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Portfolio of the specialist vascular anaesthetist

The Essential Components of the Work of a Specialist Anaesthetising Patients Undergoing Vascular Surgery

The specialist in vascular anaesthesia will have all the core generic knowledge and competencies of the generalist in anaesthesia.

The special skills and knowledge required of an anaesthetist that cares for vascular surgical patients overlap with those in other areas of sub-specialisation and so do not constitute unique abilities. Also, we recognise that there are differences in the overall competences required of vascular anaesthetists depending on frequency and magnitude of vascular involvement, and the nature of surgery undertaken in the practitioners institution. For example, the anaesthetist that only encounters infra-renal aortic surgery would not be expected to be familiar or competent to manage extra-corporeal circulation.

The aspects of perioperative care that specialists in vascular anaesthesia should demonstrate particular ability are:

1. The preoperative assessment of patients with ischaemic heart disease undergoing vascular anaesthesia.

  • Risk of surgical disease if not operated upon.
  • Specific risks associated with the type of surgery proposed
  • The prognostic significance of pre-existing morbidity (with and without surgery).

The anaesthetist should have a working knowledge of clinical cardiac risk indices (e.g. Goldman, Detsky, and Eagle) and their application to the vascular surgical patient. There must be an awareness of the importance of other concomitant disease (renal/respiratory/endocrine).

The specialist should have a working knowledge of the value of specific tests of cardiac function (e.g. echocardiography, dipyridamole thallium scanning, exercise ECG, dobutamine stress echocardiography, MUGA scanning). The specialist should be aware of the possible rôle of pre-operative angiography and the possible benefits of coronary artery bypass grafting in appropriate patients.

Vascular anaesthetists should understand specific surgical risk factors for each different type of vascular surgery (e.g. carotid endarterectomy, aortic aneurysm surgery and peripheral vascular surgery).

 

2. Preoperative Optimisation

Vascular Anaesthetists should be aware of the need for, and methods available for, improving the patients peri-operative risk in the preoperative period. In particular they should be up to date on the debate surrounding specific treatments aimed at optimising the patient preoperatively. For example, coronary angio­graphy/coronary artery by-pass grafting, the possible role of beta blockade in reducing post operative myocardial ischaemia, or the role of ACE inhibitors in improving survival in patients with left ventricular dysfunction.

 

3. Perioperative Management

The underlying principles are exactly the same whether anaesthetising vascular or non-vascular patients. However, there are some areas of perioperative management with which it is essential that anaesthetists undergoing vascular work are familiar. These include:

  • Invasive cardiovascular monitoring.
  • ECG monitoring for myocardial ischaemia e.g. CM5 etc.
  • Methods of intraoperative renal protection.
  • The role of epidural anaesthesia and analgesia.
  • The rational use of drugs to manipulate the cardiovascular system.
  • The effects of major blood transfusion and its management, including the principles and practice of acute normovolaemic haemodilution and intraoperative cell salvage.
  • Maintenance of body temperature.

 

4. Management of specific Vascular Operations

The specialist anaesthetists should be familiar with the principles underlying the management of carotid endarterectomy, aortic surgery and peripheral vascular surgery.

Carotid endarterectomy

1. The principles behind assessment and preservation of cerebral perfusion.
2. Knowledge of the advantages and disadvantages of local anaesthetic techniques.

Aortic Surgery

1. The management of aortic cross clamping and un-cross clamping.
2. The principles behind renal protection.

Peripheral Vascular Surgery

1. An awareness of the debate regarding regional verses general anaesthesia and its role in post operative graft patency.

 

5. Postoperative Management

Patients following vascular surgery have an increased requirement for the use of Intensive Care and High Dependency facilities in the post operative period. It is therefore an essential component of specialists undertaking vascular anaesthesia that they are acquainted with the appropriate use of these facilities in their patients. In particular the anaesthetists should be aware of methods available to continue intraoperative management into the postoperative period (for example appropriate fluid management, use of oxygen therapy, use of cardiovascular active drugs and the appropriate use of postoperative ventilation in specific cases).

 

6. Specific Skills

The Committee recognises that there are certain areas within vascular anaesthesia which require specific areas of expertise and experience (for example thoraco abdominal aneurysm surgery and aortic stent surgery) we do not believe that it is incumbent upon us to make any specific recommendations for experience in these areas.

 

7. The Management of Emergency Vascular Surgery

The Committee feels that this is an important area because it is in the emergency environment that patients are exposed to the greatest risk of mortality and serious morbidity because of the combination of advanced pre-existing cardiac morbidity, the inability to stabilise or optimise patient status, and major, often prolonged, hazardous surgery.

We recognise that much of this work is obliged to be undertaken by anaesthetists who are not specialists in vascular anaesthesia. We strongly support all anaesthetists involved with emergency vascular surgery and feel that the general principles behind the management of these cases are such that it is entirely appropriate them to be handled by Consultant Anaesthetists who do not have specific vascular anaesthetic lists. There is an important rôle for the Vascular Anaesthesia Society of Great Britain and Ireland in providing Continuing Medical Education to assist non-specialist anaesthetists in the performance of this occasional but challenging area of practice.