunction monitor to include:
• ECG
• invasive blood pressure monitoring
• non invasive blood pressure monitoring as a backup
• central venous pressure monitoring
• pulse oximetry
• capnography
• temperature
13

4. Other equipment
• suction
• battery powered syringe pumps
• battery powered IV volumetric pumps (infusion by gravity is
unreliable during transfer)
• intubation equipment
• self-inflating bag, valve and mask
• venous access equipment
• chest drain equipment
• DC defibrillator
• spare batteries
• warming blanket
5. An adequate supply of essential drugs to go with the patient
• Hypnotics, eg propofol or midazolam
• muscle relaxants, eg atracurium, vecuronium,- suxamethonium
may be required for re-intubation
• analgesics, eg alfentanil, fentanyl,
• anticonvulsants, eg diazepam, thiopentone
• mannitol 20%, furosemide
• vasoactive drugs, eg ephedrine, dopamine, noradrenaline
• resuscitation drugs as in hospital resuscitation boxes
• intravenous fluids
6. Communication equipment
It is essential that the transfer team should be able to communicate
easily with the designated consultant or his deputy in the referring
hospital and the neurosurgical team during the transfer. The benefits of
a mobile telephone which can be pre-programmed with useful
numbers outweigh the minimal risk of it interfering with electronic
equipment.[17]
7. Paediatric equipment
The transfer of paediatric patients will require size specific equipment
and staff experienced in the transfer of critically ill children.[6,7,18]
14

SECTION IX - EDUCATION AND TRAINING
Good practice depends upon sound education, adequate resources of
expertise, time for training and a commitment to quality throughout all
levels of the organisation. Ensuring and facilitating good educational
standards and arrangements will be a function of the consultant
responsible for inter-hospital transfers.
The fundamental requirement is that every doctor, nurse and
paramedic likely to be involved in the transfer of seriously brain
injured patients has had formal training in the theoretical and practical
aspects of the subject. This will include:
• the principles of managing a patient with an acute brain injury;
• the principles and practice of ATLS;
• the adverse physiological changes associated with moving the
patient;
• manual handling of the patient;
• practical aspects of working in an ambulance or aircraft;
• knowledge of the equipment and drugs used in transfer;
• the legal and safety aspects of transfer;
• communications.
The setting in which this education is provided will vary locally.
Learning opportunities will range from mandatory induction courses
for new hospital staff to formal multidisciplinary training courses on
transfer medicine. The latter are now run in a number of centres, and
m ay be particularly appropriate for consultants responsible for
developing and maintaining the standards of transfer.[19] All doctors,
nurses and other allied health professionals who are new to a hospital
should attend teaching sessions to learn local arrangements and
policies and meet the staff involved.
Much of the educational value of any training post comes from gaining
clinical experience under supervision. The designated tra n s f e r
consultant should be aware of the educational opportunities offered by
transfers of patients with brain injuries to the neurosciences unit. It is
15

important to involve those who take part in regular interdepartmental
audit. This will include A&E personnel, anaesthetists, paramedics, etc.
Participation of the neurosciences unit in such audit is particularly
valuable.
The quality of transfer should be audited, and critical incidents
recorded. Such information is invaluable in refining and improving
local transfer protocols. Appropriate audit tools for transfer are
available from the Royal College of Anaesthetists.[20]
16

SECTION X - RESOURCE IMPLICATIONS FOR T R A N S F E R
OF PATIENTS WITH BRAIN INJURIES
Without adequate resources it is not possible to have a good quality
transfer service. Each organisation that provides acute healthcare
should recognise that this requires specific funding which should be
considered in discussions with purchasers. Resources include staff and
equipment that may be similar to, and shared with, those used for other
secondary transfers including the movement of ICU patients within the
hospital. It should be recognised that there are significant resource
implications to the transferring hospital on-call anaesthetic team.
Hospitals involved in transfer of patients with brain injuries should set
aside a budget for this work. The budget will include the capital
equipment, the cost of which will depend upon its complexity and the
demand placed upon it, as well as the cost of servicing, maintenance,
insurance and renewal/upgrading at appropriate intervals. Portable
equipment will need regular battery replacement and will have a
shorter life than static equipment. There must be adequate provision for
clothing and personal insurance.
The responsibilities of the designated consultant for transfers include
logistics, training, audit and liaison between the parties involved and
may require dedicated programmed activities in job plans. Rotas of
doctors and nurses must take account of this work and allow staff of
adequate seniority to be released from other duties.
Retrieval teams have been set up in some regions eg Northern Ireland
[21] and are of particular importance in paediatric practice.[22]
However, the speed of transfer required for head injuries may not
permit a team to travel from the neuroscience centre. In addition, on
a rare occasion two transfers may be required simultaneously, hence
the referring hospitals will have to maintain the capability to transfer
transfer patients with a time-critical lesion. This means that any unit
potentially admitting children with head trauma should have a
contingency to undertake such a transfer and have an appropriate kit
with paediatric equipment ready for use. In an ideal world the funding
of suitably situated retrieval teams would not be an issue.
17

REFERENCES
1. Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of
monitoring (3rd ed). London: Association of Anaesthetists of Great Britain and Ireland, 2000.
2. Intensive Care Society. Guidelines for the transport of the critically ill adult. Intensive Care
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
3. NICE Guidelines. Head injury: triage, assessment, investigation & early management of head
injury in infants, children & adults. HMSO 2003 http://www.nice.org.uk
4. Early management of patients with head injury. SIGN publication No.46 Aug 2000 ISBN
1899893 27 X 2000 www.sign.ac.uk
5. Brain Trauma Foundation: American Association of Neurological Surgeons’ joint section on
neurotrauma & critical care: Guidelines for the management of severe head injury. J
Neurotrauma 1996; 13: 641-734
6. Paediatric Intensive Care Society. Standards for paediatric intensive care, including standards
of practice for the transport of the critically ill child. Bishop’s Stortford: Saldatore Ltd, 1996.
7. Paediatric Intensive Care Society. Standards document 2001
8. Warren J, Fromm RE, Orr RA et al. Guidelines for the inter-and intrahospital transport of
critically ill patients. Critical Care Medicine 2004; 32: 256-262
9. National Service Fra m e work for long term conditions.
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 /
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4105361&chk=jl7dri
10. Molyneux A. International Subarachnoid Aneurysm Trial (ISAT) Lancet 2002; 360: 1267-74
11. Neuroscience Critical Care Report progress in developing services Aug 2004
http://www.modern.nhs.uk/criticalcare/5021/7117/20040%20DoH-Neurosciences.pdf
12. Andrews PJD, Piper IR, Dearden NM. Secondary insults during intrahospital transport of
head-injured patients. Lancet 1990; 335: 327-330.
13. Morris CG Mullan B. Clearing the cervical spine after polytrauma. Anaesthesia 2004; 59:
755-61
14. Medical vehicles and their equipment - Road ambulances EN 1789:1999
http://www.cenorm.be
15. http://www.vca.gov.uk/vehicle/ambul.shtm
16. Air, water and difficult terrain ambulances – Part 2: Operational and technical requirements
for the continuity of patient care EN 13718-2:2002 http://www.cenorm.be
17. New advice issued on the use of mobile phones in hospitals. Ref 2004/0287
http://www.dh.gov.uk
18. Guidance on the Provision of Paediatric Anaesthetic Services Chapter 7, Guidelines on the
Provision of Anaesthetic Services, Published by the Royal College of Anaesthetists, January
2005 http://www.rcoa.ac.uk/docs/Paeds.pdf
19. Mark J. Transfer of the critically ill patient. Anaesthesia News July 2004 ISSN0959-2962
20. Raising the Standard: A compendium of audit recipes (February 2000) Section 9: Anaesthesia
outside theatres http://www.rcoa.ac.uk/docs/section9.pdf
21.The Northern Ireland Critical Care Transfer Service. www.nisca.org/niccats
22. Children’s Acute Transport Service www.cats.nhs.uk
18

APPENDIX I
INDICATIONS FOR INTUBATION AND
VENTILATION FOR TRANSFER AFTER BRAIN INJURY
• GCS 8 or less
• Significantly deteriorating conscious level (i.e. fall in motor score of
two points or more)
• Loss of protective laryngeal reflexes
• Hypoxaemia (PaO2 < 13 kPa on oxygen)
• Hypercarbia (PaCO2 > 6 kPa)
• Spontaneous hyperventilation causing PaCO2 < 4.0 kPa
• Bilateral fractured mandible
• Copious bleeding into the mouth (e.g. from skull base fracture)
• Seizures
An intubated patient should be ventilated with muscle relaxation, and
appropriate sedation and analgesia. Aim for a PaO2 > 13 kPa, PaCO2
4.5 – 5.0 kPa unless there is clinical or radiological evidence of raised
intracranial pressure when more aggressive hyperventilation is justified
to a PaCO2 of not less than 4 kPa. If hyperventilation is used the FIO2
should be increased.
19

APPENDIX II
TRANSFER CHECKLIST FOR NEUROSURGICAL PATIENTS
SYSTEM
CHECKLIST
Respiration PaO2 > 13 kPa?
PaCO2 < 5 kPa?
Airway clear?
Airway protected adequately?
Intubation and ventilation required?
Circulation BP mean > 80 mmHg? (adults)
Pulse < 100/min? (adults)
Peripheral perfusion?
Two reliable large iv cannulae in situ?
Estimated blood loss already replaced?
Arterial line?
Central venous access if appropriate?
Head injury GCS?
GCS trend (improving/deteriorating)?
Focal signs?
Skull fracture?
Seizures controlled?
Raised ICP appropriately managed?
Other injuries Cervical spine injury (cervical spine protection), chest
injury, fractured ribs, pneumothorax excluded?
Intrathoracic, intra-abdominal bleed?
Pelvic, long bone fracture?
Extracranial injuries splinted?
Escort
Doctor & escort adequately experienced?
Instructed about this case?
Adequate equipment and drugs?
Can use equipment and drugs?
Sufficient oxygen supplies?
Case notes and X-rays?
Transfer documentation prepared?
Where to go in the neurosurgical unit?
Telephone numbers programmed into mobile phone?
Mobile phone battery fully charged?
Name and bleep number of receiving doctor?
Money in case of emergencies?
20

APPENDIX III
ADDITIONAL INFORMATION FOR PAEDIATRICS
Most paediatric critical care networks operate an emergency retrieval
service [22]. The most appropriate method of transfer to the
neurosurgical centre or PICU should be identified according to the
clinical situation. The choice is between an emergency retrieval and
one way transfer by the referring hospital team.
The local referring hospital team should always transfer time critical
cases to avoid delay:
• rapidly expanding space occupying lesion e.g. extradural
• penetrating injury
• uncontrollable bleeding from skull base
If CT scanning is unavailable in the referring unit for any reason then
a time critical one way transfer should also occur.
Age specific mean arterial blood pressure targets to maintain CPP [22]
Age
Mean arterial blood pressure (mmHg)
< 3months 40 - 60
3 months – 1 year 45 -75
1 – 5 years 50 - 90
6 – 11 years 60 - 90
12 – 14 years 65 - 95
21

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org
Designed and produced by the r2 Partnership Ltd

AAGBI SAFETY GUIDELINE
Care of the Critically Ill Child
in Irish Hospitals 2015
Published by
The Association of Anaesthetists of Great Britain & Ireland
June 2015

Membership of the working party
Dr G Maloney
Dr M J White
Dr K Bailey
Dr A Bergin
Dr D Corcoran
Dr I Lambert
Dr D Doherty
Joint Chair, Convenor of Irish Standing Committee
Joint Chair
Honorary Secretary/Honorary Treasurer of Irish Standing Committee
Consultant Anaesthetist
Consultant Paediatrician
Consultant Paediatrician
Paediatric Intensive Care Consultant Anaesthetist
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License

Contents
1. Neonatal resuscitation in hospitals that have no paediatric service 3
2. Neonatal resuscitation in hospitals that have a paediatric service 6
3. Care of the critically ill child in hospitals without a paediatric service 7
4. Care of the critically ill child in general hospitals with a paediatric service 9
5. Inter-hospital transfer – current practice 10
6. National neonatal and paediatric retrieval services 11
7. Summary 12
Date of review: 2019
1

Introduction
Recent health controversies regarding the delivery of infants outside maternity units,
combined with areas of difficulty in caring for critically ill older children in general hospitals,
have prompted the Irish Standing Committee of the Association of Anaesthetists of Great
Britain and Ireland and the Faculty of Paediatrics, RCPI, to review some aspects of
paediatric care in general hospitals, both with and without paediatric and/or maternity units.
Many general anaesthetists are worried that expectations of the service they can provide to
critically ill children might be too great but, on the other hand, general paediatricians do not
have the skills and ongoing experience to deal with critically ill ventilated children requiring
intensive care. All anaesthetists nowadays have a paediatric module in their training but,
because of a lack of ongoing experience, many anaesthetists worry about losing their
paediatric intensivist skills. This problem in relation to the management of the critically ill
child outside a specialist paediatric hospital is not exclusive to the Republic of Ireland, and
we are aware that this debate is also occurring elsewhere.
2

1. Neonatal resuscitation in hospitals that have no paediatric service
Several hospital sites outside Dublin provide acute medical services but do not have paediatric
cover. It is not an uncommon occurrence for these units to be required to manage a newborn
infant, either as a result of the mother presenting in precipitate labour and delivering on-site
or when the infant is born outside the hospital and is brought in by a parent or the ambulance
services. In most cases such infants may only require basic support such as feeding and
temperature control. On occasion, however, these infants, as a result of prematurity or other
problems, may require more significant interventions such as airway management and
intravenous fluids. The absence of paediatric staff at these sites means that all initial support
will be provided by general adult clinicians and nurses. All possible steps should be taken to
minimise obstetric and neonatal attendances at these units; however it is important that each
of the non-paediatric units have agreed protocols to guide staff when such attendances do
occur and that they are equipped to provide a basic level of neonatal resuscitation and care.
It is suboptimal for doctors or nurses to be required to manage clinical problems in which
they are not trained or in which they do not have recent and continuing experience. In that
context it is acknowledged that all assistance provided by medical and nursing staff is in
accordance with the principle of providing limited emergency medical care. Practitioners are
simply required to do their best given the circumstances. It should also be acknowledged
that the generally thin layers of staffing in the non-obstetric/non-paediatric units around the
country mean that it is possible that, in a given situation, no anaesthetist may be available to
attend an obstetric/neonatal case because they are occupied with another emergency. The
following is recommended on this issue:
1.1 Minimising risk
• Health Service Executive (HSE) hospital groups with responsibility for any acute
medical hospital unit without an obstetric/paediatric department should make every
effort to ensure maximum public awareness as to which hospital sites do, and
which do not, provide these services. This is particularly important when those who
may have language difficulties are housed by the HSE near such a unit. A special
effort needs to be made to ensure that these vulnerable individuals understand
that if they have a pregnancy-related problem, they should proceed to the nearest
designated maternity unit.
• Each hospital site without obstetric/paediatric services should have clear signage at
the entrance detailing the hospital sites within the region where these services are
provided.
• All ambulance and general practitioner on-call services should be given clear
instructions that all acute obstetric and paediatric referrals should be directed to the
appropriate hospital.
3

