Guidance on the provision of anaesthesia services for trauma and orthopaedic surgery

37 Pages·2017·0.75 MB·English

Version number: v3 Last updated by: Jeremy
Date: 15/01/2018 This version updated by: Nicola
Guidelines for the Provision of Anaesthesia Services for Trauma
and Orthopaedic surgery
Authors
Dr Andrew Lindley Dr Baskar Manickam
Consultant Anaesthetist Consultant Anaesthetist
Leeds Teaching Hospital NHS Trust Darlington Memorial Hospital
Leeds Durham

Dr Iosifina Karmaniolou
Consultant Anaesthetist
Guy's and St Thomas' NHS Foundation
Trust
London
Chapter Development Group Members
Dr Barry Nicholls Dr Mahesh Kumar
Consultant Anaesthetist Consultant Anaesthetist
Taunton and Somerset NHS Foundation University of Morecambe Bay Trust
Trust Morecambe Bay, UK
Taunton, UK

Dr John McKenna Dr Rosie Hogg
Consultant Anaesthetist Consultant Anaesthetist
Royal London Hospital Belfast City Hospital
London, UK Belfast, UK

Dr Tal Heymann Mr Les Scott
Senior Management and Leadership Lay representative
Fellow Royal College of Anaesthetists Lay
Princess Alexandra Hospital Committee
Harlow, UK

Dr Clifford Shelton Dr Laura Beard
NIHR Doctoral Research Fellow and ST6 Trainee Anaesthetist
Trainee Anaesthetist Birmingham School Anaesthesia
Lancaster Medical School and
Wythenshawe Hospital

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Dr Marc Lyons Mr Markku Viherlaiho
Trainee Anaesthetist Senior Anaesthetic and Recovery Nurse
Edinburgh, UK British Anaesthetic & Recovery Nurses
Association
Dr Emma Stiby
Associate Specialist Anaesthetist
Musgrave Park Hospital
Belfast, UK
Acknowledgements
Peer Reviewers
Mr Joseph Aderinto Dr Rashmi Menon
Consultant Orthopedic Surgeon Consultant Anaesthetist
Leeds Teaching Hospital NHS Trust Leeds Teaching Hospital NHS Trust
Leeds, UK Leeds, UK

Chapter Development Technical Team
Dr Rachel Evley Ms Ruth Nichols
Research Fellow Royal College of Anaesthetists
University of Nottingham

