Chapter 15: Guidelines for the Provision of Anaesthesia Services for Vascular Procedures 2019
Vascular services are recognised as having a high priority in the UK. Publication of evidence that the outcome from abdominal aortic aneurysm (AAA) surgery was significantly worse in the UK than in comparable countries,1 and the 2005 NCEPOD Report ‘AAA a service in need of surgery’, led to a national Abdominal Aortic Aneurysm Quality Improvement Programme (AAAQIP) being introduced to encourage standards of best practice and reduce national mortality.2 Standardisation of care has resulted in improvements in survival following AAA repair which have now exceeded initial targets.3 The increasing use of complex endovascular stent grafts in patients assessed as high risk for open aortic surgery has added a new level of complexity to decision-making for patients with aortic pathology. Vascular anaesthetists may need to acquire additional knowledge and skills in areas such as spinal cord protection within the sphere of this growing workload and be cognisant of the implications and available options for such patients. Such procedures may require vascular anaesthetists to provide clinical care in a hybrid theatre or the interventional radiology suite.4,5,6 The majority of patients requiring arterial surgery are elderly and have a high incidence of cardiovascular, renal and respiratory disease.7,8,9,10
A very large proportion of vascular surgery is urgent in nature. This is commonly highlighted in patients who require lower limb revascularisation, major lower limb amputation or carotid endarterectomy. Current evidence suggests that carotid endarterectomy should be performed within two weeks of initial symptoms.11
Similarly data from the UK National Vascular Registry, an NCEPOD Report and the recent nationwide Getting it right first time report revealed poor outcomes in patients undergoing major lower limb amputation and considerable delays in treatment.12,13,19 A current best practice guideline has been published on major lower limb amputation, and this was followed by a best practice clinical care pathway.13,14 These reports have implications for departments who provide a vascular anaesthesia service.
There is evidence that outcome after arterial surgery is related to the caseload of both surgeons and anaesthetists, and that individual anaesthetists should not be caring for very small numbers of patients undergoing major elective and emergency aortic or carotid surgery.4,15,16 These recommendations have been one of many important drivers for continued centralisation of vascular services in the UK due to a reportedly strong relationship between case volume and patient outcome. These are national issues which affect the clinical and organisational delivery of vascular anaesthesia services.
Following the reconfiguration and centralisation of vascular services within NHS hospitals in England, services should be part of a wider regional network. Within the network, ‘arterial’ and ‘non-arterial’ centres exist to provide a comprehensive service to a population of at least 800,000.17 All arterial procedures, including endovascular, can only be provided in designated arterial centres.
Again, these reports and changes in practice have important implications for the safe provision of vascular anaesthesia services.
1. Staffing requirements
In all hospitals undertaking major vascular anaesthesia a vascular anaesthetist should be appointed clinical lead (see glossary) to manage service delivery. This should be recognised in their job plan, and they should be involved in multidisciplinary service planning and governance within the unit.
Anaesthesia for all patients undergoing major vascular surgery should be provided by or directly supervised by an anaesthetist suitably qualified, trained and experienced in vascular anaesthesia. This will usually be a consultant vascular anaesthetist, who has overall responsibility for the patient’s care. Under certain circumstances, this could be an SAS doctor who is practising regularly in this subspecialist area under the provisions of the RCoA’s guidance on the supervision of SAS doctors.18
It is recognised that staff involved in providing care for out-of-hours vascular emergencies may differ from those involved in routine daytime care. It is essential that all staff who might potentially be involved in perioperative care of the emergency vascular surgical patient are trained and competent in the aspects of care for which they are responsible. There should be provision for such staff to attend and assist in the daytime care of routine major vascular cases to update their skills and knowledge, with appropriate recognition in their respsective job plans.
Anaesthetists undertaking major vascular surgical cases should be supported by adequately trained assistants who work regularly in the vascular theatres.
Departments might occasionally need to consider allocating two consultants to work together to provide direct clinical care to patients undergoing major vascular procedures. Examples might include the exploration of infected aortic stent grafts or open thoraco-abdominal aneurysm repair.
The preoperative assessment and decisions regarding the risks of vascular surgery are often complex and time consuming, and require detailed discussions with the patient and other colleagues. Patients undergoing major vascular surgery should ideally be assessed by a vascular anaesthetist. Regular sessional time and programmed activities should be made available for anaesthetists to fulfil these requirements.22
In units designated as complex arterial centres, additional programmed time should be allocated to vascular anaesthetists delivering this service to allow them to engage with the multidisciplinary team (MDT) and provide support to allied specialties.
Where endovascular procedures are being performed in the radiology department, perioperative anaesthetic support should be identical to that provided for patients undergoing vascular surgery in the operating theatre suite.
