Chapter 17: Guidelines for the Provision of Anaesthesia Services for Burn and Plastics Surgery 2019
The range of procedures requiring anaesthesia for burn and plastic surgery is wide and includes patients of all ages. These range from those with common minor injuries (dog bites, nail bed injuries), to planned congenital cleft and hand procedures, and less frequently major burns and free-flap cases requiring multidisciplinary perioperative critical care. The recommendations in this chapter should be read in conjunction with those for general surgery, outlined in chapters 2–5, which unless otherwise stated, still apply.
Approximately 140,000 patients sustain burn injuries each year, with approximately 10% requiring admission to hospital, of which 50% are children. Burn care is stratified with four operational delivery networks in England and Wales and one in Scotland. Services are tiered for children and adults, following nationally agreed referral criteria,1 with referral to Burn Facilities, Burn Units or Burn Centres dependent on the severity and complexity of the injury and locality. The Burn Care Standards were revised in 2013 to allow services to be peer reviewed against agreed benchmarks for specialist infrastructure and staff. The recommendations in this chapter apply to all tiers of burn care services, unless otherwise stated within individual recommendations.
Anaesthetists undertaking burn surgery need to be part of a multidisciplinary team and actively partaking in decision-making, inputting into ward management (including dressing changes and analgesia), critical care, and multidisciplinary team meetings.
Understanding the complexity of surgery for major burns surgery is vital. This includes the need to be prepared for massive blood loss, difficulties with monitoring and venous access, management of heat loss, prevention of thromboembolic events, and sepsis; as well as complex analgesia requirements, and understanding the impact on the patient and their family and of ongoing care for many years ahead. Anaesthetic services are not confined to provision of care in a theatre or critical care environment. Provision of remote analgesia, sedation and anaesthesia comes with its own potential difficulties with regard to monitoring and access to anaesthetic equipment. Services need to be able to provide care to meet standards for the admission to theatre of a patient with a major burn with little notice. Repeat and prolonged surgery for major burns is likely to continue for many weeks to months, with an impact on facilities, staff and equipment. Age appropriate services for anaesthesia and critical care must meet national and RCoA standards.
Plastic surgery describes a reconstructive procedure designed to restore form and function to the body. It covers all aspects of wound healing and reconstruction after congenital, acquired (including secondary to cancer) or traumatic tissue defects. Other common conditions that can require plastic surgery include reconstruction of large skin defects, pressure sores and other chronic wounds, venous and other leg ulcers, and the results of devastating infections. Clinicians anaesthetising for plastic surgery procedures need an understanding of the principles of free-flap surgery. Age appropriate staff and facilities are required for complex surgery for congenital conditions, including cleft palate, congenital hand deformities, and trauma procedures. Prolonged procedures are common and require attention to detail regarding positioning, fluid management, blood flow, and prevention of thromboembolic complications.
Aesthetic surgery is surgery carried out solely to change a person’s appearance. Where a patient is receiving anaesthesia or sedation and is under the care of an anaesthetist for this type of surgery, the recommendations in this chapter and those relating to all types of surgery in chapters 2-4, still apply, regardless of the funding model of the setting.
1. Staffing requirements
An appropriately trained and experienced anaesthetist with regular commitments to burn and plastic surgery should be present during the conduct of general and regional anaesthesia for operative procedures, including those procedures requiring intravenous sedation where it has been agreed that this will be provided by the anaesthetic department.
An anaesthetist should be physically present when a general anaesthetic is administered. In exceptional circumstances, anaesthetists working singlehandedly may be called on briefly to assist with or perform a lifesaving procedure nearby. This is a matter for individual judgement, and the dedicated anaesthetic assistant should be present to monitor the unattended patient.8
A clinical lead for burn and plastic surgery anaesthesia should be appointed in each hospital providing anaesthesia for this specialty.
