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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


Tel: 020 7631 1650 

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Designed and produced by the r2 Partnership Ltd

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. 

Ó 2009 The Authors 

Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland 1

Suspected anaphylactic reactions associated with anaesthesia 

..................................................................................................................................... 

(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. 


2 Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland


..................................................................................................................................... 

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 




..................................................................................................................................... 

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: 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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 




..................................................................................................................................... 

• 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 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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). 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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]. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

• 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 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 


Fisher MM, Baldo BA. Mast cell tryptase in anaesthetic anaphylactoid reactions. 


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. 




..................................................................................................................................... 

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 


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. 




Tel: 020 7631 1650 

Fax: 020 7631 4352 


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

Recommendations for standards of monitoring 

during anaesthesia and recovery 2015 

Published by 

The Association of Anaesthetists of Great Britain & Ireland 

December 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. Recommendations for standards of monitoring 

during anaesthesia and recovery 2015. Anaesthesia 2016; 71: 85-93. 


http://onlinelibrary.wiley.com/doi/10.1111/anae.13316/full

Anaesthesia 2015 

Guidelines 

doi:10.1111/anae.13316 

Recommendations for standards of monitoring during anaesthesia 

and recovery 2015 : Association of Anaesthetists of Great Britain 

and Ireland* 

M. R. Checketts, 1 R. Alladi, 2 K. Ferguson, 3 L. Gemmell, 4 J. M. Handy, 5 A. A. Klein, 6 N. J. Love, 7 

U. Misra, 8 C. Morris, 9 M. H. Nathanson, 10 G. E. Rodney, 11 R. Verma 12 and J. J. Pandit 13 

1 Consultant, Department of Anaesthesia, Dundee, UK, and Chair of Working Party, AAGBI 

2 Associate Specialist, Department of Anaesthesia, Tameside Hospital, Ashton-under-Lyne, UK and Representative, 


3 Consultant, Aberdeen Royal Infirmary, Aberdeen, UK 

4 Consultant, Department of Anaesthesia, North Wales Trust, North Wales, UK 

5 Consultant, Department of Anaesthesia and Intensive Care, Chelsea and Westminster Hospital, London, UK 

6 Consultant, Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK 

7 Consultant, Department of Anaesthesia and Intensive Care Medicine, North Devon District Hospital, Barnstaple, 

Devon, UK, and Representative, Group of Anaesthetists in Training, AAGBI 

8 Consultant, Department of Anaesthesia, Sunderland Royal Hospital, Sunderland, UK 

9 Consultant, Department of Anaesthesia and Intensive Care, Royal Derby Hospital, Derby, UK 

10 Consultant, Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK 

11 Consultant, Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee, UK 

12 Consultant, Department of Anaesthesia, Derby Teaching Hospitals, Derby, UK 

13 Consultant, Department of Anaesthesia, Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK 

Summary 

This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The 

aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient 

undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at 

anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during 

anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation 

and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of monitoring 

depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon 

dioxide monitoring have been updated. 

................................................................................................................................................................. 

*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: 13 October 2015 

This Guidelines is accompanied by an editorial by Lumb and McLure, Anaesthesia, doi:10.1111/anae.13327. 

................................................................................................................................................................. 

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 Checketts et al. | Standards of monitoring 2015 

Recommendations 


regards it as essential that minimum standards of 

monitoring are adhered to whenever a patient is anaesthetised. 

These minimum standards should be uniform 

regardless of duration, location or mode of anaesthesia. 

1 The anaesthetist must be present and care for the 

patient throughout the conduct of an anaesthetic.* 

2 Minimum monitoring devices (as defined in the 

recommendations) must be attached before induction 

of anaesthesia and their use continued until 

the patient has recovered from the effects of 

anaesthesia. The same standards of monitoring 

apply when the anaesthetist is responsible for 

local/regional anaesthesia or sedative techniques.** 

3 A summary of information provided by all monitoring 

devices should be recorded on the anaesthetic 

record. Automated electronic anaesthetic 

record systems that also provide a printed copy 

are recommended. 

4 The anaesthetist must ensure that all anaesthetic 

equipment, including relevant monitoring equipment, 

has been checked before use. Alarm limits 

for all equipment must be set appropriately before 

use. The appropriate audible alarms should be 

enabled during anaesthesia. 

5 These recommendations state the monitoring 

devices that are essential (‘minimum’ monitoring) 

and those that must be immediately available during 

anaesthesia. If it is absolutely necessary to continue 

anaesthesia without an essential monitor, the 

anaesthetist should note the reasons in the anaesthetic 

record. 

6 Additional monitoring may be necessary as judged 

appropriate by the anaesthetist. 

7 Minimum monitoring should be used during the 

transfer of anaesthetised patients. 

8 Provision, maintenance, calibration and renewal of 

equipment are the responsibilities of the institution 

in which anaesthesia is delivered. The institution 

should have processes for taking advice from 

departments of anaesthesia in matters of equipment 

procurement and maintenance. 

9 All patient monitoring equipment should be 

checked before use in accordance with the AAGBI 

guideline Checking Anaesthetic Equipment 2012 [1]. 

*In hospitals employing Physician Assistants (Anaesthesia) 

[PA(A)s], this responsibility may be delegated 

to a PA(A), supervised by a consultant anaesthetist in 

accordance with guidelines published by the Royal 

College of Anaesthetists [2]. 

**In certain specific well defined circumstances, intraoperative 

patient monitoring can be delegated to a 

suitably trained non-physician health care worker during 

certain procedures performed under regional or 

local anaesthesia. 

• What other guideline statements are available on 

this topic? 

The European Board of Anaesthesiology (2012), 

the American Society of Anesthesiologists (2011) 

and the Australian and New Zealand College of 

Anaesthetists (2013) have published guidelines on 

standards of clinical monitoring. Lessons learned 

from the 2014 joint Association of Anaesthetists of 

Great Britain and Ireland’s and Royal College of 

Anaesthetists’ 5 th National Anaesthetic Project on 

accidental awareness during general anaesthesia 

were considered by the working party when updating 

this guideline. 

• Why were these guidelines developed? 

It was necessary to update the 2007 4 th edition of 

the guideline to include new guidance on monitoring 

neuromuscular blockade, depth of anaesthesia 

and cardiac output. 

• How and why does this statement differ from existing 

guidelines? 

Capnography monitoring is essential at all times in 

patients with endotracheal tubes, supraglottic airway 

devices and those who are deeply sedated. A 

peripheral nerve stimulator must be used whenever 

neuromuscular blocking drugs are given. A quantitative 

peripheral nerve stimulator is recommended. 

Depth of anaesthesia monitoring is recommended 

when using total intravenous anaesthesia with neuromuscular 

blockade. 

2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015 

Introduction 

The presence of an appropriately trained and experienced 

anaesthetist is the main determinant of patient 

safety during anaesthesia. However, human error is 

inevitable, and many studies have shown that adverse 

incidents and accidents are frequently attributable, at 

least in part, to error by anaesthetists [3, 4]. 

Monitoring will not prevent all adverse incidents 

or accidents in the peri-operative period. However, 

there is substantial evidence that it reduces the risks of 

incidents and accidents both by detecting the consequences 

of errors, and by giving early warning that the 

condition of a patient is deteriorating [5–11]. 

It is appropriate that the AAGBI should define the 

standards of monitoring for use by anaesthetists in the 

United Kingdom and Ireland. Newer monitoring 

modalities such as derived electroencephalogram 

(EEG) depth of anaesthesia and cardiac output monitors 

are not established as routine and the Working 

Party considered their place in contemporary anaesthesia 

practice in Appendices 1 and 2. 

The anaesthetist’s presence during 

anaesthesia 

An anaesthetist of appropriate experience, or fully 

trained Physician Assistant (Anaesthesia) PA (A) under 

the supervision of a consultant anaesthetist, must be 

present throughout general anaesthesia, including any 

period of cardiopulmonary bypass. Using both clinical 

skills and monitoring equipment, the anaesthetist must 

care for the patient continuously. The same standards 

must apply when an anaesthetist is responsible for a 

local/regional anaesthetic or sedative technique for an 

operative procedure. In certain well-defined circumstances 

[12], intra-operative patient monitoring can be 

delegated to a suitably trained non-physician health 

care worker during certain procedures performed under 

regional or local anaesthesia. When there is a known 

potential hazard to the anaesthetist, for example during 

x-ray imaging, facilities for remotely observing and 

monitoring the patient must be available. 

Accurate records of the values determined by 

monitors must be kept. Minimum monitoring data 

(heart rate, blood pressure, peripheral oxygen saturation, 

end-tidal carbon dioxide and anaesthetic vapour 

concentration, if volatile anaesthetic agents or nitrous 

oxide are used) must be recorded at least every five 

minutes, and more frequently if the patient is clinically 

unstable. It is recognised that contemporaneous 

records may be difficult to keep in emergency circumstances, 

but modern patient monitoring devices allow 

accurate records to be completed or downloaded later 

from stored data. Automated electronic anaesthetic 

record systems that can also make hard copies for the 

medical notes are recommended. 

Local circumstances may dictate that handing over 

of responsibility for patient care under anaesthesia to 

another anaesthetist may be necessary. If so, a detailed 

handover must be delivered to the incoming anaesthetist 

and this should be recorded in the anaesthetic 

record. A handover checklist is useful, and one example 

of this is the ‘ABCDE’ aide memoir suggested in 

the NAP5 report [13–15]. When taking over care of a 

patient (including when returning after relief for a 

break), the incoming anaesthetist should conduct a 

check to ensure that all appropriate monitoring is in 

place with suitable alarm limits (see below). 

