What are the current anaesthesia and critical‑care guidelines for adult patients (elective, emergency, or critically ill) regarding peri‑operative optimisation, airway management, fluid therapy, multimodal analgesia, lung‑protective ventilation, sedation, and sepsis management?

Current Anaesthesia and Critical Care Guidelines

Modern anaesthesia and critical care practice demands a systematic, evidence-based approach centered on optimizing oxygenation, implementing multimodal analgesia, preventing delirium, and ensuring meticulous airway management through structured team-based protocols.

Airway Management in Critically Ill Patients

The British Journal of Anaesthesia 2018 guidelines establish that critically ill patients require a fundamentally different approach than elective surgical patients, with emphasis on team coordination, pre-oxygenation, and limiting procedural attempts to prevent cardiac arrest and death. 1

Pre-Intubation Preparation

• Assemble a dedicated airway team with clearly defined roles before any intubation attempt, establishing a shared mental model through explicit verbalization of the plan 1
• Prioritize oxygenation above all else using high-flow nasal oxygen (HFNO) during pre-oxygenation and throughout the procedure to maintain SpO2 >90% 1
• Position patients head-up (25-30 degrees) to maximize functional residual capacity and pre-oxygenation effectiveness 1
• Prepare for physiological collapse by having vasopressors drawn up and ready, as up to 25% of ICU patients develop severe hypoxemia (SpO2 <80%) during intubation 1

Modified Rapid Sequence Approach

• Use a modified RSI technique rather than traditional RSI, as critically ill patients cannot tolerate apnea 1
• Avoid succinylcholine in burns patients beyond 24 hours post-injury due to hyperkalaemia risk 1
• Limit laryngoscopy attempts to three maximum before declaring failure and moving to the next rescue plan 1
• First-pass success occurs in only 70% of ICU intubations compared to >95% in operating rooms, making failure planning essential 1

Rescue Strategies

• Implement a combined Plan B/C algorithm incorporating Vortex approach elements when primary intubation fails 1
• Recognize that delays and task fixation kill patients—the typical airway-related death takes 45-60 minutes with multiple failed attempts by multiple providers 1
• Have front-of-neck access (FONA) equipment immediately available, as 6% of ICU patients have predicted difficult airways 1

Critical Pitfall: The NAP4 audit demonstrated significantly higher adverse outcomes in ICU/ED settings compared to operating rooms, primarily due to inadequate planning, poor team coordination, and failure to recognize deterioration early 1

Tracheal Extubation Strategy

The Difficult Airway Society 2012 guidelines mandate that extubation strategy must be developed before induction of anaesthesia, as complications at extubation cause death and brain injury more frequently than intubation complications. 1

Risk Stratification Before Extubation

• Classify patients as routine risk versus at-risk based on: airway pathology, surgical factors (airway/neck surgery, prone positioning), patient factors (obesity, obstructive sleep apnea), and anaesthetic factors (difficult intubation) 1
• Closed-claims data show extubation-related deaths did not decrease despite improved intubation safety, with obesity and sleep apnea as major risk factors 1

At-Risk Extubation Protocol

• Ensure full reversal of neuromuscular blockade with objective monitoring 1
• Maintain patients head-up 30-45 degrees 1
• Have immediate re-intubation equipment prepared including videolaryngoscope and supraglottic airways 1
• Consider awake extubation over deep extubation in at-risk patients 1
• Plan post-extubation monitoring location (ICU/HDU for high-risk patients) before extubation occurs 1

Peri-Operative Care of Elderly Patients

The Association of Anaesthetists 2014 guidelines establish that elderly patients require specialized multidisciplinary assessment, multimodal delirium prevention, and opioid-sparing analgesia, with care decisions based on biological age and frailty rather than chronological age alone. 1, 2

Pre-Operative Assessment

• Conduct comprehensive geriatric assessment evaluating six mandatory domains: cognitive function, functional status, nutritional status, polypharmacy, comorbidity burden, and social support 3
• Higher-risk patients (predicted mortality >10% or frailty-positive) require assessment by both a senior geriatrician and senior anesthetist with geriatric training 3, 4
• Screen for modifiable risk factors including smoking (cessation ≥4 weeks pre-op), alcohol use (abstinence 4 weeks), undiagnosed hypertension, diabetes, anemia, and malnutrition 2, 3
• Emergency patients require modified rapid assessment with collateral history from family/caregivers documenting pre-morbid status 3

