Chapter 19: Guidelines on the Provision of Anaesthesia Services for Thoracic Procedures 2024
Introduction
Thoracic anaesthesia services are provided for patients undergoing thoracic procedures. To reflect current practice, these guidelines have been more clearly divided to identify areas of differing requirement.
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. Robotic thoracic surgery is increasingly available for lung resection. 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 or major tracheobronchial surgery may sometimes require the use of extracorporeal techniques such as 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
1.1
Availability of two consultant anaesthetists, or a consultant and senior trainee or SAS doctor should be considered for more complex procedures, such as lung resection requiring ECMO1
1.2
Continuity of care should be a priority in prolonged procedures 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.2
1.3
The complexity of some procedures neccessitates anaesthetic involvement in multidisciplinary team meetings and this activity should be reflected in job plans.
1.4
Consultant or autonomously practising anaesthetists in 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.
1.5
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.
1.6
An appropriately trained consultant or autonomously practising anaesthetist should be available at all times, through a formal thoracic or cardiothoracic anaesthetic on-call rota, particularly if lung transplantation is performed.
1.7
Wherever thoracic anaesthesia and surgery are performed there should be a resident anaesthetist available at all times.
1.8
When thoracic surgery is performed with the aid extracorporeal life support (ECLS), a trained perfusion scientist must be present in the operating room until ECLS is terminated with arrangements for their return in an emergency.
2. Equipment, services and facilities
Equipment and monitoring
2.1
The same level of equipment should be available for thoracic surgery as is available in general theatres as specified in chapter 3. Additional specialty specific monitoring is required and is detailed below.3
2.2
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.4 Quantitative neuromuscular monitoring is beneficial during Robotic assisted thoracic surgery (RATS) to avoid inadvertent patient movement and injury.
2.3
Specific equipment for securing the patient in lateral decubitus position should be available. This may include a shoulder roll, head ring, Carter Brayne arm support, arm boards and table supports for the front and back of the patient. Straps or elastic tape should also be available where used routinely.
2.4
Pillows or similar padding should be available and used to ensure pressure and stress areas are adequately padded.
2.5
Commonly used forced air warmers, patient under blankets, fluid warmers, foil hats and temperature monitoring should be available.
2.6
The patient table should be capable of movements to support the appropriate positioning of the patient for thoracic surgery.
2.7
Flowtron boots or equivalent should be available to support the peripheral circulation of patients under anaesthesia in extreme positions.
2.8
Flexible fibreoptic bronchoscopy should be immediately available for all patients where lung isolation is used.5
2.9
2.10
Specific bougies designed for use with double-lumen tracheal tubes or airway exchange catheters should be available.
2.11
Clamps or specialised angle pieces should be available to isolate the lung during surgery.
2.12
Continuous positive airway pressure (CPAP) circuits should be available for management of hypoxia during one lung ventilation.
2.13
Anaesthetic assistants whether nurse or operating department practitioners, should be trained in the preparation of this specialist equipment to be able to support the anaesthetist in the delivery of lung isolation and one lung ventilation.
2.14
The anaesthetic machine should have a ventilator capable of meeting the requirements for protective lung ventilation.
2.15
Dedicated equipment for jet ventilation should be available for interventional airway procedures.8 Appropriate fittings should be checked and available for connection to rigid bronchoscopes. It should include an ultrasound machine for nerve blocks.
2.16
A variety of nerve blocking needles and catheters and appropriate infusion or elastomeric pumps for delivery of local anaesthetic should be available. Protocols should be in place for the delivery and monitoring of these infusions.
2.17
A fluid warmer allowing the transfusion of warmed blood products and intravenous fluids should be available.
2.18
A rapid infusion device should be readily available and considered for the management of major haemorrhage.9
2.19
A cell salvage service should be available for patients 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.
2.20
Ultrasound should be available for the placement of vascular catheters and should be available for regional anaesthesia techniques.
2.21
During the transfer of the patient at the end of surgery to the postoperative care unit there should be access to electrocardiogram (ECG), blood pressure monitoring, pulse oximetry, disconnection alarm for any mechanical ventilation system, fractional inspired oxygen concentration, and end-tidal carbon dioxide.4 The vast majority of thoracic patients are extubated on the operating table. Some do not have/require arterial monitoring or inspired oxygen concentration. The monitoring should be appropriate for the procedure, the patient and the distance/time to reach the postoperative unit.
