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Department of Anaesthesia and Intensive Care

Medicine

Beaumont Hospital

Guidelines & Protocols for NCHDs

2016-2017

1

Contents Page

1. First Day at Beaumont 1

2. Anaesthetic Department Administration 2-7

3. Educational Meetings / Teaching 8-9

Guidelines

4. Pre-Op Assessment Service 10-13

Primary & Secondary BP assessment 14-15

Patients with abnormal coagulation 16-18

Perioperative warfarin management 19

CHAD2 score & heparin bridging therapy 20-21

Perioperative management of insulin 22

Perioperative management of oral hypoglycaemic agents 23

Screening for OSA 524

Perioperative Goal-directed Fluid therapy 25

5. St Josephs Hospital 26-28

6. Day Case procedures 29-31

7. Neuroanaesthesia & Special situations 32-34

Neuroradiology procedures 35-36

Awake Craniotomy 37-38

8. Renal transplantation & LDRT 39-42

9. Paediatric protocols 43-44

10. Malignant Hyperthermia:Vapor-clean filter 45

11. Central Venous Catheter insertion policy 46-47

12. Acute Pain Service protocols 48-53

13. Chronic Pain Service 54

14. ICU policies and protocols 55-70

15. Consultant Administrative Roles 71-72

1

First day at Beaumont

Orientation Meetings: Prior to commencing clinical duties it is compulsory for all new

trainees to attend.

2nd

Monday in July 8.00a.m: General Hospital Orientation,

Robert Adams Lecture Theatre

Upon completion of orientation, trainees should return to theatre, and those

rostered for On-call duty should pick up the appropriate pagers.

Wednesday : Dr. Fiona Kiernan will give an introductory ICU talk at 7:45 am in

the anaesthetic conference nroom.

Friday : Dr M Halpenny will give an introductory talk on Friday 15th

July at 8am

in the anaesthetic conference room. Sr Joanne O’Brien will talk about acute pain.

Computer access & Information systems:

The “IT systems for NCHDs” handbook will be provided. Details on the use of

the PIPE (Patient Information System), Theatre Information system, e-mail +

internet access will be in this booklet. Individual training sessions are provided

for trainees in the Anaesthetic Office for the first week.

Hospital internet requires an individual user name and password – application

form obtained from Anaes. Secretary.

Intensive Care Unit: Training on the ICIP clinical information will be

available to all NCHD’s, to schedule an appointment please call John Pope at

3128.

Intensive Care Unit: A number of most commonly used protocols are already

on file within the clinical information system (ICIP) in the ICU, all other ICU

protocols will be available on the Q pulse system available on all computers

within the hospital. Access to Q pulse will be the same as your email username

and password.

Radiology PACS system requires training in order to acquire a username and

password. Training can be organised by emailing [email protected] to

book a training slot.

RCSI Beaumont Hospital Antimicrobial Guidelines: Download from app

store for free.

Identification badges – should be obtained from the Security Dept. on the Ground Floor

near the main entrance of the hospital (opening times available from Anaes. Secretary).

I.D. badges are required for access to Operating Theatre suite, and other restricted access

areas, and also serve as access swipe-cards for staff car parks.

Lockers – will have been allocated to you prior to your arrival, in the male and female

changing rooms in Theatre.

Photo I.D. - will be taken of each trainee by the Anaes. Secretary for Department records.

mailto:[email protected]

2

General Information

Mentors A Consultant mentor will be assigned to each trainee – please check list in Anaesthetic

Office and arrange to meet with your mentor as soon as possible.

Annual leave / Study leave requests Should be submitted as early as possible to the Administration SAT (for further details

see Page 5).

Modules

Requests for specific training modules should be submitted to the Anaesthesia Secretary

and will be allocated by the College Tutors. Modules for the months of July/January will

have been allocated in advance.

Schedule Weekly Theatre / ICU duty schedule for the first week will be available in the

Anaesthetic Office indicating your rostered locations.

3

Anaesthesia Department - Rostering

Weekly Schedule:

A schedule of allocations of all Anaesthesia staff is published each week. This details the

proposed rostering to Theatre lists, ICU, Acute and Chronic Pain Service etc. for the entire

week. No changes are to be made to this schedule under any circumstances without

approval by either Dr. T. O’Neill or the Consultant Co-ordinator on the day in question.

Consultant Co-ordinator:

A designated Consultant Anaesthetist is responsible each day for co-ordinating anaesthetic

staff and services. All anaesthesia staff must report to the Consultant Co-ordinator

before leaving Theatre when operating lists finish. All emergency cases placed on the

emergency board must first be discussed with the Consultant Co-ordinator

Routine Theatre Lists:

Operating lists start at 8.30a.m. (except Thursday – 9.00a.m.) and usually end by 4.30 p.m.

Anaesthesia NCHDs should be in Theatre from 8.00a.m to prepare so that induction of the

first patient can begin at 8.30 a.m.

When operating lists finish trainees must inform the Consultant Co-ordinator of the day

prior to leaving theatre. Pre-operative assessments should be completed between the time

operating lists end, and 5.00pm. NCHDs should not stay in the hospital later than 5.00pm

waiting for patients to arrive. Such patients should be assessed the following morning.

4

Anaesthesia Department – Rostering and Bleep systems.

On-Call Rostering: (Night duty and weekends)

Consultant Anaesthetists:

2 Consultants are on-call

Theatre Consultant: all theatre and anaesthesia issues

ICU Consultant

NCHDs: 3 NCHD staff are on duty at all times

Explanation of Bleeps in Beaumont Hospital

212 bleep: this is the 2nd

on call bleep and is the on call bleep for the ICU trainee.

During the day, from 8-4:30 this bleep is held by the SAT trainee that is in the

General ICU (downstairs). The second on call trainee comes in at 4pm, they go to

ICU and get a handover of the patients. They take the 212 bleep and the cardiac

arrest phone from the SAT trainee that has been in the general ICU all day.

The following morning they do a dry handover of the patients and go home by

9am.

714 bleep: This bleep is held by the 1st on-call SAT trainee.

Their call commences at 12.00 midday. When they come in they collect the bleep

from the anaesthtic office and report to the Consultant Coordinator. They do theatre

call until the following morning. They do an acute pain round with the pain sister

Sr Joanne O’Brien, leave the bleep in the office and go home by 9:30am.

313 bleep: Senior Registrar (SAT 4/5) 3

rd on call

This bleep is held by the Senior SAT in the General ICU during the day.

Third on call doctor comes in at 4pm, goes over to the ICU, gets brief handover of

any critically ill patients only, takes the bleep and goes into theatre by 4.30pm.

They then get handover from the theatre consultant co-ordinator and stay in theatre.

If they are entitled to a non clinical day, they will be paid from 8-4pm on the day

that they are on call, if they a are not entitled to a non clinical day they are not paid

for the 8-4pm before commencing on call.

Everyone has the day off post call to recover from the night of on call. Before the

3rd

on call goes home, they should go to the co-ordinator of the day and tell them of

any problems that occurred during their night on call.

824 bleep. This bleep is held by the SAT that is in Richmond ICU during the day.

That bleep is kept in Richmond ICU. The trainee collects it in the morning and

leaves it back in Richmond ICU at 5pm.

5

Cardiac arrest Dect phone is held by the ICU trainee during the day and evening until

theatre is finished. If theatre ends during the night, then the 1st on call doctor can collect

this phone from their ICU colleague before going to bed.

404 bleep Second ICU Registrar on call for Sat/Sun 9.00 – 17:00.

874 bleep: Acute post-operative pain bleep

292 bleep: Chronic Pain Management service bleep

Emergency / Out-of hours cases:

A maximum of 3 Anaesthesia sites (Theatre, X-Ray, etc) should run after 4.30 pm, and one

Anaesthesia site after 8.00pm and at weekends. Any deviation from this policy can only

occur with the agreement of the Consultant Anaesthetist on-call for Theatre.

6

Pre-operative Assessment

Comprehensive Pre-operative Assessment, including review of history, appropriate

examination of relevant systems (cardio-respiratory, hepato-renal, metabolic, with

assessment of airway and vascular access) any review of any relevant test results is integral

to provision of a Quality Anaesthesia Service.

NCHDs should liase (by phone if necessary) with the appropiate consultant anaesthetist

regarding Pre-operative assessments.

If the NCHD(s) rostered to an O.R list are not in the hospital on the day before the list - the

Consultant Coordinator & 3rd

on-call SAT will designate NCHDs to cover the pre-

operative assessments for that list.

Scheduled Patients: - are seen each evening by the NCHD assigned to that list.

Patients arriving after 5.00pm, or those added to the list after 5.00pm, should be

assessed the following day - It is not the duty of the night on-call staff to assess these

patients.

Day of Surgery patients (DOSA): - are screened at a Pre-Admission clinic, and

assessed on arrival to Theatre by the anaesthetist on that list.

Emergency Cases: - Assessment of emergency cases is arranged by the Consultant

Anaesthetic Co-ordinator.

Pre-operative patient problems should be discussed with the Consultant

Anaesthetist responsible for that list.

No patient should have surgery deferred or cancelled without Consultant input.

7

Leave

Annual Leave / Study Leave:

Annual Leave: - Is allocated according to your contract. 12 working days and days in lieu of working bank

holidays

Study Leave:

- Is allocated to those sitting recognised and appropriate examinations and courses.

Documentary evidence of exam /course registration must be provided prior to the granting

of study leave.

Application for Leave:

- All applications for leave are submitted to the Anaesthesia Secretary and will be

coordinated by the SAT 5-6 assigned to the Theatre Administration module.

Sick Leave: - In the event that you are unwell and unable to attend work, it is necessary to contact the

Consultant coordinator at 8am to inform him/her of your unavailability.

***No more than 5 NCHDs may take leave at the same time.

This rule protects all trainees from extra onerous duties. Priority is given to those who apply

first for specific weeks.

8

Educational Meetings / Teaching Programmes

ICU Conference:

Wednesday mornings 7.45 – 8.20 a.m.

Co-ordinator: Dr. Alan Gaffney

Format: Powerpoint presentation.

Anaesthesia Conference:

Thursday mornings 8.00 – 9.00 a.m.

Co-ordinator: Dr Elma Buckley

Format: Powerpoint presentation.

Audit / Research Meetings: /Journal Club:

Dates will be posted in advance. (usually Friday mornings)

Co-ordinators: Dr Edel Duggan, Dr Tanya O’Neill, Dr Rory Dwyer

Format: Presentation of proposed projects, up-date on progress of on-going projects,

papers etc. by trainees.

M+M / Clinical Risk Management meetings:

Dates will be posted in advance (usually Friday mornings)

Co-ordinator: Dr. I. Leonard

Format: Discussion of cases submitted on (yellow) Incident sheets.

Note: Cases / Incidents of special interest should be written up on yellow sheets (available

from Anaesth Secretary) + placed in Green “Clinical Risk Management” folder in Anaesthetic

Office. Cases will be presented anonymously, followed by a general discussion.

All the above meetings take place in the Anaesthetic Conference Room. Data projector and

department lap-top are available from Anaesth. Secretary for presentations.

9

Educational Meetings / Teaching Programmes

Primary and Final FCA Teaching Programme:

Co-ordinators: College Tutors: Dr. M. Bourke, Dr. Sinead Galvin and Dr. Fiona Kiernan.

Exam candidates – please notify the above Co-ordinators if you are sitting FCA Primary or

Final exam in this 6 month period.

A series of tutorials, VIVA practice, and clinical exam practice for exam candidates is

organised each 6 months, and a schedule will be posted in the Anaesthetic Office.

Tutorials generally take place at either 7.30 am or 4.30pm in the Anaesthetic Conference

Room. However times and venue may be subject to change at short notice.

A trainee from each exam group should be nominated as group co-ordinator to liase

directly with the individual tutors, to confirm tutorial times in advance.

Note: Teaching relies on the goodwill of tutors who provide teaching outside of rostered

time. It is therefore essential that all candidates attend all of the teaching sessions.

Library facilities:

RCSI Library:

Located on 1st floor – near Main Hospital Entrance.

Anaesthesia textbooks + major anaesthesia journals available.

Department textbooks:

A number of reference textbooks are located in Anaes. Office bookcase – key available

from secretary.

NB: Reference books are not to be removed from Anaes. Office.

Literature searches: Databases (Pubmed etc.) available on Anaes. Office computer in

Anaesthetic Department 1st Floor.

Educational Equipment: Available in Anaesthetic Office:

Data-projector

Dept. lap-top computer

Acetates and over-head projector (Conference Rm.)

Digital camera

10

Preoperative Assessment Service

Preoperative assessment aims to: 1. assess and optimise pre-existing co-morbidities

2. risk stratify patients

3. counsel patients regarding perioperative risk

4. educate and instruct patients on strategies that strongly influence perioperative outcome eg.

Medication management, nicotine cessation etc.

5. prevent unnecessary cancellations and improve theatre efficiency

Preoperative Assessment is currently administered in three ways:

1. ‘Day surgery’ preoperative assessment.

Patients not requiring postoperative hospital stay are assessed by a CNM trained in

preoperative assessment, beside St. Finbars Day ward. Completed basic health

preoperative assessments and investigations are reviewed on a daily basis by Dr.