Very occasionally, an anaesthetist working singlehandedly 

may be called on briefly to assist with or 

perform a life-saving procedure nearby. Leaving an 

anaesthetised patient in these circumstances is a matter 

for individual judgement, but another anaesthetist or 

trained PA(A) should be sought to continue close 

observation of the patient. If this is not possible in an 

emergency situation, a trained anaesthetic assistant 

must continue observation of the patient and monitoring 

devices. Any problems should be reported to other 

available medical staff in the area. Anaesthesia departments 

should therefore work towards having an additional 

experienced anaesthetist available (e.g. a ‘Duty 

Consultant’ or ‘floating registrar’ of appropriate seniority) 

to provide cover in such situations. 

Anaesthesia departments should make arrangements 

to allow anaesthetists working solo during long 

surgical procedures to be relieved by a colleague or PA 

(A) for meal and comfort breaks [16]. The 1998 European 

Working Time Regulation Legislation states that 

an individual should have an uninterrupted break of 

not less than 20 minutes if the working day exceeds 

six hours [17]. To meet this requirement, the presence 

of an additional experienced anaesthetist in the theatre 

suite, as described above is desirable. 



Anaesthetic equipment 

It is the responsibility of the anaesthetist to check all 

equipment before use, as recommended in the AAGBI 

guideline Checking Anaesthetic Equipment 2012 [1]. 

Anaesthetists must ensure that they are familiar with 

all the equipment they intend to use and that they 

have followed any specific checking procedures recommended 

by individual manufacturers. 

Oxygen supply 

The use of an oxygen analyser with an audible alarm 

is essential during anaesthesia. The anaesthetist should 

check and set appropriate oxygen concentration alarm 

limits. The analyser must be placed in such a position 

that the composition of the gas mixture delivered to 

the patient is monitored continuously. Most modern 

anaesthetic machines have built-in oxygen analysers 

that monitor both inspired and expired oxygen concentrations. 

Breathing systems 

During spontaneous ventilation, observation of the 

reservoir bag may reveal a leak, disconnection, high 

pressure or abnormalities of ventilation. Continuous 

waveform carbon dioxide concentration monitoring 

will detect most of these problems, so this is an essential 

part of routine monitoring during anaesthesia. The 

2011 AAGBI position statement on capnography outside 

the operating theatre recommended that it should 

be used for all unconscious anaesthetised patients 

regardless of the airway device used or the location of 

the patient [18]. There are certain circumstances in 

which capnography monitoring is not feasible, for 

example during high frequency jet ventilation. 

Vapour analyser 

The use of a vapour analyser is essential during anaesthesia 

whenever a volatile anaesthetic agent or nitrous 

oxide is in use. The end-tidal concentration should be 

documented on the anaesthetic record. 

Infusion devices 

When any component of anaesthesia (hypnotic, analgesic, 

neuromuscular blockade) is administered by 

infusion, the infusion device must be checked before 

use. Alarm settings (including infusion pressure alarm 

levels) and infusion limits must be verified and set to 

appropriate levels before commencing anaesthesia. It is 

recommended that the intravenous cannula should be 

visible throughout the procedure, when this is practical. 

When not practical, increased vigilance is required 

and correct functioning of the cannula should be regularly 

confirmed. It is recommended that infusion 

devices are connected to mains power whenever possible. 

When using a total intravenous anaesthesia technique 

(TIVA) with neuromuscular blockade, a depth 

of anaesthesia monitor is recommended (see below). 

Alarms 

Anaesthetists must ensure that all alarms are set to 

appropriate values. The default alarm settings incorporated 

by the manufacturer are often inappropriate. 

During the checking procedure, the anaesthetist must 

review and reset the upper and lower limits as necessary. 

It is recommended that anaesthetic departments 

agree consensus-based alarm limits for their monitors 

and ask their medical physics technicians to set these 

up. Audible alarms must be enabled before anaesthesia 

commences. 

When intermittent positive pressure ventilation is 

used during anaesthesia, airway pressure alarms must 

also be used to detect high pressure within the airway 

and to give warning of disconnection or leaks. 

Provision, maintenance, calibration and renewal of 

equipment are the responsibilities of the institution in 

which anaesthesia is delivered. Institutions should take 

into account (e.g., through suitably constituted equipment 

committees) the views of the anaesthetic department 

on matters relating to acquisition and 

maintenance of equipment. 

Monitor displays 

Care should be taken to configure the display setup, 

with attention to both the size and arrangement of onscreen 

data with regular updating of displayed values. 

An appropriate automatic non-invasive blood pressure 

(NIBP) recording interval should be set; NIBP monitors 

should not continue to display readings for longer 

than 5 minutes to reduce the risk of an older reading 

being mistaken for a recent one. 



Monitoring the devices 

Many devices used in anaesthetic practice need their 

own checks and monitoring. This includes monitoring 

the cuff pressure of tracheal tubes and cuffed supraglottic 

airway devices. Cuff pressure manometers 

should be used to avoid exceeding manufacturers’ recommended 

intracuff pressures which can be associated 

with increased patient morbidity. When using devices 

where manufacturers do not specify or recommended 

a maximum cuff pressure, there may still be benefit in 

avoiding high pressure inflation, as this is associated 

with reduced morbidity and improved device performance 

[19]. 

Monitoring the patient 

During anaesthesia, the patient’s physiological state 

and adequacy of anaesthesia need continual assessment. 

Monitoring devices supplement clinical observation 

in order to achieve this. Appropriate clinical 

observations may include mucosal colour, pupil size, 

response to surgical stimuli and movements of the 

chest wall and/or the reservoir bag. The anaesthetist 

may undertake palpation of the pulse, auscultation of 

breath sounds and, where appropriate, measurement of 

urine output and blood loss. A stethoscope must 

always be available. 

Monitoring devices 

The monitoring devices described above are essential 

to the safe conduct of anaesthesia. If it is necessary to 

continue anaesthesia without a particular device, the 

anaesthetist must record the reasons for this in the 

anaesthetic record and only proceed where the benefits 

or clinical urgency outweigh the risks. The following 

are considered minimum monitoring for anaesthesia: 

• Pulse oximeter 

• NIBP 

• ECG 

• 

Inspired and expired oxygen, carbon dioxide, 

nitrous oxide and volatile anaesthetic agent if used 

(see below) 

• Airway pressure 

• 

Peripheral nerve stimulator if neuromuscular blocking 

drugs used (see Appendix 3) 

• Temperature for any procedure > 30 min duration 

[20]. 

Monitoring must continue until the patient has 

recovered from anaesthesia. Anaesthesia departments 

must work towards providing capnography monitoring 

throughout the whole period of anaesthesia from 

induction to full recovery of consciousness as recommended 

by the AAGBI guideline Immediate Postanaesthesia 

Recovery 2013 [21]. 

During induction of anaesthesia in children and in 

uncooperative adults, it may not be feasible to attach 

all monitoring before induction. In these circumstances, 

monitoring must be attached as soon as possible 

and the reasons for delay recorded. 

Recovery from anaesthesia 

Minimum monitoring should be maintained until the 

patient has recovered fully from anaesthesia. In this 

context, ‘recovered fully’ means that the patient no 

longer needs any form of airway support, is breathing 

spontaneously, alert, responding to commands and 

speaking. Until this point, monitoring must be maintained 

to enable rapid detection of airway, ventilatory 

and cardiovascular disturbance. The period of transfer 

from theatre to recovery can be a time of increased 

risk depending on the local geography of the theatre 

complex and the status of the patient. Departments 

should work towards providing full monitoring, 

including capnography, in patients with a tracheal tube 

or supraglottic airway in situ, for these transfers and 

in the recovery area. Supplemental oxygen should routinely 

be given to patients during transfer to the recovery 

room and in the recovery room until at least after 

full recovery. 

In summary, the minimum monitoring for recovery 

from anaesthesia [21] includes: 


• NIBP 

• ECG 

• 

Capnography if the patient has a tracheal tube, 

supraglottic airway device in situ or is deeply 

sedated [17] 

• Temperature 



Additional monitoring 

Some patients will require additional monitoring, for 

example intravascular pressures, cardiac output 

(Appendix 1), or biochemical or haematological variables 

depending on patient and surgical factors. The 

use of additional monitoring is at the discretion of the 

anaesthetist. 

Use of depth of anaesthesia monitors, for example 

processed EEG monitoring, is recommended when 

patients are anaesthetised with total intravenous techniques 

and neuromuscular blocking drugs, to reduce 

the risk of accidental awareness during general anaesthesia 

(see Appendix 2). However, there is no compelling 

evidence that routine use of depth of 

anaesthesia monitoring for volatile agent-based general 

anaesthetics reduces the incidence of accidental awareness 

when end-tidal agent monitoring is vigilantly 

monitored and appropriate low agent alarms are set 

[13, 22]. 

Regional techniques and sedation for operative 

procedures 

Patients must have appropriate monitoring, including 

[23]: pulse oximeter, NIBP, ECG and end-tidal carbon 

dioxide monitor if the patient is sedated. 

Monitoring during transfer within the 

hospital 

It is essential that the standard of care and monitoring 

during transfer of patients who are anaesthetised or 

sedated is equivalent to that applied in the operating 

theatre, and that personnel with adequate knowledge 

and experience accompany the patient [24]. 

