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Chapter 13 Reports

Anaesthetic Guidelines

Guidelines of the Association of Anaesthetists of Great Britain and Ireland

HIV and Other Blood Borne Viruses 1992

See ‘General topics’, p. 192.

Immediate Post-Anaesthetic Recovery 1993

Association of Anaesthetists of Great Britain and Ireland 1993

Basic recovery facilities

The patient should normally be placed in the left lateral position and transferred on to a tipping trolley to the recovery room. The recovery room should be fully staffed, available at all times and be able to give continuous individual nursing care to each patient. Handover should include pre-existing diseases, airway and cardiovascular problems, postoperative orders and analgesia.

Observations should include O2 administration and saturation, respiratory rate, heart rate, blood pressure, level of consciousness, pain and i.v. infusions.

Patients should not be discharged to the ward until they can maintain their own airway and have protective reflexes, cardiovascular and respiratory stability, adequate analgesia and are normothermic.

Day-case patients on discharge should be accompanied by a responsible adult, be given written advice on analgesia and hospital contact number, and be warned against drinking alcohol and operating machinery for at least 24 h.

Recovery room

Effective emergency call system, defibrillator and anaesthetic machine must be available in the recovery room. The room must be well lit with waste gas scavenging and temperature of 21–22°C. Children should be segregated from adults.

Each bay should contain an O2 source, breathing circuit (e.g. Mapleson C), pulse oximeter, ECG, suction and BP measuring equipment.

Each recovery trolley should contain an O2 cylinder, be capable of tipping head-down, have suction equipment and have padded cot sides.

Training of recovery staff

Minimum standards of training for recovery room staff.

Blood Borne Viruses and Anaesthesia – an Update 1996

See ‘General topics’, p. 193.

The Anaesthesia Team 1998

Association of Anaesthetists of Great Britain and Ireland, 1998

Recommendations

• A team-based approach to anaesthesia offers many advantages for the provision of a high-quality anaesthesia service.
• Pre-admission screening is a vital early component of pre-anaesthetic assessment. It reduces cancellations and promotes effective usage. It does not replace the need for the anaesthetist’s preoperative visit.
• Anaesthetists must have dedicated, skilled assistance wherever anaesthesia is administered.
• Recovery areas must have trained staff available throughout all operating hours and until the last patient meets all the criteria for discharge.
• All acute hospitals providing in-patient surgical services must have an acute pain team led by a consultant anaesthetist.

Anaesthesia and Perioperative Care of the Elderly 2001

See ‘Anaesthesia for the elderly’, p. 153.

Preoperative Assessment. The Role of the Anaesthetist 2001

See ‘Preoperative assessment’, p. 216.

Provision of Anaesthetic Services in Magnetic Resonance Units 2002

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 anaesthetized 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 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 minimize the risk of personal exposure to strong magnetic fields and noise levels.

Post-Anaesthetic Recovery 2002

See ‘Post-Anaesthetic Recovery’, p. 211.

Checking Anaesthetic Equipment 2004 (3E)

See ‘Anaesthetic equipment’, p. 399.

Day Surgery – Revised Edition 2005

See ‘Day surgery’, p. 184.

Recommendations for the Safe Transfer of Patients With Brain Injury 2006

See ‘Neuroanaesthesia’, p. 83.

Consent for Anaesthesia 2006

Recommendations

• Information about anaesthesia, preferably in the form of a patient-friendly leaflet, should be provided to patients undergoing elective surgery before they meet their anaesthetist.
• The anaesthetic room immediately before induction is not an acceptable place or time to provide elective patients with new information other than in exceptional circumstances.
• The amount and the nature of information that should be disclosed to the patient should be determined by the question: ‘What would this patient regard as relevant when coming to a decision about which of the available options to accept?’
• 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.
• Anaesthetists should record details of the elements of a discussion in the patient record, noting what risks, benefits and alternatives were explained.
• A separate formal consent form signed by the patient is not required for anaesthetic procedures that are done to facilitate another treatment or as part of an inter-related process.
• Adults should be presumed to have capacity to consent unless there is contrary evidence.
• The Mental Capacity Act 2005 (MCA) allows patients without capacity to express their previously-determined wishes by means of an Advance Decision or by means of a proxy using a Lasting Power of Attorney.
• When planning to allow trainees or others to use an opportunity presented by a patient for training in practical procedures, the anaesthetist should make every effort to minimize risk and maximize 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.