Miss Nicola Hancock Ms Carly Melbourne
Project Co-ordinator (Mar 2017-) Royal College of Anaesthetists
Royal College of Anaesthetists
Declarations of Interest
0 All chapter development group members, stakeholders and external peer reviewers
1 were asked to declare any pecuniary or non-pecuniary conflict of interest, in line
2 with the GPAS conflict of interest policy as described in the GPAS Chapter
3 Development Process Document.
4
5 The nature of the involvement in all declarations made was not determined as being
6 a risk to the transparency or impartiality of the chapter development. Where a
7 member was conflicted in relation to a particular piece of evidence, they were
8 asked to declare this and then if necessary removed themselves from the discussion
9 of that particular piece of evidence and any recommendation pertaining to it.
10 Medico-legal implications of GPAS guidelines
11 GPAS guidelines are not intended to be construed or to serve as a standard of
12 clinical care. Standards of care are determined on the basis of all clinical data
13 available for an individual case and are subject to change as scientific knowledge
14 and technology advance and patterns of care evolve. Adherence to guideline
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15 recommendations will not ensure successful outcome in every case, nor should they
16 be construed as including all proper methods of care or excluding other
17 acceptable methods of care aimed at the same results. The ultimate judgement
18 must be made by the appropriate healthcare professional(s) responsible for clinical
19 decisions regarding a particular clinical procedure or treatment plan. This
20 judgement should only be arrived at following discussion of the options with the
21 patient, covering the diagnostic and treatment choices available. It is advised,
22 however, that significant departures from the national guideline or any local
23 guidelines derived from it should be fully documented in the patient’s case notes at
24 the time the relevant decision is taken.
25 Promoting equality and addressing health inequalities
26 The Royal College of Anaesthetists is committed to promoting equality and
27 addressing health inequalities. Throughout the development of these guidelines we
28 have:
29  Given due regard to the need to eliminate discrimination, harassment and
30 victimisation, to advance equality of opportunity, and to foster good relations
31 between people who share a relevant protected characteristic (as cited
32 under the Equality Act 2010) and those who do not share it; and
33  Given regard to the need to reduce inequalities between patients in access
34 to, and outcomes from healthcare services and to ensure services are
35 provided in an integrated way where this might reduce health inequalities.
36 GPAS guidelines in context
37 The Guidelines for the Provision of Anaesthetic Services (GPAS) documents should be
38 viewed as ‘living documents’. The GPAS Guidelines development, implementation
39 and review should be seen not as a linear process, but as a cycle of interdependent
40 activities. These in turn are part of a range of activities to translate evidence into
41 practice, set standards and promote clinical excellence in patient care.
42 Each of the GPAS chapters should be seen as independent but interlinked
43 documents. Guidelines on the general provision of anaesthetic services are detailed
44 in the following chapters of GPAS:
45  Chapter 2: Guidance on the provision of anaesthesia services for pre-
46 operative assessment and preparation
47  Chapter 3: Guidance on the provision of anaesthesia services for intra-
48 operative care
49  Chapter 4: Guidance on the provision of anaesthesia services for
50 postoperative care
51 These guidelines apply to all patients who require anaesthesia or sedation, and are
52 under the care of an anaesthetist. For urgent or immediate emergency
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53 interventions, this guidance may need to be modified as described in GPAS Chapter
54 5: Guidance on the provision of emergency anaesthesia services.
55 The rest of the chapters of GPAS apply only to the population groups and settings
56 outlined in the Scope section of these chapters. They outline guidance that is
57 additional, different or particularly important to those population groups and settings
58 included in the Scope. Unless otherwise stated within the chapter, the
59 recommendations outlined in GPAS Chapters 2–5 still apply.
60 Each chapter will undergo yearly review, and will be continuously updated in the
61 light of new evidence.
62 Guidelines alone will not result in better treatment and care for patients. Local and
63 national implementation is crucial for changes in practice necessary for
64 improvements in treatment and patient care.
65 Aims and Objectives
66 The objective of this chapter is to promote current best practice for service provision
67 in anaesthesia services for trauma and orthopaedic surgery. The guidance is
68 intended for use by anaesthetists with responsibilities for service delivery and
69 healthcare managers.
70 This guideline does not comprehensively describe clinical best practice in
71 anaesthesia services for trauma and orthopaedic surgery, but is primarily concerned
72 with the requirements for the provision of a safe, effective, well-led service, which
73 may be delivered by many different acceptable models. The guidance on provision
74 of anaesthesia services for trauma and orthopaedic surgery applies to all settings
75 where this is undertaken, regardless of funding. All age groups are included within
76 the guidance unless otherwise stated, reflecting the broad nature of this service.
77 A wide range of evidence has been rigorously reviewed during the production of
78 this chapter, including recommendations from peer-reviewed publications and
79 national guidance where available. However, both the authors and the Chapter
80 Development Group agreed that there is a paucity of Level 1 evidence relating to
81 service provision in anaesthesia services for trauma and orthopaedic surgery. In
82 some cases, it has been necessary to include recommendations of good practice
83 based on the clinical experience of the Chapter Development Group. We hope
84 that this document will act as a stimulus to future research.
85 The recommendations in this chapter will support the RCoA’s Anaesthesia Clinical
86 Services Accreditation process.
87
88
89
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90 Scope
91 Target Audience
92 All staff groups working in trauma and orthopaedic surgery, including (but not
93 restricted to) all grades of anaesthetists (consultant anaesthetists, specialty doctors,
94 trainee anaesthetists), nurse practitioners and operating department practitioners.
95 Target Population
96 All ages of patients undergoing trauma and orthopaedic surgery
97 Healthcare Setting
98 All settings within the hospital in which anaesthesia services for trauma and
99 orthopaedic surgery are provided.
100 Clinical Management
101 Key issues that will be covered:
102  Key components for the provision of anaesthesia services for trauma and
103 orthopaedic surgery
104  Key components needed to ensure provision of high quality anaesthetic
105 services for trauma and orthopaedic surgery
106  Areas of provision considered:
107  Levels of provision of service, including (but not restricted to) staffing,
108 equipment, support services and facilities
109  Areas of special requirement including: spinal and pelvic injuries, children,
110 pregnant trauma patients, obese patients, and elderly patients
111  Training and education
112  Research and Audit
113  Organisation and administration
114  Patient Information
115 Exclusions
116  Provision of trauma and orthopaedic surgery services provided by a specialty
117 other than anaesthesia
118  Clinical guidelines specifying how healthcare professionals should care for
119 patients
120  National level issues
121
122
123
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124 Introduction
125
126 Trauma remains the most common cause of loss of life in the under 40’s age group1
127 in the UK, and as such, Major Trauma Centres (MTCs) and Trauma Units (TUs) have
128 been established to receive patients of all ages, and improve outcomes. Early
129 anaesthetic involvement is beneficial at all stages, from the pre-hospital setting, to
130 Emergency Departments (ED), operating rooms, interventional radiology suites,
131 postoperative care units and the critical care environment. The need for significant
132 anaesthetic input and support for these complex patients is an integral part of this
133 pathway.
134
135 MTCs and TUs should have major incident plans in place to deal with mass casualites
136 from any cause.
137
138 Primary arthroplasty surgery significantly improves the quality of life and the mobility
139 of those affected. With the advancing age of our population and their increasing
140 expectations, the number of patients requiring primary arthroplasty surgery and
141 subsequent revision arthroplasty surgery continues to escalate. This population is
142 frequently elderly with co-existing medical conditions that need to be optimised
143 prior to surgery, and benefits from a multidisciplinary team approach and the use of
144 standardised protocols.
145
146 Hip fracture is the most common condition presenting for emergency orthopaedic
147 surgery in the UK with many patients aged over 65. These patients present significant
148 challenges and the input from a multidisciplinary team and early surgery is essential
149 to achieve good outcomes in this population.
150
151 Orthopaedic surgery in children ranges from closed fracture manipulation and
152 casting, to complex long bone or spine correction of congenital or acquired
153 conditions. These may be associated with neurological conditions, or specific
154 syndromes that could pose challenges to those providing anaesthesia care.
155
156 Recommendations
157 The grade of evidence and the overall strength of each recommendation are
158 tabulated in Appendix I.
159 Staffing Requirements
160 Appropriate levels of staffing are essential to deliver high quality anaesthetic input
161 into trauma and orthopaedic patients. The challenge is providing the right people at

