Chapter 5: Guidelines for the Provision of Emergency Anaesthesia Services 2024

Every department of anaesthesia undertaking emergency surgery should appoint a senior clinical lead (see Glossary) with adequate provision within their job plan and support to develop and lead emergency anaesthesia within the organisation.¹⁹ This role could include liaison with other departments.

The anaesthetic clinical lead for emergency anaesthesia should be part of a multidisciplinary team with access within the governance structure to trust board level, with explicit pathways of communication.

There should be clarity of leadership and roles to supervise the day-to-day running of emergency theatres and the emergency anaesthesia service. Those undertaking these roles should be clearly identifiable to all working that day and easily accessible at all times.

The emergency operating list should be easily accessible to all medical and operating department staff so that there is shared awareness of the emergency load and resource requirements, within the principles of patient confidentiality.^31,32 The operating list displayed in theatre should be the most current version.

The language in all communications relating to the scheduling and listing of procedures must be unambiguous and avoid the use of abbreviations. Laterality must always be written in full (i.e. left or right).¹³

Adequate emergency theatre time should be provided throughout the day to minimise delays and avoid emergency surgery being unnecessarily undertaken out of hours when the hospital may have reduced staffing to care for complex postoperative patients. Consideration should be given to staffing of additional evening (twilight) emergency sessions with autonomously practising anaesthetists.

Dedicated emergency lists for some individual surgical services (e.g. paediatrics) should be considered as they may be an effective use of resources and improve patient flow and care.²⁹

Efficient management of emergency list is essential to ensure timely access to emergency theatre. Golden patient concept to identifying and getting the first patient on the list ready has been effective in prompt starting of emergency lists. Dedicated holding bays have shown to reduce turnaround times. Such and other innovative systems should be considered to improve efficiency of emergency lists.^33,34

Documentation and communication of information on preoperative preparation are essential. Electronic systems should be considered to enable the capture and sharing of information, support risk identification and allow data to be collected and available for audit and research purposes.³⁵

Departments should consider a web-based live system that can be remotely accessed by all relevant personnel including senior staff who are on-call off site. A dynamic system can be set to order the list according to clinical priority, NCEPOD classification and time of booking. Real time updates should avoid delays and improve workflow.

Local systems should be in place to triage patients with surgical emergencies. NELA reports a proportion of patients for laparotomy arriving in theatre within three separate time frames (< 2 hours; 2–6 hours; 6–18 hours).² The World Society of Emergency Surgery study group proposed a classification to triage patients for surgical emergencies. These timeframes could be used as a guide and adapted to design local triage systems.³⁶

Prioritisation of cases based on their clinical urgency is not the sole domain of any single specialty. It requires a team approach involving discussion between different surgical groups, anaesthetists and, in some cases, critical care.⁴

There should be a locally agreed policy that explains prioritisation of non-elective cases according to clinical urgency.

Priority of access should be given to emergency patients over elective patients.^5,19,37,38 There should be a clear policy for cancelling elective surgery to enable additional emergency theatre provision.¹³

The theatre booking system should enable the identification and prioritisation of high-risk cases.

The urgency of emergency cases should be clearly and unambiguously coded.⁴

There should be regular review of delays to facilitate improved theatre access and to promote accurate urgency coding at booking.

Certain urgent procedures cannot be performed out of hours owing to patient, specialist staff or equipment factors. Hospitals should consider collecting data on these procedures and creating alternative pathways.

There should be local arrangements in place to facilitate scheduling of procedures that do not meet the description of either emergency or elective surgery.

