Anaesthesia for heart surgery

You will be seen in the anaesthetic preoperative assessment clinic in the weeks before your procedure by a specially trained nurse or doctor. This is usually done as an online video consultation.

The purpose of this appointment is to help prepare you for your procedure, to make sure we have all the important information about you and your medical care, to book any extra tests or treatment that you may need, and to share information with you about the side effects and risks of general anaesthesia.

We will also ask you about any previous anaesthetics you may have had, and if you had any problems, for example feeling sick or vomiting afterwards. It is also important that you have regular dental check-ups and are seen by a dentist every 6 months. All of this is to make sure that things run as smoothly and as safely as possible on the day.

Please have ready a list of any medications you are taking. This should include all the medications you are taking- not just the ones for your heart- and include medicines like the contraceptive pill. Most medications should be taken as usual before and after your procedure. Sometimes you may need to stop taking certain medications before a procedure. You will be given clear instructions if this is necessary.

We also need to know about smoking, vaping, alcohol and drugs, because these can affect your anaesthetic. Sometimes it can be uncomfortable talking about certain things in front of your parents or carer-givers. You may prefer to talk to doctors and nurses on your own. You will have the opportunity to speak to a member of the anaesthetic team on your own, if that is something you feel you would like to do.

At the appointment we will talk you through what to expect when you come for your anaesthetic. It is a good time to ask us any questions you may have. If you are worried about anything, please let us know and we will do our best to explain things and to hopefully make you feel less anxious.

If you feel unwell in the days or weeks before your procedure, please call us to let us know. Please let us know if you have any of the following:

• Coughs or colds
• High temperature or chills
• Vomiting or diarrhoea
• New skin rash (for example, chicken pox or shingles)

Having an infection can increase the risks of anaesthetic. Therefore, it is very important that you tell us if you have any symptoms. If the procedure can wait, it will be safer to postpone it until you are feeling better. If the procedure is urgent, we will weigh up the risks and benefits of postponing the procedure versus going ahead.

It is very important that you follow the instructions given to you about when to stop eating and drinking before your anaesthetic. This is so that your stomach is empty to reduce the risk of vomiting during the procedure.

You will be provided with specific times at which you should stop eating and drinking depending on the time of your procedure. In general, you should stop eating food 6 hours before your procedure, and you should stop drinking clear fluids (like water, or pulp-free fruit juice) 1 hour before your procedure. In certain heart conditions it is very important that you stay well hydrated and if that is the case, we will tell you to make sure to keep drinking plenty of water.

You should continue to take your regular medications with a sip of water during this time, unless instructed otherwise by a member of your healthcare team.

Piercings can heat up and burn the skin during operations.

Please remove all piercings before your procedure and leave them at home for safe keeping.

If you have piercings that might close up in a short space of time- for example tongue piercings or new piercings- please replace these piercings with a plastic bar. Please let the anaesthetic team know if you have a tongue piercings so we can be extra careful with it during your anaesthetic.

You will be seen by an anaesthetist shortly before your procedure. They will ask you questions about you and your health and will go over what was discussed in the cardiac anaesthetic preoperative assessment clinic.

Important things to tell us are:

• When you last ate and drank.
• If you feel unwell, or if you have been unwell in the last few weeks.
• What medications you are taking, and when you last took them.
• Any allergies you have.
• If you’ve had any issues after previous anaesthetics (e.g. feeling sick or vomiting).
• If you have loose teeth or dental work (e.g. braces, caps, crowns).
• If you might be pregnant.

We routinely screen for pregnancy in all girls aged 12 and older. We will ask you to go to the toilet and wee into a sample pot so we can test your urine. Please don’t go to the toilet just before you arrive on the ward, or there won’t be any urine left for us to test!

It is completely normal to feel anxious or worried when you come to the hospital. You are not the only one. Most people do. The anaesthetic team are highly trained and experienced to look after you, so try not to worry too much. We will do our very best to help you through the day every step of the way. Most people can overcome their nerves with the support of their parents or carers, doctors and nurses. In some cases, if you are feeling very anxious or overwhelmed, we can consider a giving you medication (we call them “premeds”) before you come for your procedure. It will help you relax and hopefully make things a little less stressful. You can ask us for this, or we will offer you this on the day if we think it will be useful.

You can bring one, or both of your parents/ carers with you to the anaesthetic room. Or you can come without them if you prefer- it is up to you. You can also bring anything you think will help distract or relax you, like your phone or tablet.