1.2 Communication needs
In the opinion of the working party, communication failure is probably the most common
contribution to negative outcomes in these situations. It is incumbent on hospital management
and clinicians to ensure that clear, prescriptive communication pathways have been thought
through in each unit so that the non-expert has rapid access to advice from an obstetrician
and/or paediatrician when an incident arises. Dedicated communication infrastructure may
be needed, such as dedicated bleep systems, but each unit should address its own individual
needs in this area.
1.3 Equipment and facility needs
• All non-paediatric sites should have the basic equipment required for neonatal
resuscitation and stabilisation readily available for use.
• Facility to provide less than 100% oxygen and to blend oxygen is required.
• All non-paediatric sites should have a designated facility where neonatal
equipment is located and where short-term emergency neonatal care can be
delivered.
• Hospital management should ensure that there is adequate training of staff in
neonatal resuscitation and maintenance of the necessary equipment in all nonpaediatric
sites especially in the emergency department where most clinical
events will occur.
1.4 Guidelines for management of newborn infants and imminent deliveries
presenting to a non-paediatric unit
• If the infant is active and well, transport of the mother and infant to the appropriate
obstetric/paediatric unit should be arranged. Management of the infant can be
discussed with the on-call consultant paediatrician prior to transfer.
• If the infant is significantly premature or is unwell, the on-call consultant anaesthetist,
if available, should attend to assist with the management of the baby.
• Ongoing management of a sick infant and transport arrangements should be
organised in consultation with the on-call consultant paediatrician in the designated
unit.
• Ideally, transport of a sick neonate should be conducted by paediatric staff. In the
absence of the National Neonatal Transport Service, which at the time may be
directed to other high risk neonatal transfers and is based in Dublin, there should
be capacity to provide dependable neonatal support at short notice from within
each region to give a timely response. At present staffing levels, it may not always
4

e possible for paediatric personnel to attend such a delivery outside their own
hospital. Responsibility for resourcing such a service remains with the HSE.
• If a woman presents in an advanced stage of labour, and delivery is judged to
be imminent, she should be moved immediately to the designated area within the
hospital where she can deliver her baby and neonatal care can be provided.
• If neonatal resuscitation is required over and above normal supportive care, the
on-call consultant anaesthetist, if not otherwise involved in emergency care, should
attend to assist in the resuscitation.
• The on-call consultant obstetrician and paediatrician in the regional unit should be
informed as soon as possible and they will guide further management of the mother
and baby and advise on transfer.
5

2. Neonatal resuscitation in hospitals that have a paediatric service
• Neonatal resuscitation is the responsibility of the paediatric service, which will ensure
adequate availability of trained personnel at all times. All paediatric units should be
in a position to ensure the on-site presence, throughout a 24 hour period, of at least
one staff member capable of performing full neonatal resuscitation, in accordance
with the American Academy of Pediatrics neonatal resuscitation programme.
• All paediatric personnel attending any delivery in the labour ward or theatre must
have completed the American Academy of Pediatrics neonatal resuscitation
programme. This should be updated at the end of every two-year period.
• The anaesthetist's responsibility during a caesarean section is towards the care of
the mother.
• There will be occasions, however, when paediatric staff may require the support
of anaesthetic colleagues to assist with resuscitation of an infant. If a consultant
anaesthetist and a non-consultant hospital anaesthetist are present, and if the
mother is stable, the consultant anaesthetist may assist in the neonatal resuscitation
if so requested, provided that the consultant paediatrician has been called to attend.
• In a situation where a non-consultant doctor has not yet completed the American
Academy of Paediatrics Neonatal Resuscitation course (e.g. at the beginning of
January and July when staff change jobs), he/she should only attend the labour
ward or theatre while accompanied by another member of staff with up-to-date
neonatal resuscitation qualifications.
• Acutely ill neonatal patients from the community should be directed to the appropriate
paediatric centre rather than the maternity hospitals.
6

3. Care of the critically ill child in hospitals without a paediatric service
There are currently ten acute general hospital sites outside Dublin providing acute medical
services that do not have paediatric cover. It is not uncommon for these sites to be required
to manage a critically ill child, either as a result of a traumatic injury or an acute medical
condition. Every effort should be made to minimise the frequency of these attendances but
when they do occur, it is important that there are clear, concise and workable guidelines for
clinical management.
3.1 Minimising risk – the National Clinical Paediatric Programme
recommends
• There should be consensus among all units in a region regarding the age criteria
for a paediatric patient.
• HSE with responsibility for any acute medical hospital unit without a paediatric
service should take robust steps to ensure maximum public awareness of which
hospital sites do, and which do not, provide these services.
• Where vulnerable populations who may have language difficulties are housed by
the HSE near units without paediatrics, specific, targeted communication intiatives
may be needed to ensure their understanding that, if their child is acutely unwell,
they should proceed to the nearest designated paediatric unit.
• Each hospital site without a paediatric service should have clear signage at the
entrance detailing the hospital sites within the region where these services are
provided.
• Paediatric Advanced Life Support/Advanced Paediatric Life Support (PALS/APLS)
training should be available to front-line staff in non-paediatric hospitals. It is
recommended that an APLS certified or suitably trained staff member should be on
duty at all times.
• The ambulance service should be given clear instructions that all ill children
should be taken to the nearest hospital with a paediatric service. The ambulance
service should only take an ill child to a non-paediatric hospital site in extreme
circumstances such as a child requiring active cardiopulmonary resuscitation or
with an upper airway obstruction.
• General practitioner/GP on-call services should be given clear instructions that all
acute paediatric referrals should be directed to the appropriate site.
7

3.2 Who is in charge?
Children with injuries/surgical problems and children with acute medical emergencies (e.g.
status epilepticus, acute severe asthma, meningococcal sepsis or diabetic ketoacidosis)
should continue to be placed under the care of adult clinicians prior to transfer. In units with
an emergency department consultant on-site, it may be agreed locally that he/she should
take primary responsibility for critically ill children. Where there is anaesthetic involvement,
care should be jointly anaesthetic with the admitting clinician. The admitting clinician and/or
anaesthetist should consult directly with the paediatric consultant in the receiving hospital
prior to transfer.
With the expected introduction of paediatric retrieval, clinical responsibility will transfer to
the Retrieval Team on departure from the referring hospital. The consultant paediatrician
assumes clinical responsibility when the child arrives in the receiving hospital.
3.3 Paediatric clinical guidelines
It is the responsibility of each non-paediatric hospital unit to have a set of paediatric
guidelines available which cover the management of the common paediatric emergencies.
These guidelines should be facilitated by the paediatricians and other relevant consultant
specialists in the region.
3.4 Paediatric resuscitation trolleys
Each non-paediatric hospital unit should have a formal paediatric resuscitation trolley set up
in the A&E department. The use of the Broselow tape system is strongly recommended for
the management of the child in the A&E setting.
3.5 Paediatric drug formulary
The British National Formulary for Children is now widely accepted as the standard paediatric
formulary in Ireland. An up-to-date copy of this publication should be available in all nonpaediatric
A&E departments, with new editions replacing old as they are published. APLS/
PALS manuals should also be available.
The Our Lady’s Children’s Hospital, Crumlin, formulary and prescribing guide app is available
for download from the iTunes Store for a small fee.
8

4. Care of the critically ill child in general hospitals with a paediatric service
Children are admitted to the hospital under the care of a paediatrician or surgeon. If they are
deemed to be critically ill, the admitting consultant (paediatrician or surgeon) should consult
with the anaesthetic consultant about admission to ICU or ventilated transfer to another
centre as they deem appropriate. Management in ICU should be jointly anaesthetic and
paediatric (or surgical). Some hospitals have high dependency areas on the paediatric unit
and it may be appropriate to maintain children requiring respiratory support in this setting
with appropriately trained nurses.
The AAGBI recognises the dilemma faced by general anaesthetists who feel they are
working outside their usual area of practice when dealing with critically ill children. The best
local expertise should be used in the management of these children. The anaesthetist is
generally the most skilled person available to deal with intubation and ventilation of children
outside the neonatal period.
A decision whether to transfer the child to a paediatric intensive care unit is made jointly by
the local hospital clinicians and the paediatric intensivist. Referring hospitals should seek
telephone advice from the tertiary paediatric intensive care unit (PICU) using the centralised
telephone referral (1890-213-213) and online via http://www.hse.ie/go/picu. This is the
only avenue of referral to PICU in the Republic of Ireland, regardless of the nature of the
presenting complaint. Initial communication should be a consultant-to-consultant referral
between the referring physician and receiving paediatric intensivist.
In general, critically ill children presenting outside of the tertiary paediatric centres should be
resuscitated, stabilised and prepared for transfer to a PICU. Should a decision be made to
admit a child to an adult ICU, the child’s care should be shared by the admitting consultant
and the consultant anaesthetist. Ongoing telephone advice from the paediatric intensivist
should be readily available.
Care of a critically ill child in an adult ICU should only occur in exceptional circumstances.
There should be local protocols and guidelines readily available for the management
of mechanical ventilation, physiological monitoring, intravenous fluid and medication
administration, which reflects current practice in PICU. The centralised referral line and
website should be considered as a resource to guide the management of paediatric patients
under these circumstances.
There are some situations when, after consultation with the tertiary unit, a critically ill child
may not be transferred out, such as:
• When there is no paediatric intensive care bed available in the tertiary centre.
• When the child is too ill to transfer.
• When the outcome is deemed to be very poor, or when brainstem death has
occurred. Care of a child with a neurological determination of death for the purposes
of organ donation is a niche area in medicine, best done by PICUs with practice and
protocols for this.
9

Nursing care of the critically ill child requires ICU and paediatric nursing expertise. Ideally
the nurse managing the child should have PICU training. However in situations where this
is not available, nursing may be provided by the joint management of an ICU nurse and a
paediatric nurse. It is the responsibility of hospital management to ensure the availability
of appropriately trained nursing staff to meet the needs of critically ill children. Suitable
equipment should be available both in the emergency department and in the ICU.
Training: In spite of the fact that all anaesthetists undergo a paediatric module during training,
the Group recognises that loss of paediatric skills is an issue.
APLS training with regular updates for all staff who may be involved with critically ill children
is desirable, alongside available supranumary clinical sessions in anaesthesia and PICU
available in the paediatric hospitals.
5. Inter-hospital transfer – current practice
Children undergoing treatment in general hospitals with paediatric departments may need
to be referred to a specialist paediatric unit for investigation and/or treatment. The manner
in which such transfer is carried out will depend on the severity of the child’s condition, and
the urgency of transfer.
Where the condition is serious and has already warranted admission to the ICU, common
current practice is for the ICU anaesthetic staff to accompany the patient. This arrangement
has the obvious benefit that specialised interventions such as mechanical ventilation are
supervised by the trained staff, but at the same time takes specialist staff away from the
primary admitting unit.
It is recommended that a member of the paediatric team also accompanies such critically
ill patients. While the specialist interventions are quite properly the remit of the ICU doctor
(almost always anaesthesia staff), the underlying condition may well be more familiar to
paediatricians.
It is apparent that this joint approach, while carrying obvious benefits for the paediatric
patient, is not the universally adopted practice. The AAGBI recommends a joint paediatric/
anaesthetic approach.
The AAGBI recognises that transfers will inevitably be required without direct input from the
National Retrieval Service. It is recommended that the most senior personnel are available
to accompany the child, both from paediatrics, anaesthetics and an experienced paediatric
nurse.
10

6. National neonatal and paediatric retrieval services
Among consultants working in paediatrics and anaesthetics there is consensus that, for
critically ill children who need to be transferred to tertiary units, a ‘paediatric retrieval system’
is required. This has been demonstrated to provide optimal, specialised PICU facilities
during an especially hazardous phase of the child’s management. This service already
exists for newborns up to the age of 6 weeks (National Neonatal Transport Service) and for
adults (Mobile Intensive Care Ambulance Service). Children outside these age groups are
currently denied this service. The National Neonatal Transport Service is awaiting funding
to extend its service to 24 hours, 7 days a week.
The need for a nationwide paediatric retrieval service has been well accepted internationally
and this document should be viewed as a strong recommendation for the implementation of
such a service, available 24 hours a day and 7 days a week.
The transport team should consist of members as determined by the paediatric hospital.
The team requires access to road ambulance and occasionally air transport. The provision,
staffing and day-to-day management of the paediatric service should be under the control of
the paediatric receiving hospitals.
11

7. Summary
The purpose of this document is to provide guidelines to improve the quality of care of
critically ill children.
The AAGBI recognises that care of critically ill infants and children outside a paediatric
hospital is a problematic area for hospital management, nurses, clinicians, paediatricians
and general anaesthetists.
Mothers in labour should be encouraged to attend hospitals with an on-site obstetric and
paediatric service, and to bypass hospitals which do not have these services. HSE should
put in place signage and communication lines to ensure that this occurs.
When, in spite of the above, a newborn baby or woman in advanced labour presents
to a hospital without paediatric or obstetric departments, and if there is a need for more
resuscitation of the infant than standard supportive care, the consultant anaesthetist or their
delegate, and any other consultants deemed necessary, should assist in the resuscitation
of the infant. Paediatricians and anaesthetists in general hospitals, when presented with a
critically ill child, should arrange for jointly conducted safe and rapid transfer of the child to
a PICU.
There is a need for national 7-day/24-hour neonatal and paediatric retrieval services. These
services should be managed centrally by the neonatal intensive care services of tertiary
maternity hospitals for critically ill neonates and the paediatric intensive care services of
tertiary paediatric hospitals, to ensure prompt and safe transfer of critically ill children and
newborns. Until these retrieval services become available, a joint anaesthetic/paediatric
team should transfer critically ill children with advice from the receiving unit. All staff that may
be involved with critically ill children should be trained in paediatric advanced life support.
12

13

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

Catastrophes in Anaesthetic Practice –
dealing with the aftermath
2005
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org
September 2005

MEMBERSHIP OF THE WORKING PARTY
Dr Michael Wee
Dr David Bogod
Prof Alastair Chambers
Prof Michael Harmer
Dr Iain Wilson
Dr David Saunders
Dr Barbara Bahlmann
Mrs Sandy Gaskins
Dr Sara Hunt
Dr Janet Prentice
Chair, Association of Anaesthetists of
Great Britain and Ireland (AAGBI)
Editor-in-Chief, Anaesthesia
Honorary Secretary, AAGBI
President, AAGBI
Council member, AAGBI
Council member, Royal College of Anaesthetists
Group of Anaesthetists in Training
Chartered Psychologist
Chair, Group of Anaesthetists in Training
Doctors Support Network
Acknowledgements: Mr Bertie Leigh of Hempsons Solicitors and Dr Stuart
White, Consultant Anaesthetist for their helpful comments on the document.
Review Date June 2010

CONTENTS
Section 1. Summary 2
Section 2. Introduction 3
Section 3. Actions to take after the event 5
Section 4. The role of the anaesthetic department 9
Section 5. The Trust response 10
Section 6. How a catastrophe may affect you personally 13
Section 7. Critical incident stress debriefing (CISD) 17
Section 8. Medico-legal issues and the GMC 19
Section 9. Sources of help 24
Section 10. References and further reading 27
1

