Chapter 18: Guidelines for the Provision of Anaesthesia Services for Cardiac and Thoracic Procedures 2019
Cardiothoracic anaesthesia services are provided for patients undergoing cardiac and thoracic procedures. To reflect current practice, these guidelines have been more clearly divided to identify areas of differing requirement. Anaesthetists in cardiac surgical services are now more frequently required to provide anaesthesia for invasive cardiology procedures.
Cardiac surgery may involve adult, paediatric and neonatal patients and includes many forms of open and closed heart surgery, both elective and emergency. Some complex procedures are increasingly performed in hybrid operating rooms, where operating theatres have enhanced radiological imaging facilities. Cardiac surgery may also include heart or heart and lung transplantation, and the implantation of ventricular assist devices to support patients with advanced heart failure.
There are a number of different unit models for delivery of cardiac surgery: large standalone tertiary centres with supraregional services, units in large multispecialty university centres and smaller units in a large general hospital setting. The degree of specialisation of the anaesthetists and their job plans are likely to reflect this setting.
Cardiac anaesthetists should be integrated into the multidisciplinary nature of each cardiac unit and take an active part in shaping services and analysing quality. Cardiac anaesthetists frequently have critical care cover in their job plans, which may assist integration of services. Patient mortality audit data is currently in the public domain for each unit and each surgeon and anaesthetist should have an understanding of how their own role contributes to patient outcomes.1
The nature of cardiac surgery demands that all patients should be cared for postoperatively in a unit that conforms to the standards of Level 2 or 3 critical care facilities. Patients may frequently have complications and require rapid escalation of the level of care. Anaesthesia and critical care services should work together to ensure that these services are flexible and responsive to the needs of the patients.
Cardiac anaesthesia provides an important area of training for trainee anaesthetists. It offers training in the perioperative care of patients with severe heart and lung disease that is essential for all anaesthetists, whatever their future area of practice.
Thoracic surgery may include surgery on the lungs (including lung transplantation), pleura, thymus, oesophagus and other thoracic structures, as well as the chest wall. Less invasive video assisted surgery is now mainstream practice for most types of surgery, but particularly for those patients with effusions, pneumothoraces and tumours. Surgery for patients who have sustained trauma to the thorax is becoming more common and may be integrated into major trauma centres. Interventional large airway services are frequently provided alongside thoracic surgery. Tracheobronchial surgery for congenital abnormalities of the large airways in children is a supraregional service.
Anaesthesia for lung transplantation may sometimes require the use of cardiopulmonary bypass. There is an expanding use of extracorporeal membrane oxygenation for acute lung injury that may involve anaesthetists in defined centres.
1. Staffing requirements
Availability of two consultant anaesthetists, or a consultant and senior trainee or SAS doctor should be considered for more complex procedures, such as thoracoabdominal aortic aneurysm repair.2
Continuity of care should be a priority in prolonged cases and when this is not possible, a formal documented process with some overlap should be in place for handover of clinical care from one anaesthetist to another.3
The complexity of some cases may necessitate anaesthetic involvement in multidisciplinary team meetings and this activity should be reflected in job plans.
Consultant anaesthetists in cardiac and thoracic units should be responsible for the provision of service, teaching, protocol development, management, research and quality improvement. Adequate time should be allocated in job plans for these activities.
Each unit should have a designated clinical lead (see glossary) anaesthetist who is responsible for cardiac anaesthesia services. This should be recognised in their job plan and they should be involved in multidisciplinary service planning and governance within the unit.
An appropriately trained consultant cardiac anaesthetist should be available at all times, through a formal on-call rota.4
Trained staff and appropriate facilities should be immediately available for emergency resternotomy and bypass. A suitably trained resident anaesthetist should be immediately available for emergencies.5
Appropriate local arrangements should be made for the care of postoperative surgical patients being managed outside the main cardiothoracic intensive care unit (ICU), for example postoperative recovery areas and wards.6
Interventional cardiology services increasingly require anaesthesia, critical care and nursing resources depending on procedural complexity and patient morbidity. General anaesthesia may be needed to facilitate complex interventions or required in an emergency for invasive cardiological procedures. Both eventualities require that appropriate anaesthetic staffing, skilled assistance, equipment and monitoring should be available.2
At centres where 24/7 primary percutaneous coronary interventions are performed, and in designated heart attack centres, which include out of hospital cardiac arrest patients, there should be provision for immediate availability of a resident anaesthetist, skilled assistance and appropriate equipment and facilities.
