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TRAINEE HANDBOOK 2018 For trainees with an interest in neuroanaesthesia & neuro- crical care Edited by Dr Omar Siddique (NACCS Trainee Rep)
TRAINEE HANDBOOK 2018
For trainees with an interest in neuroanaesthesia & neuro-
critical care
Edited by Dr Omar Siddique (NACCS Trainee Rep)
A President’s Welcome Dr Judith Dinsmore
President NACCSGBI
Consultant Neuroanaesthesia, St George’s Hospital, London
Inside:
A President’s Welcome………...2
Trainee Representative .......... 3
Structure of Training .............. 5
The Final FRCA……………………...6
A Trainee’s perspective ......... 8
Neuroanaesthesia Fellowship 10
Trauma and Neuro ................. 12
The Consultant Journey ......... 14
O n behalf of everyone on NACCSGBI Council I would like to extend a warm welcome to you all. I hope you enjoy the accompanying articles from a variety of individuals from many different backgrounds but all with an interest in neuroanaesthesia & neurocritical care. We are the oldest specialist anaesthetic society in the country having evolved from the Neurosurgical Travelling club, founded in 1965. Our roles are to advance education in the study of the art and science of neuroanaesthesia and neurocritical care for the benefit of the public, to promote high standards of practice and patient care and to encourage research in the fields of neuroanaesthesia and neurocritical care. However, we also aim to be valuable resource for everyone with an interest in the speciality especially trainees. We are available throughout your anaesthetic career – during your neuro modules, working towards the FRCA and FICM exams and when it comes to adding that little extra whilst brushing up your CV in preparation for consultant jobs. We already have linkmen representing neuroanaesthesia & neurocritical care in all 39 neurosurgical centres allowing us to collect, distribute and exchange information. The addition of trainee representatives would be a huge asset to this network allowing participation in large scale data collection. Our last ASM in London attracted over 300 delegates from 22 countries. This year’s ASM was successfully held in Bristol on 10th & 11th May and abstracts will be published in the Journal of Neurosurgical Anesthesiology. Additional educational events include updates at the RCOA and AAGBI and we contribute to meetings with GAT, ICS, ILAE and RSM. Members have access to our web based survey tool for online surveys of members, our travel grant of up to £1200 (details are available on our website). We contribute up to £20,000 via the NIAA for neuro research and NACCS members contribute and have free access to the ‘eBrain’ on-line learning package – a really useful educational resource.
We work in cooperation with other societies and organisations on clinical pathways, audit and guidance to support service improvement related to neuroanaesthesia and neurocritical care including:
Stakeholder for Adult Critical Care CRG.
Revised the GPAS chapter on neurosurgery for
RCOA.
Supporting the ACSA process by providing standards for neuroanaesthetic departments.
Membership of the Adult Neurosurgery CRG.
The 2015 Neuroanaesthesia addition to the
2012 RCoA Audit Compendium.
Input into the guidelines for CPR in neurosurgical patients.
NHS Stakeholder event: Mechanical
Thrombectomy in Acute Ischaemic Stroke and guidance on the anaesthetic management of Intra-arterial Thrombectomy.
Published guidance with SBNS: measurement of CPP as a guide to good practice for clinical work & research.
We are working with ICS and FICM regarding
the future of neurocritical care and training in the UK.
We are working with the AAGBI to update
guidance on Transfer of the brain injured patient, TIVA and on MRI.
Representation on recent guidance on
management of Devastating Brain Injury.
NACCSGBI members benefit from substantial discounts for the ASM and our other educational meetings. This, along with additional advantages such as access to monthly CPD, travel grants, research grants, surveys via the website, and with annual trainee membership at only £10– how can you resist? We are delighted to welcome our first Trainee Rep, Omar Siddique. He has some great ideas and I know will be a huge asset to the Society.
‘I was afforded a blank sheet of paper, the role being new with no expectations.’
Trainee Representative - The Future of
NACCS
Dr Omar Siddique BM FRCA
Trainee Representative NACCSGBI
ST4 Anaesthetics, Wessex Deanery
U pon first encountering anaesthesia, an air of
mystery often accompanied the wizard like
demeanour of the anaesthetist. Guiding the
patient smoothly from a state of anxiety to a state
of total calm, enabling the surgeon’s sorcery to
take place. If anaesthesia is the ministry of magic, I
perceived neuroanaesthesia as the dark arts. JK
Rowling described this form of magic as ‘many,
varied, ever changing and eternal’ with spells
taught to ‘immobilise an opponent without causing
pain or lasting harm’. These thoughts could have
quite easily echoed the theatre walls whilst
stabilising the polytrauma patient with spinal cord
injury, or hurrying from Neuro ICU to a CT scanner
whilst striving to keep Cushing’s at bay.
The journey
My first exposure had ignited enough curiosity to
shed some further light onto the mysterious
specialty. The first destination was a post Primary
FRCA simulation fellowship at the University
Hospital Southampton on Neuro Intensive Care.
