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Adherence to NICE guidelines may be used to measure clinical effectiveness of an organization and guidelines ultimately exist in order to improve patient care. This chapter summarizes some of the recent publications relevant to anaesthetic practice.
NICE guidance
Guidance on the use of ultrasound locating devices for placing central venous catheters[1]
Literature suggests that the failure rate for initial insertion of central venous catheters (CVCs) is as high as 35%. Complications such as inadvertent arterial puncture and pneumothorax are well described, becoming more likely in the obese patient or in those with distorted anatomy. The potential advantage of ultrasound (US) guidance is the reduction in incidence of complications associated with initial venous puncture. NICE reviewed 20 clinical trials and an economic analysis model to conclude that evidence supports the clinical and cost-effectiveness of the use of US.
Guidance summary:
2D US guidance is the preferred method for cannulating the internal jugular vein. It should be considered for all CVC insertions in both adults and children, whether elective or emergency.
Operators should have training in US-guided technique.
Doppler US is not recommended.
Landmark method should be taught alongside US technique. Operators should maintain their ability to use landmark method in case of emergency situations when US is not available.
Inadvertent perioperative hypothermia[2]
This guideline applies to surgical patients undergoing elective or emergency surgery under general, regional or combined anaesthesia. It does not cover procedures under local anaesthesia, pregnant women, patients <18 years, patients undergoing therapeutic hypothermia or head injured patients with impaired temperature regulation. It outlines steps to be taken in the perioperative period to prevent and treat hypothermia.
Key guidance applicable to the anaesthetist:
Patients should be managed as higher risk if: ASA II–V, preoperative temperature <36.0 °C, undergoing combined general and regional anaesthesia, major or intermediate surgery, at risk of cardiovascular complications or have received premedication.
Temperature should be measured on arrival in the anaesthetic room and every 30 minutes until end of surgery.
Critical incident reporting should be considered if temperature is <36.0 °C on arrival in the anaesthetic room and induction of anaesthesia should not begin until temperature is >36.0 °C unless dictated by clinical urgency.
Ambient temperature in theatre should be 21.0 °C whilst the patient is exposed and may be reduced once forced air warming is established.
Patients should be covered and only exposed for surgical preparation.
IV fluids >500 ml and blood products should be warmed to 37.0 °C using a fluid warming device.
High-risk patients having surgery <30 minutes and all patients having surgery >30 minutes should be warmed from induction using a forced warm air device.
Forced warm air devices should be set at maximum and adjusted to maintain temperature of at least 36.5 °C.
Irrigation fluids should be warmed to 38–40 °C.
Temperature should be recorded and documented on admission to recovery and every 15 minutes. Patient should not be discharged unless temperature is >36.0 °C. If temperature is <36.0 °C patients should be actively warmed using forced air warming until discharge or until temperature is 36.5–37.5 °C.
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