More than 65 years ago, Dr. Bjorn Ibsen, a Copenhagen anesthesiologist, was savvy enough to recognize the need to create the first ICU – the stimulus for which was the polio epidemic of 1952-53. At that time, over 300 patients a week were being admitted to his hospital in respiratory failure. Many of these patients required positive pressure ventilation and an intensive level of bedside care. Specifically, this initial action by Dr. Ibsen showed value in having an anesthesiologist intensivist to staff critical care units. Despite the field of anesthesiology being at the forefront of creating dedicated medical wards and teams to care for patients, the need for critical care services expanded faster than the number of anesthesiologists being trained.
The Anesthesiologist Intensivist in the ICU and O.R.
We are now training more anesthesiologist intensivists than ever before. Anesthesia critical care medicine fellowship positions in the U.S. have more than doubled (80 in 2008-09 to 196 in 2018-19) over the last 10 years. Fellowship programs in critical care anesthesia (47 in 2008-09 to 62 in 2018-19) have increased as well. More anesthesiology intensivists would mean more critical care-trained anesthesiologists in the O.R. and more anesthesiologist intensivists in the ICU.
What does an anesthesiologist intensivist bring to the O.R.? First, they bring the ability to connect the critical care environment to the O.R. environment in several ways. One manner is on the relationship front – the surgical team would see the same anesthesiologist in the O.R. and the ICU, caring for the same patient. This visualization of continuity of care leads to trust and understanding, well beyond the anesthesiologist intensivist’s theoretical knowledge of critical care medicine. Second, all critical care starts in the O.R.; thus, early, well-planned resuscitation, including invasive monitoring, early goal-directed fluids, lung protective ventilation, and assessment of impending organ system failure would help the ICU team receive a patient who is well optimized and has an ongoing plan moving forward. Third, most intensivists would also have well-acquired point-of-care ultrasound skills, complex ventilation skills (including, but not limited to, mechanical ventilation with high PEEP, newer sophisticated modes and the use of supplemental pulmonary vasodilators if needed). Anesthesiologist intensivists would also have invasive line insertion and management abilities and the comfort of using multiple pressor agents and/or dilators, alone or in combination, for improved outcomes.
What does an anesthesiologist intensivist bring to the ICU? As a continuum of care for the surgical critical care setup, the anesthesiologist intensivist brings the ability to perform bedside point-of-care ultrasound and echocardiography to guide therapy. Other skills of the critical care anesthesiologist are the ease of managing complex airway and advanced mechanical ventilation scenarios, including the perceived ease of handling muscle relaxants while intubating a critically ill patient. An anesthesiologist intensivist in the ICU is also tuned in to the physiology and pharmacology of sedation, muscle relaxants and the complex interplay of these with organ system function. Communication is a key tenet for better clinical outcomes, and the anesthesiologist intensivist in the ICU does have the ability to call in to, or visit, the O.R., prepare for an incoming disaster from the O.R., communicate with the anesthesia team in the O.R. at all times, and help transport critically ill patients back and forth from the O.R.
Anesthesiologist intensivists are trained to be detailed and yet pragmatic when it comes to handling medical information. Being a good communicator and building effective interpersonal relationships are extremely important; this starts with talking to surgeons, other specialists and key members of the team, all of whom need to understand daily plans and goals of care. Anesthesiologist intensivists provide essential information briefly but eloquently, especially since in a difficult circumstance there may be limited time available for this task. In such a situation, it is imperative to ensure that all participants have a full and correct understanding of the facts.
Families of ICU patients have tremendous stress related to their loved one. An anesthesiologist intensivist can provide an appropriate yet empathetic view of “the bigger picture” during goals-of-care discussions. These discussions might encompass a patient in the O.R. and the ICU, as well as life beyond the ICU, rather than focus on minor details that distract the family from the real problem at hand. This relationship building continues in the rounding environment, where the ability of the anesthesiologist intensivist to be a leader of multidisciplinary rounding ICU teams comes to the fore. Similarly, anesthesiologist intensivists lead rapid-response teams, code teams and hospital critical care resuscitation response committees. This creates a strong footprint outside of the ICU environment and continues to build strength and versatility in the specialty. More recently, several anesthesiologist intensivists have taken up leadership roles as directors of entire service lines, thus leading the critical care charge of large hospital systems both within and outside the ICU, as well as across the entire specialty of different critical care units. As directors of surgical operations and critical care service lines, they have the unique ability to connect the O.R. with the ICU on an administrative and operational front, something that few others can boast of.
Perioperative Expertise and Beyond
Timely preoperative discussions should be led by versatile physicians, such as anesthesiologists intensivists, who can speak to the requirements and the course of patients needing postoperative ICU care. Anesthesiologists are involved in preoperative testing and optimization of patients before operations. They see a complete picture of the needs of a high-risk patient during and after surgery, and how surgery and anesthesia can impact the patient’s pre-existing comorbidities. Anesthesiologists trained in critical care, therefore, bridge an important gap between the patient and surgical specialties, in order to plan a course for the patient with the goals of successful completion of surgery and recovery in the ICU. They can also be the perfect physician high-risk patients can talk to about their goals of care. Further, they allow a patient to understand what they may face after surgery, including prolonged postoperative mechanical ventilation, requirement for dialysis, sedation, paralysis, need for invasive lines and prolonged ICU stay, to name a few. It has been shown that this early and thoughtful communication can reduce the rates of tensions and conflicts between surrogates, critical care physicians and critically ill patients. Importantly, most anesthesiology residents rotate through the ICU.
Hence, even a resident’s basic knowledge of the ICU can help enlighten patients regarding their expected experiences. Discussion with an anesthesiologist intensivist can reduce the amount of stress and anxiety patients encounter and make the journey more seamless for the patient, from the anesthesia clinic to the O.R. and then to the ICU and eventually the ward.
Anesthesiologists trained in critical care, therefore, bridge an important gap between the patient and surgical specialties, in order to plan a course for the patient with the goals of successful completion of surgery and recovery in the ICU. They can also be the perfect physician high-risk patients can talk to about their goals of care.
Anesthesia Critical Care: The Future
That the future is bright would be a gross understatement for the specialty of anesthesia critical care. There is a definite need for the anesthesiologist trained in critical care to step up and take charge of ICUs as clinicians, academicians, educators, researchers and medical directors. The essential tenets of the practice of anesthesiology connect well with the practice of critical care. This has already been recognized in Europe, much of Asia and the Australian continent. We, as proud critical care anesthesiologists, need to take ownership of the specialty and own this space, since we are an added value to hospital systems beyond the confines of the four walls of the O.R. and the ICU.