Residents’ Review: In the ICU

< Back

October 1, 2013 Volume 77, Number 10
Residents’ Review: In the ICU Aditya Venkataraman, M.D.

The current mantra surrounding physician anesthesi-ologists reiterates that perioperative medicine is the new paradigm. Suffice it to say, we must be actively involved in preoperative, intraoperative and postoperative care. While pre- and intraoperative management of surgical patients is indubitably our realm, the postoperative phase for our sickest patients is much more nebulous domain. The reality is that numerous specialties care for patients in the postoperative ICU setting, immediately after an anesthesiologist has transferred care. Internal medicine, general surgery, emergency medicine and anesthesiology have all laid claim to the intensive care medicine landscape. With so many specialties included, the debate ensues regarding which faction is best-suited to care for these critically ill patients. Which specialty provides the greatest facility and skill-set to care for these patients? Objectively speaking, anesthesiology sits atop this virtual totem pole. As the bridge between all surgical and internal medicine specialties, we possess the ideal skill-set to care for multiple critically ill patients simultaneously. While each ICU patient may present a wide variety of medical challenges, including medical, surgical, trauma, cardiothoracic, transplant, burn, neurological or even pediatric issues, the basic tenets of intensive care medicine remain universal. Irrespective of the type of ICU to which a critically ill patient is admitted, critical care mandates application of decisive differential diagnoses and implementation of treatment algorithms in a swift and methodical manner. The congruency between this skillset and that of the anesthesiologist on a day-to-day basis is profound and undeniable.

Conversely, the acumen and clinical skillset acquired from the practice of intensive care medicine can be directly translated into the field of intraoperative medicine. The practice of anesthesiology could just as aptly be described as the practice of acute physiology. ICU medicine reinforces the ultimate goal of organ system homeostasis in the perioperative setting. The anesthesiologist also gains a more sophisticated understanding of physiology outside of the cardiovascular and pulmonary system. The implications of intraoperative management on long-term renal function, fluid balance, postoperative infection and even chronic pain are elucidated, and anesthesiologists may practice with greater thoughtfulness and understanding in the operating room.

The American Board of Anesthesiology mandates a minimum of four months of ICU training for all anesthesiology trainees enrolled in ACGME-accredited residencies. However, the current landscape of perioperative medicine strongly suggests that anesthesiologists ought to assume a much greater role in the tapestry of postoperative care. We are intimately familiar with intraoperative events and their implications on the greater perioperative course. We are experts in airway management, treatment of acute cardiovascular and pulmonary derangements, prudent transfusion of blood products and acute pain management. If the >sine qua non of the anesthesiologist is vigilance at all times, then this >modus operandi translates directly to the ICU setting on a much broader scale. Above all else, the dogma of intraoperative medicine requires decisive, swift and thoughtful intervention. The core of anesthesiology residency training instills these exact skills on a daily basis. Thus, the requisites for care of a critical care population become second nature, enabling care for a multitude of patients.

The bridge between the various subspecialties of medicine and surgery separates physician anesthesiologists from the myriad other specialties involved in critical care medicine. We garner a most unique perspective ideally suited for direct care of a perioperative, critically ill patient. Now is the time for residents in training to embrace this opportunity and expand upon an already robust armamentarium and pursue extended training in critical care environments, either through electives in residency or formal fellowship training. A burgeoning patient population with ever-increasing co-morbidities mandates the most skilled of physicians with the tools to deliver precise and compassionate care. We, as physician anesthesiologists, must heed the call.

Aditya Venkataraman, M.D. is Anesthesiology Critical Care Fellow (PGY-5), UT Houston Medical School, Houston, Texas.