ANAESTHESIA, PAIN & INTENSIVE CARE www.apicareonline.com CONTROVERSIES Its the anesthesiologists who are the best ones to run an ICU: against Carlos R Degrandi Oliveira, MD, MSc, TSA, Santos, Brazil ABSTRACT Carlos R Degrandi Oliveira, Av. Historically the contribution of anesthesiology is undeniable, however, often related Epitácio Pessoa, 131 ap. 104, perioperative practical skills are not the only components of intensive care. Today, the Santos, São Paulo, Brazil skills of a trained intensivist have enormous diversity. Actually too big to be owned 11045-301; by a classic specialty, whatever. Intensive medicine has become a unique, complex Phone: +55 13 991529799; multidisciplinary profession with different backgrounds transcending a host of other E-mail: [email protected] specialties. Anesthesiology could be a leader in some contexts, however, seems to be a leadership to be regained, in other scenarios, intensive medicine is already hopelessly Correspondence: individualized, and stands out. Considering the heterogeneous development and Carlos R Degrandi Oliveira, Av. policies around the world, currently no other specialty is in a position to consider itself Epitácio Pessoa, 131 ap. 104, naturally competent to assume the responsibility of conducting an ICU. Santos, São Paulo, Brazil 11045-301; Key words: Anesthesiology; Care unit, Intensive; Care, Intensive Phone: +55 13 991529799; E-mail: [email protected] Citation: Oliveira CRD. Its the anesthesiologists who are the best ones to run an ICU: Received: 14 Sep 2018 against.Anaesth Pain & Intensive Care 2018;22 Suppl 1:S9-S12 Reviewed: 10 Nov 2018 Corrected & Accepted: 12 Nov 2018 The poliomyelitis epidemic in Copenhagen in the idea of keeping severely ill patients together in 1952 was an early milestone in the creation of the one place.1,2 current intensive care units. Bjorn Ibsen (1915- In the early days of intensive medicine, the main 2007), an anesthesiologist, noted that the negative objectives were to treat the complications resulting pressure respirator commonly used at that time from the prim ary disease: to maintain breathing was unable to provide adequate ventilation to the and circulati on. Specialists in internal medicine, patients’ lungs. Ibsen then administered intermittent nephrology, infectious diseases, neurology and others positive pressure ventilation with the aid of a manual were routinely needed, each covering their own area ventilation bag attached to an endotracheal tube with of expertise.2 a cuff or tracheostomy cannula. Early it was observed that this conduct associated with physiotherapy Anesthesiologists have not always been in leadership. under blood gas control would reduce mortality. In many cases , hospitals wanted more than one Manual ventilation of patients was performed by unit and form ed a group of intensive care units, teams of medical students who took turns and allowed each speciali zing in different surgical and medical the survival of several patients. Subsequently, it was disciplines. This modality had disadvantages. also applied in patients with drug overdoses, tetanus Patient care was fragmented, causing management and chest trauma with improvement in survival. It difficulties. Specialized intensive care units were well was the embryo of the ICU that arose largely as a developed in their field of interest. However, when consequence of the anesthesiologist’s experience patients deve loped problems outside that area of in artificial ventilation and in the application of expertise, they were not adequately treated.2 equipment and techniques for purposes other than The discussio n on the subject passes through the the administration of anesthetics. Epidemics and formation of the intensivist. Currently, despite the other catastrophes of the last century have reinforced recognition of the broad mix of skills required, over S9 ANAESTH, PAIN & INTENSIVE CARE; VOL 22(Suppl) October 2018 the decades, the evolution of intensive medicine comfort and recovery, end of life, pediatric care, training programs has remained highly variable, patient transportation, safety, management and often fragmented and unable to provide a uniform professionalism.6,7 combination of skills and competencies. Anesthesiology includes anesthesia, perioperative Australia was a pioneer in establishing formal care, intensive care medicine, emergency medicine qualifications for intensivists, and the Australian and pain therapy, and is recognized as one of the Faculty of Anaesthesists organized the first leading medical specialties in the treatment of patient examination for intensivists in 1979. In the USA safety issues.8 Because of its history and singularities, and many European countries, several surgical and anesthesiology is the specialty most often