Download Training in Cardiothoracic Anaesthesia and Critical Care

Training in Cardiothoracic Anaesthesia and Critical Care
Dr Chris Rigg Jan 2010
Background
Cardiothoracic Anaesthesia has been regarded by many as a sub-specialty of
anaesthesia for many years. However, to date, no organisation has set out to identify
what the basic requirements should be to fulfil a training in cardiothoracic
anaesthesia. Rather institutions have sought to define their own requirements for
consultant posts.
In recent years other subspecialties have sought to define their training requirements.
Intensive Care Medicine has developed as a specialty under the auspices of the
Intrecollegiate Board for Training in Intensive Care Medicine. This has led to the
development of Basic Specialist training, Intermediary training and Advanced training
in Intensive Care medicine. Doctors are now able to obtain dual accreditation in
Anaesthesia and Intensive Care Medicine within the framework of a seven year
training scheme (e.g. linked with a parent specialty such as Anaesthesia).
Chronic Pain has also developed a one year higher specialist pain training syllabus
which many departments are looking to deliver within the confines of a seven year
Anaesthesia training scheme.
The Royal College of Anaesthetists is supportive of trainees wishing to gain
experience in sub-specialties within Anaesthesia without setting out to define what
training would be appropriate to define a specialist. In their document ‘The CCST in
Anaesthesia’ with regard to cardiothoracic anaesthesia it recommends …
a) 1-3 months cardiothoracic anaesthesia experience pre-Fellowship in SpR years
1-2 and that
b) Up to 1 year can be taken during the final two years of training as full time
dedicated work in a single subspecialty (e.g. in this instance cardiothoracic
anaesthesia)
In North America a new sub-specialty is developing. The Society of Cardiovascular
Anaesthesiologists has sought approval from the Accreditation Council for Graduate
Medical Education (ACGME) for accreditation of cardiothoracic anaesthesiology
training as a new sub-specialty.
As module coordinator and recent college tutor for East Coast School of Anaesthesia I
am aware that trainees are seeking a more formalised approach to sub-specialty
training within the confines of a seven year CCST.
The provision of training in cardiothoracic anaesthesia clearly involves a sound
foundation in the principles and practice of anaesthesia for cardiac and thoracic
surgical procedures. However, given the involvement of consultant cardiothoracic
anaesthetists in manning cardiac intensive care units some time training in aspects of
cardiac critical care would seem relevant. Similarly as echocardiography has become
more widely used this would also be a relevant target for trainees to achieve a
standard in. Finally, as in any modern training programme provision should be made
for audit/research and the appropriate appraisal and assessment of trainees.
To conclude, I feel that now is the time to define a national standard for one year’s
training in cardiothoracic anaesthesia and critical care. This document sets out to
outline my personal ideas as to what such a year should include and it is hopefully a
starting point for discussion with consultant cardiac colleagues, ACTA, RCOA, SCTS
and ICS.
A one year training in Cardiothorcaic Anaesthesia and Critical Care.
1. Cardiac Anaesthesia
Knowledge
 Cardiac pathophysiology as it relates to ischaemic heart disease,
valvular heart disease (aortic stenosis and regurgitation, mitral stenosis
and regurgitation), cardiomyopathies, constrictive pericarditis and
cardiac tamponade
 Cardiopulmonary Bypass
 Principles underlying echocardiography
 Principles in managing adult patients with congenital heart disease and
their management during anaesthesia
 Principles involved in anaesthesia for Transplantation
Skills
 Preoperative assessment of patients with cardiac disease, including an
understanding of cardiac catheterisation, echocardiography,stress
testing and radionuclide imaging
 Anasethesia for high risk cardiac procedures, including valve surgery
 Management of cardiopulmonary bypass and its complications,
myocardial protection and weaning from bypass.
 Use of Tranoesophageal echocardiography and transthoracic
echocardiography
 Anasethesia for Catheter Lab …
ASD closure
Implantable Defibrillator
Pacemakers / Resynchronisation
therapy
Electrical mapping
 Emergency cardiac anaesthesia …
Resternotomy
Aortic Dissection
Aortic Aneurysms
Ischemic Mitral Regurgitation
Iscahemic Ventricular Septal
Defect
Trauma
 Insertion of arterial, central venous and pulmonary artery catheters and
interpretation of data
2. Thoracic Anaesthesia
Knowledge
 Pathophysiology of One Lung Ventilation
 Airway assessment
 Bronchoscopic Anatomy and Fibroptic interpretation.
Skills
 Preoperative assessment and preparation of patients for thoracic
surgeryand their suitability for that surgery and anesthsia with
particular focus on fitness for lung resection
 Principles of one lung ventilation and ventilatory management
 Insertion and accurate placement of single and double lumen
endobronchial tubes and the use of fibroptic bronchoscope to check
their placement.
 Insertion and use of Bronchial Blockers
 Insertion and management of thoracic epidurals
 Principles and management of chest drains.
 Anaesthesia for thoracic procedures including
bronchoscopy,mediastinoscopy, video assisted thoracoscopic surgery
and thoracotomy for lung resection
 Anaesthesia for miscellaneous procedures …
Oesophagoscopy
Oesophagectomy
Thymectomy
Thoracoabdominal
aneurysms
 Postopertaive management following thoracic procedures including
analgesia
 Management of chest trauma including pneumothorax and
haemothorax
3. Cardiac Critical Care
Trainee must already possess Basic Training in ICM (3 months as CT 12) and should be encouraged to obtain Intermediary training in ICM (6
months as SpR)
Knowledge and skills











