Critical Care During the Coronavirus Crisis—Reflections on the Roles of Anesthesiologists in Meeting the Challenges of the Pandemic

Abstract

ANESTHESIOLOGISTS across the United States have a rich history in critical care that spans more than 60 years. The American Board of Anesthesiology first offered certification in critical care in 1986.1Hanson 3rd, CW Durbin CG Maccioli GA et al.The anesthesiologist in critical care medicine: Past, present, and future.Anesthesiology. 2001; 95: 781-788Crossref PubMed Scopus (41) Google Scholar This development followed an unsuccessful attempt to create a unified board certification process for all critical care physicians from various backgrounds, including anesthesiology, internal medicine, pediatrics, and surgery.1Hanson 3rd, CW Durbin CG Maccioli GA et al.The anesthesiologist in critical care medicine: Past, present, and future.Anesthesiology. 2001; 95: 781-788Crossref PubMed Scopus (41) Google Scholar,2Napolitano LM Rajajee V Gunnerson KJ et al.Physician training in critical care in the United States: Update 2018.J Trauma Acute Care Surg. 2018; 84: 963-971Crossref PubMed Scopus (11) Google Scholar Since the introduction of board certification, the participation of anesthesiologists in critical care has not kept pace with that by other specialists from emergency medicine, internal medicine, and surgery who have expanded their role in adult critical care, including cardiothoracic critical care.1Hanson 3rd, CW Durbin CG Maccioli GA et al.The anesthesiologist in critical care medicine: Past, present, and future.Anesthesiology. 2001; 95: 781-788Crossref PubMed Scopus (41) Google Scholar, 2Napolitano LM Rajajee V Gunnerson KJ et al.Physician training in critical care in the United States: Update 2018.J Trauma Acute Care Surg. 2018; 84: 963-971Crossref PubMed Scopus (11) Google Scholar, 3Stoltzfus DP Watson CB Ries MC Anesthesiology critical care medicine fellowship training.Anesth Analg. 1995; 81: 441-445PubMed Google Scholar This lack of growth prompted concerns about the future of anesthesiologists in critical care both in the 1990s and early in the new millenium.1Hanson 3rd, CW Durbin CG Maccioli GA et al.The anesthesiologist in critical care medicine: Past, present, and future.Anesthesiology. 2001; 95: 781-788Crossref PubMed Scopus (41) Google Scholar,3Stoltzfus DP Watson CB Ries MC Anesthesiology critical care medicine fellowship training.Anesth Analg. 1995; 81: 441-445PubMed Google Scholar It is likely that the participation of anesthesiologists in critical care throughout the United States continues to be highly variable depending on multiple factors, including sex, opportunities, and location.4Nwozuzu A Fontes ML Schonberger R Mobile extracorporeal membrane oxygenation teams: The North American versus the European experience.J Cardiothorac Vasc Anesth. 2016; 30: 1441-1448Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 5Lane-Fall M Miamo TA Aysola J et al.Diversity in the emerging critical care workforce: Analysis of demographic trends in critical care fellows from 2004 to 2014.Crit Care Med. 2017; 45: 822-827Crossref PubMed Scopus (22) Google Scholar, 6Capdeville M Ural KG Patel PA et al.The educational evolution of fellowship training in cardiothoracic anesthesiology: Perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2018; 32: 607-620Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The current coronavirus pandemic and its catastrophic consequences have highlighted the imperative for anesthesiologists to be key stakeholders in critical care.7Augoustides JG Critical care during the coronavirus crisis – challenges and considerations for the cardiothoracic and vascular anesthesia community [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Google Scholar In areas hit by the full intensity of the pandemic, anesthesiologists have converted postanesthesiology care units into intensive care units; deployed anesthesia machines as ventilators; and created acute- care teams to address the unique challenges of clinical care in this setting, including airway management.7Augoustides JG Critical care during the coronavirus crisis – challenges and considerations for the cardiothoracic and vascular anesthesia community [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Google Scholar, 8Sommer P Lukovic E Fagley E et al.Initial clinical impressions of the critical care of COVID-19 patients in Seattle, New York City, and Chicago [E-pub ahead of print].Anesth Analg. 2020; Crossref PubMed Scopus (34) Google Scholar, 9Chopra V Toner E Waldhorn R et al.How should US hospitals prepare for coronavirus disease 2019 (COVID-19) [E-pub ahead of print].Ann Int Med. 2020; Crossref Scopus (103) Google Scholar, 10Christian MD Sprung CL King MA et al.Triage care of the critically ill and injured during pandemics and disasters.Chest. 2014; 146: e615-e745Google Scholar, 11Dries D Reed MJ Kissoon N et al.Special populations: Care of the critically ill and injured during pandemics and disasters: Chest consensus statement.Chest. 2014; 146: e755-e865Abstract Full Text Full Text PDF Scopus (20) Google Scholar Beyond direct clinical care in the frontlines of the pandemic, anesthesiologists also are leading operations for surge planning, educating physicians about ventilator management, and designing guidelines for sedation and analgesia in patients with coronavirus 2019.10Christian MD Sprung CL King MA et al.Triage care of the critically ill and injured during pandemics and disasters.Chest. 