Halpenny, Dr. Leonard, Dr. O’Neill and Dr. Buckley.

2. ‘Day of Surgery Admission (DOSA)’ preoperative assessment.

Patients who require postoperative in-hospital stay, but are suitable for admission on the

morning of their surgery are assessed by a CNM trained in preoperative assessment, beside

St. Finbars Day ward. Completed preoperative basic health assessments and investigations

are reviewed on a daily basis by Dr. Halpenny, Dr. Leonard and Dr. O’Neill.

3. The Anaesthetic Preoperative Assessment Clinic.

Patients who are either high risk, or require *high risk surgery are assessed at a clinic

administered by a Consultant anaesthetist, anaesthetic registrar and secretary every

Wednesday morning from 8-11am in Clinic F of the outpatients department. Patients are

referred to the Anaesthetic Preoperative Assessment Clinic by written referral from a

consultant surgeon. Referrals are triaged by Dr. Duggan and Dr. O’Neill. Patients

reviewed at the clinic are extensively evaluated and risk assessed by a consultant

Anaesthetist, and a letter sent back to the referring surgeon detailing the perioperative plan.

Ms Anne Doyle, secretary to the Anaesthetic Preoperative Assessment clinic, is

contactable at extension 4741.

*It is generally accepted that the majority of high risk procedures, defined as greater than 5%

combined incidence of cardiac death and non-fatal MI, fall into the following categories:

1. Major cardiac and non-cardiac thoracic procedures

2. Aortic and other major supra-inguinal vascular procedures

3. Anticipated prolonged surgical exposure associated with large fluid shifts and/or blood

loss.

A complete preoperative basic health assessment includes:

11

Medical History - Surgical procedure

- Cardiac status

o Refer to ‘ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation

and care for non-cardiac surgery’ at

http://circ.ahajournals.org/content/116/17/e418.full

o CHADS2 score patients with AF

- Pulmonary status including recent PFT’s

- Haemostasis status

- Diabetes

o Refer to refer to NHS guidelines for ‘The management of adults with diabetes

undergoing surgery and elective procedures’ at

http://www.diabetes.nhs.uk/areas_of_care/emergency_and_inpatient/perioperative_

management/

o Patients with HbA1C>8.5% not suitable for day surgery

- OSA

o If OSA is strongly suspected on clinical grounds or a screening tool (STOPBANG,

Epworth sleepiness score), and surgery is not urgent, referral for sleep studies

should be made.

o If surgery is urgent, then patients should be treated as if they have a diagnosis of

OSA, and managed accordingly.

o Patients instructed to take CPAP machine with them to hospital

o Patients requiring strong postoperative opioids are unlikely to be suitable for day

surgery

- Past surgical history

o Reference made to previous anaesthetic records where available

- Allergies and intolerances to medication/latex

- Current medications

o ARB/ACEI: hold morning of surgery/suspend for 1 dosage interval before surgery.

If drug already taken, monitor BP carefully at induction

o B Blockers: Continue if patient has been taking. Consider initiating if patient has

high CV risk

o Clopidogrel, Prasugrel after PCI & stent deployment: surgery should be

avoided for at least 4 weeks after BMS. Surgery should be avoided for 1 year after

DES. If surgery cannot be avoided during the above time periods, DAT should be

continued perioperatively unless strongly indicated. If deemed necessary to

discontinue Clopidogrel or prasugrel perioperatively, aspirin should be continued,

where possible to decrease cardiac risk.

o Warfarin: Refer to ‘The perioperative management of patients who are receiving

warfarin therapy: and evidence based and practical approach’, Douketis, Blood

2011 at

http://bloodjournal.hematologylibrary.org/content/117/19/5044.full

o Dabigatrin: Refer to ‘Regional anaesthesia in the patient receiving antithrombotic

& antiplatelet therapy’ Horlocker, BJA 2011 at

http://bja.oxfordjournals.org/content/107/suppl_1/i96.long

o OCP (Oestrogen containing): stop 4 weeks preoperatively. If unable to stop eg.

Urgent surgery, ensure adequate VTE prophylaxis perioperatively

o Insulin/oral hypoglycemics: refer to NHS guidelines for ‘The management of

adults with diabetes undergoing surgery and elective procedures’ at

http://www.diabetes.nhs.uk/areas_of_care/emergency_and_inpatient/perioperative_

management/

http://circ.ahajournals.org/content/116/17/e418.full

http://www.diabetes.nhs.uk/areas_of_care/emergency_and_inpatient/perioperative_management/


http://bloodjournal.hematologylibrary.org/content/117/19/5044.full

http://bja.oxfordjournals.org/content/107/suppl_1/i96.long



12

o Tamoxifen: may increase the risk of DVT; discuss with oncologist before deciding

to stop medication preoperatively

o MAOI’s including Selegiline for Parkinsons disease

o Medications contributing to the patients current state of medical homeostasis

should be continued eg. Neuro/psych medications, anti-epileptics, antiarrhythmic

agents, B Blockers, Statins, Calcium Channel blockers

- Functional status (the ability to perform four or more METS; the Duke Activity Status

Index)

- Smoking history, Alcohol consumption

- Possibility of pregnancy

- Religion eg. Jehovahs Witness

- Personal or family history of anaesthesia problems

Physical examination - Weight, height and BMI

- STOPBANG & Epworth sleepiness score if BMI>35 (to screen for OSA)

- BP, HR, SpO2 on RA

o Studies have shown an increased relative risk for adverse cardiac outcomes in

hypertensive patients undergoing surgery

o Vascular and cerebrovascular autoregulation remain abnormal for several weeks,

therefore non-urgent surgery should be delayed for several weeks, where possible,

to allow adequate BP control.

o White coat hypertension should be outruled by 24hr ambulatory BP monitoring

before treatment is initiated.

o Delay in non-urgent surgery is justified in patients with BP≥ 160/100 mmHg

WITH end-organ damage, and patients with BP≥180/110 mmHg

o Refer to NICE guidelines ‘The clinical management of hypertension in adults’ at

http://guidance.nice.org.uk/CG127/QuickRefGuide/pdf/English

- Airway exam

- Cardiac Exam

- Pulmonary exam

Investigations ECG: consider performing if no ECG within last year in patients, regardless of age, with history

of diabetes, hypertension, chest pain, CCF, smoking, PVD, poor functional status or morbid

obesity.

Coagulation studies: consider performing if patient has a known history of coagulation

abnormalities or recent history suggesting coagulation problems or is on anticoaglants.

FBC: consider performing if patient has a history of anaemia or medical condition resulting in

blood loss or anaemia. A baseline preoperative haemoglobin may be performed if significant

blood loss is anticipated.

U&E: consider performing if patient has a history of renal disease, or if the patient is taking

medications that can interfere with potassium/sodium homeostasis eg. ACE inhibitors, ARB’s .

CXR: consider performing if patient has signs (eg. abnormal SpO2 on RA) or symptoms

suggesting new or unstable cardiopulmonary disease.

Pregnancy test: consider performing if patient is of child-bearing age and

a. history suggests possible pregnancy, eg. delayed menstruation , or

http://guidance.nice.org.uk/CG127/QuickRefGuide/pdf/English

13

b. patient is concerned about possible pregnancy, or

c. the possibility of pregnancy is uncertain

Based on the results of the preoperative basic health assessment and aforementioned

investigations, more in-depth studies may be required such as EST, Echocardiogram, cardiac MRI.

Risk prediction scoring systems

Various scoring systems for predicting perioperative risk include the POSSUM/PPOSSUM score,

Lee revised cardiac risk index, ASA score and Detsky scoring system. Risk prediction tools can

be useful in deciding whether or not a high risk patient is suitable for surgery.

Preoperative assessment is usually done within 5-30 working days of the planned procedure and is

valid for 3 months.

November 2012

14

Figure 1: Primary care blood pressure assessment of patients before referral for elective

surgery. *Investigations and treatment should continue to achieve blood pressures <

140/90mmHg. ABPM and HBPM, ambulatory and home blood pressure measurement; DBP and

SBP, diastolic and systolic blood pressure.

Adapted from Anaesthesia 2016

15

Figure 2: Secondary care blood pressure assessment of patients after referral for elective

surgery. *The GP should be informed of blood pressure readings in excess of 140mmHg systolic or

90mmHg diastolic, so that the diagnosis of hypertension can be refuted or confirmed and treated as

necessary. DBP and SBP, diastolic and systolic blood pressure.

16

Ta

ble

1: R

ecom

men

da

tion

s related

to d

rug

s use

d to

mo

dify

coagu

latio

n. R

ecom

men

ded

min

imum

times are b

ased in

most circu

mstan

ces on tim

e to p

eak d

rug

effect + (elim

inatio

n h

alf-life 9 2

), after which

time <

1⁄4

of th

e peak

dru

g lev

el will b

e presen

t. For th

ose d

rugs w

hose actio

ns are u

nrelated

to p

lasma lev

els, this

calculatio

n is n

ot relev

ant. D

ata used

to p

op

ulate th

is Tab

le are deriv

ed fro

m A

SR

A an

d E

SR

A g

uid

elines [1

, 2] an

d in

form

ation p

rovid

ed b

y d

rug m

anufactu

rers. Th

ese

recom

men

datio

ns relate p

rimarily

to n

eurax

ial blo

cks an

d to

patien

ts with

norm

al renal fu

nctio

n ex

cept w

here in

dicated

.

(Harro

p-G

riffiths et al. A

naesth

esia 2013

17

Tab

le 1 co

ntin

ued

: Reco

mm

end

atio

ns rela

ted to

dru

gs u

sed to

mod

ify co

agu

latio

n

18

Figure 3: Relative risk related to neuraxial and peripheral nerve blocks in patients with

abnormalities of coagulation. (Harrop-Griffiths et al. Anaesthesia 2013)

Block category Examples of blocks in category

Higher risk

Epidural with catheter

Single-shot epidural

Spinal

Paravertebral blocks Paravertebral block

Lumbar plexus block

Lumbar sympathectomy

Deep cervical plexus block

Deep blocks Coeliac plexus block

Stellate ganglion block

Proximal sciatic block (Labat, Raj, sub-gluteal)

Obturator block

Infraclavicular brachial plexus block

Vertical infraclavicular block

Supraclavicular brachial plexus block

Superficial perivascular blocks Popliteal sciatic block

Femoral nerve block

Intercostal nerve blocks

Interscalene brachial plexus block

Axillary brachial plexus block

Fascial blocks Ilio-inguinal block

Ilio-hypogastric block

Transversus abdominis plane block

Fascia lata block

Superficial blocks Forearm nerve blocks

Saphenous nerve block at the knee

Nerve blocks at the ankle

Superficial cervical plexus block

Wrist block

Digital nerve block

Bier’s block

Local infiltration

Normal risk

19

Figure 4: Perioperative Management of Warfarin Therapy (Blood, 12 May 2011, Vol. 117, No.19

20

Table 2: Suggested risk stratification scheme for perioperative arterial and venous

thromboembolism

Thrombo

embolic

risk

category

Clinical indication for warfarin therapy

Atrial fibrillation Mechanical heart valves Venous

thromboembolism

High CHADS2 score: 5

or 6

Recent (< 3

months)

stroke/TIA

Rheumatic

valvular heart

disease

Any mechanical mitral

valve

Older aortic mechanical

valve (caged-ball,

tilting disk)

Recent (< 3 months)

stroke or TIA

16. Recent (< 3

months) VTE

17. Severe

thrombophilia*

Moderate CHADS2 score: 3 or 4 Bileaflet aortic valve

prosthesis with at least one

risk factor†

VTE within past 3-12

months

Non-severe

thrombophilia‡

Recurrent VTE

Active cancer

Low CHADS2 score: 0-2

(without previous stroke

or TIA)

Bileaflet aortic bileaflet

without any risk factors†

VTE > 12 months ago

Adapted with permission from Douketis J, et al. Chest. 2008;133(6 suppl):299S-339S.7

CHADS2 indicates Cardiac failure-Hypertension-Age-Diabetes-Stroke; VTE, venous thromboembolism; and TIA,

transient ischemic attack.

* Severe thrombophilia: deficiency of protein C, protein S, or antithrombin; antiphospholipid syndrome, or multiple

abnormalities.

↵† Risk factors: atrial fibrillation, cardiac failure, hypertension, age > 75 years, diabetes, stroke, or TIA.

↵‡ Non-severe thrombophilia: heterozygous factor V or factor II mutation.

Table 3: Stroke risk according to CHADS2 score in patients with atrial fibrillation in

nonperioperative and perioperative clinical settings.

21

CH

ADS

2

scor

e

Nonperioperative setting:

annual stroke rate (95% CI)*

Perioperative setting: 30-day

postoperative stroke rate (95% CI)†

0 1.9 (1.2-3.0) 1.01 (0.83-1.21)

1 2.8 (2.0-3.8) 1.62 (1.46-1.79)

2 4.0 (3.1-5.1) 2.05 (1.87-2.24)

3 5.9 (4.6-7.3) 2.63 (2.26-3.04)

4 8.5 (6.3-11.1) 3.62 (2.66-4.80)

5 12.5 (8.2-17.5) 3.65 (1.83-6.45)

6 18.2 (10.5-27.4) 7.35 (2.42-16.3)

CHADS2 indicates Cardiac failure-Hypertension-Age-Diabetes-Stroke; and CI, confidence interval.

