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1
Luginbühl, Martin, and Arvi Yli-Hankala. Assessment of the components of anaesthesia. Edited by Antony R. Wilkes and Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0026.
Full textAbstract:
In modern anaesthesia practice, hypnotic drugs, opioids, and neuromuscular blocking agents (NMBAs) are combined. The introduction of NMBAs in particular substantially increased the risk of awareness and recall during general anaesthesia. Hypnotic drugs such as propofol and volatile anaesthetics act through GABAA receptors and have typical effects on the electroencephalogram (EEG). During increasing concentrations of these pharmaceuticals, the EEG desynchronization is followed by gradual synchronization, slowing frequency, and increasing amplitude of EEG, thereafter EEG suppressions (burst suppression), and, finally, isoelectric EEG. Hypnotic depth monitors such as the Bispectral Index™, Entropy™, and Narcotrend® are based on quantitative EEG analysis and translate these changes into numbers between 100 and 0. Although they are good predictors of wakefulness and deep anaesthesia, their usefulness in prevention of awareness and recall has been challenged, especially when inhalation anaesthetics are used. External and patient-related artifacts such as epileptiform discharges and frontal electromyography (EMG) affect the signal so their readings need careful interpretation. Their use is recommended in patients at increased risk of awareness and recall and in patients under total intravenous anaesthesia. Monitors of analgesia and nociception are not established in clinical practice but mostly remain experimental although some are commercially available. Some use EEG changes induced by noxious stimulation (EEG arousal) or quantify the frontal EMG in relation to EEG, while others are based on the sympathoadrenergic stress response. Various other devices are also discussed in this chapter.
2
Jakobsson, Jan. Anaesthesia for day-stay surgery. Edited by Philip M. Hopkins. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0068.
Full textAbstract:
Day-stay surgery is becoming increasingly common the world over. There are several benefits of avoiding in-hospital care. Early ambulation reduces the risk for thromboembolic events, facilitates wound healing, and avoiding admission reduces the risk for hospital-related infection. Additionally, the risk of neurocognitive side-effects can be avoided by returning the elderly patient to their home environment. Day-stay anaesthesia calls for adequate and structured preoperative assessment and patient evaluation, and the potential risk associated with surgery and anaesthesia should be assessed on an individual basis. Need for preoperative testing should be based on functional status of the patient and preoperative medical history but even the surgical procedure should be taken into account. Preoperative fasting should be in accordance with modern guidelines, refraining from food for 6 hours and fluids for 2 hours prior to induction in low-risk patients. Preventive analgesia and prophylaxis of postoperative nausea and vomiting (PONV) should be administered preoperatively. Local anaesthesia should be administered prior to incision, constituting part of multimodal analgesia. The multimodal analgesia strategy should also include paracetamol and a non-steroidal anti-inflammatory drug in order to reduce the noxious stimulus from the surgical field. Third-generation inhaled anaesthetics or a propofol-based maintenance are both feasible alternatives. Titrating depth of anaesthesia by using an EEG-based depth of anaesthesia monitor may facilitate the recovery process. The laryngeal mask airway has become commonly used and has several advantages. Ultrasound-guided peripheral blocks may facilitate the early postoperative course by reducing pain and avoiding the use of opiates. Perineural catheters may be an option for prolongation of the block following painful orthopaedic procedures but a strict protocol and follow-up must be secured. Not only pain but even nausea and vomiting should be prevented, and therefore risk stratification, for example by the Apfel score, and PONV prophylaxis in accordance with the risk score is strongly recommended. Early ambulation should be encouraged postoperatively. Safe discharge should include an escort who also remains at home during the first postoperative night. Analgesics should be provided and be readily available for self-care when the patient comes home. Pain medication should include an opioid; however, the benefit versus risk must be assessed on an individual basis. Patients should also be instructed about a rescue return-to-hospital plan. Quality of care should include follow-up and analysis of clinical practice, and institution of methods to improve quality should be enforced for the benefit of the ambulatory surgical patient.
3
Walker, Matthew C. Convulsive and non-convulsive status epilepticus. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199688395.003.0030.