Anaesthetists should always be supported by dedicated, appropriately skilled and trained assistants, and the recovery facilities should be staffed during all operating hours and have appropriate anaesthetic support until the patient meets agreed discharge criteria.9
There should be adequate numbers of competent medical and non-medical staff to provide 24/7 cover for emergency burn and plastics anaesthesia.10
There should be specific consultant programmed activity for burn anaesthesia in hospitals where burn surgery is undertaken.11
Where burn services are providing a Burn Centre level of care, there should be a 24/7 rostered availability of ST3 or above specialty registrars or appropriately experienced staff grade, associate specialist and specialty (SAS) doctors and emergency consultants. In Burn Centres that provide paediatric services, there should be a 24-hour rostered availability of consultant paediatric anaesthetists.11
There should be sufficient programmed activity time available for anaesthetists to assess patients perioperatively and attend multidisciplinary ward rounds.
There should be sufficient programmed activity to provide support to sedation and analgesia services for burn patients.
The clinical lead (see glossary) anaesthetist in burn and plastic surgery units will be responsible for the provision of service, teaching, production of guidelines, management, research, and audit, and be able to support quality improvement initiatives. Sufficient time should be included in job plans to support these activities and the continuing professional development of those anaesthetists.
2. Equipment, services and facilities
General equipment, services and facilities for anaesthesia are described in chapters 2–5. Additional specialised recommendations for burn and plastic surgery anaesthesia are given below.
Appropriate equipment should be available to enable prone positioning of patients.13
Airway and ventilation
A difficult airway trolley, including the equipment necessary for failed intubation and surgical airway access, should be available.14 Appropriate specialist intubation equipment, including fibre-optic intubation equipment should be available. A fibre-optic scope should be available to assess inhalational injury.15,16,17,18,19
Equipment necessary for the formation of a surgical airway, including cricothyroidotomy, should be available.20
Ventilators with advanced ventilatory mode functions should be available.21
Equipment to comply with the Association of Anaesthetists standards for anaesthetic monitoring should be available.23
Pulse-oximetry ear probes should be available.22
An arterial blood-gas machine should be immediately available.
Equipment to measure carbon monoxide levels in blood should be available.15
Equipment for delivery of anaesthesia services out
Many burn-injured patients will require frequent sedation or anaesthesia for procedures outside the operating theatre. These should take place in a specified location that is provided with all the equipment required for the safe delivery of anaesthesia and to meet minimum monitoring standards.5,23,27
Equipment for temperature management
The combination of lengthy procedures in cold operating theatres, large exposed areas of body surface, and administration of large volumes of fluids, can lead to marked intraoperative hypothermia. The consequences of hypothermia can be serious and affect outcomes in burn and plastic surgery patients.31 Potential complications include cardiac events, coagulation disorders and blood loss, increased incidence of surgical wound infection, postoperative shivering, and prolonged hospital stay, as well as the increased costs associated with surgery.32 The requirement for intraoperative analgesia and recovery times have been shown to be significantly lower for warmed plastic surgery patients.31
Consideration should also be given to the provision of radiant heaters and more sophisticated warming devices.15
Burn patients are at particular risk of thromboembolic complication.
For burn and plastic surgery patients, mechanical methods of VTE prophylaxis, including graduated compression stockings, intermittent pneumatic compression devices, and venous foot pumps, should be available for any procedure that lasts more than one hour, and for all patients receiving general anaesthesia.26,34
Debridement of major burns has the potential for significant blood loss.
Equipment for blood transfusion should be available, including rapid transfusion devices.
Point of care testing for coagulation and haemoglobin, including thromboelastometry, could be considered to allow targeted use of blood products in major surgery for burns.35
Advice from a haematologist should be available at all times.
There should be adequate, age-appropriate critical care facilities, including high-dependency and intensive care units fulfilling national standards, to allow the timely admission of patients who require these services following surgery, including those with resuscitation burns and undergoing free-flap surgery.6,11,25,39
A burns theatre should be located in immediate proximity to any service providing critical care for burn patients.11
A dedicated burns theatre should be adequately stocked and resourced. Theatre anaesthetic equipment and transport monitoring should be compatible with that used in the critical care rooms. Single use patient items are preferred, and protocol-based cleaning is needed between cases.15
Anaesthetic led sedation for dressing changes should take place in rooms equipped with monitoring, piped medical gases, scavenging (where needed), suction, an anaesthetic machine, and drug-infusion pumps.
