Chapter 14: Guidelines for the Provision of Neuroanaesthetic Services 2024

Published: 31/01/2023


Neuroanaesthesia encompasses a wide range of emergency and elective work. Anaesthesia for intracranial oncology, vascular, hydrocephalus, trauma/neurotrauma, functional surgery, complex spinal surgery, as well as anaesthesia for diagnostic and interventional neuroradiological procedures, including MRI, all lie within the specialty.

Neuroanaesthesia is mainly delivered in neuroscience units, which may be based in specialist centres, teaching hospitals or district general hospitals. Neuroanaesthesia input is often required as part of multidisciplinary working with patients with complex head and neck cases.

Service demands on the departments of neuroanaesthesia and neuroanaesthetists have changed. Recent developments such as mechanical thrombectomy in the management of ischaemic stroke have the potential to significantly increase service delivery requirements in the future. Staffing departments of neuroanaesthesia and neurocritical care will be influenced by the development of intensive care medicine as a separate specialty.

The recommendations in this chapter aim to provide guidance for departments of anaesthesia to help them ensure adequate and safe service provision of neuroanaesthesia.

1. Staffing requirements


In each hospital providing neuroanaesthesia, a neuroanaesthetist should be appointed as the clinical lead (see Glossary) to manage service delivery. Adequate time for this role should be included in the lead’s job plan.

GPP Strong

There should be a specified and therefore identifiable group of neuroanaesthetists who cover the neuroanaesthesia service and these clinicians should have sufficient programmed activities to deliver the elective and emergency service.2,3

C Strong

There should be designated consultants in referring hospitals and neuroscience units with overall responsibility for the organisation, infrastructure and processes to enable safe transfer of patients with a brain injury.4

C Strong

An appropriately trained and experienced anaesthetist should be present for all neurosurgical operating lists and interventional neuroradiology sessions, with sufficient consultant-programmed activities to provide adequate supervision and support to anaesthetists in training and staff grade, associate specialist or specialty (SAS) anaesthetists.3,5

C Strong

Adequate anaesthetic cover should be available to provide general anaesthesia and sedation for diagnostic neuroradiology (i.e. brain and spine imaging) sessions, including computed tomography (CT) and MRI.

GPP Strong

Hospitals should have well-integrated arrangements that ensure anaesthetists covering long neurosurgical procedures or overrunning lists have regular breaks covered by an appropriate colleague for refreshment and comfort breaks.6,7,8,9 If a case is expected to run over three sessions, consideration should be given to organising a second anaesthetist.

C Strong

There should be local policy and agreement on how to staff late running lists and lists scheduled to run more than three sessions to prevent fatigue and patient safety issues.

GPP Strong

An appropriately skilled and experienced resident anaesthetist should be available at all times to care for postoperative and emergency patients. The experience and skills necessary to provide this cover are not usually found in anaesthetists in training in stage 1.3

C Strong

Out of hours, consultants should be immediately available (see Glossary) by telephone for advice and be able to attend the hospital within 30 minutes. Suitably skilled and experienced theatre staff should also be available.

GPP Strong

If the consultant on call is not a neuroanaesthetist, there should be a clearly defined and understood process for the provision of specialist advice from neuroanaesthesia colleagues. Where possible, local arrangements should be considered to facilitate this telephone advice in non-neuroscience centres when required.

GPP Strong

Departments that participate in national initiatives (e.g. services for thrombectomy) should review their staffing arrangements to ensure timely emergency cover.10,11 Thrombectomy should have a protocol-led service, ideally staffed by neuroanaesthetists.12

C Strong

Anaesthetic assistants should be appropriately skilled and should have up-to-date experience in neuroanaesthesia.

GPP Strong

All post-anaesthetic recovery staff looking after neuroscience patients should be able to recognise and describe complications following neuroanaesthesia and should possess skills to obtain multidisciplinary assistance and escalate treatment according to departmental protocols and guidance.