↵* Based on risk for stroke in untreated patients.

↵† Based on linked administrative database from 1996-2001 of patients with atrial fibrillation who were

hospitalized for surgery, but no information on perioperative anticoagulation is available (adapted with

permission from Kaatz S, et al. J Thromb Haemost. 2010;8(5):884-89011).

Table 4: Suggested perioperative anticoagulation management in patients who receive heparin

bridging

Patient

group

Preoperative

management

Postoperative management

Low-

bleeding-risk

surgery

Stop therapeutic-dose

LMWH on morning (20-

24 h) before surgery

Omit evening dose

with BID regimen

Give 50% total

dose with OD

regimen

Resume therapeutic-dose LMWH*

approximately 24 h after surgery (eg, the

following day), when there is adequate

hemostasis.

High-

bleeding-risk

surgery

Stop therapeutic-dose

LMWH on morning (20-

24 h) before surgery

Omit evening dose with

BID regimen

Give 50% total dose

with OD regimen

Delay resumption of therapeutic-dose

LMWH for 48-72 h after surgery, when

hemostasis is secured

OR

administer only low-dose LWMH† when

hemostasis is secured or avoid the use of

LMWH altogether.

LMWH indicates low-molecular-weight heparin; BID, twice daily; and OD, once daily.

↵* Therapeutic-dose regimen refers to a weight-adjusted regimen, for example, enoxaparin 1 mg/kg BID or dalteparin

100 IU/kg BID.

↵† Low-dose regimen refers to a fixed-dose (not weight-adjusted) regimen, for example, enoxaparin 40 mg OD or

dalteparin 5000 IU OD.

22

Table 5: Guidelines for the peri-operative adjustment of insulin (short starvation period –

no more than one missed meal). Barker et al. Anaesthesia 2015

If the patient requires a VRIII then the long-acting background insulin should be continued but at 80% of the dose the

patient usually takes when he/she is well.

VRIII, variable-rate intravenous insulin infusion

23

Table 6: Guidelines for peri-operative adjustment of oral hypoglycaemic agents (short

starvation period – no more than one missed meal). Barker et al. Anaesthesia 2015

24

Figure 5: STOP BANG questionnaire

STOP BANG: Screening for Obstructive Sleep Apnoea

Answer the following questions to find out if you are at risk for Obstructive Sleep Apnoea.

STOP

S (snore) Have you been told that you snore? YES / NO

T (tired) Are you often tired during the day? YES / NO

O (obstruction) Do you know if you stop breathing or has anyone YES / NO

witnessed you stop breathing while you are asleep?

P (pressure) Do you have high blood pressure or are you on YES / NO

medication to control high blood pressure?

If you answered YES to two or more questions on the STOP portion, you are at risk for

Obstructive Sleep Apnoea. It is recommended that you contact your primary care provider to

discuss a possible sleep disorder.

To find out if you are at moderate to severe risk of Obstructive Sleep Apnoea, complete the

BANG questions below.

BANG

B (BMI) Is your body mass index greater than 28? YES / NO

A (age) Are you 50 years old or older? YES / NO

N (neck) Are you a male with a neck circumference greater than YES / NO

17 inches, or a female with a neck circumference greater

than 16 inches?

G (gender) Are you a male? YES / NO

The more questions you answer YES to on the BANG portion, the greater your risk of having

moderate to severe Obstructive Sleep Apnoea.

25

Figure 6: Perioperative Goal-directed Fluid therapy.

July 2013

26

St. Josephs Hospital Raheny

Anaesthesia is provided in St. Joseph’s Hospital four days each week, Monday to Thursday.

There are two theatres running each Monday, Tuesday and Thursday and one theatre on

Wednesdays. Current casemix includes procedures for Chronic Pain, ENT, Urology, General,

Vascular, Colorectal and Plastic surgery.

All patients referred to St. Joseph’s should be ASA 1-2. Due to the unavailability of laboratory

facilities in the hospital the type of procedure that can be safely carried out is limited. The

majority of surgical cases are day cases. Pre-operative assessment of many of these patients

currently takes place in Beaumont Hospital Day Ward or in the Anaesthetic Pre Assessment

Clinic. Those patients who are not seen in the assessment clinic or who are not day cases are

reviewed on the morning of surgery. Patients suitable for surgery in St Joseph’s should where

possible meet the criteria outlined in the following pages.

The Anaesthesia trainee is attached to St Joseph’s for one month out of a six month period as

part of the modular training which is in place in Beaumont Hospital. The on-call NCHD in St.

Joseph’s is a surgical trainee. Anaesthesia trainees are not on call for St. Joseph’s Hospital. All

on-call duties will be undertaken in Beaumont Hospital. Trainees working in St. Joseph’s should

attend all the tutorial sessions / meetings in Beaumont Hospital.

27

Guidelines for patient selection for surgery in

St Joseph’s Hospital, Raheny

All patients referred to St. Joseph’s should be ASA 1 (normal healthy individual) or ASA 2 (mild

systemic disease that does not limit activity). Some ASA 3 patients, depending on the planned

procedure, may be suitable for admission to St. Joseph’s. These cases should either be discussed

with the appropriate Consultant Anaesthetist or alternatively the patients should be referred to

the Anaesthetic Preoperative Assessment Clinic for review.

The following patients are not suitable for admission to St Joseph’s:

CVS disease:

Poorly controlled hypertension (BP>170/100)

Unstable angina

CCF

MI within 3 months

Symptomatic valvular heart disease

Implantable defibrillator

Poor exercise tolerance (< 1 flight stairs)

Respiratory disease:

Poorly controlled or severe asthma (frequent attacks, active wheeze, recent

steroids, hospital admission within 1 year)

Poorly controlled COPD

Sleep apnoea

GI:

Liver disease (cirrhosis)

Renal:

Dialysis dependent renal failure

Neurological:

Poorly controlled epilepsy

TIA / CVA within 6 months

Endocrine:

Poorly controlled diabetes mellitus

Poorly controlled thyroid disease

28

Many of the following patients are likely to be unsuitable for admission to St

Joseph’s. They should be referred to the Anaesthetic Preoperative Assessment

Clinic

Obesity:

BMI > 38

Airway:

History of / documented difficult intubation

Restricted neck movement

Reduced mouth opening

Anaesthesia problems:

Malignant hyperpyrexia - known / family history

Suxamethonium apnoea – known / family history

Any family history of reaction to anaesthesia

CVS:

Peripheral vascular disease

Pacemaker

Neurological:

History of subarachnoid haemorrhage or AVM

Spinal cord problems

Haematological:

Coagulopathy, increased INR (> 1.5 ) decreased platelet count (< 100)

Longterm warfarin therapy

Cancer, metastasis, chemotherapy, radiotherapy

Musculoskeletal:

Rheumatoid arthritis

SLE

Any connective tissue disease

ASA status

ASA 3 (if suitable procedure)

Age

There is no upper age limit for admission to St. Joseph’s. Patient suitability should

be determined by the presence or absence of intercurrent disease.

Procedures

Patients with signigicant co-morbidity scheduled to undergo TURP, TURBT or

rectopexy should be seen in the Pre-operative Assessment Clinic prior to surgery.

29

Day Surgery Protocols

Criteria for Adult Patient Selection for Day Care Surgery under General

Anaesthesia:

Social Criteria

Responsible adult to escort home + supervise at home overnight

Lives within 1 hour drive

Telephone at home

Physical Fitness

Generally fit and ambulant

Not grossly obese ( BMI < 35 )

The patient should be able to climb one flight of stairs

Do not book patients who have:

➢ Cardiovascular disease:

Poorly controlled hypertension ( BP > 170/100 )

Unstable angina or CCF

MI, TIA or CVA within last 6 months

Symptomatic valvular heart disease

➢ Respiratory disease:

Poorly controlled or severe asthma (Previously hospitalised,

frequent attacks, on steroids now or recently )

Poorly controlled obstructive airways disease (Unable to climb one

flight of stairs )

➢ Diabetes

IDDM or very poorly controlled NIDDM

➢ Narcotic Addiction

➢ Advanced multiple sclerosis, motor neurone disease, dystrophia

myotonica or myasthenia gravis

➢ Severe psychiatric disease

➢ Family history of malignant hyperpyrexia or suxamethonium apnoea

Patients who do not meet these criteria may be suitable for day surgery

but need to be arranged with the consultant anaesthetist on the list.

30

Investigations Required for Adult Day Care Surgery under General

Anaesthesia

All preoperative investigations should be determined by the patient's symptoms or by the procedure

➢ Full Blood count / Haemoglobin (Hb)

A routine Hb is only indicated where the history suggests that the patient

has a risk of anaemia ( e.g. menorrhagia, rectal bleeding or renal disease ).

➢ Creatinine / Urea and electrolytes

Patients who are hypertensive, on diuretics or who have a history of renal

disease.

➢ ECG's

Age > 60 yrs

Any history of the following:

- Chest Pain

- Palpitations

- Dyspnoea

- Diabetes

- Cardioactive drugs

- Hypertension

- > 60 years old

➢ Chest Radiography

A routine preoperative CXR is not necessary for day care surgery.

Patients who have had a recent chest infection or recent exacerbation of C.O.P.D. Should have

a CXR.

If you think a patient needs a CXR, he/she is almost certainly unfit for day surgery.

31

Guidelines on Pain Management in Day Care Surgery:

Aim at a balanced or multimodal Analgesic plan. Start with a combination of Paracetamol,

NSAID, short-acting opioid (fentanyl) plus local or regional analgesia where appropriate.

Opioids in Day Care Surgery:

Opioids such as morphine and pethidine are considered to have a length of action too long for day

care surgery. They are not recommended for use in day care surgery patients due to their

unwanted postoperative sequelae: PONV, sedation and respiratory depression.

Fentanyl should be used as an intraoperative analgesic in day care anaesthesia. It is also

considered the opioid of choice in the immediate recovery for patients with moderate to severe

pain. When fentanyl is given intravenously for moderate to severe pain in the recovery room,

supplementary oral or rectal analgesia should also be prescribed. This allows the oral or rectal

analgesic to take effect as the short acting opioid is wearing off.

Prescriptions for post operative pain relief in Day Care Surgery

A combination of NSAID, codeine and paracetamol are recommended. Patients should be told to

take their oral medications before going to bed so that they do not wake up in severe pain.

Oral Contraceptive Pill and Hormone Replacement Therapy - Guidelines for

Day Care Patients undergoing General Anaesthesia

It is advised that the following patients discontinue the combined OCP for a minimum of four

weeks before their operation:

1. Operations on the lower limb, especially if a tourniquet is to be used.

2. Patients who have a history of DVT or pulmonary embolus.

3. ? ↑ BMI

4. ? Smokers

The combined OCP need not be stopped for other types of ambulatory day surgery unless

otherwise specified by their surgeon. Patients should be advised to take other precautionary

methods to ensure

that they do not become pregnant while discontinuing the combined OCP.

Hormone Replacement therapy for the menopause and progesterone-only contraceptives need not

be stopped before any type of ambulatory day-care surgery under general anaesthesia. Patients

however should inform their anaesthetist that they are on these medications.

32

Neuroanaesthesia

NB: These are Guidelines rather than rigid protocols. Practice varies between different

consultants and with different patients.

Pre-op:

Detailed pre-operative assessment including:

Presenting complaint, GCS, presence of focal neurological deficits, signs of raised ICP.

-convulsants.

Some conditions require more specific detailed assessment e.g. pituitary adenomas – may

have acromegaly, Cushings disease etc – potential difficult intubations.

Anaesthesia for craniotomy:

GA: Propofol or Thiopentone, Vecuronium, Fentanyl.

Note: No muscle relaxants (after intubating dose) for acoustic neuroma surgery - as

surgeon needs to monitor facial nerve function.

To control ICP before intubation: Repeat bolus Propofol 50mg or Thiopentone 100mg /

Remifentanil / Lignocaine / -blocker.

Large bore IV x 2, arterial line, Rae or reinforced ET tube, urinary catheter, temp. probe.

Repeat bolus propofol or thiopentone before insertion of headpins.

Maintenance of Anaesthesia:

Sevoflurane or TIVA. + Fentanyl or Remifentanil. ± Muscle relaxation (use stimulator).

Normocapnia or mild hypocapnia., Maintain MAP > 80 (to maintain CPP)

Normothermia; Maintain normal serum Na+; avoid head-down position

Intra-op: CVS changes may indicate surgery near vital centres (e.g brainstem

compression during CP angle tumour surgery); alert surgeon if marked haemodynamic

disturbance

Therapies which may be required; Mannitol 0.5 gm/kg (if cerebral oedema) Thiopentone

bolus (e.g if temporary clip to be applied during aneurysm surgery, give slowly +

maintain BP) Dexamethasone (if cerebral oedema).

Post-operative management:

Aim to extubate smoothly; check GCS; monitor neuro-obs post-op.

Analgesia: regular Paracetamol, DF 118 IM/PO, Morphine if required e.g. if extensive

bony work. NSAIDs - controversial because of bleeding risk.

33

Special situations:

Recent SAH:

Usually on Nimodipine (Ca++ antagonist) - BP may be labile.

Avoid surge in blood pressure at intubation while maintaining MAP.