The patient should be physiologically as stable as 

possible for transfer. Before transfer, appropriate monitoring 

must be commenced. Use of a pre-transfer 

checklist is recommended [13]. Oxygen saturation, 

ECG and NIBP should be monitored in all patients. 

Intravascular or other monitoring may be necessary in 

special cases. An oxygen supply sufficient to last the 

duration of the transfer is essential for all patients. If 

the patient has a tracheal tube or supraglottic airway 

in situ, end-tidal carbon dioxide should be monitored 

continuously. Airway pressure, tidal volume and respiratory 

rate must also be monitored when the lungs are 

mechanically ventilated. 

Monitoring depth of anaesthesia is desirable when 

transferring anaesthetised patients who have received 

neuromuscular blocking drugs (TIVA is invariably 

used in these circumstances), but will remain difficult 

to provide until portable, battery-powered depth of 

anaesthesia monitors become widely available. 

Anaesthesia in locations outside the 

operating suite 

The standards of monitoring used during general and 

regional anaesthesia or sedation administered by an 

anaesthetist should be the same in all locations. 

When anaesthetists are called to administer general 

or regional anaesthesia and/or sedation in locations 

outwith the operating theatre (for example 

emergency department, cardiac catheter lab, radiology, 

department electroconvulsive therapy suite, endoscopy, 

pain clinic, community dental clinic critical care, delivery 

suite), the same minimum essential standards of 

monitoring already outlined in this document should 

apply: 


• NIBP 

• ECG 

• Inspired and expired oxygen, carbon dioxide, 

nitrous oxide and volatile anaesthetic agent if used 

• Airway pressure 

• 

Peripheral nerve stimulator when neuromuscular 

blocking drugs used (see Appendix 3) 

• Temperature in procedures > 30 min duration. 

Competing interests 

No external funding and no competing interests 

declared. 

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Appendix 1: Cardiac output monitors 

There are a range of cardiac output monitors available 

– such as those estimating cardiac output from pulse 

pressure, carbon dioxide rebreathing, lithium dilution 

or oesophageal Doppler measurements – however, 

their routine use is uncommon. Although the literature 

base is large, there is little evidence that one type of 

monitor is consistently superior to another. Training 

in the use of the technique adopted is essential. Invasive 

methods, such as those requiring a pulmonary 

artery catheter, are more accurate but, because of the 

small risk of serious complications associated with the 

use of the pulmonary artery catheter, their routine use 

outside of cardiac surgical centres cannot be recommended. 

There are concerns about accuracy and reliability 

with many cardiac output monitors. The percentage 

error of pulse contour analysis, oesophageal Doppler, 

partial carbon dioxide rebreathing, and transthoracic 

bio-impedance has been shown to be greater than 

30%, a widely accepted cut-off [25]. The use of cardiac 

output monitoring for assessment of fluid responsiveness 

has been shown to be more accurate, but interpatient 

variability and dynamic changes in stroke volume 

may be significant [26]. 

The cardiac output monitors currently available all 

have advantages and disadvantages associated with 

their use, and the AAGBI Working Party cannot recommend 

one type over another. 

In summary: 

• the pulmonary artery catheter is the most accurate, 

but less invasive monitoring has superseded its routine 

use outside of cardiac surgery [27]; 

• there is conflicting evidence about whether the use 

of cardiac output monitoring improves patient outcomes, 

and this is an area of ongoing research; 

• echocardiography can be used to estimate cardiac 

output and allows cardiac function and filling status 

to be directly observed - however, training and 

experience in its use is required [28, 29]; 

• there remains doubt about the accuracy of all cardiac 

output monitoring devices currently available, 

and data are mostly confined to patients whose 

lungs are mechanically ventilated; 

• the use of cardiac output monitors to assess fluid 

responsiveness has some evidence base. 

Appendix 2: Depth of anaesthesia 

monitors 

EEG-based depth of anaesthesia monitors have been 

variously recommended as an option in patients at 

greater risk of awareness or those likely to suffer the 

adverse effects of excessively deep anaesthesia, and also 

in patients receiving TIVA [30]. Data on the efficacy 

of these devices in correctly predicting accidental 

awareness during general anaesthesia (AAGA) or correctly 

predicting an adequate level of anaesthesia, 

remains inconsistent and debated [31]. However, data 

from these monitors may provide an additional source 

of information on the patient’s condition. 

The NAP5 project published in 2014 made a number 

of recommendations on risk factors for AAGA and 

the place of depth of anaesthesia monitoring [13], 

which can be summarised as: 

• the incidence of reports of AAGA was 1 in 8000 

when neuromuscular blocking drugs were used (as 

high as 1:670 in caesarean section) and 1 in 

136 000 when they were not (i.e., implying a focus 

should specifically be on paralysed patients); 

• 

about half of the reports of AAGA occurred 

around the time of induction of anaesthesia and 

transfer from anaesthetic room to the operating 

theatre. 

• 

almost 20% of AAGA reports occurred at the time 

of emergence from general anaesthesia and were 

commonly if not universally related to inadequate 

reversal of neuromuscular blockade 

Building on these recommendations, the AAGBI 

Working Party makes the following recommendations: 

• Depth of anaesthesia monitoring is recommended 

when neuromuscular blockade is used in combination 

with TIVA; 

• Depth of anaesthesia monitoring should logically 

commence from induction of anaesthesia and be 

continued at least until the completion of surgical 

and anaesthetic interventions (i.e., up to the point 

where it is intended to awaken the patient); 



• Depth of anaesthesia monitoring is recommended 

during transfer of patients receiving TIVA and 

neuromuscular blockade, but presents difficulties, 

because portable battery powered depth of anaesthesia 

monitors are not widely available. Such 

devices may come to the market in the future and 

their efficacy will need to be separately evaluated; 

• during inhalational anaesthesia, end-tidal anaesthetic 

vapour monitoring with preset low agent 

alarms appears a suitable and effective means of 

estimating depth of anaesthesia; 

• The isolated forearm technique is another technique 

to monitor depth of anaesthesia [32]. If used 

as a ‘depth of anaesthesia monitor’, care should be 

taken to ensure its safe conduct, especially in relation 

to avoiding excessive, prolonged cuff inflation. 

The interpretation of a positive movement to command 

with isolated forearm technique needs careful 

interpretation, as does the subsequent management 

of a patient who has moved in response to spoken 

command [33]. 

Appendix 3: Monitoring of 

neuromuscular blockade during 

induction, maintenance and 

termination of anaesthesia 

A measure of neuromuscular blockade, using a peripheral 

nerve stimulator, is essential for all stages of 

anaesthesia when neuromuscular blockade drugs are 

administered. This is best monitored using an objective, 

quantitative peripheral nerve stimulator. Ideally 

the adductor pollicis muscle response to ulnar nerve 

stimulation at the wrist should be monitored. Where 

this is not possible, the facial or posterior tibial nerves 

may be monitored [34]. 

There is variability in the duration of action of 

non-depolarising neuromuscular blocking agents. 

Residual neuromuscular blockade can be detected in up 

to 40% patients for up to two hours after their administration 

[35, 36]. Patient harm may result from postoperative 

hypoxaemia in the post anaesthesia care unit 

[37, 38] and a risk of AAGA at extubation [13]. 

The NAP5 project on AAGA reported on the role 

of neuromuscular blockade in contributing to AAGA, 

and how patients interpret unintended paralysis in 

extremely distressing ways. 

Recommendations: 

• a peripheral nerve stimulator is mandatory for all 

patients receiving neuromuscular blockade drugs 

• 

peripheral nerve stimulator monitors should be 

applied and used from induction (to confirm adequate 

muscle relaxation before endotracheal intubation) 

until recovery from blockade and return of 

consciousness; 

• while a ‘simple’ peripheral nerve stimulator allows 

a qualitative assessment of the degree of neuromuscular 

blockade; a more reliable guarantee of return 

of safe motor function is evidence of a train-of-four 

ratio > 0.9. 

• a quantitative peripheral nerve stimulator is 

required to accurately assess the train of four ratio 

[34], but other stimulation modalities (e.g. double 

burst or post tetanic count) can also be used for 

assessment. Anaesthetic departments are encouraged 

to replace existing qualitative nerve stimulators 

with quantitative devices. 


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


Safe Management of 

Anaesthetic Related Equipment 

Published by 



Telephone 020 7631 1650 Fax 020 7631 4352 


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 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 



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 Elect 


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 


Checking Anaesthetic Equipment 3, 2004. http://www. 

aagbi.org/publications/guidelines/docs/checking04.pdf 


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] 


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


Tel: 020 7631 1650 

Fax: 020 7631 4352 


www.aagbi.org

Peri-operative management 

of the obese surgical patient 2015 

Published by 


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. 


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


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 



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]. 



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 



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 



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- 



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 



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- 



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 



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% 



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 



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 



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]. 



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 



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- 



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- 



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 



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: 



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 



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 



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 . 



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 



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 



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- 



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. 



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 



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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Peri-operative management of the 

surgical patient with diabetes 2015 

Published by 


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. 




Guidelines 

doi:10.1111/anae.13233 

Peri-operative management of the surgical patient with diabetes 

2015 


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 


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


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 

2 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland

Barker et al. | Guidelines on peri-operative management of diabetes Anaesthesia 2015 

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. 




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 


Calculate total dose of 

morning insulin(s); give 

half as intermediateacting 

only in the 

morning; check blood 

glucose on admission; 

leave evening meal 


Stop until eating 

and drinking 

normally 


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 


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. 



