Anaesthesia at Royal Brompton Hospital

The anaesthesia team provides anaesthetic services and pain management to patients undergoing surgery in the operating theatres, catheter laboratories, the adult, paediatric intensive care and high dependency units, the CT, MRI and the BRU suites at Royal Brompton Hospital.

The number of patients undergoing anaesthesia each year is approximately 2,300. Of these, around 1,050 adult patients undergo heart operations, approximately 800 adult patients undergo lung and chest operations, and about 450 children undergo heart operations, chest operations and associated investigations.

The anaesthetic department comprises of 18 consultants, eight specialist registrars and two clinical fellows. The annual caseload comprises approximately 1,100 adult cardiac cases of which 65 per cent are patients undergoing coronary bypass grafting, 20 per cent valve repair or replacement and 15 per cent combined or complex procedures. In addition, approximately 750 thoracic cases and 450 paediatric cases are performed each year. Of the latter 250 require cardiopulmonary bypass. The department also provides consultant-led service for the management of acute ascending aortic and intrathoracic aortic dissections.


Our expertise

Alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is an extremely rare lung disease (less than one case per million of population) in which the alveoli of the lung become congested with a mixture of excess lipoprotein (surfactant derived) material and non-functional macrophages. Dr Cliff Morgan is the consultant with special interest in the management of these patients. 

Anaesthesia for transcatheter valve and device implantation

Percutaneous aortic valve implantation is a new and exciting development in the treatment of severe aortic stenosis in those patients unfit for conventional aortic valve surgery. The anaesthesia for these patients is complex due to the physiological responses to the relatively rapid conversion of severe aortic stenosis to aortic regurgitation, to normal valve function, in the presence of often major comorbid disease. 

We also treat some patients with severe mitral regurgitation with mitral clips to reduce the regurgitation. The clips are placed purcutaneously with regurgitation tested by TOE during the procedure under stress conditions. 

Patients also undergo anaesthesia for percutanceous pulmonary valve replacement and various other intracardiac devices. The percutaneous valve implantation team are a multi-disciplinary group who work closely together to achieve the best possible outcome for these high-risk patients. Consultants with special interest in the procedure are Dr A Kelleher, Dr TC Aw, Dr K Fogg and Dr S Trenfield

Anaesthesia for resection of intra-cardiac tumours

In conjunction with surgeons from The Royal Marsden we undertake about 20 nephrectomy and resection of intracardiac tumour extension cases a year, in patients with renal cell carcinoma. Challenges involve potentially massive haemorrhage secondary to IVC occulsion and collateral formation, and also tumour embolisation during dissection. A structures team approach, using cell salvage, rapid infuser systems, a period of cardiopulmonary bypass, and intraoperative transoesophageal echocardiographies allows safe resection of these extensive tumours. Consultants with special interest in this procedure are Dr K Fogg and Dr D Alexander

Anaesthesia for thoracic surgery

The anaesthetic department provides advanced lung isolation strategies for patients undergoing thoracic surgery. Anaesthesia for complex thoracic procedures such as chest wall resections, laser surgery, lung volume reduction surgery and upper and lower airway surgery involving multiple surgical teams (thoracic, ENT, plastic and cardiac) is provided by the department. Dr K Fogg, Dr S Trenfield, Dr TC Aw and Dr T Pickworth lead this service. 

Anaesthesia for patients with pulmonary hypertension

Royal Brompton Hospital has a specialised team for the diagnosis and management of pulmonary hypertension. We anaesthetise patients with severe pulmonary hypertension for various surgical procedures, both cardiac and non-cardiac. Dr B Keogh, Dr D Alexander and Dr TC Aw have special interest in this area. In conjunction with specialists in pulmonary hypertension and adult congenital heart disease and obstetricians from the Chelsea and Westminster Hospital, we provide anaesthesia and post-operative care for high-risk pregnant women with congenital or acquired cardiac disease, including those with severe pulmonary hypertension. Dr D Alexander has special interest in this area. 

Anaesthesia for complex aortic surgery

The department provides anaesthetic service for complex aortic surgery including surgery on the ascending aorta, aortic arch and descending thoracic aorta including endovascular stenting. Monitoring of cerebral function, deep hypothermia and strategies to preserve cerebral and spinal cord function are provided. Dr K Fogg, Dr D Alexander, Dr TC Aw and Dr A Ghori have special interest in this area. 

Difficult airway management

The department is well equipped for the management of a difficult airway. The theatres have a difficult airway trolley for dults and paediatric anaesthesia. Apart from the normal kit there are flexible and rigid bronchoscopes, as well as video laryngoscopes and jet ventilators. We conduct regular training sessions in the management of difficult airways. The department, along with the thoracic surgeons, manages patients with infraglottic airway obstruction. Dr M Renna has special interest in airway management. 