SECTION 1. SUMMARY
• The majority of anaesthetists are likely to be involved with an
anaesthetic catastrophe at some point in their careers.
• The psychological impact on staff following death or serious injury
to a patient should not be underestimated.
• It is vital that members of the anaesthetic department support the
anaesthetist and a senior colleague or mentor should be assigned to
this role.
• Contemporaneous records of the event must be kept.
• The clinical commitment of the anaesthetist concerned should be
reviewed immediately by the clinical director.
• A team approach should be adopted to breaking bad news with
relatives. This should not be done over the telephone.
• The task of breaking bad news should not be carried out by a trainee
or staff grade or associate specialist (SAS) doctor without a
consultant present.
• Each hospital must have a procedure for dealing with and
investigating catastrophic events.
• Critical incident stress debriefing by trained facilitators with further
psychological support may assist individuals to recover from the
traumatic event.
• Anaesthetists are strongly advised to be a member of a medical
defence organisation.
2

SECTION 2. INTRODUCTION
Although deaths due to anaesthesia are extremely uncommon with an
estimated incidence of 0.5-0.8 per 100,000 anaesthetics 1,2, we are all
likely to experience a death on the operating table at some point in our
careers. In the majority of cases, death is expected and the cause
understood. However, when death or serious injury is unexpected, the
experience can be extremely traumatic for all concerned including the
theatre team, ward and ancillary staff. The 2000-2002 Confidential
Enquiry into Maternal and Child Health report recommended that
anaesthetists and staff who were involved in a maternal death should
receive supportive counselling 3 .
A survey of two hundred and fifty one anaesthetists from twelve NHS
hospitals in England showed that 92% had experienced an intraoperative
death; 60% of deaths were expected occurring mainly in
emergency surgery (80%). 4
Whether a death is 'expected' or 'unexpected' may be irrelevant, as the
anaesthetist involved may be emotionally affected by any intraoperative
death or serious injury to the patient. The training and ethos
of anaesthesia to avoid harm and maintain patient safety at all times
puts additional stress on the anaesthetist. 5-9 The psychological effects
of an intra-operative death or serious injury on a background of
continuing stress, may tip the balance towards acute personal,
psychological or physical disaster. 10
When a death or serious injury occurs in a private hospital, the
anaesthetist may feel particularly vulnerable. Private hospitals may not
have the support systems which are available in the NHS. However, it
is the responsibility of the chief executive officer or the general
manager of the private hospital to put in motion their governance and
risk management systems to deal with a catastrophe.
It is incumbent on colleagues, hospital, Trust, family and society in
general to provide practical help and support to the anaesthetist
3

involved according to individual needs. This is part of good clinical
and corporate governance, and risk management.
Unfortunately, research into the effects and management of intraoperative
deaths is minimal. The aim of this document is to suggest
pragmatic ways of dealing with the aftermath of a death or serious
injury during anaesthesia.
4

SECTION 3. ACTIONS TO TAKE AFTER THE EVENT
Consult departmental guidelines if available. 11
a) Immediate Actions
Records
Keep an accurate and contemporaneous record of the anaesthetic and
event. These should be legible, timed, dated and signed. Electronically
stored monitoring records should be printed and filed in the notes. If
stored monitoring records are unavailable, recordings should be made
on the basis of recollection as accurately as possible and preferably
corroborated by staff who were present at the time. Where practical,
it is advisable during attempted resuscitation to allocate one member
of the team to record times, the personnel involved, interventions
including details of all drugs, fluids used and outcomes. Original notes
and charts must not be altered in any way at a later date. Amendments
and additions must be recorded separately, timed, dated and signed.
If the anaesthetist is unable to write notes immediately, a full
retrospective account must be made as soon as possible. It is essential
that this account concurs with the records in the notes and the
recordings from the monitors or explains the discrepancy. The date
and time of this retrospective record should be noted and signed (in
black ink to allow photocopying). Any subsequent entries to the
contemporaneous notes should be made in the same way. If it has not
already been recorded, the anaesthetist should document details of the
discussions with the patient pre-operatively regarding the risks of
anaesthesia and surgery. It is important to keep copies of the records
and make personal notes as these may be required later (see Section
8).
Dealing with the anaesthetist
For trainees or SAS grades, the responsible consultant should attend in
person and deal with the situation. A consultant anaesthetist should
inform a colleague who should attend the hospital and assist with the
5

aftermath. A decision will need to be made whether the anaesthetist
should continue with his/her list or on-call. There is no standard
advice in this situation although individual Trusts may have their own
policies which should be followed (see Section 5). The decision is best
made after assessing the situation between the anaesthetist involved, a
senior colleague and the clinical director.
Dealing with the patient
In the event of a death, inform the Coroner (England and Wales) or
Procurator Fiscal (Scotland) and the patient's general practitioner as
soon as possible by telephone or other immediate means. The Coroner
or Procurator Fiscal may decide to conduct their own investigation.
The anaesthetist involved should contact his/her defence organisation.
It is important to complete a Trust critical or adverse incident form.
In the event of death, all lines, tubes and other equipment connected
to the patient must be left in place. If there is any cause for concern
regarding the placement of the endotracheal tube, its position should
be confirmed and recorded by an independent anaesthetist. The body
should be transferred to an appropriate area for further investigation if
necessary. In some circumstances, the Coroner may instruct a
pathologist to investigate. At a later stage after the body has been
prepared for viewing, the relatives may attend to pay their last respects.
Although it may be difficult to do, in the event of a medical catastrophe
where the patient survived, it is important for the anaesthetist
concerned to take an interest in the progress of the patient. This will
involve regular visits to the ITU or rehabilitation unit. Failure to do so
may paint a negative perception that the anaesthetist did not care.
Regular communication with the family is also helpful.
Dealing with relatives
Breaking bad news should not be done over the telephone. It will be
necessary to invite the relatives to come to hospital informing them that
some complication had occurred but no details should be given. There
may be pressure from the relatives to get information over the phone
6

ut this should be politely and firmly resisted without antagonism. If
there is no immediate family to accompany the relative, ask the relative
to bring a friend. Some hospitals have established a bereavement
service which can be helpful for grieving relatives.
The interview with the family
This will consist of an initial interview, possibly followed by more
depending on the situation. Find a suitable quiet and comfortable
room free from interruption for the interview. Do not speak to the
family on your own or allow the surgical team to do this. A team
approach is essential.
Before the interview, decide who should be the spokesperson. Speak
to the family with your surgical colleague who may already have
encountered members of the family prior to the operation. Other team
members should include theatre or ward staff, chaplaincy staff and
other support staff including an interpreter if appropriate. A senior
colleague should accompany trainees and SAS doctors for support.
Explain the 'bad news' first in a straightforward and honest way,
followed by answering any questions which may arise. If the cause of
the disaster is known, then this should be explained in lay language.
Giving an apology does not imply fault. However, if no cause has
been identified, do not speculate or offer an opinion. Take time, listen
and empathise. Use an interpreter in cases where understanding of
English is limited. Give the family the time to take in the bad news and
do not give them too much information initially.
Other members of the team interviewing the family can contribute
during questioning led by the spokesperson. If appropriate, inform the
relatives that a full investigation will take place and that this may take
some time. If appropriate, reassure the relatives that all that could be
done was done to keep their relative alive and that their relative was
not in pain or aware during the resuscitation attempts. This knowledge
may be comforting to them.
7

It may be necessary to conduct a second interview after a relatively
short period of time to give further information, answer questions or to
clarify certain issues. Further interviews may be necessary in the
future.
b) 'Later' Actions
Equipment and drugs
The clinical director or a consultant not involved with the incident
should take responsibility for checking the patient and equipment. If
there is suspicion of equipment failure or a hazard affecting the theatre,
a decision may be made to take the theatre or anaesthetic machine out
of commission until further notice.
All anaesthetic equipment, drug syringes and ampoules should be
kept, and moved to a secure store room for investigation. An accurate
record should be made of all the checks undertaken including time
and date of inspection. All disposable equipment including syringes
and ampoules, airway devices etc. should be kept in a secure box.
Further investigation may be required by medical equipment
maintenance personnel, manufacturers or toxicologists.
Dealing with the theatre team
The team should be initially debriefed at a time to suit all staff and
preferably within a few hours of the catastrophe. The aim is to provide
and record information, and to gain feedback while details are still
fresh. It is also useful to allay anxieties or misconceptions experienced
by members of the theatre team. The presence of a trained counsellor
may be useful to assist staff traumatised by the event (see Section 6).
Dealing with the media
The media may try to approach staff at the hospital or at home. A Trust
manager trained with dealing with the media should be the only
person communicating with them. All media enquiries should be
directed to this manager.
8

SECTION 4. THE ROLE OF THE DEPARTMENT OF
ANAESTHESIA
It is vital that members of the anaesthetic department support the
anaesthetist who may be stressed and traumatised. 12 A stressed
anaesthetist will be more prone to making errors. (see Sections 6 and 7)
It is important to listen to the individual and encourage him/her to talk
and refrain from being judgemental. Informal, sympathetic peer
review with a few colleagues is often useful. Keep all conversations
confidential. At a later date, when the cause of the catastrophe is
known, a departmental mortality and morbidity meeting may be useful
to inform and learn lessons from the incident.
An experienced and sympathetic senior anaesthetic colleague should
be assigned to act as mentor and provide support for as long as
necessary. The mentor should be known and accepted by the
anaesthetist concerned. Members of the department may have to take
over the involved anaesthetist's duties including on call commitments,
for a period of time.
The anaesthetist will feel particularly vulnerable when a catastrophe
occurs in a private facility. It is the responsibility of the concerned
anaesthetist to inform his/her colleagues of the catastrophe in order to
obtain as much assistance as possible. The assistance from the
department and colleagues should not be any less than if the
catastrophe had occurred in an NHS facility.
9

SECTION 5. THE TRUST RESPONSE
Each Trust should have a policy detailing the response to serious
incidents. Medical managers are responsible to the Chief Executive for
managing the process.
Following a serious incident, the Trust should immediately review the
safety of patients and staff, the clinical systems, drugs and equipment
employed, and any implications for the NHS at large. Every Trust is
different and specific roles will differ. Communication between all
involved must be a high priority to ensure that timely, effective action
is taken.
Out of hours, depending on the nature of the incident, the on-call
consultant and duty manager must be informed.
The role of the Clinical Director (CD)
Working with their manager, the CD is responsible for Trust patient
safety in anaesthesia. The CD should make an assessment of the nature
of the incident to determine whether the catastrophe could recur or put
other patients or staff at risk.
Urgent actions:
• Secure the area or equipment until investigated.
• Identify and support all staff involved. The anaesthetist should be
interviewed as soon as possible and, after discussion, a decision
made regarding continuation of work.
• Keep a record of all actions.
• Check that the relatives have been contacted, and cared for.
Contact the patient's GP.
• Ascertain if there is any evidence of an equipment or drug problem.
• Ascertain if there is any evidence of poor staff performance or
system failure.
• If there is suspicion of a criminal act, the police need to be
contacted.
• Contact the GP.
10

• Check that the Coroner (England and Wales) or Procurator Fiscal
(Scotland) has been informed.
• Ensure that an incident form has been completed and the Trust
governance team is involved. They will liaise with Health & Safety
Executive (HSE), Medicines and Healthcare Products Regulatory
Agency (MHRA), National Patient Safety Agency (NPSA) and other
NHS organisations as necessary.
Follow up actions:
• Report findings to the Medical Director as soon as possible (within
24 hours). Discuss the incident, and decide plans for an initial
investigation.
• Initiate support for the anaesthetist involved. Meet the anaesthetist
along with another colleague who will be asked to mentor the
individual to provide support. Regular meetings should be
scheduled with the mentor. Depending on the nature of the
incident, explain the next steps which will usually involve contact
with the Medical Director and possibly the legal department. Keep
notes of this meeting.
• After discussion, consider taking the anaesthetist off call or duty and
arrange for a few days leave while the incident is investigated. The
anaesthetist may need support on return by working with a
colleague for a short time. Involve Occupational Health if illness is
a possibility.
• Together with the appropriate manager ensure that the relevant
theatre staff are supported, and have been debriefed.
• Arrange for statements to be made by all who were present during
the incident using the Trust proforma. Statements should be
descriptions of what happened rather than interpretations of events.
Statements may be legally disclosable in the future, so accuracy and
care is essential.
The role of the Medical Director (MD)
The MD will work with the CD to ensure that all appropriate steps have
been taken following the incident. In consultation with the Chief
Executive Officer, the MD will decide the nature of the inquiry
11

equired for the incident. This is a rapid decision based on the
available evidence, and may be an internal or external inquiry. The
NPSA Incident Decision Tree is useful at this stage. Serious incidents
will require a root cause analysis. The inquiry should be started within
two weeks and report its findings within six weeks.
Most deaths or serious injury have a clinical explanation, and the likely
underlying cause can be determined. The Coroner or Procurator Fiscal
will determine whether an Inquest/Inquiry will be required.
The MD will take responsibility for organising contact with the media.
Outcome from the inquiry may result in a number of possible actions:
• Personnel issues may require Occupational Health review, possible
disciplinary action including the GMC or retraining issues. The
National Clinical Assessment Authority (NCAA) may need to be
involved.
• Deaneries and the Royal College of Anaesthetists may become
involved for trainees.
• Equipment report to the MHRA and HSE.
• Prevention of future incidents utilising a systems approach for risk
management.
12

SECTION 6. HOW A CATASTROPHE MAY AFFECT
YOU PERSONALLY
The following symptoms are 'common' feelings to have after a
traumatic incident. It is also important for colleagues and family to
recognise these symptoms and offer help.
Reliving the event
The impressions left by the event may be so strong that it is re-lived
long after it actually happened. Flashbacks and daydreams are
common, as is re-experiencing of the feelings that surfaced during or
after the event. Sometimes you may suddenly start to feel as if the
original event is about to happen again. This can be alarming, but be
assured that it is not unusual.
Shock
It could be that you don't feel anything for a while; instead you feel
numb, exhausted and cold and it can become difficult to do everyday
things.
Restless and Wound-up
You may find it difficult to rest and concentrate. You may also have
problems sleeping. You may become irritable and tearful.
Doom and Gloom
You may feel the world is no longer a safe place and that the future is
no longer bright. You may feel vulnerable and disappointed with life.
Anger
Strong feelings of rage or anger about what has happened can occur.
You may feel strongly towards those you feel had some responsibility
for what happened, or just that nothing is fair.
13

Fear
You may become afraid of new things, or of being left alone; leaving
your loved ones; or of just going out. Other fears centre on breaking
down, losing control, having unbearably intense feelings or worry that
the original event might happen again.
Guilt
Often people feel guilty and wonder whether more could have been
done.
Relationships
Stresses and strains previously taken as being part of life can appear
unbearable to someone who had been through a traumatic incident. A
tendency to withdraw from close contact with relatives, friends and
colleagues is often observed. This can lead to additional problems.
Longer term relationship problems can get worse and you can feel that
'absolutely nobody understands what I am going through'.
Physical Effects
Your body also reacts to the trauma, sometimes straight away and
sometimes much later on. You may feel the following:-
• Tiredness. All traumatic incidents are demanding on the body and
use up a lot of energy. This may continue after the incident is over.
You may stay hyper-aroused for a long time and eventually become
exhausted.
• Muscle Tension. Being wound-up for too long can be unpleasant.
Stiffness and tension can lead to localised pains, headaches,
dizziness, breathing and swallowing problems.
• Other effects. As the body works overtime, you can become aware
of palpitations, hands shaking, or that you are sweating excessively.
You may also get nausea, diarrhoea or menstrual problems.
You may experience some or all of these reactions only occasionally,
or all the time. It is important to remember they are all recognised and
a natural consequence of the event, and are a sign that you are coping
with something that is very difficult for a person to deal with.
14

