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34. Greenwood E, Nimmo S, Paterson H, Homer N, Foo I.
Intravenous lidocaine infusion as a component of multi-
modal analgesia for colorectal surgerydmeasurement of
plasma levels. Perioper Med 2019; 8: 1
35. Tran DQ, Bravo D, Leurcharusmee P, Neal JM. Transversus
abdominis plane block: a narrative review. Anesthesiology
2019; 131: 1166e90
36. Ng SC, Habib AS, Sodha S, Carvalho B, Sultan P. High-dose
versus low-dose local anaesthetic for transversus
abdominis plane block post-Caesarean delivery analgesia:
a meta-analysis. Br J Anaesth 2018; 120: 252e63
37. Wieczorek PM, Schricker T, Vinet B, Backman SB. Airway
topicalisation in morbidly obese patients using atomised
lidocaine: 2% compared with 4%. Anaesthesia 2007; 62: 984e8
38. Yang SS, Wang NN, Postonogova T, et al. Intravenous
lidocaine to prevent postoperative airway complications
in adults: a systematic review and meta-analysis. Br J
Anaesth 2020; 124: 314e23
39. Joshi GP, Kehlet H, Rawal N. Surgeon-administered
regional analgesia to replace anaesthetist-administered
regional analgesia: need for communication and collabo-
ration. Br J Anaesth 2019; 123: 707e9
40. Scherrer V, Compere V, Loisel C, Dureuil B. Cardiac arrest
from local anesthetic toxicity after a field block and
transversus abdominis plane block: a consequence of
miscommunication between the anesthesiologist and
surgeon. A A Case Rep 2013; 1: 75e6
41. Joshi GP, Janis JE, Haas EM, Ramshaw BJ, Nihira MA,
Dunkin BJ. Surgical site infiltration for abdominal surgery:
a novel neuroanatomical-based approach. Plast Reconstr
Surg Glob Open 2016; 4: e1181
42. Whiteman A, Bajaj S, Hasan M. Novel techniques of local
anaesthetic infiltration. Contin Educ Anaesth Crit Care Pain
2011; 11: 167e71
43. Weibel S, Jelting Y, Pace NL, et al. Continuous intravenous
perioperative lidocaine infusion for postoperative pain
and recovery in adults. Cochrane Database Syst Rev 2018; 6:
Cd009642
44. Abu Elyazed MM, Abdelghany MS, Mostafa SF. The analgesic
efficacy of pecto-intercostal fascial block combined with
pectoral nerve block in modified radical mastectomy: a
prospective randomized trial. Pain Physician 2020; 23: 485e93
45. Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K,
Weinberg G. Updates in our understanding of local
anaesthetic systemic toxicity: a narrative review. Anaes-
thesia 2021; 76: 27e39
46. Cabrini L, Baiardo Redaelli M, Ball L, et al. Awake fiberoptic
intubation protocols in the operating room for anticipated
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British Journal of Anaesthesia, 127 (4): 501e505 (2021)

doi: 10.1016/j.bja.2021.06.023
Advance Access Publication Date: 3 August 2021
© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Evidence-based guidance for use of intrathecal morphine as an

alternative to diamorphine for Caesarean delivery analgesia
Pervez Sultan and Brendan Carvalho*
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA,
USA

*Corresponding author. E-mail: bcarvalho@stanford.edu

Summary
Intrathecal morphine in combination with fentanyl is an effective and safe alternative to diamorphine for Caesarean
delivery analgesia. Evidence suggests minimal differences in clinical efficacy and side-effects between intrathecal
morphine and diamorphine. Recommended intrathecal morphine doses for Caesarean delivery analgesia are 100e150 ug.

Keywords: analgesia; Caesarean delivery; diamorphine; intrathecal; morphine; neuraxial; opioid

