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Knowledge, Skills, Attitudes and Behaviour - Neuroanaesthesia

Created: 20/12/2006
Updated: 20/12/2006
 

Neuroanaesthesia - Knowledge, Skills, Attitudes and Behaviour

This is a ‘Key Unit of Training’ in which SpR 1/2 trainees should spend the equivalent of at least 1 month of training and, normally, not more than 3 months.
Anaesthetic training for Neurosurgery and Neuroradiology will take place within designated specialist centres with the appropriate critical care facilities.

Knowledge

Preoperative assessment and management of patients with neurological disease
Anaesthesia for imaging relevant to the CNS
Anaesthesia for MRI including problems of magnetic fields
Anatomy of the skull and skull base
Anatomy, physiological control and effect of drugs on cerebral blood volume and flow, ICP, CMRO2
Principles of anaesthesia for craniotomy, to include vascular disease, cerebral tumours and posterior fossa lesions
Anaesthetic implications of pituitary disease including endocrine effects (acromegaly) and trans-sphenoidal surgery
Perioperative management of interventional neuroradiological procedures
Anaesthesia for spinal column surgery and anaesthetic implications of spinal cord trauma
Principles of immediate postoperative management including pain relief and special considerations with narcotics
Principles of neurological monitoring
Implications of prion diseases for the anaesthetist and other staff
Anaesthetic and critical care implications of neuromedical diseases: 
    Guillain-Barré syndrome 
    myasthenia gravis - pharmacological management / thymectomy 
    myasthenic syndrome 
    dystrophia myotonica 
    muscular dystrophy 
    paraplegia and long-term spinal cord damage 
    control of convulsions including status epilepticus 
    Tetanus 
    trigeminal neuralgia including thermocoagulation

Skills

The trainee will be supervised during the provision of anaesthesia for:
Planned 
    intracranial surgery 
    spinal surgery
Emergency neurosurgery for 
    head trauma
Safe patient positioning – prone, park-bench (lateral)
The trainee will be instructed in the non-surgical management of the head
trauma patient
Resuscitation and patient transfer
Monitoring: 
    insertion of arterial lines 
    insertion of CVP lines 
    techniques for detection and management of air embolism 
    EEG and evoked potentials 
    intracranial pressure measurement 
    spinal drainage
Critical Care: 
    indications for ventilation 
    the role of drugs 
    management of raised intracranial pressure and manipulation of cerebral perfusion pressure
    fluid and electrolyte balance in neurocritical care
Complications 
    treatment of raised intracranial pressure 
    cerebral protection and prevention of cerebral ischaemia 
    management of patients for organ donation
Neuroradiology 
    practical aspects of patient management for CT and MRI anaesthetic considerations in interventional radiology

Attitudes and behaviour

To understand the problems of obtaining consent in patients with impaired consciousness.
To appreciate the limits of medical intervention
To gain the ability to establish a rapport with the operating neurosurgeon and exchange information during surgery on aspects of changes in the patient’s vital signs which are relevant to the operative procedure
To communicate well with the nursing staff in the ICU, patients, relatives and other hospital staff
To offer comfort to the patient and relatives when there is no prospect of survival
To understand the requirements for organ donation

Workplace training objectives

Trainees should gain an understanding of the principles of neuroanaesthesia and the associated neuro-critical care in order to manage, with safety, patients for routine operations on the brain and spinal cord. For patients with head injury, trainees should be able to manage their resuscitation, stabilisation and transfer.

Recommended local requirements to support training

Neuroanaesthesia should only take place in Neuroscience Centres.

Staffing levels in the operating theatre should be sufficient to allow anaesthetists to work in teams during long operations.

Interventional neuroradiology requires full neuroanaesthesia cover by consultants

Neuro-critical care is a joint responsibility between neuroanaesthesia and neurosurgery; there should be specific sessions for neuroanaesthetists in Critical care.

The provision of beds for neuro-critical care must be adequate, the ventilation of patients in other areas should only occur in exceptional circumstances.

Operating theatres, Intensive Care Units (ICU) and neuroradiology facilities including scanners should all be in close proximity.

For patients with Head Injuries
The care of head injured patients is an integral part of neuroanaesthesia. Specialist units accepting these patients need to make specific arrangements including protocols, staff training and rapid availability of facilities. Optimal management will improve outcome and save resources in the long term.

Local guidelines on the transfer of patients with head injuries should be drawn up between the referring hospital trusts and the neurosurgical unit which should be consistent with established national guidelines. Details of the transfer of the responsibility for patient care should also be agreed.

Only in exceptional circumstances should a patient with a significantly altered conscious level requiring transfer for neurosurgical care not be intubated.


ArticleDate:20061220
SiteSection: Article
 
   
    
                                            
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