The year at UHS gave me the exposure to a variety
of clinical settings. These ranged from managing
acute ICP rises, >30 out of hospital transfers,
mastering the art of subclavian access in
polytrauma patients, as well as enhancing
communication and compassion during organ
donation and end of life care.
There were many non-clinical opportunities,
extending from setting up regional multi-
disciplinary simulation to implementing a portable
CT scanner. I was kindly invited to help facilitate
the Annual Scientific Meeting for NACCSGBI
(Southampton) in 2016. This well run event
enabled me to meet many enthusiastic figures in
the world of neuro. The air of mystery was
disappearing and in its place a progressive,
innovative and dynamic group of clinicians. The
curiosity had now evolved into fascination,
enhanced by my experience of intermediate
neuroanaesthesia. Utilising the knowledge
and skill obtained during anaesthetic training,
coupled with a background in neuro intensive
care set me in good stead during my neuro
lists. The impact of good attention to detail,
understanding pathology and applying
principles of pharmacology and physiology
could lead to significant impact and improve
patient outcome.
Being aware that I was a relatively junior
trainee, I remained open-minded and aimed to
explore all branches of anaesthesia and critical
care. With this in mind, I acknowledged my
interest in this specialty, however strived to
gain more insight. Unfortunately, outside of
the immediate deanery and local neuro centre,
the information was scarce. This is reflected
amongst trainees across the UK, with their
experience during intermediate
neuroanaesthesia being the predominant
deciding factor. There is little information
regarding opportunities as a trainee,
experiences of having undertaken fellowships
and life as a consultant.
Council Role
In the summer of 2017, NACCSGBI council had
decided to address the issue of trainee
involvement by seeking the contribution of a
trainee representative. I was delighted to have
been approached as it was the perfect
opportunity to be directly involved in enabling
further progression and change. The council
meet 4 times a year with a focal point being
the Annual Scientific Meetings. I was afforded
a blank sheet of paper, the role being new with
no set expectations.
Trainee Links
If you are interested in becoming a
trainee lead for your local neuro
centre please contact your local
neuro linkman. Alternatively
contact the naccs email address or
twitter.
Trainee Membership
For access to monthly CPD, travel
grants, research grants, surveys via
the website please join NACCSGBI
for only £10 (trainee rate) on the
following website:
http://naccsgbi.org.uk/
membership/consultants-trainees/
Email: [email protected]
@NACCSGBI
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Trainee Presentations at NACCS ASM held annually (Southampton 2016)
This enthusiasm turned to anxiety and
trepidation. I was to be thrust into the midst
of the leading representatives for the oldest
specialist anaesthetic society in the UK. The
dark arts were turning into dementors. In the
words of JK Rowling, ‘Fighting them is like
fighting a many-headed monster, which, each
time a neck is severed, sprouts a head even
fiercer and cleverer than before.’ You’d be
pleased to know my experience was the polar
opposite! Sitting with the council on a warm
summer day, armed with my action plan,
PowerPoint as my weapon. I was greeted with
great welcome and enthusiasm. My views
attentively acknowledged and opinions sought
on each of the issues raised during the
meeting. I left excited about my role and the
part I could potentially play.
My aim as trainee representative, and goals
shared by the council are:
Act as a direct link between trainees and
NACCSGBI.
Enhance society online and social media.
Improve awareness and engagement
with trainees interested in
neuroanaesthesia/critical care.
Future plans
There has been ongoing work behind the
scenes to implement a variety of projects in
order to enhance trainee involvement in
NACCS. The first of which has been the
continued support by all council members
engaging with the role of trainee rep.
Trainee Handbook: The publication of
the handbook is to provide opportunity
for trainees with an interest in the
specialty to gain further insight. It has
only been possible with the support of
all the authors that have contributed
their experiences.
Trainee link rep: We have allocated roles
for trainee leads for each of the 39 neuro
centres in the UK. They will liaise with
the national trainee rep regarding local
training issues, ideas and involvement.
We have currently appointed leads for 8
centres across the UK including London,
Oxford, Nottingham, Middlesbrough,
Southampton and South East Scotland.
Trainee Association: Plans to launch a
trainee led group NECCTA
(NEuroanaesthesia & Critical Care
Trainee Association) is currently
underway. The aim is to co-ordinate
quality improvement projects/surveys
centrally using trainee leads from each
neuro centre. This will create an
infrastructure to enhance training in
neuroanaesthesia and implement
change.
I am extremely grateful for the opportunity to
become a part of the NACCS council. It has
given me insight into decision making on an
international scale, provided a platform to
implement change and has been an enjoyable
experience. It is also a welcome change to the
customary visits to Red Lion Square!