There is nothing permanent except change.
Heraclitus
Pain after Caesarean delivery is a leading concern for
women, and inadequately controlled pain may increase
opioid consumption, delay functional recovery, and nega-
tively impact maternaleneonatal bonding and breastfeed-
ing.1,2 Spinal anaesthesia is the most common technique for
elective Caesarean delivery, and as such readily facilitates
intrathecal opioid administration. Neuraxial opioids (such as
morphine or diamorphine) are considered an essential part of
a multimodal post-Caesarean delivery analgesic strategy.2e5
In the UK, single-dose diamorphine is the recommended
neuraxial opioid for Caesarean delivery4; however, outside the
UK, intrathecal morphine is the most commonly administered
neuraxial analgesic in this setting.2,3,6 Recent drug shortages
 502 - Editorials
of diamorphine have forced clinicians in the UK to explore
alternatives. When drug shortages are faced, institutions can
look to other healthcare systems for strategies of how to
deliver the same quality of care without compromising patient
outcomes, including analgesic efficacy, drug-related side-ef-
fects, and maternal experience.
Here we compare intrathecal morphine and diamorphine
with regards to their physicochemical properties, pharmaco-
kinetics, and pharmacodynamic (efficacy and side-effect)
profiles. We also provide optimal intrathecal dosing and
monitoring strategies with evidence-based guidance to enable
UK clinicians to transition confidently from using intrathecal
diamorphine to intrathecal morphine for Caesarean delivery.
Physicochemical properties and
pharmacokinetics
The higher lipid solubility of diamorphine (octanolewater
coefficient of 280) promotes a more rapid onset than that of
morphine. Intrathecal morphine requires up to 60e90 min to
achieve peak effect and consequently provides limited intra-
operative analgesia.7 Therefore, intrathecal morphine must be
combined with a lipophilic opioid (e.g. fentanyl, which has a
high octanolewater coefficient of 816) to improve intra-
operative analgesia, facilitate use of lower local anaesthetic
doses and thereby decrease spinal hypotension, reduce
intraoperative nausea and vomiting, and prolong time to first
postoperative analgesia request.8
The hydrophilic nature of morphine (octanolewater coef-
ficient of 1.4) suggests a longer duration of action and prolonged
postoperative analgesia.7 However, although the half-life of
intrathecal diamorphine (6e8 min) is significantly shorter
than for intrathecal morphine (14e360 min),9 the duration of
action of diamorphine depends on more than the CSF con-
centration. Diamorphine is a pro-drug with no intrinsic opioid
activity, but because of its high lipid solubility, it diffuses
rapidly into neural tissue where esterases release the active
compounds 6-acetylmorphine and morphine. These agents
are much less lipid soluble, and therefore remain in high
concentrations within the substance of the cord, which con-
tains mu opioid receptors, and only very slowly diffuse from
the peri-receptor aqueous phase back into the CSF.10
Theoretically, these pharmacokinetic properties suggest
that diamorphine should result in a lower incidence of centrally
mediated side-effects (such as delayed respiratory depression,
itching, drowsiness, and nausea) than morphine. The more
hydrophilic morphine has high CSF bioavailability, excellent
spinal penetration, prolonged duration of action, and less sys-
temic absorption compared with lipophilic opioids.11 The long
duration of action of morphine is attributable to the slow rate of
clearance of the drug from opioid receptors; it remains within
the CSF for prolonged periods and diffuses slowly to the plasma
compartment.12 Morphine is not metabolised within the CSF,
and therefore, morphine-6-glucoronide is not detected in CSF
after intrathecal administration.13
Pharmacodynamic clinical comparison of
efficacy and side-effect profiles
There are only two studies that have compared intrathecal
morphine and diamorphine for analgesia after Caesarean de-
livery. Both studies had small samples sizes and were not non-
inferiority study designs that should be considered when
comparing a readily available alternative (such as preservative-
free morphine combined with fentanyl) to a drug in short sup-
ply that is embedded in clinical practice (such as diamorphine).14
Husaini and Russell15 performed a randomised controlled
study in 40 women comparing patient-controlled analgesia
(PCA) morphine requirements after morphine 200 mg or dia-
morphine 200 mg co-administered with a standardised dose of
intrathecal bupivacaine as part of a multimodal analgesia
regimen. There were no differences found between groups for
the primary outcome of postoperative opioid requirement, or
any of the secondary pain (static or dynamic VAS pain scores)
or nausea outcomes. Furthermore, there was no difference in
the speed of onset, maximum cephalad spread, or duration of
the block between the two groups. However, pruritus and
drowsiness VAS scores were significantly higher in the
morphine group. A limitation of this study is that equipotent
doses were not utilised, with diamorphine being relatively
under-dosed and morphine relatively over-dosed compared
with contemporary recommended doses.
Barkshire and colleagues16 performed a randomised double-
blinded trial in 60 women comparing intrathecal morphine
100 mg and intrathecal diamorphine 250 mg together with a
standardised dose of bupivacaine and fentanyl (12.5 mg) as part
of a multimodal analgesia regimen. For the primary outcome
of 24 h PCA morphine consumption, no difference was
reported between groups. For the remaining secondary
outcomes of time to first PCA demand (240 vs 249 min),
number of women requiring anti-emetic treatment, number of
women receiving additional analgesics, dynamic VAS pain
scores, and time taken to pass urine, no differences were found
between groups. Furthermore, no differences were reported
between groups for time of block onset or median block cephalad
spread. The authors concluded that intrathecal diamorphine
250 mg is a suitable alternative to morphine 100 mg (and pre-
sumably vice versa).
Despite the paucity of studies directly comparing neuraxial
morphine with diamorphine, current evidence suggests min-
imal difference in clinical efficacy and side-effects between
the drugs in the Caesarean delivery setting.
Optimal dosing strategies and
recommendations
Multiple dose-finding studies have been conducted to determine
the optimal dosing of intrathecal morphine for Caesarean de-
livery analgesia. Studies suggest the optimal dose for intrathecal
morphine in this setting is around 75e100 mg; however, lower
doses of 50 mg in a setting of multimodal analgesia may provide
reasonable analgesia.7 The advantage of using higher intrathecal
morphine doses is to prolong the analgesic duration. A meta-
analysis by Sultan and colleagues17 compared low (50e100 mg)
and higher (>100e250 mg) doses of intrathecal morphine for
Caesarean delivery. The time to first analgesic request (primary
outcome) was longer (mean difference of 4.5 h; 95% confidence
interval [CI]: 1.9e7.1) in the high-dose group; however, the in-
cidences of nausea or vomiting (odds ratio [OR] 0.44 [95% CI:
0.3e0.7]) and pruritus (OR 0.34 [95% CI: 0.2e0.6]) were signifi-
cantly less with lower doses. Given that the balance between
analgesia and neuraxial-opioid-related side-effects is depen-
dent on patient preference, a patient-centred approach has been
proposed by which women should where possible select the
intrathecal morphine dose they receive, based on preoperative
information outlining the balance between pain relief and
 Editorials - 503

