The anaesthetist’s role

Anaesthetists are specialist doctors whose main role is to provide anaesthesia (putting patients to sleep) and pain management for patients undergoing surgery. After medical school and 2 years of general training, it takes 7 years and many exams to become an anaesthetist. Anaesthetists are involved in all stages of the surgical journey, including helping patients prepare for an operation and supporting their recovery afterwards. They also work outside theatres; they are part of the cardiac arrest and trauma teams and care for critically ill patients in the emergency department and on intensive care units. Provision of pain relief in labour, obstetric anaesthesia and specialist management of acute and chronic pain are other important roles. Safety and teamwork form a critical part of anaesthetic training. Whatever the hospital setting, anaesthetists are trained to deliver safe, high quality, patient-focused care.

Spinal anaesthetists have chosen to sub-specialise in this area of complex surgery, often completing further training to ensure they are experts in this field. The patient will meet their anaesthetist on the day of surgery, but many centres now invite patients to attend an outpatient assessment clinic before their operation.

 

Anaesthetic clinic

If a patient is called to an anaesthetic pre-operative clinic, full medical history and examination will be done. Occasionally further tests may be ordered to assess an individual’s heart and lungs more closely. In some circumstances a specialist opinion may be necessary (for example, from a heart or lung specialist). A plan for regular medications and how to manage any medical problems in the run up to surgery will then be discussed. The aim is to understand the patient’s baseline function and assess if there is any way to improve function before surgery.

All medical professions are encouraged to form decisions collaboratively with their patients, which means discussion and understanding of the risks as well as the benefits of surgery. Although anaesthetists do not take separate written consent, these discussions inform the consent process. Common areas for discussion would include the following

 

1) Management of bleeding

Maintaining a good blood supply and appropriate blood pressure during surgery is essential to protect the heart, brain, kidneys, and of course spinal cord. Some spinal operations can be associated with substantial bleeding. Spinal anaesthetists are experts at managing and reducing the effect of any blood loss. Common strategies include:

• Iron: if blood tests done in pre-operative assessment show low iron stores, iron supplementation in the weeks before surgery may help improve the blood count and the oxygen carrying capacity of the patient’s blood. Sometimes surgery may be postponed to allow this improvement or facilitate further investigation. Iron treatment can be given as a course of tablets, or the patient may be asked to attend the hospital for intravenous treatment.

• Cell salvage: in this technique any blood that is lost during the operation is salvaged. It is washed and given back to the patient. Because it is the patient’s own blood, the risks are low. Sometimes it is not available, or it is not possible to collect all lost blood and a blood transfusion may still be needed.

• Blood transfusion: patients might have to be given blood donated by volunteers. Strict criteria are followed before the use of this limited resource. The donated blood must be matched exactly to the patient’s blood type to minimise the chance of allergic-type reactions. The rigorous screening of donated blood in this country makes the risk of transmitting any infections very low. More information for patients to make an informed decision about donated blood can be found at www.nhsbt.nhs.uk.

2) Positioning

Often spinal operations are done with the patient lying on their front (prone). Patients are anaesthetised lying on their back/semi-recumbent and then turned, under anaesthesia, onto the operating table. Spinal operations can take many hours, and the patient remains in one position throughout. The theatre team are meticulous in positioning patients in a safe way. Despite this care, the duration of surgery means that sometimes pressure marks develop on the skin where the patient rested, commonly in bony areas, including the forehead and chin, chest, hips, and knees. These marks usually settle a few days after surgery. More rarely, a pressure injury can develop that takes longer to heal. Patients often have a swollen face after long surgery, called dependent oedema, which is similar to having swollen ankles after a long journey. It will settle on its own.

A rare (one in 500 cases) complication of operations done in the prone position is post-operative visual loss. There are different causes but risk factors include certain types of positioning equipment, long surgery time, with large blood loss and low blood pressure, being male, and having diseases such as diabetes. Great care is taken to protect the face when placing a patient to ensure there is no direct pressure on the eyes. The head and neck are placed in a neutral position and kept at or above heart level where possible.