Clipping of intra-cerebral aneurysm:

Avoid hypertension / tachycardia prior to securing the aneurysm (risk of rupture)

Normothermia to mild hypothermia.

Temporary clip may be applied to a feeding vessel: Maintain high MAP to ensure

adequate collateral circulation. Thiopentone bolus may be requested by surgeon.

Risk of catastrophic haemorrhage if aneurysm ruptures - hence need for large bore IV

access and cross-matched blood available.

Post-op vasospasm may occur and may present as GCS or focal deficit. Management is

triple H therapy: Hypervolaemia, Haemodilution, Hypertension (Noradrenaline if req’d).

Coiling of intra-cerebral aneurysm:

Procedure done in X-Ray Dept. under GA – see Neuroradiology section.

Sitting position:

Risk of venous air embolism + paradoxical embolism if patient has PFO. Therefore pre-

op. Echo specifically to look for PFO – which is contraindication to sitting position

surgery.

Risk of CVS instability: Insert central line, MAST trousers, ensure adequate volume

loading ± vasopressors

Risk of venous air embolism: monitor for air embolism with ETCO2 / precordial Doppler

Prone position:

Reinforced ETT, Secure ETT carefully, Ensure secure IV access, Protect pressure points

Pituitary surgery:

-operative Endocrine abnormalities e.g.

fects

Post-op: may develop other endocrine conditions e.g. DI, Addisons, hypothyroidism.

Surgical approach may be:

1) Transphenoidal via a)Nose (direct or endoscopic) or b)Sub-labial approach

or

2) Craniotomy.

Hydrocephalus:

- unless an EVD (external ventricular drain) has been placed.

Hydrocephalus often secondary to SAH, tumour, meningitis, head injury, spina-bifida.

Often paediatric patients

34

GA for MRI scan:

Issues:

Magnetic field

Poor access to patient.

Use MRI compatible machine / ventilator / monitoring; ECG, SaO2, NBP, CO2

GA for complex spinal/ cranial surgery involving motor evoked potential (MEP) monitoring:

• MEP is incompatible with virtually ALL commonly used volatile anaesthetic agents. In fact

0.2-0.3 MAC of volatile agent can abolish MEP.

• Thus; use TIVA

• Induction: Propofol +/- fentanyl

• Paralysis for intubation: small dose of short acting nondepolarizer or remifentanil TCI

• Maintenance:

• TIVA: Propofol Infusion (75-300 mcg/kg/min)

• N20 allowed up to 70%

• Remifentani TCI (0.05-0.2 mcg/kg/min)

• Morphine sulfate 0.1-0.3 mg/kg does according to length of

operation and other anaesthetic/patient factors

Avoid ALL Neuromuscular agents during maintenance of anaesthesia unless patient safety

necessitates use

Adjuncts: The use of the BIS monitor is highly recommended.

35

Neuroradiology Procedures

Guidelines for GA's for Coiling/Embolisation in Neurovascular (Room 10) in

X-Ray

Most patients will have had a recent subarachnoid haemorrhage and will have the same co-

morbidity and risks as those patients presenting for clipping of intracerebral aneurysms.

Consequently these patients should be reviewed prior to the procedure and their baseline

neurological status documented.

Familiarise yourself with the layout and the equipment in Room 10 prior to arriving for your first

list.

Ensure you are familiar with the anaesthetic machine as it differs from the Operating Theatre.

Prior to commencing the list it is important to check all anaesthetic equipment as there are no

anaesthetic nursing staff in the X-ray department.

In Particular:

1. Check the suction machine and connections.

2. Check the anaesthetic machine and particularly ensure that the oxygen cylinder is full and

functioning and that an ambu-bag is available. The oxygen cylinder is not attached to the

anaesthetic machine as it is a ceiling mounted machine.

Ensure that:

3. Bougies and introducers are attached to the side of the machine. All other equipment for

management of a difficult airway is located in the difficult airway trolley outside the door of

Room 10 (McCoy Laryngoscopes, intubating LMAs etc). We do not have a fibreoptic scope

in X Ray. Any patient that may potentially require one should be induced in theatre where

experienced staff and equipment are available.

4. All other airway equipment is located in the trolley beside the anaesthetic machine i.e.

Selection of ETT'S, LMA'S, Airways (Oral and Nasal) O2 tubing, venturi masks and C-

Circuits.

5. All Anaesthetic drugs (except those requiring refrigeration) are available in Room 10 in the

anaesthetic trolley. It is usual practice to bring drugs with you from theatre (except for

DDA's) and it is advisable to have a syringe of suxamethonium drawn up.

6. The Cardiac Arrest trolley is located directly outside the main door of Room 10 (beside the

difficult airway trolley). The defibrillator is checked daily by nursing staff.

Conduct of Anaesthesia:

1. Ideally 2 Anaesthetists and a designated member of nursing staff should be present at

induction.

36

2. All patients should be induced on a trolley (the x-ray table has no head-down tilt or side

restraints and the bed takes up too much room)

3. It is usual practice to insert an arterial line either prior to induction under LA or prior to

intubaton. The use of sedation in these patiens is not generally recommended. Take note of

the patients baseline MAP and neurological status prior to starting.

4. Induction

The aim is to prevent a re-bleed due to surges in blood pressure balanced with the maintenance

of cerebral perfusion pressure-which may be compromised due to vasospasm.

Drugs: Fentanyl

Thiopentone 3-5mg or Propofol 1-2 mg/kg

Vecuronium or Atracurium

+/- Lignocaine 1mg/kg

It is preferable to intubate and ventilate patients for the procedure. RAE ET Tubes are usually

used.

5. Maintenance

- 02/N20 or 02/ air. Sevoflurane titrated to a MAC of 1

-Aim to maintain MAP within 20% of baseline (particularly important if there is evidence of

vasospasm on the angiogram) Phenylephrine 50 mcg boli or indeed infusion may be required to

do this as the procedure itself is not very stimulating.

- Heparin 7000iu is administered at the radiologists request once they have positioned their

catheters close to the aneurysm. Make a note of the time of administration as a second dose of

1000iu is usually required at one hour. For extremes of body weight give 100 i.u/kg.

- Ensure that protamine is available (located in top drawer of anaesthesia trolley) as in the event

of aneurysm rupture you may be asked to administer it (ml per ml of Heparin 1000iu/ml)

Fluids

All patients with recent subarachnoid haemorrhage should be catheterised for the procedure.

This facilitates the administration of fluids should there be evidence of vasospasm on angiogram.

No glucose containing fluids should be given as maintenance.

Emergence

Do not attempt to wake up the patient until they are on a tilting trolley and you have designated

nursing help.

The endotracheal tube is usually removed prior to transfer to Theatre Recovery.

The equipment and drugs necessary for re-intubation should accompany the patient to Recovery

Room including a c-circuit, mask and ambu bag.

Only transfer the patient once you are satisfied that there is no airway comprimise.

Post-Op Observations and Analgesia:

Aim for MAP around awake baseline

Neurological observations are required and it is therefore important to advise Recovery staff of

pre-existing neurological deficits Simple analgesia such as paracetamol should be all that is required.

37

Awake Craniotomy

Environmental Considerations

• Limit access points to theatre

• Minimise background noise

• Reduce volume of alarms

• Caution with intercom use (NB preliminary pathology results)

• Remind all present that patient is awake @ time out

Pre-operative visit

• Name (as answers to)

• Age

• Actual Weight

• Ideal Body Weight

• Dominant hand

• Airway examination

• Patient insight and potential for delirium

• Focal neurological deficit

Seizures

Type

Frequency

AEDs

Surgical

• Lesion location

• Lesion type

• Planned patient position

• Mayfield Pins (Y/N)

• Incision site

• Crosses midline (Y/N)

• Urinary catheter (Y/N)

If No PU in holding area

Limit IV fluids (10ml/kg)

• Pressure points checked, protected

• Risk assess for nerve/plexus injury

• Face visible and accessible at all times

Monitoring

• ECG

• NIBP (caution patient discomfort with frequent measurments)

• Arterial line

• SpO2

• Capnography

• Temperature (bladder/skin/axilla)

38

• EEG

• EMG

IV Access

• Ports accessible

Airway

• Nasal prongs

• Face mask

• Nasal trumpet (prep with cophenylcaine in holding area)

• Correctly sized LMA, ETT and layrngoscope to hand

Sedation Planning

• Premedication Agents (NB timing)

• Anxiolytic

• Antisialogogue

• Antiemetic

• Propofol TCI

• Remifentanil

• Dexmedetomidine

Scalp Block

• Agent

• Max allowable dose

• Volume at each site

• Total dose

• Allowable top up doses (confirmed with surgeon)

Seizure management

• Baseline AEDs (optimized preoperatively)

• Cold Saline

• Propofol

• Thiopentone

Osmotherapy

• 20% mannitol

• 3% saline

39

Figure 7: Nerves for scalp blockade

Renal Transplantation

Pre-op:

Detailed Pre-op Assessment including: cause of ESRF, significant co-morbidities native

urine output pre-op, mode of dialysis, vascular access, site(s) of fistula, date/time of last

HD/CAPD exchange, and post-dialysis bloods.

40

Protect fistula site and avoid IV/arterial cannulation on that limb

Check immunosuppressants have been administered.

If patient had multiple prev. transplants - check surgical plan is for vascular anastomosis to

iliac vessels - Occasionally after multiple transplants aorto-caval anastomosis is required.

Monitoring:

Non-invasive: NBP, ECG, SPO2, EtCO2

Invasive: - CVP line (Bi-lumen is routinely inserted post induction.

- Arterial line only if indicated by CVS status.

- Urinary catheter with hourly monitoring bag.

Induction and Maintenance:

Machine check, suction equipment, Pre-O2.

Propofol or Thiopentone

Atracurium to facilitate tracheal intubation. Suxamethonium only if significant risk of

aspiration. Suxamethonium contraindicated if K+ is > 5.0 mmol/L.

Sevoflurane in O2 / N2O or 02 air.

Opioids: Incremental Fentanyl / Morphine

Ventilate to normal PO2/ PCO2

Check VBG at least hourly to monitor K+ and acid/base status.

Reversal: conventional dose of Neostigmine/Glycopyrollate.

NOVEMBER 2015

Because of a recent survey conducted by the Department of Microbiology, it has been

recommended that antibiotic prophylaxis be given, not in the ward to transplant recipients

but in the Anaesthetic room on induction of anaesthesia. The recommended antibiotic of

choice is Cefuroxime. If the patient is allergic to Cefuroxine or has a strong Penicillin

allergy the recommendation is Aztreonam and Teicoplanin. Prior to administering any

antibiotic if there is a record microbiology reports on the system indicating specific drug

resistance please check this so that an individual antibiotic could be prescribed if it is

appropriate. In the interim the default antibiotic of choice Cefuroxime which should be

administered after induction of anaesthesia in the anaesthetic room.

Fluid management:

Volume loading intra-operatively improves graft survival. Vigilance required to balance

benefit of fluid loading vs. risk of fluid overload.

Haemodialysis patients - may be hypovolaemic if recently dialysed.

CAPD patients - more likely to be normovolaemic.

Crystalloids more appropriate than colloids.

0.9% NaCl used

41

Gelofusin OK, Voluven not appropriate

Some consider alternating use of NaCl 9% with Hartmanns to prevent the acidosis

associated with large NaCl infusion.

Generally ~ 2 litres of crystalloid are given .

May give greater volumes if graft dysfunction + no evidence of circulatory overload.

Diuretics:

Mannitol - 0.25g /kg given routinely during vascular anastomosis - prior to reperfusion.

- repeat dose may be required later if graft fails to produce urine.

Frusemide may also be required [0.5 mg /kg in live-related grafts / up to 3mg/kg in cadaveric

grafts].

Heparin: Some surgeons ask for heparin prior to revascularisation of the kidney.

Haemodynamic instability:

Hypotension - Usually due to hypovolaemia.

- Inotropes occasionally needed.

Hypertension - good renal perfusion pressure improves graft survival - therefore active

lowering of BP not encouraged - unless significant hypertension occurs.

- -blocker: labetolol /metoprolol

- GTN / SNP (increased risk of cyanide toxicity in ESRF)

Post-operative analgesia:

Morphine or oxycodone PCA are used routinely.

May need reduced or less frequent doses due to altered pharmacokinetics.

Post-operative Care:

CXR – to assess volume status and position of central line.

Supplemental O2 by facemask x 24hrs.

Post-op. fluid management is by transplant surgery team.

Living donor renal transplant (LDRT)

Guidelines for Donor Evaluation Before donation:

• the live donor must receive a complete medical and psychosocial evaluation,

• receive appropriate informed consent and be capable of understanding the information

presented in that process to make a voluntary decision; and

• all donors should have standard tests performed to ensure donor safety.

42

Detailed preoperative anaesthetic assessment for living (as for any patients but also include):

• Hypertension patients with BP > 140/90 mmHg are generally not acceptable as donors;

need to be optimized first.

• CVS risk- Major/intermediate predictors of CVS risk as per AHA standards are

contraindicated for donation. Minor predictors like old age, abnormal ECG , uncontrolled

hypertension warrant individual consideration.

• Obesity- BMI >35kg/m2 should be discouraged from donating, especially when other co-

morbid conditions are present.