GPP Strong

Where departments use post-anaesthetic recovery units for extended recovery, the post-anaesthetic recovery staff caring for those patients should have a registered nurse or operating department practitioner: patient ratio of 1:2, as in a level 2 critical care unit. However, the care of an individual patient should be delivered on a one to one basis until the patient is able to maintain their own airway, has respiratory and cardiovascular stability and is able to communicate (where applicable).8 Departments should have procedures in place to demonstrate the adequacy of medical cover for such extended recovery units.

GPP Strong

2. Equipment, services and facilities

General equipment, services and facilities for anaesthesia are described in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients and Guidelines for the Provision of Emergency Anaesthesia. Specialised recommendations for neuroanaesthesia are given below.



Specific equipment for difficult airway management should be available in a clearly labelled trolley.

GPP Strong

Units should have access to ultra-short-acting opioids with stable context-sensitive half times deliverable by infusion using software accommodating a range of appropriate pharmacokinetic models that permits intraoperative cardiostability, smooth emergence from anaesthesia and rapid and accurate postoperative neurological assessment.

GPP Strong

Equipment that complies with Association of Anaesthetists standards for anaesthetic monitoring should be available.13

C Strong

Consideration should be given to continuing as much clinically indicated neuromonitoring as safely possible when the patient is transferred between critical care unit, theatres, interventional suite, MRI and CT scanners.14,15

B Strong

Monitoring equipment to detect venous air embolism and catheters for air aspiration should be available. The use of multiorifice catheters should also be considered.16,17

C Strong

Those units conducting functional neurosurgery or surgery for correction of scoliosis, other relevant spinal surgery, or surgery for some cranial lesions (e.g. cerebellopontine angle tumours) should have the appropriate equipment and adequate numbers of trained staff for intraoperative neurophysiological testing. Neuroanaesthetists should be aware of the implications of this testing for anaesthesia, including blood pressure management, use of neuromuscular blockade, and the use of total intravenous anaesthesia.14,17,18,19

B Strong

Equipment for safe positioning of patients with a wide range of body habitus should include:

  • appropriately sized mattresses
  • positioning aids to minimise risk of eye injury, nerve injury as well as skin damage (e.g. pressure sores) during potentially prolonged operations
  • fixings to prevent accidental movement during the procedure.
GPP Strong

Equipment to monitor patient temperature and to provide targeted temperature management should be available.20

B Strong

Availability of a cell salvage system should be considered for procedures associated with a risk of blood loss greater than 500 ml or exceeding 25% of circulating volume.21,22,23 Staff who operate this equipment should receive training in how to operate it and should use it frequently to maintain their skills.

C Moderate

The department should consider having a mobile phone available to staff for transfers of brain-injured patients.4 The transferring team should have access to mobile phones with the relevant contact details during the transfer to enable them to communicate with the receiving unit if required.

C Moderate

Support services


There should be same-day availability of ultrasound investigations, including echocardiography.

GPP Strong

Neuroradiology support should be available 24/7 for interpretation of neuroimaging.

GPP Strong

In hospitals with a dedicated neuroanaesthesia service dedicated neurology input should be available.

GPP Strong

Online imaging results from referring hospitals and within the neuroscience centre should be available locally, and consideration should be given to the provision of remote access for all anaesthetists who provide cover to neuroanaesthesia out of hours.

GPP Strong

There should be onsite laboratory provision or near-patient testing for blood gases, serum electrolytes, platelet function assay (if available), activated clotting time and viscoelastic haemostatic assays to allow safe management of patients in the operating theatre and angiography suite.24

C Strong

Rapid access to other biochemical and haematological investigations and blood transfusion should be provided.25

B Strong



Transfer times between the procedure room and critical care should be minimised. In new buildings, this may be achieved by having theatres, the critical care unit and radiological facilities within close proximity and preferably on the same floor. An integrated approach should be taken when planning new facilities.29

B Strong

Post-anaesthetic recovery facilities with appropriately trained staff and equipment should be available for elective and non-elective procedures.26

C Strong

3. Areas of special requirement


General recommendations for children’s services are described in GPAS Chapter 10: Guidelines for the Provision of Paediatric Services.