avoidance of side-effects. Studies suggest that this patient- Respiratory depression

centred approach may be preferable to traditional stand-
The most feared complication associated with the use of
ardised dosing protocols.18,19
intrathecal opioids is respiratory depression. The physico-
The National Institute for Health and Care Excellence sug-
chemical and pharmacokinetic properties of morphine sug-
gests an intrathecal diamorphine dose of 300e400 mg for post-
gest that intrathecal morphine may confer a higher risk of
Caesarean delivery analgesia.4 Although the equi-analgesic
delayed respiratory depression secondary to rostral spread
intrathecal morphine dose has not been determined, current
within the CSF compared with diamorphine. However, this
recommended intrathecal doses for Caesarean delivery anal-
increased risk has not been confirmed clinically, and the
gesia include morphine 100e150 mg plus fentanyl 10e15 mg.
actual risk of respiratory depression of either drug, adminis-
Intrathecal fentanyl is needed intraoperatively because of the
tered at clinically recommended doses, is extremely small. A
delayed onset of intrathecal morphine; however, fentanyl has
systematic review reported that the incidence of clinically
a limited role postoperatively with a duration of ~2 h.7 Data
significant respiratory depression (defined as the requirement
suggest that the expected duration of action of intrathecal
for an intervention, such as airway intervention, oxygen
morphine (as measured by time to first analgesic request)
therapy, pharmacological therapy, or more than verbal stimuli
ranges from 9.7 to 26.6 h after 50e100 mg doses and from 13.8 to
to rouse the patient), with contemporary doses of neuraxial
39.5 h after higher doses (>100e250 mg).17 Despite concerns
morphine or diamorphine, was 1.08e1.63 per 10 000 women.6
that intrathecal morphine may be less effective when given
The vast majority of studies included in the analysis of this
concurrently with intrathecal fentanyl (hypothesised because
review involved neuraxial morphine administration (63 out of
of acute spinal opioid tolerance),20 a follow-up study reported
the 78 included studies). Additionally, the ASA Closed Claims
minimal clinically significant reduction in postoperative
Project database found no cases related to intrathecal
opioid requirement and analgesia associated with the addition
morphine after Caesarean delivery in the past two decades,
of intrathecal fentanyl to morphine.21