• Acceptable donor renal function- GFR <80ml/min generally precludes donation.

• Urinalysis for protein & blood- A 24 hour urine protein >30mg is a contraindication to

donation; patients with persistent microscopic haematuria should not be considered for

kidney donation.

• Diabetes- Individual with a history of diabetes should not donate.

• Stone disease- An asymptomatic potential donor with history of single stone may donate if

no hypercalcuria/cystinuria or no UTI.

• Malignancy- Usually excluded from live kidney donor.

• Urinary tract infection- Donor urine should be sterile before donation.

Living related donor transplant are performed electively with donor and recipient anaesthetised

within few hours apart; in separate rooms.

The traditional approach is a subcostal lateral incision but usually is performed laparoscopicly.

The left kidney is preferred because of better surgical exposure and longer vascular

supply.

Monitoring/ IV access:

Non-invasive: NBP, ECG, SPO2, EtCO2

Invasive: - Normally not required (+/- Arterial line) .

- Urinary catheter with hourly monitoring bag.

IV access: 1-2 large peripheral IV cannulas usually suffice

Induction and Maintenance:

Machine check, suction equipment, Pre-O2.

Propofol or Thiopentone

Atracurium to facilitate tracheal intubation.

Sevoflurane in O2 / N2O or 02 air.

Opioids: Incremental Fentanyl / Morphine

Ventilate to normal PO2/ PCO2

Reversal: conventional dose of Neostigmine/Glycopyrollate

Position is lateral with table flexed and kidney rest elevated.

To maintain good diuresis, fluid administration is generous (10-20 ml/kg/hr) using isotonic

crystalloids intraoperatively.

Diuretics:

Loop diuretics and/or mannitol may be used to promote diuresis from the grafted kidney.

43

Post-operative analgesia:

PCA morphine/ Oxycodone.

Kidney from living donor may be flushed with preservative solution or iced Hartmann’s.

The cold ischemia time in a living donor should be restricted to 20-30 minutes while the

warm ischemia time should not exceed 3-5 minutes.

44

Paediatric Anaesthesia Guidelines

Day Case: Anaesthetic review on ward/ reception area.

(Intern should contact anaesthetist on list if problems detected pre-op)

Consider pre-med if child is very anxious

(Midazolam 0.5mg/kg orally, max.20mg)

Pre-op fasting: No solids for 6 hours (including breast milk or formula)

May have: Clear fluids up to 2 hrs. before surgery

(non-particulate only i.e. H20 +/- sugar, apple juice)

Premedication: Midazolam 0.5mg/Kg PO (max 20mg)

Temazepam syrup 0.5 mg/kg PO

EMLA/Ametop: Dorsum both hands, or ACF if no veins visible on hands

Parents: In elective cases, a parent is allowed into Anaesthetic room by

arrangement with the anaesthetist.

Children with symptoms of URTI:

Determine whether pyrexial, chest signs, off form /off food. Discuss case with Consultant

anaesthetist

Analgesia options:

Theatre: (1) Paracetamol: 20-40 mg per kg P.R.

This is the loading dose only

(2) Diclofenac: 1-2mg per kg PR.

Loading dose only

(3) Fentanyl: 1mcg/kg IV – monitor resps

(4) Morphine: 100 micro grams 0.1mg/kg IV or IM

(CHECK DOSE) not to be given to day cases

An anti-emetic should normally be given with opiates

Ondansetron 0.1.mg/kg IV =/- Dexamethasone 0.05mg/kg

(5) Use local anaesthetic where possible

Recovery: If rescue analgesia required consider

1) Fentanyl: 0.5 micrograms/kg via slow IV injection and repeat if

required

(2) Morphine: 0.05 mg/kg slowly IV

(CHECK DOSES) + Monitor respiration

Consider if an anti-emetic required

(3)Have paracetamol and /or NSAID been given?

45

Post-op analgesia options: Use WHO ladder

Commence with regular simple analgesia PO/PR e.g. Paracetamol &/

NSAID

Paracetamol: 15 mg/kg 6 hourly PO or PR

Diclofenac: 1 mg/kg 8° P.O./PR or

Ibuprofen: 7.5mg / kg 6-8° P.O.

Supplement with rescue or regular opiate as appropriate

Oral analgesia to consider

Oromorph 100-200micograms/kg PO

Oxycodone 100-150 micrograms/kg PO

Chart antiemetic as required

Ondansetron 0.1 mg/kg IV 8 hourly prn.

Fluids if required: Measure blood glucose post induction of anaesthesia in children under

10kg or those with prolonged fasting.

< 10 kgs Maintenance fluid: Use Hartmann’s with added Dextrose [see below]

For 5% Dextrose: Remove 25mls of solution from a 500ml bag of

Hartmann’s. Add 25 mls of 50% Dextrose to the remaining 475mls of

Hartmann’s soln.

For 2.5% Dextrose: Remove 12.5mls of solution from a 500ml bag of

Hartmann’s. Add 12.5mls of 50% Dextrose to the remaining 487.5mls

of Hartmann’s soln.

Monitor blood sugars. Increase or reduce glucose content as required.

Replacement fluid: Use Hartmann’s or 0.9% NaCl

Fluid bolus: Use Hartmann’s solution or 0.9% NaCl only (NEVER

with added Dextrose)

10-20 kgs Maintenance fluid:

Hartmann’s at 4 mls/kg for 1st 10kgs

2 mls/kg for next 10kgs

Replacement fluid: intra-op-Hartmann's or 0.9%NaCl

Discuss any concerns with Consultant

46

Malignant Hyperthermia

Vapor-Clean Filter

1) MH Susceptible patients

Turn fresh gas flow to >10 L/min x 90 seconds

After 90 seconds place filters on expiratory and inspiratory limbs

Remove the soda lime (not required but may be changed if desired)

Attach new ventilating tubing

With filters in place, turn fresh gas flow to 3 L/min for the entire

case

Vapor-Clean filters are good for 12 hours. If the case lasts longer

than 12 hours, replace filters with new Vapor-Clean filters.

2) MH Crisis

Turn off anaesthesia vapours immediately

Turn fresh gas flow to >10 L/min

Remove existing ventilator tubing

Place Vapor-Clean filters on expiratory and inspiratory limbs

Attach new ventilator tubing

Vapor-Clean filters for MH Crisis can only be used for 1 hour. If the

case lasts longer than 1 hour, replace filters with new Vapor-Clean

filters.

Protocol authorised by Dr. Michael Moore, 11th

April 2016.

47

Central Venous Catheter insertion policy

The Dept. of Anaesthesia receives a large number of requests for insertion of central lines.

Procedure delays have occurred due to incomplete patient information, and late requests have

resulted in ‘elective’ lines being sited during out-of-hours. In order to improve efficiency of

this service, and to facilitate departmental audit, the following departmental policy has been

agreed.

Central Line booking and audit policy:

All requests for central line insertion on any particular day must be received by

Anaesthetic Consultant Co-ordinator no later than 11.00am on that day.

This should allow adequate time for morning rounds etc to be completed.

Requests for central line insertion will not be accepted (ie. written on the emergency

board) without receipt by the Anaesthetic Co-ordinator of a completed Request form

(you should become familiar with CVC request forms which are available in the

Anaesthetic Office and on all wards).

Completion of CVC Request form

Section A: should have been completed by the requesting doctor.

Section B: of the request form is to be completed and signed by the anaesthetist who

inserts the line. Please ensure that you follow-up your patient to the Recovery Room

and sign off form when you have reviewed CXR.

Completed form:

Front (white) copy: Please file in the patients chart

(in ‘Operation notes’ section with anaesthetic and surgical notes).

Back (yellow) copy: Please ensure patient ID details are included and detach and file

in CVC Audit folder in Anaesthetic Office. [or give to Anaesthetic Secretary for

filing].

**** Please note CVC insertion Clinical Guidelines (next page).

48

Central Venous Catheter (CVC) insertion – Clinical Guidelines

Department of Anaesthesia, Beaumont Hospital.

Discuss indication with Consultant Anaesthetist [Co-ordinator / On-call](e.g. TPN,

antibiotics etc).

Do not routinely replace catheters solely to prevent catheter-related sepsis1.

In patients suspected of having catheter-related infection do not use guidewire techniques

to replace catheters. Use clean insertion site.

CVCs should be inserted: - In Operating Theatre with appropriate monitoring

- During regular day-time hours

unless in emergency or in ICU patient

Check Coagulation profile (INR, APPT, Plts) on day of procedure.

Do not insert CVC in anti-coagulated / Clopidogrel (Plavix)-treated patients unless in

emergency.

Prevention of catheter-related blood-stream infection:

Use maximal sterile barrier precautions2

and chlorhexidine skin antisepsis (allowed

to dry before skin puncture).2

Select catheter insertion site associated with least risk of injury / infectious

complications 3

Use catheter with the minimum number of ports essential for patient management 1

If single lumen access only required, consider PICC (peripherally-inserted central

catheter).

If CVC is for long-term use, consider antibiotic-impregnated catheter 3

Consider ultrasound-guided placement in all cases. Consider referral to Vascular

Interventional Radiology service for “selected patients at high-risk of complications” 4

In the event of accidental insertion of wide-bore CVC into subclavian / femoral artery

leave catheter in situ consult Vascular Surgery / Interventional Radiology service for

possible endovascular repair with closure device (Angioseal / PerClose)

Always confirm correct placement of CVCs with CXR.

Ensure CVC Request / Audit form is completed by the attending anaesthetist:

- Front (White) sheet is completed and filed in patient’s chart

- Back (Yellow) sheet is completed and filed in audit folder in Anaesthetic office

References:

1. CDC guidelines for the prevention of catheter-related infections MMWR 2002; 51: RR-10

2. Berenholtx SM Eliminating catheter-related blood stream infection in the intensive care unit.

Critical Care Medicine 2004;32:2014-20

3. McGee DC et al. Preventing complications of central venous catheterisation. NEJM 2003;

348: 1123

4. Muhm M. Ultrasound-guided central venous access. BMJ 2002; 325: 1373

September 2012

49

Acute Pain Service

Consultants:

Dr. Josh Keaveny

Dr. Valerie Pollard

Pain Nurses: Ms. Joanne O’Brien Ms Aideen Hanlon

RANP Pain Management CNMI Pain Management

Bleep 403 Bleep 779

Mon/Wed/Thurs 08.00 – 16.15

Tues 08.00 – 18.00

Fri 08.00 – 14.15

Dect. Phone 8380

Anaesthesia NCHD Pain Bleeps:

Chronic Pain SAT - Bleep 292

Mon - Fri. 08.00 - 17.00

On call Reg / SAT- Bleep 714

Out-of-hours, weekends and bank holidays.

Please Note:

Daily Acute Pain Round : Monday – Friday 8.15 a.m

Post call Reg. / SAT (#714)

50

Management of Patient's for post-operative ward based Epidural

Analgesia.

Patients receiving postoperative Epidural pain management are currently nursed in the

following areas ICU, RICU, AB Clery Ward, Hardwick Ward, St. Luke's Ward and St.

Damiens Ward, Banks Ward, CCU.

Any patient requiring epidural analgesia post operatively who is not from one of the

above wards must have their bed confirmed on one of these wards prior to epidural

insertion.

Epidurals and Anti-coagulant therapy:

Patients on Plavix are not suitable candidates for Epidurals unless they have been off

their anti-coagulant for approximately 2 weeks prior to surgery.

Patients on Clexane should have it charted for 18.00 hours. This will facilitate insertion

and removal of the epidural catheter. (We recommend that a patient does not have

an epidural inserted or removed unless 10 hours has passed since their last

Clexane injection. When reviewing patients pre-operatively, who are suitable for

epidural analgesia, please insure that their anti-coagulation therapy is appropriately

prescribed.

Patients should have a Coag screen taken prior to insertion and removal of the epidural

catheter if clinically indicated.

Following removal of the Epidural Catheter, the patient should not have Clexane for at

least 4 hours. Patients may mobilise 1 hour post removal of an epidural catheter unless

otherwise clinically indicated.

Prescription of Epidural infusions:

Ward based epidural analgesia is an Anaesthetic lead service. The anaesthetists are

responsible for prescribing the epidural infusion on the patients drug Kardex and on the

Epidural Assessment Sheet.

The infusion (0.1% Bupivicaine with 2 mcg per ml Fentayl) consists of the following:

190mls NaCl

50 mls 0.5% Bupivicaine

10mls Fentanyl (2 mcg per ml - 500mcg)

Total = 250 mls

Pre-filled Epidural Infusion bags of the above concentration are available from the

pharmacy. Yellow prescription labels are also available in each anaesthetic room.

The patient will be charted for an infusion range e.g. 2 – 15 mls per hour with 15 mls being

the maximum the patient can receive in this example. This maximum is programmed into

the infusion pump and cannot not be exceeded.

Infusion pumps are set up in the Recovery Room. Please insure that you are familiar with

how to programme the Epidural pumps (Graesby 9500) used in Beaumont. A user guide is

available in the Recovery Room.

51

Epidurals are normally left in-situ for a maximum of 5 days. Patients on Epidural analgesia

are reviewed by the Pain Team on a daily basis. Patients should be reviewed by the Pain

Team prior to the epidural being discontinued and appropriate alternative analgesia

prescribed.

