Give your child breakfast in the morning, before 07.30am. He/she will then need to be starved for 6 hours prior to surgery. Clear drinks however, are allowed in reasonable quantities up to 2 hours before the operation (11.30am if the surgical list is due to start at
13.30). For example, you can give your child water or diluted fruit juice, but not milk or coke.
If your child is breast fed, he/she can have a last feed 4 hours before surgery is due (about
09.30am), and then can be given clear fuids up to 2 hours before surgery.
(If you have any queries, please contact the main switchboard number and bleep the SHO
anaesthetist on call bleep 930) Department of Anaesthesia January 2015
APPENDIX B.9
GUIDELINES TO PAEDIATRIC RESUSCITATION (update 2002) Introduction
A child in distress will be admitted under the care of a consultant paediatrician, but its wellbeing is the duty of all staf present in the hospital
1 The full paediatric arrest team should be called initially. Avoid calling out team members individually to assist with deteriorating child.
2 All team members must be available at all times to deal with the child during its stay at East
Surrey Hospital.
3 Paediatric Arrest Team
i) Membership of paediatric arrest team
ii) Duties of members of paediatric resuscitation team:
SpR paediatrics-the team leader
Hands of and, therefore, able to oversee resuscitation episode, ensure each step has been followed, request investigations, take advice from surgeons, plan post resuscitation care with consultant paediatrician (especially planning transfer of patient), re-assess situation regularly.
SpR anaesthetics, SHO anaesthetics
In charge of airway and ventilation, initiation of IPPV and level 2 care (intensive care). Provide support with IV access, invasive monitoring and fuid management.
SHO paediatrics, SHO A&E
IV access, blood tests, x-matching, infusion, drug administration, catheter, drain etc.
Anaesthetic and paediatric staf should liaise to provide constant medical supervision during the patient's stay at East Surrey Hospital.
Sister Outwood, sister in charge, night co- ordinator
Permanent Associate As required
SpR paediatrics, team leader A&E nurse(s) Surgeon: orthopaedic, surgery
SpR anaesthetics A&E SHO Paediatric consultant
SHO paediatrics Anaesthetic SHO Anaesthetic consultant
Outwood sister RTO X-ray technician
Sister in charge/night co-
ordinator ODP ICU staf
Porter Outreach nurse
brings Broselow bag from Outwood if arrest occurs outside A&E, Outwood or theatres. Organises paediatric nursing cover.
Nurse Outwood
Aug 2016
1
In charge of nursing care of patient until transfer, record of events on PICU chart. The chart needs to be photocopied and sent away with the patient. One copy stays in the ICU.
A&E nurse
Record events in A&E, dispense drugs, check doses on Broselow tape if needed.
Porte r
Will collect resuscitation trolley from ICU, if needed outside one of the main areas.
Inform the on-call paediatric & anaesthetic consultants as early as possible. The paediatric consultant is responsible for liaison with the receiving lead centre &
organisation of the child's transfer.
4 Initial
resuscitation
Initial resuscitation takes place on site. Paediatric resuscitation kits are available in the following area-A&E, Outwood ward, ICU side room. Each trolley has been issued with the equipment most relevant to its clinical area. However, they all have the necessary kit for BLS and initial ALS.
Redwood DTC limited range according to age group treated in DSU. Most extra equipment available from theatre
A&E standard non Broselow lay
outOutwood non Broselow layout, comprehensive IV section to suit paediatric needs
ICU non Broselow layout, standard arrangement. Keep Broselow tape
The Broselow tape is available in each location although the colour coded system
is only now used in Redwood DTC and Radiology in a simplified version with colour coded drawers. Additional equipment is available on request in all clinical areas.
Broselow bags are available in A&E and in ICU for use in areas which do not keep resuscitation equipment. The capacity of these bags is limited and a porter should be sent to bring one of the arrest trolleys, possibly from ICU.
5 Level 1 (HDU) care
should be administered in the relevant clinical area, unless the child presents with a critical illness which threatens to deteriorate acutely.
Aug 2016
2 6 Level 2
care
Level 2 care: stabilization, preparation for transfer and holding of the paediatric patient is
carried out in the ICU side room. A paediatric nurse will be seconded from Outwood ward to assist the medical team. ICU nursing staf will assist where possible.