3) Spinal cord monitoring

To reduce the risk of neurological injury, some spinal operations require the spinal cord to be monitored. After anaesthesia fine needles are placed in the scalp and in some major muscle groups, which allows the neurophysiology team to check that nerve signals can travel in both directions along the spinal cord, between the brain and the arms and legs. Both feeling (sensory) and movement (motor) nerves are tested. Should there be any alerts about potential nerve injury, all steps to optimise blood flow to the spinal cord are taken. If necessary, any straightening or instrumentation of the spine may be temporarily reversed or removed. Stretching of the spinal cord may reduce blood flow, and be the cause of the problem. Finally, if all other attempts are exhausted and spinal monitoring suggests there may still be a problem, a ‘wake up test’ may be needed. For this test the operation is stopped and the patient kept on their front while the anaesthetic is gradually reduced. The patient slowly wakes to a point between being awake and being fully anaesthetised. Usually, they are asked to wriggle their toes. As soon as the assessment is complete, the anaesthetic is restarted. This event is rare and usually patients have no recall of it. It is more common when the risk of spinal cord injury is increased, for example if the spinal cord is abnormal before starting surgery or if the curvature is very pronounced.

4) Pain management

Managing a patient’s pain after surgery is an important part of the anaesthetist’s role. Simple pain killers such as paracetamol and ibuprofen are often prescribed, together with morphine-based drugs (opioids). Treatment may be oral or intravenous, depending on the patient, the type and duration of surgery, and local practice. Common choices of these drugs include morphine, oxycodone, and sometimes fentanyl. Patient controlled analgesia (PCA) is popular because it allows individual control of intravenous opioids via a pump with a button so that the delivery of pain killers can be managed by the patient. For patients already using opioids, optimising pain relief can be more difficult and alternative pain killers such as ketamine may be considered. The pain relief strategies available at the hospital should be discussed in detail before the operation. Medicines to help manage side-effects, such as nausea, vomiting, or constipation, should also be prescribed.

 

How can I prepare for my operation?

Recovery from surgery puts a lot of stress on the body. The effect of major surgery and the healing process has been likened to doing intense exercise continuously for several days. It is therefore helpful to optimise fitness before surgery.

Patients should try to stay as active as possible and try to improve their fitness. Some patients will be restricted by their curvature; however, any exercise is encouraged, such as gardening, walking the dog, using exercise bikes, or swimming. Local gyms can sometimes offer simple fitness programmes tailored to your needs.

Following a healthy balanced diet can improve surgical outcomes . Further information can be found at: www.nhs. uk/live-well/eat-well

Avoiding smoking and reducing alcohol intake is strongly recommended. As well as damaging the lungs and reducing the blood’s oxygen carrying capacity, smoking is particularly bad for wound and bone healing, both of which are critical after spinal surgery.

Some people with spinal problems are in severe pain before surgery and have needed to use strong morphine-based pain killers, which can lead to tolerance to the pain-relieving properties of morphine. Minimising the use of opiates as much as possible before an operation may be beneficial.

 

On the day of surgery

The day has finally arrived! No doubt a mix of nervous anticipation awaits. Theatres start promptly, which unfortunately will mean an early start. There may be some waiting around so if possible, bring a book and a family member or friend.

Depending on the planned time of surgery different fasting instructions will have been given. An empty stomach helps to prevent any regurgitation of stomach contents during anaesthesia. Being nervous can delay emptying of the stomach and so these fasting times are quite generous to reduce risks. Follow the advice given from the hospital, being careful not to fast for any longer than necessary. It is really beneficial to stay as hydrated as possible and patients waiting for surgery will be encouraged to drink water until 2 hours before their operation.