Facilities
2.22
Designated thoracic, or cardiothoracic wards should be considered.
2.23
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 situations should be in place.
2.24
RATS should be delivered in a theatre with adequate capacity to allow comfortable movement of staff around the patient and robot, to safely accommodate all of the additional equipment including robot, operating console and monitoring stack, and to allow sufficient space for rapid removal of the robot in an emergency to facilitate resuscitation.
2.25
After major thoracic surgery, patients should be transferred to an appropriately sized, equipped and staffed post-anaesthetic recovery area. Planned or emergency access to intensive or high-dependency care should be available.11
2.26
Non-invasive ventilation facilities should be available in the immediate postoperative period, for example bilevel positive airway pressure (BiPAP), CPAP and high-flow nasal oxygen therapy (HFNO). HFNO should be available in theatres for induction and support of anaesthesia as required.12
2.27
2.28
Preoperative assessment clinics should be established to optimise patient preparation for surgery and reduce same day cancellations. Smoking cessation support should be available to all thoracic patients.
Support services
2.29
Thoracic surgery should be supported by a specialist pain service. Pain relief protocols should be clearly defined for thoracic surgery patients.15
2.30
Physiotherapy services should be available during the preoperative preparation and postoperative care of patients undergoing thoracic surgery. to discuss anaesthetic risk/consent in pre-assessment clinic rather than on the day of admission/surgery.
2.31
Access to measurements of cardiorespiratory function should be available for patients undergoing thoracic surgery, including a facility for cardiopulmonary exercise testing and access to echocardiography.
2.32
There should be immediate access to expert radiology advice, x-ray facilities and computerised axial tomography services for patients undergoing thoracic surgery.
2.33
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.16
2.34
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.17
2.35
Immediate access to expert haematology advice, haematology laboratory services and blood products should be available.
3. Areas of special requirement
Children
3.1
Children undergoing thoracic procedures have special requirements and the responsibility for their care should ideally lie with a dedicated paediatric anaesthetist, particularly a cardiothoracic or thoracic paediatric anaesthetist.18 Surgery should only be performed in a specialist tertiary paediatric centre.
3.2
Paediatric thoracic 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 critical care, including adequate arrangements for retrieval and transfer of patients.19,20
Transplant patients
This includes patients undergoing heart or lung transplantation, and patients who have previously received a transplant who require further thoracic surgery.
3.4
Consultants or autonomously practising anaesthetists providing anaesthesia for lung transplantation should have appropriate training and substantial experience of advanced cardiorespiratory monitoring and support.
3.5
Thoracic anaesthetists working in non-transplant centres should be familiar with the principles of the anaesthetic management of patients who have previously undergone lung transplantation.26
3.6
3.7
Facilities should be available for the storage, administration and routine monitoring of immunosuppressive medication.
3.8
Access to specialist support services such as diabetic medicine and dietetics for patients with cystic fibrosis should be available.
Pregnant patients
Patients requiring thoracic surgery during pregnancy will typically be undergoing an urgent or emergency intervention. Indications include chest trauma.
3.9
Thoracic anaesthetists should be familiar with the normal physiological effects of pregnancy and the general principles of obstetric anaesthesia.
3.10
Where thoracic surgery is scheduled to occur immediately after Caesarean section, there should be early involvement of obstetricians, specialist obstetric anaesthetists, neonatal paediatricians and midwifery services.
3.11
Equipment, services and facilities should be equivalent to those found in an obstetric unit.28
3.12
Whenever possible, escalation in care should ideally not lead to the separation of mother and baby.
Chronic thromboembolic pulmonary hypertension
3.13
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
3.14
The use of extracorporeal membrane oxygenation (ECMO) for the management of adults with severe respiratory failure is centralised in a number of specialist cardiothoracic centres. Anaesthetists often institute ECMO and support retrieval of patients from non-specialist hospitals. Anaesthetists providing ECMO should be suitably trained.29
3.15
ECMO support may be used to provide procedural support for selected thoracic surgical procedures such as central airway surgery or severe broncho-pulmonary fistulae – such provision requires specialist care and should be centralised to appropriate centres.