Whether in a dedicated paediatric neurosurgical unit or not, every child requiring elective neurosurgery should have care delivered by an anaesthetist or anaesthetists who possess the relevant competencies as demanded by the patient’s age, disease and comorbidities.

GPP Strong

New appointees to consultant posts with a significant or whole-time interest in paediatric neuroanaesthesia should have successfully completed stage 3 training in paediatric anaesthesia as defined in the certificate of completion of training (CCT) in anaesthesia.27

C Strong

Paediatric and neuroscience centres should consider partnering to help each to maintain expertise of the other area.

GPP Moderate

In a true emergency situation involving a child requiring urgent neurosurgery for a deteriorating condition admitted to an ‘adult only’ neurosurgical service, the most appropriate surgeon, anaesthetist and intensivist available would be expected to provide lifesaving care, including emergency resuscitation and surgery.28

C Moderate

Equipment and accessories appropriate for the age and size of any patient should be available and maintained in accordance with manufacturers' recommendations.

GPP Strong

In non-paediatric centres, appropriate immediate neurocritical care facilities should be available for all children until they can be transferred to a specialist centre.

GPP Strong

Critically ill patients

Many patients who undergo neurosurgery will be cared for pre or postoperatively in a critical care setting. Many neuroanaesthetists also work in neurocritical care settings. The provision of neurocritical care in a critical care setting is outside the scope of this chapter and is described in the Guidelines for Provision of Intensive Care Services.1


Neurocritical care should commence/continue in theatre; therefore standard operating protocols for invasive lines, monitoring and tracheal tubes should reflect local critical care policy.

GPP Strong

Departments of emergency medicine may also wish to adopt these standard operating procedures.

GPP Moderate

Magnetic resonance imaging

Recommendations on the provision of anaesthesia services for imaging services are described comprehensively in GPAS Chapter 7: Guidelines for the Provision of Anaesthesia Services in the Non-theatre Environment. Increasing numbers of neurosurgical units will have an interventional magnetic resonance (MR) suite that combines an operating theatre with an adjacent MR scanner; either in the same room or separated by shielded doors.


All staff working in MRI units must be trained in MR safety. The use of checklists before transfer to the scanner should be routine.29

GPP Strong

Mechanical thrombectomy services


Mechanical thrombectomy for acute ischaemic stroke should be available in specialist stroke centres; most are based within neurosurgical units. This will involve a formal network with an acute stroke centre served by regional comprehensive stroke centres.

GPP Strong

Anaesthetic support for mechanical thrombectomy should involve anaesthetic staff with appropriate training and experience in neuro-anaesthetic care and remote site anaesthesia. Operating department practitioner/anaesthetic nurse support should be available.30

GPP Strong

Protocols should be developed to ensure that accurate clinical information is available in a timely manner to the anaesthetist to avoid any delays in treatment. There should be an agreed process for alerting the mechanical thrombectomy team if anaesthetic provision is unavailable to allow referral to another mechanical thrombectomy centre.

C Strong

The decision whether to perform mechanical thrombectomy under local or general anaesthesia is based on the individual patient; with close communication with the neurointerventionalist. All patients should receive monitoring with the provision to convert to a general anaesthetic if needed.13

C Strong

Agreed local guidelines should include who should be managed under general anaesthesia.

GPP Strong

Anaesthetic care should be consultant or autonomously practising anaesthetist led, when possible. A neurocritical care facility should be available if needed after the procedure or a monitored bed on a hyperacute stroke unit as appropriate.