Some aspects of preoperative anaesthetic assessment and preparation of the emergency patient differ from those of the elective patient. These include severity of illness, fluctuating condition of the patient and the 24/7 nature of emergency work. Staffing levels and seniority of anaesthetists should be adequate to enable preoperative anaesthetic planning and assessment that is appropriate to the patient’s risks associated with surgery. This should be informed by a formal assessment of risk of mortality and morbidity.^2,4,39

There should be a formalised integrated pathway for non-elective adult general surgical care, which should be patient centred and include:^2,5,19,29,40

• a clear diagnostic and management plan made on admission⁴¹
• early identification of comorbidities (including diabetes, dementia, cardiac pacemakers and internal defibrillators) and their management according to hospital guidelines
• medicine reconciliation to assess the risk of existing medications (including anticoagulation) and the risk associated with stopping long term medication³⁸
• preoperative investigations and testing as appropriate^42,43
• consider ‘Think Drink’ or similar at time of handover meeting or booking⁴⁴
• communication of mortality risk to members of the multidisciplinary team; this allows early senior input, including senior members of the anaesthetic team, and allocation of resources proportion to the patient’s risk of death following surgery^2,4
• informed consent for surgery including identification of decision making proxies i.e. a lasting power of attorney^2,5
• a plan for postoperative care.^2,5

All hospitals should have guidelines in place for the recognition and management of patients with sepsis; compliance with these guidelines should be regularly audited.^10,45,46

An anaesthetist, anaesthesia associate or advanced nurse practitioner should preoperatively assess all patients undergoing emergency surgery who require anaesthesia. Adequate time should be available for this assessment to occur as clinical urgency allows.^43,47

A full anaesthetic management plan should be recorded in the patient's records or anaesthetic chart and should be initiated preoperatively.⁴⁸

The experience and expertise of the anaesthetist assessing the patient preoperatively should be appropriate for the complexity and level of risk of the patient.⁴⁶ The decision to operate on high-risk patients should be made at a senior level, involving surgeons and those who will provide intra and postoperative care.^4,5,19

Preoperative assessment of patients, especially those at very high risk, can benefit from a multidisciplinary team approach involving cross specialty advice.⁴⁹ Early consultation with appropriate medical specialties should occur for appropriate conditions, such as delirium, acute kidney injury, diabetes mellitus and ischaemic heart disease.⁴

All decisions concerning the consent process (see Section 9) and treatment plans, including decisions about whether or not to operate and do not attempt cardiopulmonary resuscitation (DNACPR), should be documented clearly, noting what risks, benefits and alternatives were explained to the patient within the time constraints of emergency care.^47,50

There should be a system in place for alerting medical staff to any change in the clinical condition of the emergency surgical patient while awaiting surgery.^41,51

There should be provision for preoperative admission of the critically ill patient to level 2 and/or level 3 care facilities for stabilisation and optimisation if required.^3,10

Guidelines for fasting before anaesthesia for emergency surgery should comply with national guidelines.⁵²

Guidelines for postoperative planning should include plans for nutrition, including facilitation of enteral access or vascular access for parenteral support.^53,54,55

There should be a formalised integrated pathway for non-elective adult general surgical care which should be patient centred and should include risk assessment and identification of the high-risk patient. The integrated pathway should include risk assessment and identification of the high-risk patient.^2,4,5,40

There should be locally agreed guidelines for risk assessment and documentation. A number of risk prediction tools such as the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM), Surgical Outcome Risk Tool (SORT), American College of Surgeons- National Surgical Quality Improvement Program (ACS-NSQIP), National Emergency Laparotomy Audit (NELA) are commonly used. Mortality risk should be assessed preoperatively and documented on the consent form.^56,57

All patients should undergo venous thromboembolism risk assessment and receive appropriate thromboprophylaxis.^5,58 This should include guidance on the novel oral anticoagulants and the management of patients requiring emergency surgery who are receiving them.⁵⁹

Preoperative risk stratification should inform the decision making process for critical care admission.^2,24

All areas, including emergency departments, admitting acutely ill patients should have early warning pathways to ensure prompt recognition of a deteriorating patient to trigger an appropriate response.⁶⁰ This should include policies for early medical review and early escalation to the responsible consultant surgeon or equivalent.^{10,49,61,62,63,64}

Transport of patients within the hospital and between hospitals should be undertaken in a timely manner, without unnecessary delays and in accordance with established guidelines and standards.^{10,65,66,67,68}

Staffing should be provided at a level such that emergency theatre activity and critical patient care are not compromised when intra and inter hospital transfers are undertaken.⁶⁵

All necessary equipment to facilitate safe transport of the patient should be available at all times.^10,65,67 Standardisation of transfer bags should be considered.⁶⁵

Departments should have local guidelines for intrahospital transfers.

