CRITICAL CARE MEDICINE
Bendixen and colleagues, in 1965, reviewed the pathophysiology
of respiratory failure and detailed methods of mechanical respiratory support in
their seminal book Respiratory Care[32]
(also see Chapter 75
). This
documented the beginning of anesthesiology's involvement with care of critically
ill patients outside the operating room. Initially, our role was to provide adequate
ventilation for a patient and to determine when weaning from mechanical ventilation
was feasible. As it became obvious that respiratory function was only one aspect
of care of the critically ill, anesthesiologists became knowledgeable in cardiovascular
support, nutrition, infection, and various diagnostic procedures needed for these
patients (see Chapter 74
).
In 1986, the Residency Review Committee for Anesthesiology (RRCA)
began to accredit training programs in critical care medicine (CCM) in departments
that already had core residency training programs. At the same time, the ABA began
examinations in CCM leading to subspecialty certification. This followed fruitless
negotiations with the specialties of surgery and pulmonary medicine in attempting
to define CCM jointly and to
Figure 2-2
The number of critical care medicine programs in departments
of anesthesiology and the number of residents in these programs for the years 1989–2003.
(Data provided by the American Board of Anesthesiology.)
issue only one type of certification. Figure
2-2
demonstrates that there is interest in CCM by anesthesiology residents,
although that interest has waned noticeably since publication of the last edition
of this book. The number of CCM programs remains stable at around 50, with the number
of trainees at a 10-year low of 50. Twenty percent of the programs reported no trainees
in 2003, compared to approximately 500 trainees in pulmonary critical care. This
is in marked contrast to the positive response following development of programs
in pain management. This trend is unfortunate, because hospitals, given the transition
to ambulatory care described previously, are devoting more and more of their bed
space to intensive care. It also casts doubt on the vision of the anesthesiologist
as the perioperative wizard.
One factor that may mitigate this loss of interest in critical
care is recent research by Pronovost and colleagues, among others, that demonstrated
improved outcomes in patients undergoing abdominal aneurysm resection when a physician
specifically trained in critical care made daily rounds and directed postoperative
care.[33]
This has stimulated the Leapfrog Group,
a consortium of corporate purchasers of health care, to specifically request that
dedicated intensivists work in the settings with whom they contract. Related cost
obstacles are imposing, but the effort continues.
Some hospitals are taking a global approach and forming ICU administration
groups that include all relevant physician specialties and jointly decide medical
and administrative policies. Critical care, however, is practiced not only in critical
care units. With increasing frequency, PACUs are substituting for the inadequate
number of critical care beds. Appropriate resources and personnel must therefore
be available in the PACU to serve these patients in a manner that is similar to what
is available in the ICU.
The ABA, the RRCA, and the Society of Academic Anesthesiology
Chairs/ASA Program Directors are discussing a 48-month curriculum for anesthesiology
training (to encompass the Clinical Base Year) that emphasizes much more extensive
training in critical care.