The patient should have no systemic narcotics or sedation charted while on an

epidural infusion (this includes all night sedation and Zydol/Tramadol).

Epidural infusions do not need to be 'weaned'. An infusion rate which provides the patient with

an excellent block for their pain management should continue unchanged, providing their BP

etc. is stable.

Anaesthetist’s responsibilities:

Confirm bed availability with the ward and pump availability with the Pain nurse or

the Recovery Room staff prior to insertion of the epidural catheter.

Prescribe epidural infusion on patient Kardex using the yellow prescription sticker.

Discontinue any other opioids or sedatives previously charted.

If the patient is for paracetamol +/- a NSAID, please chart same on the regular

prescription and not PRN. Please insure that the appropriate route, dose and interval is

documented.

Fill in information fields on the Epidural observation sheet with particular reference to

the cms at the skin of the epidural catheter.

Please ensure that the correct dressing is used and that the insertion site is visible

through the see through dressing. Please do not cover the insertion site with white

tape.

Inform Recovery Staff of expected time of arrival. Patients with epidural infusions are

nursed in the Recovery Room for approximately 1.5 hours prior to transfer to the ward.

Please establish patients 'block' level and document same on the Epidural observation

sheet.

Ward staff will contact the pain nurses or the Pain Reg on bleep 292 during office

hours and Bleep 714 after hours with any issues that arise with Epidural patients.

If you are called to see a patient with an epidural infusion after hours please document

call in the patients chart and leave a message for the Pain Nurse with the details of the

call.

Please refer to the ‘Algorithm of Care’ for the removal and subsequent management of

epidural catheters. See attached.

If you have any queries regarding Epidural Analgesia please contact:

Joanne O' Brien Aideen Hanlon

Pain Nurse Specialist: Bleep 403 CNMI; Pain Management: Bleep 779

52

Figure 8: Algorithm of Care: Removal of Epidural Catheter

Before Removal

Check coagulation

status Normal

INR <1.4

< 1.4

Raised

INR > 1.4

> 1.4

Last dose of once

daily LMWH > 12 hrs

ago No Yes

Yes

No Yes

No

Presence of other anti-

coagulation & or anti-

platelet therapy

Continue motor and

sensory observations 4

hourly x 24 hrs –

Document any leg

weakness/numbness at

time of catheter

removal

Contact the Pain Team

or anaesthetist on call

immediately to review

patient

Consider Epidural

haematoma

Immediate MRI

required

Please note the time Epidural removed or fell out on epidural observation sheet in the space provided.

Ideally the catheter should be removed before mid-day. If after 12.00 hrs hold evening dose of LMWH

Do not give LMWH for at least 6 hours after epidural catheter removed/fell out

If patient requires additional thrombolytic, anti-coagulant and or anti-platelet therapy other than LMWH in

the 24 hours post removal of catheter please discuss with Pain Team or anaesthetist on call Bleep 714

The Pain Team can be contacted Mon – Fri on bleeps 292 or 403 or 779 during office hours and bleep 714

after hours.

Patients may be reviewed by the Pain Team or anaesthetist on call in the 24 hours post removal of catheter.

If you have any concerns please contact us immediately.

Epidural Catheter Removal Algorithm/ 2010/Pain Team

4 Hours after removal

of Epidural check if

the patient complains

of leg numbness

/weakness or severe

back pain

Do Not remove epidural

catheter.

Contact and discuss with Pain

Team or Anaesthetist on call

(Bleep 714)

Continue 4 hrly

observations until 24 hrs

passed – report any

changes to motor or

sensory status

(numbness/weakness)

to the Pain Team or

anaesthetist on call

immediately

Remove Epidural before

mid-day and document

time of removal.

Do not give LMWH until

at least

6 hrs have passed

If catheter removed after

mid-day hold evening

dose of LMWH – Discuss

same with patient’s

primary team

53

Care of patients using Patient Controlled Analgesia, PCA The following points are a guide and do not replace the existing hospital protocol. They should

be used only in consultation with Beaumont Hospital's 'Protocol for the nursing care and

management of patients on Patient Controlled Analgesia'.

Ms. Joanne O' Brien, Clinical Nurse Specialist, Pain Management.

Introduction: Patient Controlled Analgesia is a form of analgesia where the patient administers his or her

own analgesia intravenously by communicating their requirements via a handset. When the

handset is pressed the pump delivers a fixed bolus of opiate, after which an immediate

'lockout' time commences. During the 'lockout' time the pump will ignore any requests for

analgesia. It has been reported that patients receive greater satisfaction with PCA then with

conventional analgesia (Chumley et al., 1999). PCA is available for patients requiring opioid

analgesia for the relief of post operative pain and for patients with acute painful conditions

who have unsatisfactory management of pain by other methods.

Prescribing and Programming PCA Pumps: PCA must be prescribed by an Anaesthetist on the 'PCA Assessment Sheet' and on the

PCA section at the back of the 'Drug Prescription and Administration Record'.

The concentration of Morphine/ Oxynorm or Pethidine used in the PCA is:

- Morphine/Oxynorm 1mg/ml

- Pethidine mg/ml 10mg/ml

The pump is programmed only by trained personnel who have been trained to do so, i.e.

Anaesthetist, Anaesthetic/Recovery Nurse, or the Pain Nurse/Specialist

Two qualified staff (nursing or medical) should check the programme on the written

instructions of an anaesthetist. The standard program is as follows:

Morphine: Pethidine: Oxynorm:

Bolus Dose: 1mg 10mg 1 mg

Lockout: 7 minutes 7 minutes 7 minutes

4 hourly Limit: 30/40mg 300 mg 30mg

Changing the PCA syringe: The PCA syringe maybe changed by staff who have:

Completed and passed their 'Intravenous Study Day'

Attended a tutorial demonstration on PCA and changing a syringe provided by the Pain

Nurse. (It is the nurses responsibility to arrange this tutorial).

Have had supervised practice on changing a PCA syringe.

Patient observation and assessment: Patient PCA observations and Pain Assessment scores are recorded on the PCA Flow Chart as

follows:

1 hourly x 8 hours

4 hourly thereafter if patient stable.

Assessment involves the documentation of the patient’s respiratory rate, pain score, sedation

score, side effects and the number of demands made and boluses received, which is then

signed by the nurse.

54

PCA Administration: PCA must be administered through a dedicated peripheral line or a dedicated lumen of

central access. No blood products or drugs are to be give through the PCA line.

Maintenance fluids should run with the PCA through the 'Y' connector PCA giving set at all

times, in order to keep the line patent.

The PCA giving set should be changed every 72 hours.

Disposal of Syringe Contents: The contents of incompletely used syringes from PCA pumps should be discarded by soaking

the fluid in to non-sterile gauze swabs. These are then placed in a yellow sharps bin together

with the empty syringe. This has been agreed with Beaumont Hospital Pharmacy Department.

Troubleshooting: Occlusion Problems: If the line is occluded the pump will alarm and 'occlusion' will show on

the pumps front screen.

Check line clamps are free.

Check patient’s intravenous cannula and site for patency.

Once the reason for the occlusion is detected and the problem corrected open

the pump cover, release and then close the activator (syringe pusher), close the

pump lid and press the start button.

Four Hour Dose Exceeded: In the event of a patient reaching their maximum dose within four hours of the pump

commencing, the pump will stop and alarm, and 'four hour limit exceeded' will appear on the

pump screen.

Silence the alarm

Assess and record the patients pain score and observations.

Follow pathways (A) or (B) below as appropriate:

a) If the patient reaches their 4 hourly dose limit inside three hours of commencing the PCA

they should be reviewed by an anaesthetist prior to the pump being restarted.

b) If the patient reaches their 4 hourly dose limit after 3 hours of the pump commencing, they

may be assessed by two registered nurses who are experienced with PCA. If the patients

sedation score is greater then or equal to 2 and their respiratory rate is greater then 10 and

both nurses are satisfied with the patients observations, then the pump maybe reset by

following the instructions on the Pump screen.

Note: If the patient reaches their dose limit a second time they should be reviewed by an

anaesthetist before the pump is reset.

Patient Review: Patients are reviewed daily by the Pain Nurse/Specialist and post-call Reg/SpR or more often

if required. Any alterations to the PCA program or patient management are made on the

instruction of the Consultant anaesthetist / Pain registrar (bleep 292), or ICU anaesthetist.

Special Precautions: Patients should have all other Opiates or Benzodiazepines by any other routes discontinued

prior to commencement of PCA (this includes all night sedation and Zydol).

55

Chronic Pain Service

The Chronic Pain Service in Beaumont Hospital is provided on Monday to Friday 08.00 –

1800.

Outpatient clinics are provided by both Dr Keaveny and Dr Pollard twice weekly.

Interventional lists are conducted twice weekly in theatre in Beaumont Hospital, three times a

week in St Joseph’s Hospital, Raheny.

Implantable procedures (spinal cord stimulators and implantable intrathecal pumps) are

usually conducted on Wednesday/Thursdays if a bed is available. This is entirely dependent on

bed and theatre availability and may vary from week to week. In-patient referrals are seen as

required on the wards. Referrals are received from a variety of specialities within Beaumont

Hospital and St Joseph’s Hospital Raheny.

Monday AM OPD Beaumont (Dr Keaveny)

PM X-ray St. Joseph’s (Dr Keaveny)

Tuesday AM Theatre Beaumont (Dr Pollard)

PM OPD Beaumont (Dr Pollard)

Wednesday AM Theatre Beaumont (Dr Keaveny)

PM X-ray St. Joseph’s (Dr Pollard)

Thursday Inpatient Referrals

Implantable Procedures in OT

Friday AM X-ray St Joseph’s (Dr Pollard)

PM Inpatient Referrals

56

Beaumont Hospital

Intensive Care Guidelines

Review date: January 2017

Introduction:

There are two ICUs at Beaumont Hospital, General ICU and Richmond ICU. There are 22

ICU beds though 5 remain unopened due to staff shortages. The Units admit approximately

1,000 patients each year.

Beaumont is the National Neurosurgical Centre for adults and for children > 6 years of age. It

is the National Centre for kidney transplantation and cochlear implantation, one of the national

centres for cancer care and a regional centre for vascular, GI and Urological surgery. It is the

Model 4 hospital for the RCSI (North Eastern) Hospital Group.

Clinical Issues:

Responsibility for Care

Care of patients is shared between ICU Consultant and the Admitting Consultant. As a general

principle the Admitting team manage the underlying condition while the ICU team are

responsible for the day-to-day care of the patient while in ICU. For changes in patient care

involving the admitting team's specialty, the ICU team should liaise with the admitting team.

Similarly, for proposed changes in ICU management, the admitting team should liaise with the

ICU team.

ICU Registrars should work within their level of competence, based on their knowledge and

clinical experience. If the ICU Registrar on-call has any concerns about the appropriate

management of any patient they should contact the 3rd on-call or the ICU Consultant on-call.

ICU Organisation:

ICU staffing: 08.00-17.00 ICU Consultant

SAT 5/6 (#313)

ICU SAT / Registrar (#212)

RICU (Neurosurgical ICU) SAT / Registrar (#824).

Electronic patient record

All documentation in ICU is electronic on the Clinical Information System (CIS). The CIS

manager is Mr John Pope. You will be allocated a time for training on the system and given a

password.

Please write notes and document all procedures in the CIS. These updates will be

incorporated into the paper Handover sheet for each change of shift. Complete a Discharge

Summary form when patient is going to ward; this is particularly important for out-of-hours

discharges.

57

Schedule:

8:30 - 9:00 “Hand-over” ICU ward-round – this is a dry round held at the nurses

station in GICU; after this the post-call Registrar goes home.

The 212 and 313 Registrars deal with any issues in GICU and begin reviewing patients in

preparation for the Consultant round at 10:00. The 824 Registrar goes to Richmond ICU to

deal with any urgent issues.

9:45 – 10:00 Pre-round Coffee break.

10:00 Consultant-led multidisciplinary rounds.

12:00 -13.00 Clinical Microbiology ward-round.

14:00 Perform procedures, daily ICU progress note

16:00 Handover round with the SpR/ Registrar on-call overnight.

ICU SAT 5/6 should inform the 3rd-on-call SAT for the night of any

patients who are causing concern.

17:00 RICU Registrar gives the cardiac arrest phone to the on-call ICU

Registrar (212).

GICU Registrar Duties (#212);

First on-call for GICU 09.00-17.00 and for both Units after 17.00.

Reviewing patients in A&E and receiving inter-hospital transfers.

ICU admissions; Document clinical evaluation, chart review and a review of labs, X-rays

and other investigations and an appropriate treatment plan.

ICU discharges; Write a discharge summary, with diagnoses and management plan.

The on-call Registrar should order chest X-rays for the next day as appropriate.

Neurosurgical (Richmond) ICU Registrar Duties: (#824);

First on-call for RICU 09.00-17.00

Transfers to the Radiology department.

Cardiac arrest calls during daytime.

58

CT scans

It is the policy of the ICU Dept that all transfers of ventilated patients outside ICU (for CT

scans, MRI, angio, Cardiac cath, etc) are discussed with the ICU team beforehand, doctor to

doctor.