7 Level 3 care
Intubated children should be transferred to a tertiary referral centre as soon as practical, and the regional paediatric retrieval team involved as early in the child's management as possible. South Thames Regional Retrieval Service - Paediatric Intensive Care - Direct line 0207 9558856
8 Inform the on-call paediatric & anaesthetic consultants as early as possible. The paediatric consultant is responsible for liaison with the receiving lead centre
& organisation of the child's transfer.
9 The child remains the responsibility of the paediatric team at all stages of the resuscitation and subsequent stabilisation.
Paediatric resuscitation/ICU equipment available in adult ICU at East Surrey Hospital
Portable, multi-channel monitoring equipment
IVAC volumetic pump
Infusion pump
Warming blankets
Infusion warmers
Blood gas analyser
Anaesthetic & resuscitation drugs
Resuscitaire
Broselow tape
Dose and infusion guidelines on wall of side room
SIMS babypack and Veolar for bigger children
Board
All observations, treatments, procedures and decisions should be recorded on the PICU
chart.
Emergency Drugs
Atropine 20 μg/kg
Adrenaline 10 μg/kg (0.1ml of 1/10,000)
100 μg/kg in sepsis, anaphylaxis or profound vasodilation.
Calcium 0.2 ml/kg of 10% CaCL2 (about 5mg/kg of elemental calcium) HC03 1mEq/kg (1 ml/kg of 8.4% HCO3)
Glucose 0.25 - 1 g/kg (2.5-10 ml/kg of 10% Dextrose) Amiodarone 5 mg/kg iv bolus (up to 15 mg/kg/day)
Adenosine 50 μg/kg STAT. Rapid iv injection. Increase by 50 μg/kg if needed - Maximum
300 μg/kg.
PGEl 0.05 to 0.1 μg/kg/min. Maintenance 0.005 to 0.02 μg/kg/min Dobutamine* 1-20 μg/kg/min
Dopamine* 1-20 μg/kg/min Adrenaline* 0.1 - 1 μg/kg/min
*Dilution
3 mg of drug/kg in 50 ml of solution: 1 ml/h is 1 μg/kg/min 0.3 mg of drug/kg in 50 ml of solution: 1 ml/h is 0.1 μg/kg/min Anaesthetic agents
Induction Agents
Aug 2016
1 Thiopentone 3-5 mg/kg (1 ml = 25 mg) Propofol 2-3 mg/kg (1 ml = 10 mg)
Ketamine 1-2 mg/kg (concentration varies) Sedation/analgesia
Midazolam 50-100 μg/kg (2 ml=10 mg) Fentanyl 1-2 μg/kg (1 ml = 50 μg) Morphine 0.1 mg/kg on IPPV or
50 μg/kg boluses if spontaneously breathing or <3/12 old Muscle relaxants
Suxamethonium 1-2 mg/kg (1 ml = 50 mg) Atracurium 0.5 mg/kg (1ml = 10 mg) Mivacurium 0.2 mg/kg (1 ml = 2 mg) Rocuronium 0.6 mg/kg (1 ml = 10 mg)
There is an excellent website from the South Thames Regional Retrieval Service website which includes drug doses and protocols for the management of most paediatric emergencies. Look under the education and guidelines section. h tt p:/ / www .s t rs .n hs .uk
Appendix B.10
POLICY FOR OB TAI NING CONSE NT FO R ANAE STHE T ICS A ND PR OCEDURE S You will find the full Surrey and Sussex Healthcare NHS Trust consent policy on the Intranet under Policies and Procedures. Another text which is very useful for anaesthetists is the 2006 publication from the Association of Anaesthetists called
“Consent for Anaesthesia”. You will find a copy in the department, or on line at w
w w . aa g bi . or g .
Consent is a patient’s agreement for a health professional to provide care. For consent to be valid, the patient must:-
Be competent, or have the capacity to take or make a particular decision.
Have received sufficient information to make or take the decision. Not be acting under duress or undue influence
Feel that he/she has the option to refuse or change his/her mind prior to the procedure being undertaken.
Consent may be implied and non-verbal (e.g. ofering an arm for blood pressure measurement), oral (for minor procedures involving little or no risk) or written.
Seeking consent can be described as “joint decision- making”: the patient and health professional need to come to an agreement on the best way forward, based on the patient’s values and
preferences and the health professional’s clinical knowledge.
A two stage consent process is advocated, where the patient is given information, say, in a clinic, and has time to think about options before coming to a decision about treatment. For this reason it is important that leaflets about anaesthesia in general terms are given to patients in the pre- admission clinic, so that everything is not left to the pre-anaesthetic visit, which nowadays is often a very short time before surgery.