GPP Strong

All units should audit their practice regularly to look at types of anaesthesia, timing, agents used and complications and review of service delivery.

GPP Strong

Pregnant neurosurgical patients

Recommendations on the provision of anaesthesia services for the obstetric population are comprehensively described in GPAS Chapter 5: Guidelines for the Provision of Emergency Anaesthesia Services 2022.

4. Training and education

Opportunities for neuroanaesthesia training occur particularly during stage 2 and stage 3 (specialist interest area). Some anaesthetists in training (especially those considering a career in neuroanaesthesia or critical care) may opt for a further or longer attachment as a specialist interest area in stage 3 of the curriculum.


Any autonomously practising anaesthetist working in neuroanaesthesia must undertake continuing professional development (CPD) in neuroanaesthesia and must have sufficient regular programmed activities within this field to ensure that their specific skills and experience are maintained.27

C Strong

Departments should consider providing newly appointed consultants with a mentor to facilitate their development especially in a sub-speciality they may have limited experience.

GPP Strong

Consultant anaesthetists who provide out of hours cover to the neuroscience unit but do not provide neuroanaesthesia in working hours should be able to demonstrate the maintenance of appropriate skills and knowledge through regular clinical involvement and CPD.

GPP Strong

Elective neuroanaesthesia for highly specialised procedures that have limited case numbers (e.g. craniofacial procedures, awake neurosurgery and deep brain stimulation) should be provided by a dedicated subgroup of neuroanaesthetists within the department to ensure that they are able to treat sufficient numbers to maintain their competence in these areas.

C Strong

The use of simulation training for critical incident scenarios should be available to all members of the multidisciplinary team. Examples include the cardiopulmonary resuscitation of patients not in the supine position, patients with their head pinned, or where anaesthesia is being provided in an isolated site.31

C Strong

As anaesthetists in training spend limited time in the specialty, departments should facilitate the delivery of structured training programmes, developed by the school of anaesthesia.5

GPP Strong

Anaesthetists in training should be encouraged to attend other training opportunities within the neuroscience unit, such as grand rounds, radiology and pathology case conferences, and morbidity and mortality meetings.

B Strong

Fellowship posts should be identified to allow additional training for those who wish to follow a career in neuroanaesthesia or neurocritical care.32 Such posts should provide similar or enhanced levels of teaching, training and access to study leave as regular training posts.

B Strong

5. Organisation and administration

Detailed recommendations for organisation and administration of anaesthesia services can be found in GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for Perioperative Care of Elective and Urgent Care Patients.


Much of neurosurgery involves acute work with a high degree of urgency. The provision of associated services should recognise this need and inappropriate delay should not be allowed to occur as a result of lack of key personnel or facilities. Laboratory services, neuroradiology, availability of operating theatre time and sufficient levels 1–3 bed provision should all be organised to cope with these demands.

GPP Strong

There should be sufficient numbers of clinical programmed activities in consultants’ job plans to provide cover for all elective neurosurgical operating lists and to provide adequate emergency cover.

GPP Strong

Departments of neuroanaesthesia and neurocritical care, even if part of a large general department, should be provided with adequate secretarial and administrative support.

GPP Strong

The neuroanaesthesia multidisciplinary team should be involved in the local and regional planning of relevant neuroscience services (e.g. thrombectomy).

GPP Strong

Face-to-face and/or telemedicine preadmission clinics for elective neurosurgery should be available, with early input from the department of neuroanaesthesia, particularly for high-risk patients and those where additional time and discussion are required, such as awake craniotomy.33 All centres should be able to demonstrate that discussion of perioperative risk is routine and that specific risks related to, for example prone positioning, are communicated.34,35,36

B Strong

Preoperative assessment clinics should ensure that the patient is optimised as best as possible for elective neurosurgery (e.g. for correction of anaemia), as this can reduce the length of hospital stay, need for blood transfusion and postoperative morbidity.25

B Strong

Patients suitable for daycase neurosurgery should be identified and should follow an agreed pathway.37

B Strong

Hospitals should have systems in place to facilitate multidisciplinary meetings for neuroscience services.