Typically reactions start to lessen within a week or so before fading
away altogether over a longer period of time. If they do not, then it is
important that you should take the initiative and talk to someone about
your reactions to extreme stress.
Longer Term Reactions
Some feelings may not occur until later and you may not notice them
until someone else points them out. Try not to become defensive. You
may lose confidence in pursuing everyday activities and things that you
once did without a second thought can become difficult for a time.
You may become emotionally detached, feeling cut off from people to
whom you are usually close, or become irritable and annoyed with
them.
What you can do to help yourself
The most important thing is to avoid bottling up feelings you have
about what happened, however shocked or surprised you may be. Be
careful - accidents happen more frequently after severe stress,
especially in the home or on the road.
• Cooperate with all investigations.
• Get support from a senior colleague or mentor and arrange regular
meetings.
• Talk about the event with your colleagues and your relatives.
Talk to others who are not directly involved with the situation (see
Section 9).
• Try not to isolate yourself.
• Get colleagues to help with difficult cases and take up some of your
duties.
• Don't smoke or drink too much or self-medicate. Consult your
general practitioner.
• Give yourself time to recover.
15

When to ask for help
Sometimes events are too severe (or too personal) for reactions to
improve with time. If this happens to you, you might want more help,
particularly if:
• Memories, dreams and images of the traumatic event continue to
intrude on your consciousness, making you feel frightened and
deprived of rest.
• Your bodily sensations remain overwhelming.
• Your feelings are not giving you any peace.
• You remain exhausted, wound-up and feel 'burnt out'.
• Your work performance is affected.
• You have to keep active to avoid feeling upset.
• You have nightmares or sleep problems.
• You have nobody to openly share your feelings.
• You find yourself getting uncontrollably angry.
• You feel lonely and isolated.
• You feel or become accident prone and cannot concentrate.
• Your relationships suffer, or other people comment that you've
changed.
• You find yourself relying on medication or alcohol.
If you experience any of the above, talk to a close colleague or mentor
and get some help.
16

SECTION 7. CRITICAL INCIDENT STRESS
DEBRIEFING (CISD)
Psychological debriefing is a set of procedures which includes Critical
Incident Stress Debriefing (CISD) and on-going psychological
counselling. These activities involve the giving of information aimed at
preventing psychological morbidity and aiding recovery after a
traumatic event. CISD was developed to reduce immediate distress
and identify individuals likely to develop longer term psychological
problems.
There has been some controversy on the efficacy of CISD. 13 It was
originally developed to be carried out by trained facilitators in order to
mitigate stress responses amongst emergency responders. Some
research has questioned its efficacy 14,15 but these may have been based
on groups that have not been managed by appropriately trained
counsellors or on participants who have not been followed up with
further psychological support.
Appropriately trained and experienced counsellors can advise on the
structure and process of debriefing sessions. 16 Although CISD was
originally designed to be carried out in large groups made up of all
those affected by the trauma, there is growing evidence that it may be
more effective initially to group participants by professional role or
make trained counsellors available both on-site and off-site to suit
individual preferences. 17 If large group sessions are thought to be
advisable, these can be arranged at a later date.
Whatever CISD process is decided upon, Trusts must ensure that any
affected member of staff has the opportunity to see a trained counsellor
within the first 72 hours after the event.
Doctors are notoriously reluctant to seek professional help and some
anaesthetists will continue to feel traumatised long after the event.
Although Trusts have a duty of care towards staff, each individual also
17

has a responsibility to ensure they are fit to work. It is important for
colleagues and mentors to recognise signs of stress and remind
individuals of the psychological resources available to them.
18

SECTION 8. MEDICO-LEGAL ISSUES AND THE GMC
Any professional involved in a medical catastrophe in their practice
should want to encourage and assist in an investigation into what, if
anything, went wrong and why. While the prospect of medico-legal
consequences will weigh heavily on the mind of any anaesthetist
involved in a catastrophic outcome, it should be remembered that very
few such cases actually result in a formal disciplinary hearing or action
for compensation. Adherence to the guidelines in this document
should mean that the concerns of all parties will be adequately
addressed, which will minimise the bad feeling that sometimes drives
relatives to seek legal redress.
The wheels of medico-legal processes turn slowly and memory can
become very inaccurate as time passes. The best explanation for one's
actions is a comprehensive, contemporaneous and accurate record of
events (see Section 3); these should be stored in an appropriate
location and may need to be kept for many years. Your defence
organisation, mentor and department will be able to help you prepare
for any medico-legal or disciplinary investigations.
Legal Representation
If the incident happened in your employing NHS Trust, then you are
covered by your employer for civil litigation, i.e. negligence claims
through the NHSLA (National Health Service Litigation Authority). 18
However, it is always advisable to also have legal cover via one of the
medical defence organisations, who should be informed of any
unexpected death of a patient in your care. Personal representation of
this sort is particularly important if there is any possibility of
disagreement or dispute between you and your Trust, if the incident
involves a private patient (in which case you are not covered by your
NHS employer) or if there is any possibility of criminal charges being
brought against you.
19

Suspension
It is not unusual for a clinician involved in a major untoward incident
to be asked to stop clinical work pending the investigation of an
incident. Sometimes this is by agreement to alter or change duties, and
on occasion it takes the form of suspension by the employer.
Suspension is, at least officially, a neutral measure aimed at protecting
the individual, the Trust and its patients while inquiries are conducted.
The suspended clinician will be kept on full pay, although admitting
privileges to local private hospitals are nowadays usually curtailed for
the duration. The anaesthetist may well be barred from visiting the
Trust, and will be strongly advised not to discuss the matter in question
with the media. Suspension should nowadays be a short-term
measure, only employed to allow the facts to be clarified and
appropriate disciplinary procedures to be considered.
Possible sequence of events
• Internal inquiry
• Coroner's inquest (England and Wales) or Procurator Fiscal's
(Scotland) Investigation
• Criminal prosecution
• GMC investigation
• Civil litigation
Internal Inquiry
It is very likely that an unexpected peri-operative death or serious
injury will lead to an internal inquiry. This is a fact-finding exercise,
usually conducted by a senior clinician (often the medical or clinical
director) who will interview and take statements from everyone
involved. If asked to attend for interview, it is advisable to inform your
medical defence organisation who may offer to send one of their
representatives to accompany you; in any event, it is a good idea to
take a trusted colleague or mentor along.
20

Inquests
In England and Wales, suspicious or unexpected deaths have to be
reported to the Coroner, who will then decide whether to hold an
Inquest. Coroners have wide powers of discretion as to which cases
they wish to investigate. If in any doubt, clinicians are strongly
recommended to inform the Coroner's Officer. The system is different
in Scotland where sudden or unexpected deaths are investigated by the
Procurator Fiscal who has the authority to ask for the assistance of the
police in his/her investigation and may call a Fatal Accident Enquiry.
Inquests often happen many months after the death, so good recordkeeping
is essential. The Inquest is an enquiry into the identity of the
deceased and, more importantly, the cause of death: it is not supposed
to be about allocation of blame or determining negligence. However,
there is an increasing tendency for interested parties - particularly the
family of the deceased - to instruct legal representatives who are able,
at the Coroner's discretion, to indulge in a degree of cross-examination
of the witnesses. If the Coroner is persuaded that there is a genuine
wider public interest in the outcome, then he/she may even choose to
empanel a jury, at which point the Inquest starts to become more like
a traditional adversarial Law Court. The Trust will provide legal cover
for these situations but, again, the concerned anaesthetist is strongly
advised to consult his/her own defence organisation in plenty of time
before the Inquest.
Criminal Prosecution
Any clinician would be very concerned at the thought of a police
investigation following a catastrophic outcome. Previously very
unusual, police involvement has become more common following
recent high-profile events such as the Shipman Inquiry and disasters
involving blocked anaesthetic tubing and intrathecal administration of
vincristine. 20-22 If they feel that there are suspicious circumstances or,
perhaps more likely, that one or more of the clinicians have been
grossly negligent, the police may recommend to the Crown
Prosecution Service that criminal proceedings should be pursued;
occasionally, the Coroner's verdict may encourage such action.
21

The potential implications of a criminal prosecution cannot be
overstated. Gross negligence, i.e. "reckless disregard for the welfare of
the patient" attracts a charge of manslaughter which, if proven, will
inevitably lead to erasure from the medical register and, often,
imprisonment. Even if cleared of such a charge, the accompanying
media publicity and stigma will often profoundly impact upon the
clinician's professional and private life.
General Medical Council (GMC)
The GMC requires doctors in practice to take appropriate action if they
are aware of concerns about another individual's ability to practice
safely. This requirement extends to medical directors who may feel it
appropriate or necessary to report an incident which might indicate a
problem with a doctor's competence or performance. The GMC will
let the individual know that they have received a complaint or
comment about them and invite a response; once again it is vital to
inform one's medical defence organisation as early as possible.
Following initial investigation, the GMC case examiners may decide
that no further action is warranted, issue a formal warning or refer the
case to the Fitness to Practice Panel for final adjudication. 23 The case
examiners can also ask the Interim Orders Committee to consider
temporary suspension from, or restrictions to, the doctor's practice
while investigation is underway. Once again, if this does eventually
proceed to a formal hearing, the time delay can be very significant and
the importance of good contemporaneous notes is vital.
The NHS does not provide doctors with legal representation for GMC
hearings. Membership of a medical defence organisation is strongly
recommended.
22

Civil Litigation
A possible outcome of an unexpected peri-operative death or serious
injury is a civil case for negligence being brought against the Trust (if
NHS) or the individual practitioner (if private). This is a slow process,
with prolonged preliminary stages designed to minimise the number of
cases coming to Court, and the anaesthetist will often have little idea
of what is happening after his/her initial involvement in supplying a
witness statement. It is not unusual for civil cases to drag on for five
years or more after the precipitating event. If it is a child who has
suffered injury, the claim may not be made for many years.
There are a number of reasons why the NHSLA may decide that a civil
suit should be settled out of court. It is often a frustrating experience
for anaesthetists who are confident that they could defend their own
actions in a public arena, but there may be other aspects of the case
which cannot be defended. It may be worth making vigorous
representations to the NHSLA if it seems that such an action will be
contemplated, although decisions are often made on pragmatic
grounds and rarely reversed. At the time of writing, the Central Legal
Office, the Scottish equivalent of the NHSLA, appears to be taking a
more aggressive stance in defending doctors who they feel have not
been negligent.
Should you be called to give evidence, it is essential to have good
quality records and to spend as much time as necessary rehearsing the
facts of the case; it is very difficult to jog one's memory from a large
bundle of case notes in the stressful environment of the witness box. It
is advisable to go over the events of the case with a colleague and, if
unfamiliar with the workings of the law, visit the court beforehand to
get an idea of layout, behaviour and protocol. Try not to get flustered
by cross-examination, answer politely, slowly and truthfully,
addressing the Judge at all times, and do not be tempted into giving an
expert opinion.
23

SECTION 9. SOURCES OF HELP
Consult your medical defence organisation in the first instance.
Support services within the NHS
Occupational Health Department
Every NHS Trust has an Occupational Health Department that provides
advice on the effects of work on health and the effects of health on
work. Each NHS Trust provides a confidential counselling service for
staff. Arrangements vary between Trusts but it is often linked with the
Occupational Health Department.
General Practitioner
All doctors should be registered with a local GP. If you feel that the
stress of your job, or of any particular incident at work, is affecting your
health, you should make an appointment to see your GP. GP practices
often have access to counselling services.
Phone based resources
Doctors' SupportLine
0870 765 0001 www.doctorssupport.org
Confidential, anonymous telephone helpline for doctors with any
concerns whether work related or not. Staffed by trained volunteer
doctors. Open 36 hours / week
BMA Counselling Line
08459 200 169
Confidential counselling service for discussing personal, emotional
and work-related problems. Available 24 hours / day; 365 days / year.
For BMA members and their families only.
Samaritans
08457 909090 www.samaritans.org
Confidential emotional support for people who are experiencing
feelings of despair, including those contemplating suicide. Available
24 hours / day; 365 days / year.
24

AAGBI Sick Doctor's Scheme
020 7631 1650
This service is currently under review. Please contact the AAGBI for
information.
Web based resources
Support4Doctors
www.support4doctors.org
A website run by the Royal Medical Benevolent Fund that aims to put
doctors and their families in touch with a range of organisations who
can help. Covers areas such as: Work & Career; Money & Finance;
Health & Well-Being; Family & Home.
BMA Doctors for Doctors
www.bma.org.uk then click on doctors health and wellbeing.
A web-based resource pack intended as a self-help tool to aid doctors
in accessing appropriate help for any difficulties in which they may
find themselves. For BMA members.
BMJ Careers Discrimination Matching Scheme
www.bmjcareers.com/discrimination/
It provides the opportunity for doctors who feel that they have been
discriminated against in some way, to receive informal support from
another doctor. Communication is purely electronic.
Support Groups and similar resources
Doctors' Support Network
0870 321 0 642 www.dsn.org.uk
Confidential self-help support group for doctors with mental health
problems.
Meetings around the UK; Newsletter; email support groups.
25

Sick Doctors Trust
0870 444 5163 www.sick-doctors-trust.co.uk
Undertake to provide early intervention and treatment for doctors
suffering from addiction to alcohol or other drugs, thus protecting
patients while offering hope, recovery and rehabilitation to affected
colleagues and their families.
Suspended Doctors Group of the Society of Clinical Psychiatrists
01725 513367 (Dr Peter Tomalin)
Confidential support for any hospital doctor who has been suspended,
including advice based on the experience of others. Also has a
network of psychiatrists around the country to whom doctors can be
referred if they are becoming unwell.
Financial Support
Royal Medical Benevolent Fund
020 8540 9194 www.rmbf.org
Provides support ranging from specialist information and advice to
financial assistance.
Royal Medical Foundation
01372 821011
www.royalmedicalfoundation.org
Provides support to medical practitioners and/or their dependants who
find themselves in financial hardship.
BMA Charities
020 7383 6334
Established to help all doctors (not just BMA members) and their
dependants in times of need.
26