2014; 146: e615-e745Google Scholar, 11Dries D Reed MJ Kissoon N et al.Special populations: Care of the critically ill and injured during pandemics and disasters: Chest consensus statement.Chest. 2014; 146: e755-e865Abstract Full Text Full Text PDF Scopus (20) Google Scholar, 12Phua J Weng L Ling L et al.Intensive care management of coronavirus disease (COVID-19): Challenges and recommendations.Lancet Resp Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (887) Google Scholar As of 2018, fewer than 4% of anesthesiologists in the United States had board certification in critical care (data provided by the American Board of Anesthesiology upon the authors’ request; data received June 17, 2019). As a comparison, more than 10% were board certified in pain medicine, and 6% were board certified in pediatric anesthesiology, and although low, there has been some growth in in the prevalence of anesthesiologists who are board certified in critical care in the past 25 years, given that in 1986 fewer than 2% of anesthesiologists had subspecialty certification in critical care, according to the data from the American Board of Anesthesiology. The focus on critical care due to the coronavirus pandemic might further stimulate an interest in board certification in this specialty, given the inspiring roles of anesthesiologists in leading and providing care on the frontlines.13Augoustides JG Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 14Augoustides JG Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Abstract Full Text Full Text PDF Scopus (15) Google Scholar, 15Zhao S Ling K Yan H et al.Anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedures [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Google Scholar, 16He Y Wei J Bian J et al.Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019.J Cardiothorac Vasc Anesth. 2020; 24: 1397-1401Abstract Full Text Full Text PDF Scopus (31) Google Scholar This possible surge in demand for fellowship training in adult critical care could be met by the steady growth in fellowship opportunities across the United Stattes.17San Francisco Match. Critical care anesthesiology fellowship. Available at: https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=25&typ=1&name=CriticalCareAnesthesiology#. Accessed April 25, 2020.Google Scholar According to statistics from San Francisco Match, the number of critical care fellowships in the United States has grown by 21.3% from 47 programs in 2014 to 57 programs in 2018.17San Francisco Match. Critical care anesthesiology fellowship. Available at: https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=25&typ=1&name=CriticalCareAnesthesiology#. Accessed April 25, 2020.Google Scholar The number of fellowship positions offered also has grown accordingly, by 39.3% from 150 positions in 2014 to 209 positions in 2018.17San Francisco Match. Critical care anesthesiology fellowship. Available at: https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=25&typ=1&name=CriticalCareAnesthesiology#. Accessed April 25, 2020.Google Scholar This growth also has occurred in adult cardiothoracic anesthesiology, with a 22.2% increase in programs from 54 in 2014 to 66 in 2018.18San Francisco Match. Adult cardiothoracic anesthesiology fellowship. Available at: https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=24&typ=1&name=Adult%20Cardiothoracic%20Anesthesiology#. Accessed April 25, 2020.Google Scholar The number of fellowship positions in adult cardiothoracic anesthesiology also has increased by 33.3% from 168 positions in 2014 to 224 positions in 2018.18San Francisco Match. Adult cardiothoracic anesthesiology fellowship. Available at: https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=24&typ=1&name=Adult%20Cardiothoracic%20Anesthesiology#. Accessed April 25, 2020.Google Scholar The growing interest in cardiothoracic critical care also may be boosted by the pandemic, thereby encouraging aspiring fellows to train both in critical care and cardiothoracic anesthesiology at a time when capacity is higher than ever before.19Neelankavil J Goeddel LA Dwarakanath S et al.Mentoring fellows in adult cardiothoracic anesthesiology for academic practice in the contemporary era – perpsectives from mentors around the United States.J Cardiothorac Vasc Anesth. 2020; 34: 521-529Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Recently, we performed an electronic survey of leaders in academic anesthesiology departments in conjunction with the Society of Academic Associations of Anesthesiology and Perioperative Medicine. In this survey, more than 75% (23/30) of respondents noted that a critical care anesthesiologist held a system-wide leadership position at his or her respective institution. These positions included chief operating officer, senior vice president, and chair for critical care medicine in their respective hospitals. Furthermore, all respondents viewed having an anesthesiology presence within adult critical care medicine as positive. Respondents were mixed about the financial implications of anesthesiologists practicing critical care, with 23.3% (7/30) stating that it required additional financial support, 30% (9/30) stating that it garnered additional revenue, and 46.7% (14/30) having a neutral position. Upon completion of the survey, respondents also described their vision for critical care within anesthesiology. From a total of 23 free text responses, 5 major themes could be defined as follows: further encouragement of resident interest; greater expansion into cardiothoracic critical care; the importance of critical care to the future of anesthesiology; the priority for greater support and recognition; and boosted ownership in critical care medicine by anesthesiologists (Table 1). Notably, a major theme is the ongoing expansion of critical care anesthesiologists into cardiothoracic critical care with concomitant integration of extracorporeal membrane oxygenation into the practice of perioperative medicine.13Augoustides JG Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Abstract Full Text Full Text PDF Scopus (13) Google Scholar,14Augoustides JG Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [E-pub ahead of print].J Cardiothorac Vasc Anesth. 