GPP Strong

A World Health Organization (WHO) checklist adapted for neuroscience procedures should be in use.38

C Strong

The theatre team should all engage in the use of the WHO surgical safety process, commencing with a team brief and concluding the list with a team debrief.38 Debrief should highlight things done well and should also identify areas requiring improvement. Teams should consider including the declaration of emergency call procedures specific to the location as part of the team brief.

C Strong

For standalone neuroscience centres, local arrangements should be in place for specialist opinion and review of patients by other disciplines. A named consultant neuroanaesthetist should be identified to facilitate such liaison.

GPP Strong

Hospitals should review their local standards to ensure that they are harmonised with the relevant national safety standards (e.g. National Safety Standards for Invasive Procedures in England or the Scottish Patient Safety Programme in Scotland).39,40

C Strong

Local guidance should be developed for the intrahospital transfer of neuroscience patients, based on guidance from the Neuroanaesthesia and Neurocritical Care Society (NACCS), the Association of Anaesthetists and the Intensive Care Society.41,42,43

C Strong

Each department should appoint a designated liaison consultant responsible for identifying the strategic pathways and logistical pitfalls of the intrahospital transfer of neurosurgical patients. The appointment should ensure that any identified problems are either removed or mitigated.

GPP Strong

Communication with critical care should occur at the earliest possible time (preoperative clinic letter) to enhance the appropriate allocation of beds.

GPP Strong

Postoperative procedures


Standardisation of the handover process can improve patient care by ensuring information completeness, accuracy and efficiency.44,45 The use of perioperative care bundles should be considered.42

B Strong

The 24/7 acute pain service should be available for neurosurgical patients and staff should be trained to address the specific needs of neurosurgical patients, such as those with impaired communication.46

C Strong

Pain is a useful outcome measure for audit.47,48 The utility of specific local and regional techniques for neurosurgical patients is established and pain teams should be aware of these techniques.46,49

B Strong

Postoperative cognitive deficit (POCD) and delirium can be masked by a patient’s neurological condition. Identifying the potential causes for POCD and surveillance for delirium should be a part of the entire perioperative patient journey for all staff and the condition should be managed appropriately by the multidisciplinary team.8,49,50,51

C Strong

6. Financial considerations

Part of the methodology used in this chapter in making recommendations is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.

The vast majority of the recommendations are not new recommendations, but they are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, and so it is not possible to calculate the financial impact of the recommendations in this chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.


It is recognised that equipment for neurosurgical patients can be expensive; this should be considered through business models.

GPP Strong

7. Research, audit and quality improvement


Departments of neuroanaesthesia should be encouraged to develop research interests, even if not part of an academic department. Research collaboration with other neuroscience disciplines is good practice. Taking part in national anaesthesia and critical care projects is to be encouraged.41,52

C Strong

Audit programmes should be developed locally but should include continuous audit of transfer of neuroscience patients, neurocritical care capacity and demand, rates of unplanned admission and readmission to the intensive care unit, and the caseload of anaesthetists in training, among others. In general, local practice should be audited against compliance rates with national and expert consensus guidelines.5,41,53

C Strong

Collaborative audit with the other neuroscience disciplines should be encouraged, as well as close liaison and joint transfer audits with referring hospitals.6

C Strong

Regular morbidity and mortality meetings should be held jointly with neurosurgeons, interventional neuroradiologists and other relevant stakeholders.

GPP Strong

All departments should maintain active links to national bodies and societies (e.g. NACCS Link Doctor Scheme) to facilitate national audit and dissemination of information.