A naesthesia for neurosurgery, neuroradiology and critical care remains an essential component of both the intermediate and higher levels of training outlined by the Royal College of Anaesthesists (RCOA). A national training survey by the Neuroanaesthesia Society of Great Britain and Ireland (NASGBI) in 20151 identified considerable variation in the length and structure of the Neuroanaesthesia modules offered by different Neurosurgical units across the UK. Standardised core learning outcomes and the competencies required at each level of training, however, are clearly mapped out in the relevant Annex documents. Core Level Training (www.rcoa.ac.uk/CCT/AnnexB) Trainees are not expected to have specific exposure to neuroanaesthesia during Core Level Training. However, the syllabus as detailed within “Annex B” includes a number of knowledge and skills competencies within other domains that are directly relevant to neuroanaesthesia and critical care and these frequently appear in the Primary FRCA exam. Intermediate Level Training (www.rcoa.ac.uk/CCT/AnnexC) Most units (93%) deliver intermediate training in a single block over a fixed period of time (mean 10 weeks), with the majority requiring a fixed number of half-day sessions (mean of 20)1. Core clinical learning outcomes are mapped to the “Annex C” curriculum, directed towards the development of knowledge and skills relevant to the perioperative anaesthetic care of patients undergoing major elective and emergency neurosurgery, neuroradiology and spinal surgery. Higher Level Training (www.rcoa.ac.uk/CCT/AnnexD)
Most units also continue to deliver higher training in one block (mean duration 11 weeks), most commonly with a minimum requirement of 20 sessions1. As detailed in “Annex D”, learning outcomes are directed towards building upon those competencies established at Intermediate Level, with an emphasis on more independent management of non-complex conditions.
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Neuroanaesthesia Training in UK:
An Overview
Dr Steve Phillips BM FRCA
ST5 Anaesthetics, Wessex Deanery Advanced Training (www.rcoa.ac.uk/CCT/AnnexE) Trainees wishing to pursing in a career in Neuroanaesthesia in a tertiary centre are advised to express an interest to their programme director at an early stage to arrange to undertake a six to twelve month period of advanced training. Trainees are encouraged to gain experience in more than one centre if possible. Core clinical learning outcomes focus on establishing expertise in independent perioperative anaesthetic care across a wide variety of complex neurosurgical and neuroradiological procedures. One month will be spent in neurocritical care. Advanced training also places an emphasis on non-clinical learning outcomes, including directing departmental clinical governance activity and the demonstration of multi-disciplinary leadership and teaching. Trainees looking to establish practice in anaesthesia for paediatric neurosurgery require an individual advanced training programme, the development of which will require early discussion with the deanery training programme director and the RCOA Training Department.
Post-CCT Fellowships
In some centres it may be desirable to obtain extra experience in neuroanaesthesia prior to becoming a consultant. Details of a number of posts can be found on the Training and Fellowships page at www.naccsaagbi.org.uk.
References
1. Campbell R, Dinsmore J. Lessons from a national
training survey in neuroanaesthesia. RCOA Bulletin 2016; 95:36-48.
FRCA Examinations
Topics relevant to neuroanaesthesia and neurocritical care can frequently appear in both the primary and final FRCA exams. Areas of focus have been listed below.
Primary FRCA
Airway Management: Acute cervical spine injury Trauma & Stabilisation: Traumatic brain injury; Principles of assessment (including GCS), management, prevention of secondary brain injury Induction of General Anaesthesia: Hazards associated with brain injury Perioperative Medicine: Cervical spine XR Anatomy: Spinal cord (including blood supply), meninges Physiology & Biochemistry: CSF, Cerebral circulation & Intracranial pressure Physics & Clinical Measurement: Cerebral perfusion monitoring
Final FRCA Topics
Neuropharmacology: Common anaesthetic agents and Cerebral
physiology Neurophysiology: Cerebral blood flow & Intracranial pressure Traumatic brain injury Subarachnoid Haemorrhage Anaesthetic implications of Neuroradiological procedures Venous Air Embolism Intracranial Surgery and Craniotomy Posterior Fossa Surgery Transphenoidal Surgery: Pituitary, Cushings syndrome & Acromegaly Acute spinal cord injury: Assessment, management, autonomic dysreflexia Spinal surgery Safe positioning for neurological and spinal surgery: Prone and sitting positioning Brainstem death: Physiology, management and testing
Learning Resources
The Anaesthesia Tutorial of the Week and BJA Education articles (formerly CEACCP; Continuing Education in Anaesthesia, Critical Care and Pain) listed in the following tables are an excellent source of information for many of the topics listed above.