SECTION 10. REFERENCES AND FURTHER READING
1. Lunn JN, Hunter AR, Scott DB. Anaesthesia-related surgical
mortality. Anaesthesia 1983;38:1090-94.
2. Australian and New Zealand College of Anaesthetists. Safety of
anaesthesia-related mortality, 1997-1999. http://www.anzca.edu.au/
publications/reports/mortality/mort_97_1.htm.
3. Why Mothers Die 2000-2002. Confidential Enquiries into
Maternal and Child Health. RCOG Press, London.
4. White SM, Akerele O. Anaesthetists' attitudes to intraoperative
death. Personal communication from Dr. Stuart White.
5. Bacon AK. Death on the table. Anaesthesia 1989; 44:245-8.
6. Bacon AK. Major anaesthetic mishaps- handling the aftermath.
Current Anaesthesia and Critical Care 1990, 1:253-7.
7. Aitkenhead AR. Anaesthetic disasters: handling the aftermath.
Anaesthesia 1997; 52: 477-82.
8. White SM. Death on the table. Editorial. Anaesthesia 2003;
58:515-9.
9. Smith IC and Jones MW. Surgeon's attitudes to intraoperative
death: a questionnaire survey. British Medical Journal 2001,
322:896-7.
10. Hawton K, Clements A, Sakarovitch C, Simkin S and Deeks DJ.
Suicide in doctors: a study of risk according to gender, seniority
and specialty in medical practitioners in England and Wales 1979-
1995. Journal of Epidemiology and Community Health 2001;
55:296-300.
11. Cooper JB, Cullen DJ, Eichhorn JH, Philip JH and Holzman S.
Administrative guidelines for response to an adverse anaesthesia
event. Journal of Clinical Anaesthesia 1993; 5:79-84.
12. Stress in Anaesthetists. 1997. Association of Anaesthetists of Great
Britain and Ireland. http:/www.aagbi.org/pdf/28doc.pdf.
13. Kenardy JA. The current status of psychological debriefing. British
Medical Journal 2000; 321:1032-3.
14. Everly, G. & Boyle, S. 2001. Critical Incident Stress Debriefing
CISD: A Meta-analysis. Ellicott City, MD: International Critical
Incident Stress Foundation.
27

15. Emmerik AAP, Kamphuis JH, Hulsbosch AM and Emmelkamp
PMG. Single session debriefing after psychological trauma: a
meta analysis. The Lancet 2002; 360:766-71.
16. Mitchell J T. 2003. Not always as it appears. CISM Perspectives.
www.cismperspectives.com
17. Carr K R. 2003. Critical Incident Stress Debriefings for Cross-
Cultural Workers: Harmful or helpful? MMCT. PO Box OS-3063
Osu-Accra, Ghana, West Africa. http://www.mmct.org/ article9/ htm
18. http://www.nhsla.com/NR/rdonlyres/B0148219-A94C-469D-
A5FC-127A418926E8/0/AVeryBriefGuideforClinicians.pdf
19. http://www.dh.gov.uk/PolicyAndGuidance/HumanResources
AndTraining/ModerninsingProfessionalRegulation/DoctorsAnd
DentistsDisciplinaryFrameworkArticle/fs/en?CONTENT_ID=40727
71&chk=x9pnf/
20. http://www.the-shipman-inquiry.org.uk/
21. Carter JA. Checking anaesthetic equipment and the Expert Group
on Blocked Anaesthetic Tubing (EGBAT). Anaesthesia 2004; 59:
105-7.
22. http://news.bbc.co.uk/1/hi/health/3133076.stm
23. http://www.gmc-uk.org/probdocs/fitness to practice guidance/
factsheets/fitness to practice procedures explained.pdf.
28

29

21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org
Designed and produced by the r2 Partnership Ltd

AAGBI SAFETY GUIDELINE
Blood Transfusion and the Anaesthetist
Intra-operative Cell Salvage
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org September 2009

Membership of the working party
Prof M Y K Wee
Dr D Thomas
Dr R Verma
Ms J Jones
Dr S Catling
Dr J Isaac
Dr F Howard
Mrs S Milton
Ex Officio
Dr R J S Birks
Dr D K Whitaker
Dr L W Gemmell
Dr A W Harrop-Griffiths
Dr I H Wilson
Dr I G Johnston
Dr E P O’Sullivan
Dr D G Bogod
Chair and AAGBI Vice President
Joint Chair, UK Cell Salvage Action
Group
AAGBI Council Member
UK Cell Salvage Action Group
UK Cell Salvage Action Group
Royal College of Anaesthetists
GAT Chair
Association for Perioperative Practice
President
Immediate Past President
Honorary Secretary
Immediate Past Honorary Secretary
Honorary Treasurer
Honorary Treasurer Elect
Honorary Membership Secretary
Editor-in-Chief, Anaesthesia
Acknowledgements
The working party is grateful to Danny McGee, representing
the College of Operating Department Practioners and Catherine
Howell representing the UK Cell Salvage Action Group.

Contents
1 Recommendations 2
2 Introduction 3
3 Getting organised and competencies 4
4 Operative indications 7
5 Technical aspects 8
6 Special circumstances 10
7 Financial considerations 14
References 15
Appendices 18
Endorsements and/or Support
This guideline has the endorsement and/or support of the
following bodies:
• British Orthopaedic Association
• College of Anaesthetists of Ireland
• Royal College of Obstretricians & Gynaecologists
• Royal College of Surgeons in Ireland
• Royal College of Surgeons of Edinburgh
• Royal College of Surgeons of England
• Vascular Anaesthesia Society of Great Britain & Ireland
• Vascular Society of Great Britain & Ireland
To be reviewed by 2014
© Copyright of the Association of Anaesthetists of Great Britain & Ireland. No
part of this book may be reproduced without the written permission of the
AAGBI
1

1. Recommendations
• The use of Intra-operative Cell Salvage (ICS) reduces the
demand on allogeneic (donor) red cells and is a cost effective
measure.
• Trusts should provide the resources required to set up and
maintain an ICS service in a safe, appropriate and cost
effective manner.
• Each Trust needs to ensure there is a clinical lead for ICS.
• A member of the theatre management team is responsible for
ensuring overall management and facilitation of the ICS
service.
• All personnel using ICS must be adequately trained and
competent in its use.
• Pre-operative assessment clinics should provide information
on ICS to patients.
• All ICS cases undertaken require documentation and audit of
use to enable future service planning and quality assurance.
2

2. Introduction
The challenge to ensure a safe and adequate supply of blood
components for transfusion continues. It has been recognised
that there are morbidities associated with the immunological
complications of allogeneic blood transfusion. The cost of
allogeneic blood components is increasing as testing and
processing to avoid transfusion transmitted infection becomes
more sophisticated. An additional concern is that the donor pool
is decreasing.
The use of ICS reduces the demand on allogeneic (donor)
red cells and is a cost effective measure. The Chief Medical
Officer’s National Blood Transfusion Committee in England
document ‘Strategies for Blood Conservation’ recommends
three main strategies to reduce demand: ICS, better education of
practitioners, and better pre-operative patient preparation.
Analysis of a recent survey showed that 53% of UK hospitals
now use ICS [1]. The principal aim of this document is to
facilitate and promote the safe and competent use of ICS to
enhance patient care.
3

3. Getting organised and
competencies
Greater awareness of the need for blood conservation should
help influence clinicians to make wider use of autologous blood
recovery techniques.
Lead ICS clinician
The lead clinician should ideally be someone working in the
theatre setting, i.e. a consultant anaesthetist or surgeon and a
member of the Hospital Transfusion Committee. Their role is to
provide information, support and direction. This includes:
• Responsibility for the overall ICS programme within an
organisation.
• Ensuring that agreed procedures and protocols are adhered
to.
• Informing clinical staff about the benefits of the autologous
programme.
• Identifying clinical situations where cell salvage can be used.
• Advising on the use of ICS in special circumstances, e.g.
malignancy, sepsis, and obstetrics.
• Developing a safe out of hours ICS service where
appropriate.
4

Operational management
Operational manager
A senior member of the theatre management team should
be responsible for the organisation and facilitation of the ICS
service by:
• Identifying a member of staff who will take on the role of coordinating
the cell salvage service.
• Being involved in the purchase of equipment and service
contracts.
• Liaising with the lead ICS clinician to produce and
implement local protocols and guidelines.
ICS co-ordinator
In larger Trusts, there may be a need for a cell salvage coordinator.
The co-ordinator should be fully trained and
competent in the operation of all types of cell salvage machines
used in an organisation. The cell salvage co-ordinator is a
member of the theatre staff who is responsible for:
• Delivering and recording of training and competency
assessment.
• Arranging for cell salvage to be available at the clinician’s
request. If the service is not available, this should be
reported to the lead ICS manager and clinician.
• Maintaining records of all procedures undertaken to ensure
accurate auditing and quality assurance.
• Providing information for the Hospital Transfusion Committee
(HTC) and national audits as appropriate.
5

Competencies
Documents supporting competency assessment are available on
the Better Blood Transfusion website:
www.transfusionguidelines.org.uk.
Click on Better Blood Transfusion Toolkit on the left hand menu,
then Appropriate Use and then UK Cell Salvage Action Group.
Alternatively most search engines will take you straight to the
relevant section if you insert ‘UK Cell Salvage Action Group’.
6

4. Operative indications
ICS is indicated in surgery with:
• Anticipated blood loss of >1000mls or >20% Estimated
Blood Volume.
• Patients with a low Hb or increased risk factors for bleeding.
• Patients with multiple antibodies or rare blood types.
• Patients with objections to receiving allogeneic (donor)
blood.
In cases with Jehovah’s Witnesses where a decision to use ICS is
made, this should be discussed with the patient pre-operatively
and informed consent obtained. All blood salvaged will need to
be labelled clearly. Use of the standard UK label issued for cell
salvage is recommended. It is essential that any adverse events
whether clinical or technical are reported to Serious Hazards of
Transfusion (SHOT).
Procedures which may be suitable for ICS
(See Appendix 1 on page 18).
7

5. Technical aspects
The surgical team should be aware of the technical issues
relating to the quality of cell salvage.
During surgery, blood loss can be removed from the operative
site by a combination of suction and swabs. Depending on the
type of surgery, blood loss to swabs during surgery has been
estimated at between 30% and 50% of the total surgical blood
loss. By washing swabs, the blood that is normally discarded
can be collected and the overall efficiency of red cell recovery
improved.
ICS should be temporarily discontinued when substances not
licensed for intravenous (IV) use are present within the surgical
field and could potentially be aspirated into the collection
reservoir. The standard theatre suction should be used to
aspirate the surgical field and the wound should be irrigated
with copious 0.9% sodium chloride before resuming ICS.
Examples of substances that should not be aspirated into the ICS
system include:
• Antibiotics not licensed for IV use
• Iodine
• Topical clotting agents
• Orthopaedic cement
To optimise the yield and quality of salvaged blood a large bore
suction tip (minimum 4mm, e.g. Yankauer sucker) should be
used and surface skimming minimised. Try to avoid aspirating
blood mixed with large quantities of air from the surgical field.
8

To reduce haemolysis the vacuum pressure should always be set
as low as practicable.
A standard blood administration set is usually adequate.
There are special circumstances where additional filters are
recommended (see overleaf).
9

6. Special circumstances
The decision to use blood that is potentially contaminated
with bacteria, amniotic fluid or malignant cells should be
made by the clinicians caring for the patient, taking into
account the latest evidence and consideration of the risks
and benefits for the individual patient.
Malignancy
The manufacturers of ICS devices do not recommend its use
in patients undergoing surgery for malignant disease. This is
due to concerns about the possibility of malignant cells being
reinfused and giving rise to metastases. However, in addition
to the many reports in the literature of the use of ICS in cancer
surgery without obviously leading to early metastasis, two recent
studies have shown no difference in biochemical recurrence or
long term survival after radical prostatectomy and cystectomy
between patients receiving ICS and those that received no blood
[2,3].
A recent prospective study of hepatocarcinoma surgery also
showed no difference in recurrence rates between those who
did and did not receive cell salvaged blood [4].
In contrast, there is evidence that allogeneic transfusion is
independently associated with an increased rate of both
postoperative infection and disease recurrence [5-8].
Consequently, in April 2008 the use of ICS in urological
malignancies was approved by NICE [9]. ICS can now be
used routinely during surgery for urological malignant disease.
Aspiration of blood from around the tumour site should be
avoided to minimise contamination of salvaged blood with
malignant cells. There is in vitro evidence that blood filtration
through leucodepletion filters significally reduce malignant
10

cell numbers. Some clinicians use a leucodepletion filter (Pall
Leukoguard RS) to reduce the reinfusion of malignant cells
which may be contaminating the cell salvaged red cells, whilst
others reinfuse unfiltered without apparent problems. It is
important to remember the manufacturers’ guidance on the use
of these filters by not pressurising the reinfusion bag.
Obstetrics
The main concern surrounding the use of ICS during obstetric
haemorrhage is the risk of reinfusing fetal contaminants with
the theoretical risk of causing amniotic fluid embolus (AFE).
However, to date there are no proven cases in the literature
of AFE caused by reinfusion of salvaged blood, and the use
of cell salvage in obstetrics is approved by NICE. The use
of leucodepletion filters in this situation has also shown a
significant reduction in contamination from amniotic fluid [10-
13].
ICS is being increasingly used in the UK in obstetrics for women
at risk from massive obstetric haemorrhage during caesarean
section [14]. In the year 2005-2006, 38% of UK maternity units
used ICS, and 28% included the use of ICS in their Massive
Obstetric Haemorrhage (MOH) protocol [15]. Early theoretical
concerns over amniotic fluid embolism have not been borne out
in clinical practice, and 80% of maternity units identified lack
of training, rather than safety concerns, as the barrier to more
frequent use of ICS.
Obstetric use also raises the concern of reinfusion of fetal red
cells from the operative field, as the cell saver cannot distinguish
fetal from maternal red cells [16]. If the mother is rhesus
negative (and the fetus RhD positive) the extent of maternal
exposure should be determined by Kleihauer testing as soon
as possible and a suitable dose of Anti D given. (N.B. the RhD
negative mother would be routinely receiving Anti D after
obstetric haemorrhage).
11

Bowel contamination
The use of ICS in the presence of bowel contents is contraindicated
by the manufacturers unless there is catastrophic
haemorrhage. However, the evidence indicates that wound
infection rates after laparotomy for abdominal injuries is no
different for patients receiving allogeneic or cell salvaged
blood, with no correlation between organisms grown from the
cell saved blood and those causing postoperative pneumonias,
bacteraemias or urinary tract infections [17,18].
A recent prospective RCT of laparotomy for abdominal trauma
showed that ICS significantly reduced allogeneic blood usage
with no effect on postoperative infection or mortality [18].
While salvage from grossly contaminated fields should be
avoided, procedures involving bowel resection may use ICS for
at least part of the procedure.
If deemed clinically necessary the following practical tips may
help:
• Initial evacuation of the soiled abdominal contents.
• Additional washing (increasing the volume of IV normal
saline [0.9% NaCl] which the machine uses to wash the
salvaged blood).
• Ensure use of broad spectrum antibiotics.
It is unlikely that bowel contamination in such traumatised
individuals will lead to problems in decision making about
the use of ICS, but hopefully the points raised can enable all
concerned to make an informed management choice.
12

N.B. SHOT has received a few recent reports of hypotension
that appear to be temporally related to reinfusion of cell
salvaged blood. The clinical/equipment details of each case are
currently being investigated to establish whether there are any
common features. The web version of this document will be
updated accordingly.
13