Recommendations for Standards of Monitoring During Anaesthesia and Recovery 2007 (4E)

See ‘Monitoring’, p. 410.

Guidelines for the Management of a Malignant Hyperthermia Crisis 2007

See ‘Malignant hyperthermia’, p. 131.

Perioperative Management of the Morbidly Obese Patient 2007

See ‘Anaesthesia for the morbidly obese patient’, p. 137.

Guidelines for the Management of Severe Local Anaesthetic Toxicity 2007

See ‘Pharmacology’, p. 380.

Suspected Anaphylactic Reactions Associated With Anaesthesia 2009 (4E)

See ‘Anaphylactic reactions’, p. 158.

Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting 2004

Royal College of Anaesthetists & Association of Anaesthetists of Great Britain & Ireland (www.aagbi.org/publications/guidelines/docs/epidanalg04.pdf)

See ‘Pain’, p. 355.

OAA/AAGBI Guidelines for Obstetric Anaesthesia Services 2005

Association of Anaesthetics of Great Britain and Ireland and the Obstetric Anaesthetists Association. Revised Guidelines

See ‘Obstetrics’, p. 302.

Management of Anaesthesia for Jehovah’s Witnesses 2005 (2E)

See ‘Blood’, p. 170.

Blood Transfusion and the Anaesthetist – Blood Component Therapy 2005

See ‘Blood’, p. 166.

Blood Transfusion and the Anaesthetist – Red Cell Transfusion 2008

See ‘Blood’, p. 166.

Infection Control in Anaesthesia 2008

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 utilized 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.

Blood Transfusion and the Anaesthetist – Intraoperative Cell Salvage 2009

See ‘Blood’, p. 167.

National Institute for Health and Clinical Excellence Guidelines

Guidance on the Use of Ultrasound Locating Devices for Placing Central Venous Catheters 2002

(www.nice.org.uk/nicemedia/pdf/49_English_patient.pdf)

Summary

• 2-D imaging ultrasound guidance should be the preferred method when inserting of central venous catheter into the internal jugular vein in adults and children in ‘elective situations’.
• 2-D imaging ultrasound guidance should be considered in most clinical situations where CVC insertion is necessary, whether the situation is elective or an emergency
• Everyone who uses 2-D imaging ultrasound guidance to insert central venous catheters should have appropriate training to ensure they are competent to use the technique.
• Audio-guided Doppler ultrasound guidance is not recommended for use when inserting central venous catheters.

Obesity – Guidance on the Prevention, Identification, Assessment and Management of Overweight and Obesity In Adults And Children 2006

(www.nice.org.uk/CG043)

See ‘Anaesthesia for the obese patient’, p. 138.

Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital 2007

(www.nice.org.uk/nicemedia/pdf/CG50QuickRefGuide.pdf)

See ‘Intensive Care’, p. 252.

Atrial Fibrillation: the Management of Atrial Fibrillation 2006

(www.nice.org.uk/CG036NICEguideline)

See ‘Cardiovascular system’, p. 9.

Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures 2008

(www.nice.org.uk/nicemedia/pdf/CG64PIEQRG.pdf)

See ‘Cardiovascular system’, p. 12.

Ultrasound-Guided Regional Nerve Block 2009

(www.nice.org.uk/Guidance/IPG285)

Summary

• Current evidence on the safety and efficacy of ultrasound-guided regional nerve block appears adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit.
• Clinicians wishing to perform this procedure should be experienced in the administration of regional nerve blocks and trained in ultrasound guidance techniques.

Ultrasound-Guided Catheterization of the Epidural Space 2008

(www.nice.org.uk/nicemedia/pdf/IPG249Guidance.pdf)

See ‘Pain’, p. 354.

Intraoperative Blood Cell Salvage in Obstetrics 2005

(www.nice.org.uk/IPG144distributionlist)

See ‘Obstetrics’, p. 307.

Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults 2007

(www.nice.org.uk/nicemedia/pdf/CG56QuickRedGuide.pdf)

See ‘Trauma’, p. 240.