Postoperative care of cardiac patients on the Intensive Care Unit
Provision of appropriate sedation and analgesia
Use of care bundles on ITU
Nutrition (Enteral and Parenteral)
Modes and selection of Ventilation.
Weaning from Ventilation.
Advanced ventilation strategies … Management of ARDS
One lung ventilation
Bronchopleural Fistulae
Management of Oliguria and Renal Failure (including Renal
Replacement therapy) in cardiac patients
Management of Hypotension on Cardiac Intensive Care – focussing on
Bleeding / Cardiac tamponade / Cardiac Failure / Sepsis Syndrome.
Knowledge and experience in using inotropic and other vasoactive
drugs.
Management of Left Ventricular Failure, Pulmonary Hypertension and
Right Ventricular Failure





Management of Sepsis (Surviving Sepsis Campaign)
Knowledge of indications and use of IABP and VADs.
Knowledge and use of Pulmonary Artery floatation catheters.
Knowledge and use of Pacemakers.
Recognition and management of haematological, neurological and
gastrointestinal complications in postoperative cardiac patients.
 Use of echocardiography, ultrasound and CT scan.
 Insertion of chest drains
 Performance of Percutaneous Dilational Tracheostomy and
management of tracheostomies.
4. Echocardiography
 Basic training in transoeophageal echocardiography. The trainee
should also demonstrate a commitment to sit the examination and
achieve accreditation in Transoesophageal echocardiography.
 Basic training in transthoracic echocardiography eg FATE
5. Research and Audit.
 Knowledge and participation in audit or research project
 Demonstration of abilities to appraise the literature by publishing a
paper, case report, audit, poster or presentation.
6. Appraisal and Assessment
 Review of Log Book – cases both supervised and unsupervised
 Regular Appraisals with Supervisor (e.g. 3 monthly appraisals during a
one year attachment)
 Assessment by 360 assessment / two case based discussions (CBD) /
mini CEX (IABP / PAC / TOE)
 Exam success :- Perioperative TOE
References
1. The Royal College of Anaesthetists The CCST in Anaesthesia. A manual for
trainees and trainers.
2. Barnard MJ and Ashley EMC Cardiothoracic anaesthesia is there a future?
Bulletin 39. Royal College of Anaesthetists 2006
3. Rigg CD Cardiac intensive care within the UK – a 2008 survey. JICS Vol 10
No 2 April 2009