Chapter 14: Guidelines for the Provision of Neuroanaesthetic Services 2019
Neuroanaesthesia encompasses a wide range of emergency and elective work. Anaesthesia for intracranial oncology, vascular and functional surgery, complex spinal surgery, as well as anaesthesia for diagnostic and interventional neuroradiological procedures including MRI scanning 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 in 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.
There should be a specified and therefore identifiable group of neuroanaesthetists who cover the neuroanaesthesia service and have sufficient programmed activities to deliver the elective and emergency service.4
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 trainee anaesthetists and SAS anaesthetists.
Adequate anaesthetic cover should be available to provide general anaesthesia and sedation for diagnostic radiology sessions, including computed tomography (CT) and magnetic resonance imaging (MRI) scans.
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 training grades below ST3.
Out of hours, consultants should be immediately available by telephone for advice and be able to attend the hospital within 30 minutes. Suitably skilled and experienced theatre staff should also be available.
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.
Anaesthetic assistants should be appropriately skilled and have up to date experience in neuroanaesthesia.
All post anaesthetic recovery staff looking after neuroscience patients should be able to recognise and describe complications following neuroanaesthesia and possess skills to obtain multidisciplinary assistance and escalate treatment according to departmental protocols and guidance.
Where departments use post anaesthetic recovery units for extended recovery, the post anaesthetic recovery staff caring for those patients should have the competencies to manage Level 2 critical care patients and there should be a registered nurse/patient ratio of 1:2, as in a Level 2 critical care unit.10 Departments should have procedures in place to demonstrate the adequacy of medical cover for such extended recovery units.
2. Equipment, services and facilities
General equipment, services and facilities for anaesthesia are described in chapters 2–5. Specialised recommendations for neuroanaesthesia are given below.
Specific equipment for difficult airway management should be available.
Units should have access to ultra short acting opioids with stable context sensitive half times deliverable by infusion a software accommodating a range of appropriate pharmacokinetic (PK) models to permit intraoperative cardiostability, smooth emergence from anaesthesia and rapid and accurate postoperative neurological assessment.
Equipment to comply with Association of Anaesthetists standards for anaesthetic monitoring should be available.11
Depth of anaesthesia monitoring, including processed electroencephalography (EEG) monitors, should be available intraoperatively and for transfer.12
Monitoring equipment to detect air embolism and catheters for air aspiration should be available. The use of multiorifice catheters should also be considered.13
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 (TIVA).13,14
Equipment for safe positioning of patients with a wide range of body habitus should include:
- appropriate 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.
Equipment to monitor patient temperature and to provide targeted temperature management should be available.15
There should be same day availability of echocardiography investigations, including echo and ultrasound scanning.
Neuroradiology support should be available 24/7 for interpretation of neuroimaging.
In hospitals with dedicated neuroanaesthesia service there should be dedicated neurology input available.
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.
There should be onsite laboratory provision, or near patient testing, for blood gases, serum electrolytes, platelet function assay, activated clotting time and thromboelastography, to allow safe management of patients in the operating theatre.18
Rapid access to other biochemical and haematological investigations and blood transfusion should be provided.
Transfer times between the procedure room and intensive care should be minimised. In new buildings, this may be achieved by having theatres, the intensive care unit and radiological facilities within close proximity and preferably on the same floor. An integrated approach should be taken when planning new facilities.19
Postoperative recovery facilities, with appropriately trained staff and equipment, should be available to all neurosurgical and neuroradiological patients undergoing surgery, both elective and emergency.21
3. Areas of special requirement
General recommendations for children’s services are described in chapter 10.
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.
New appointees to consultant posts with a significant or whole time interest in paediatric neuroanaesthesia should have successfully completed Advanced Level training in paediatric anaesthesia as defined in the certificate of completion of training (CCT) in anaesthesia.22
Paediatric and neuroscience centres should consider partnering to help each maintain expertise of the other area.
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 life saving care, including emergency resuscitation and surgery.23
Equipment and accessories appropriate for the age and size of any patient should be available and maintained in accordance with manufacturers' recommendations.
Appropriate neurocritical care facilities should be available for all children.
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 Faculty of Intensive Care Medicine and Intensive Care Society 2016 publication, Guidelines for the provision of intensive care services.1 Neurocritical care should commence in theatre, therefore standard operating protocols for invasive lines, monitoring and tracheal tubes should reflect local critical care policy. Departments of emergency medicine may also wish to adopt these standard operating procedures.
Recommendations on the provision of anaesthesia services for imaging services are comprehensively described in chapter 7.
Pregnant neurosurgical patients
Recommendations on the provision of anaesthesia services for the obstetric population are comprehensively described in chapter 5, section 3.
4. Training and education
Opportunities for neuroanaesthesia training occur at ST3–ST4 and, post fellowship, at ST5–ST7. A key learning objective is the initial management and transfer of the brain injured patient. Some trainees (especially those considering a career in neuroanaesthesia or critical care) will opt for a further/longer attachment at an advanced level.
Consultants and SAS doctors working in neuroanaesthesia should have sufficient regular programmed activities within this field to ensure that their specific skills and experience are maintained.
Departments should consider providing newly appointed consultants with a mentor to facilitate their development in neuroanaesthesia if they have had limited experience in the specialty as a trainee.
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 continuing professional development (CPD).