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 


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 


admission; leave the 

evening meal dose 

unchanged 

Whilst a VRIII is 

being used 

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 



Take as normal Take as normal Take as normal Stop until eating and 


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 


Pioglitazone Take as normal Take as normal Take as normal Stop until eating and 


* 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; 




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 



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- 




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 



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 




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]. 


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. 




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. 


No external funding and no competing interests 

declared. 

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outcome of hyperglycemia in the perioperative period in noncardiac 

surgery. Diabetes Care 2010; 33: 1783–8. 

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441–2. 

5. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other 

risk factors, and 12-yr cardiovascular mortality for men 

screened in the Multiple Risk Factor Intervention Trial. Diabetes 

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associated with the unsafe use of insulin products. http:// 

www.nrls.npsa.nhs.uk/resources/collections/10-for-2010/insulin/?entryid45=74287 

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and utilisation of critical care resources amongst highrisk 

surgical patients in a large NHS trust. Anaesthesia 2008; 

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8. Pearce RM, Harrison DA, James P, et al. Identification and 

characterisation of the high-risk surgical population in the United 

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national survey of in-patient diabetes services in the United 

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among trainee doctors in the management of diabetes: the 

Trainees Own Perception of Delivery of Care (TOPDOC) Diabetes 

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11. Walid MS, Newman BF, Yelverton JC, et al. Prevalence of previously 

unknown elevation of glycosylated hemoglobin in 

spine surgery patients and impact on length of stay and total 

cost. Journal of Hospital Medicine 2010; 5: E10–4. 

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(HbA1C) in non-diabetic and diabetic vascular patients. Is 

HbA1C an independent risk factor and predictor of adverse 

outcome? European Journal of Vascular and Endovascular Surgery 

2006; 32: 188–97. 

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Journal of Surgery 2009; 96: 1358–64. 

14. Halkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative 

hemoglobin A1c level is associated with reduced long-term 

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glycosylated haemoglobin (HbA1c) is a risk marker in 

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16. Kreutziger J, Schlaepfer J, Wenzel V, Constantinescu MA. The 

role of admission blood glucose in outcome prediction of surviving 

patients with multiple injuries. Journal of Trauma – 

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1043–5. 

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fluid therapy in adults in hospital. NICE guideline CG174, 

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with pre-existing peripheral sensorimotor neuropathy or diabetic 

polyneuropathy. Anesthesia and Analgesia 2006; 103: 

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29. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a 

meta-analysis of 915 patients. Neurosurgical Review 2000; 

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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. 

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loading may be used in type 2 diabetes patients. 

Acta Anaesthesiologica Scandinavica 2008; 52: 946–51. 

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of diabetic ketoacidosis in adults, September 2013. 

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33. National Patient Safety Agency. The fourth report of the Patient 

Safety Observatory. Safety in doses: medication safety incidents 

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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: 

42–50. 

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Agent Administration to Adult Patients, 2nd edn. London: 

RCR, 2010. 

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Adults. Quality Standard 6, March 2011. www.nice.org.uk/ 

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11/08/2015). 



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 


intravenously 

Basal insulin 

continued No basal insulin 

STOP + give 100 ml 

glucose 20% 

intravenously 

STOP + consider 


intravenously 

Reduced rate (e.g. insulin-sensitive patients 

(i.e. < 24 IU.day 1 )) 

0.2 IU.h 1 + give 


intravenously 

0.2 IU.h 1 + give 


intravenously 

Basal insulin 

continued No basal insulin 


glucose 20% 

intravenously 



intravenously 

Increased rate (e.g. insulin-resistant patients 

(i.e. > 100 IU.day 1 )) 

0.5 IU.h 1 + give 


intravenously 

0.5 IU.h 1 + give 


intravenously 

Basal insulin 

continued 


glucose 20% 

intravenously 


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 




> 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 


intravenously 




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 



Tel: 020 7631 1650 

Fax: 020 7631 4352 


www.aagbi.org

Out of Hours Activity 

(Anaesthesia) 

Guiding Principles and Recommendations 

JOINT POSITION STATEMENT 


and 


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

OAA / AAGBI Guidelines for 

Obstetric Anaesthetic Services 2013 

3 

Published by 


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 



Tel: 020 7631 1650 

Fax: 020 7631 4352 


Website: www.aagbi.org 

Obstetric Anaesthetists’ Association 


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. 


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


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 

1. Association of Anaesthetists of Great Britain & Ireland and Obstetric Anaesthetists’ Association. 

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. 

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32


Tel: 020 7631 1650 

Fax: 020 7631 4352 


www.aagbi.org


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 


Lecturer in Medical Ethics & Law 

Royal College of Nursing 


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.


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 


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. 


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 




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 


3 Kennedy I. The Bristol Royal Infirmary 

Inquiry. Final Report. July 2001. 

http://www.bristol-inquiry.org.uk/ 

final_report/index.htm [accessed 10 


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 


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 


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 


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 


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 


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 

HIV without his consent? Broadcast 

12th September 2007. http:// 

www.bbc.co.uk/radio4/science/ 

ethicscommittee_s3_tr3.shtml 




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.

The measurement of adult blood pressure 

and management of hypertension before 

elective surgery 2016 

Published by 


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. 



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 


• 

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- 


Anaesthesia 2016, 71, 326–337 

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. 



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 


Anaesthesia 2016, 71, 326–337 


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 



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 



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. 


Anaesthesia 2016, 71, 326–337 


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 



Surgeon receives referral 

No 

Documented 

SBP < 160 mmHg 

AND 

DBP < 100 mmHg 

in past year? 

Yes 

Proceed 

Request measurements from GP 



100 mmHg? 

Yes 

Proceed 

No 

Measure blood pressure up to 

three times 



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 


Anaesthesia 2016, 71, 326–337 


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. 


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. 


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. 


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 



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 


Third quartile 

Event rates 120/1000 100/1000 36/1000 29/1000 33/1000 28/1000 15/1000 13/1000 


Lowest quartile 

Event rates 60/1000 46/1000 17/1000 11/1000 17/1000 14/1000 6/1000 5/1000 


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. 


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. 


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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. 



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. 



Tel: 020 7631 1650 

Fax: 020 7631 4352 


www.aagbi.org

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

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


Interhospital Transfer 

Published by 



Telephone 020 7631 1650 Fax 020 7631 4352 


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 


Ex-Officio 

Dr D K Whitaker 

Dr R J S Birks 

Dr I H Wilson 


Dr I G Johnston 

Dr D G Bogod 

President 

President Elect 




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 


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


Tel: 020 7631 1650 

Fax: 020 7631 4352 


www.aagbi.org


Infection Control in Anaesthesia 

2 

Published by 



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 


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 




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


doi:10.1111/j.1365-2044.2008.05657.x 

..................................................................................................................................................................................................................... 

GUIDELINES 

Infection Control in Anaesthesia 


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. 



Infection control in anaesthesia Anaesthesia, 2008, 63, pages 1027–1036 

..................................................................................................................................................................................................................... 

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. 




Infection control in anaesthesia 

..................................................................................................................................................................................................................... 

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 




..................................................................................................................................................................................................................... 

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. 





..................................................................................................................................................................................................................... 

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. 




..................................................................................................................................................................................................................... 

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. 





..................................................................................................................................................................................................................... 

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]. 




..................................................................................................................................................................................................................... 

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]. 





..................................................................................................................................................................................................................... 

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. 




..................................................................................................................................................................................................................... 

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). 




Telephone: 020 7631 1650 

Fax: 020 76314352 

E-mail: info@aagbi.org 

Website: www.aagbi.org


Immediate Post-anaesthesia Recovery 2013 

Published by 



Telephone 020 7631 1650 Fax 020 7631 4352 


www.aagbi.org March 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. 

Immediate Post-anaesthesia Recovery 2013. Anaesthesia 

2013; 68: pages 288-97. 


http://onlinelibrary.wiley.com/doi/10.1111/anae.12146/abstract

Guidelines 

Immediate post-anaesthesia recovery 2013 


Ireland 

Membership of the Working Party: D. K. Whitaker (Chair), 

H. Booth, 3 P. Clyburn, W. Harrop-Griffiths, H. Hosie, 1 

B. Kilvington, 3 M. MacMahon, P. Smedley 2 and R. Verma 4 

1 Scottish Multiprofessional Anaesthetic Assistants Development Group 

2 British Anaesthetic and Recovery Nurses Association 

3 College of Operating Department Practitioners 


Summary 

1 After general, epidural or spinal anaesthesia, all patients should be 

recovered in a specially designated area (henceforth ‘post-anaesthesia 

care unit’, PACU) that complies with the standards and recommendations 

described in this document. 

2 The anaesthetist must formally hand over the care of a patient to 

an appropriately trained and registered PACU practitioner. 

3 Agreed, written criteria for discharge of patients from the PACU to 

the ward should be in place in all units. 

4 An effective emergency call system must be in place in every PACU 

and tested regularly. 





Whitaker et al. | Guidelines: Immediate post-anaesthesia recovery 

5 No fewer than two staff (of whom at least one must be a registered 

practitioner) should be present when there is a patient in a PACU 

who does not fulfil the criteria for discharge to the ward. 

6 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. 

7 All patients must be observed on a one-to-one basis by an anaesthetist 

or registered PACU practitioner until they have regained control 

of their airway, have stable cardiovascular and respiratory systems 

and are awake and able to communicate. 

8 All patients with tracheal tubes in place in a PACU should be monitored 

with continuous capnography. The removal of tracheal tubes 

is the responsibility of the anaesthetist. 

