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Home | Articles | Referral | Anaesthetics – Unscheduled Procedures Requests

Anaesthetics – Unscheduled Procedures Requests

Last updated 7th September 2021

General

  1. Members of the Dept of Anaesthesia will have familiarity and competence in a number of procedures performed on ward patients and are happy to be consulted in order to improve patient care.
  2. However there is an expectation that attempts should be made to perform these procedures within normal working hours and within the primary team wherever possible: the resident ‘1st call’ anaesthetist has responsibilities to multiple time critical clinical areas and therefore the department does not carry direct responsibility for perfoming these procedures.
  3. In general all requests for ‘unscheduled procedures’ should come to the ‘1st call’ anaesthetist unless it is clearly within the remit of the ICU consultant.

‘Difficult’ Peripheral Venous Cannulae

  1. These should only be referred after the ‘middle grade’ doctor on the referring team has reviewed the patient in person and attempted insertion.  The excuse ‘if the FY1 can’t do it I will not be able’ is not valid and those middle graders can be offered one on one training in theatre with an anaesthetic consultant.
  2. If it is agreed that the anaesthetist will attempt to place the cannula the referrer should be reminded that it remains their responsibility to ensure venous access is performed in a clinically appropriate time frame.  If the anaesthetist does not attend within that time frame the patient should be re-referred.

Longer Term Venous Access (>2-3 Weeks) or Impossible Peripheral Access

  1. It is important to assess the indication and the urgency of request. Do they have existing venous access, will they miss antibiotic doses, can they be discharged to OPAT when inserted?
  2. Urgent cases. The urgency should be ascertained and they should in general be booked on the emergency theatre list. The referrer or anaesthetist can do this by phoning 32105.
  3. If non-urgent the referrer should ask them to book the case with Patient Access (Lorri Kirkcaldie) for the Friday morning vascular access list. If that list does not have availability within an appropriate time frame they should be booked on to the emergency list.
  4. Requests specifically for Hickman lines or Portacaths (usually for venous access for >4-6 weeks) should be booked with Patient Access as above. If a clinical discussion is required then Drs Rutherford, Peel and Christie are the appropriate consultants with expertise.

Arterial Lines

  1. These may be indicated within the HDU areas for frequent blood sampling and for blood pressure monitoring, particularly when inotrope/vasopressor infusions are in place. The ‘necessity’ for frequent blood sampling is often overstated.
  2. It is appropriate for these to be referred by middle grade staff and performed by resident anaesthetists if the indications are reasonable.
  3. In general the on call anaesthetic consultant should be made aware of any patient within an HDU who is requiring significant vasopressor/inotropic support.

Lumbar Punctures

  1. Diagnostic lumbar punctures will usually be performed by the primary team.
  2. Referrals will only be accepted if the most senior resident doctor has attempted and the referring consultant has been contacted and the indications discussed and agreed. Exceptions may be if there have been multiple previous failed attempts, if there are structural spinal column abnormalities etc.
  3. If the 1st call anaesthetist does agree to perform the procedure the referrer should be reminded that it remains their responsibility to ensure the lumbar puncture is performed in a clinically appropriate time frame.
  4. Therapeutic lumbar punctures will usually be scheduled cases for treatment of Idiopathic Intracranial Hypertension. Some will have had difficult procedures in the past and therefore it may be appropriate for these not to be attempted by the primary team but referred directly after the indications are discussed with the referring consultant.
  5. If time allows then the referrer can discuss scheduling with anaesthetist responsible for rota (Dr Edwards) but some are more urgent and are appropriately handled by the 1st call anaesthetist.
  6. Therapeutic lumbar punctures for insertion of drugs (usually chemotherapy) should NOT be performed by anaesthetists without the specific competencies for using those drugs intrathecally. The ‘Intrathecal Register’ is held and updated by Dr Wrathall and currently does not include any anaesthetists with competencies outside of anaesthetic practice.

Chest Drains

  1. Chest drains are often within the competency of someone in the primary team but it is recognised that this is not always the case.
  2. Chest drain insertion required ‘in hours’ should usually be discussed with the respiratory team. Out of hours requests can be directed to the surgical middle grade who is more likely to have the competencies than the resident anaesthetist.
  3. If these referral routes fail the referring consultant can discuss these cases with the on call anaesthetic consultant as there will usually be an anaesthetist within the on call team who is competent in chest drain insertion.

Other Procedures

  1. All other procedures should in general be a consultant to consultant referral as they are likely to be uncommon clinical situations where the indications and management plan require discussion.
  2. This policy is intended to supplement rather than replace common sense. Optimum patient management and safety should be the cornerstone of all decisions reached.