Each unit should have a designated clinical lead (see glossary) anaesthetist for thoracic anaesthetic services. This should be recognised in their job plan and they should be involved in multidisciplinary service planning and governance within the unit.
An appropriately trained consultant anaesthetist should be available at all times, through a formal thoracic or cardiothoracic anaesthetic on-call rota, particularly if lung transplantation is performed.
Wherever thoracic anaesthesia and surgery are performed there should be a resident anaesthetist available at all times.
2. Equipment, services and facilities
Equipment and monitoring
The standard of monitoring in the operating theatre should allow the conduct of safe anaesthesia for surgery as detailed by the Association of Anaesthetists standards of monitoring.10
During the transfer of the patient at the end of surgery to the postoperative care unit there should be access to electrocardiogram (ECG), invasive blood pressure monitoring, pulse oximetry, disconnection alarm for any mechanical ventilation system, fractional inspired oxygen concentration, and end-tidal carbon dioxide.10
Physiological monitoring alarm settings should be appropriate for the specific procedure.13
A fluid warmer allowing the transfusion of warmed blood products and intravenous fluids should be available.14
Availability of a rapid infusion device should be considered for the management of major haemorrhage.14
A cell salvage service should be available for cases where massive blood loss is anticipated and for patients who decline blood products. Staff who operate this equipment should receive training and use it frequently to maintain their skills.
Ultrasound should be available for the placement of vascular catheters.15
Transoesophageal echocardiography should be immediately available.
Complex cases may require additional monitoring, such as pulmonary arterial pressure monitoring, measurement of cardiac output and cerebral near-infrared spectroscopy.
Monitoring during cardiopulmonary bypass should conform to the standards recommended by the joint working group of the Society of Clinical Perfusion Scientists of Great Britain and Ireland, Association for Cardiothoracic Anaesthesia and Critical Care (ACTACC), and Society for Cardiothoracic Surgery in Great Britain and Ireland.7
An intraaortic counter pulsation balloon pump should be available.19
Equipment for temporary pacing should be available.
Designated thoracic, cardiac or cardiothoracic wards should be considered.
Cardiac and thoracic surgery should ideally be performed in dedicated operating rooms. It is unlikely that an operating room will be kept available at all times for emergencies. Local arrangements for urgent and emergency cases should be in place.
In some centres, selected cardiac surgical patients are managed in facilities other than designated ICUs following surgery. These are variously referred to as the high dependency unit (HDU), cardiac recovery or cardiac fast-track unit. These areas aim to minimise the period of mechanical ventilation. The equipment, monitoring and staffing requirements for such a facility are no less than the requirements of patients cared for in Level 3 ICU. Agreed clinical criteria for the appropriate case mix should be in place. Suitably experienced anaesthetic and surgical staff should be immediately available. Arrangements should be in place for escalation to a Level 3 ICU facility as required.6
Facilities should be available for the decontamination and safe storage of transoesophageal echocardiography probes in line with local and national recommendations.24,25,26 There should also be a method to report, archive and retrieve all echocardiography studies performed in cardiac theatres.
After major thoracic surgery, patients should be transferred to an appropriately sized, equipped and staffed post-anaesthetic recovery area. Planned or emergency access to ICU or HDU should be available.27
Non-invasive ventilation facilities should be available in the immediate postoperative period, for example bilevel positive airway pressure (BiPAP), continuous positive airway pressure (CPAP) and high-flow nasal oxygen therapy (HFNO).26
Thoracic surgery units should consider developing an enhanced recovery after surgery (ERAS) programme.29
Where possible, point of care or near-patient testing should be used for blood gas analysis, measurement of electrolytes and blood sugar, haemoglobin and coagulation. This might include platelet mapping, thromboelastography or thromboelastometry.30
Immediate access to expert haematology advice, haematology laboratory services and blood products should be available.