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This chapter describes the definition, epidemiology, classification, diagnosis, and treatment of status epilepticus, concentrating on the roles that electroencephalography (EEG) plays. The term status epilepticus now encompasses a range of conditions from continuous convulsive seizures to clinically subtle non-convulsive seizures, which may manifest as changes in behaviour or personality. EEG is critical for the diagnosis of non-convulsive status epilepticus. Furthermore, the progression of convulsive status epilepticus is to an electromechanical dissociation in which continuous electrical seizure activity may have no or minimal clinical manifestations. In the later stages of status epilepticus, EEG is necessary to monitor treatment, but is confounded by the interpretation of periodic EEG patterns, which represent a continuum from interictal through to ictal activity. Post-status epilepticus EEG patterns have prognostic value: periodic epileptiform discharges, burst suppression patterns (off anaesthesia) and repetitive seizure activity are indicative of a poor long-term prognosis.
4
Prout, Jeremy, Tanya Jones, and Daniel Martin. Obstetric anaesthesia. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199609956.003.0024.
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This chapter covers the knowledge required for higher training in obstetric anaesthesia. Physiological changes of pregnancy, along with their relevance to anaesthetic management are highlighted. Common maternal comorbidity and the impact on antenatal course, delivery and anaesthesia are summarized. Modern labour analgesia techniques are compared. Anaesthetic management of common obstetric emergencies e.g. fetal distress, preeclampsia, massive haemorrhage, abnormal placentation, amniotic fluid embolus and uterine inversion are described. Finally, the recent Confidential Enquiry into Maternal Death is summarized along with the role of early warning scores to improve future care.
5
Phillips, Alistair, and Harry Akerman. Anaesthesia. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198757689.003.0003.
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Pain-free surgery can be imposed on the hand and wrist without resort to general anaesthetic. Options include local anaesthetic infiltration which can, in higher volumes mixed with adrenaline, allow surgery without a tourniquet. This technique (wide awake local anaesthetic without tourniquet or WALANT) permits the patient to move the fingers without the muscle paralysis induced by the regional anaesthetic and tourniquet, adding invaluable information, e.g. in tendon transfers. The efficacy of specific peripheral nerve blockade and brachial plexus block can be enhanced by ultrasound or nerve stimulation. Intravenous blockade (Bier’s) is effective. Tourniquets (finger, forearm, above elbow) are essential in hand surgery to provide a view unimpeded by blood (although WALANT can achieve this at the expense of a more oedematous field for procedures in a small field).
6
Craven, Rachael, Hilary Edgcombe, and Ben Gupta, eds. Global Anaesthesia. Oxford University Press, 2020. http://dx.doi.org/10.1093/med/9780198809821.001.0001.
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The Oxford Specialist Handbook of Global Anaesthesia is an authoritative and comprehensive reference tool for anaesthetists practising in low-resource settings. It provides essential information to trained anaesthetists on delivering care without the equipment, drugs, and colleague support they might be used to in high-resource settings. Written by international experts in the field it will be useful to anaesthetists planning to work in remote and rural areas or countries with poor healthcare resources. It will also be useful to those working as part of disaster and emergency response medical teams. The technical and organizational aspects of delivering anaesthesia in austere environments are addressed, as are drugs and equipment that might be unfamiliar to anaesthetists practising in high-resource settings, e.g. ketamine and draw-over anaesthesia. The sub-specialties of obstetrics, paediatrics, burns, pain, trauma, and critical care are all covered in the clinical section. Useful reference tables, including a drug formulary, ensure that this book is the essential ‘survival guide’ for any trained anaesthetic practitioner planning to work or teach in a remote or resource-poor environment.
7
Collis, Rachel, Sarah Harries, and Abrie Theron, eds. Obstetric Anaesthesia. 2nd ed. Oxford University Press, 2020. http://dx.doi.org/10.1093/med/9780199688524.001.0001.