7. Financial considerations
To keep the cost argument simple, it becomes self evident that
if there is a machine available and a competent operator, then
the direct and recurring costs can be quite easily calculated.
Each 250 ml of salvaged and washed red cells is equivalent to
a unit of concentrated red cells, e.g. SAGM. Both have a similar
volume and haematocrit and therefore could be regarded as
therapeutically equal, if time is allowed for the stored red cells
to become biochemically active.
The current red cell unit cost in the UK is approximately £140
(although the price has been intentionally held steady for some
years). The disposable costs vary depending on which cell
salvage machine is being used, but range from approximately
£100 to £170. One can see that at this level saving an average
of 1 to 1.5 units of red cell equivalent per case salvaged will
cover the disposable costs. As prices will inevitably change it is
recommended that readers bear in mind the date of publication
of this booklet.
If the hardware for cell salvage is not available within the
Trust where you work you may find a generic business
case helpful. Readers requiring a generic business case,
which can be adapted to their own circumstances can
obtain this by going straight to the UK Cell Action Salvage
Group area of the Better Blood Transfusion Website as
explained on page 6 or by placing ‘UK Cell Salvage Action
Group’ in a search engine.
14

References
1. UK CSAG National Questionnaire April 2007.
http://transfusionguidelines.org.uk/docs/pdfs/bbt-03_icsagnewsletter-01_20080420.pdf
(accessed 17.01.09).
2. Neider AM, Carmack AJK, Sved PD, Kim SS, Manoharan
M, Soloway MS. Intra-operative cell salvage during radical
prostatectomy is not associated with greater biochemical
recurrence rate. Adult Urology 2005; 65: 30-4.
3. Neider AM, Manoharan M, Yang Y, Soloway MS. Intraoperative
cell salvage during radical cystectomy does not
affect long term survival. Adult Urology 2007; 69; 881-4.
4. Muscari F, Suc B, Vigouroux D, et al. Blood salvage
autotransfusion during transplantation for
hepatocarcinoma: does it increase the risk of neoplastic
recurrence? Transplant International 2005; 18 (11): 1236-
9.
5. Kinoshita Y, Udagawa H, Tsutsumi K, et al. Usefulness of
autologous blood transfusion for avoiding allogeneic
transfusion and infectious complications after esophageal
cancer resection. Surgery 2000; 127: 185-92.
6. Jones KR, Weissler MC. Blood transfusion and other risk
factors for recurrence of cancer of the head and neck.
Archives of Otolaryngology - Head and Neck Surgery
1990; 16: 304-9.
7. Woolley AL, Hogikyan ND, Gates GA, Haughey BH,
Schechtman KB, Goldenberg JL. Effect of blood transfusion
on recurrence of head and neck carcinoma. Retrospective
review and meta-analysis. Annals of OtoRhinoLaryngology
1992; 101: 724-30.
15

8. Takemura M, Osugi H, Higashino M, Takada N, Lee S,
Kinoshita H. Effect of substituting allogeneic blood
transfusion with autologous blood transfusion on outcomes
after radical oesophagectomy for cancer. Annals of
Thoracic and Cardiovascular Surgery 2005; 11: 293-330.
9. National Institute for Heath and Clinical Excellence. No
258. April 2008. http://www.nice.org.uk/Guidance/IPG258/
Guidance/pdf/English (accessed 17.01.09).
10. National Institute for Heath and Clinical Excellence. No
144 November 2005. http://guidance.nice.org.uk/IPG144
(accessed 17/01/09).
11. The Confidential Enquiry into Maternal and Child Health
(CEMACH). Saving Mothers’ Lives: reviewing maternal
deaths to make motherhood safer - 2003-2005. The
Seventh Report on Confidential Enquiries into Maternal
Deaths in The United Kingdom. London: CEMACH:
http://www.cmace.org.uk/Publications/CEMACH-
Publications/Maternal-and-Perinatal-Health.aspx
(accessed 21/07/08).
12. Waters JH, Biscotti MD, Potter PS, Phillipson E. Amniotic
fluid removal during cell salvage in the caesarean section
patient. Anesthesiology 2000; 92: 1531-6.
13. Sullivan I, Faulds J, Ralph C. Contamination of salvaged
maternal blood by amniotic fluid and fetal red cells during
elective caesarean section. British Journal of Anaesthesia
2008; 101(2): 225-9.
14. Allam J, Cox M, Yentis SM. Cell salvage in obstetrics.
International Journal of Obstetric Anesthesia 2008; 17:37-
45.
16

15. Teig M, Harkness M, Catling S, Clarke V. Survey of cell
salvage use in obstetrics in the UK. International Journal of
Obstetric Anesthesia 2007; 16: S30.
16. Catling SJ, Williams S, Fielding AM. Cell salvage in
obstetrics: an evaluation of the ability of cell salvage
combined with leucocyte depletion filtration to remove
amniotic fluid from operative blood loss at caesarean
section. International Journal of Obstetric Anesthesia 1999;
8: 79-84.
17. Ozmen V, McSwain NE, Nichols RL, Smith J, Flint
LM. Autotransfusion of potentially culture-positive blood
in abdominal trauma: preliminary data from a prospective
study. Journal of Trauma 1992; 32: 36-9.
18. Bowley DM, Barker P, Boffard ND. Intra-operative blood
salvage in penetrating abdominal trauma: a randomised,
controlled trial. World Journal of Surgery 2006; 30: 1074-
80.
Websites
www.transfusionguidelines.org.uk
www.aagbi.org
www.nataonline.com
www.bbts.org.uk
17

Appendix 1
Procedures and situations which may be suitable for ICS
Vascular Surgery, Trauma
& Orthopaedics
Open aortic aneurysm repair -
(elective and emergency)
Splenic/liver trauma
Spinal surgery
Revision hip replacement
Pelvic and femoral fractures
(In primary hip and knee
replacement it may be better
to consider post operative
drainage systems)
Urology
Radical cystectomy
Radical prostatectomy
Nephrectomy
Pelvic clearance
General Surgery
Hepatectomy
Abdominal/thoracic trauma
Emergency laparotomy
Cardiac
All major procedures (post-op
drainage may be of use if
mediastinal drainage is of high
volume)
18

Obstetric
Emergency use: major
obstetric haemorrhage at
caesarean section, laparotomy
for postpartum haemorrhage
genital tract trauma, etc.
Elective use: anticipated
haemorrhage at caesarean
section, e.g. placenta praevia/
accreta, large fibroid uterus,
etc.
Gynaecology
All major procedures, e.g.
pelvic clearance
Head and Neck
Major procedures
Jehovah’s Witnesses or
any patient refusing
a blood transfusion
Consideration should also be
given to post-op drainage and
reinfusion where indicated
All surgical procedures where
blood loss is expected to have
an impact
Maximum benefit of cell salvage can be gained by
capture of emergency cases which often require large
volume blood component support.
19

Appendix 2
Diagram of ICS set-up
Drawn for the UK ICS Action Group by Medical Illustration
Department - University Hospital of South Manchester NHS
Foundation Trust.
20

21 Portland Place, London, W1B 1PY
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AAGBI SAFETY GUIDELINE
Checking Anaesthetic Equipment 2012
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org June 2012

This guideline was originally published in Anaesthesia. If you wish to refer to
this guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland. Checking
Anaesthetic Equipment 2012. Anaesthesia 2012; 67: pages 660-68. This
guideline can be viewed online via the following URL: http://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2044.2012.07163.x/abstract
© The Association of Anaesthetists of Great Britain 2012

Guidelines
Checking Anaesthetic Equipment 2012
Association of Anaesthetists of Great Britain and
Ireland
Membership of the Working Party: A. Hartle (Chair), E. Anderson,
V. Bythell, L. Gemmell, H. Jones 1 , D. McIvor 2 , A. Pattinson 3 ,
P. Sim 3 and I. Walker
1 Royal College of Anaesthetists
2 Medicines and Healthcare products Regulatory Agency
3 British Association of Anaesthetic and Respiratory Equipment
Manufacturers Association
Summary
A pre-use check to ensure the correct functioning of anaesthetic
equipment is essential to patient safety. The anaesthetist has a primary
responsibility to understand the function of the anaesthetic equipment and
to check it before use. Anaesthetists must not use equipment unless they
have been trained to use it and are competent to do so. A self-inflating bag
must be immediately available in any location where anaesthesia may be
given. A two-bag test should be performed after the breathing system,
vaporisers and ventilator have been checked individually. A record should
be kept with the anaesthetic machine that these checks have been done.
The ‘first user’ check after servicing is especially important and must be
recorded.
Reuse of this article is permitted in accordance with the Creative Commons Deed, Attribution
2.5, which does not permit commercial exploitation.
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 1

Anaesthesia 2012
Hartle et al. | Checking anaesthetic equipment
..................................................................................................
This is a consensus document produced by expert members of a Working
Party established by the Association of Anaesthetists of Great Britain and
Ireland (AAGBI). It has been seen and approved by the AAGBI Council.
This article is accompanied by an Editorial. See page 571 of this issue.
You can respond to this article at http://www.anaesthesiacorrespondence.com
Accepted: 18 March 2012
• What other guideline statements are available on this topic?
Guidelines on checking anaesthetic equipment have been published by
the Association of Anaesthetists of Great Britain and Ireland (AAGBI),
and amongst others, the American Society of Anesthesiologists, the
Australian and New Zealand College of Anaesthetists and the World
Federation of Societies of Anesthesiologists.
• Why was this guideline developed?
The increasing sophistication and diversity of anaesthesia workstations
made the AAGBI’s existing guideline less universally applicable.
Incidents reported to the Medicines and Healthcare products
Regulatory Agency (MHRA), National Patient Safety Agency (NPSA)
and AAGBI also highlighted priority checks that would avoid harm.
• How does this statement differ from existing guidelines?
The checklist specifies outcomes rather than processes and covers all the
equipment necessary to conduct safe anaesthesia, not just the
anaesthesia workstation. It has been written by Officers and Council
members of the AAGBI in conjunction with representatives of the Royal
College of Anaesthetists (RCoA), MHRA, NPSA and manufacturers. It
was modified after a consultation with the membership of the AAGBI
and industry. It has been trialled and modified in simulator settings on
different machines. It has been endorsed by the Chief Medical Officers
of England, Scotland, Wales and Northern Ireland.
• Why does this statement differ from existing guidelines?
The guideline reflects anaesthetic practice and staffing in the UK and
Ireland and is applicable to any anaesthetic machine, including those yet
to be developed.
The pre-use check to ensure the correct functioning of anaesthetic
equipment is essential to patient safety. The importance of this pre-use
check is recognised worldwide and the check has been included in the
2 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland

Hartle et al. | Checking anaesthetic equipment Anaesthesia 2012
World Health Organization’s Surgical Safety Checklist [1]. The AAGBI
published the third edition of Checking Anaesthetic Equipment in 2004,
and this has gained widespread acceptance in the profession. Changes in
anaesthetic equipment and introduction of microprocessor-controlled
technology necessitate continued revision of this document.
This new edition of the safety guideline updates the procedures
recommended in 2004 and places greater emphasis on checking all of the
equipment required. A Working Party was established in 2009 comprising
Officers and Council Members of the AAGBI and representatives of the
Group of Anaesthetists in Training (GAT), RCoA, MHRA and the British
Association of Anaesthetic and Respiratory Equipment Manufacturers
Association (BAREMA). The Working Party reviewed the 2004 guideline,
together with guidelines published by other organisations, and in addition
reviewed incidents reported to the MHRA and the National Reporting and
Learning Service (NRLS) of the NPSA [2]. The accompanying Checklist for
Anaesthetic Equipment 2012 has been completely reformatted (Fig. 1).
There are two new checklists – the first to be completed at the start of
every operating session, the second a short set of checks before each case.
The detail of how to perform these checks is given in this safety guideline.
The first draft was circulated to the membership of the AAGBI and to
manufacturers for comments, and the guideline amended in the light of
these. Several versions of the checklist were trialled in simulators using
different machines. The final version of the checklist was then submitted
for further usability tests in simulators. The guideline and checklists have
been endorsed by the Chief Medical Officers of England, Scotland, Wales
and Northern Ireland.
The principles set out in previous guidelines have governed
amendments in this new edition. It must be emphasised that failure to
check the anaesthetic machine and ⁄ or the breathing system features as a
major contributory factor in many anaesthetic misadventures, including
some that have resulted in hypoxic brain damage or death. The RCoA
recognises the importance of these safety checks, and knowledge of them
may be tested as part of the FRCA examination [3].
The anaesthetist has a primary responsibility to understand the
function of the anaesthetic equipment and to check it before use
Anaesthetists must not use equipment unless they have been trained to use
it and are competent to do so [4]. The NHS Clinical Negligence Scheme
for Trusts and NHS Quality Improvement Scotland require that hospitals
ensure all personnel are trained to use and to check relevant equipment
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Hartle et al. | Checking anaesthetic equipment
Figure 1 Checklist for Anaesthetic Equipment 2012.
[5, 6]. This may take place at induction for new staff or at the introduction
of new equipment. This responsibility may be devolved to the department
of anaesthesia, but where such a department does not exist other
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This checklist is an abbreviated version of the publication by the Association of Anaesthetists of Great Britain and
Ireland 'Checking Anaesthesia Equipment 2012'.
Figure 1 (Continued).
arrangements must be made. A record of training must be kept. The use of
routine checks and associated checklists is an important part of training in
anaesthesia, and is part of the RCoA’s Competency Based Training.
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Modern anaesthetic workstations
The AAGBI checklist for anaesthetic equipment is applicable to all
anaesthetic workstations and should take only a few minutes to perform. It
represents an important part of safe patient care. It is not intended to
replace the manufacturer’s pre-anaesthetic checks, and should be used in
conjunction with them. For example, some modern anaesthetic workstations
will enter a self-testing cycle when the machine is switched on, in
which case those functions tested by the machine need not be retested by
the user. The intention is to strike the right balance so that the AAGBI
checklist for anaesthetic equipment is not so superficial that its value is
doubtful or so detailed that it is impractical to use. Manufacturers may
also produce checklists specific to their device; these should be used in
conjunction with the AAGBI checklist for anaesthetic equipment.
The checking procedure described covers all aspects of the anaesthetic
delivery system from the gas supply pipelines, the machine and breathing
systems, including filters, connectors and airway devices. It includes an
outline check for ventilators, suction, monitoring and ancillary equipment.
The anaesthetic equipment must be checked by trained staff on a
routine basis using the checklist and according to the manufacturer’s
instructions, in every environment where an anaesthetic is given. A record
should be kept with the anaesthetic machine that these checks have
been done.
Each hospital must ensure that all machines are fully serviced at the
regular intervals designated by the manufacturer and that a service record
is maintained. As it is possible for errors to occur when reassembling an
anaesthetic machine, it is essential to confirm that the machine is correctly
configured for use after each service. The ‘first user’ check after servicing
is especially important and must be recorded.
Equipment faults may develop during anaesthesia that were either not
present or not apparent on the pre-operative check. This may be caused by
pipeline failure, electrical failure, circuit disconnection or incorrect
configuration, etc. An immediate and brief check of equipment should
be made if there is a critical incident involving a patient, even if the
equipment was checked before the start of the case, as the incident may be
caused by a primary problem with the equipment.
The checking procedure described in this publication is reproduced in
an abbreviated form, as a sheet entitled Checklist for Anaesthetic
Equipment 2012 (Fig. 1). This laminated sheet should be attached to each
anaesthetic machine and used to assist in the routine checking of
anaesthetic equipment.
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Procedures for checking anaesthetic equipment
The following checks should be carried out at the beginning of each
operating theatre session. In addition, specific checks should be carried out
before each new patient during a session or when there is any alteration or
addition to the breathing system, monitoring or ancillary equipment.
It is the responsibility of the anaesthetist to make sure that these checks
have been performed, and the anaesthetist must be satisfied that they have
been carried out correctly. In the event of a change of anaesthetist during an
operating session, the status of the anaesthetic equipment must be
confirmed, including that a formal check has been performed.
Before using any anaesthetic equipment, ventilator, breathing system
or monitor, it is essential to be fully familiar with it. Modern anaesthetic
workstations are complex devices. It is essential that anaesthetists have full
training and formal induction for any machines they may use. A quick
‘run-through’ before the start of an operating session is not acceptable.
Careful note should be taken of any information or labelling on the
anaesthetic machine that might refer to its current status.
Alternative means of ventilation
The early use of an alternative means of ventilation (a self-inflating bag
that does not rely on a source of oxygen to function) may be life-saving. A
self-inflating bag must be immediately available in any location where
anaesthesia may be given [7, 8]. An alternative source of oxygen should be
readily available.
Perform manufacturer’s machine check
Modern anaesthesia workstations may perform many of the following
checks automatically during start-up. Users must know which are included
and ensure that the automated check has been performed.
Power supply
Check that the anaesthetic workstation and relevant ancillary equipment
are connected to the mains electrical supply (where appropriate) and
switched on. The anaesthetic workstation should be connected directly to
the mains electrical supply, and only correctly rated equipment connected
to its electrical outlets. Multisocket extension leads must not be plugged
into the anaesthetic machine outlets or used to connect the anaesthetic
machine to the mains supply.
Hospitals should have back-up generators, and many operating
theatres will have their own back-up system. Anaesthetists should know
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what is available where they are working. Back-up batteries for anaesthetic
machines and other equipment should be charged.
Switch on the gas supply master switch (if one is fitted).
Check that the system clock (if fitted) is set correctly.
Gas supplies and suction
To check the correct function of the oxygen failure alarm involves
disconnecting the oxygen pipeline on some machines, whilst on machines
with a gas supply master switch, the alarm may be operated by turning the
master switch off. As repeated disconnection of gas hoses may lead to
premature failure of the Schrader socket and probe, these guidelines
recommend that the regular pre-session check of equipment includes a ‘tug
test’ to confirm correct insertion of each pipeline into the appropriate socket.
It is therefore recommended that, in addition to these checks, the
oxygen failure alarm must be checked on a weekly basis by disconnecting
the oxygen hose whilst the oxygen flowmeter is turned on, and a written
record kept. In addition to sounding an alarm, which must sound for at
least 7 s, oxygen failure warning devices are also linked to a gas shut-off
device. Anaesthetists must be aware of both the tone of the alarm and also
which gases will continue to flow on the particular model of anaesthetic
machine in use.
Medical gas supplies
Identify and take note of the gases that are being supplied by pipeline,
confirming with a ‘tug test’ that each pipeline is correctly inserted into the
appropriate gas supply terminal. Note that excessive force during a ‘tug
test’ may damage the pipeline and ⁄ or gas supply terminal.
1 Check that the anaesthetic apparatus is connected to a supply of oxygen
and that an adequate reserve supply of oxygen is available from a spare
cylinder.
2 Check that adequate supplies of any other gases intended for use are
available and connected as appropriate. All cylinders should be securely
seated and turned off after checking their contents.
3 Carbon dioxide cylinders should not be present on the anaesthetic
machine. Where a blanking plug is supplied this should be fitted to any
empty cylinder yoke.
4 Check that all pressure gauges for pipelines connected to the anaesthetic
machine indicate 400–500 kPa.
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5 Check the operation of flowmeters, where these are present, ensuring that
each control valve operates smoothly and that the bobbin moves freely
throughout its range without sticking. If nitrous oxide is to be used, the
anti-hypoxia device should be tested by first turning on the nitrous oxide
flow and ensuring that at least 25% oxygen also flows. Then turn the
oxygen flow off and check that the nitrous oxide flow also stops. Turn on
the oxygen flow and check that the oxygen analyser display approaches
100%. Turn off all flow control valves. (Machines fitted with a gas supply
master switch will continue to deliver a basal flow of oxygen).
6 Operate the emergency oxygen bypass control and ensure that flow
occurs from the gas outlet without significant decrease in the pipeline
supply pressure. Ensure that the emergency oxygen bypass control
ceases to operate when released.
Suction
Check that the suction apparatus is functioning and all connections are
secure; test for the rapid development of an adequate negative pressure.
Breathing system and vaporisers
Whole breathing system
Check all breathing systems that are to be used and perform a ‘two-bag
test’ before use, as described below [9]. Breathing systems should be
inspected visually and inspected for correct configuration and assembly.
Check that all connections within the system and to the anaesthetic
machine are secured by ‘push and twist’. Ensure that there are no leaks or
obstructions in the reservoir bags or breathing system and that they are
not obstructed by foreign material. Perform a pressure leak test (between
20 and 60 cmH 2 O on the breathing system by occluding the patient-end
and compressing the reservoir bag.
Vaporisers
Manual leak testing of vaporisers was previously recommended routinely.
It should only be performed on basic ‘Boyle’s’ machines and it may be
harmful to many modern anaesthetic workstations. Refer to the
manufacturer’s recommendation before performing a manual test.
Check that the vaporiser(s) for the required volatile agent(s) are fitted
correctly to the anaesthetic machine, that any locking mechanism is fully
engaged and that the control knobs rotate fully through the full range(s).
Ensure that the vaporiser is not tilted. Turn off the vaporisers.
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Check that the vaporiser(s) are adequately filled but not overfilled, and
that the filling port is tightly closed.
Manual leak test of vaporiser
1 Set a flow of oxygen of 5 l.min )1 and with the vaporiser turned off,
temporarily occlude the common gas outlet. There should be no leak
from any part of the vaporiser and the flowmeter bobbin (if present)
should dip.
2 Where more than one vaporiser is present, turn each vaporiser on in
turn and repeat this test. After this test, ensure that the vaporisers and
flowmeters are turned off.
Changing and filling vaporisers during use. It may be necessary to
change a vaporiser during use. Where possible, repeat the leak test; failure
to do so is a common cause of critical incidents [10]. Some anaesthetic
workstations will automatically test vaporiser integrity.
It is only necessary to remove a vaporiser from a machine to refill it if
the manufacturer recommends this. Vaporisers must always be kept
upright. Tilting a vaporiser can result in delivery of dangerously high
concentrations of vapour [11].
Carbon dioxide absorber
Inspect the contents and connections and ensure there is adequate supply
of carbon dioxide absorbent. Check the colour of the absorbent.
Alternative breathing systems
For Bain-type and circle co-axial systems, perform an occlusion test on the
inner tube and check that the adjustable pressure limiting (APL) valve,
where fitted, can be fully opened and closed.
Correct gas outlet
Particular care must be exercised in machines with an auxiliary common
gas outlet (ACGO). Incidents of patient harm have resulted from
misconnection of a breathing system to an ACGO or misselection of the
ACGO [12].
Whenever a breathing system is changed, either during a case or a list,
its integrity and correct configuration must be confirmed. This is
particularly important for paediatric lists when breathing systems may
be changed frequently during a list.
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Ventilator
Check that the ventilator is configured correctly for its intended use. Ensure
that the ventilator tubing is securely attached. Set the controls for use and
ensure that adequate pressure is generated during the inspiratory phase.
Check that alarms are working and correctly configured.
Check that the pressure relief valve functions correctly at the set pressure.
Two-bag test
A two-bag test should be performed after the breathing system, vaporisers
and ventilator have been checked individually [9].
1 Attach the patient-end of the breathing system (including angle piece
and filter) to a test lung or bag.
2 Set the fresh gas flow to 5 l.min )1 and ventilate manually. Check the
whole breathing system is patent and the unidirectional valves are
moving (if present).
3 Check the function of the APL valve by squeezing both bags.
4 Turn on the ventilator to ventilate the test lung. Turn off the fresh gas
flow or reduce to a minimum. Open and close each vaporiser in turn.
There should be no loss of volume in the system.
Breathing systems should be protected with a test lung or bag when
not in use to prevent intrusion of foreign bodies.
Scavenging
Check that the anaesthetic gas scavenging system is switched on and
functioning. Ensure that the tubing is attached to the appropriate exhaust
port of the breathing system, ventilator or anaesthetic workstation [13].
Monitoring equipment
Check that all monitoring devices, especially those referred to in the
AAGBI’s Standards of Monitoring during Anaesthesia and Recovery
guidelines [14], are functioning and that appropriate parameters and
alarms have been set before using the anaesthetic machine. This includes
the cycling times, or frequency of recordings, of automatic non-invasive
blood pressure monitors. Check that gas sampling lines are properly
attached and free from obstruction or kinks. In particular, check that the
oxygen analyser, pulse oximeter and capnograph are functioning correctly
and that appropriate alarm limits for all monitors are set. Be aware of the
‘default’ alarm settings if using these.
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Gas monitoring lines are often the cause of a significant leak; check that
they are properly attached and any sampling ports not in use have been
blanked off. To eliminate the need to change the sampling line repeatedly,
the gas monitoring line should be assembled as an integral part of the
breathing circuit by attaching it proximal to the patient breathing filter.
Airway equipment
These include bacterial filters, catheter mounts, connectors and tracheal
tubes, laryngeal mask airways, etc.; check that these are all available in the
appropriate sizes, at the point of use, and that they have been checked for
patency.
A new, single-use bacterial filter and angle piece ⁄ catheter mount must
be used for each patient. It is important that these are checked for patency
and flow, both visually and by ensuring gas flow through the whole
assembly when connected to the breathing system, as described below.
Check that the appropriate laryngoscopes are available and function
reliably. Equipment for the management of the anticipated or unexpected
difficult airway must be available and checked regularly in accordance with
departmental policies [15]. A named consultant anaesthetist must be
responsible for difficult airway equipment and the location of this
equipment should be known.
Total intravenous anaesthesia (TIVA)
When TIVA is used there must be a continuous intravenous infusion of
anaesthetic agent or agents; interruption from whatever cause may result
in awareness. A thorough equipment check is therefore the most
important step in reducing the incidence of awareness. Anaesthetists
using TIVA must be familiar with the drugs, the technique and all
equipment and disposables being used.
The Safe Anaesthesia Liaison Group (SALG) has produced safety
guidance on guaranteeing drug delivery during TIVA [16]; SALG made
the following recommendations:
1 An anti-reflux ⁄ non-return valve should always be used on the
intravenous fluid infusion line when administering TIVA.
2 Sites of intravenous infusions should be visible so that they may be
monitored for disconnection, leaks or infusions into subcutaneous
tissues.
3 Clinical staff should know how to use, and to check, the equipment
before use.
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4 Organisations should give preference to purchasing intravenous
connectors and valves that are clearly labelled.
Ancillary and resuscitation equipment
Check that the patient’s trolley, bed or operating table can be tilted headdown
rapidly. A resuscitation trolley and defibrillator must be available in
all locations where anaesthesia is given and checked regularly in
accordance with local policies.
Equipment and drugs for rarely encountered emergencies, such as
malignant hyperthermia and local anaesthetic toxicity must be available
and checked regularly in accordance with local policies. The location of
these must be clearly signed [17, 18].
Single-use devices
Any part of the breathing system, ancillary equipment or other apparatus
that is designated ‘single-use’ must be used for one patient only, and not
reused. Packaging should not be removed until the point of use, for
infection control, identification and safety. (For details of decontamination
of reusable equipment, see the AAGBI safety guideline Infection Control in
Anaesthesia [19].)
Machine failure
In the event of failure, some modern anaesthetic workstations may default
to little or no flow, or oxygen only with no vapour. Users must know the
default setting for the machine in use. Alternative means of oxygenation,
ventilation and anaesthesia must be available.
‘Shared responsibility’ equipment
As a member of the theatre team, the anaesthetist will share responsibility
for the use of other equipment, e.g. diathermy, intermittent compression
stockings, warming devices, cell salvage and tourniquets, but should have
received appropriate training. Involvement with this equipment, especially
‘trouble shooting’ problems that arise intra-operatively, must not be
allowed to distract anaesthetists from their primary role.
Recording and audit
A clear note must be made in the patient’s anaesthetic record that the
anaesthetic machine check has been performed, that appropriate
monitoring is in place and functional, and that the integrity, patency
and safety of the whole breathing system has been assured. A logbook
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should also be kept with each anaesthetic machine to record the daily presession
check and weekly check of the oxygen failure alarm. Modern
anaesthesia workstations may record electronic self tests internally. Such
records should be retained for an appropriate time. Documentation of the
routine checking and regular servicing of anaesthetic machines and patient
breathing systems should be sufficient to permit audit on a regular basis.
Recovery
There must be clear departmental procedures for the daily and other
checks of equipment that is used in recovery. This may also include preuse
checks of patient-controlled analgesia and epidural pumps, etc. [20].
Disclaimer
The AAGBI cannot be held responsible for failure of any anaesthetic
equipment as a result of a defect not revealed by these procedures.
References
1. National Patient Safety Agency. WHO Surgical Safety Checklist NPSA ⁄ 2009 ⁄
PSA002 ⁄ U1, January 2009, NPSA. http://www.nrls.npsa.nhs.uk/resources/
?entryid45=59860 (accessed 09 ⁄ 04 ⁄ 12).
2. Cassidy CJ, Smith A, Arnot-Smith J. Critical incident reports concerning anaesthetic
equipment: analysis of the UK National Reporting and Learning System (NRLS) data
from 2006–2008. Anaesthesia 2011; 66: 879–88.
3. Royal College of Anaesthetists. CCT in Anaesthetics Annex B Basic Level Training
Edition 2 Version 1.2, August 2010. http://www.rcoa.ac.uk/index.asp?PageID=1479
(accessed 29 ⁄ 01 ⁄ 2012).
4. Association of Anaesthetists of Great Britain & Ireland. Safe Management of
Anaesthetic Related Equipment, 2009. http://www.aagbi.org/publications/guidelines/docs/safe_management_2009.pdf
(accessed 29 ⁄ 01 ⁄ 2012).
5. NHS Litigation Authority. NHSLA Risk Management Standards for Acute Trusts Primary
Care Trusts and Independent Sector Providers of NHS Care, January 2010. London:
NHSLA, 2010.
6. NHS Quality Improvement Scotland. Clinical Standards for Anaesthesia July 2003.
http://www.nhshealthquality.org/nhsqis/files/ANAES_STND_JUL03.pdf (accessed
29 ⁄ 01 ⁄ 2012).
7. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2005 ⁄ 062 07
November 2004 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON2022493
(accessed 29 ⁄ 01 ⁄ 2012).
8. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2010 ⁄ 036 06 May 2010
http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/
CON081785 (accessed 29 ⁄ 01 ⁄ 2012).
9. Australian and New Zealand College of Anaesthetists. Recommendations on Checking
Anaesthesia Delivery Systems, 4.2.3.4.2, 2003. http://www.anzca.edu.au/
resources/professional-documents/ps31.html (accessed 29 ⁄ 01 ⁄ 2012).
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10. Medicines and Healthcare products Healthcare Regulatory Agency. MDA ⁄ 2010 ⁄ 052
02 June 2010 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON085024
(accessed 29 ⁄ 01 ⁄ 2012).
11. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2003 ⁄ 039 06
November 2003 http://www.mhra.gov.uk/Publications/Safetywarnings/Medical
DeviceAlerts/CON008613 (accessed 29 ⁄ 01 ⁄ 2012).
12. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2011 ⁄ 108 01 December
2011 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/
CON137664 (accessed 29 ⁄ 01 ⁄ 2012).
13. Medicines and Healthcare products Regulatory Agency. MDA ⁄ 2010 ⁄ 21, 10 March
2010. http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/
CON076104 (accessed 29 ⁄ 01 ⁄ 2012).
14. Association of Anaesthetists of Great Britain & Ireland. Standards of Monitoring during
Anaesthesia and Recovery 4, 2007. http://www.aagbi.org/publications/guidelines/
docs/standardsofmonitoring07.pdf (accessed 29 ⁄ 01 ⁄ 2012).
15. Difficult Airway Society. Recommended Equipment for Management of Unanticipated
Difficult Intubation, July 2005. http://www.das.uk.com/equipmentlistjuly2005.htm
(accessed 29 ⁄ 01 ⁄ 2012).
16. Safe Anaesthesia Liaison Group. Guaranteeing Drug Delivery in Total Intravenous
Anaesthesia, September 2009. http://www.aagbi.org/news/docs/tiva_infonov09.pdf
(accessed 29 ⁄ 01 ⁄ 2012).
17. Association of Anaesthetists of Great Britain & Ireland. Management of a Malignant
Hyperthermia Crisis, 2007. http://www.aagbi.org/publications/guidelines/docs/
malignanthyp07amended.pdf (accessed 29 ⁄ 01 ⁄ 2012).
18. Association of Anaesthetist of Great Britain & Ireland. Management of Severe Local
Anaesthetic Toxicity 2, 2010. http://www.aagbi.org/publications/guidelines/docs/
standardsofmonitoring07.pdf (accessed 29 ⁄ 01 ⁄ 2012).
19. Association of Anaesthetists of Great Britain & Ireland. Infection Control in
Anaesthesia 2, 2008. http://www.aagbi.org/publications/guidelines/docs/infection_control_08.pdf
(accessed 29 ⁄ 01 ⁄ 2012).
20. Association of Anaesthetists of Great Britain & Ireland. Immediate Post anaesthetic
Recovery, 2002. http://www.aagbi.org/publications/guidelines/docs/postanaes02.pdf
(accessed 29 ⁄ 01 ⁄ 2012).
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 15