linked to medical specialties as well as anesthesiology have intensive medicine.9,10 developed their own training programs resulting in The contribution of anesthesiology is undeniable, intensive care subspecialties within a major specialty. however, often related perioperative practical skills In the Nordic countries and in Italy, intensive are not the only components of intensive care. Today, medicine has developed as a natural extension of the skills of a trained intensivist have enormous anesthesiology.3 diversity. In fact too big to be owned by a classic Intensive medicine was established as a primary specialty, whatever. specialty in Spain and Switzerland. In 10 countries The days have passed, and a good intubation ability of the European Union, intensive medicine can be has not long been a good anesthesiologist, nor a good practiced as a specific qualification with a common intensivist. The competence needed to cope with the training program for specialists with certification critical conditions gradually changed and different in several basic disciplines (anesthesiology, cardiac skills, apparently belonging to other specialties, surgery, cardiology, internal medicine, neurology, became crucial in the practice of intensive medicine.11 neurosurgery, pediatrics, respiratory medicine Although intensivists may have a different specialty and surgery). A specific qualification is an area of or specific field of interest, they should have broad specialization as well as a major specialty qualification knowledge of the skills needed to treat the patient in which extra specialization is required outside the as a whole, and these have increased dramatically mainstream field to provide high quality patient in recent years. Intensivists routinely perform care. In the remaining 17 countries of the European hemofiltration, ultrasound, ECMO, bronchoscopy, Union and the other two countries in the economic parenteral nutrition, antibiotic therapy and many area, intensive medicine is part of the anesthesiology other complex treatments in their daily practice. training program, among others, with different training periods ranging from 6 to 24 months. The Anesthesiologists-intensivists are in small numbers, training program for anesthesiology also varies from as is the case in the USA. In 2001 less than 4% of 36 to 72 months in these countries.4 the 25,000 board-certified anesthesiologists have the Certificate of Special Competence in Critical Care. The United Kingdom is a pioneer in Europe in Of the 7,800 members of the Society of Critical Care the development of competency-based training Medicine, approximately 35% are internists, 25% are in intensive care medicine with access to various surgeons, and only 12% are anesthesiologists.12 Of the basic skills. This approach emphasizes skills and 56,345 physicians certified in anesthesiology in 2016, competencies, not just knowledge.3,5 only 2,153 (3.8%) are also diplomates in critical care Competency-based training has been supported by medicine.13,14 the European Union, and the European Society of According to some authors intensive medicine in Intensive Care Medicine has played a leading role the USA suffers from a complex identity crisis. To in its development. In this case, the duration of begin with, physicians of other specialties tend to the training depends on the individual time spent be ambiguous about the role of intensivists, and the on the achievement of each specific competency. general population is not aware of their duties. In The CoBaTrICE (International Competency Based contrast to traditional specialties such as cardiology Training Program in Intensive Care Medicine in or gastroenterology where responsibilities are Europe) focused on writing a competency-based generally known to the lay public, or in contrast training program to set the minimum standard of to newly developed specialties such as emergency knowledge, skills and attitudes. This standard includes medicine, the enigmatic roles of an intensivist may resuscitation, diagnosis, disease management, differ depending on a primary specialty, the patient interventions, procedures, perioperative care, population or even between ICUs within the same S10 ANAESTH, PAIN & INTENSIVE CARE; VOL 22(Suppl) October 2018 hospital.15 work around the critical patient, being a reference and also an interface between the patient and other The obstacles of primary intensive medicine are many. specialists when the skills of a single professional are The standardization of education, accreditation, insufficient. Their intensive medicine training can current educational arrangement of the various be built on other specialties such as anesthesiology, specialties (anesthesiology, internal medicine, surgery, as is often the case