For most older patients and teenagers, we will put a cannula (a thin tube connected to a ‘drip’) in the back of your hand or forearm before you go off to sleep. This can be done on the ward or when you come to the anaesthetic room. We can put some numbing cream on beforehand to reduce any discomfort, and with this, most people don’t find the cannula too bad. We then use this cannula to give you the anaesthetic medication that will drift you off to sleep nice and quickly.

The other option is for you to breathe in and out an anaesthetic gas through a facemask. This usually takes a minute or two. It can take a little longer, the bigger you are.

In some cases, for example certain heart conditions, it is safer to go off to sleep with the cannula, rather than the anaesthetic gas. Depending on your heart condition we will advise you what the best option is for you.

Before you go off to sleep, we will put some monitors on:

• A cuff will be placed on your upper arm to monitor your blood pressure.
• Stickers will be placed on your chest to monitor your heart rate and rhythm.
• A clip will be placed on your finger to monitor your oxygen levels.

When you are asleep, we will place some additional monitoring to help us to keep you safe during your operation:

Arterial line

We will insert a cannula into an artery, usually in your wrist but sometimes elsewhere, to allow us to monitor you blood pressure very closely during your operation. They usually do not cause any problems. In rare cases the artery may become damaged or blocked, which can affect the blood flow to your arm or leg. In the unlikely event that this were to occur, it usually resolves with removal of the arterial line. Sometimes it may require treatment. It is extremely rare for any permanent harm, such as limb damage, to occur because of an arterial line.

Central line

This is a catheter that we insert it into a large vein in the neck or groin. It allows us to monitor the pressure in your heart and give medications to support your heart and blood pressure that can’t be given elsewhere. We use sterile precautions and an ultrasound to see during the procedure, to reduce the risk of complications.

Complications can include:

• Infection which will require antibiotics and possibly line removal
• Blood clot in the vein which may require blood-thinning medications or line removal
• Bleeding
• Injury to the lung
• Abnormal heart rhythm

Transoesophageal echocardiography (TOE)

An ‘echo’ is a type of scan used to look at the heart and nearby blood vessels. We may insert a probe through your mouth into your oesophagus to perform an echo during the procedure. This carries a very small risk of damage to your oesophagus, tongue, teeth and lips.

An anaesthetist will stay with you the whole surgery. They will make sure you are asleep throughout, monitor you to make sure you are safe and comfortable, and will wake you up at the end when it’s all done.

Most young people will receive a blood transfusion and/ or other blood components during cardiac surgery. This is to stop you becoming anaemic and to help the blood clot after surgery. Anaemia is the medical word for when you have a low amount of haemoglobin in your blood which means your blood can’t carry as much oxygen as it should do.

When your operation is finished, we will bring you to the cardiac intensive care unit (CICU) where you will be looked after. In some cases, we will wake you up in the operating room, make sure you are comfortable, and then transfer you to CICU. In other cases, we will bring you to CICU still asleep. You will then wake up at a later time on CICU.

Very occasionally during cardiac surgery we use an anaesthetic medication called Sugammadex. Sugammadex can interact with the hormone progesterone and so can reduce the effectiveness of the progesterone-only pill (“mini pill”), the combined pill, implants and intra-uterine devices. This medication is not always used, but if it is, and you are using hormonal contraception, you should be aware of the risk of contraception failure. Please let your anaesthetist know if you are using hormonal contraception so that we can offer you appropriate advice. If you are taking the contraceptive pill, you should follow the missed pill advice from your GP or the information leaflet that comes with your pill. If you are using another type of hormonal contraception, you should use additional methods of contraception, such as condoms, for 7 days.

Anaesthesia is extremely safe in most cases. Certain heart conditions can increase the level of risk involved. Your anaesthetist will discuss this with you and will tailor your anaesthetic to you to make it as safe as possible. This list is a general description of the risks of anaesthesia.

Common side effects include:

• Feeling sick, maybe vomiting
• Sore throat
• Feeling dizzy or confused
• We have medications to help if you are feeling sick. The other side effects usually resolve quickly on their own.

Uncommon side effects include:

• Breathing problems, sometimes needing treatment, or extra time in hospital for observation
• Brusing or damage to skin or lips

Even rarer side effects include:

• Eye injury
• Damage to teeth

Very serious complications of anaesthesia are extremely rare and include:

• Having a bad allergic reaction
• Awareness during a surgery
• Death or disability

It is important to remember that there will be a highly trained anaesthetist with you the entire time to monitor you, to make sure you are asleep throughout the procedure, and to make sure you are as safe as possible.

For perspective, the risk of death as a direct result of an anaesthetic in a healthy person is between 1 in 100,000 and 1 in 1,000,000 (1 million). This is similar to the risk of being killed by lightning.