In addition to staying hydrated, another key tip is to stay as warm as possible. Bring a dressing gown or extra layers to wear whilst waiting. If asked to put on a hospital gown, then be sure to wrap up warm after this is on. You can keep these extra layers on until just before being anaesthetised. Staying warm has been shown to improve outcomes in planned surgery.

Anaesthetic room

When it is time for your surgery a member of the operating theatre team will meet you to bring you round to theatre. In the UK most people are anaesthetised in a dedicated anaesthetic room. Here you will meet the anaesthetic assistant (sometimes called an ODP) and other members of the theatre team who will complete final checks to confirm your identity, consent for surgery, and other critical information (eg, allergy status). Some people may feel anxious seeing so many new faces; however, it is important to remember that all these staff are focused on safety and making the operation a success. You may ask for a friend or relative to accompany you to the anaesthetic room, which is routine for younger patients.

Basic monitoring will be attached; ECG stickers to monitor the heart, a finger probe for oxygen saturations, and a blood pressure cuff. A cannula will be placed to allow injection of drugs for induction of anaesthesia and you will often be asked to breathe some oxygen from a face mask. A sticker to monitor depth of anaesthesia may be placed on your forehead.

Once anaesthetised, some more advanced monitoring and usually more intravenous (IV) cannulas will be sited. An arterial line may be placed into an artery in the wrist to measure blood pressure very accurately. A blood pressure cuff can give a reading up to once every minute. An arterial line gives a blood pressure reading with every heartbeat. Occasionally the anaesthetist will discuss siting this line before induction, if closer monitoring is required. A urinary catheter is often inserted for longer operations to help drain the bladder both during and after surgery.

 

In theatre

When ready, the patient will be moved into the operating theatre and positioned on the operating table. Moving an anaesthetised patient is complex and requires a full team working together. Before final preparation for surgery the surgeon and anaesthetist will each do a full inspection to make sure they are both happy with the position to minimise the risks discussed earlier. The anaesthetist will typically continue to do regular inspections during the operation.

 

Maintaining anaesthesia

Throughout surgery unconsciousness is maintained by continuous delivery of anaesthetic agents. Some agents are inhaled via the breathing circuit, others are delivered intravenously. There will always be an anaesthetist at the bedside monitoring the patient to ensure their vital signs are within a safe range and to give medicines and fluids as appropriate. The whole team works together, led by the anaesthetist, to keep the patient safe during the different stages of surgery. The team manages the cell saver if in use and if donor blood is required, it is organised.

To monitor how anaesthetised someone is, the anaesthetist may choose to use a depth of anaesthesia monitor. This gives extra information to help ensure the right amount of anaesthetic is delivered because too much is potentially as bad as not enough.

 

Recovery

Once the operation is finished patients are carefully positioned into a hospital bed, lying on their back. The delivery of anaesthetic is stopped, and the patient wakes. In anticipation of the wake up, the anaesthetist will have already administered strong pain relief and anti-sickness medications. The amount and type of painkiller given is individually tailored, taking into account information from the pre-operative assessment. The aim is to allow the patient to wake up as comfortable as possible, but also to avoid giving too much, which can increase risk of having side-effects such as nausea or vomiting. Patients are then moved to recovery where they will be closely monitored by their own nurse. The recovery nurse can help with ‘fine tuning’ of pain relief and strong painkillers, and anti-sickness medications will be prescribed for the nurses to give as necessary. The nurses work closely with the anaesthetists to ensure all medical needs are taken care of. Once patients are awake and comfortable and all vital signs are safe they will be moved to a ward or critical care location depending on both the pre-operative plan and how the operation went.

The main challenges with spinal anaesthetics relate to managing large teams, complex patient positioning, and complex surgery that can result in significant blood loss. A specialist spinal anaesthetist is an expert in managing all these problems and communicating with the highly experienced team, to help achieve the ultimate goal of safe, successful surgery. More information about anaesthesia can be found at www. rcoa.ac.uk/patient-information.

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