Lead: Dr. Jose Bastos
Radiology includes a number of areas in which anaesthetists may be involved:
- Interventional radiology : Three interventional radiology suites (two general and one neuro). These are on the first floor.
- Two CT scanners and one MRI scanner on the first floor.
- One CT scanner attached to resus.
This guide sets out standards for provision of anaesthetic services in remote areas.
It does not cover anaesthesia and sedation provided by ACCU doctors, and in particular it does not cover airway management in the emergency department and on the wards.
Patients receiving anaesthesia in non-theatre areas should receive the same standards of care as in theatre areas.
Doctors from the Adult Critical Care Unit will accompany critically-ill patients requiring radiology investigations (CT/MRI). The anaesthetic department will provide anaesthetic support for ACCU patients undergoing interventional procedures (this does not include insertion of lines that should be supported by ACCU doctor who accompanies patient).
Staffing
Anaesthetists working in non-theatre areas should be familiar with the working environment and should have attended the departmental induction.
Junior anaesthetists should not provide solo anaesthetic care in non-theatre areas. 1220-tier specialty trainees and fellows may do so if familiar with the environment and the type of case.
Anaesthetists must familiarise themselves with equipment and location of resuscitation devices in the radiology and endoscopy departments:
The resus trolley and difficult airway trolley are located in the corridor outside the IR2 room
For CT/MRI the nearest crash trolley is located in the CT/MRI corridor.
Anaesthetists must be assisted by a suitably trained anaesthetic practitioner. Most ODPs and anaesthetic nurses who work in interventional radiology and in endoscopy do so regularly. Practitioners who are not familiar with the environment they are asked to work in, should request assistance.
All staff working in areas where X-rays are used must be familiar with local rules for radiation safety, found on Trust Intranet. In particular, staff must wear protective lead gowns and thyroid shields.
Staff must also follow MRI safety precautions when working in MRI, with special regard to ferrous metal objects in their possession.
Anaesthetic equipment
Equipment standards are the same as for theatre areas.
All beds and trolleys used to induce anaesthesia should be capable of tipping into a head down position.
Equipment for monitoring SpO2, ECG, NIBP, EtCO2 and inspiratory/expiratory gases and vapours should be available for all patients receiving GA or sedation by an anaesthetist, in accordance with Association of Anaesthetists’ standards of monitoring.
Anaesthetic machines and other equipment must be checked before use in accordance with the AAGBI guidelines. Anaesthetic machine checks should be recorded in log by the anaesthetic practitioner and on anaesthetic chart by the anaesthetist, as in theatre areas.
The anaesthetist and assistant must ensure an adequate supply of oxygen is available before starting any procedure. Back up cylinders should always be available in addition to the piped oxygen supply. Capnomask or when indicated nasal specs with a CO2 port should be used.
An MRI compatible anaesthetic machine and monitoring equipment are available in the MRI suite.
Medications
Standard anaesthesia medications and emergency drugs, including Naloxone, sugammadex and flumazenil are stored in each interventional radiology angiography suite. Anaesthetists working in CT, MRI and endoscopy need to bring their own medications: these are stored in the portable anaesthesia equipment trolley that the ODP/anaesthetic nurse will bring down from 4th floor theatres.
Dantrolene and intralipid are available in the recovery areas for 4th floor and 3rd floor theatres.
IR angiography suites 1-3 and endoscopy have their own controlled drug store cupboards and CD books. CDs for use in CT/MRI must be signed out from another theatre and accounted for in the CD book for that theatre, in accordance with the trust CD policy.
As in theatre areas, local anaesthetic solutions are stored separately from intravenous infusion solutions.
Patients
Most patients undergoing anaesthesia in non-theatre areas do not undergo the standardised nurse-led preoperative assessment used for elective theatre cases. This is often because the procedures are urgent, or the patients are already admitted to ward beds, or transferred from another hospital.
Except for emergent patients most endoscopy patients requiring anaesthetic services are elective and therefore they are assessed by PAC.
All patients must be seen by an anaesthetist prior to provision of anaesthesia or sedation by an anaesthetist. Usually these patients can be seen in the IR holding bay.
Some patients having anaesthetic support for investigations, such as day-case MRI scans, have learning difficulties or other special needs. Such cases need to be planned in advance.
Safe conduct of Anaesthesia
Working in IR involves multidisciplinary working with excellent teamwork and communication at all times.
Local Safety Standards for Invasive Procedures have been produced for Interventional Radiology and endoscopy and these must be followed.
In particular, there must be a team brief.
In IR the team brief is at 08:30 in front of angiography suite 3.
Sign in, Time Out and Sign Out are completed using the appropriate LocSSIPs forms, as in theatre areas.
In IR and CT/MRI, the anaesthetist should consider inducing anaesthesia on a tipping trolley or bed. In MRI, anaesthesia is usually induced on a trolley using standard monitoring equipment, and MRI-compatible monitors are placed once the patient is asleep.
Calling for help
Each IR angiography suite, CT/MRI room and endoscopy room has an emergency buzzer that is audible in that area’s recovery room.
Anaesthetists requiring specific anaesthetic assistance should call for the senior anaesthetic registrar (bleep or fast bleep 1220 or call 45803) or cardiac arrest (2222) as appropriate.
If an anaesthetist has any concerns about the safety of waking or extubating an anaesthetised patient in a remote area they should discuss with the 1220 registrar, theatre 12 consultant on on-call consultant about whether to bring the patient to a theatre area.
Recovery
Patients should be recovered either in the procedural room or in a dedicated recovery after emergence from anaesthesia. Interventional radiology has a dedicated 4 bed recovery unit staffed with recovery nurses. The same happens with Endoscopy that has a dedicated recovery nurse team for cases involving anaesthetic support on Thursdays only.
Overnight, it is common for patients who have been treated with mechanical thrombectomy to be recovered by the anaesthetist and anaesthetic assistant, and then transferred to the stroke ward once recovery is adequate.
Any request for transfer to main recovery needs to be requested and discussed in advance.
Out of hours patients may need to be brought to 4th floor recovery if they require a recovery area.
Any transfers from non-theatre areas must be done with full monitoring in accordance with Association of Anaesthetists’ standards.