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Starting work on the labour ward is very challenging for all junior anaesthetists. This handbook is an easily navigated practical reference guide for anaesthetists new to this environment, as well as other members of the labour ward multi-disciplinary team; midwives, obstetricians, and Consultant Anaesthetists who visit labour ward less frequently or only when on-call. It covers all aspects of obstetric anaesthesia that the trainee anaesthetist will encounter during their obstetric training module, and is essential reading for FRCA exam preparation. Since the first edition, there is no doubt that the pregnant population has become more complex, with increasing maternal age and BMI, and challenging co-morbidities presenting more frequently. As well as providing updates from recent MBRRACE reports and national guidelines, new techniques, drugs, and technology, such as point of care testing have been included. New chapters covering the application of ultrasound in obstetric anaesthesia, recognition of the sick and septic patient, maternal obesity and neonatal resuscitation have been introduced. Previous chapters, e.g. haemorrhage, have been extensively updated, with the latest management protocols and algorithms based on recent published research in obstetric bleeding. We have retained our practical guides to performing, managing, and trouble-shooting regional techniques that are more problematic on labour ward, and our extensive A–Z of rarer conditions has updated references. More conventional chapters on maternal physiology and pathophysiology provide readers with essential examination material. The importance of anticipating risk in the antenatal period through high risk anaesthetic assessment clinics and postpartum management of tricky neurological complications is also well covered.
8
Wilkes, Antony R. Equipment in anaesthesia. Edited by Antony R. Wilkes and Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0024.
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The anaesthetist will routinely use many different types of medical devices during normal working practice, and will have access to many other devices for more challenging use in emergency and other difficult scenarios. The anaesthetist will expect and rely on each medical device to work first time and not to compromise the safety of the user, the patient, their relatives, or other healthcare workers in the vicinity. The equipment will also be expected to be effective, that is, that it will perform as expected when used in a defined population of patients (e.g. small children). Manufacturers and users of equipment use risk management procedures to reduce the risk to patients and others of using the equipment. Following use, the equipment will need to be reprocessed to make it safe for use for a subsequent patient, or disposed of safely.
9
Bodenham, Andrew R. Vascular access during anaesthesia. Edited by Michel M. R. F. Struys. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0049.
Full textAbstract:
Vascular access, both arterial and venous, at peripheral and more central sites is relatively new in historical medical terms and has only really developed into mainstream practice in the last 60 years. Other routes of drug and fluid administration via the gut and inhalation preceded it by centuries. It is a core skill for anaesthetists and intensivists, yet is not always well taught or is left out of core training curricula, with the assumption that skills will just be picked up early along the way. Like many procedures, it can be surprisingly easy to learn the basics, but many hazards and difficulties await the less skilled or inexperienced operator. A thorough knowledge of applied anatomy, practical skills, and recognition and management of complications are essential for safe practice. The increasing use of ultrasound, ECG guidance, X-ray screening, and other devices, and improved design of access devices allow much safer and more successful procedures. Many patients will now have long-term devices in situ, which can be used during anaesthesia and critical care. Such devices are increasingly inserted or removed by anaesthetists. Space precludes a detailed description of actual techniques for all routes of access; only general principles will be covered in this chapter.
10
Brandt, Sebastian, and Hartmut Gehring. Anaesthesia for medical imaging and bronchoscopic procedures. Edited by Peter F. Mahoney and Michel M. R. F. Struys. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0077.
Full textAbstract:
Anaesthesia in ‘remote areas’ is required for medical imaging (CT, MRI, PET-CT), angiography, endoscopy, and interventions (stenting, thrombectomy, coiling, laser therapy, biopsies, radiotherapy) in a number of medical disciplines (paediatrics, radiology, cardiology, pulmonology, gastroenterology, surgery, cardiac surgery, emergency medicine). The spectrum of anaesthetic techniques is broad. It reaches from standby (monitored anaesthesia care), through analgesia and sedation (with spontaneous breathing), to general anaesthesia and mechanical ventilation. Regional anaesthesia techniques are also required under certain circumstances. In the last few years there has been a move away from open procedures to interventional techniques. The complexity of these interventions has increased (i.e. interventional cardiac valve replacements) and the patients tend to be older and suffer from a multitude of co-morbidities. Many of these interventions are performed in the ‘hostile environment’ of the intervention suite. Intervention suites are typically not designed to offer anaesthetists an ideal working area. The space may be limited and medical equipment impedes access to the patient. The infrastructure may be suboptimal (e.g. no central medical gases supply). Protection for staff and equipment against radiation and high magnetic fields must be considered. Loud noise from machinery and shielded walls, doors, and windows may hinder communication and hearing acoustic alarms. The distance to the operating theatre may be considerable and thus support from senior anaesthetists and supply of additional equipment may take some time to arrive. Anaesthesia outside the operating theatre is sometimes underestimated as trivial. Performing a ‘quick’ interventional case can evolve within seconds into a challenge even for the experienced anaesthesiologist if a surgical or anaesthesiological complication occurs. Non-operating-theatre anaesthesia has a higher severity of injuries and more substandard care than operating theatre anaesthesia. This is not acceptable and anaesthetists must ensure the same high standard of anaesthesia care and patient safety both inside and outside the operating theatre.