Preoperative risk factors

Examples: cardiopulmonary/neurological
Patient risk Low risk,
comorbidity, known or suspected OSA,
stratification healthy
obesity (BMI≥40 kg m–2), chronic
opioid use/abuse, hypertension

Neuraxial Ultra low dose Low dose High dose

morphine IT ≤0.05 mg IT >0.05 and ≤0.15 mg IT >0.15 mg
dosing* EPI ≤1 mg EPI >1 and ≤3 mg EPI >3 mg

• Routine postoperative
Respiratory Every 2 h clinical
vital sign monitoring
monitoring VF and sedation
• No additional
frequency assessments
respiratory monitoring
and duration for 12 h
required

ASA general guidelines

• VF and sedation assessments:
Perioperative risk factors
every 1 h for first 12 h;
Examples: general anaesthesia,
*Use additional then every 2 h for 12–24 h
concomitant sedating medications
multimodal analgesia • Consider additional monitoring
(benzodiazepines, sleeping aids,
(e.g. scheduled NSAIDs+ modalities (e.g. pulse oximetry,
magnesium administration),
paracetamol) capnography); continuous vs
i.v. opioid administration,
continual intermittent monitoring
desaturation event in recovery
as needed

Fig 1. Monitoring algorithm from the Society for Obstetric Anesthesia and Perinatology consensus statement for prevention and detection
of respiratory depression associated with administration of neuraxial morphine for Caesarean delivery analgesia. EPI, epidural; IT,
intrathecal; OSA, obstructive sleep apnoea; VF, ventilatory frequency. Figure adapted from Bauchat and colleagues.3
 504 - Editorials
despite the majority of practices in the USA using intrathecal
morphine for Caesarean delivery, which impacts 1.3 million
women per year within the USA.3
The Society for Obstetric Anesthesia and Perinatology
recently published a consensus statement for respiratory
monitoring after intrathecal morphine administration in the
obstetric setting (Fig. 1).3 For doses of intrathecal morphine
50 mg, no additional monitoring is required; for doses of
50e150 mg, in the absence of risk factors for respiratory
depression, 2-hourly clinical assessment of respiratory rate and
sedation for 12 h is recommended; and for doses 150 mg or in
high-risk patients, clinicians are encouraged to follow ASA and
American Society of Regional Anesthesia and Pain Medicine
recommendations, which advise for an extended duration of
monitoring (hourly for 12 h, and then 2-hourly for 12e24 h;
Fig. 1).22
Practical considerations
When changing routine practice, anaesthetists must remain
cognizant of the potential for drug administration errors
because of lack of familiarity with drug vials, mixing of opi-
oids (fentanyl and morphine), and the drawing up of correct
doses of these drugs. Morphine preparations containing
preservatives are currently available within the drug cup-
boards of anaesthetic rooms throughout UK labour wards.
Clinicians should aim to remove all preservative-containing
morphine because of the potential for risks associated
with neuraxial preservative administration, including
arachnoiditis. Different morphine preparations containing
different concentrations should similarly be removed from
obstetric operating theatres and labour wards. Time must
also be spent adequately educating anaesthetists and oper-
ating department practitioners before instituting any routine
change in policy. Ideally, standardised doses should be agreed
upon and used by all providers. Both authors of this editorial
had to transition from using intrathecal diamorphine to
morphine after moving from the UK to the USA. We both feel
that intrathecal morphine in combination with fentanyl
provides excellent intra- and post-Caesarean delivery anal-
gesia, and that providers should feel confident in their ability
to deal with diamorphine shortages, given the availability of
such a well-studied, safe, and effective alternative. There
should be no reason for anaesthetists within the UK to be
concerned about the quality of analgesia or rates of morbidity