Staff with skills including expertise in spinal cord protection, monitoring of anticoagulation, visceral perfusion and one-lung ventilation should be available in specialist units.
2. Equipment, services and facilities
The following equipment, support services and facilities are required for the efficient and safe functioning of the vascular anaesthesia service.
Major vascular surgery often requires the use of large amounts of ancillary equipment. This should be available in vascular theatres and operated by appropriately trained staff. Equipment should include radiological equipment, rapid fluid infusers, cell salvage machines and extra-corporeal circulation devices where appropriate.
Transoesophageal echocardiography (TOE) may be useful in the identification of thoracic aortic pathology, successful deployment of thoracic stent grafts and detection of early complications. When required, TOE should be performed by certified practitioners with expertise in its use and interpretation.
Units undertaking vascular surgery in which spinal cord or cerebral ischaemia is a significant risk factor should consider having the appropriate equipment for intraoperative neurophysiological monitoring. Examples include monitoring of evoked potentials, cerebral perfusion and function, CSF pressure and drainage.
Equipment to perform one-lung ventilation should be available when thoracoscopic or thoraco-abdominal procedures are performed.
All relevant staff should be appropriately trained in the use of the above equipment.
Vascular theatres should be of adequate size to facilitate the use of this equipment safely, with additional storage capacity.
Facilities to provide postoperative level 1 and 2 care should be available 24/7.
In centres performing arterial surgery, adequate level 2 and 3 critical care facilities should be available onsite to facilitate both routine and emergency workloads. This should include the ability to provide renal replacement therapy.2
Where anaesthesia is provided for endovascular procedures the anaesthetic facilities and equipment should be equivalent to those of a modern operating theatre environment. This includes post-anaesthesia recovery facilities with adequate levels of trained recovery room staff.31
Endovascular procedures involve significant potential exposure of the patient and staff to ionising radiation. Recommendations for facilities and training outlined in chapter 7 should be followed.32 Suitable lead aprons and lead barriers, and eyewear and dose meters should be available for the anaesthetic team in such an environment.
3. Areas of special requirement
Preoperative assessment and preparation
The preoperative evaluation of patients presenting for vascular surgery presents particular challenges because of the incidence of coexisting disease, in particular cardiovascular, respiratory, renal disease, and diabetes.4,33,34
The specific aims of preoperative vascular assessment are:
- to perform a risk assessment
- to allow referral and optimisation of coexisting medical conditions
- to permit consideration and institution of prevention measures, including:
- lifestyle evaluation and interventions to support modification of risk factors (cessation of smoking, weight management, nutrition and regular activity/exercise)
- ensuring availability of access to appropriate support services (pharmacy and dietetics)
- to enable clinical decision making with the wider vascular team, including:
- planning and preparation
- reviewing the risks and benefits of surgery
- establishing the best surgical options for an individual
- allowing for the timing of surgery and required facilities to be planned
- to facilitate shared decision making with the patient.
General recommendations for preoperative assessment are described in chapter 2.35
Risk stratification based on clinical history may help guide management.36 However, determination of a patient’s functional capacity may be difficult if exercise tolerance is limited by peripheral vascular insufficiency, respiratory or other disease.10,35 Clinical guidelines should be developed for further investigation, referral, optimisation, and management according to local facilities and expertise.37
To guide clinical decision-making, cardiopulmonary exercise testing should be considered for patients undergoing aortic surgery to establish functional capacity and the presence and severity of cardiopulmonary disease. Test results may also be helpful in guiding collaborative decision-making as to the most appropriate treatment option for patients.36
Increasing numbers of elderly patients are undergoing vascular surgery. There is evidence that a comprehensive geriatric assessment, targeting syndromes such as frailty and sarcopenia, have a positive impact in terms of shared decision-making and clinical outcomes for those patients who undergo vascular surgery. This is a growing area of clinical practice, which is directly benefiting the vascular surgical population.
4. Training and education
Anaesthetists with an appropriate level of training should manage patients undergoing major elective vascular surgery.
In order to maintain the necessary knowledge and skills, vascular anaesthetists should have a regular commitment to the specialty, and adequate time must be made for them to participate in relevant multidisciplinary meetings and continuing professional development (CPD) activities. This should include the facility and resources to visit other centres of excellence in order to exchange ideas and develop new skills where appropriate.
Vascular anaesthetists should have the appropriate skills and knowledge regarding invasive cardiovascular monitoring, cardioactive or vasoactive drugs, strategies for perioperative organ protection (renal, myocardial and cerebral), the management of major haemorrhage, and the maintenance of normothermia.39
Some anaesthetists may have responsibility for management of major vascular surgical cases on an occasional or out-of-hours basis. Departments of anaesthesia should ensure that opportunities are made available for these anaesthetists to maintain appropriate skills and knowledge. Notwithstanding this, all anaesthetists must recognise and work within the limits of their professional competence.