There should be immediate access to expert radiology advice, x-ray facilities and computerised axial tomography services for patients undergoing cardiac or thoracic surgery.
Access to measurements of respiratory function should be available for patients undergoing cardiac or thoracic surgery, including a facility for cardiopulmonary exercise testing.
Physiotherapy services should be available during the preoperative preparation and postoperative care of patients undergoing cardiac or thoracic surgery.
All anaesthetic equipment should be checked before use in accordance with the Association of Anaesthetists published guidelines. Anaesthetic machine checks should be recorded in a log and on the anaesthetic chart.31
Pain relief protocols should be clearly defined for thoracic and cardiac surgery patients.32
For cardiac patients, dedicated echocardiography equipment, including transoesophageal echo should be immediately available in the operating suite and postoperative care areas. Those who deliver intraoperative echocardiography services should be trained to the level of competence defined by specialist bodies.33,34,35
There should be access to a range of specialist cardiology services.
24/7 access to cardiac electrophysiology services should be available.
3. Areas of special requirement
Children undergoing cardiac and thoracic procedures have special requirements and the responsibility for paediatric anaesthetic care may be shared with paediatric anaesthetists.37
Paediatric cardiac surgical patients should be cared for in a unit designed and equipped to care for paediatric patients and staffed by appropriately trained nurses. Such a unit should meet the standards defined for paediatric intensive care, including adequate arrangements for retrieval and transfer of patients.38,39
Adult congenital heart disease patients
This group comprises adult patients who have had cardiac disease diagnosed in childhood; those who present with a new primary diagnosis of congenital heart disease; and patients requiring heart surgery for the failures or complications arising from the prior interventional management of congenital cardiac lesions.45
Children currently transition to adult congenital heart disease services at the age of 16–18 years, although transition services are integrated into the care pathway from age 12 years. Anaesthetists should be aware of legislation and good practice guidance relevant to young and vulnerable adults.40,46
Specialist anaesthetists should be involved in the discussion of referrals and planning when this is conducted in the setting of a multidisciplinary team. This should be recognised in job plans.
This includes patients undergoing heart or lung transplantation, and patients who have previously had a transplant who require further cardiothoracic surgery.
Consultants providing anaesthesia for heart or lung transplantation should have appropriate training and substantial experience of advanced cardiovascular monitoring and support.
Cardiothoracic anaesthetists working in non-transplant centres should be familiar with the principles of the anaesthetic management of patients who have previously undergone heart or lung transplantation.47
Facilities should be available for the storage, administration and routine monitoring of immunosuppressive medication.
Patients requiring cardiac or thoracic surgery during pregnancy will typically be undergoing urgent or emergency intervention. Indications include chest trauma, acute coronary ischaemia, aortic or coronary dissection, decompensated valvular disease and acute cardiomyopathy.
Cardiothoracic anaesthetists should be familiar with the normal physiological effects of pregnancy and the general principles of obstetric anaesthesia.
Where cardiothoracic surgery is scheduled to take place immediately after Caesarean section, there should be early involvement of obstetricians, specialist obstetric anaesthetists, neonatal paediatricians and midwifery services.
Equipment, services and facilities should be equivalent to those found in an obstetric unit.48
Whenever possible, escalation in care should ideally not lead to the separation of mother and baby.
A multidisciplinary team should agree and document plans for the peripartum management of patients with known congenital or acquired cardiac disease in advance. Staff and facilities should be available for monitored or operative delivery, and for managing acute decompensation.
Chronic thromboembolic pulmonary hypertension patients
A subgroup of patients with chronic thromboembolic pulmonary hypertension (CTEPH) will benefit from surgery and should be managed in designated national centres. Currently only one UK centre provides specialist surgical intervention for patients with CTEPH.