9 There should be a specially designated area for the recovery of children 

that is appropriately equipped and staffed. 

10 All standards and recommendations described in this document 

should be applied to all areas in which patients recover after anaesthesia, 

to include those anaesthetics given for obstetric, cardiology, 

imaging and dental procedures, and in psychiatric units and community 

hospitals. Only registered PACU practitioners who are 

familiar with these areas should be allocated to recover patients in 

them as and when required. 

11 Patients’ dignity and privacy should be respected at all times but 

patients’ safety must always be the primary concern. 

12 When critically ill patients are managed in a PACU because of bed 

shortages, the primary responsibility for the patient lies with the 

hospital’s critical care team. The standard of nursing and medical 

care should be equal to that in the hospital’s critical care units. 

13 Audit and critical incident reporting systems should be in place in 

all PACUs. 

.................................................................................................... 



Ireland (AAGBI). It has been seen and approved by the AAGBI Council. 

Accepted: 7 December 2012 

2 © 2013 The Association of Anaesthetists of Great Britain and Ireland

Whitaker et al. | Guidelines: Immediate post-anaesthesia recovery Anaesthesia 2013 


This guidance replaces previous guidelines issued by the Association 

of Anaesthetists of Great Britain and Ireland (AAGBI) published in 

2002 [1]. European guidance was published in 2009 [2]. 

• 

Why was this guideline developed? 

The AAGBI Council decided to update its previous guidance as part 

of the AAGBI’s process of regular review of its guidelines, in the 

light of recent developments and advances. 

• 

How and why does this statement differ from existing guidelines? 

The guideline uses the widely used term ‘post-anaesthesia care unit’ 

(PACU) to refer to all areas that would formerly have been called 

‘recovery rooms’. The guideline recommends that all PACU staff 

should be trained to nationally recognised standards and be familiar 

with relevant safeguarding/child protection procedures as appropriate, 

and that all patients with tracheal tubes in place in PACUs 

should be monitored with continuous capnography. These recommendations 

align this guideline with other recent guidance on these 

and related topics. 

In 1985, the AAGBI published recommendations for the improvement 

and management of recovery facilities in hospitals. These were 

updated in 1993 and 2002 [1]. However, many changes in practice, 

workload, expectations and staff training have occurred in the last 

10 years, and the recommendations in this new document reflect these 

changes. 

Another change that has taken place in this time is the use of the 

term PACU in some hospitals as an abbreviation for ‘post-anaesthesia 

care unit’ and in others, post-anaesthesia recovery unit (PARU). This 

document primarily considers care delivered in the immediate postoperative 

period and will use the term PACU to refer to all areas that 

would formerly have been called ‘recovery rooms’. 

Every patient undergoing general anaesthesia or central neuraxial 

blockade for surgery should be recovered in a designated area as 

described in this document. These recommendations are not concerned 

with those patients recovering from sedation, as guidelines with respect 

to this area of practice have been published separately [3]. 

The PACU facility 

As the number and complexity of surgical procedures have increased, 

immediate postoperative care has developed from a brief period of 




observation in a convenient area near the operating theatre suite to a 

more prolonged and active period of monitoring and intervention in a 

specifically designed clinical environment. 

The NHS Estates Agency of the Department of Health issues regulations 

and guidelines with respect to the design and building of hospitals 

and their facilities. Health Building Note (HBN) 26 refers to operating 

departments, and includes advice on the design of PACUs [4]. Other 

factors involved in design include guidance on fire precautions (Health 

Technical Memoranda, Fire Practice Notes), operational management 

(Health Guidance Notes), specialised building systems (Health Technical 

Memoranda), engineering services (Model Engineering Specifications), 

contracts and commissioning (Concode) and recommendations on 

energy, water and waste [4, 5]. 

The PACU should be in a central position within the theatre complex 

enabling ease of access from the operating theatre but with a separate 

outside access for transfer of patients to the ward. Health Building 

Note 26 relates the size of a PACU to the number of operating theatres 

served, e.g. a recovery area for a typical department of eight theatres 

would have 16 bays, 12 of 13.5 m 2 and four larger ones of 26 m 2 [4]. 

However, it recognises that the size and number of beds should also 

reflect the number of cases per session and the average time spent in 

the PACU. The ratio of PACU beds to operating theatres should not be 

less than two. The bed spaces should allow unobstructed access for trolleys, 

x-ray equipment, resuscitation carts and clinical staff. The facility 

should be open-plan, allowing each recovery bay to be observed but 

with the provision of curtains for patient privacy. The PACU should be 

mechanically ventilated, as the environment is potentially polluted by 

anaesthetic gases. Other facilities should include storage areas for equipment, 

a dirty utility room, a secure supply of drugs, easy access to sinks 

and space for information technology equipment and clerical activities. 

All PACU bed spaces should have 12 electrical socket outlets (six 

each side of the bed), one oxygen pipeline outlet, one medical air outlet, 

two vacuum outlets, an adjustable examination light, a push-button 

emergency call system, and physiological monitors with a display screen 

and recording system for patient data [6]. An exhaled gas scavenging 

system must be available for the occasional use of an anaesthetic 

machine. The dećor should provide an attractive ambiance and, if possible, 

windows should be present. Lighting should not be harsh and 

should comply with recommended standards [4]. Local lighting to assist 

clinical examination must also be available. Noise levels should be kept 



as low as possible and the ceiling should be sound absorbent. Good 

communication systems linking PACU staff with the operating theatres, 

wards and other clinical facilities are essential. An effective emergency 

call system must be in place, with alarm and telephone or intercom 

links to operating theatres and rest areas. All members of staff must be 

aware of this system and it should be tested at least weekly. At least two 

separate landline telephones are recommended to facilitate both incoming 

and outgoing calls during incidents, as in all important clinical 

areas. 

There should be access to a staff rest area near to, but outside, the 

immediate recovery area. Other facilities should include toilets, showers, 

clean duty clothes and secure storage for personal possessions. Patient 

and staff safety should be assured by appropriate security systems, especially 

at night. 

Monitoring, equipment and drugs 

An appropriate standard of monitoring should be maintained until the 

patient is fully recovered from anaesthesia [6]. Clinical observation 

should therefore be supplemented as in the operating theatre by a minimum 

of pulse oximetry, non-invasive blood pressure monitoring, ECG 

and, if patients’ tracheas remain intubated or they have their airways 

maintained with a supraglottic or other similar airway device, continuous 

capnography [7, 8]. Difficult airway equipment [9], a nerve stimulator 

for assessing neuromuscular blockade, a thermometer and patient 

warming devices should be immediately available. It is recommended 

that there should be full compatibility between operating theatre, PACU 

and ward monitoring equipment. 

All drugs, equipment, fluids and algorithms required for resuscitation 

and management of anaesthetic and surgical complications should 

be immediately available. Consideration should be given to providing 

dedicated trolleys or carts for this purpose. 

PACU staff 

No fewer than two staff (of whom at least one must be a registered 

practitioner) should be present when there is a patient in the PACU 

who does not fulfil the criteria for discharge to the ward. Staffing numbers 

should allow one-to-one observation of every patient by an anaesthetist, 

registered PACU practitioner or other properly trained member 

of staff until they have regained airway control, respiratory and cardiovascular 

stability, and are able to communicate. In addition, there 




should be an anaesthetist who is supernumerary to requirements in the 

operating theatres immediately available for patients in PACU. There 

should be a consultant anaesthetist lead for the PACU appointed, with 

appropriate time allocated in his/her job plan [10], and dedicated anaesthetic 

sessions in the PACU should be considered in large, busy units. 

The provision of a satisfactory quality of care during recovery from 

anaesthesia and surgery relies heavily on investment in the education 

and training of PACU staff. Maintenance of standards requires continuous 

updating, e.g. resuscitation skills, new airway techniques and 

advances in pain management. Regular team rehearsal of emergency 

scenarios should be considered. PACU staff are specialist and often play 

a key role in the education of others, including theatre staff, ward-based 

nurses, midwives and trainee doctors. 

All specialist staff should have received appropriate training to 

nationally recognised standards such as the UK National Core Competencies 

for Post-anaesthesia Care [11]. Training should be tailored to 

meet the needs of the individual staff member and the PACU, but practical 

training and maintenance of skills must supplement theoretical 

knowledge. At all times, at least one member of staff present should be 

a certified Acute Life Support (ALS) provider and, for children, hold an 

appropriate paediatric life support qualification. All staff should be 

encouraged to attain and maintain at least one such life support qualification, 

e.g. ALS, APLS, PLS, PILS. 

Continued professional development and the training of other staff 

is facilitated by activities such as the establishment of lead practitioners 

in certain areas, e.g. pain relief, life support, infection control, paediatrics, 

liaison with ward staff, health and safety matters, and training cocoordination. 

PACUs should consider rotation of duties with the local 

high dependency units (HDUs) and intensive care units (ICUs), an 

audit programme, educational posters, journal clubs and tutorials. 

Specialist PACU staff normally work as part of a team in large 

PACUs attached to main operating theatre suites, but many hospitals 

have isolated PACUs, e.g. for obstetrics, cardiac catheter laboratories 

and facilities for electroconvulsive therapy, which may only be used 

intermittently, although sometimes for high-risk patients. Patient safety 

considerations dictate that patients recovering in these environments 

should only be cared for by registered PACU practitioners who are 

members of the hospital’s core PACU team and who are familiar with 

these areas and allocated to work in them as and when required. 