1 The Trauma Audit and Research Network (Accessed Aug 2016).
https://www.tarn.ac.uk/Home.aspx
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162 the right place at the right time. Trauma care can be particularly difficult as it occurs
163 frequently out of hours, and may present with multiple casualties at any time.
164 1.1 Each unit should have a designated consultant anaesthetist who is the lead
165 for anaesthesia services for trauma and a designated lead for anaesthesia
166 services for orthopaedic surgery. This should be recognised in their job plan
167 and they should be involved in multidisciplinary service planning and
168 governance within the unit.
169 1.2 Anaesthetists with a specific interest in orthopaedics and trauma should deliver
170 regular theatre sessions to ensure the maintenance of their skills and
171 experience.
172 1.3 All patients undergoing anaesthesia should be under the care of a consultant
173 anaesthetist whose name is recorded as part of the anaesthetic record. 2,3,4 A
174 Staff Grade and Specialty (SAS) anaesthetist could be the named anaesthetist
175 on the anaesthetic record if local governance arrangements have agreed in
176 advance that, based on the training and experience of the individual doctor
177 and the range and scope of their clinical practice, the SAS anaesthetist can
178 take responsibility for patients themselves in those circumstances, without
179 consultant supervision.
180 1.4 Theatre staff should be available who are appropriately trained, skilled and
181 experienced in the various surgical specialties that may present in the
182 treatment of patients with multiple injuries.
183 1.5 Anaesthesia for the emergency control of major traumatic haemorrhage, and
184 other damage-limiting interventions in the operating theatre or radiology
185 intervention suite, should be consultant anaesthetist led. Where consultants are
186 not resident, clear lines of communication and notification should be in place
187 to allow early attendance to trauma calls.
188 1.6 MTC and TU anaesthetic departments should consider appointing anaesthetists
189 with an interest in pre-hospital care. Anaesthetists who provide pre-hospital
190 care in the field should be qualified to do so.5
191 Emergency department (ED)
192 1.7 Major trauma patients arriving in the ED of MTCs and TUs should be met by a
193 multidisciplinary team 24/7. An anaesthetist with appropriate airway and