2020; Abstract Full Text Full Text PDF Scopus (15) Google ScholarTable 1Major Themes in the Future of Critical CareThemeTypical ExamplesFoster trainee interest•“We need more residents interested in the specialty - applicant pool very shallow, inadequate to fill programs.”•“I think there is an increasing demand and we should be encouraging more of our graduates to pursue critical care training.”•“It will be bright if more of our young people participate.”Expansion into cardiothoracic critical care•“We are the people placing cannulas for extracorporeal membrane oxygenation, and running the cardiothoracic intensive care unit.”•“Critical care anesthesiologists are more in demand than when I graduated, particularly in the cardiothoracic intensive care units.”•“Absolutely with the success in adult extracorporeal membrane oxygenation, we now have nearly 15 intensive care/cardiothoracic anesthesiologists who participate in placement of ECMO cannulas, care for the sickest patients in the hospital, and provide a 24 hour echocardiography service. This is the future of anesthesia.”•“Also anesthesiologists have become the main providers of cardiac surgery critical care and seem to have a unique role in this environment.”Future practice of anesthesiology•“The future of operating room anesthesia for anesthesiologists is uncertain, but there will always be critically ill patients to care for.”•“Essential, central to the survival of the specialty.”•“Essential to the future of the specialty.”•“I think it is very positive and should be promoted. It helps define all anesthesiologists as doing more than working in the operating room and certainly separates us from others who want to do our jobs providing operative anesthesia.”•“Unlimited potential in academic and private practice.”•“Future is bright, with increasing demand for our services.”•“I personally see a future where more providers are dual anesthesiologist-intensivists.”Priority for support•“Potentially an expanding presence, but it will require the entire specialty to emphasize the importance of this aspect of training.”•“The balance of power between the departments and departmental leadership support must be fully established to enable secure time in the intensive care unit.”Bigger footprint in critical care landscape•“All anesthesiologists should be critical care physicians.”•“We have to own this.”•“It should be at the forefront of the specialty.”•“We need to increase our presence in the field of critical care to be harmonious with our European colleagues who are the primary providers and leaders in their intensive care units.”Abbreviation: ECMO, extracorporeal membrane oxygenation. Open table in a new tab Abbreviation: ECMO, extracorporeal membrane oxygenation. As the coronavirus crisis continues, the roles of anesthesiologists outside the operating room environment will expand and add value across their health systems. The response to the crisis likely will grow the roles of anesthesiologists in critical care, including the cardiothoracic arena. It will remain important to harmonize this growth with developments in the critical care landscape, including calls for refined training certification requirements.20Tisherman SA Spevetz A Blosser SA et al.A case for change in adult critical care training for physicians in the United States: A white paper developed by the Critical Care as a Specialty Task Force of the Society of Critical Care Medicine.Crit Care Med. 2018; 46: 1577-1584Crossref PubMed Scopus (13) Google Scholar Furthermore, there also are opportunities for adult cardiothoracic anesthesiology to learn from the European experience in fellowship development as the evolution in this subspecialty continues.21El Tahan MR Mendoza Vasquez LE Alston RP et al.Perspectives on the fellowship training in cardiac, thoracic, and vascular anesthesia and critical care in Europe from program directors and educational leads around Europe.J Cardiothorac Vasc Anesth. 2020; 34: 512-520Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The challenges ahead for fellowships in adult cardiothoracic anesthesiology include board certification and better integration with cardiothoracic critical care.22Capdeville M Hargrave J Patel PA et al.Contemporary challenges for fellowship training in adult cardiothoracic anesthesiology: Perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2020 Feb 11; ([E-pub ahead of print])Abstract Full Text Full Text PDF Scopus (10) Google Scholar,23Troianos CA The time is now for board certification in cardiac anesthesia.J Cardiothorac Vasc Anesth. 2020; 34: 5734Abstract Full Text Full Text PDF Scopus (3) Google Scholar This dynamic interface between cardiothoracic anesthesiology and critical care offers multiple opportunities for both subspecialties to harmonize, thrive, and strengthen their clinical impact and delivered value. None. The authors thank the Society of Academic Associations of Anesthesiology and Perioperative Medicine for survey distribution.