Transfer and handover of care to the PACU team 

The transfer of patients from the operating theatre to the PACU and 

elsewhere has been considered in two publications by the AAGBI [6, 

12]. Before transfer, the anaesthetist should be satisfied that the PACU 

staff are competent and able to take responsibility for the patient. If this 

cannot be assured, the anaesthetist should stay with the patient, either 

in the operating theatre or the PACU, until the patient is fit to return 

to the ward. It is essential that the anaesthetist formally hands over care 

of the patient to an appropriately trained and registered PACU practitioner. 

Formal handover checklists can improve the safety of handovers 

and should be developed for local use. 

The patient should be physiologically stable on departure from the 

operating theatre, and the anaesthetist must decide on the extent of 

monitoring during transfer. This will depend on factors such as proximity 

to the PACU, the patient’s level of consciousness and both respiratory 

and cardiovascular status. If the PACU is not immediately adjacent 

to the operating theatre, or if the patient’s condition is poor, adequate 

mobile monitoring is required, i.e. a minimum of pulse oximetry and 

non-invasive blood pressure, ECG and capnography if the trachea is intubated, 

with the immediate availability of a nerve stimulator, and a 

means of measuring body temperature [6]. The anaesthetist is responsible 

for ensuring that this transfer is accomplished safely. Supplemental 

oxygen should be administered to all patients during transfer unless the 

patient did not receive supplemental oxygen during surgery. All lines 

should be flushed to remove any residual anaesthetic drugs if necessary 

and checked to be patent, adequately secured and protected. Details of 

any difficulties experienced during intubation or other relevant procedures 

should be included in the handover [9]. 

Management of patients in the PACU 

Patients must be observed on a one-to-one basis by an anaesthetist, registered 

PACU practitioner or other properly trained member of staff 

until they have regained airway control, respiratory and cardiovascular 

stability, and are able to communicate. This recommendation is paramount 

and must be observed, even if it causes delay in the throughput 

of patients. All PACUs must be staffed to a level that allows this to be 

routine practice, even at times of peak activity. Life-threatening complications 

may occur during this period [13], and failure to provide adequate 

care may prove catastrophic for patients, their relatives and the 




Table 1 Minimum information to be recorded for patients in the postanaesthesia 

care unit. 

• Level of consciousness 

• Patency of the airway 

• Respiratory rate and adequacy 

• Oxygen saturation 

• Oxygen administration 

• Blood pressure 

• Heart rate and rhythm 

• Pain intensity on an agreed scale 

• Nausea and vomiting 

• Intravenous infusions 

• Drugs administered 

• Core temperature 

• Other parameters depending on circumstances, e.g. urinary output, central 

venous pressure, expired CO 2 , surgical drainage volume. 

staff involved, and may have serious medicolegal consequences. Patients 

must be kept under clinical observation at all times, and all measurements 

should be recorded, preferably by an automatic recording system 

networked with theatre systems. The frequency of observations will 

depend upon the stage of recovery, the nature of the surgery and clinical 

condition of the patient. The frequency of the observations and the 

quality of record keeping should not be influenced by staffing levels. 

Certain information should be recorded as a minimum (Table 1). 

For all patients, the National Patient Safety Agency (NPSA) recommended 

dataset of their last name, first name, date of birth and NHS 

number [14] should be recorded in that order, together with their time 

of admission, time of fitness for discharge, time of discharge and destination 

in a central register. 

Pain, nausea and vomiting 

No patient should be returned to the ward until control of postoperative 

nausea and vomiting and pain is satisfactory. All PACU staff should be 

specifically trained in the management of patients with patient-controlled 

analgesia, epidurals, spinals and peripheral nerve blockade. Nurse administration 

of intravenous analgesics, e.g. paracetamol, non-steroidal 

anti-inflammatory drugs (NSAIDs) and opioids prescribed by the anaesthetists 

as part of a specific protocol, facilitates rapid and flexible pain 



control. Such protocols should incorporate precise instructions on the 

administration of the drugs and the recognition and management of their 

side-effects. Nurse administration of intravenous opioids should not occur 

unless there is the immediate availability of an anaesthetist. All syringes 

containing drugs should be clearly labelled. 

Tracheal tubes and other airway devices 

On many occasions, patients will be handed over to the PACU nurse with 

a laryngeal mask airway or other supraglottic airway device in place. The 

nurse must be specifically trained in the management of these patients 

and in the removal of the airway device. An anaesthetist should be immediately 

available to assist if problems occur while the airway device is in 

place or when it is removed by a qualified member of the PACU staff. 

The incidence of upper airway obstruction that may lead to postobstructive 

pulmonary oedema and severe hypoxia can be minimised by 

the use of oropharyngeal airways, bite blocks, airway devices incorporating 

them or similar devices [9]. 

The removal of tracheal tubes from patients in the PACU is the 

responsibility of the anaesthetist, who may delegate the removal to an 

appropriately trained member of the PACU team who is prepared to 

accept this responsibility. 

Discharge from the PACU 

Every PACU should have well-defined minimum criteria for fitness for 

the discharge of patients to the general ward or other clinical areas 

(Table 2). 

Discharge from the PACU is the responsibility of the anaesthetist 

but the adoption of strict discharge criteria allows this to be delegated 

to PACU staff. If the discharge criteria are not met, the patient should 

remain in the PACU and the anaesthetist should be informed. An 

anaesthetist must be available at all times when a patient who has not 

reached the criteria for discharge is present in the PACU. Patients who 

have potential airway problems or complications should be reassessed 

by the responsible anaesthetist before discharge from the PACU [9]. 

If there is any doubt as to whether a patient fulfils the criteria, or if 

there has been a problem during the recovery period, the anaesthetist 

who gave the anaesthetic (or another anaesthetist with special duties in 

the PACU) must assess the patient. After medical assessment, patients 

who do not fulfil the discharge criteria may be transferred to an appropriate 

HDU or ICU. 




Table 2 Minimum criteria for discharge of patients from the postanaesthesia 

care unit. 

• The patient is fully conscious, able to maintain a clear airway and has protective 

airway reflexes 

• Breathing and oxygenation are satisfactory 

• The cardiovascular system is stable, with no unexplained cardiac irregularity 

or persistent bleeding. The specific values of pulse and blood pressure 

should approximate to normal pre-operative values or be at an acceptable 

level, ideally within parameters set by the anaesthetist, and peripheral perfusion 

should be adequate 

• Pain and postoperative nausea and vomiting should be adequately controlled, 

and suitable analgesic and anti-emetic regimens prescribed 

• Temperature should be within acceptable limits [15]. Patients should not 

be returned to the ward if significantly hypothermic 

• Oxygen therapy should be prescribed if appropriate 

• Intravenous cannulae should be patent, flushed if necessary to ensure 

removal of any residual anaesthetic drugs and intravenous fluids should be 

prescribed if appropriate 

• All surgical drains and catheters should be checked 

• All health records should be complete and medical notes present. 

Handing over to ward staff 

Patients should be transferred to the ward accompanied by two members 

of staff, at least one of whom should be suitably trained. The anaesthetic 

record, together with the recovery and prescription charts, must 

accompany the patient and clearly indicate to the ward staff the details 

of relevant drugs administered in theatre and PACU, e.g. analgesics and 

antibiotics. The PACU nurse must ensure that full clinical details are 

relayed to the ward nurse, with particular emphasis on ongoing problems 

and the management of infusions. Local policies should be developed 

for the safe handover of infusion devices and syringe pumps, e.g. 

the collecting ward nurse checking and signing for the pump settings. 

Formal handover checklists can improve the safety of handovers and 

should be developed for local use. 

Local anaesthesia and regional anaesthesia 

The principles of management of any patient undergoing local anaesthesia, 

either alone or in addition to general anaesthesia, are the same as 

for any other patient. Information given on handover to PACU staff 



should include the site and type of local block, drug, dosage, time of 

administration and anticipated duration of action. Instructions for ward 

staff should include further pain relief and any particular positional 

requirements for the patient. Information for the patient includes the 

anticipation of return of sensation and motor function, care with hot 

and cold items and weight-bearing. 

Considerations after spinal and epidural anaesthesia include noting 

the level of analgesia achieved, the time and dose of drug administered, 

cardiovascular status, bladder care, details of any continuous infusions, 

degree of motor block and the time of anticipated motor and sensory 

recovery. Many of these considerations apply also to plexus blocks and 

major nerve trunk blocks. All PACU staff should be trained in the recognition 

and management of local anaesthetic toxicity and have immediate 

access to a supply of Intralipid [16]. 

Children 

Children have special needs reflecting fundamental psychological, anatomical 

and physiological differences from adults. These needs are best 

met by having a designated, separate paediatric recovery area that is 

child-friendly and staffed by nurses trained in the recovery of babies, 

children and young people. The area should be kept warm to prevent 

hypothermia and provision should be made for a parent or carer to 

rejoin the child in the recovery area as soon as they are awake [17]. 

All staff working in PACU should be familiar with the relevant procedures 

and personnel if there are Safeguarding or Child Protection 

concerns that arise whilst the child is in theatre [18, 19]. 

Equipment must include a full range of sizes of facemasks, breathing 

systems, airways, nasal prongs and tracheal tubes. Essential monitoring 

equipment includes a full range of paediatric non-invasive blood 

pressure cuffs and small pulse oximeter probes. Capnography should 

also be available. 

All drugs, equipment, fluids required for paediatric resuscitation 

and other emergencies should be immediately available. Consideration 

should be given to providing a separate dedicated paediatric 

trolley for this purpose. Guidelines and commonly used algorithms 

for paediatric emergencies should be readily available and regularly 

rehearsed. 