Venous Thromboembolism: Reducing the Risk 2010

http://guidance.nice.org.uk/CG92)

See ‘Anaesthesia for orthopaedic surgery’, p. 107.

Intraoperative Nerve Monitoring During Thyroid Surgery 2008

(www.nice.org.uk/nicemedia/pdf/IPG255Guidance.pdf)

See ‘Thyroid disease’, p. 125.

Inadvertent Perioperative Hypothermia 2008

(www.nice.org.uk/nicemedia/pdf/CG65Guidance.pdf)

See ‘Thermoregulation’, p. 148.

Other guidelines

Local Anaesthesia for Intraocular Surgery

Royal College of Anaesthetists and Royal College of Ophthalmologists 2001

See ‘Anaesthesia for ophthalmic surgery’, p. 102.

Guidelines for Autologous Blood Transfusion

British Committee for Standards in Haematology Blood Transfusion Task Force 1997

See ‘Blood’, p. 165.

Guidelines on Post-Exposure Prophylaxis (PEP) for Health Care Workers Occupationally Exposed to HIV

Department of Health 1997 (www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4072980.pdf)

See ‘Human immunodeficiency virus’, p. 191.

Cadaveric Organs for Transplantation. A Code of Practice for the Diagnosis of Brain Stem Death

Department of Health 1998 (www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4011718.pdf)

See ‘Organ donation and transplantation’, p. 204.

Standards and Guidelines for General Anaesthesia for Dentistry

Royal College of Anaesthetists 1999

See ‘Dental anaesthesia’, p. 88.

Guidelines for the Prevention of Endocarditis

Report of the Working Party of the British Society for Antimicrobial Chemotherapy 2006 (http://jac.oxfordjournals.org/cgi/reprint/dkl121v1)

See ‘Cardiovascular system’, p. 13.

Guidelines on the Prevention of Postoperative Vomiting (POV) in Children

The Association of Paediatric Anaesthetists of Great Britain and Ireland 2007 (www.apagbi.org.uk/docs)

See ‘Paediatrics’, p. 319.

Consensus Guideline on Perioperative Fluid Management in Children V 1.1

Association of Paediatric Anaesthetists of Great Britain and Ireland 2007 (www.apagbi.org.uk/docs/Perioperative_Fluid_Management_2007.pdf)

See ‘Paediatrics’, p. 314.

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 2008

(www.ics.ac.uk/ downloads/2008112340_GIFTASUP\%20FINAL_31-10-08.pdf)

See ‘Intensive care’, p. 265.

British Thoracic Society Guideline for Emergency Oxygen Use in Adult Patients 2008

See ‘Oxygen’, p. 364.

British Guideline on the Management of Asthma

British Thoracic Society and Scottish Intercollegiate Guidelines Network 2009 (www.brit-thoracic.org.uk/ClinicalInformation/Asthma/AsthmaGuidelines/tabid/83/Default.aspx)

See ‘Anaesthesia for asthmatics’, p. 49.

Bibliography

Association of Anaesthetists of Great Britain and Ireland. Checklist for anaesthetic machines. London: AAGBI; 1990.

Association of Anaesthetists of Great Britain and Ireland. HIV and other blood borne viruses – guidance for anaesthetists. London: AAGBI; 1992.

Association of Anaesthetists of Great Britain and Ireland. Immediate postanaesthetic recovery. London: AAGBI; 1993.

Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring during anaesthesia and recovery, 4th ed. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2007.

Association of Anaesthetists of Great Britain and Ireland. Peri-Operative Management of the Morbidly Obese Patient. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2007.

Infection control in anaesthesia. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland, 2008.

Association of Anaesthetists of Great Britain and Ireland. Recommendations for the safe transfer of patients with brain injury. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2006.

Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and the anaesthetist – red cell transfusion. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2008.

Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and the anaesthetist – blood component therapy. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2005.

Association of Anaesthetists of Great Britain and Ireland. Post-anaesthetic recovery. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2002.

Association of Anaesthetists of Great Britain and Ireland and the British Society of Allergy and Clinical Immunology. Revised guidelines. Suspected anaphylactic reactions associated with anaesthesia. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 4th ed., 2009.

Association of Anaesthetists of Great Britain and Ireland. A report received by Council of the Association of Anaesthetists on blood borne viruses and anaesthesia – an update. London: AAGBI; 1996.