Association of Anaesthetists leaflets are distributed by the Trust Pre-admission service.
The Trust has four types of consent form.
Form 1
The normal form, in which the doctor obtaining consent documents the procedures to be undertaken and the most important complications which could occur. The patient is able to note procedures which they do NOT want to have (e.g. removal of ovaries during a hysterectomy operation), and signs the form. This form includes consent for necessary general or local anaesthesia.
Consent must be obtained by a surgeon competent to undertake the operation and accurately describe the efects and usual complications of the operation.
There is no need for a separate consent to anaesthesia form, however it is expected that the type of anaesthesia will be discussed with the patient and
documented in the anaesthetic record in the box designated for this purpose.
For simple anaesthetics, information should be given about sore throat, risk to teeth and type of post-operative analgesia.
For complex GAs, information on the above plus central line (pneumothorax risk but use of sonosite etc), arterial line, nasogastric tube, urinary catheter. Discussion about PCA/ epidural should take place, and the patient’s views sought about preference.
Likelihood of HDU/ITU and brief description is expected, also risks of complications such as myocardial infarction and cerebro- vascular accident.
For regional anaesthesia, including epidurals, as above, mention benefits (decreased blood loss, decreased venous thrombo-emboli, good pain relief) and risks for Upper limb, common temporary numbness/heaviness, ptosis, rarer, pneumothorax,
hoarseness, failure.
Lower limb, common temporary numbness, headache, hypotension, urinary retention, itching, and more serious but rare nerve damage. Refer to recent national audit of complications of central neural blockade, see patients guide at
w
w w . your a n a es t h e t ic . c o . u k . There is also a patient information leaflet available for brachial plexus block.
Form 2 is for parents to consent to operations on behalf of their children.
Form 3 is for minor procedures requiring no anaesthetic.
Form 4 is for patients who lack capacity to consent for themselves, but where
treatment is clearly in their best interests. (e.g. surgical treatment for fractured neck of femur in a patient with dementia). Should such a patient have an applicable
Advance Directive forbidding surgery in such circumstances, this must be respected and surgery cannot take place. See below for use in ICU.
Mental capacity
All adults are presumed to have the mental capacity to consent for themselves unless proven otherwise. No one else can consent for a patient who lacks mental capacity, either temporarily or permanently. The exception to this is someone who holds a Lasting Power of Attorney on behalf of a patient under the conditions described in the Mental Capacity Act. (See section 6 of the Trust Consent Policy).
Treatment may be given to an incapacitated adult on a “best interests” basis, as long as it has not been refused in advance in a valid and applicable advance directive (Living Will, see section 7 of the Trust consent Policy).
Children
Parents give consent for children under the age of 16. Anyone with “parental responsibility” can consent, so that this means, for example, school staf at a boarding school acting in loco parentis. Parents may withhold consent to some treatments on religious or other grounds, but you may still administer treatment which is required to save the child’s life. If the child’s condition is not life threatening, but treatment is required to prevent deterioration of the child’s health, then a court order will be required, and you should seek legal advice on Ext. 2707.
Out of hours, the duty General Manager holds the contact details for Capsticks, the Trust’s Solicitors, and they will brief an on call judge who can give a response
immediately. This whole process should only take about half an hour, and so if someone on the team can be used to initiate the process, it is preferable to do this.
16-17 year olds can consent for themselves.
While inducing anaesthesia it is sometimes difficult to judge the amount of restraint acceptable for an uncontrollable child, even if the parent concurs with the use of
restraint. It is occasionally preferable to cease treatment, with explanation to the child and parent and make a robust plan for another day.
Obstetrics
It is important to have made available written material about analgesia in labour before the parturient is compromised by drugs, fatigue, pain, or anxiety. However the patient must be provided with appropriate information at the time of any procedure, and the Labour Ward Anaesthetic Documentation includes a checklist which may be ticked as a record of matters discussed.
Sometimes a Birth Plan may include reference to forms of analgesia which are or are not acceptable, and the birth plan can be viewed as an advance directive in this regard. If, however, a competent woman whose birth plan declines an epidural anaesthetic, then requests one in labour, this should be respected, although a signature to agree to the procedure is wise in this event.
A competent pregnant woman can refuse any treatment, even to the extent of causing the death of her child. An emergency court order can be requested but is only likely to be successful if the court concludes that the woman lacks capacity.