Children are more likely to become restless or disorientated after 

surgery and require one-to-one supervision throughout their PACU 




stay. Provision should be made to protect a child from injury in this situation 

by supplying washable cot or bed protectors. Postoperative vomiting, 

bradycardia and laryngeal spasm are more common. The latter 

can result in major life-threatening desaturation, as infants and small 

children become hypoxaemic 2–3 times more quickly than adults. 

Children should not be denied adequate pain relief because of a fear 

of side-effects. It can be difficult to assess pain, especially in the pre-verbal 

child. However, suitable techniques are available and protocols for 

pain management in children should be readily available [20, 21]. When 

intravenous and epidural analgesic drugs are given to babies and children, 

systems must be in place to double-check doses, which may be 

less familiar if used infrequently. 

Before discharge from the PACU, the need to ensure that the dead 

space of all intravenous cannulae is flushed and patent is particularly 

important in children [22]. 

Patients’ perspective 

The written information given to patients before their admission to hospital 

should explain the purpose and nature of the PACU. Anaesthesia 

and Anaesthetists: Information for Patients and their Relatives published 

by the Royal College of Anaesthetists and the AAGBI is an example of 

this [23]. Information for children and young people of all ages about 

anaesthesia is also available [24]. 

Although the design of recovery facilities is, by necessity, open-plan, there 

should be provision for patients’ privacy and dignity, e.g. curtains. However, 

safety considerations override their use during resuscitation and the management 

of other crises. If other awake patients are also present in the PACU, 

curtains should only be closed around the awake patients and not the patient 

who is being resuscitated. Most patients find PACUs unpleasant, and they 

should be transferred out as soon as discharge criteria are met. 

Staff in some hospitals may require access to interpreters and translators 

to facilitate communication with non-English speaking patients. 

Anaesthesia and recovery in special areas 

Anaesthesia is often administered in areas such as obstetric, x-ray, cardiology, 

dental and psychiatric units, and in community hospitals. All 

standards and guidelines described in this document must be completely 

fulfilled at any site in which anaesthesia is administered and immediate 

postanaesthesia recovery planned. 



Critically ill patients 

The primary goal of a PACU is to provide postoperative patients with 

the optimum standard of care during the initial period of their recovery 

from anaesthesia and surgery. During times of bed or staff shortages in 

critical care areas, and because of the resources available, PACUs are 

occasionally used for the contingency management of and delivery of 

care to critically ill patients [25]. During such times, it must be recognised 

that the primary responsibility for the patient lies with the consultant 

in charge of the ICU and his/her team. An ICU-trained nurse must 

care for the patient on a one-to-one basis, with immediate access to 

senior ICU nursing assistance. The standard of medical and nursing 

care should be equal to that within the ICU, and a specific action plan 

should be formulated by the critical care team to facilitate discharge to 

a more appropriate area as soon as possible. The delivery of critical care 

in a PACU for longer than 4 h should trigger the collection of a Critical 

Care Minimum Data Set (CCMDS) [25]. There should be a mechanism 

in place for PACU personnel either to collect this data set or to request 

its collection. 

End of life care in the PACU 

Occasionally, a patient who is expected to die imminently will be taken 

to the PACU. The patient should be managed according to an endof-life 

care pathway, in isolation from others who should ideally be 

unaware of the situation. Relatives must be able to be present and a 

dedicated nurse should be available [26]. 

Audit and quality control in the PACU 

The recording of key quality and outcome data from all patients passing 

through the PACU should be routine for all hospitals [27]. The data 

recorded from PACU patients should be compared with national and 

local benchmarks with the express aim of improving and maintaining 

the quality of pre-, intra- and postoperative care, and measuring compliance 

with national standards. The AAGBI recommends that a minimum 

dataset should be recorded for all patients admitted to a PACU 

(Table 3). In addition to these, some PACUs may wish to record data 

relating to patients’ satisfaction with their care in the PACU. 

Some of these data should be available from Trust and Health 

Board IT systems, and resources should be made available to integrate 

these systems with recording of PACU data to facilitate PACU data 




Table 3 Minimum dataset to be recorded for all patients admitted to a 

post-anaesthesia care unit. 

• Last name, first name, date of birth and NHS number 

• Gender 

• ASA physical status 

• Surgical procedure performed 

• Names of anaesthetist and surgeon 

• Type of anaesthesia 

• Time of admission 

• Core temperature on admission to the PACU 

• Incidence and severity of postoperative nausea and vomiting 

• Severity of pain experienced in the PACU 

• Analgesia given in the PACU 

• Time of fitness for discharge from the PACU 

• Time of discharge from the PACU 

• Complications 

entry, storage and interpretation. Information derived from this data collection 

should be analysed and fed back to anaesthetists and theatre teams 

in a way that will allow individuals and teams to compare their performance 

with others. Interpretation of these data by experienced anaesthetists 

is important, and both patients’ characteristics and the nature of the 

surgery should be taken into account before conclusions are drawn. Local 

clinical governance arrangements will usually require discussion of any 

incidents at regular multidisciplinary PACU team meetings. 

In addition to these data, there should be a list of adverse incidents 

that should be recorded and fed into a clinical governance programme 

that records and disseminates the incidence of adverse incidents, and 

can investigate individual incidents if appropriate. These might include: 

Cardiopulmonary arrest 

Major airway complications 

Death 

Severe pain that is difficult to treat 

Prolonged stay (> 2h) 

Significant hypothermia (< 35 °C) 

Need to call an anaesthetist to review a patient 

• 

Need for ventilatory support (CPAP, tracheal intubation, lung ventilation) 



• Need for cardiovascular support (inotropes, vasoconstrictors, anti-arrhythmics) 

Return to the operating theatre before discharge from PACU 

• Inadequate reversal of neuromuscular blocking drugs. 

Reports of such incidents should be accompanied by clinical information 

that will allow further analysis. 

The PACU is also a useful area in which to monitor compliance 

with Trust initiatives that seek to improve patient care and safety. These 

might include: 

Compliance with WHO checklist performance 

Administration of antibiotics 

Thrombo-embolic prophylaxis 

Compliance with analgesic and anti-emetic protocols 

• 

Completion of postoperative instructions relating to oxygen therapy, 

pain therapy, fluid management, wound and drain management, 

restarting of oral intake and other elements of early postoperative care. 


DKW is a Past President of the AAGBI and is currently Chairman of 

the European Board of Anaesthesiology Safety Committee, and a member 

of the European Board of Anaesthesiology/European Society of Anaesthesiology 

Patient Safety Task Force. No external funding or 

competing interests declared. 

Acknowledgement 

The Working Party is very grateful to Dr K. Wilkinson for providing 

help and advice, particularly on the care of children. 

References 

1. Association of Anaesthetists of Great Britain & Ireland. Immediate Postanaesthetic 

Recovery. London: AAGBI, 2002. 

2. Vimlatia L, Gilsanzb F, Goldikc Z. Quality and safety guidelines of postanaesthesia 

care Working Party on Post Anaesthesia Care (approved by the European Board and 

Section of Anaesthesiology, Union Europeénne des Médecins Spećialistes). European 

Journal of Anaesthesiology 2009; 26: 715–21. 

3. Royal College of Anaesthetists. Implementing and Ensuring Safe Sedation Practice 

for Healthcare Procedures in Adults. http://www.rcoa.ac.uk/system/files/PUB- 

SafeSedPrac.pdf (accessed 03/12/2012). 

4. NHS Estates. Health Building Note 26, Facilities for Surgical Procedures: volume 1. 

London: The Stationery Office, 2004. 




5. Health Facilities Scotland. Scottish Health Planning Note 00-07: Resilience Planning 

for the Healthcare Estate. http://www.hfs.scot.nhs.uk/publications/1253180726- 

SHPN%2000-07%20Final.pdf (accessed 03/12/2012). 

6. Association of Anaesthetists of Great Britain and Ireland. Recommendations for 

Standards of Monitoring During Anaesthesia and Recovery. http://www.aagbi.org/ 

sites/default/files/standardsofmonitoring07.pdf (accessed 03/12/2012). 

7. Association of Anaesthetists of Great Britain and Ireland. AAGBI safety statement: 

the use of capnography outside the operating theatre. http://www.aagbi.org/ 

sites/default/files/Safety%20Statement%20-%20The%20use%20of%20capnography%20outside%20the%20operating%20theatre%20May%202011_0.pdf 

(accessed 

03/12/2012). 

8. European Section and Board of Anaesthesiology UEMS. EBA Recommendation for 

the Use of Capnography. http://www.eba-uems.eu/resources/PDFS/EBA-UEMS-recommendation-for-use-of-Capnography.pdf 

(accessed 03/12/2012). 

9. Royal College of Anaesthetists. Major Complications of Airway Management in the 

UK, 4th National Audit Project. http://www.rcoa.ac.uk/system/files/CSQ-NAP4- 

Full.pdf (accessed 03/12/2012). 

10. Association of Anaesthetists of Great Britain and Ireland. Guidance on the 2003 

(New) Contract and Job Planning for Consultant Anaesthetists. http://www.aagbi. 

org/sites/default/files/jobplanning05.pdf (accessed 03/12/2012). 

11. Association of Anaesthetists of Great Britain and Ireland. UK National Core Competencies 

for Post-anaesthesia Care. http://www.aagbi.org/sites/default/files/corecompetencies2013.pdf 

(in press). 