Where transfers between hospitals are foreseeable (e.g. transfers to major trauma, neurosurgical or paediatric centres) local arrangements should be in place to ensure safe and timely transfer, which may involve a retrieval service.⁶⁵

Transfers should be carried out by appropriately trained and competent staff. Arrangements should be in place for insurance (personal and medical indemnity), crash test compliant equipment, ambulance booking procedures, procedures for receiving patients, communication between medical teams and families, documentation, and procedures for repatriation of staff and equipment.^10,65,67

Hospitals should collect data on inter and intrahospital transfers, including the effects on the emergency theatre and critical patient care. The transfer arrangements should not result in the interruption of a busy emergency list.

Handovers for patients requiring an emergency procedure should be structured to ensure continuity of care.⁷¹

Handover protocols for patients requiring an emergency procedure should include clear documentation of care delivered and the future treatment plan for the patient.^13,72

Organisations must create standardised documentation for patients undergoing invasive emergency procedures that promotes the sharing of patient information between individuals and teams at points of handover, and forms a documented record for future reference.¹³

There should be appropriate overlap between shift changes, to ensure adequate time for handover. Time for handover should be included in job plans and rotas and accounted for in work shift planning.^48,73

The following policies and guidelines (see Glossary) should be immediately and reliably available at sites where emergency anaesthesia and sedation are provided:

• management and running of the emergency theatre, including an escalation plan for emergency theatre capacity and staffing⁵
• management of anaesthetic emergencies, including subspecialty emergencies
• difficult airway management, including the ‘can’t ventilate, can’t oxygenate’ scenario, fasting times, preanaesthetic assessment of the airway, availability and maintenance of the equipment and training of staff^74,75,76
• major haemorrhage protocol, including clinical, laboratory and logistic responses^74,75
• blood transfusion policy, including transfusion for inter- and intrahospital transfers⁷⁹
• safe extubation of patients following emergency anaesthesia guideline
• management of the deteriorating patient guideline^77,78
• whom to call and what facilities can be used if two or more emergencies occur simultaneously
• a policy for the management of organ donation and retrieval^10,82,83
• a policy for managing delirium in the perioperative period
• a policy for the management of airborne and bloodborne infections. 

Appropriate clinical policies and standard operating procedures for operating theatres should be in place and available at all times, including a resuscitation policy and major incident plans.⁸⁴

All staff, including anaesthesia assistants, locum, agency and trust grade staff must have undergone an appropriate induction that includes the contents of relevant policies and standard operating procedures.¹³

An escalation policy should be in place for all medical, healthcare professional and managerial staff. An emergency protocol should be in place and understood by all relevant staff. This should include the names and method of contact, which should be prominently displayed in appropriate areas. Internal hospital telephone switchboards should have ready access to rotas and methods of contacts.

A clear method of communication between and within theatre teams, including related areas (e.g. obstetric or paediatric wards) should be in place concerning the urgency category of an emergency, escalation and who to contact.⁸⁵

The National Safety Standards for Invasive Procedures eight sequential step standards (which includes five steps to safer surgery) should be used for all invasive procedures. A modified checklist with fewer items may be more appropriate in some emergencies.^{5,19,86,87,88,89}

Local standard operating procedures should be developed for postoperative monitoring and management of patients who need a higher level of care after emergency surgery including how to provide critical care standards in non-critical care areas if critical care beds are not available.⁹⁰

There should be a clear process in place for the referral of emergency patients requiring critical care, including paediatric patients, to an appropriate facility^.9,49,62

Use of blood products should be minimised whenever possible by the employment of restrictive transfusion thresholds together with methods to minimise blood loss and allogenic transfusion.⁷⁷

Hospitals must have audited policies and procedures for the administration of blood and blood components that comply with standards set out by the National Blood Transfusion Committee.⁷⁹ Hospitals should have systems in place to ensure that blood can be crossmatched, issued and supplied in a timely manner.