Elective or tunnelled CVCs, PiCC lines, chest drains, percutaneous tracheostomies, Chronic Pain procedures.
An anaesthetic procedure which is not a prelude to a surgical one requires a consent form to be completed by the anaesthetist (Form 1). For a course of chronic pain procedures, the original consent form will suffice, with appropriate follow up notes on every occasion in the clinical notes.
Intensive care
The principles of consent apply to patients who are critically ill just as much to the general hospital population. The Mental Capacity Act requires that eforts be made by clinicians to involve critically ill patients in decisions about their care e.g. using other methods of communication with intubated but conscious patients.
Form 4 should be used for percutaneous tracheostomies, noting the risks of haemorrhage, misplacement, pneumothorax, infection or blockage.
Most ICU patients will be unconscious or have fuctuating consciousness, and then it is recognized that doctors may treat patients in their best interests. ” Best “interests does not always equate to” best medical interests” and for the patient’s overall best interests to be assessed it is necessary to consult widely with other health professionals and the patient’s family.
If there are no immediate family, or in instances where there is disagreement between the doctors and family about a course of action, the Mental Capacity Act has put in place a system of Independent Mental Capacity Advocates (IMCAs) who have been duly appointed and trained to speak on behalf of a patient who lacks capacity. This system is currently in its infancy and time
will tell how useful the system will prove to be.
IMCAs are expected to be used in all elective surgical situations where a patient lacks capacity.
Valerie Newman 09.04.2009
Appendix B.11
REGIONAL BLOCK
HOLDER
The anaesthetic department has introduced a regional block bleep holder (blp 504).
This bleep is carried by a trainee and is aimed at increasing training opportunities in Regional Anaesthesia at East Surrey Hospital. The bleep holder is marked with a purple star on the rota. During the daytime the bleep holder should be bleeped by any doctor in theatre who is performing a regional block. This will enable this person to observe/perform a variety of different blocks during their time at East Surrey Hospital.
It is strongly advised that when carrying 504, you should check all the operating lists for that day to pick up potential cases of interest. You should also make contact with the anaesthetists running these lists to inform them of your interest and remind them to call you via 504.
This bleep is a baton bleep which is a l s o used to run our Fascia Iliaca Block service for patients with fractured NOF (see below) and is passed on at night to the obstetric bleep holder. The 504 bleep holder is contacted by A&E or orthopaedics whenever a new #NOF is admitted and is responsible for ensuring that the block is done in a timely fashion. The block should be done mainly by the CEPOD SHO (930) over the 24h period but 504 should coordinate and help out if 930 is not free to ensure there are no delays for the patient to be seen and treated.
FRACTURE NECK OF FEMUR SERVICE
The anaesthetic department provides a fascia iliaca block service 24/7 to patients with #NOF as they arrive to A&E. This is to try and improve the analgesia of these patients. Ideally the blocks remain in situ with an infusion of local anaesthetic running until the patient comes to theatre.
The regional block bleep holder (blp 504) will be bleeped by the A&E nursing staf requesting a block. It is the responsibility of 504 to ensure the block is done within 1 hour of being called.
If busy in theatre the RA block bleep holder should ask for assistance from the CEPOD consultant (daytime) or Obstetrics registrar during weekends and out of hours to ensure the block is done in time.
More information regarding the FIB service is available on the intranet in the
anaesthetic section. Training will be organised in the first few weeks for those of you who need to learn how to do a Fascia Iliaca Block.
APPENDIX B.12
APPENDIX B.14
BLOOD COMPETENCIES
All anaesthetists joining the department need to be assessed as satisfactory on the following competencies in order to be involved in the process of blood
transfusion.
Obtaining and sending of a blood sample for G&S or X match
Receiving and administering blood products
Attend a lecture on blood transfusion which is usually incorporated in the Induction Day timetable. Alternatively it can be attended on one of the Trust’s education afternoons.
These competencies are valid for 3 years when they will need to be repeated and are transferable to other Trusts. The assessments are co-ordinated by Dr Fiona J Lamb (Fi o n a . l a mb@sa s h . n hs . u k ).
Certificates of these competencies from other Trusts may be accepted after these have been presented for review to Dr Lamb.
APPENDIX B.15
DEPARTMENTAL GUIDELINE FOR ANAESTHETISTS WHEN DEALING WITH A PATIENT WHO MAY HAVE/ WAS AWARE DURING ANAESTHESIA.
Further information is available on the Anaesthetic Intranet site regarding this issue