12. Association of Anaesthetists of Great Britain and Ireland. The Anaesthesia Team 3. 

London: AAGBI, 2010 http://www.aagbi.org/sites/default/files/anaesthesia_ 

team_2010_0.pdf (accessed 03/12/2012). 

13. Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from 

the anaesthetic incident monitoring study (AIMS). Anaesthesia 2002; 57: 1060–6. 

14. NHS. Guidance on the Standard for Patient Identifiers for Identity Bands. http:// 

www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60136&type=full&- 

servicetype=Attachment (accessed 03/12/2012). 

15. National Institute for Health and Clinical Excellence. Management of Inadvertent 

Perioperative Hypothermia in Adults. http://www.nice.org.uk/CG065 (accessed 

03/12/2012). 

16. Association of Anaesthetists of Great Britain and Ireland. Management of Severe 

Local Anaesthetic Toxicity. http://www.aagbi.org/sites/default/files/la_toxicity_ 

2010_0.pdf (accessed 03/12/2012). 

17. Royal College of Anaesthetists. Guidance on the Provision of Paediatric Anaesthetic 

Services. http://www.rcoa.ac.uk/system/files/CSQ-GPAS8-Paeds_0.pdf (accessed 

03/12/2012). 

18. Royal College of Anaesthetists. Child Protection and the Anaesthetist: Safeguarding 

Children in the Operating Theatre. http://www.rcoa.ac.uk/system/files/PUB-Child- 

Protection.pdf (accessed 03/12/2012). 

19. Royal College of Anaesthetists. Safeguarding Children and Young People: Roles and 

Competencies for Health Care Staff. http://www.rcoa.ac.uk/system/files/PUB-Safeguarding-Children_0.pdf 

(accessed 03/12/2012). 



20. Royal College of Nursing. The Recognition and Assessment of Acute Pain in Childhood. 

http://www.rcn.org.uk/__data/assets/pdf_file/0004/269185/003542.pdf 

(accessed 03/12/2012). 

21. Association of Paediatric Anaesthetists. Good Practice in Post-operative and Procedural 

Pain. http://www.apagbi.org.uk/sites/default/files/APA%20Guideline% 

20part%201.pdf (accessed 03/12/2012). 

22. NHS. Residual anaesthetic drugs in cannulae. http://www.nrls.npsa.nhs.uk/ 

resources/type/signals/?entryid45 = 65333 (accessed 03/12/2012). 

23. Royal College of Anaesthetists. Anaesthesia Explained: Information for Patients and 

their Relatives. http://www.rcoa.ac.uk/system/files/PI-AE-2008.pdf (accessed 03/ 

12/2012). 

24. Royal College of Anaesthetists. Information for Children and Parents. http:// 

www.rcoa.ac.uk/node/429 (accessed 03/12/2012). 

25. Royal College of Nursing. Standards for Contingency Management and Delivery of 

Critical Care in a Post Anaesthesia Care Unit (PACU). http://www.rcn.org.uk/ 

__data/assets/pdf_file/0010/351784/003842.pdf (accessed 03/12/2012). 

26. Marie Curie Palliative Care Institute. Liverpool Care Pathway for the Dying Patient. 

http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/ (accessed 03/12/2012). 

27. Royal College of Anaesthetists. Audit Recipe Book, Section 3: Post-operative Care. 

https://www.rcoa.ac.uk/system/files/CSQ-ARB2012-SEC3.pdf (accessed 03/12/ 

2012). 



Tel: 020 7631 1650 

Fax: 020 7631 4352 


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. 


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. 


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. 


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. 


›› 

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. 



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. 



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 


›› 

Guidance on CPD online (accessed 23 November 2009) www.gmc-uk.org/education. 


›› 

Continuing professional development guidelines (2nd edition), 2010 (in press). 

›› 

Raising the standard: a compendium of audit recipes (2nd edition), 2006. 



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. 



Attribute 2: apply knowledge and experience to practice 


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. 



›› 

Good practice in prescribing medicines: supplementary guidance, 2008. 

›› 

Withholding and withdrawing life-prolonging treatments: good practice in decision making, 2006. 


›› 

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. 


›› 

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. 



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. 



Attribute 3: keep clear, accurate and legible records 


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. 



›› 

Information management: guidance for anaesthetists, 2008. 



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. 



Attribute 4: put into effect systems to protect patients and improve care 


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. 



›› 

Raising concerns about patient safety, 2008. 


›› 

Syringe labelling in critical care areas, 2004. 


›› 

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. 



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. 



Attribute 5: respond to risks to safety 


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. 



›› 

0–18 years: guidance for all doctors, 2007. 

›› 

Raising concerns about patient safety, 2008. 


›› 

Child protection and the anaesthetist: safeguarding children in the operating theatre – 

intercollegiate document, 2007. 


›› 

Anaesthesia and peri-operative care of the elderly, 2001. 

›› 

Infection control in anaesthesia (2nd edition). AAGBI safety guideline, 2008. 



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. 



Attribute 6: protect patients and colleagues from any risk posed by your health 


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. 



›› 

Fatigue and anaesthetists, 2004. 

›› 

Welfare resource pack, 2008. 



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. 



Attribute 7: communicate effectively 


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. 



›› 

Catastrophes in anaesthetic practice: dealing with the aftermath, 2005. 



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. 



Attribute 8: work constructively with colleagues and delegate effectively 


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. 



›› 

Management for doctors, 2006. 


›› 

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. 



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. 



Attribute 9: establish and maintain partnerships with patients 


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. 



›› 

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. 


›› 

Consent for anaesthesia (2nd edition), 2004. 



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. 



Attribute 10: show respect for patients 


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. 



›› 

Confidentiality, 2009. 

›› 

Maintaining boundaries: supplementary guidance, 2006. 

›› 

Personal beliefs and medical practice: supplementary guidance, 2008. 



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. 



Attribute 11: treat patients and colleagues fairly and without discrimination 


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. 



›› 

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. 


›› 

Consultant trainee relationships – a guide for consultants, 2001. 

›› 

Management of anaesthesia for Jehovah’s Witnesses (2nd edition), 2005. 



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. 



Attribute 12: act with honesty and integrity 


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. 



›› 

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. 


›› 

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. 



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

Day Case and Short Stay Surgery 

2 

Published by 


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 


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 


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. 




Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 1

Guidelines: Day case and short stay surgery 

..................................................................................................................................... 

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). 


2 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland


..................................................................................................................................... 

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 




..................................................................................................................................... 

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). 




..................................................................................................................................... 

(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. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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) 




..................................................................................................................................... 

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]. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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. 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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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43 Pavlin DJ, Pavlin EG, Fitzgibbon DR, Koerschgen ME, Plitt TM. Management 

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outcome after day surgery. Anaesthesia 2009; 64: 150–5. 

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Journal of One-day Surgery 2008; 18: 45–7. 

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to the day case setting: the Torbay hospital proposal. Journal of One-day Surgery 

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surgery. British Medical Journal 2001; 322: 473–6. 

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public research study conducted for the Royal College of Anaesthetists for 

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58 Mitchell M. General anaesthesia and day-case patient anxiety. Journal of Advanced 

Nursing 2010; 66: 1059–71. 

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downloads/generaladvice.pdf, 2010 (accessed 03 ⁄ 01 ⁄ 2011). 




..................................................................................................................................... 


1 Association for Perioperative Practice. Staffing for Patients in the 

Perioperative setting. Harrogate: AfPP, 2008. 

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for Children – Standard for Hospital Services. London: DoH, 2003. 

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for the Protection and Welfare of Children. London: DoH, 1999. 

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HSE, 2010. 

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University Press, 2009. 

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Porto: International Association for Ambulatory Surgery, 2006. 

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children in the Health Services. Just for the Day. London: The Stationery 

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Making it happen. London: HMSO, 1991. 

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12 Raeder J. Clinical Ambulatory Anesthesia. New York: Cambridge 

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13 Scottish Health Planning Note 52: Accommodation for Day Care: Part 

1: Day surgery unit. Glasgow: Health Facilities Scotland, 2001. 

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Medicine Series. London: BMJ Books, 2000. 

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www.audgen.gov.ie/documents/annualreports/2008/Appropriation_ 

Account_2008Rev1.pdf (accessed 11 ⁄ 01 ⁄ 2011). 




..................................................................................................................................... 

Appendix 1 

Sample screening questionnaire for use in day surgery. University Hospital of 

North Staffordshire, with permission. 




..................................................................................................................................... 




..................................................................................................................................... 

Appendix 2 

Sample patient information sheet for use in day surgery. Royal Surrey County 

Hospital NHS Foundation Trust, with permission. 




..................................................................................................................................... 

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 

___________________________________________________ 




..................................................................................................................................... 

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 




..................................................................................................................................... 

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 





Tel: 020 7631 1650 

Fax: 020 7631 4352 


Website: www.aagbi.org 

The British Association of Day Surgery 

35-43 Lincoln’s Inn Fields, London, WC2A 3PE 

Tel: 020 7973 0308 

Fax: 020 7973 0314 

Email: bads@bads.co.uk 

Website: www.bads.co.uk


Checking Anaesthetic Equipment 2012 

Published by 



Telephone 020 7631 1650 Fax 020 7631 4352 


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 


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 


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


Hartle et al. | Checking anaesthetic equipment 

.................................................................................................. 



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 


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. 


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 




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 



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. 




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. 



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 




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. 



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. 




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. 



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. 




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. 



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 




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 

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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). 

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(accessed 29 ⁄ 01 ⁄ 2012). 



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