Hospitals admitting emergency surgical patients should provide, at all times, a dedicated fully staffed operating theatre appropriate to the clinical workload. There should be provision to increase necessary resources to manage fluctuating workload and provide an acceptable standard of care.^13,27,38

The level of staffing should be sufficient to provide a continuous emergency anaesthesia service in the theatre complex without interruption. Other service requirements (e.g. remote sites, trauma calls and advice) should be anticipated and managed through local arrangements.¹³ Such service requirements should not result in interruption of busy emergency lists.⁹³

Staff working in emergency theatres have to deal with multiple surgical teams, a wide range of procedures, unpredictable situations at short notice and changes to planned activity. Staffing levels in the emergency theatres should reflect appropriate skill mix and seniority to deal with the demands of the service.¹⁴

Staff working in emergency theatres should have a wide range of competencies to manage a range of specialties and complexities.⁶⁹

The role of an ‘emergency theatre coordinator’ (see Glossary) should be considered for departments with a large emergency workload so that patient flow and prioritisation of cases can be actively managed.

Non-clinical aspects of managing an emergency list should be adequately supported for efficient running of the list.⁴⁸

At all times there should be sufficient breadth in training and competence of the anaesthetic staffing 24/7 to undertake all likely emergency procedures.

The emergency team should be led by an autonomously practising anaesthetist (see Glossary) and include other healthcare professionals involved in the delivery of anaesthesia for emergency surgery, including other departments such as radiology, medicine and emergency departments.³  Hospitals should consider developing teams of anaesthetists, surgeons and perioperative physicians with particular interest and expertise in high-risk emergency surgery.⁹⁰

Anaesthetists assigned to provide cover for emergency lists should not also be assigned to undertake other activities such as elective work or supporting professional activities or independent practice.⁹⁴

Anaesthesia for emergency surgery should be delivered by a competent individual with appropriate supervision; the level of supervision should reflect the severity of the case and the seniority of the individual in accordance with the RCoA’s Guidance on Supervision arrangements for anaesthetists.⁹⁵

Anaesthetists in training should be given the appropriate level of responsibility, according to their competence and level of training, to gain the experience of emergency anaesthesia to enable them to function as a consultant later in their career. Anaesthetists in training must be appropriately supervised at all times; rotas and staffing arrangements should be in place to facilitate this training.⁹⁶

Anaesthesia associates should work under the supervision of a consultant anaesthetist at all times as outlined by the RCoA.^97,93 In some emergency situations, a ratio of one to one and direct supervision may be more appropriate in view of the high incidence of comorbidities, complications and mortality.

Patients receiving emergency anaesthesia care in a non-theatre location should be cared for by anaesthetists with the same level of competency and assistance as those receiving emergency care in the theatre environment. Certain circumstances may require additional assistance; local arrangements should allow sufficient personnel and resources to support this assistance.^85,99

There should be dedicated administrative staff to support all aspects of the emergency anaesthesia service and to support and coordinate non-clinical activity.^13,94

Whenever emergency surgery is undertaken, the recovery unit should be open continuously and adequately staffed.⁸⁵ Until patients can maintain their own airway, breathing and circulation, they should be cared for on a one-to-one basis, with an additional member of staff available at all times.⁷²

Recovery staff should have immediate access to the appropriate clinician in the perioperative period.

Working to deliver emergency surgery is often a stressful, challenging environment. Stress, 'burnout' and mental ill health are major causes of sickness absence. NHS organisations should ensure that those in leadership positions work to promote and protect the health and wellbeing of staff.¹⁰⁰

There should be adequate staffing levels to ensure that rest breaks can be taken without interrupting the flow of the emergency theatre(s). Appropriate facilities for these rest breaks should be provided.^100,101,102

When members of the emergency team are involved in a critical incident, it may not be possible to find an immediate replacement. The situation and clinical commitment of individuals involved should be immediately reviewed by an appropriate senior person and if necessary alternative arrangements to cover the emergency service should be made.¹⁰³

Appropriate equipment to meet minimum standards of monitoring and for safe management of crisis situations should be readily available in all areas where patients are cared for in a theatre complex.¹¹²

Patients receiving emergency anaesthesia care in a non-theatre location should have access to anaesthetic equipment, monitoring, drugs and personnel as in the theatre environment.