Association of Anaesthetists of Great Britain and Ireland. Checking anaesthetic equipment 3. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2004.

Consent for anaesthesia. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland, 2006.

Association of Anaesthetists of Great Britain and Ireland. Guidelines for the management of a malignant hyperthermia crisis. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2007.

Association of Anaesthetists of Great Britain and Ireland. Pre-operative assessment. The role of the anaesthetist. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2001.

Association of Anaesthetists of Great Britain and Ireland. The anaesthesia team. London: AAGBI; 1998.

Association of Anaesthetists of Great Britain and Ireland. Management of anaesthesia for Jehovah’s witnesses, 2nd ed. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2005.

Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists Association. Revised Guidelines, OAA/AAGBI guidelines for obstetric anaesthesia services. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2005.

Association of Anaesthetists of Great Britain and Ireland. Peri-Operative Management of the Morbidly Obese Patient. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2007.

Association of Anaesthetists of Great Britain and Ireland. Peri-Operative Management of the Morbidly Obese Patient. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland; 2007.

Association of Anaesthetists of Great Britain and Ireland: Immediate postanesthetic recovery. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland, 1993.

The anaesthesia team, 1998. Reproduced with the kind permission of the Association of anaesthetics of Great Britain and Ireland. www.aagbi.org/publications/guidelines/docs/epidanalg04.pdf. Reproduced with the kind permission of the Association of anaesthetists of Great Britain and Ireland.

British Committee for Standards in Haematology Blood Transfusion Task Force: Autologous Transfusion Working Party, Napier J.A., Bruce M., Chapman J., et al. Guidelines for autologous transfusion. II. Perioperative haemodilution and cell salvage. Br J Anaesth. 1997;78:768-771.

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients, 2008 http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf.

British National Formulary. Infective endocarditis prophylaxis. British National Formulary. 37(5.1), 1999.

Department of Health. A code of practice for the diagnosis of brain stem death including guidelines for the identification and management of potential organ and tissue donors. London: HMSO; 1998.

Department of Health. Guidelines on post-exposure prophylaxis (PEP) for health care workers occupationally exposed to HIV, 1997 www.dh.gov.uk/en/PublicationsAndStatistics/LettersAndCirculars/ProfessionalLetters/ChiefOfficerLetters/DH_4004143.

Neuroanaesthesia Society of Great Britain and Ireland and the Association of Anaesthetists of Great Britain and Ireland. Recommendations for the transfer of patients with acute head injuries to neurosurgical units. London: NSGBI/AAGBI; 1996.

NICE. Guidance on the use of ultrasound locating devices for placing central venous catheters, 2002 http://guidance.nice.org.uk/TA49/Guidance/pdf/English.

NICE. Atrial fibrillation: the management of atrial fibrillation. London: National Institute for Health and Clinical Excellence; 2006. 2006 www.nice.org.uk/CG036NICEguideline

NICE. Obesity – Guidance on the prevention, identification, assessment and manage-ment of overweight and obesity in adults and children. London: National Institute for Health and Clinical Excellence; 2006. 2006 www.nice.org.uk/CG043

NICE. Ultrasound guided catheterisation of the epidural space, 2008 http://guidance.nice.org.uk/IPG249/Guidance/pdf/English.

NICE. Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London: National Institute for Health and Clinical Excellence; 2008. 2008 www.nice.org.uk/nicemedia/pdf/CG64PIEQRG.pdf

NICE. Inadvertent perioperative hypothermia. NICE clinical guideline, 2008 www.nice.org.uk/CG065.

NICE. Ultrasound guided regional nerve block. London: National Institute for Health and Clinical Excellence; 2009. 2009 http://guidance.nice.org.uk/IPG285/PublicInfo/pdf/English

O’Driscoll B.R., Howard L.S., Davison A.G. on behalf of the: British Thoracic Society: British Thoracic Society guideline for emergency oxygen use in adult patients. Thorax. 2008;63(Suppl VI):vi1-vi68.

Royal College of Anaesthetists & Association of Anaesthetist of Great Britain & Ireland. Good practice in the management of continuous epidural analgesia in the hospital setting, 2004 www.aagbi.org/publications/guidelines/docs/epidanalg04.pdf.