2 Supervision of SAS and other non-consultant anaesthetists in NHS hospitals. RCoA, 2015.
(http://bit.ly/2hZnHed)
3 Henning J, Woods K. Management of major trauma. Anaesth Intensive Care
2014;15(9):405-407.
4 Oakley P, Dawes R, Rhys Thomas GO. The consultant in trauma resuscitation and
anaesthesia. BJA 2014;113(2):207-210.
5 Sub-specialty Training in Pre-hospital Emergency Medicine. Intercollegiate Board for
Training in Pre-hospital Emergency Medicine. London, 2012. (http://bit.ly/2gPrW9g)
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194 damage control resuscitation competencies to manage trauma patients
195 should be part of this team.
196 1.8 Whenever possible, trauma team members should be called in advance of the
197 patient’s arrival to allow time for briefing, and drug and equipment
198 preparation. The team should also assemble before inter-hospital trauma
199 transfer, allowing the transfer of imaging and treatment plans to be defined in
200 advance.
201 1.9 The use of general anaesthesia, sedation and regional anaesthesia for
202 procedures undertaken in the ED should be managed according to guidance
203 from the Academy of Medical Royal Colleges and Royal College of
204 Anaesthetists.6,7
205 Transfer
206 1.10 The transfer of trauma patients to a MTC will normally be facilitated by the
207 referring hospital. The referring hospital should have robust arrangements in
208 place to enable this to occur safely without compromising clinical activity at
209 their base hospital.8
210 1.11 There should always be an adequate number of staff to ensure safe transfer
211 and positioning of anaesthetised patients.
212 1.12 Patient positioning during transfer should be discussed at the team brief and
213 the relevant lead person identified.
214 Elective orthopaedics
215 1.13 Elderly patients presenting for elective surgery frequently have pre-existing
216 comorbidities that require careful review and peri-operative planning. As such,
217 the pre-assessment service for elective patients should be consultant led, by
218 anaesthetists with an interest in, and appropriate experience in, delivering
219 anaesthetic care to orthopaedic patients.9
220 Hip fracture
221 1.14 Anaesthetsits should be involved alongside surgical collegues and
222 orthogeriatricans, in discussions on pre-operative planning, timing of surgery,
223 and postoperative care, especially for high risk patients.

