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Fatigue in Anaesthesiology

Definition

• Fatigue is the state in which sustained wakefulness and circadian disruption produce a measurable reduction in cognitive speed, vigilance and psychomotor accuracy, together with loss of motivation to continue a task
  • “inability or unwillingness to continue effective performance of a mental or physical task”
• In anaesthetists ≥ 16 h awake, reaction times resemble those seen at a blood-alcohol concentration of 0.05 %.

Patient and Clinician-centred Harms

Harm domain	Key findings	Clinical relevance
Patient safety	Extended (> 24 h) or night shifts increase self-reported major medical errors by ≈ 60–100 %.	Higher incidence of drug-dose mistakes, airway events and lapses in monitoring.
Operator performance	Simulator studies show slower response to alarms, poorer crisis-resource management and mood deterioration after night duty.	Compromises non-technical skills essential for crisis management.
Clinician health	Repeated circadian disruption is linked to burnout, depression, obesity, cardiovascular disease and RTCs on the commute.	Mandates departmental safety culture and travel-home policies.

Regulatory & Guideline Landscape (SA & UK)

Jurisdiction	Over-arching regulations	Anaesthesia-specific guidance	Maximums / duties
South Africa	Basic Conditions of Employment Act (BCEA) allows ≤ 55 h week for essential services if overtime consented.	SASA Practice Guidelines 2022 recommend ≤ 80 h week averaged 6 weeks; ≤ 16 h continuous for theatre; ≤ 24 h only where activity intermittent (e.g. ICU).	10 h protected rest between duties; 24 h rostered recovery after night call.
United Kingdom	Working Time Regulations 1998 (WTR)—≤ 48 h week (17-week average), 11 h rest/24 h, 24 h rest/week.	Association of Anaesthetists / RCoA “Fight Fatigue” campaign and Managing Fatigue–departmental guide (2018, reaffirmed 2022).	Emphasise nap culture, safe commuting, dedicated rest facilities.

Best-practice Roster Design

• Plan ≤ 4 consecutive nights; avoid quick return (< 11 h) shifts.
• Forward-rotating (days → evenings → nights) reduces circadian strain.
• Rostered non-clinical time (10–25 %) safeguards CPD, audit and wellbeing.
• Smart leave allocation immediately post-block to ensure recovery.

On-shift Fatigue Counter-measures

Strategy	Evidence-based effect	Practical tip
Prophylactic sleep 2 h nap before night duty	↓ subjective sleepiness scores	Dark, quiet rest facility 13:00–15:00.
Short nap 20–30 min at ~03:00	Restores PVT performance for ≈ 3 h	Set two alarms; allow 15 min sleep inertia recovery.
Strategic caffeine 100–200 mg PO/IV at start of duty & post-nap	↑ vigilance, ↓ errors	Avoid within 6 h of intended sleep.
Bright-light exposure 2 000–10 000 lux	Phase-shifts melatonin, sustains alertness	Use theatre task lighting during night lists.

• PVT= Psychomotor Vigilance Test.

Equipment & Environment Safeguards

• Two-person checks for critical drug/infusion changes after midnight.
• Pre-listed rest breaks in hand-over sheet (“safety huddles”).
• 24 h access to hot food, hydration, shower and secure sleep pod
• Post-call taxi / hospital transport funding in line with RCoA GPAS Chapter 1.

Departmental Governance Duties

1. Fatigue risk management system (FRMS) within overall clinical-governance framework.
2. Education–mandatory annual teaching on sleep physiology, caffeine, driving safety.
3. Incident reporting–include “fatigue contributory factor” tick-box.
4. Wellbeing surveillance–audit rota compliance, sickness, near-miss data; present at M&M.

SASA Recommendations

1. Controlled Work Hours
   • Implement controlled work hours in conjunction with improved handover strategies.
2. Fatigue Alleviation Strategies
   • Prophylactic sleep
   • Naps
   • Improved rostering
   • Caffeine avoidance
3. Adequate Supervision and Work Hours
   • Schedule for adequate supervision of providers and ensure not to exceed maximum recommended working hours.
4. Equipment Checking Discipline
   • Maintain strict discipline in checking equipment.
5. Personnel to Workload Ratios
   • Ensure adequate and appropriate personnel to workload ratios.
6. Conducive Work Environment
   • Create a conducive work environment.
7. Compliance with Recommended Rest Periods
   • Exposure to after-hours work must conform to recommended rest periods.

Links

• Anaesthetist substance abuse
• Practice guideline
• Practice management

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References:

1. Gregorÿ, P. and Edsell, M. (2014). Fatigue and the anaesthetist. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 14(1), 18-22. https://doi.org/10.1093/bjaceaccp/mkt025
2. Association of Anaesthetists. Fight Fatigue–Information Packs. 2022
3. Royal College of Anaesthetists. Fatigue and Anaesthetists–2nd edition. 2018.
4. South African Society of Anaesthesiologists. Practice Guidelines 2022.
5. Howard SK et al. Simulation study of rested versus sleep-deprived anaesthesiologists. Anesthesiology 2003;98:1345-55.
6. Lockley SW et al. Effect of reducing interns’ weekly work hours on sleep and patient safety. N Engl J Med 2004;351:1829-37.
7. Suter B et al. Extended-duration shifts and medical errors: systematic review and meta-analysis. AHRQ Evidence Report 2023.

Summaries:

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Copyright

© 2025 Francois Uys. All Rights Reserved.

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