Access to a high dependency unit for patients undergoing reconstructive surgery should be available.40
3. Areas of special requirement
Wherever children and young people undergo anaesthesia, their particular needs should be recognised, and they should be managed in age appropriate facilities and be looked after by staff with relevant experience and ongoing training.2
Children with burns should be cared for in burn services in accordance with the National Burns Care Referral Guidance and with staff and facilities according to the Burn Care Standards.11
Children requiring surgery for cleft lip and palate should be treated by a specialist cleft service.
Wherever sedation services for paediatric burn management exist, anaesthetists should be involved with setting up, monitoring and auditing the service.
Anaesthetists who prescribe sedation for paediatric burn patients should have received appropriate training.41
Anaesthetists who prescribe oral sedation for paediatric burn patients do not need to be physically present for the procedure for which sedation is being prescribed, but they, or other suitably trained and experienced staff, need to be available to return immediately if the need arises.42
A hospital education and play service should be available for children.11
It is essential to exclude non-accidental injury in children with burn injuries.
Healthcare workers, including the anaesthetist, must be aware of the local policy for child protection, and they have an obligation to document and report any concerns to a responsible individual.43
Major burn injuries and complex plastic surgery cases often require critical care services. Recommendations for the provision of such services are described in Guidelines for the provision of intensive care services.6
Staffing models should promote shared care between burn and critical care teams as this may improve safety.45
Dressing changes, with or without showering or bathing, are a frequent accompaniment to the early phase of burn treatment. Where possible, they are conducted without general anaesthesia.
4. Training and education
Different levels of training and ongoing education are required, depending on the level of service provision provided by hospitals.
Patients requiring burn or plastic surgery procedures should be managed by anaesthetists who have an appropriate level of training in this field, have regular commitment to the burn and plastic surgery specialty, and have acquired the relevant knowledge and skills needed to care for these patients.
In order to maintain the necessary repertoire of skills, anaesthetists providing a burn and plastic surgery anaesthetic service should have a regular commitment to the specialty, and adequate time must be made for them to participate in a range of relevant continuing medical education (CPD) activities.
A small number of centres perform burn surgery. These centres should offer external training opportunities for anaesthetists, nursing staff, physiotherapists and other members of the multidisciplinary team.48
Anaesthetists who provide emergency care outside burn services should be trained in the initial management of the patient with severe burns, including timely emergency assessment, resuscitation, and transfer to a burns service, through the EMSB (Emergency Management of the Severe Burn) or an equivalent course.49
5. Organisation and administration
Requirements for links to other departments
Teams rather than individuals deliver care of the burn-injured patient. Effective teamwork can increase safety, whilst poor teamwork can have the opposite effect. It is therefore important that burn services anaesthetists develop good working relationships and lines of communication with other healthcare professionals involved in burn patients’ care.49
The anaesthetist should be part of a burns multidisciplinary team.11
Organisation of lists
Burn surgery operating lists should be scheduled in working hours.51
Additional burn surgery operating lists may be planned at weekends and bank holidays to prevent unnecessary delays in treatment.50
Any scheduled burn lists should be organised and staffed by appropriately trained anaesthetists and surgeons, working regularly in that area, who have no conflicting clinical commitments.50
Patients requiring planned or emergency burn surgery should be cared for by theatre staff with current experience in burn care.11 Anaesthetists who provide emergency care outside burn services should be trained to manage the initial treatment of the patient with severe burns, including timely emergency assessment, resuscitation, and transfer to a burns service.