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Neuroanaesthesia in FRCA
Dr Steve Phillips BM FRCA
ST5 Anaesthetics, Wessex Deanery
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BJA Education / CEACCP
Anaesthesia Tutorial of the Week
Topic Date Link
Anaesthetic considerations for posterior fossa surgery
October 2014 https://doi.org/10.1093/bjaceaccp/mkt056
Anaesthesia for awake craniotomy February 2014 https://doi.org/10.1093/bjaceaccp/mkt024
Traumatic brain injury: an evidence-based review of management
December 2013 https://doi.org/10.1093/bjaceaccp/mkt010
Cerebral physiology August 2013
https://doi.org/10.1093/bjaceaccp/mkt001
Acute management of aneurysmal subarachnoid haemorrhage
April 2013 https://doi.org/10.1093/bjaceaccp/mks054
Paediatric neuroanaesthesia December 2010 https://doi.org/10.1093/bjaceaccp/mkq036
Cervical spine surgery June 2007 https://doi.org/10.1093/bjaceaccp/mkm015
Controversies in neuroanaesthesia, head injury management and neurocritical care
April 2006
https://doi.org/10.1093/bjaceaccp/mkl007
Topic Date Link
Management of the head injured patient July 2012 https://www.aagbi.org/sites/default/files/264%20Management%20of%20the%
Neurosurgery and the parturient March 2012 https://www.aagbi.org/sites/default/files/253%20Neurosurgery%20in%
The Hypothalamic-pituitary axis Part 1: Anatomy & physiology
July 2010 https://www.aagbi.org/sites/default/files/186-The-hypothalamic-pituitary-axis-
The Hypothalamic pituitary axis Part 2: Anaesthesia for pituitary surgery
July 2010
https://www.aagbi.org/sites/default/files/189-The-hypothalamic-pituitary-axis-
Management of subarachnoid haemorrhage December 2009 https://www.aagbi.org/sites/default/files/163-Management-of-subarachnoid-
Anticoagulation & intracranial bleeds - Management of the anticoagulated patient presenting with intra-cranial haemorrhage
January 2008 https://www.aagbi.org/sites/default/files/82-Anticoagulation-Intracranial-bleeds.pdf
Cerebral physiology Part 1 - Cerebral blood flow and pressure
October 2007 https://www.aagbi.org/sites/default/files/69-Cerebral-Physiology-part-1.pdf
Cerebral physiology Part 2 - Intracranial pressure October 2007
https://www.aagbi.org/sites/default/files/71-Cerebral-Physiology-part-2.pdf
N euroanaesthesia is a fascinating and challenging subspecialty, or at
least that’s how I see it. It is also one of the more polarising anaesthetic
subspecialties. Much like obstetrics or pain, trainees that I have worked
with in Mersey deanery seem to feel passionately about
neuroanaesthesia, be it positively or otherwise!
You will have already guessed that this article comes from the viewpoint
of an enthusiast. As such, I struggle to recognise some of the perceived
drawbacks. I am regularly confronted by colleagues who question my
career direction, citing their personal hang-ups with neuroanaesthesia.
Trainees claim neuroanaesthesia ‘lacks variety’; that ‘nobody gets better’;
that the pace of surgery and recovery is ‘frustrating’. With equal regularity
I give the following riposte:
‘Name me another anaesthetic specialty were we encounter as many
patients, and families, thrust into genuinely unforeseen physical and
emotional distress as we do in neuroanaesthesia. Whether it be a brain
tumour, and cerebral haemorrhage or spinal insult; the ramifications of
neurological injury are often life altering. We hope that this alteration is
temporary, and that with timely, specialist intervention the lives to which
they were accustomed can be returned to them. The majority of people
presenting to neurological centres are victims of misfortune, and I can
think of nothing more rewarding than attending to them in their moment
of need‘.
Now this sounds a little cheesy, no doubt. However, I do wholeheartedly
believe in the sentiment, and I see this embodied in the neuroanaesthetic
consultants that I have had the pleasure of working with at The Walton
Centre during specialist training. I am sure this attitude is evident across
the UK, having met similarly passionate individuals at NACCSBGI meetings.
For a trainee, the annual meetings are a fantastic way of gaining a wider
appreciation of the specialty and its exciting future direction.
I would like to address some of the aforementioned trainee hang-ups.
Firstly, the notion that neuro lacks variety is, to me, absurd. The surgical
repertoire is ever expanding, with innovation in neurosurgery outstripping
that of many other surgical specialties. For example, the functional disease
services are undergoing considerable expansion. With this comes a
demand for more novel anaesthetic methods that allow continuous
assessment of higher cerebral functions. Finally, there are few other
anaesthetic environments where, as a trainee, you are exposed to the
interventional suite, critical care, MRI scanner and theatre in a single day;
potentially with a single patient. Add to this the diversity of the patient
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A Trainee’s Perspective Dr Marc WH Lyons FRCA MSc RAMC
ST7 Anaesthesia, North West Deanery
‘The notion that neuro lacks variety is, to me, absurd. The surgical repertoire is ever expanding, with innovation in neurosurgery outstripping that of many other surgical specialties.’
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and spectrum of disease, and hopefully you can see how challenging
neuroanaesthesia can be.
I am not going to entertain the notion that nobody survives neurological
insult. The ability of the human species to heal is truly miraculous, and
nowhere is this more vividly evident than within a neuro critical care unit.
There are, of course, some patients who experience a poor recovery or
worse, and this is saddening for all involved. Prognostic uncertainty
remains a problem for neurologists, surgeons, and anaesthetists alike; but
this, for now, must be accepted.
However, poor outcomes are not exclusive to neuroanaesthesia. The NHS
operates on, and supports more frail and elderly patients than ever
before. Combine this with a strong desire for patient autonomy, and
greater emphasis on the wishes of kin, and it is inevitable that assurance
over outcome becomes complicated. Providing sound medical advice to
allow informed decision making is all, as a profession, we can provide.