6 Safe Sedation Practice for Healthcare Procedures: Standards and Guidance. AoMRC,
London 2013 (http://bit.ly/2cFQKQN).
7 Guidance on the provision of anaesthesia services for acute pain management. RCoA,
London 2017.
8 Interhospital Transfer. AAGBI, London 2009 (http://bit.ly/1UlMpxJ)
9 Guidance on the provision of anaesthesia services for pre-operative preparation and
assessment. RCoA, London 2017.
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224 1.15 Adequate provision of theatre capacity and staff should be available to
225 facilitate surgery within 36 hours of hospital admission.10,11
226 2 Equipment, Services and Facilities
227 Equipment
228 2.1 A range of operating tables with attachments for spinal, thoracic, pelvic and
229 limb trauma procedures should be available.
230 2.2 Tourniquets and inflation devices of suitable sizes should be available for upper
231 and lower limb surgery requiring a bloodless field.
232 2.3 A cell-salvage service should be available for major trauma cases where
233 massive blood loss is anticipated.12,13 Staff who operate this equipment should
234 receive training in how to operate it, and use it with sufficient frequency to
235 maintain their skills.
236 2.4 Warming devices for patients should be available for use in the anaesthetic
237 room, operating theatre, recovery unit and ED.14
238 2.5 Elective orthopaedic and planned trauma cases should have their
239 temperature checked pre-operatively on the ward.14 Active warming devices
240 should be available for patients prior to coming to theatre.

10 Association of Anaesthetists of Great Britain and Ireland. Management of proximal
femoral fractures 2011. Anaesthesia 2012;67:85-98.
11 Best Practice Tariff (BPT) for Fragility Hip Fracture Care User Guide. The National Hip
Fracture Database http://bit.ly/2D4dBD2 (accessed January 2018).
12 AAGBI Safety Guideline: Blood transfusion and the anaesthetist – intraoperative cell
salvage. AAGBI, London 2009 (http://bit.ly/1nGJ4HM).
13 Samolyk KA, Beckmann SR, Bissinger RC. A new practical technique to reduce
allogenic blood exposure and hospital costs while preserving clotting factors after
cardiopulmonary bypass: the Hemobag. Perfusion 2005;20(6):343–349.
14 Hypothermia: prevention and management in adults having surgery. NICE, London
2016 (www.nice.org.uk/guidance/cg65).
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241 2.6 A rapid infusor allowing the infusion of warmed intravenous fluids and blood
242 products should be available.15
243 2.7 Equipment for portable monitoring and ventilation should be available in the
244 resuscitation room.16,17
245 2.8 Equipment to facilitate haemodynamic and cardiac output monitoring should
246 be available.
247 2.9 A ‘difficult airway trolley’ should be immediately available in all areas where
248 major trauma patients are received. These should be equipped as defined in
249 the DAS guidelines, and include video laryngoscopes, fibreoptic scopes, jet
250 ventilation and surgical airway equipment.18,19
251 Facilities
252 2.10 In MTCs and TUs, the resuscitation room receiving bays should be large enough
253 to allow simultaneous emergency procedures to be performed by trauma
254 team members.
255 2.11 Hospitals that receive patients with major trauma should ideally have an
256 emergency operating theatre and a radiology intervention suite situated
257 sufficiently close to the ED to allow rapid transfer of trauma patients.
258 2.12 An emergency operating theatre should be rapidly available at all times for
259 major trauma patients. The available equipment should be suitable for a full
260 range of emergency trauma procedures. Use of this theatre for non-immediate
261 cases should be tightly controlled. If the designated emergency theatre is
262 occupied, there should be a robust, flexible and agreed backup plan to
263 obtain an appropriate alternative theatre for the next emergency case.
264 2.13 MTCs receiving major trauma patients should have a trauma theatre equipped
265 with a radiolucent operating table that allows fluoroscopic imaging of all body
266 parts without repositioning the patient.

15 Association of Anaesthetists of Great Britain and Ireland. The use of blood components
and their alternatives. Anaesth 2016;71:829–842.
16 Association of Anaesthetists of Great Britain and Ireland. Recommendations for
standards of monitoring during anaesthesia and recovery 2015. Anaesthesia 2016;71:
85-93.
17 Association of Anaesthetists of Great Britain and Ireland. Immediate Post-anaesthesia
Recovery 2013. Anaesthesia 2013;68(3):288-297.
18 Major complications of airway management in the United Kingdom: 4th National Audit
Project. RCoA and DAS, London 2011 (http://bit.ly/2lOLZIw).
19 Setting up a Difficult Airway Trolley (DAT). DAS, London (Accessed Oct 2017)
(http://bit.ly/1nJbXu0).
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