Specialist equipment that is not commonly used or that is not time critical should be available if required (e.g. Oxford pillow, cell saver, hoists and transoesophageal EEG).

Emergency theatres should be equipped with an appropriate ventilation system. Details of ventilation and air change times should be known and factored into list management in all areas where an aerosol generating procedure may be performed during emergency anaesthesia.^104,105

The geographical arrangement of theatres, emergency departments, critical care units, cardiac care, interventional radiology and imaging facilities should allow for the rapid transfer of critically ill patients.

Appropriate blood storage facilities should be in close proximity to the emergency operating theatre and should be clearly identifiable. Satellite storage facilities or a clear process for preservation of the cold chain should be in place to enable resuscitation to be effectively performed in appropriate non-theatre locations such as interventional radiology suites.

Hospitals should ensure that staff are trained and competent to use the equipment provided.

Equipment should be properly maintained and replaced in a timely and planned fashion.^106,107

Theatre operating tables should be available to permit all types of emergency surgery to be undertaken. Appropriate operating tables with imaging access (carbon fibre), adjuncts for proper positioning and warming devices should be available.

There must be appropriate equipment available for transfer of the patient within the theatre, together with the appropriate staff trained to use it safely.^106,108,109

There must be full provision of personal protective equipment and shielding from blood spray, radiation and hazardous substances for all staff working in the operating theatre. Guidance should be provided on its use.^108,110,111

Near-patient testing for haemoglobin, blood gases, lactate, blood sugar and ketones should be readily available (see Glossary) for emergency theatres.¹¹²

Near-patient testing for coagulopathy should be considered, particularly in areas where major blood loss is likely. If near-patient testing is not available, laboratory testing should be readily available.^77,113

A fully equipped resuscitation trolley should be available in all areas in which emergency anaesthesia is undertaken. These trolleys should be colour coded and should maintain uniformity within the trust, to improve safety.^77,114

High-flow nasal oxygen should be available in the emergency theatres.^{76,115,115,115,116}

A rapid infuser allowing the infusion of warmed intravenous fluids and blood products should be available in the emergency theatre.^76,117,118 Staff should undergo regular training in its use and they should be able to troubleshoot common problems.

A cell salvage service should be available for cases where massive blood loss is anticipated. Staff who operate this equipment should receive training in how to operate it, and should use it with sufficient frequency to maintain their skills.^78,119

Equipment necessary to provide a range of patient analgesia should be available. There should be adequate facilities for postoperative monitoring of patient analgesia.^8,116

Ultrasound equipment should be available in areas where emergency anaesthesia is provided and should facilitate I.V., access procedures for analgesia and diagnostics.

The standards of monitoring provided in all locations where emergency procedures are performed, including non-theatre locations, should be the same as those provided in theatres.¹¹² This includes temperature and end tidal CO₂ in recovery.

Appropriate equipment for invasive blood pressure, central venous pressure and cardiac output monitoring should be readily available.

Equipment for monitoring the depth of anaesthesia should be available for patients receiving emergency anaesthesia (e.g. processed EEG) particularly if total intravenous anaesthesia is used for emergency surgery.^121,122

All areas in which emergency anaesthesia is undertaken should be adequately stocked at all times with the range of medications required for immediate use in all types of urgent cases appropriate to the case mix accepted by the hospital. Prefilled syringes supplied by the pharmacy should be considered, especially in busy units.

Anaesthesia teams should consider carrying prelabelled and/or prefilled drug boxes.¹²³

Specialist medications that are not commonly used or that are not time critical should be readily available (see Glossary) if required (e.g. dantrolene, esmolol, N acetylcysteine, octreotide).

All practitioners must follow the practices outlined in the GMC decision making and consent guidance.¹⁴¹ Documentation of the risks discussed or the dialogue leading to a decision is required in accordance with paragraphs 50–55.