Lastly, describing recovery times as ‘frustrating’ is decidedly short-sighted
and lacking in empathy. It is easy for patients to become dehumanised
when lay in a hospital bed for days, weeks or even months. I consciously
remind myself that before they were a patient, they were a son; a wife; a
grandparent. That they have people who depend on them; care for them;
love them. I find the photos that tend to line the bay of long-stay patients
act as much as a reminder to me, as it does to the patient. By adopting this
approach I soon feel the sense of urgency and responsibility that I felt
when they arrived via emergency transfer.
Training in neuroanaesthesia offers many learning opportunities, both
specialist and generic. Due to the multidisciplinary nature of care,
communication is vital throughout all phases. Preparation for theatre must
be meticulous, and requires attention to medical, pharmacological and
surgical factors. Intraoperative care can be complicated, with a focus on
maintenance of normal neurophysiology, monitoring, and patient
positioning. Lastly, the post-operative recovery is unique in that
attainment of a pre-operative conscious level cannot always be
guaranteed, and extra vigilance must be shown to ensure patient safety.
Each time I have returned to The Walton Centre throughout the various
stages of training, I have found an evolution in anaesthetic management,
with novel techniques and ideas emerging. The reorganisation and
centralisation of services not only functions to achieve clinical excellence
for all, but also acts to provide quality learning environments with
knowledgeable personnel. This has certainly been true of my experiences
thus far, and I hope to have a long career in this fascinating field.
Dr Lyons has successfully obtained a CCT in Anaestheisa and has returned to the Walton Centre to undertake a post CCT fellowship.
T he scope of neuroanaesthesia is rapidly changing with increasing
requirement to provide anaesthesia for complex neurosurgical,
neurological and neuro-radiological procedures including thrombectomy.
Anaesthetic technique can have a significant impact on the perioperative
outcome of neurologically at-risk patients.
Spending a year as a fellow in Neuroanaesthesia in a different area or
country will not only provide you with an additional clinical experience but
will also help you to broaden your teaching, research and leadership
abilities. There are various national as well as international fellowships
available. It depends on your personal circumstances where you want to
do your fellowship. You may be able to achieve your educational goals by
travelling to your preferred international destination for your fellowship.
The Training fellowship section at www.naccsgbi.org.uk offers you the list
of fellowships available in the UK. A Travel fellowship is also offered to the
members of NACCSGBI, the details of which can be found on the website.
Make sure you meet or talk to alumni of the fellowship programme to get a
first-hand account of what the fellowship is like, so you can better
understand how to navigate your fellowship experience.
Committing yourself to a career in neuroanaesthesia means that you would
have already engaged with the speciality in a deeper manner than other
specialities. Being proactive and enquiring about current quality
improvement projects or research projects in the department before you
commence your fellowship will help you to pre-plan your year
appropriately.
How to enhance your learning opportunities:
Keep a logbook of clinical cases during your fellowship year. Make
sure you acquire broad experience and skills in various aspects of
neurosurgical anaesthesia including complex spine surgeries,
neurovascular procedures as well as anaesthesia for functional brain
surgery. Reading up and revising topics before you do specific cases
will be very useful. Actively search out for cases that are of particular
interest to you. Work place based assessments focusing on important
learning areas will help you to learn and improve. Anaesthetic list
management tools will provide you with feedback on your non-
technical skills so that you can take up independent responsibility of
managing lists by the end of your fellowship.
You may not be able to gain experience in all aspects of neuroanae
thesia in a single centre. e.g. paediatric neurosurgery or thrombecto
my. With more and more neurosurgical centres aiming to set up the
thrombectomy service; a small amount of pre-planning to spend few
days in a centre offering this training opportunity will be very useful.
Advanced airway skills are complimentary to neuroanaesthesia. You
may want to consider spending 6 months in advanced airway
fellowship/training or else consider enhancing your experience in
fibreoptic intubations with respiratory or max-fax team.
Interventional neuroradiology is a rapidly expanding area. Ensure you
maximise your experience in anaesthetising for neuro-radiological
procedures such as aneurysms, AVMs and thrombectomy.
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Making The Most Of Your Fellowship Dr Smita Gosavi FRCA
ST7 Anaesthesia, St George’s Hospital London
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Look out for specialty related courses such
as simulation based courses, resuscitation
courses and courses run by your local
postgraduate medical centre to optimise
your learning.
Research, management and teaching:
There is more to a fellowship year than purely
clinical experience. Look for opportunities to
enhance your experience in academic and
management related activities, as well as
medical simulation programmes. Enquiring
about on-going departmental research projects
or planning new research projects well before
starting your fellowship will help you to
complete your projects within the timeframe of
fellowship. Weekly morning meeting is a very
good platform to present your work along with
monthly morbidity and mortality reports. Make
sure you actively participate in teaching locally
as well as offer to organise regional study days.
All of this will help you to prepare for your
future consultant post.
Conferences:
There are various national and international
neuro anaesthetic as well as neurosciences
conferences. The Neuroanaesthesia society
(www.naccsgbi.org.uk) and American society
(www.snacc.org) have annual conferences.
