ASCCA: Supporting Critical Care at a Critical Time

he American Society of Critical Care Anesthesiologists (ASCCA) is a subspecialty organization within the greater ASA. ASCCA is the only professional association exclusively devoted to critical care medicine as practiced by anesthesiologists. Any anesthesiologist with an interest in care of the critically ill patient, however, is welcome to join.

Research
It is an exciting time to be an intensivist! Over the past decade we have learned that: 1) patients suffering from either acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) when ventilated with a tidal value of 6 ml/kg ideal body weight will have reduced mortality and increased ventilator-free days compared to patients ventilated with a tidal value of 12 ml/kg ideal body weight;¹ 2) postoperative “tight” glucose control in intensive care unit (ICU) patients will reduce morbidity and mortality;² 3) treatment with human recombinant activated protein C (drotrecogin alfa activated) reduces mortality in patients with severe sepsis and septic shock whose APACHE II scores are greater than 25;³ 4) elevation of the head of the bed in ventilated patients will reduce the incidence of nosocomial pneumonia;⁴ 5) use of “stress” doses of hydrocortisone will reduce the duration of vasopressor support and mortality in patients with septic shock;⁵ and 6) implementation of a multifaceted intervention program⁶ and use of catheters impregnated with antiseptics or antibiotics⁷ will reduce the risk of the development of catheter-related bloodstream infection. Anesthesiology-based intensivists were active researchers in a number of these seminal studies! Equally important, each of these studies affects the practice of operating room anesthesiology in some fashion.

Progress will continue in the care of our patients in the ICU. Much of that progress will come from basic science and clinical research. ASCCA is committed to providing support for ongoing research. With gracious financial means from Abbott Laboratories, ASCCA has partnered with the Foundation for Anesthesia Education and Research (FAER) to provide a yearly grant (ASCCA-FAER-Abbott Laboratories Physician Scientist Award) on a competitive basis to young anesthesiologists investigating issues of importance to the care of critically ill patients. Our most recent recipient is Pratik P. Pandharipande, M.D., from Vanderbilt University School of Medicine. The title of his grant is “A Randomized, Double Blind Trial in Ventilated ICU Patients Comparing Treatment With an a2 Agonist versus a Gamma Aminobutryic Acid (GABA)-Agonist to Determine Delirium Rates, Efficacy of Sedation and Analgesia and Clinical Outcomes Including Duration of Mechanical Ventilation and 3-month Cognitive Status.” Since it has been recently shown that delirium is an independent risk factor for death in the ICU,⁸ Dr. Pandharipande’s research plan is particularly timely. His research findings may well impact how anesthesiologists care for patients coming from or going to the ICU.

Education
“The Resident’s Guide to the Intensive Care Unit” is an educational resource for anesthesiology residents that ASCCA developed more than a decade ago. It is now in the process of its third revision under the editorship of William E. Hurford, M.D., F.C.C.M. (University of Cincinnati) and Associate Editors Daniel S. Talmor, M.D. (Beth Israel Deaconess Medical Center, Boston, Massachusetts), Lawrence J. Caruso, M.D. (University of Florida) and J. Steven Hata, M.D. (University of Iowa). The goal is to change the guide to follow the new training requirements proposed by the Residency Review Committee for Anesthesiology of the Accreditation Council for Graduate Medical Education, e.g.: a) progressive curricula for residents and ICU fellows and b) have the document competency based. In addition the guide will ultimately be Web-based with hyperlinks to pertinent articles.

Membership
As noted previously, ASCCA welcomes any anesthesiologist for membership, not just intensivists. While the number of anesthesiologists practicing critical care medicine is in transition (see other articles in this NEWSLETTER), and the numbers are expected to grow, one of the missions of ASCCA is the education of all anesthesiologists in caring for the critically ill.

Advocacy
ASCCA is an active member of the Critical Care Workgroup (CCWG), which is a consortium of the six national specialty societies with interests in the practice of critical care medicine. The CCWG represents the economic interests of intensivists to the Centers for Medicare & Medicaid Services and the Relative Value Scale Update Committee.

Annual Meeting
The ASCCA Annual Meeting will be held on Friday, October 13, 2006, before the start of the ASA Annual Meeting. Program Co-chairs Louis Brusco, M.D., F.C.C.M., and Michael F. O’Connor, M.D., have posted the preliminary program at our Web site <www.ascca.org>. The meeting promises to be exciting and highly educational. Finally we are encouraging departmental chairs and program directors to sponsor one CA-2 resident to attend our meeting. Each resident who attends will be paired with a senior ASCCA member during the meeting to foster growth of our subspecialty.


References:
1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000; 342(18):1301-1308.
2. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patient. N Engl J Med. 2001; 345(19):1359-1367.
3. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001; 344(10):699-709.
4. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004; 32(6):1396-1405.
5. Annane D, Sebille V, Charpentier C, et al. Effect of Treatment With Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients With Septic Shock. JAMA. 2002; 288(7):862-871.
6. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004; 32(10):2014-2020.
7. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med. 1999; 340(1):1-8.
8. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004; 291(14):1753-1762.

Stephen O. Heard, M.D., F.C.C.M., is Professor and Chair, Department of Anesthesiology, University of Massachusetts Medical Center and University of Massachusetts Medical School, Worcester, Massachusetts.

Gerald A. Maccioli, M.D., F.C.C.M., is ASA Director for North Carolina, and Chair, ASA Committee on Critical Care Medicine.