Royal College of Anaesthetists. Sedation and anaesthesia in radiology. In Report of a Joint Working Party. London: RCA; 1992.

Royal College of Anaesthetists and College of Ophthalmologists. Report of the Joint Working Party on Anaesthesia in Ophthalmic Surgery. London: RCA and Co, 1993.

Royal College of Anaesthetists. Standards and guidelines for general anaesthesia and dentistry. London: RCA; 1999.

Royal College of Radiologists. Making the best use of a department of clinical radiology. Guidelines for doctors, 3. RCR, London, 1995.

National confidential enquiries into perioperative deaths (NCEPOD)

CEPOD was established in 1988 to review surgical and anaesthetic practice in the UK. The first report covered three areas, but it has been a national report (NCEPOD) since 1989. It involves all NHS and most private hospitals. The reports are anonymous and confidential and are peer-reviewed by consultants representing the medical colleges.

CEPOD 1987

Covered three areas (i.e. not national): N.E. Thames Health Authority (HA), Northern HA and South Western HA.

Recommendations

• Need for national assessment of clinical practice
• No SHO/registrar should undertake any emergency case without consultation with their consultant/SR
• Resources should be concentrated on a single site
• Neurological and neonatal surgery should be performed in specialist units
• Patients must be adequately resuscitated preoperatively if possible
• Moribund patients should be allowed to die with dignity.

NCEPOD 1989 – Children

Involved all hospitals, i.e. first national CEPOD. Covered deaths in children ≤10 years occurring within 30 days of surgery, of which there were 115 non-cardiac deaths and 160 cardiac deaths.

Recommendations

• Anaesthetists should not undertake occasional paediatric anaesthesia
• No trainee should anaesthetize a child without discussion with the consultant
• Neonates should be transferred to a paediatric centre.

NCEPOD 1990 – Deaths

Random sample of 20% of adult postoperative deaths; 19 000 deaths, mostly within 5 days of surgery; 59% of anaesthetists were working without assistance.

Recommendations

• All essential services should be on one site
• Surgeon and anaesthetist should be in agreement about need for surgery
• Proper pain relief needs a high-dependency unit
• Provision of daytime emergency theatre is needed to prevent delays
• All grades of anaesthetist should be involved in audit and continuing education.

NCEPOD 1991/2 – Specific Procedures

Reviewed 15 specific surgical procedures from all specialities.

Recommendations

• Surgical and anaesthetic skills should be more matched to the condition of the patient
• 42% of deaths after total hip replacement were found to have a pulmonary embolus. Therefore a local policy on prophylaxis must be determined and followed
• Some patients with GI obstruction had no NG tube, resulting in aspiration
• Stresses importance of fluid balance in the elderly
• Patients about to die should not be subjected to surgery
• Capnography and ventilator disconnect alarms are underused.

NCEPOD 1992/3

Reviewed 19 816 deaths in patients aged 6–70 years.

Recommendations

• Trainees with less than 3 years’ training should not anaesthetize without appropriate supervision
• Practitioners should recognize their limitations and not hesitate to consult a more experienced colleague
• The skills of the anaesthetist and surgeon should be appropriate for the physiological and pathological status of the patient
• Appropriately trained staff must accompany all patients with life-threatening conditions during transfer between and within hospitals
• The medical profession must develop and enforce standards of practice for the management of many common acute conditions (e.g. head injury, aortic aneurysm, GI bleeding).

NCEPOD 1993/4 – Postoperative Deaths

Reviewed one death per consultant surgeon or gynaecologist.

Recommendations

• Surgical operations should not be started in hospitals without appropriate critical care services
• Anaesthetist must have appropriately skilled and dedicated non-medical assistants
• Consultation between surgeons and anaesthetists needs to be more frequent in order to promote a team approach
• The use of protocols in the management of certain clinical conditions needs to be increased.

NCEPOD 1994/5 – Postoperative Deaths

Reviewed 1818 deaths within 3 days of surgery.

Recommendations

• High-dependency and ICU beds are still inadequate and resources need to be increased to correct deficiencies
• Communication between specialists and between grades needs to be more frequent and more effective
• Patients >90 years of age, those with aortic stenosis, those who need radical pelvic surgery and those in for emergency vascular operations require individual attention by consultant anaesthetists and consultant surgeons
• Clinical records and data collection need to be improved.