There are many prizes on offer. Also all the oral
presentations and selected abstracts are
published in the Journal of Neurosurgical
Anaesthesiology. The European neurosciences
conference (www.euroneuro2018.org) and
Indian society of neuroanaesthesia
(www.isnacc.org) are other platforms where
you can present your work in form of posters or
oral presentations.
Make sure you look at the abstract deadlines
early so that you organise your study leave and
submit your work in time.
It is important that you enjoy your fellowship
clinically as well as socially. Attending and
presenting at conferences is a very good way to
develop good social networks with your future
colleagues.
Neuroanaesthesia: wider scope
Paediatric neuroanaesthesia
If you want to pursue a career which involves
both paediatric anaesthesia and
neuroanaesthesia, a period of six months in a
nationally-accredited or recognized centre for
paediatric neurosurgery is essential;
irrespective of your chosen parent specialty.
Further guidance can be obtained by referring
to Safe and Sustainable Paediatric Neurosurgery
Standards and Recommendations 2012.
Neuro-intensive care
For jobs with interest in neuro-critical care, it is essential that you complete minimum 6 months higher/advanced training in neuroanaesthesia along with your training in intensive care medicine. Details of various fellowships can be found on the Training fellowship part of www.naccsgbi.org website.
In summary, neuroanaesthesia is a very
rewarding and rapidly expanding subspecialty
with increasing recognition of fellowship
programmes nationally as well as
internationally. The fellowship rotation provides
you with comprehensive training not only in
clinical neuroanaesthesia but it offers valuable
experience in perioperative neuro-monitoring,
pre-operative assessment of high risk
neurosurgical patients and neurosciences
research. This varied experience will prepare
you to have a complete approach towards
working as perioperative physicians for
neurologically at-risk patients.
This fellowship can be one of the most valuable
experiences of your professional career as a
neuro-anaesthetist, so make the most of it and
enjoy the ride…!!
Useful resources:
Neuroanaesthesia and Critical Care Society of Great Britain and Ireland www.naccsgbi.org Society for Neuroscience in Anaesthesiology and Critical Care www.snacc.org Paediatric Neuroanaesthesia Network (PNAN) Contact www.aagbi.org.uk The Society of British Neurological Surgeons www.sbns.org.uk
Dr Gosavi has since obtained a Consultant post and is currently working at King’s College Hospital as a Consultant in Neuroanaesthesia.
Fellowships
• Neurosciences and Trauma Critical
Care, Addenbrooke’s Hospital,
Cambridge University Hospitals NHS
Foundation Trust:
• Plymouth Hospitals NHS Trust Neurocritical care fellowship programme: ([email protected])
• National Hospital for Neurology and
Neurosurgery, Queen Square University College London Hospitals NHS Trust Neuroanaesthesia and Neurocritical Care Fellowship Programmes: [email protected]
• Neuroanaesthesia Fellowship at the
Queen Elizabeth Hospital, Birmingham (QEHB): [email protected]
• University of Texas Southwestern
Medical Center Neuroanesthesia Fellowship: [email protected]
The fellowships above refers to those currently listed on NACCS website. There are many more available in the UK and abroad. Please contact your local neuro centre for more details.
T he organisation and delivery of major trauma services has changed
over the last 5-7 years in the UK. Driving these changes has been the
aim to reduce mortality1 in the younger age groups and has led to the
introduction of numerous new standards of care from point-of-injury
(POI) to rehabilitation. However, an improvement in trauma mortality is
likely at a cost to increased morbidity. It is known that the major cause
of morbidity in these patients is secondary to traumatic brain injury
(TBI), and this has implications for both the individual and society2.
Managing a patient post-TBI can provide challenges, learning
opportunities and professional satisfaction.
Pre-hospital
On arrival at a trauma scene, after confirming safety, the pre-hospital
team rapidly assess a patient, commence management and plan
transfer to definitive care. Since the re-organisation of trauma services,
the pre-hospital team use a standardised ‘Major Trauma Triage Tool’
which includes specific clinical features of neurological injury. If TBI is
suspected the patient undergoes spinal immobilisation plus, if
practicable, commencement of the secondary neurological injury
prevention measures and is transferred to the nearest ‘Major Trauma
Centre’ which has, by definition, 24/7 access to neuroimaging and
neurosurgical services.
Emergency Department (ED) & Neuroanaesthesia
Once in the ED a patient is met by a ‘Major Trauma Team’ which
includes both an anaesthetist and intensivist, who conduct a ‘primary
survey’ to identify and manage immediately life-threatening injuries.
During the primary survey clinical features may already indicate a
significant primary neurological injury and so secondary neurological
injury prevention measures are commenced or continued using the
guidelines such as those from the Brain Trauma Foundation3.
Often this is concurrent with overall patient management but will
involve challenging tracheal intubation due to cervical spine
immobilisation, mechanical ventilation to achieve gas targets and blood
pressure management, especially the control of haemorrhage.
Through-out this clinical encounter appropriate clinical decision making
is vital for positive patient outcomes and involves constant team
dialogue and discussion. After the primary survey, depending on clinical
stability, the patient is either
transferred to the operating theatre or
more likely to CT for a whole-body scan.