Extracorporeal membrane oxygenation
The use of extracorporeal membrane oxygenation (ECMO) for the management of adults with severe respiratory failure is currently confined to five UK cardiothoracic centres. Anaesthetists often institute ECMO and support retrieval of patients from non-specialist hospitals. Anaesthetists providing ECMO should be suitably trained.49
Cardiac catheter laboratories
Anaesthetists are requested to provide services for an increasing number of structural, electrophysiological and interventional cardiology procedures, including emergency procedures. The same conditions and requirements apply as for the radiology department outlined in chapter 7,50 with some additional conditions:
Anaesthetists should be aware of the risks of exposure to ionizing radiation in cardiac catheterisation laboratories and ensure they use protective garments and screens and wear exposure monitoring devices if requested to do so.51
The use of dedicated anaesthetic monitoring equipment, in addition to any monitoring used by cardiologists, is recommended. A remote or slave anaesthetic monitor display should be available to cardiologists.
Cardiac patients are often at high risk of cardiac arrest. Sufficient space and facilities should be available for managing this eventuality.
Cardiovascular instability may, on occasion, necessitate the use of extracorporeal support. Catheter laboratories should have sufficient space, medical gas outlets, electrical sockets, network sockets, and other essential facilities to meet this demand.
Where revision of rhythm management devices is considered to be at high risk of needing emergency surgical intervention, cardiopulmonary bypass equipment and a plan for surgery should be available at the start of the procedure.
In recent years there has been a trend towards assessment of elective patients in preadmission clinics, typically one to two weeks before surgery. This allows routine paperwork and investigations to be completed before admission, permits ‘same day’ admission and reduces the likelihood of delays or cancellation.52 Anaesthetists should be part of the preadmission clinical pathway which might include prehabilitation measures and this activity should be reflected in job plans. 53,62
4. Training and education
Cardiac and thoracic anaesthesia is a ‘key unit of training’ for intermediate-level training in anaesthesia.54 Trainee anaesthetists should be of appropriate seniority to be able to benefit from this area of training, at least specialist trainee year 3.
All trainees should be appropriately clinically supervised at all times.55
Trainees should have an appropriate balance between thoracic, cardiac and ICU training based on their individual requirements.56
Trainees planning to embark in a career in cardiac anaesthesia should be encouraged to undertake training and accreditation in transoesophageal echocardiography.34
Consultant anaesthetists intending to undertake anaesthesia for cardiac or thoracic surgery should have received training to a higher level in cardiac and/or thoracic anaesthesia, for a minimum of one year in recognised training centres, as part of general training.53 Those providing intensive care for cardiac surgical patients should have received training to the minimum level as defined by the Faculty of Intensive Care Medicine special skills year in cardiothoracic intensive care.6
Consultant anaesthetists intending to follow a career of paediatric cardiothoracic anaesthesia should have higher training in general paediatric anaesthesia of at least one year followed by a specialist training period of an appropriate duration in the subspeciality.
All staff should have access to adequate time, funding and facilities to undertake and update training that is relevant to their clinical practice, including annual mandatory training such as basic life support.
Fellowship posts should be identified to allow additional training for those who wish to follow a career in cardiac or thoracic anaesthesia to help ensure there are adequate numbers of skilled anaesthetists in the specialty. These should be suitable for trainees who wish to take time out of training programmes, or for those who are post certificate of completion of training (CCT). Such posts should provide similar or enhanced levels of teaching, training and access to study leave as for regular training posts.
Departments should consider providing all newly appointed consultants, particularly those with limited experience, with a mentor to facilitate their development in cardiac or thoracic anaesthesia.
5. Organisation and administration
Anaesthetic involvement in the leadership of cardiothoracic units should be considered.
There should be a forum for discussion of matters relevant to both surgeons and anaesthetists, for example protocol development and critical incidents.
Clinical protocols should be developed from national guidelines and reviewed on a regular basis.
Hospitals should have systems in place to facilitate multidisciplinary meetings for both cardiac and thoracic services.
The theatre team should all engage in the use of the World Health Organization (WHO) surgical safety process,57 commencing with a team brief, and concluding the list with a team debrief. The debrief should highlight things done well and also identify areas requiring improvement. Teams should consider including the declaration of emergency call procedures specific to the location as part of the team brief.
Hospitals should review their local standards to ensure that they are harmonised with the relevant national safety standards, e.g. National Safety Standards for Invasive Procedures in England (NatSSIPs) or the Scottish Patient Safety Programme in Scotland.58,59 Organisational leaders are ultimately responsible for implementing local safety standards as necessary.