A local training module should be provided for anaesthetists in training according to their grade, supervised by a nominated educational lead. This programme should develop understanding of the widespread nature of cardiovascular disease, optimisation and risk stratification, as well as perioperative management. The RCoA revised training curriculum (2010) provides explicit detail of the requirements.40
5. Organisation and Administration
Departments should ensure that vascular anaesthetists and support staff are available to provide a year round service. This should include prospective cover for sickness and planned leave.4
Where organisational infrastructure is lacking to safely undertake major or complex vascular cases, e.g. where no critical care bed or vascular anaesthetist is available, clinical staff should not be pressured into proceeding with surgery.
Under circumstances where prolonged or complex vascular procedures are scheduled on a regular basis, appropriate agreement, planning, funding and resources should be in place.
Programmed time should be available in job plans to support appropriate attendance at multidisciplinary team meetings and preoperative assessment clinics.
Paticipation in morbidity and mortality and governance meetings, and participation in audit and development of local protocols, should be supported in the job plans.
The following guidelines should be held and be easily accessible:
- management of lumbar drains
- postoperative management of blood pressure following a carotid endarterectomy (CEA)
- emergency ruptured AAA.
6. Financial considerations
Part of the methodology used in this chapter in making recommendations is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.
The vast majority of the recommendations are not new recommendations; they are rather a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, and so it is not possible to calculate the financial impact of the recommendations in this chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.
7. Research, audit and quality improvement
All departments undertaking major vascular surgical cases should organise regular multidisciplinary audit meetings with vascular surgeons and radiologists. These should occur in addition to departmental clinical governance meetings.43 Regular audit or evaluation of the following aspects of vascular patient care may include:
- survival of and complications in patients undergoing surgery, including review of unexpected outcomes
- survival in patients treated non-surgically, e.g. abdominal aortic aneurysm including cause of death, where appropriate
- compliance with recommended national guidance timeframes, e.g. VSQIP, including reasons for delay or cancellations of major elective cases
- techniques and quality of perioperative pain management for elective and emergency cases
- utilisation of intraoperative blood conservation strategies and impact on blood component usage
- impact of MDT process on clinical decision-making in patient management
- patient-reported outcome and experience measures with the vascular service.
It is recommended that individual vascular anaesthetists register with, and contribute to, the UK national audit database (National Vascular Registry),43 which incorporates a section dedicated to ‘anaesthesia’ as developed between the Vascular Anaesthesia Society of Great Britain and Ireland and partnership organisations. The systems needed to provide the necessary data should be available and supported.
Departments should facilitate the collection of data required for anaesthetists undertaking major vascular cases to keep a personal logbook.
Where new quality improvement initiatives are being considered for patients undergoing vascular procedures, an appropriately conducted impact evaluation is recommended before commencement. This should involve all local stakeholders likely to be affected, ideally including patient representatives. An appropriately conducted pilot evaluation, with clearly defined outcome measures, may be appropriate prior to consideration of full-scale implementation.
8. Implementation support
The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process on payment of an appropriate fee. Once subscribed, they are provided with a ‘College guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the standards document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards (and by doing so to test the GPAS recommendations) to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
It is important to engage in a shared decision-making process with patients to discuss the risks and benefits of scheduled or elective major vascular surgery. Details should be explained to the patient in an appropriate setting and in language they can understand. Patient information materials should be made available to support the patient’s decision with regard to choices on anaesthesia and analgesia.
These discussions should occur well in advance of planned surgery to allow reflection and informed decision-making. All such discussions should be documented, although it is still necessary to give relevant explanations at the time of the procedure.
Options for anaesthesia and all aspects of perioperative care, including risks and benefits, should be discussed with the patient by the responsible anaesthetist.
Areas for future development
Following the systematic review of the evidence, the following areas are recommended for further research:
- comprehensive geriatric assessment for vascular procedures
- implementation of prehabilitation programmes.
Clinical Lead – SAS doctors undertaking lead roles should be autonomously practising doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role, and they should participate in quality improvement and CPD activities. Individuals should be fully supported by their clinical director and be provided with adequate time and resources to allow them to effectively undertake the lead role.
Immediately – unless otherwise defined, ‘immediately’ means within five minutes.
Vascular anaesthetist – an anaesthetist with regular sessional committment to major arterial surgery who has developed expertise in preoperative cardiovascular risk assessment, has specific knowledge of the principles underlying the main index vascular procedures, and who maintains regular CPD in the field of vascular anaesthesia.