The reasons are; (i) to outline the proposed procedure to the ICU team who will

be caring for the patient

(ii) to discuss the risks and benefits of the proposed procedure

(especially how an investigation will change management)

(iii) to reach a consensus that the benefits outweigh the risk

(iv) it is professional courtesy to liaise directly with medical

colleagues

Transfers of patients outside ICU should only be undertaken after this direct contact has

occurred and there is agreement that the procedure is appropriate.

ICU staff are not responsible for pre-meds or for provision of anaesthesia in X ray or

elsewhere. These requests should be referred to the Consultant Coordinator in Theatre.

ICU Cover out-of-hours:

17.00 to 08.00; one ICU Registrar (#212) covers both Units. They start work at 16.00 Mon-

Friday, allowing I hour for handover before the daytime staff go home. The ICU Registrar rota

is normally 1-in-6.

The ICU Registrar reviews patients outside ICU who may need ICU care and attends cardiac

arrest calls etc. This is a large workload for one person. If not all demands can be met at times,

your primary responsibility is to the critically ill patients in ICU. The ICU Registrar must

always be immediately available to ICU for emergencies.

When there is only one SAT covering ICU, requests for CT scans etc in ICU patients are put

on the Emergency Board and dealt with as Theatre cases. The Theatre on-call consultant

should be informed if all 3 Junior Doctors on-call are clinically committed with none available

for emergency response.

The SAT 5/6 on-call is available for support in ICU as required. The ICU Consultant on-call

should be contacted for any patient who causes clinical concern, for issues regarding bed

availability and if the Unit is too busy for the on-call staff to manage.

Weekends;

The ICU SAT works a 24 hour shift; they are supported by a second ICU Registrar (#824)

from 09.00 – 18.00.

Collect bleep no 824 in RICU at 09.00

09.00 - handover round with ICU registrar on-call from previous night. After handover,

824 Registrar usually covers RICU and assists First on-call SAT.

The ICU Consultant on-call does a full ward round on each weekend day around 11.00.

59

Evaluation of ward patients re ICU Admission:

Requests for evaluation of seriously ill ward patients are common. Normally the patient will

have been reviewed by the Registrar on-call for the referring team before asking the ICU team

to review. It is important to see the patient and perform an appropriate assessment as soon as

possible.

Whether or not the patient is admitted to ICU, the ICU team must always write an evaluation

note. This should contain recommendations for treatment and advice on future contact in the

event of a clinical deterioration. The care of patients on the ward remains the responsibility of

the team on the ward until they are admitted to ICU.

MICAS (Mobile Intensive Care Ambulance Service):

Beaumont runs this service one week in four, Monday to Friday, 9.00 -18.00. A Registrar will

be rostered for the service on these weeks.

The ICU Consultant on-call is responsible for all decisions relating to the service. The ICU

Consultant decides whether the transfer is an appropriate use of the service and will prioritise

if there is more than one request. Direct communication with the referring unit is mandated for

all patients. The transferring registrar must contact the ICU Consultant for direction if any

issues arise at any stage during transfer.

Tracheostomy ward round.

Wednesday 13.30

ICU SAT 5/6 accompanies SLT, physio and ENT Registrar to review tracheostomy patients

on the ward, provide advice to ward staff and move towards decannulation if appropriate.

When inserting a central venous catheter, Registrar should document compliance with the

‘Care Bundle for CVC insertion’ by completion the appropriate section under ‘Procedures’ in

the CIS.

60

General & Clinical Guidelines

Admissions to GICU: (June 2014)

1. ICU admission is appropriate for patients with a ‘reasonable’ expectation of survival to a

‘reasonable’ quality of life.

Ensure that the Consultant of the referring team is aware of proposed ICU admission and

agrees it is appropriate.

2. Patients should be reviewed at Ward or ED level before admission to ICU to ensure

admission is necessary and appropriate. ICU beds are a scarce and expensive resource.

Appropriate utilisation ensures that as many patients as possible will benefit.

3. Decisions re admission to GICU are made by the ICU Consultant on-call. If an in-patient

very clearly needs ICU admission, the Registrar need not discuss the decision to admit with

the Consultant. If it is unclear whether ICU admission is appropriate or if the patient is being

transferred from another hospital the decision to accept (or refuse) must be made by the

Consultant on-call for ICU, ideally after direct discussion with the referring Consultant.

4. If a decision is made to admit a patient to either Unit, this must be communicated to the

Nurse in-charge who will inform the Bed Manager.

5. All patients admitted to ICU must be under the care of a Medical or Surgical ‘Admitting

Consultant’; this is usually organised by the Referring team.

6. Bed management in RICU is primarily the responsibility of the Neurosurgical team on-call.

However when GICU is full (8 beds), RICU beds are used for non-Neurosurgical patients, the

agreement of the Neurosurgical team is required. This should be arranged by the ICU

Registrar. If there is any difficulty, contact the ICU Consultant on-call.

7. Because of the need to have ICU beds available for emergencies overnight, the aim is to

have an ‘emergency bed’ empty at 17.00 each evening before day staff leave. This bed may be

available in either GICU or RICU. Bed managers must prioritise beds for discharges from ICU

in order to have an emergency bed empty in ICU

8. To ensure an emergency bed is available by 17.00 may lead to cancellation of elective

surgery or a temporary refusal of a patient transfer from other hospitals. However there may

be situations where we should accept critically ill patients from other hospitals who cannot get

an ICU bed elsewhere rather than keep the ‘emergency bed’ empty when it might not be

required. This will be at the discretion of the ICU Consultant.

9. Because of the pressure on ward beds from Casualty admissions bed managers tend not to

transfer patients out of ICU unless all ICU beds are full.

If ICU beds are occupied by patients who are discharged for care in the ward the ICU

Consultant may feel it appropriate either to

(i) to allocate their bed for a patient undergoing elective surgery

or

(ii) to accept a transfer from another hospital

61

This is on the basis that a ward bed will be found for the discharged ICU patient when bed

managers know the ICU bed is needed for another patient. This should be done in liaison with

the CNM in the Unit.

10. Decisions regarding ICU bed utilisation depends upon; the number of critically ill patients,

the complexity of care provided, the availability of additional nurses and the overall bed

situation in the hospital. Ensuring the safety of the patients already in ICU and the urgency of

need of the patient who requires ICU admission are also factors. The ICU Consultant, after

discussion with the CNM in-charge, is in the best position to balance all these factors and must

take responsibility for the final decision re admission (or not) to ICU.

Cardiac Arrests:

Cardiac arrest calls in Beaumont hospital are communicated by means of a portable phone.

Upon answering this phone, the location of the arrest will be communicated.

During the day the RICU Registrar (#824) is responsible for attending cardiac arrests. Out-of-

hours, the ICU Registrar-on-call (#212) carries the cardiac arrest phone.

The cardiac arrest phone is handed over each morning to the RICU Registrar who is

responsible for attending arrests during the daytime. The RICU Registrar must take the arrest

phone to the hospital switchboard to have the battery changed each morning.

The policy of the Department is that the ICU Registrar’s primary responsibility is to the

patients in ICU. When assisting at a cardiac arrest they should secure the airway. When

satisfied that ventilation is adequate and the patient is stabilised, the ICU Registrar should

hand over manual ventilation to the cardiac arrest team. The ICU Registrar is expected to

liaise with other members of the anaesthesia/ICU team to ensure that the post arrest patient is

transferred to a safe environment (Generally ICU).

If the ICU Registrar is committed in the ICU and unable to go to a cardiac arrest, he/she will

contact the Senior Registrar on-call (#313) who will endeavour to provide a timely anaesthetic

response.

Care of Ventilated patients after cardiac arrest or awaiting an ICU bed

It sometimes happens that a patient who has been intubated and ventilated in the ward or

Emergency Dept has to wait for an ICU bed.

Our policy is for the ICU Registrar to establish an airway. When he is satisfied that ventilation

is satisfactory and the patient is stable, he should leave the patient in the care of the team and

return to the Unit. The patient will be transferred to ICU immediately a bed is available. The

patient remains under the care of the Ward or ED team until the patient is admitted to ICU but

the ICU Registrar will provide regular review for support and advice.

The first duty of care of the ICU Registrar is to the patients in the two ICUs and he/she must

be immediately available to these. We feel strongly it is not safe to have patients ventilated

outside ICU and for that reason we endeavour to always have an empty bed in ICU to allow

immediate admission of ventilated patients.

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Contingency Plan for when an ICU bed is required but all beds are full. (Updated 2014)

If an ICU bed above our official complement (currently 8 beds in GICU and 7 beds in RICU)

is required for a critically ill patient the contingency plan is to open an additional bed in GICU

or in RICU, depending on the specialty of the patient. If further beds are required the ICU

Consultant and the CNMs in each Unit will liaise to agree the most appropriate site.

Prior to an extra bed in GICU being used the following should be observed:

1. The ICU SAT contacts the ICU Consultant on call to confirm the need for an ICU bed.

2. The decision to transfer the new patient to the extra bed in General Intensive Care should

only be taken after the following options are deemed inappropriate or unsatisfactory:

(i) Transfer a patient to the ward with a nursing special (if required)

(ii) Transfer an appropriate patient to CCU

(iii) Transfer a patient to an ICU bed in another hospital

3. If an extra GICU bed is to be used:

The Nurse in-charge in ICU will contact the relevant DNM (or Nursing Admin)

The ICU Consultant will discuss the situation with the CNM in GICU.

The DNM (or Nursing Admin), in collaboration with the CNM, will attempt to

source an ICU nurse to care for the patient in the additional GICU bed.

Use of Recovery Room:

In extreme cases where both ICU`s are full and the extra beds are already in use it may be

necessary to use Recovery / Theatre. In this instance the Recovery / Theatre nurses may be

asked to assist with providing care for these patients with the support of ICU trained staff and

according to patient need.

Medical care of the patient and appropriate medical support for the nursing staff in the

recovery room will be co-ordinated and provided by the on-call anaesthetists as assigned by

the Anaesthetic Specialist Registrar (#313). An anaesthetist will remain within the theatre

complex at all times but may not necessarily remain in the Recovery Room.

The ICU Consultant Anaesthetist may need to inform the Theatre Consultant Anaesthetist of

the position in order to manage theatre appropriately in light of the situation.

In circumstances where the Recovery room is being used to nurse an ICU patient, the

emergency capacity of the operating theatre is reduced by one theatre.

It is accepted that care of the patient in the Recovery Room is unlikely to be to the same

standard as in a fully commissioned bed in ICU. Thus this option is only undertaken when it is

the 'least-worst' option in trying to ensure that all patients receive the best care possible with

the resources available.

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Standard Clinical Care for All admissions: (Admission bundle on CIS)

Early enteral nutrition,

Antacid prophylaxis (e.g. ranitidine 50 mg tds)

Venous thromboembolism prophylaxis (except in Neurosurgical patients).

Appropriate sedation regime

K+, P04, Mg++, supplements

Aperients and laxatives

The ‘5 moments of Hand Hygiene’ is an Intranet based obligatory course on this topic. Please

complete the course and short questionnaire. Regular audits of hand hygiene practice are

undertaken in the Unit.

VAP bundle for all patients Sedation reviewed and stopped daily as per protocol

30o head-up position

Oral Corsodyl paste b.d. in all patients

Sepsis; SSC care bundle; http://www.sccm.org/Documents/SSC-Guidelines.pdf

TO BE COMPLETED WITHIN 3 HRS OF PRESENTATION

1. Measure lactate level

2. Obtain blood cultures prior to administration of antibiotics

3. Administer broad spectrum antibiotics

4. Administer 30ml/kg crystalloid for hypotension or lactate ≥ 4mmol/L

TO BE COMPLETED WITHIN 6 HRS OF PRESENTATION:

5. Apply vasopressors (for hypotension that does not respond to initial fluid

resuscitation) to maintain a mean arterial pressure (MAP) ≥ 65mmHg

6. In the event of persistent hypotension after initial fluid administration (MAP < 65

mm Hg) or if initial lactate was ≥ 4 mmol/L, re-assess volume status and tissue

perfusion.

7. Re-measure lactate if initial lactate elevated.

Care bundle for Insertion of Central Venous Catheter: (May 2011)

Pre-insertion:

Valid indication documented

Avoid femoral site unless clinically indicated

Patient explanation

Ensure maximal sterile precautions:

Handwash

Sterile gown, hat, mask and gloves.

Central venous catheter pack, trolley for CVC insertion

Chlorhexidine 2% skin prep, allowed to dry

Fenestrated sterile drape, full body cover

Sterile field within drape opening

Silver chlorhexidine impregnated central venous catheter

Sterile adhesive semi-permeable occlusive dressing

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If Catheter related infection is suspected:

Blood culture through new line only if blood stream infection suspected

Culture tip if old line being removed only if infection of the CVC line or insertion site

suspected

Check CXR for appropriate location of catheter tip

Document the procedure in the CIS in Procedures section

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Traumatic Brain Injury; management guidelines,

Beaumont Neurosurgical ICU

(May, 2016)

All patients at risk of

be modified at the discretion of senior clinicians.

Management of raised ICP is primarily the responsibility of the Neurosurgical team

Step I

MAP > 80, ICP < 20, CPP > 60

30o head up, no venous obstruction

SaO2 ≥ 97% ; PaO2 ≥ 11 kPa, PaCO2 4.5 – 5.0 kPa, PEEP +5cm. Use Volume Control

ventilation.

