FRCA Notes

Remote Site Anaesthesia

Resources

  • A remote site is defined by the RCoA as:

    • Any location where an anaesthetist is required to provide anaesthesia or sedation away from the main theatre suite and where it cannot be guaranteed that help will be available

  • Common locations include:
    • Emergency department
    • Endoscopy
    • Radiology department: CT | MRI | Interventional radiology suite
    • Cardiac catheter laboratory: elective or emergency interventional procedures
    • CCU e.g. for cardioversions
    • Radiotherapy unit for planning and treatment e.g. brachytherapy
    • Psychiatric units e.g. for ECT
  • Locations are often geographically remote, which causes a relative isolation
  • Patients may be undergoing emergency procedures, adding to the risk of complications
  • Many of the risks are associated with unfamiliarity and inadequate planning, so can be mitigated through good communication and preparation

Environment

  • The site is often remote in both horizontal (corridors/locked doors) and vertical (stairs/lifts) fashions
  • There may be other hostile factors, such as:
    • Lack of space (in general) or specifically for anaesthetic equipment
    • Poor lighting
    • Higher noise levels
    • Unfavourable temperature
    • Different or inadequate equipment

  • There may be enivronmental hazards to staff, such as:
    • Ionising radiation
    • Magnetism
    • Exposure to volatile gases from inadequate scavenging

Equipment

  • The usual array of equipment in main theatres may not be available, especially specialised equipment e.g. VL
  • Equipment may be different and/or an element of unfamiliarity with available kit
  • Monitoring lines and ventilator tubing may be longer e.g. MRI
  • Moveable equipment, C-arms, trolleys etc. risk dislodgement of lines or airways

Assistance

  • The ODP may not be familiar with equipment, environment or location either
  • There may be greater difficulty in accessing equipment, including (controlled) drugs

  • Local staff may not understand or appreciate the requirements and risks of anaesthesia
  • Help from other anaesthetists may not be readily available, or only so with a delay

Patients

  • The patient cohort is complicated by typically being:
    • Older and frailer
    • Paediatric patients
    • Medically complex including those with cognitive or learning difficulties
    • Critically ill patients
    • Patients undergoing emergency procedures

Procedures

  • Procedures may be of variable duration, with varying degrees of stimulation
  • Some interventions preclude easy access to the patient and/or their airway
  • Necessitate distant monitoring e.g. MRI

Outcomes

  • Higher mortality compared to operating theatre anaesthesia
  • Higher likelihood of adverse events, and higher likelihood that they were preventable

Perioperative management of the patient undergoing remote site anaesthesia


  • Thorough pre-assessment to the same standard as for any other surgery
  • Particular focus on respiratory, cardiovascular and renal reserve
  • Highlight allergies, particularly iodine or shellfish allergy if there is a plan to use iodinated contrast
    • Fatal reactions occur in 1:10,000 exposures
  • Understanding of the underlying pathology and the planned interventions

  • Cases should be overseen by a consultant anaesthetist
  • The anaesthetist should familiarise themselves in advance with the environment and the location of equipment, including resuscitation equipment

  • Effective, timely communication with the other personnel involved is paramount
    • The nature and particular requirements of the procedure being undertaken
    • Plans for patient transfer and in case of emergency
    • Team briefings and use of WHO (or derivative) checklists

    Anaesthetic technique

    • Anaesthetic technique should be chosen based on:
      • Patient factors inc. the need to maintain physiological stability
      • Procedural factors inc. the requirement for patient immobility
      • Remote site factors inc. available equipment and the ability to manage complications

    Monitoring

    • AAGBI as standard
    • Temperature monitoring, as environments may be deliberately cooled for other purposes e.g. equipment

    Positioning

    • Meticulous positioning is important:
      • There may be limited access to the patient intra-procedurally
      • Secure IV access and ability to give drugs rapidly
      • Adequate pressure padding; may be on uncomfortable tables/trolleys

    Other intraoperative care

    • Aim to maintain normovolaemia, particularly if there is a risk of contrast-induced nephropathy
    • Temperature management as standard
    • VTE prophylaxis as required
    • Prophylactic antibiotics as indicated

    • Patients recovered in a remote site should receive the same standard of care as in main theatres
    • This relies on adequate environment, equipment and staffing - may necessitate transfer of the patient to a suitable recovery area
    • The anaesthetist should remain with the patient, or in the vicinity, until stable