associated with intrathecal preservative-free morphine and
fentanyl, which are effective alternatives.
Declarations of interest
PS is an Arline and Pete Harman Endowed Faculty Scholar of
the Stanford Maternal and Child Health Research Institute. BC
has no conflicts to declare.
References
1. Sutton C, Carvalho B. Optimal pain management after
cesarean delivery. Anesth Clin 2017; 35: 107e24
2. Bollag L, Lim G, Sultan P, et al. Society of Obstetric Anes-
thesia and Perinatology (SOAP) Enhanced Recovery After
Cesarean (ERAC) consensus statement. Anesth Analg 2021;
132: 1362e77
3. Bauchat J, Weiniger C, Sultan P, et al. Society for Obstetric
Anesthesia and Perinatology consensus statement:
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tion of respiratory depression associated with adminis-
tration of neuraxial morphine for cesarean delivery
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4. National Institute for Health and Care Excellence.
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from: https://www.nice.org.uk/guidance/ng192/chapter/
Recommendations (accessed 25 May 2021).
5. Roofthooft E, Joshi G, Rawal N, Van de Velde M. PROSPECT
Working Group of the European Society of Regional
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elective caesarean section: updated systematic review
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6. Sharawi N, Carvalho B, Habib A, Blake L, Mhyre J, Sultan P.
A systematic review evaluating neuraxial morphine and
diamorphine-associated respiratory depression after ce-
sarean delivery. Anesth Analg 2018; 127: 1385e95
7. George R, Carvalho B, Butwick A, Flood P. Postoperative
analgesia. In: Chestnut D, Wong C, Tsen L, et al., editors.
Chestnut’s obstetric anesthesia: principles and practice. 6th
Edn. Philadelphia, PA: Elsevier; 2020. p. 627e69
8. Matheson K, McKeen D. Efficacy of intrathecal fentanyl for
Cesarean delivery: a systematic review and meta-analysis
of randomized controlled trials with trial sequential
analysis. Anesth Analg 2020; 130: 111e25
9. Moore A, Bullingham R, McQuay H, Allen M, Baldwin D,
Cole A. Spinal fluid kinetics of morphine and heroin. Clin
Pharmacol Ther 1984; 35: 40e5
10. Stevens L, Wootton C. The pharmacokinetic properties of
diamorphine. In: Scott D, editor. Diamorphine: its chemistry,
pharmacology and clinical use. New York: Woodhead
Faulkner; 1988. p. 15e43
11. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphine
and respiratory depression: finding the right balance. Drugs
2011; 71: 1807e19
12. Sandouk P, Scherrmann J, Chauvin M. Rate-limiting
diffusion processes following intrathecal administration
of morphine. Eur J Clin Pharmacol 1986; 30: 575e9
13. Hanna M, Peat S, Woodham M, Knibb A, Fung C. Analgesic
efficacy and CSF pharmacokinetics of intrathecal
morphine-6-glucuronide: comparison with morphine. Br J
Anaesth 1990; 64: 547e50
14. Toledo P, Singh PM, Sultan P. Can noninferior be superior?
Anesth Analg 2021; 132: 663e5
15. Husaini S, Russell I. Intrathecal diamorphine compared
with morphine for postoperative analgesia after
Caesarean section under spinal anaesthesia. Br J Anaesth
1998; 81: 135e9
16. Barkshire K, Russell R, Burry J, Popat M. A comparison of
bupivacaine-fentanyl-morphine with bupivacaine-
fentanyl-diamorphine for caesarean section under spinal
anaesthesia. Int J Obstet Anesth 2001; 10: 4e10
17. Sultan P, Halpern SH, Pushpanathan E, Patel S, Carvalho B.
The effect of intrathecal morphine dose on outcomes after
elective cesarean delivery: a meta-analysis. Anesth Analg
2016; 123: 154e64
18. Carvalho B, Sutton C, Kowalczyk J, Flood P. Impact of pa-
tient choice for different postcesarean delivery analgesic
protocols on opioid consumption: a randomized pro-
spective clinical trial. Reg Anesth Pain Med 2019; 44: 578e85
19. Carvalho B, Mirza F, Flood P. Patient choice compared with
no choice of intrathecal morphine dose for Caesarean