11
Schwarte, Lothar A., Stephan A. Loer, J. K. Götz Wietasch, and Thomas W. L. Scheeren. Cardiovascular drugs in anaesthetic practice. Edited by Michel M. R. F. Struys. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0019.
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Anaesthetists should be familiar with currently available cardiovascular drugs used to maintain cardiovascular stability and achieve haemodynamic goals in surgical patients. The first part of this chapter summarizes antihypertensive agents, and the second part discusses positive inotropic drugs and vasopressors, which can be used perioperatively. Selection of vasoactive agents should be guided by the therapeutic goal (e.g. decreasing or increasing blood pressure or blood flow) and the underlying pathophysiology. Choice of catecholamines in a given situation should be based on the desired effects, that is, goals that can be monitored. Generally speaking, it is easier to affect blood pressure than cardiac output, and how to optimize regional and microcirculatory blood flow remains uncertain. Regardless of the chosen intervention, its haemodynamic effects should be closely monitored and always evaluated against the clinical effects. Recent developments include the definition of haemodynamic goals (goal-directed therapy) and clinical end-points, which seem to decrease morbidity and mortality, regardless of the goals defined and interventions used. With regard to mortality, use of inotropic agents has been associated with adverse outcomes, whereas the use of vasodilators has not. Inotropes in combination with vasodilators have the highest mortality.
12
Herbert, Lara, and Bruce McCormick. Respiratory disease. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198719410.003.0005.
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This chapter describes the anaesthetic management of the patient with respiratory disease. It describes the assessment of respiratory function and preoperative respiratory investigations, and ventilatory strategies to reduce pulmonary complications. Common respiratory conditions covered include respiratory tract infection, smoking, asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea, sarcoidosis, restrictive pulmonary disease, and the patient with a transplanted lung. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described. Recommendations for the patient who may require post-operative respiratory support (e.g. non-invasive ventilation) are provided.
13
Herbert, Lara, and Bruce McCormick. Respiratory disease. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198719410.003.0005_update_001.
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This chapter describes the anaesthetic management of the patient with respiratory disease. It describes the assessment of respiratory function and preoperative respiratory investigations, and ventilatory strategies to reduce pulmonary complications. Common respiratory conditions covered include respiratory tract infection, smoking, asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea, sarcoidosis, restrictive pulmonary disease, and the patient with a transplanted lung. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described. Recommendations for the patient who may require post-operative respiratory support (e.g. non-invasive ventilation) are provided.
14
Pohl, A. Dislocations of the hip and femoral head fractures. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199550647.003.012050.
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♦ Most injuries are high violence, so look for associated injuries♦ Immediate closed reduction usually best under general anaesthetic♦ Do not proceed to open reduction without appropriate imaging studies♦ Surgical approach depends on injury pattern♦ Some long term complications can be minimized/avoided by appropriate early treatment (e.g. avascular necrosis).
15
Hughes, Jim. Orthopaedics. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198813170.003.0008.