There should be sufficient numbers of clinical programmed activities in consultants’ job plans to provide cover for all elective cardiac and thoracic operating lists and to provide adequate emergency cover.60
Perfusion services should be included in a clinical directorate or equivalent, under the managerial control of a consultant, who may be a consultant anaesthetist.
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, but they are 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.
Service developments outside the operating theatre, e.g. interventional cardiology, often place unintended demands on anaesthetists. The business plans for such services should include provision for anaesthetic services.
7. Research, audit and quality improvement
Most research in cardiac and thoracic anaesthesia will be undertaken in specialist cardiothoracic units and should be given high priority.
Regular clinical audit of the work of cardiac and thoracic anaesthesia services is essential. This might also include submission of data to national audits, such as the ACTACC national audit project which includes both cardiac and thoracic anaesthesia topics. Information technology (IT) support should be available for such activities.1,61
Centres should consider contributing to multidisciplinary national benchmarking audits such as the National Cardiac Benchmarking Collaborative (NCBC).62
All cardiac and thoracic units should have regular morbidity and mortality meetings. These should have a list of patients to discuss in advance, an attendance register, and minutes with learning points. Consultant anaesthetists should attend these meetings and where possible inclusion in job plans should be considered. Trainees should be encouraged to attend during their attachments.
Robust procedures should be in place to report and investigate adverse incidents involving equipment, staff or patients. The published outcomes of these investigations should be disseminated to all relevant anaesthetists and others.
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.
9. Patient information
In order to give valid informed consent, patients need to understand the nature and purpose of the procedure. Full guidance, including on providing information to vulnerable patients, can be found in chapter 2.62 Specific considerations for cardiac and thoracic surgery are outlined below:
Booklets providing information for patients about their stay in hospital should be available for all patients. This will include the patient information booklets published by the British Heart Foundation on cardiac disease, prevention, treatment and lifestyle modification, and those by the British Thoracic Society on lung disease and the Roy Castle Lung Cancer Foundation for information about lung cancer and its surgical treatment. Sources of information about the anaesthetic should also be available.63,64,65,66,67
Information about cardiac rehabilitation generally, and information regarding the availability of such courses locally, should also be available.
Information on specific individual risks of invasive monitoring, e.g. risk of injury due to arterial and central venous lines, should be available to patients.
All cardiothoracic units should provide patient information about preoperative smoking cessation, including how to access local services to support patients wishing to quit before their operation.
Areas for future development
There is an increasing use of mechanical circulatory support in cardiac anaesthesia, cardiac critical care and cardiology services within the NHS. As experience and the evidence base of this grows, more marginal indications for mechanical support will emerge. Post-cardiotomy support following transplantation and pulmonary endarterectomy is established, while venoarterial ECMO (VA-ECMO) following cardiac surgery generally has poor outcomes.68 Where services require percutaneous support, e.g. ECMO in cardiology, business cases should include provision of senior anaesthetic and intensive care support.
Risk of stroke increases with patient age and surgical complexity. Access to acute stoke services is, most often, only required following embolic stroke. Under these circumstances patients should have access to the same rehabilitation facilities as other stroke patients.
There is an expansion of minimally invasive and percutaneous procedures, eg balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension deemed unsuitable for surgery. Evidence of symptomatic and prognostic benefit is awaited.
Service provision for cardiac surgery in children and adults with congenital heart disease is currently under review, with a proposed model of care and draft designation standards.38
Robot assisted thoracic surgery (RATS) is currently undertaken in a small number of UK centres and may provide better surgical outcomes due to improved surgical dexterity and stereoscopic high definition operating conditions. There is currently a paucity of literature supporting improved clinical outcomes or cost effectiveness of RATS and the technique presents unique challenges for anaesthesia.69
Video assisted thoracic surgery (VATS) with regional anaesthesia or spontaneously breathing general anaesthesia is described in the literature and currently being performed by a small number of units in the UK. There are theoretical advantages of avoiding general anaesthesia, lung isolation and positive pressure ventilation70 and many procedures can be performed without these interventions by a suitably trained team with good patient selection. Evidence of the putative benefits of using these strategies is emerging.71,72,73
Clinical lead – SAS doctors undertaking lead roles should be autonomously practicing 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.