analgesia: a randomized clinical trial. Br J Anaesth 2017;
118: 762e71
20. Cooper D, Lindsay S, Ryall D, Kokri M, Eldabe S, Lear G.
Does intrathecal fentanyl produce acute cross-tolerance
to i.v. morphine? Br J Anaesth 1997; 78: 311e3
21. Carvalho B, Drover D, Ginosar Y, Cohen S, Riley E. Intra-
thecal fentanyl added to bupivacaine and morphine for
British Journal of Anaesthesia, 127 (4): 505e508 (2021)
doi: 10.1016/j.bja.2021.04.025
Advance Access Publication Date: 14 June 2021
© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
What we do, what we call ourselves, and how we spell it
J. Robert Sneyd
Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
E-mail: robert.sneyd@pms.ac.uk
Keywords: anaesthesiologist; anaesthetist; CRNA; nurse; physician; professionalism
What is in a name? However you spell it, anaesthesia, or at
least the administration of anaesthetic drugs, is not solely the
preserve of anaesthetists. British Anaesthesia Associates,
American Certified Registered Nurse Anesthetists (CRNAs),
and an international spectrum of specialist nurses and tech-
nicians all provide sedation and anaesthesia with varying
degrees of medical supervision. The accountability frame-
works may differ, but their practice is nevertheless lawful.
Anaesthetic drugs (typically hypnotics) are prescribed by
physicians in ICUs and emergency departments (and less
frequently elsewhere). Medically qualified specialist anaes-
thetists regard these alternate providers with a range of
emotions reflecting their perceived status as valued colleagues
or unwelcome competitors. One approach is to emphasise the
value of specialist postgraduate training in anaesthesia and to
reflect that with a special name. Thus, in 1902, American
physician anaesthetists became anesthesiologists,1 and their
counterparts in continental Europe and Ireland are now
anaesthesiologists.
For decades, the American Society of Anesthesiologists
(ASA) and the American Association of Nurse Anesthetists
(AANA) have battled over supervision, independent practice,
and recently over names. A faction within AANA failed to
change its name to the American Association of Nurse Anes-
thesiologists, and recently the ASA intervened to prevent
CRNAs from describing themselves as nurse anesthesiologists
and received a supportive opinion from the Supreme Court of
New Hampshire.2 At stake is the desire to distinguish medi-
cally qualified (‘physician’) providers of anaesthesia from
those without a medical degree. Increasingly, individuals
trained as CRNAs may complete an additional experiential
programme and a project to earn the title Doctor of Nursing
Practice, thereby entitling them to the title Doctor.
Overlap of roles between clinical professions is normal. In the
UK, nurses triage, diagnose, manage, prescribe, and lead. None
Editorials - 505
cesarean delivery may induce a subtle acute opioid
tolerance. Int J Obstet Anesth 2012; 21: 29e34
22. American Society of Anesthesiologists Task Force on
Neuraxial Opioids, Horlocker T, Burton A, et al. Practice
guidelines for the prevention, detection, and management
of respiratory depression associated with neuraxial opioid
administration. Anesthesiology 2009; 110: 218e30
of these are the unique responsibility of doctors. The difference
between doctors and nurses is therefore not defined by abso-
lutes. Rather, it is a question of degree and the balance of ac-
tivities. A doctor particularly deals with uncertainty, working
towards a diagnosis for the undifferentiated sick patient, then
developing a treatment plan and supervising its execution. The
equivalent in anaesthetic practice might be an acute, unex-
pected emergency during otherwise ‘plain sailing’ anaesthesia.
The COVID-19 pandemic has demanded extraordinary flexi-
bility from healthcare workers, and in turn their responses have
been remarkable. Operating theatre anaesthetists have switched
to intensive care, orthopaedic surgeons served in teams turning
patients prone, and undergraduate training has been
adapted.3e6 In Europe and in the USA, CRNAs adapted their
anaesthesia skills to the ward environment and made valuable
contributions in the ICU.7,8 Overall capacity in intensive care is
clearly inadequate and the workforce requires flexibility and
expansion.9 The lead time for traditionally trained intensivists is
enormous and the circumstances demand that other solutions
at least be considered. The Competency-Based Training in
Intensive Care Medicine in Europe programme was established
in 2003 to harmonise medical postgraduate curriculum stan-
dards.10 It has subsequently provided important elements for
training nurses as advanced critical care practitioners.11
In February 2021, Health Education England announced the
development of a core capabilities framework for four medical
associate professions: anaesthesia associates, physician as-
sociates, surgical care practitioners, and advanced critical care
practitioners.12 The development of well-defined (compe-
tency-based) roles for non-medical providers with proper
regulation by statutory bodies is therefore well underway and
unlikely to be reversed.
If doctors are generally happy with their position vis-a -vis
the nursing staff, why then such angst about nurse anaes-
thesiologists or perhaps nurse anaesthetists in general?