Ensure you arrive at the hospital in plenty of time to start the list.
You will need time to see your patients and prepare both the anaesthetic room and theatre before your first patient arrives.
In your first few months as a novice, you should try and formulate an anaesthetic plan for each patient you have seen and discuss this with your supervising consultant. This should also be communicated to your anaesthetic assistant.
As you gain experience with different specialties and procedures you will be given increasing responsibility and autonomy to formulate and put into practice your own anaesthetic plan.
You should always consider specific patient, anaesthetic and surgical factors that could influence your chosen anaesthetic plan.
The key steps to preparing your theatre are:
- preparation of the anaesthetic room
- checking the anaesthetic machine
- preparing and checking your basic anaesthetic equipment
- preparing your drugs for induction and those to use in case of an emergency
- preparation of the theatre itself
- checking the anaesthetic machine
- additional and specialist equipment checks.
It is important to appreciate that some anaesthetic assistants have many years of experience and you should not ignore probing questions from them about the plans or decisions you have made. These challenges may indicate that, in their experience, other anaesthetists would not being doing it this way.
Checking the anaesthetic machine
It is mandatory to do a full machine check prior to the start of every list.
The checklist can be printed out as an aide memoire or you can send it to your smart phone and access it via iBooks or similar applications.
Preparing your basic anaesthetic equipment:
- monitors – ensure that your monitors are working, configured correctly and with appropriate alarms and volume limits set.
- airway equipment – ensure you have a full range of the required equipment including spares. This includes:
- bacterial filters, connectors and catheter mounts – these should be checked for patency
- tracheal tubes and laryngeal mask airways
- appropriately sized face masks and Guedel airways
- laryngoscopes with appropriately sized blades
- equipment for the management of the anticipated or unexpected difficult airway must be available and checked regularly in accordance with departmental policies
- ancillary and resuscitation equipment:
- check that the patient’s trolley, bed or operating table can be tilted head down rapidly
- a resuscitation trolley and defibrillator must be available in all locations where anaesthesia is given and checked regularly in accordance with local policies
- equipment and drugs for rarely encountered emergencies, such as malignant hyperthermia and local anaesthetic toxicity must be available, checked regularly in accordance with local policies and the location of these must be clearly signed.
Preparing your drugs
You should prepare and label the drugs you need for induction of anaesthesia:
- induction agent e.g. propofol, thiopental, midazolam
- opioids to blunt the cardio-vascular response to airway manipulation e.g. fentanyl or alfentanil
- muscle relaxants
- depolarizing if Rapid Sequence Induction is indicated (suxamethonium)
- non-depolarizing for routine intubation e.g. atracurium, vecuronium, rocuronium
- saline flush
- antiemetics if indicated
- antibiotics which may be required at induction depending on the type of surgery
- volatile or intravenous agent to keep the patient asleep.
It is recommended that you have the following emergency drugs drawn up, labelled and ready to use before any case:
- Suxamethonium (100mg in 2 ml)
- Atropine (1mg in 1 ml).
In addition to this many anaesthetists also prepare vasopressor agents for use in hypotension which may be associated with induction or spinal/epidural anaesthesia:
- Ephedrine (30 mg in 10 mls of saline)
- Metaraminol (10 mg in 20 mls of saline).
Preparing your theatre
In addition to preparing your anaesthetic room you must also prepare the operating theatre:
- anaesthetic machine check – it is mandatory to do a full check on the anaesthetic machine in theatre prior to every list
- check that you have the appropriate operating table and equipment to support the patient and protect pressure areas from injury during surgery
- check that you have appropriate equipment to avoid hypothermia including active patient and fluid warming devices
- consider whether any additional invasive or non-invasive monitoring equipment is required.
WHO Surgical Safety Checklist
The WHO introduced the Surgical Safety Checklist in order to increase the safety of patients undergoing surgery. It has been made mandatory by the NPSA as part of the 5 Steps to Safer Surgery programme, the principles of which are detailed below.
Team brief
The anaesthetic, surgical and theatre team should meet at the start of the day to discuss/plan the list and to highlight any specific requirements or concerns.
Sign in
The anaesthetist and anaesthetic assistant should ensure that this part of the checklist is completed before induction of anaesthesia. This involves:
- checking patient details against the notes and consent form for the specified operation and site of surgery
- checking for allergies and aspiration risk
- confirming that you are prepared for any airway issues and blood loss
- confirming that you have checked the anaesthetic equipment and drugs.
Time out
This is performed by the theatre team prior to ‘knife-to-skin’. The planned procedure is reconfirmed by reference to the patients identification, the consent form, site of operation mark and associated imaging. The aim is to also ensure that the team is fully aware of the planned procedure, any surgical/anaesthetic issues including antibiotic requirements, thromboprophylaxis, glycaemic control and are prepared for potential complications.
Sign out
Performed before the patient leaves theatre:
- the procedure that has been performed is confirmed and documented
- swabs and instrument checks/counts are correct
- key concerns for recovery/ward are summarized
- specimens have been labelled and sent for the appropriate investigation.
Team debrief
This occurs at the end of the list or operating day:
- all team members must discuss the running of the list to highlight any problems that have arisen and need addressing
- it is also an opportunity to discuss what went well and learn from events that didn’t go so well.