Electrophysiology, ablation and cardiac resynchronisation

The department provides anaesthetic services to the four cardiac catheterisation laboratories as well as the biomedical research unit lab and scanners. Anaesthesia and anaesthetic led sedation are provided for patients undergoing complex arrhythmia correction and ablation. Patients with significant dysfunction are anaesthetised for cardiac resynchronisation therapy to improve their cardiac function. Dr R Stenz and Dr M Renna have special interest in these procedures. 

Peri-operative coagulation and blood conservation

The anaesthetic department, along with consultant haematologist Dr L Tillyer and clinical scientist Simon Davidson, takes acute interest in monitoring and reducing the use of blood products during cardiac surgery. With point-of-care testing and a well-supported haematology service, it has been actively improving the management of patients with peri-operative coagulopathies. Dr A Kelleher is the consultant with special interest in this area. 

Peri-operative acute pain management

Acute pain is pre-emptively managed with the emphasis on the prevention of pain and providing satisfactory pain relief peri-operatively. The service is ably supported by consultants and two pain management clinical nurse specialists. Dr K Fogg is the consultant with special interest in acute pain management in adults. 

The paediatric pain relief service has been running since 2005. A weekly, consultant-led ward round supports the daily nurse-based service ensuring that all patients (both medical and surgical) are provided with optimum analgesia. Regular training, both ward-based and at well-attended courses, supports the service that provides for enteral, intravenous and paravertebral analgesic techniques. Patients requiring ongoing intravenous techniques are managed in a high dependency area. 

Twenty-four hour cover by a consultant anaesthetist is available for all patients. Dr S Jagger, who is qualified in pain management, leads the paediatric programme. 

Sedation by non-anaesthetists

The department runs a course for all non-anaesthetic staff administer sedation or care for sedated patients. This course is run three times per year, and consists of a half-day of lectures and, for those interested, a further half-day recognising and treating complications in the Chelsea and Westminster Hospital simulation centre. This course has been running since 2005, and is now proving popular with staff from other hospitals in London. Dr D Hunter leads the programme. 

Transoesophageal echocardiography (TOE)

Eight consultant anaesthetists within the department have obtained a formal qualification in peri-operative TOE. Supported by Professor S Price, consultant cardiologist, who has a special interest in peri-operative echocardiography we perform around 1,200 intra-operative and diagnostic TOE studies per year in theatres, the interventional catheter laboratories and adult intensive care unit.

Our TOE equipment consists of seven dedicated scanners including three 3-D enabled machines. All images are stored on a network server and can be reviewed and reported on terminals across the hospital. Maintenance of all TOE probes is provided by the clinical engineering team.

Our anaesthetic trainees benefit from bedside, hands-on TOE teaching and also TOE lectures as part of their structured training programme.

Dr R Stenz and Dr TC Aw have a special interest in TOE and its development.

Education and training

Cardiothoracic anaesthesia

We have an active training programme in all aspects of cardiothoracic anaesthesia. This is led by the college tutor, Dr Arshad Ghori, and includes a comprehensive lecture programme in which protected lectures, journal clubs and case scenarios take place each Wednesday morning. 

In addition, one day per month is devoted to clinical governance, including morbidity and mortality reviews, audit and teaching. Anaesthesia-based adverse incident reporting reviews take place once every three months.  

There is also a weekly cardiovascular grand round aimed at showcasing innovations and clinical care within the Trust and a range of other teaching opportunities within other departments to which the anaesthetic trainees are welcomed.

All members of staff have access to the Imperial College, National Heart & Lung Institute and departmental libraries. In addition, the trainees have their own reading room in which five computers with full search facilities and internet access are available for their sole use. 

The Trust runs regular EPLS and ALS courses and all trainees are encouraged to maintain current certification.  

Dr M Hodson is the director of medical education for the Trust. 

Simulation training

The simulated paediatric resuscitation team training programme (SPRinT) uses the most advanced simulation baby and child mannequins to recreate life-threatening events and runs regular paediatric simulations throughout the hospital to improve multi-disciplinary team performance in time-critical situations. Crash trolleys, resuscitation equipment and real drugs are used to create scenarios that are as true to life as possible.

The SPRinT programme was recognised for advancing simulation resuscitation training to cardiothoracic inter-professional teams through the development of novel tools, including the patented open-chest Harley model, the open-chest ECMO model and an innovative adult open-chest model to promote patient safety and enable rapid responses to critically ill adults. Dr M Lane leads the programme in the anaesthetic department.

The department also provides simulation for thoracic surgery (Dr S Trenfield) and transoesophageal echocardiography (Dr TC Aw).