NCEPOD 1995/6 – Out-of-Hours Operating

Reviewed 53 162 ‘out-of-hours’ cases performed over a period equal to 1 week’s work for each participating hospital.

Key points

• Decision-making – too many decisions were taken by juniors; the decision to operate should be made by consultants
• Preoperative management – guidance from experienced staff was needed, including preoperative ICU admission if necessary
• Management of intravenous fluids – was sometimes poor
• Records and charts – were often poorly kept.

Recommendations

• All hospitals admitting emergency surgical patients must be of sufficient size to provide 24-hour operating rooms. There should also be sufficient medical staff to perform these functions
• These provisions should be continuous throughout the year: trauma and acute surgical emergencies do not recognize weekends or public holidays
• Patients expect to be treated and managed by trained and competent staff. Patients assume trainees to be taught appropriately and supervised as necessary. Consultants should acknowledge these facts and react accordingly.

NCEPOD 1996/7 – Specific Surgical Procedures

Reviewed 2541 deaths following specific surgical operations.

Recommendations

Obstructed airway in head and neck surgery. Management should be planned between surgical and anaesthetic staff. Awake fibreoptic intubation and tracheostomy using LA should be considered among the options. A fibreoptic intubating laryngoscope should be readily available for use in all surgical hospitals.

Anaesthesia for carotid endarterectomy. Invasive arterial pressure monitoring should be routine and perioperative BP control needs to be excellent.

Oesophageal surgery. Preoperative resuscitation was often inadequate. One-lung ventilation should be performed by anaesthetists with appropriate experience in the technique. Attention to postoperative respiratory care is essential to achieve a good outcome.

CVP monitoring during anaesthesia and surgery. May be indicated for patients with acute or chronic medical conditions. CVP is a core anaesthetic skill that needs regular practice.

Non-steroidal anti-inflammatory drugs. Must be used with caution in patients with renal impairment, hypertension and cardiac failure, GI ulceration and asthma.

Other recommendations. Morbidity/mortality meetings should take place in all anaesthetic departments. Surgeons need to recognize the limits of surgical procedures; a decision to operate may not be in the best interests of the patient.

NCEPOD 1997/8 – Deaths at the Extremes of Age

Reviewed 19 643 deaths occurring within 30 days of surgery in children (≤15 years) and elderly (≥90 years).

Recommendations: Paediatric surgery

• Anaesthetic and surgical trainees need to know when they must inform their consultants before undertaking any paediatric procedures
• The death of any child within 30 days of surgery should be subjected to peer review
• The concentration of paediatric surgical services would increase expertise and reduce occasional practice.

Recommendations: Surgery for the elderly

• Fluid management is often poor and should be accorded the same status as drug prescription. Multidisciplinary reviews to develop good working practices are required
• A team of senior physicians, surgeons and anaesthetists need to be closely involved with these patients who have poor physical status and high intraoperative risk
• Pain management must be provided by those with appropriate specialized experience
• The decision to operate must be accompanied by a decision to provide appropriate postoperative care
• No elderly patient requiring an urgent operation, once fit for surgery, should wait more than 24 hours.

NCEPOD 1998/9 – One in Ten Sample of Death

Will allow comparison with the 1992 NCEPOD report which considered one in five deaths. Will be available on NCEPOD website (www.ncepod.org.uk).

Bibliography

Buck N., Devlin H.B., Lunn J.N. The Report of a Confidential Enquiry into Perioperative Deaths. London: Nuffield Provincial Hospitals Trust and the King Edward’s Hospital Fund for London; 1987.

Callum K.G., Gray A.J.G., Hoile R.W., et al. Extremes of Age: The Report of the National Confidential Enquiry into Perioperative Deaths 1999. London: NCEPOD; 1999.

Campling E.A., Devlin H.B., Lunn J.N. The Report of the National Confidential Enquiry into Perioperative Deaths 1989. London: NCEPOD; 1990.

Campling E.A., Devlin H.B., Hoile R.W., et al. The Report of the National Confidential Enquiry into Perioperative Deaths 1990. London: NCEPOD; 1992.