GPP Strong

Clinical research staff allocation to clinical activities (beyond those job planned) should be limited to situations of major strain in the resources, such as major departmental emergencies.54

C Moderate

8. Implementation support

The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, provides a set of standards based on the recommendations contained in the GPAS chapters. As part of the scheme, departments of anaesthesia  self-assess against the standards and undertake quality improvement projects to close the gap. Support is provided by the RCoA in the form of the good practice library, which shares documents and ideas from other departments on how to meet the standards. Further advice can be obtained from the ACSA team and department’s assigned College guide.

The ACSA standards are regularly reviewed on at least a three yearly basis to ensure that they reflect current GPAS recommendations and good practice. This feedback process works both ways and the ACSA scheme regularly provides CDGs with comments on the GPAS recommendations, based on departments’ experience of implementing the recommendations.

Further information about the ACSA scheme can be found here:

9. Patient information

The Royal College of Anaesthetists has developed a range of Trusted Information Creator Kitemark-accredited patient information resources that can be accessed from the RCoA website, including information on sedation, resources for children and young people and accessible resources. Our main leaflets are now translated into more than 20 languages, including Welsh.

Detailed recommendations regarding patient information and consent are described in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.


Patients should be provided written information (in a format of their choice) specific to the neurosurgical procedure they are planned to undergo, which explains the procedure, any preoperative preparation required, the risks, benefits and relevant advice in an easy to understand language.

GPP Strong

All patients (and relatives where appropriate and relevant) should be fully informed about the planned procedure and should be encouraged to be active participants in decisions about their care, including the option of doing nothing.8

C Strong

For patients undergoing diagnostic procedures such as MRI, although separate written consent for anaesthesia is not mandatory in the UK, all discussions about sedation and anaesthesia should be documented. Discussion should include methods of induction, associated risks, side effects and potential benefits of the procedure. It is not the responsibility of the anaesthetist to explain the indications for the procedure.55,56

C Moderate

If the patient is planned to be discharged on the same day after their procedure, relevant information should be provided on discharge, including contact details for the neurosurgical service. Other relevant recommendations for daycase anaesthesia outlined in Guidelines for the Provision of Anaesthesia Services for Day Surgery should be followed.57

C Strong

For procedures such as awake craniotomies, departments should consider giving patients information in different formats including audiovisual. Consideration should be given to offering patients who are anxious about their awake procedure a prior visit to various areas of operating theatres.

GPP Moderate

The possibility of a parent or carer being present at induction and/or during recovery from anaesthesia should be explored where this is considered to be in the best interests of the patient.

GPP Moderate

Areas for future development

We recommend that further consideration be given to research in the following areas:

  • development of daycase neurosurgery, including craniotomies
  • enhanced recovery for neurosurgical patients
  • the use of cardiopulmonary exercise testing and other prognostic tools for neurosurgical patients
  • routine use of echocardiography following subarachnoid haemorrhage
  • employment of anaesthesia associates for the provision of neuroanaesthesia services in conjunction with consultants
  • effectiveness and accuracy of early warning scores in neurosurgical patients
  • use of virtual preoperative assessment clinics for assessment of long-distance patients in tertiary neurosurgical centres
  • use of retrieval teams to transfer emergency patients
  • use of processed EEG monitors during inter- and intrahospital transfer for neurosurgical patients undergoing ventilation of the lungs with neuromuscular blockade.


Autonomously practising anaesthetist - a consultant, or an associate specialist, specialist doctor and speciality doctor (SAS) doctor who can function autonomously to a level of defined competencies, as agreed within local clinical governance frameworks. 

Clinical lead – doctors undertaking lead roles should be autonomously practising doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality improvement and CPD activities. Individuals should be fully supported by their clinical director and should be provided with adequate time and resources to allow them to effectively undertake the lead role.

Immediately – unless otherwise defined, ‘immediately’ means within five minutes.

Neuroanaesthetist – will have regular neuroscience sessions (most often at least two sessions per week), will be involved in neuroscience morbidity and mortality conferences and will carry out regular CPD in this area.


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