Informed consent should take into account the benefits and risks of the procedure, alternative options available and the option of doing nothing. Consent should be sought at the earliest possible opportunity in view of limited time available for the patients having emergency surgery to consider the information.^4,15,142,143 All discussions should be clearly documented. With the exception of life or limb threatening emergencies, a patient’s primary consent should never be taken in the anaesthetic room.⁸⁹

As part of a quality improvement programme, hospitals should develop a local understanding of the adequacy of their consent process and information supplied to patients undergoing emergency surgery, by proactively seeking patient feedback and allocating appropriate resources to this process.¹⁴⁴

Assessment of capacity must be time and decision specific; an individual’s capacity to make particular decisions may fluctuate or be temporarily affected by factors such as pain, fear, confusion, the effects of medication or intoxication by alcohol or other drugs.^60,145

Interventions that are unlikely to alter outcomes and may add to patient distress should be recognised and communicated with the patient and their relatives or supporters at the earliest opportunity.¹⁴⁶

A team approach should be considered for breaking bad news and discussions around clinical benefit and end-of-life decisions with patients and relatives.

Discussion and reasons behind decisions taken, as well as the information given to the patient and relatives, should be clearly recorded.^147,148

Mortality discussions (see Glossary) should be documented for patients undergoing an emergency laparotomy.¹⁴⁹

Hospitals should have pathways to alleviate pain and suffering, which should be individualised to the needs of the patient and discussed with their relatives or supporters.¹⁵⁰

Hospitals should have local policies (see Glossary) for when a patient dies in theatre or soon after in recovery. This should include arrangements to maintain dignity for the patient and to give relatives the best support possible. It should also include arrangements to minimise the impact on other patients being treated in the theatre complex.

Hospitals should offer the same level of access for discussion and explanation to relatives of patients who die in the theatre complex or not having undergone surgery as they do for those who die in critical care.

Where end-of-life care is instituted, it should be in accordance with national and local guidance and audited for quality in the same way that surgical care is audited.¹⁵¹

Hospitals should have a treatment escalation plan and/or DNACPR guidance and documentation that complies with national requirements.^115,152

Patients who may require surgical procedures with DNACPR decisions in place should have senior members of the anaesthesia and surgical team review the condition of the patient and the DNACPR status. Where feasible, a discussion should take place with the patient and their next of kin. It may be appropriate to suspend components of a DNACPR decision (e.g. tracheal intubation) to allow surgery to proceed safely.⁸⁰

Older patients who are admitted following trauma should have a geriatric assessment.¹⁵⁴

All older patients who require emergency surgery should be routinely assessed for multimorbidity, frailty, cognition and polypharmacy.^3,7,8,58

Planning of care and decisions to operate should reflect the outcomes for older patients who are having emergency surgery, and should include discussion of issues around risks and benefits, clinical benefit and realistic longer-term outcomes (e.g. a requirement for nursing home care). This discussion should involve the multidisciplinary team as well as the patient, families and carers where possible.⁸

Previous DNACPR orders are not necessarily a contraindication to surgery and should be reviewed on a case by case basis by the multidisciplinary team, in discussion with the patient and their next of kin, prior to anaesthesia if at all possible.^159,160

Postoperative pain protocols should be individualised to suit each patient and should take account of any possible cognitive impairment.¹⁶¹ Specific algorithms for the assessment of pain and postoperative analgesia protocols are recommended in older patients.Specific pain assessment tools such as Pain Assessment in Advanced Dementia Scale (PAINAD) and Doloplus 2 are recommended in older patients should be considered.¹⁶²

The risk of postoperative functional decline following emergency surgery should be considered. Policies (see Glossary) should be developed for the prevention, recognition and management of common postoperative geriatric complications and/or syndromes, including delirium, falls, functional decline and pressure area care.^8,10,163

Patients with a frailty score of 5 and above should receive a comprehensive geriatric assessment. There should be a focus on multidisciplinary working and integrated pathways to reduce complications. This includes shared decision making based on best treatment options and informed patient preferences.