Campling E.A., Devlin H.B., Hoile R.W., et al. The Report of the National Confidential Enquiry into Perioperative Deaths 1991/2. London: NCEPOD; 1993.

Campling E.A., Devlin H.B., Hoile R.W., et al. The Report of the National Confidential Enquiry into Perioperative Deaths 1992/3. London: NCEPOD; 1995.

Campling E.A., Devlin H.B., Hoile R.W., et al. The Report of the National Confidential Enquiry into Perioperative Deaths 1995/6. London: NCEPOD; 1997.

Gallimore S.C., Hoile R.W., Ingram G.S., et al. The Report of the National Confidential Enquiry into Perioperative Deaths 1994/5. London: NCEPOD; 1997.

Gray A.J.G., Hoile R.W., Ingram G.S., et al. The Report of the National Confidential Enquiry into Perioperative Deaths 1996/7. London: NCEPOD; 1998.

Lunn J.N., Devlin H.B., Hoile R.W. The Report of the National Confidential Enquiry into Perioperative Deaths 1993/4. London: NCEPOD; 1996.

Summary of the revised guidelines for the management of massive obstetric haemorrhage

Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994

• Summon all the extra staff required, particularly the duty anaesthetic registrar
• Inform haematology and blood transfusion
• Take blood for cross-matching and coagulation studies. Order a minimum of 6 units, only using group O Rh D-negative blood if transfusion must be given immediately. Use of packed cells requires additional colloid (gelatins or hydroxyethylstarch solutions, not dextrans) once >40% blood volume is lost
• Insert at least two 14G intravenous cannulae. CVP measurement should be continuously displayed and invasive BP is extremely useful
• Perform regular Hb, platelet and coagulation studies. Restoring normovolaemia is a priority. Consider FFP, cryoprecipitate and platelets
• Pressure bags ensure rapid fluid administration. Blood filters are rarely necessary and slow down infusion rates. Administer all fluids, and in particular blood, through a blood warmer
• Additional calcium is only necessary if there is evidence of Ca2+ deficiency. Use 10% calcium chloride in preference to gluconate
• Regular monitoring of pulse, BP, CVP, blood gases and urinary output. Consider early transfer to an intensive care unit.

Summary of Guidelines for the Treatment of Obstetric Haemorrhage in Women Who Refuse Blood Transfusion

Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1996

• Mostly Jehovah’s Witnesses, of which there are 125 000 in the UK
• Massive obstetric haemorrhage may occur rapidly, and in patients who may refuse blood transfusion, the management of massive haemorrhage should be considered in advance
• Patients who refuse blood transfusions should be managed in a unit which has facilities for prompt management of haemorrhage, including hysterectomy
• Hb and ferritin should be monitored closely during pregnancy and haematinics used throughout pregnancy to maximize iron stores. Donation of blood for subsequent autotransfusion is inappropriate, because the amount of blood required to treat massive obstetric haemorrhage is far in excess of the amount that could be donated during pregnancy
• Extra vigilance is required in managing these patients, to detect early bleeding and clotting abnormalities. Prompt and early intervention is necessary, particularly with regard to surgery
• The consultant anaesthetist and haematologist should be informed as soon as abnormal bleeding has been detected
• Dextrans should be avoided for fluid replacement because of their possible effects on haemostasis. Intravenous crystalloid and plasma expanders such as Haemaccel should be used. Intravenous vitamin K should be given if bleeding is severe. Desmopressin, methylprednisolone and fibrinolytic inhibitors such as aprotinin and tranexamic acid should be considered
• The use of hyperbaric oxygen therapy has enabled survival with a haemoglobin concentration of 2.6 g/dl, although it is recognized that it is unrealistic to book women only where this facility is available
• If the patient refuses to accept blood or blood products, her wishes must be respected. Any adult patient (over 18 years old) who has the necessary mental capacity to do so is entitled to refuse treatment, even if the refusal is likely to result in death
• If the woman survives the acute episode, erythropoietin, parenteral iron therapy and adequate protein for haemoglobin synthesis should be given.

Reports on confidential enquiries into maternal and child health

Definitions of maternal deaths

Maternal deaths. Deaths of women while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not accidental or incidental causes.

Direct. Deaths resulting from obstetric complications of the pregnant state, from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.