It is the anaesthetist and/or intensivist’s
role to ensure safe transfer of the
intubated patient, including
maintenance of secondary neurological
injury prevention parameters.
Occasionally a patient requires direct
transfer to theatre for decompensation
of a space-occupying brain lesion, but
more likely surgery is required to
control ongoing major haemorrhage.
During this time the anaesthetist is
responsible for maintaining secondary
neurological injury prevention
parameters as well as identifying and
managing suspected raised intracranial
pressure to reduce neurological
deterioration.
12
Neuroanaesthesia & Neurocritical
Care in Trauma
Dr Emma Watson BSc (Hons) MBBS FRCA FFICM
ST6 Military Dual ICM/Anaesthesia, Northern Deanery
Dr Natalie Glover BSc (Hons) MBBCh FRCA (Edin)
Consultant Anaesthetist, Royal Air Force
13
Neurocritical Care
For a sedated patient, during the admission period we continue with
secondary neurological injury prevention measures and commence
additional monitoring, such as invasive blood pressure, to allow
optimal compliance. Continual neurological assessment is required and
can be achieved through a range of means, from regular CT scan
evaluation to invasive intracranial pressure monitoring. In a non-
sedated patient regular Glasgow Coma Score evaluation is a suitable
and non-invasive method for monitoring neurological deterioration.
Deterioration in neurological parameters is initially managed medically
with consideration of further imaging and contacting the neurosurgical
team. Alongside direct neurological management the patient should
also receive standard critical care measures, such as nutrition, and it is
important to ensure a secondary survey is conducted in all trauma
patients. Rehabilitation should commence as soon as possible as this
also improves patient morbidity outcomes.
Managing a trauma patient with severe TBI can be complex, especially
if they have multiple injuries involving multiple medical and surgical
specialties. The intensivist has a privileged role in patient management
by overseeing and ensuring a timely collaborative multidisciplinary
approach to achieve optimal patient outcomes.
Military
During armed conflict major trauma is inevitable, with blast trauma
most likely to cause TBI4. Other neurological injuries experienced by
military personnel occur via penetrating trauma, road traffic accidents
and misadventure, however we also experience medical causes of
neurological injury such as cerebrovascular accidents. Due to the high
incidence of neurological injury in military trauma, all military
anaesthetists and intensivists are required to attain and maintain the
specific skills to manage these patients, irrespective of their ‘day job’.
In addition, to provide timely quality clinical management we must
consider and achieve the safe transfer of the critically injured patient.
This often involves initial helicopter or land transfers from POI to a
medical facility followed by longer-haul air transfers after initial
stabilization. These transfers carry significant risk to a patient with
multiple injuries especially if their injury pattern includes TBI;
decompensation of any body system can rapidly affect neurological
physiology and prevent attainment of secondary neurological injury
prevention parameters.
Personal Experience
As mentioned, major trauma often includes TBI in both civilian and
military environments, involves relatively young patients and optimal
management can significantly improve their outcomes. This is partially
why my interest is in neuroanaesthesia and neurocritical care, but also;
For optimal patient management a range of clinical and
interpersonal skills are required which differ depending on the
working environment.
Patients with TBI require a multidisciplinary approach, presenting
challenges and learning opportunities.
Patient management requires a meticulous approach by
individuals who are knowledgeable about physiology and
pharmacology. In addition, individualised patient management by
specialists is likely to have better outcomes.
Since TBI cause significant morbidity and mortality there is an
interest in research, plus increasing evidence to help guide
management.
The skills and knowledge required to manage TBI patients are
transferrable to other acute environments.
References
1. NHS Commissioning Board 2103. NHS STANDARD CONTRACT FOR MAJOR TRAUMA
SERVICE (ALL AGES) SCHEDULE 2- THE SERVICES A. SERVICE SPECIFICATIONS https://
www.england.nhs.uk/wp-content/uploads/2014/04/d15-major-trauma-0414.pdf
2. Centers for Disease Control and Prevention. TBI data and statistics. (accessed 12 Dec
2017). https://www.cdc.gov/traumaticbraininjury/severe.html Date: 30 Mar 2017
3. Carney N, et al. Brain Trauma Foundation TBI guidelines: Guidelines for the
Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2016; 0:1-
10.
4. Champion HR, Holcomb JB, Young LA. Injuries from explosions. Journal of
Trauma 2009;66(5):1468–1476
W hen I was an anaesthetic SpR at St Mary’s in the late 1990s, there
were no trauma networks with some moderate head injuries being looked
after in district general surgical wards. Nor did interventional
neuroradiology exist with cerebral aneurysmal clipping being NICE
standard care in 2001. Remifentanil had yet to be introduced into the UK
and TIVA was still a mathematical concept. I left medicine, moved to
Australia, raised a family and had a career change working in the niche
market of mergers and acquisitions. After the global financial market
collapse in 2008, my family and I moved back to the UK and I came back to
my first career, anaesthetics and intensive care medicine.