Preassessment
3.16
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.30 Anaesthetists should be part of the preadmission clinical pathway, including implementing interventions to promote enhanced recovery, this activity should be reflected in job plans.3,31,32,33
3.17
Patients listed for thoracic surgery should have timely access to pre-operative investigations such as lung function and echocardiography, particularly for tumour resection surgery.
4. Training and education
4.1
Thoracic anaesthesia is a ‘key unit of training’ in both the 2010 intermediate level training in anaesthesia34 and in the newer 2021 Curriculum Stage 2.35of training. Trainee anaesthetists should be of appropriate seniority to be able to benefit from this area of training. Stage 3 training of the 2021 Curriculum also requires trainees to be proficient in inserting double-lumen airways and bronchial blockers which may require further thoracic surgery experience to complete.36
4.2
All trainees should be appropriately clinically supervised at all times.37
4.3
Trainees should have an appropriate balance between thoracic anaesthesia and ICU training based on their individual requirements.38
4.4
Consultant or autonomously practising anaesthetists intending to deliver anaesthesia for thoracic surgery should have received training to a higher level in thoracic anaesthesia. This should be undertaken as a Special Interest Area in Stage 3 training for a period of 3 - 6 months in a recognised training centre.36 Those providing critical care for cardiothoracic surgical patients should have received training as described by the Faculty of Intensive Care Medicine(see Cardiothoracic Critical Care, section 1.6 Guidelines for the Provision of Intensive Care Services).39
4.5
Consultant or autonomously practising anaesthetists intending to follow a career in paediatric thoracic or 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.
4.6
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.
4.7
Fellowship posts should be identified to allow additional training for those who wish to follow a career in 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. Such posts should provide similar or enhanced levels of teaching, training and access to study leave as for regular training posts.
4.8
Departments should consider providing all newly appointed consultants or autonomously practising anaesthetists, particularly those with limited experience, with a mentor to facilitate their development in thoracic anaesthesia.
5. Organisation and administration
5.1
Anaesthetic involvement in the leadership of thoracic units should be considered.
5.2
There should be a forum for discussion of matters relevant to both surgeons and anaesthetists, for example protocol development and critical incidents.
5.3
Clinical protocols should be developed from national guidelines and reviewed on a regular basis.
5.4
5.5
Hospitals should have systems in place to facilitate multidisciplinary meetings for thoracic services.
5.6
All handovers should contain representatives for the multidisciplinary teams from both theatre and the receiving area and should be documented and structured to ensure continuity of care.41
5.7
The theatre team should all engage in the use of the World Health Organization surgical safety process42 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.
5.8
5.9
There should be sufficient numbers of clinical programmed activities in clinicians’ job plans to provide cover for all elective thoracic operating lists and to provide adequate emergency cover.45
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.
6.1
Service developments outside the operating theatre often place unintended demands on anaesthetists. The business plans for such services should include provision for anaesthetic services.
7. Research, audit and quality improvement
7.1
Most research in thoracic anaesthesia will be undertaken in specialist cardiothoracic units and should be given high priority.
7.2
Regular clinical audit of the work of thoracic anaesthesia services is essential. This might also include submission of data to national audits, such as the ACTACC national audit project, which includes thoracic anaesthesia topics. Information technology support should be available for such activities.46,47
7.3
All thoracic units should have regular morbidity and mortality meetings. These meetings should be provided with a list of patients to discuss in advance, an attendance register, and minutes with learning points. Consultants or autonomously practising anaesthetists should attend these meetings and they should be included in job plans. Trainees should be encouraged to attend during their attachments.
7.4
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.
7.5
Units with preassessment clinics should attempt to take part in research looking at preoptimisation and prehabilitation.
8. Implementation support
The 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
The Royal College of Anaesthetists has developed a range of Trusted Information Creator Kitemark accredited patient information resources that can be accessed from the RCoA website. Our main leaflets are now translated into more than 20 languages, including Welsh.
To be able 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 2.3 Specific considerations for thoracic surgery are outlined below:
9.1
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 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.3,48,49,50,51,52
Areas for future development
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.53
Video-assisted thorascopic surgery 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 ventilation54 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.55,56,57
Glossary
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 continuing professional development 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.