Indirect. Deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.

Table 13.1 Direct deaths attributed to anaesthesia – United Kingdom: 1985–2005

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Figure 13.1 Percentage of direct deaths assessed as having substandard care by cause of death—United Kingdom: 2003–2005.

Why Mothers Die 2000–2002

Confidential Enquiries into Maternal and Child Health (CEMACH) 2005

There were 261 maternal deaths in 2000–2002, of which seven were directly attributable to anaesthesia and a further 20 in which perioperative/anaesthesia management contributed to the death.

Key recommendations:

Service provision

Dedicated obstetric anaesthesia services should be available in all consultant obstetric units to provide high dependency care, epidural analgesia, anaesthesia and postoperative recovery. Difficult cases requiring special skills may require the assistance of anaesthetic colleagues in other subspecialties, as well as colleagues in other disciplines.

Anaesthesia training must ensure competence in airway management, especially the recognition and management of oesophageal intubation.

Obese pregnant women (BMI >35) are at greater risk from anaesthesia and should be referred to the anaesthetist early.

Supportive counselling of anaesthetic personnel involved in a maternal death is essential.

Individual practitioners

Invasive monitoring should be used, particularly in the presence of haemodynamic instability (e.g. haemorrhage). Samples for arterial blood gas estimation should be taken early and any metabolic acidosis should be taken seriously.

Care of women at high risk of, or with, major haemorrhage must involve a consultant obstetric anaesthetist at the earliest possible time. Early critical are referral and early institution of intensive therapy should be considered where appropriate.

Women with suspected raised intracranial pressure require expert neurological assessment and consultant with all appropriate specialties to determine the optimal mode of delivery.

Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer 2003–2005

Confidential Enquiries into Maternal and Child Health (CEMACH) 2007

There were 150 maternal deaths in 2003–2005, of which six were directly attributable to anaesthesia and a further 31 in which perioperative/anaesthesia management contributed to the death.

Learning points:

Management of obstetric haemorrhage. Women with placenta praevia who have had a previous caesarean section are at risk of massive haemorrhage and should be managed in units with immediate access to blood transfusion and intensive care. These cases require consultant anaesthetist involvement.

The earlier recognition of hypovolaemia would be helped by the routine use of an early warning score system. Blood pressure parameters may need adjusting in patients with pregnancy-induced hypertension. Where there is a possibility of bleeding, a near-patient method of haemoglobin estimation may be life-saving and should be available in all obstetric units.

High volume infusions of intravenous fluid must be warmed beforehand. Women who are being resuscitated should be insulated and actively warmed. Hypothermia at temperatures <33.8°C produces a significant coagulopathy, despite the presence of normal clotting factor levels. In the situation of hypothermia and dilutional coagulopathy, both rewarming and administration of coagulation factors are required. If tachycardia persists after intraoperative haemorrhage, the woman must remain in theatre until both surgeon and anaesthetist are satisfied that her condition is stable. Invasive monitoring should be used when the cardiovascular system is compromised by haemorrhage or disease.

Uterine atony may be prevented by slow i.v. syntocinon. However, syntocinon causes hypotension, particularly in the hypovolaemic patient when it should be given slowly.

Anaesthesia and sepsis. Cardiovascular collapse can happen suddenly in septic patients. Circulatory support requires invasive monitoring and careful fluid resuscitation in a Critical Care unit or operating theatre environment.

Anaesthesia and obesity. All obstetric units should develop protocols for the management of morbidly obese women. These should include pre-assessment clinics, special ward and theatre equipment such as large blood pressure cuffs, beds and operating tables and long regional block needles. Management by consultant anaesthetists is essential and difficulties with airway management and intubation should be anticipated. Invasive arterial blood pressure measurement should be considered in morbidly obese women where NIBP is often inaccurate. All morbidly obese women in childbirth should be given prophylactic low molecular weight heparin.

Bibliography

Confidential Enquiries into Maternal and Child Health (CEMACH). Why mothers die 2000–2002. The 6th Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, 2005. December www.cemach.org.uk

Confidential Enquiries into Maternal and Child Health (CEMACH). Saving mothers’ lives: Reviewing maternal deaths to make motherhood safer 2003–2005. The 7th Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, 2007. December www.cemach.org.uk

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