A nurse led sedation service should be supported by an immediately available burn anaesthetist.41
Contingency plans for urgent procedures
Timely access to theatre staff with experience in burn care should be available outside of normal working hours.11
Theatre teams should be informed whenever a major burn case is expected or has arrived. A member of the theatre team should be responsible for ensuring the availability of appropriately trained staff and facilities.11
All specialist burn services should participate in major incident planning with national and regional networks.11
Providers of emergency care outside burn services should have the knowledge and equipment needed to treat burn-injured patients should there be an extended delay in transporting the patients to a burn centre, as might be the case in a mass casualty incident.54
Agreed local clinical guidelines should be in use which have been produced by an appropriately constituted multiprofessional team, comprising anaesthetists, specialist nurses, surgeons, critical care clinicians, pharmacists, specialty consultants and managers. These guidelines should cover at least the following:
- assessment and management of pain and itch, including the recording of pain and itch scores11,58
- sedation for painful procedures11
- initial assessment and management of burn-injured patients11
- recognition and management of the acutely unwell and deteriorating patient, including the need to escalate care and transfer to a higher level of care11
- assessment and management of burns to the face and airway11
- transfer policy, including the resources required11
- all trusts with an emergency department should have a plan for the management of major incidents involving burn-injured patients59 which makes reference to the national burn major incident plan11
- management of multi-drug resistant infections
- perioperative temperature control15,60
- major haemorrhage and transfusion policy 35
- provision of sedation and anaesthesia outside of the operating theatre environment52
- a lipid rescue protocol should be in place where local anaesthetic infiltration is used.61
Organisation of lists
Elective plastic surgery operating lists should be separated from those for plastic surgery trauma to allow efficient planning in advance for elective cases, prevent cancellation of elective cases and allow a flexible response to emergencies.50
Hospitals should provide scheduled local anaesthetic lists, using a dedicated area for initiating and assessing local nerve blocks. Organising cases in this way fosters the development and maintenance of expertise in the anaesthetists and support staff, and minimises delay between cases.
For planned burn and plastic surgery there should be a preoperative assessment clinic organised as described in chapter 2.
There should be specific guidelines for assessing a suspected difficult airway, for example in patients with head and neck malignancy and in reconstructive burn surgery.62
Where major elective reconstructive surgery requiring postoperative critical care provision is undertaken, the funding for, and provision of, these beds should be planned to meet the demands of the service, so that unnecessary cancellations can be minimised.
All major head and neck surgery should be overseen by a named consultant anaesthetist with a subspecialty interest in this area.63
When very long surgical procedures are scheduled on a regular basis, appropriate funding and resources should be in place to support long duration lists.
Contingency plans for urgent procedures
All major head and neck surgery should be overseen by a named consultant anaesthetist with a subspecialty interest in this area.50
Patients should not unnecessarily undergo surgery at night. In order to prevent this, planned operating lists may be necessary in the evening and weekend, in addition to scheduled weekday trauma sessions.50
Any scheduled plastic surgery trauma lists should be organised and staffed by senior anaesthetists and surgeons, working regularly in that area and without conflicting clinical commitments.50
Departments should develop and regularly review burn and plastic surgery referral guidelines and major incident plans.53
Agreed local clinical guidelines should be in use, produced by an appropriately constituted multiprofessional team, comprising anaesthetists, specialist nurses, surgeons, critical care clinicians, pharmacists, specialty consultants and managers. These guidelines should cover at least the following:
6. Financial Considerations
The costs of burn care are high due to the combination of specialised treatment and the often long lengths of stay.65 Part of the methodology used in this chapter is a consideration of the financial impact for each of the recommendations made. Very few of the literature sources referenced have included financial analysis.
The majority of the recommendations are not new, but are a synthesis of pre-existing work. Current compliance rates with the recommendations are unknown, and so it is not possible to calculate the financial impact of their implementation in future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.
7. Research, audit and quality improvement
Anaesthesia for burn and plastic surgery should be included in regular anaesthetic department mortality and morbidity meetings, audit meetings and quality improvement programmes.
Multidisciplinary audit meetings involving surgical teams should be encouraged, where mortality and morbidity should be discussed alongside all serious untoward incidents relative to the service.
Anaesthetic departments should be integrated into the overall clinical audit and governance structure of the hospital. Each anaesthetic department undertaking anaesthesia for burn and plastic surgery should have a system in place for the routine audit of important areas such as:
Burn services should undergo regular peer reviews within the national burn care network.11
Departments of anaesthesia should be encouraged to develop local key quality indicators relevant to their activity, which will assist in the process of supporting quality improvement.11
Research in anaesthesia for burn and plastic surgery should be encouraged. Staff members undertaking research should have received appropriate training.69
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
Patients with difficult airways
When an awake fibre-optic intubation is required, patients should be informed. As part of a difficult airway follow up, patients should be informed verbally and in writing about any airway problem the anaesthetist encountered, and be advised to bring this to the attention of anaesthetists during any future preoperative assessment. The patient’s GP should also be informed in writing.70
Where alternative techniques are available, the patient’s preference must be fully taken into account.71
Areas for future development
Topics in anaesthesia for burn and plastic surgery in need of further research:
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.