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 in order to maintain their competence in these areas.
The use of simulation training for critical incident scenarios should be available to all members of the multidisciplinary team. Examples include CPR of patients not in the supine position, patients with their head pinned, or if anaesthesia is being provided in an isolated site.24
As trainees spend limited time in the specialty, departments should facilitate the delivery of structured training programmes, developed by the school of anaesthesia, to ensure all core topics are covered. To ensure that their time in neuroanaesthesia is of maximum benefit, departments might consider allowing the trainees some flexibility in list attachments so once case mix is known, they can allocate themselves to the list which provides the optimum training opportunity.
Trainees should be encouraged to attend other training opportunities within the neuroscience unit, such as grand rounds, radiology and pathology case conferences, and mortality and morbidity meetings.
Fellowship posts should be identified to allow additional training for those who wish to follow a career in neuroanaesthesia or neurocritical care. These should be suitable for trainees who wish to take time out of training programmes, or for those who are post CCT. Such posts should provide similar or enhanced levels of teaching, training and access to study leave as regular training posts.
5. Organisation and administration
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 level 1–3 bed provision should all be organised to cope with these demands.
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.
Departments of neuroanaesthesia and neurocritical care, even if part of a large general department, should be provided with adequate secretarial and administrative support.
Consultants in neuroanaesthesia should be involved in the local and regional planning of any novel neuroscience services e.g. thrombectomy.
Preadmission clinics for elective neurosurgery should be available, with early input from the department of neuroanaesthesia particularly for high risk cases and those where additional time and discussion are required, e.g. awake craniotomy. All centres should be able to demonstrate that discussion of perioperative risk is routine and that specific risks related to, e.g. prone positioning are communicated.25,26,27
A World Health Organization (WHO) checklist adapted for neuroscience procedures should be in use.
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.30 Debrief should highlight things done well and 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.
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.
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 Scotland31,32 Organisational leaders are ultimately responsible for implementing local safety standards as necessary.
Local guidance should be developed for the intrahospital transfer of neuroscience patients, based on guidance from Neuro Anaesthesia and Critical Care Society of Great Britain and Ireland (NACCS), Association of Anaesthetists and the Intensive Care Society. 33
Each department should appoint a designated liaison consultant responsible for identifying the strategic pathways and logistical pitfalls of the intra-hospital transfer of neurosurgical patients. The appointment should ensure any identified problems are either removed or mitigated.
Communication with critical care should occur at the earliest possible time (preoperative clinic letter) to enhance the appropriate allocation of beds.
The 24/7 acute pain service should be available for postoperative neurosurgical patients and be trained to address the specific needs of neurosurgical patients such as those with impaired communication.
General intraoperative policies outlined in chapter 3 should be held and easily accessible. The following policies for neuroanaesthesia should also be available:
- management and transfer of neuroscience patients40
- CPR for patients with their head pinned and for those in the non-supine position
- patients with severe head injury.
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 and this should be considered through business models.
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.33,41
Audit programmes should be developed locally but should include continuous audit of transfer of brain injured patients, neurocritical care capacity and demand, rates of unplanned admission and readmission to the intensive care unit, and the caseload of trainees. In general, local practice should be audited against compliance rates with national and expert consensus guidelines.33,42
Collaborative audit with the other neuroscience disciplines should be encouraged.
Regular morbidity and mortality meetings should be held jointly with neurosurgeons, interventional neuroradiologists and other relevant stakeholders.
Departments should be encouraged to maintain active links to national bodies and societies, e.g. NACCS Linkman Scheme, to facilitate national audit and dissemination of information.
8. Implementation support
The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process on payment of an appropriate fee. Once subscribed, they are provided with a ‘College guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the standards document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards (and by doing so to test the GPAS recommendations) to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
9. Patient information
Each department should provide written information specific to neurosurgical procedures, including relevant risks for surgery conducted in the prone position and postoperative visual loss (POVL).
All patients (and relatives where appropriate and relevant) should be fully informed about the planned procedure and be encouraged to be active participants in decisions about their care. Recommendations about the provision of information and consent processes outlined in chapter 2 should be followed.43
Although separate written consent for anaesthesia is not mandatory in the UK, there should be a written record of all discussions, including those of the requesting clinician, with patients undergoing sedation or anaesthesia for diagnostic procedures such as MRI scans. 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.44
The scope of the authority that has been given by a patient should not be exceeded except in an emergency. In an emergency clinical situation in which it is not possible to find out a patient’s wishes, a patient should be treated without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment provided should be the least restrictive of the patient’s future choices.45,46,47,48
Areas for future development
We recommend that further consideration be given to research in the following areas:
- development of day case neurosurgery including craniotomies
- enhanced recovery for neurosurgical patients
- the use of cardio pulmonary exercise testing (CPEX) and other prognostic tools for neurosurgical patients
- routine use of echocardiography following subarachnoid haemorrhage
- utilisation of physicians' assistant (anaesthesia) for 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 pEEG monitors during inter and intrahospital transfer of neurosurgical patients undergoing ventilation of the lungs with neuromuscular blockade.
Clinical lead - SAS doctors undertaking lead roles should be autonomously practicing 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 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 – Neuroanaesthetists will have regular neuroscience sessions (most often at least 2 sessions per week), be involved in neuroscience M&Ms and carry out regular CPD in this area.