Patients over 65 years of age should be reviewed and co-managed with a physician with expertise in the care of older surgical patients.¹⁶⁴

All patients over the age of 65 undergoing emergency laparotomy should have a formal assessment of frailty. Surgeons, anaesthetists and intensivists should ensure frailty has been taken into account when assessing the mortality risk as the NELA risk score does not take frailty into account.¹²⁹ 

There should be planning at local and regional level for the increase in resources that will be required for increasing numbers of older patients needing emergency surgery.⁸

The location for undertaking emergency paediatric procedures is often a pragmatic compromise but should, as far as is possible, replicate the location and conditions of paediatric care delivered in the elective setting. Anaesthesia for children should be undertaken or supervised by anaesthetists who have undergone appropriate training and have maintained their competence.^136,165

Hospitals should define the extent of emergency surgical provision provided for children and the thresholds for transfer.

Emergency paediatric surgical care should be provided within a network of secondary and tertiary care providers. Networks should agree standards of care and formulate care pathways for emergency surgery.

Departments should participate in regular network audits of emergency paediatric surgical work.^{166,167,168,169}

Children with severe comorbidities who require emergency anaesthesia should be treated in a specialist paediatric centre. However, if transfer is not feasible, the most appropriately experienced senior anaesthetist should provide anaesthesia and support resuscitation and stabilisation.^170,171

Transfer of children to specialist centres is usually undertaken by regional paediatric emergency transfer services. Time critical transfers such as neurosurgical emergencies may need to be transferred by the referring hospital. Local policies (see Glossary) should be in place for the management of such transfers and the most experienced anaesthetist with appropriate skills; an anaesthetic practitioner should accompany the child.¹⁷³

An operating table in the emergency area, hoists, beds, positioning aids and transfer equipment appropriate for patients with obesity should be available and staff should be trained in its use and their limitations.^97,173

Specialist positioning equipment for the induction of anaesthesia and intubation in the patient with obesity should be available in the emergency area.¹⁷³

Patients with morbid obesity who require emergency surgery should have experienced anaesthetists and surgeons available (typically, but not exclusively, at consultant level) to minimise operative time.¹⁷³ A surgical team familiar with emergency surgery in patients with morbid obesity and the complications associated with laparoscopic surgery should be available.

Patients with morbid obesity should be considered for level 2 or 3 critical care postoperatively, including the provision of continuous positive airway pressure therapy and other respiratory support measures.¹⁷³

As there are additional risks for patients with obesity, consider undertaking these procedures within daylight hours.

Hospitals should have care bundles for the anaesthetic management of common and high-risk surgical emergency patients to improve outcomes.^2,43,175

A coordinator to link multidisciplinary care, promote enhanced recovery and collect perioperative data should be considered in hospitals with significant high-risk emergency surgery activity.⁹⁰

Systems should be in place to ensure timely surgical review (typically at a consultant level) of high-risk patients, access to diagnostic imaging and urgent reporting. An assessment of mortality risk should be made explicit to the patient and recorded clearly on the consent form and in the patient’s records.¹²⁹

There should be a documented evaluation of mortality and relevant morbidity risk prior to surgery using a standardised perioperative risk tool.^149,176,177 This will inform both clinicians and the patient about decision making and consent.² Guidance to reduce non-beneficial surgery and improve end-of-life care should be considered.⁹⁰

High-risk patients should have timely access to appropriate care including resuscitation, antibiotics, interventional radiology or surgery.¹⁷⁶

Hospitals should have policies for the assessment and management of suspected sepsis. ‘The Sepsis Six’ is a pragmatic approach to this.¹⁷⁶ Early consideration of surgery and antibiotic prophylaxis should be considered in patients who are at high risk of sepsis.

High-risk patients (5% or above mortality risk) or lower-risk patients undergoing high-risk surgery should receive direct consultant anaesthetist and consultant surgeon delivered care in the operating theatre.^2,178

Older high-risk patients undergoing an emergency laparotomy should have a postoperative geriatric medicine review.¹⁵⁶

High-risk patients (5% or above mortality risk) or lower-risk patients undergoing interventions that require higher postoperative care due to the nature of the procedure, should receive postoperative care in the critical care unit.²

Hospitals should consider postoperative critical care if more than four units of blood have been transfused, as this increases risk of pulmonary and infectious complications and mortality.^2,179

Postoperative facilities should be provided to support the best choice of analgesia for patients undergoing an emergency laparotomy.¹⁸⁰

Multidisciplinary clinical involvement including critical care, geriatric, paediatric, diabetic teams and other specialists should be considered throughout the perioperative pathway of the patient as appropriate.