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This chapter covers the basic approaches and techniques used in orthopaedic surgery, including the insertion and positioning of hardware and fixators, closed and open techniques (including manipulation under anaesthetic), and the typical imaging requirements for these. The discussion includes elective and trauma cases, as well as emergency procedures that may be performed out of regular working hours. They generally involve either repair to the skeleton and joints after injury (e.g. resiting a dislocated joint or aligning and supporting a fractured long bone) or alterations (such as fusion or replacement of a damaged joint or lengthening of a bone with a growth defect).
16
Allegaert, Karel, and Kristel Van Calsteren. Maternal, fetal, and neonatal pharmacokinetics. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0005.
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Most drugs are not thoroughly evaluated for use during pregnancy, delivery, or postpartum (e.g. breastfeeding). The same holds true for early infancy, and results in extensive off-label, unlicensed pharmacotherapy in these specific subpopulations. At present, most drug labels do not contain any instructions for use during pregnancy, in infancy, or during breastfeeding, yet these are the main concerns of healthcare providers considering medical treatment. Anaesthetists commonly treat pregnant women with similar dosing regimens recommended for use in adults and subsequently titrate to effect. The (dis)continuation of breastfeeding in the postpartum period following anaesthesia is commonly based on opinions instead of scientific evidence. This chapter describes the alterations in pharmacokinetics (absorption, distribution, metabolism, elimination) in pregnant women with specific emphasis on placental drug transport, and in neonates, with additional emphasis on breastfeeding. Drugs commonly administered by anaesthetists to women in the peripartum period are discussed with particular reference to the changed pharmacodynamics in both mother and infant.
17
Devlin, Hugh, and Rebecca Craven. Central nervous system. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198759782.003.0012.
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The central nervous system (CNS) in relation to dentistry is the topic of this chapter. Nerve conduction is described, then the physiology of facial and dental pain and processing of afferent pain nerve impulses in the cerebral cortex. We discuss abnormal sensations of allodynia and paraesthesia. Pain control with non-steroidal anti-inflammatory drugs or paracetamol is explained. The function of the cranial nerves and the autonomic nervous system are described. We explain the nerve pathways involved in salivation, lachrymation, and taste sensation. We propose some techniques for treating the nervous patient, e.g. modelling, systematic desensitization, and feedback. Effective local anaesthesia is essential in gaining the cooperation of nervous patients. The major types of local anaesthetics are compared. The techniques for inferior alveolar and superior alveolar nerve blocks are described as are drugs commonly used in dental sedation. There are final sections on drug problems encountered in dental practice and on dementia.
18
Ranucci, Marco, Serenella Castelvecchio, and Andrea Ballotta. Perioperative management of the high-risk surgical patient: cardiac surgery. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0077.
Full textAbstract:
During the last decade, as a result of continually improving surgical strategy and the technology which supports it (e.g. anaesthesia), cardiac surgery is offered to patients with advanced age and those with increasingly complex co-existing conditions that were previously considered to be contraindications. In addition, an increasing number of patients have previously undergone angioplasty, thereby delaying their initial coronary artery bypass graft surgery to a more advanced age. In general, candidates for cardiac surgery may now be not only older than in the past, but also more likely to have health problems such as hypertension and diabetes. Risk stratification may help to identify ‘the’ high-risk patient: ‘pre-warned is pre-armed’. In high-risk cardiac surgery patients, the surgical treatment options and perioperative care must be tailored to each patient, in order to optimize the benefits and minimize the risk of detrimental effects. The preoperative anticoagulation practice is an important aspect, balancing the risk between ischaemic and bleeding complications. New antiplatelet agents and oral anticoagulants have been recently delivered, and their role in patients scheduled for heart surgery is an additional important issue.
19
Ranucci, Marco, Serenella Castelvecchio, and Andrea Ballotta. Perioperative management of the high-risk surgical patient: cardiac surgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0077_update_001.