Temp 36-37ºC (cool if necessary): Bld Sugar 5-8 mmol/L, Na+ 140-150 mmol/dl

Sedation; Propofol 2 - 4 mg/kg/hr.

Midazolam 5 -10 mg/hr, morphine 5-10 mg/hr

Consider remifentanil 0.1 –

If on propofol - do daily lipid screen; if plasma triglycerides - reduce dose.

After 48 hr of propofol – use lower dose range

Occasional brief cough or motor response is tolerated if no prolonged

Ranitidine 50mg 8 hrly IV, enteral feeding

Phenytoin 15 mg/kg (over 30 min) if indicated (seizures, depressed #).

If ICP > 20 consider CT; if CT or surgery not indicated - proceed to Step II

Step ll

20% Mannitol 0.4g/kg x 3 or until plasma osmolality ≥ 320 mosm/l

Consider bolus 1ml/kg 8% NaCl * or 3 ml/kg 3% saline

Use infusion of saline 3% to increase Na+

If ICP > 20, consider CT; if CT or surgery not indicated - proceed to Step III

Step lll

Consider lowering CO2 to 4.0 kPa

Consider anti-epileptics if EEG shows seizures.

Consider

Consider

Step IV (if ICP remains > 20)

Consider EVD or decompressive craniectomy

Consider thiopentone; 250 mg boluses up to 3-5 g + thiopentone 2.5% infusion @ 5-20 mls/hr.

Titrate to Burst Suppression Ratio 70-90 % on EEG. Maintain CPP with fluids and

vasopressors (noradrenaline).

Children; as above but guidelines for CPP are lower to reflect normal values for each age i.e.

CPP 40 - 60 mmHg for neonates to teenagers respectively.

Propofol only for short periods (up to 6 hrs).

* To prepare 8% saline, remove 60 ml from 250ml bag of 0.9% saline and replace with 60 ml

30% saline.

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ICU Education & Training

There are 2 regular ICU teaching sessions per week with core topics presented by Registrars

and Consultants (Wed and Fri).

A comprehensive teaching programme is provided for 2 months before the JFICMI Fellowship

exam in May.

Two-month modules of ICU training at Beaumont are accredited for SAT training and for the

Fellowship exam of the Joint Faculty of Intensive Care Medicine.

The ICU was accredited both for six months SAT training and for a 12-month post-CST

Fellowship up to January 2015. Unfortunately this has been suspended pending resolution of

certain issues related to training. We are hopeful these will have been resolved by reinspection

in December 2015 and training recognition will be reinstated.

ICU SAT post (ICU Fellow).

1. This post provides specialist training for a 6-12 month period in ICU to prepare trainees for

a Consultant post in Intensive Care.

2. These posts are open to trainees from a range of acute specialties although the trainees are

initially expected to come from Anaesthesia.

3. The College expects that these trainees will be assigned exclusively in Intensive Care

medicine and this has been our practice to-date.

4. Where the ICU fellow is in the final years of training i.e. SAT Year 5/6, we will

accommodated non-clinical time and are strongly committed to continuing this even when

both ICU fellow and ICU SAT 5/6 require non-clinical days. We will continue to

accommodate ICU modules for SATs 5/6 in Anaesthesia.

5. The Anaesthesia SAT 5/6 doing an ICU module will stay on the 313 rota at night. Thus the

number of SATs on the 313 rota will remain unchanged.

6. The ICU fellow will participate in the ICU on-call rota (212). They will do call 1:6.

7. The ICU SAT 5/6 will occupy a module formerly occupied by an SAT 3-4. This will leave

3 ICU modules available for SAT 3-4 / Registrars.

8. Specific training opportunities will be explored for the ICU SAT 5/6 e.g. sessions for

echocardiography, bronchoscopy, etc. To facilitate this, we will try to organise their Non-

clinical day on a set day of the week every week.

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Educational Facilities

Anaesthesia and ICU Departmental Google Drive

Each NCHD will be sent a link to our shared folder and instructions on how to access the drive.

The drive contains over 100 clinically important guidelines and articles, with a particular emphasis

on ICU. All that is required on the part of the NCHD is to have a google account. All files may

be accessed via Google Drive Smartphone App.

RCSI ejournal access

RCSI provide online access to a large library of journals. Login details can be arranged by means

of filling out necessary forms in the RCSI library at the front of the hospital ((01) 809 2531

This login gives access to all resources at www.rcsi.ie/beaumontlibrary including:

Medline (same content as PubMed but with links to RCSI full text e-journals)

Embase (larger database than Medline that is an essential resource for literature searching

for systematic reviews)

Cochrane (systematic review database and clinical trials)

Web of Science (citation database useful for literature searching for systematic reviews)

Scopus (citation database useful for checking citations, H Indexes required when applying

for funding/promotions)

Up-To-Date (peer reviewed clinical topics summarising the content of core medical

journals)

Dynamed (summaries of clinical conditions, good source for international clinical

guidelines and quick answers to clinical questions)

Clinical Key (collection of e-books and multimedia resources including videos of clinical

procedures)

E-Journals

E-Books

All resources can be accessed from home PCs or Beaumont Hospital PCs using the login. The

logins expire after 1 year so need to be updated each year.

Q Pulse

Username: Beaumont email username

Password: Beaumont email password

This database contains more than 200 clinical practice guidelines,

For ICU guidelines, Login search ICU

Policies procedures Guidelines – ICU section

Crit-IQ

An Australian Educational and Reference Resource website containing podcasts, modules, exam

preparation, and up-to-date analysis of latest literature.

Website: http://crit-iq.com/index.php/home

Access by individual prescription kindly subsidised by Orion Pharma

https://outlook.beaumont.ie/owa/redir.aspx?C=jT-U87iKSE-lnRFnUCZ9mJgyiO7u89IIHLIjdwpD_cptHw3VrDABz35gOXOEjiIpcsCBdWR5zg8.&URL=http%3a%2f%2fwww.rcsi.ie%2fbeaumontlibrary

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Other useful resources

Topic Source

Care bundle for Insertion of Q Pulse, ICIP

Central Venous Catheter

Traumatic Brain Injury management Q Pulse, ICIP

guidelines

Guidelines for induced hypothermia Q Pulse, ICIP

Beaumont ICU Ventilator Associated Q Pulse, ICIP

Pneumonia Prevention Guideline

Protocol for use of Citrate based Q Pulse, ICIP

CVVH in Beaumont Hospital

Crib card for Novalung Vision α Oscillator Q Pulse, ICIP

ICSI checklist for Diagnosis of www.anaesthesia.ie/intensive-care-medicine

Brainstem Death Q Pulse, ICIP

ICSI recommendations for www.anaesthesia.ie/intensive-care-medicine

Medical Management of the

Adult Organ Donor Q Pulse, ICIP

Non Heart Beating Organ Donation Q Pulse, ICIP

Deaths reportable to the coroner www.coronerdublincity.ie/faqs/appa.html

http://www.anaesthesia.ie/intensive-care-medicine

http://www.anaesthesia.ie/intensive-care-medicine

http://www.coronerdublincity.ie/faqs/appa.html

Explanatory Note

The purpose of these guidelines is to provide a resource for clinicians caring for potential organ

donors in an effort to maximise the success of the organ donation process. These are intended to

be in the form of a brief (one page) checklist rather than a substantial document for ease of use.

They are based on up to date evidence (where evidence is available) and accepted international

practice guidelines.

Once a patient has been identified as an organ donor several pathophysiological processes can

take place which can potentially render organs unfit for transplantation. The below guidelines

include interventions intended to minimise these occurrences.

It is fully understood that not all Intensive Care Units (ICUs) are able to provide all of the

interventions included. The philosophy behind this Checklist is to support Units to use their

local individual expertise to the maximum.

Important concepts

1. Ensure adequate volume status (but fluid overload may prevent utilisation of the lungs).

CVP may be useful for volume status trends.

2. Recognise and treat diabetes insipidus early

3. Vasopressin* is the first choice vasopressor for refractory hypotension after adequate

fluid resuscitation.

4. Methylprednisolone* 1 gm 24hrly ± T3 (Liothyronine*- if available) should be

administered to all patients

5. Minimise ventilator disconnections and recruit after any disconnection

6. Use lung protective ventilation strategies – Vt 6 -8ml/kg

7. An accurate measured height (cm) is extremely important (heel to forehead with tape

measure). Weight should be obtained from NOK if possible.

* Each ICU should ensure that the medications recommended in these guidelines are

available and in date at all times

Donation after Brainstem Death Donor Organ Optimisation – Checklist

ICSI October 2012

70

Priorities

1. Assess fluid status and correct hypovolaemia

2. Identify and treat diabetes insipidus

3. Vasopressin as first choice vasopressor

4. Methylprednisolone 15mg/kg in all donors

5. Perform lung recruitment manoeuvres, Vt 6-8ml/kg

Respiratory

1. Minimise circuit disconnections (e.g. do apnoea test using

a C-circuit with PEEP)

2. Perform lung recruitment manoeuvres (esp after disconnections)

3. Lung protective ventilation (VT 6-8ml/kg ideal body weight,

PEEP 5-10 cm H2O)

4. 30-45 degrees head-up positioning

5. For lung donation – do bronchoscopy for sputum clearance

Cardiovascular

1. Ensure euvolaemia with fluid boluses.

Excess fluid may be harmful to lungs.

2. Vasopressin (0.5 – 4 Units/hr) is first choice if vasopressor required

3. If Noradrenaline required, try to limit dose

4. Liothyronine (T3) – /hr infusion (if available)

Thromboprophylaxis – in all cases

1. TED stockings

2. Calf compressors

3. Low molecular weight heparin

Fluid Balance/Metabolic

1. Methylprednisolone for all patients

(15mg/kg – max 1gm, every 24 hrs)

2. Ensure normal electrolytes

3. Desirable urine output is 1.0 – 2.5ml/kg/hr. If urine output

> 4ml/kg.hr administer DDAVP 1-2 mcg i.v. /s.c.

4. Start insulin infusion. Maintain normoglycaemia (4-10 mmol/l),

with dextrose if necessary

5. Continue enteral feeds

Donation after Brainstem Death Donor Organ Optimisation - Checklist

ICSI October 2012

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Monitoring & Investigations

1. Arterial line necessary (preferably left radial)

2. CVC desirable – use R jugular or subclavian (not femoral)

3. 12 lead ECG

4. Chest X-Ray

5. Echocardiogram if possible if cardiac donation considered

6. Monitor cardiac output if possible

7. Maintain normothermia

8. Minimise medications only to those necessary

9. Height; .................cm Weight.......................

Physiological Goals

1. PaO2 > 10.0 kPa (FiO2 <0.4 if possible)

2. PaCO2 4.5 – 6.5 kPa (or higher if pH > 7.25)

3. MAP > 60mmHg and < 90 mmHg

4. CVP 6-14 cmH20 if possible

5. Temp 36 – 37.5 degrees

6. Blood Glucose 4.5 – 10 mmol/L

7. Urine output 1.0 – 2.5 ml/kg/hr

8. Na+ < 150 mmol/l

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Consultant Anaesthetist Administrative Roles – July 2016

Dr Mags Bourke College Tutor, Paediatric Committee; Trauma Committee, Major

Disaster Planning

Dr Elma Buckley Honorary Secretary, Pre-Op Assessment Service.

Dr Frances Conway Haemovigilance / Transfusion Committee

Dr Edel Duggan Honorary Treasurer, Pre-Op Assessment Service;

Director National Poisons Centre; Regional Anaesthesia Service;

Resuscitation Committee; Point of Care Testing Committee;

Audit / Research meetings Co-ordinator.

Dr Rory Dwyer ICU Audit. Senior Lecturer RCSI

Dr Alan Gaffney Transplant Organ retrieval Co-ordinator, ICU teaching/ meetings

Coordinator

Dr Sinead Galvin College Tutor

Dr Michele Halpenny Chairman, Pre-Op Assessment Service; Day Case Anaesthesia

Service

Dr Anne Hennessy College council representative, Vice President of College, Chair

of Examination committee CAI

Dr Josh Keaveny Chronic Pain Service, Director of Acute Pain Service.

Dr Fiona Kiernan College Tutor

Dr Irene Leonard Anaesthetic representative of Medical Executive, Lead in

Morbidity and Mortality and Safety, Theatre administration.

Dr Michael Moore Anaesthesia Intern Tutor; Anaesthesia Equipment Co-Ordinator;

Anaphylaxis Co-Ordinator; Drugs and Therapeutics Committee

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Dr Adriana Nizam Lead administrative role - St Joseph's Raheny

Dr Tanya O’Neill Theatre Roster Organiser; Pre-Op Assessment Service; Regional

Anaesthesia Service; Haemovigilance Committee

Dr James O'Rourke ICU Director, Senior Clinical Lecturer RCSI,

Dr Valerie Pollard Acute and Chronic Pain Service

Dr Michael Power Intensive Care Medicine Service

Dr Aidan Synnott Anaesthesia Equipment Co-Ordinator; Living Related

Transplantation Committee.

Dr Criona Walshe Intensive Care Medicine Service, Early Warning Score

Committee.

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