21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

This checklist is an abbreviated version of the publication by the Association of Anaesthetists of Great Britain and
Ireland 'Checking Anaesthesia Equipment 2012'. It was originally published in Anaesthesia.
If you wish to refer to this guideline, please use the following reference: Checklist for anaesthetic equipment 2012.
Anaesthesia 2012; 66: pages 662–63. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2012.07163.x/abstract

VOLUNTARY CODE OF PRACTICE
FOR BILLING PRIVATE PATIENTS
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
www.aagbi.org
April 2008

Contents
Introduction 1
Summary of recommendations 2
General comments 3
Before treatment 4
During treatment 7
After treatment 8
Emergencies 10
Appendices 11

Introduction
The Association of Anaesthetists of Great Britain & Ireland (AAGBI) has
produced this Voluntary Code of Practice for Billing Private Patients in
response to requests from members and in order to guide members in
matters relating to invoicing patients for private medical services. The private
health market is experiencing change, and there is pressure for anaesthetists’
fees to be paid directly by third parties as part of a treatment “package” or
network. The AAGBI believes it important that the direct professional and
contractual relationship between consultant anaesthetist and private patient
be maintained. The guidance provided in this document underlines this
relationship and gives advice on how to invoice patients. The idea behind
this document is not to provide a mandatory method for managing financial
issues in private practice but to offer a voluntary code of practice to which
members can subscribe if they wish. Those who do may choose to indicate
their compliance with this code in their invoices.
The AAGBI would welcome comments on this document from members,
patients and PMIs.
Will Harrop-Griffiths
Honorary Secretary, for the Independent Practice Committee of the AAGBI
1

1.0 Summary of recommendations
1.1 Consultants set the fees that they charge their patients. Private
Medical Insurers (PMIs) set benefit levels for their customers. There
is no necessary correlation between fees and benefits.
1.2 Once a patient has agreed to the fee to be charged by the consultant
for a procedure, there exists a contract under which the patient
becomes liable for the payment of the fee, regardless of whether or
not the patient holds private medical insurance.
1.3 Consultants should charge transparent and reasonable fees, and
should make every effort to inform their patients of the fees before
surgery.
1.4 Insured patients should be encouraged to check the benefit levels
provided by their particular policy with their PMIs before undergoing
surgery.
1.5 The fee charged should ideally include the totality of the care
involved in the planned procedure. Any additional fees should be
disclosed to the patient before surgery.
1.6 Consultants may send invoices to the patients, their PMIs or both.
The AAGBI recommends that consultants always send the invoice
to the patient. A copy of the invoice may also be sent to insured
patients’ PMIs.
2

2.0 General comments
2.1 When a consultant anaesthetist (henceforth “consultant”) offers
medical care to a private patient in return for a disclosed fee and
the patient agrees to this arrangement, a contract is created in which
the patient is wholly responsible for the payment of the consultant’s
fee.
2.2 This contract is not affected by the fact that the patient is a subscriber
to a PMI; the patient remains ultimately responsible for payment of
the fee but the PMI may pay some or all of the fee to the consultant
on behalf of the patient.
2.3 Consultants set the level of the fees that they charge; PMIs set the
benefit limits for their customers. The benefits provided by PMIs
to their customers allow the payment of consultants’ fees wholly
or in part. There is thus no necessary correlation between the fees
charged by consultants and the benefits paid by PMIs.
2.4 There exists no legally enforceable contract between a consultant
and a PMI except where both parties enter willingly into such a
contract.
2.5 Private patients will remain responsible for payment of a consultant’s
fee under the contract between them unless the consultant agrees to
accept that the responsibility for payment should be confined to the
PMI or other third party.
3

3.0 Before treatment
3.1 Whenever possible, the consultant should inform the patient before
treatment of the likely fee 1 or explain how it will be determined
unless he is prepared to limit his fee to whatever that patient’s
benefit maxima may happen to be 2 . Where, as often happens,
patients take the decision to undergo an operation before they have
spoken to their anaesthetist, they should be advised to contact the
consultant anaesthetist if they wish to be told more about the fee
that will be charged.
3.2 The scope of the fee quoted by the consultant should be explained.
It may for example be a totalled fee for all the planned elements of
the expected treatment process, such as:
3.2.1 Routine pre-operative evaluation whether performed shortly
before surgery or some time in advance;
3.2.2 Intra-operative care, including payments to assistants or
consultant colleagues for services provided during the
treatment;
3.2.3 All drugs and equipment used in connection with the
procedure;
3.2.4 Invasive monitoring lines used before, during or after
surgery;
3.2.5 The performance of peripheral or neuraxial regional
anaesthetic or analgesic techniques supplementary to or in
place of general anaesthesia; and
1 A sample letter is provided in Appendix 1
2 If the consultant is prepared to accept whatever benefit the PMI offers for the procedure,
he need not warn the patient of his fee. If he does not warn the patient of the
fee, he should not demand that the patient pay any shortfall if the PMI benefit is less
than the fee charged.
4

3.2.6 Postoperative care, to include HDU and ICU care, and the
management of continuous neuraxial of peripheral analgesic
techniques.
3.3 If the fee quoted does not cover the totality of planned care, the
consultant should tell the patient and clearly describe the additional
fees that may be charged.
3.4 The patient should be warned that if the procedure and care differs
from that planned, the fee may also vary, but that this variation will
be fixed by the same means 3 . If any specific variations are envisaged
these should be described at least in outline and the fee scales
explained.
3.5 The consultant may choose to provide a separate estimate of HDU
or ICU fees. This is advisable where it is less likely that these costs
may be incurred.
3.6 The consultant should recommend that all patients check the
benefit levels that are available for the treatment under the policy
held with the PMI.
3.7 The patient should be told that he is ultimately responsible for the
payment of the fee or the payment of any shortfall.
3.8 The consultant may wish to ask the patient to sign a financial
agreement before the treatment in which the patient guarantees that
the consultant’s fee will be paid.
3.9 If the consultant chooses not to be paid directly by the PMI, the
patient should be told as long before the planned treatment as
possible.
3 If the fee for the planned procedure is, for instance, 125% of the benefit maximum
provided by the patient’s PMI, then the fee for the procedure actually performed
would be expected to be approximately 125% of the benefit maximum offered by
the PMI for the actual procedure performed.
5

3.10 The consultant should tell the patient if he knows that he is not
recognised for benefits by the patient’s PMI.
3.11 The consultant should keep a record of the fee quoted to the
patient.
3.12 It is acceptable for a consultant to request payment of fees in
advance of treatment under certain circumstances.
3.13 Sometimes fees are in fact negotiated by a third party on behalf
of the doctor. The fee set by the consultant anaesthetist may be
agreed with the patient by the surgeon or by the surgeon’s secretary
or other agent. Sometimes it will be by a hospital administrator.
Consultant anaesthetists must ensure that their agents have a clear,
complete and up-to-date list of their charges and that they make a
record of precisely what has been agreed.
3.14 Sometimes, particularly in emergencies or where there are
linguistic problems, the patient’s agreement will be given by an
accompanying relative or other agent acting on their behalf. In all
these circumstances it is vital to ensure that the representative has
the authority of the principal they represent. Parents and spouses
have ostensible authority to negotiate on behalf of their children
and partners; in all other cases the doctor will be wise to ensure that
there is a binding agreement with someone identifiable.
3.15 If separate charges are to be made by the consultant in respect of
anaesthetic agents, other drugs or equipment, he should ensure that
the patient appreciates this.
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4.0 During treatment
4.1 If the consultant surgeon and anaesthetist plan to use a coding
system, e.g. CCSD codes, when billing the patient, they should
agree the code or codes relating to the procedure or procedures
performed, and should ensure that members of the operating theatre
staff are informed of these codes.
4.2 In choosing codes, the consultants should agree upon the code or
codes that best describe the procedure or procedures performed,
bearing in mind that some codes are specifically constructed so as
to include the performance of more than one procedure. Consultants
should not break up the elements of a single surgical or anaesthetic
procedure into its constituent parts in order to maximise the benefit
provided to the patient by his PMI.
7

5.0 After treatment
5.1 Accounts 4 should be sent to the patient, the patient’s PMI or to
both 5 .
5.1.1 If the consultant agrees to set his fee within the PMI’s benefit
maxima, he can send an account only to the PMI if he so
wishes. Alternatively, he can send an account to the patient
and a copy to the PMI (or vice versa), making clear that he
has done so.
5.1.2 If the consultant’s fee is likely to be in excess of the PMI’s
benefit, he would be wise to send an account to the patient
and, if he so wishes, a copy to the PMI (or vice versa). He
should make clear to the patient whether he wishes the
patient to forward the account to the PMI or whether he has
sent a copy to the PMI.
5.1.3 If the patient does not hold private medical insurance or
if the consultant does not wish to be paid directly by the
PMI, the consultant should send an account to the patient
and should ask to be paid directly by the patient. Under
these circumstances, the consultant should offer to provide
the patient with a receipt so that the patient can then claim
benefits from his PMI if he has one.
5.1.4 If a consultant uses a billing service, he should consider
himself responsible for the fees charged in the bills sent on
his behalf and for the way in which the fees are collected.
5.2 Only one invoice (and copy if appropriate) should be sent for each
discrete treatment episode.
4 A sample invoice is provided in Appendix 2.
5 The AAGBI recommends that consultants always send the invoice to the patient. A
copy of the invoice may also be sent to insured patients’ PMIs.
8

5.6 Consultants are not obliged to put a CCSD code on their accounts,
unless they have entered into an agreement with the patient or his
PMI to do so, but may assist the patient if codes are included in the
account.
5.7 The consultant may include a descriptive narrative of the procedures
performed in the account in order to assist correct coding by the
PMI but should not do so in order to maximise benefit payment.
5.8 The consultant should not normally allocate portions of his fee to
particular codes or narratives. The fee should represent the whole
amount payable for the entire treatment episode.
5.9 The consultant may, if it has been specified as a term of the contract,
set a time limit for payment and should detail any penalties or
additional payments that will be incurred by late payment.
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6.0 Emergencies
6.1 Emergency treatment is more complex and carries more risk than
elective treatment. It also frequently takes longer than elective
treatment and is often more disruptive of the doctor’s life, being
conducted outside routine working hours. Thus the doctor will
frequently feel it is appropriate to charge a higher fee.
6.2 Some procedures specified by CCSD codes are always performed
as emergencies and the PMIs’ benefit maxima associated with those
procedures may take this into account.
6.3 Other procedures specified by CCSD codes are commonly
performed electively so that benefit maxima are less likely to cover
the fees consultants charge for acting in an emergency. Where the
consultant charges a higher fee because of some factor particular
to the case, such as the fact that it has been performed as an
emergency, then this should be made clear to assist the patient in
explaining the situation to the PMI.
6.4 The consultant should make every effort to warn the patient of
his fee in advance of surgery but this may not be possible in an
emergency, in which case the patient, or whoever has contracted
on their behalf, will have incurred a liability to meet a fee that is
reasonable in the circumstances.
6.5 The fee that will be reasonable in the circumstances will take into
account the issues mentioned in 6.1 above. If the patient cannot
be warned of the fee in advance of surgery, the fee that will be
reasonable in the circumstances will be based on the appropriate fee
for the equivalent elective procedure, with an additional proportion
added to the extent that the factors described in paragraph 6.1
arise.
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Appendix 1
PRO FORMA LETTER FROM SURGEON TO PATIENT IN ADVANCE OF SURGERY
Dear ,
I am writing to confirm that your admission has been arranged to the on at for surgery that afternoon. It is essential
you have nothing to eat after on the morning of admission. You may
drink clear fluids until and the ward staff will then advise on fluid
intake.
Mr ’s fee for
will be approximately £. In addition, the approximate fee for
the anaesthetist, Dr , will be £.
If you wish to make a claim from your medical insurance company, please
obtain a claim form, complete the subscriber’s section and give it to the
admissions officer on admission.
You are advised to check with your insurance company the level of your
cover and the exact allowances to which you are entitled under the terms and
conditions of your particular policy. Many insurance companies do settle the
surgeon’s and anaesthetist’s fees in full but in some cases a shortfall occurs.
Payment of any shortfall is your responsibility. If in doubt, I suggest that you
send a copy of this letter to your insurance company, asking them to send you
an agreement in writing as to of the above fees they will cover.
Yours sincerely,
Secretary to
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Appendix 2
EXAMPLE OF AN INVOICE
To Mr A Patient
Address
Dr H Featherstone FRCA
Consultant Anaesthetist
For Professional Services
At the John Snow Hospital on 29/2/2008
21 Portland Place
London W1B 1PY
Tel: 020 7631 1650
PMI Ref: HF 04786
Provider Ref: 152320
Procedure:
Ectomy and refashioning
CCSD Code: X2365
£325.00
Terms: payment within 30 days
Either: If you have insurance please forward this to your insurers
Or:
A copy of this invoice has been forwarded to your insurers
With compliments
12

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21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org