Neuroanaesthesia and neurocritical care had changed since my first
exposure in 1996. During my ST4 neuroanaesthetic intermediate block at
St George’s, I could see how neurotrauma and interventional
neuroradiology had led the growth of neuroanaesthesia and neurocritical
care as a speciality with some of these changes stemming from the greater
understanding of cerebral physiology and pathophysiology.
I enjoyed both my cardiac and neuro blocks during that year, both are
similar in the relationship between anaesthetist and surgeon. An
understanding of the relevant anatomy and physiology by the anaesthetist
can be useful in the heart failing to come off bypass after an emergency
CABG or the tense brain seen on decompressive craniectomy.
It was the range of neurosurgical and neuroradiological procedures
including functional neurosurgery, awake craniotomies, mechanical
thrombectomy, as well as the polytrauma patient on neuro ICU that
confirmed my choice between cardiac and neuroanaesthesia. From there I
applied for the fellowship at the National Hospital for Neurology and
Neurosurgery at Queen Square for my ST6 year.
My year fellowship was divided into nine months of neuroanaesthesia and
three months of neurocritical care. During my first couple of months I
learnt the art of neuroanaesthesia for various neurosurgical and
neuroradiological procedures. A senior neuroanaesthetic fellow advised
me to buy the book that the ST1 neurosurgeons started with, “Neurology
and Neurosurgery Illustrated” because understanding the anatomy for
neurosurgery takes the knowledge from intermediate to advanced level
neuroanaesthesia. It was the most useful book I bought for the fellowship
year and I would recommend it to all advanced neuroanaesthetic
trainees..
For my last three months of my fellowship, I rotated through the
neurosurgical and neuromedical critical care units being part of the ward
rounds with Professor Martin Smith and Dr Nicholas Hirsh. Those three
months helped consolidate my understanding of the treatment of the
critically unwell neurosurgical and neuromedical patient as well as an
acquiring an appreciation of neurosurgical decision making. It would be
14
My Journey: Becoming A Consultant In
Neurocritical Care & Neuroanaesthesia
Dr Manni Waraich MBBS FRCA PGDBA EDIC FFICM.
15
remiss of me not to mention the neurocritical care textbooks that I
read during that time – “Core Topics in Neuroanaesthesia and
Neurointensive Care” and “The Oxford Textbook of Neurocritical
Care”.
As well as my neuroanaesthetic/neurocritical care training, my
fellowship also included trainee management roles such as the fellow
and anaesthetic trainee rota and being involved in organising local
neuro teaching and neuro simulation days.
From Queen Square, I went onto complete my advanced intensive
care medicine training including six months at Brighton with its
combined general and neuro ICU, which complemented my previous
ICM experience with the separate neuro ICU at St George’s and the
standalone neuro unit at Queen Square.
There are nine formal neuroanaesthetic/neurocritical care fellowships
in the UK. The aim of any fellowship is to equip you with the clinical
and non-technical skills to pursue your chosen career, but networking
is also important. So, when you do your fellowship, I urge you to enjoy
your fellowship both clinically and socially. The colleagues that you
meet and work with will probably be your neuroanaesthetic
colleagues in the future.
My complete training journey involved neuroanaesthesia and
neurocritical care at two major trauma centres and three
neurosurgical centres, giving me a total of fourteen months
neuroanaesthesia and twelve months neurocritical care and just
under 300 neuroanaesthetic cases in my logbook when I completed
training for joint CCT in 2016.
I joined NACCSGBI when I was an ST4 and have been to every ASM
since 2012. It is likely to be the best £10 you will spend in your
training. The meetings are well organised and again gives you an
opportunity to network with other trainees and meet consultants
from the neurosurgical centres up and down the country. I met Roger
Lightfoot at the 2014 Sheffield ASM dinner, he probably doesn’t
remember that, but it did make my informal visit to Southampton for
the consultant post a little less daunting.
I have now been a consultant at Southampton for just over a year with
a 50/50 split between neurocritical care and neuroanaesthesia in my
job plan. This has allowed me to pursue projects that are important to
me.
I am privileged to be on the Women in Intensive Care Medicine
(WICM) committee, an initiative from the Faculty of Intensive Care
Medicine looking at what we can do to address the gender disparity in
ICM. Intensive care medicine is a fulfilling and rewarding career that
does allow a good work life balance. I have two daughters, who are
now both at university, with the youngest one having just started as a
medical student at Birmingham. I am there for the facetime questions
on anatomy, the reading of job applications and of course being the
on-call chauffer.
Building on from being an educational supervisor for advanced ICM
trainees, I am going to be part of the interview panel for the 2018 ST3
ICM posts. I am hoping not to be as nervous as the candidates on the
day but am excited at the same time to meet our future intensivists.
I am teased by the nurses and junior fellows on neuro ICU, that I can
usually be found attached to my Sonosite X-Porte. I am a FICE mentor
and take any opportunity to use and teach POCUS on my ward rounds.
Working with other FICE mentors within the Wessex Deanery, we are
building a network to facilitate FICE/CUSIC accreditation amongst our
trainees and consultants.
Hopefully my story has given you that spark of interest in this growing
and exciting speciality.
‘The advancement of education for the public benefit in the
science of neuroanaesthesia and neurointensive care.’