Hospitals should have clinical and managerial strategies to reduce complications that have been shown to have a major impact on both short and long term outcomes.^6,91

Patients who have poorly controlled diabetes are at risk of serious complications and may require meticulous management of fluid, electrolyte and insulin therapy. All locations including remote sites where emergency surgery is performed should be able to manage patients with poorly controlled diabetes 24/7.¹⁸¹

Hospitals should consider appointing a lead anaesthetist for diabetes. Organisations should ensure that staff involved with caring for patients with diabetes have access to and complete regular training.¹⁸³

Hospitals should have mechanisms to promote early identification of the emergency surgical patient with diabetes. Patients with diabetes should be identified on the administrative electronic system.¹⁸¹

Hospitals should involve patients in their own diabetes management.¹⁸¹ 

Patients with diabetes needing emergency surgery should be assessed for multimorbidity and polypharmacy and should have an individualised explicit plan for managing their diabetes during the periods of starvation and surgical stress. Hospitals should consider a multidisciplinary review of these patients, including the involvement of senior anaesthetic staff and specialist diabetic medical and nursing staff.

Hospitals should have explicit policies (see Glossary) for managing diabetic patients having emergency procedures including policy on the safe use of variable rate intravenous insulin infusions. The use of a variable rate intravenous insulin infusion adds extra complexity to the fluid and electrolyte management of the surgical patient and this will require additional medical and nursing resources, which sometimes may be better provided in a critical care environment rather than a surgical ward.

To reduce the harm associated with variable rate intravenous insulin infusions, periods of starvation should be kept to a minimum. This may involve prioritisation of patients with diabetes for investigations and for theatre.

The patient with diabetes who needs emergency surgery is at additional risk of pressure ulcers, nerve damage, acute coronary syndrome and acute kidney injury and hospitals should have policies to prevent these.

There should be a multidisciplinary team approach to care for pregnant women requiring non-obstetric emergency surgery involving anaesthetists, obstetricians, surgeons, paediatricians and midwives.^184,185,186

Surgery should be undertaken where neonatal and paediatric services are readily available whenever possible.¹⁸⁴

Fetal heart rate monitoring should be available. Local policies should outline its use, taking into account fetal viability, the physical ability to perform it and the availability of a healthcare provider able to intervene for fetal indications.^184,185,187

Informed consent for the surgical procedure should include consideration of fetal wellbeing, the possibility of caesarean delivery and any risks related to anaesthesia for mother and child.¹⁸⁶

Equipment for maternal positioning and uterine displacement should be available.¹⁸⁵

Local guidance, including provision for training and audit, should be available for:

• aspiration prophylaxis¹⁸⁵
• difficult airways and failed intubation^{76,186,188,189}
• cardiopulmonary resuscitation in the pregnant woman and perimortem caesarean delivery^187,188,190
• anti-D immunoglobulin administration¹⁹¹
• major haemorrhage, venous thromboembolism prophylaxis and sepsis^{122,184,187,192}
• anaesthesia and surgery in breastfeeding mothers^193,194
• safe medication administration, including avoidance of codeine in breastfeeding mothers¹⁹⁵

Maternal deaths should be reported to the local HM Coroner and to encourage learning and reflection should be reported to MBRRACE-UK. As a post-mortem examination is commonly performed, careful consideration should be given before removing medical devices which may be relevant to the cause of death.¹⁹⁰ 

Hospitals must have local policies in place for the identification, support and safeguarding of vulnerable adults.^6,142

Staff should have regular training in the application of the legislation determining mental capacity in the part of the UK in which they are working and should have defined access to patient advocates.¹⁹⁶ This is a rapidly changing area and clinicians should have access to expert advice or a second opinion from an experienced clinician.

Hospitals should have policies to support patients and staff of diverse religious beliefs and cultural backgrounds.¹⁴²

Hospitals should have arrangements in place to provide language support, including interpretation and translation services (including sign language and Braille). This information should comply with the NHS England Accessible Information Standard.¹⁹⁷