Full textAbstract:
During the last decade, as a result of continually improving surgical strategy and the technology which supports it (e.g. anaesthesia), cardiac surgery is offered to patients with advanced age and those with increasingly complex co-existing conditions that were previously considered to be contraindications. In addition, an increasing number of patients have previously undergone angioplasty, thereby delaying their initial coronary artery bypass graft surgery to a more advanced age. In general, candidates for cardiac surgery may now be not only older than in the past, but also more likely to have health problems such as hypertension and diabetes. Risk stratification may help to identify ‘the’ high-risk patient: ‘pre-warned is pre-armed’. In high-risk cardiac surgery patients, the surgical treatment options and perioperative care must be tailored to each patient, in order to optimize the benefits and minimize the risk of detrimental effects. The preoperative anticoagulation practice is an important aspect, balancing the risk between ischaemic and bleeding complications. New antiplatelet agents and oral anticoagulants have been recently delivered, and their role in patients scheduled for heart surgery is an additional important issue.
20
Ranucci, Marco, Serenella Castelvecchio, and Andrea Ballotta. Perioperative management of the high-risk surgical patient: cardiac surgery. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0077_update_002.
Full textAbstract:
During the last decade, as a result of continually improving surgical strategy and the technology which supports it (e.g. anaesthesia), cardiac surgery is offered to patients with advanced age and those with increasingly complex co-existing conditions that were previously considered to be contraindications. In addition, an increasing number of patients have previously undergone angioplasty, thereby delaying their initial coronary artery bypass graft surgery to a more advanced age. In general, candidates for cardiac surgery may now be not only older than in the past, but also more likely to have health problems such as hypertension and diabetes. Risk stratification may help to identify ‘the’ high-risk patient: ‘pre-warned is pre-armed’. In high-risk cardiac surgery patients, the surgical treatment options and perioperative care must be tailored to each patient, in order to optimize the benefits and minimize the risk of detrimental effects. The preoperative anticoagulation practice is an important aspect, balancing the risk between ischaemic and bleeding complications. New antiplatelet agents and oral anticoagulants have been recently delivered, and their role in patients scheduled for heart surgery is an additional important issue.
21
Ranucci, Marco, Serenella Castelvecchio, and Andrea Ballotta. Perioperative management of the high-risk surgical patient: cardiac surgery. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0077_update_003.
Full textAbstract:
During the last decade, as a result of continually improving surgical strategy and the technology which supports it (e.g. anaesthesia), cardiac surgery is offered to patients with advanced age and those with increasingly complex co-existing conditions that were previously considered to be contraindications. In addition, an increasing number of patients have previously undergone angioplasty, thereby delaying their initial coronary artery bypass graft surgery to a more advanced age. In general, candidates for cardiac surgery may now be not only older than in the past, but also more likely to have health problems such as hypertension and diabetes. Risk stratification may help to identify ‘the’ high-risk patient: ‘pre-warned is pre-armed’. In high-risk cardiac surgery patients, the surgical treatment options and perioperative care must be tailored to each patient, in order to optimize the benefits and minimize the risk of detrimental effects. The preoperative anticoagulation practice is an important aspect, balancing the risk between ischaemic and bleeding complications. New antiplatelet agents and oral anticoagulants have been recently delivered, and their role in patients scheduled for heart surgery is an additional important issue.
22
Jenkins, Ian A., and David A. Rowney. Resuscitation, stabilization, and transfer of sick and injured children. Edited by Jonathan G. Hardman and Neil S. Morton. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0074.
Full textAbstract:
Even though anaesthetists may not regard themselves as specialists in the care of critically ill children, they are still at the forefront of the immediate care of critically ill children. Whether they have developed an interest in paediatric anaesthesia or because they have subspecialized in general intensive care, anaesthetists will find themselves called upon by colleagues in the emergency department or in paediatrics to exercise the knowledge and skills that no other group in the hospital possess. Additionally, when these children need to be moved either to a scanner or hyper-acutely to a tertiary unit (e.g. for neurosurgical intervention), then the skills and specific knowledge of the anaesthetist will be called upon again. These elements are recognized in the syllabi of both the Fellowship of the Royal College of Anaesthetists and the Fellowship of the Faculty of Intensive Care Medicine. This chapter gives the background to the characteristics of critically ill children, sets out the important elements of the conditions that will be commonly encountered, and provides a full résumé of the preparations that transferring teams will need in terms of personnel, their knowledge, skills, and equipment, and also a full exploration of the various methods of transport, road ambulance, rotary- and fixed-wing aircraft, and what all these entail for the clinical team.