Intra-Operative Management

• Implement opioid-sparing multimodal analgesia using combinations of paracetamol, NSAIDs, and regional blocks, reserving opioids as last resort in low doses 2, 5
• Maintain core temperature ≥36°C through active warming for procedures >30 minutes 2
• Ensure senior surgeon and senior anesthesiologist presence in operating room for all high-risk cases 3
• Apply WHO Surgical Safety Checklist with age-specific modifications 2

Post-Operative Delirium Prevention

• Postoperative delirium occurs in up to 50% of elderly surgical patients and is strongly associated with increased mortality, yet remains underdiagnosed 1, 4
• Implement multicomponent prevention bundle: early mobilization (30 minutes day of surgery, 6 hours/day thereafter), adequate hydration, sleep promotion without heavy sedation, cognitive stimulation, and reorientation 2, 4
• Avoid heavy sedation when attempting regional anesthesia in cognitively impaired patients, as this negates benefits and increases delirium risk 3
• Use CAM-ICU or standard CAM tool for systematic delirium screening 4

Pain Management in Elderly

• Peri-operative pain is common but underappreciated in elderly patients, particularly those with cognitive impairment who cannot effectively communicate pain 1, 2
• Implement multimodal opioid-sparing analgesia with paracetamol as first-line, NSAIDs second-line, and opioids in reduced doses as last resort 2, 4
• Conduct regular pain assessments using age-appropriate tools including behavioral scales for cognitively impaired patients 4

Critical Pitfall: Anaesthetists must not ration surgical or critical care based on age alone—biological age and frailty status determine outcomes, not chronological age 1, 3

Enhanced Recovery Protocols

Immediate Post-Operative Phase

• Facilitate early oral feeding with fluids as soon as patient is lucid and solids after 4 hours 2
• Remove urinary catheters within 24 hours for most patients 2
• Promote early mobilization starting day of surgery 2
• Implement end-of-surgery checklist verifying core temperature, hemoglobin concentration, and age-adjusted analgesic dosing 3

Critical Care Admission Criteria

• All patients with predicted perioperative mortality >10% must be admitted to level 2 or 3 critical care facilities 3, 4
• Implement physiological track-and-trigger systems (Modified Early Warning Score) with age-adjusted activation thresholds (heart rate >90 bpm, systolic BP <110 mmHg for frail elderly) 3, 4
• Establish rapid response teams including intensivists experienced in postoperative surgical management 3

Failure-to-Rescue Prevention

• The difference between high and low mortality hospitals is not complication incidence but effective rescue once complications occur 3
• Monitor closely for 72 hours post-surgery as this is the typical window for delirium and complications 4
• Ensure continuous monitoring with Critical Care Outreach team involvement for deteriorating patients 4

Multimodal Analgesia Principles

The Enhanced Recovery After Surgery Society recommends multimodal analgesia using combinations of analgesics acting on different sites and pathways to achieve pain relief with minimal opiate consumption. 5

Analgesic Ladder Approach

• First-line: Paracetamol (acetaminophen) for all patients unless contraindicated 2, 5
• Second-line: NSAIDs (if no contraindications) 2, 5
• Third-line: Regional anesthesia/local infiltration when anatomically appropriate 2, 5
• Last resort: Opioids in lowest effective doses, particularly in elderly and cognitively impaired patients 2, 5

ICU-Specific Analgesia

• Short-acting analgesics and analgesic adjuncts for sedation are superior to hypnotic-based sedation in intubated patients 6
• Mechanistic approaches and multimodal techniques are the most effective strategy to improve outcomes in critically ill patients 6
• Consider regional anesthesia techniques (epidural, peripheral nerve blocks) as part of multimodal approach in surgical ICU patients 6

Critical Pitfall: Inadequate pain control has deleterious effects on multiple organ systems in critically ill patients, yet inconsistencies in pain assessment and analgesic prescription result in suboptimal management 6

Communication and Capacity

• Assume elderly patients have mental capacity to make treatment decisions unless clearly demonstrated otherwise 1, 2
• Provide patient education in oral, written, and pictorial formats to both patient and relative/caregiver 2
• Ensure good communication is essential to capacity assessment process 1
• If patients clearly lack capacity, seek proxy information to determine treatment in patient's best interests 1
• Maintain continuity of care through reciprocal information flow between patients, relatives/carers, and primary/secondary care services 2