key: cord-0978172-reujlq5a
authors: Kiefer, Jessie J.; Rock, Peter; Augoustides, John G.; Mazzeffi, Michael A
title: Critical Care during the Coronavirus Crisis – reflections on the roles of anesthesiologists in meeting the challenges of the pandemic
date: 2020-05-08
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.04.061
sha: 1748e5f149bc5be2a6aae8b7271a250816d0405a
doc_id: 978172
cord_uid: reujlq5a

nan

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. 1 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. 1, 2 Since this introduction of board certification, the particpiation of anesthesiologists in critical care has not kept pace with other specialists from emergency medicine, internal medicine, and surgery who have expanded their role in adult critical care including cardiothoracic critical care:. [1] [2] [3] This lack of growth prompted concerns about the future of anesthesiologists in critical care both in the 1990's and early in the new millenium. 1;3 It is likley that the participation of anesthesiologists in critical care throughout the United States continues to be highly variable depending on multiple factors including gender, opportunities and location. [4] [5] [6] The current coornavirus pandemic and its catastrophic consequences have highlighted the imperative for anesthesiologists to be key stakeholders in critical care. 7 In areas hit by the full intensity of the pandemic, anesthesiologists have converted post-anesthesiology care units into intensive care units, deployed anesthesia machines as ventilators, and created acute care teams to address the unique challenges of clincial care in this setting, including airway management. [7] [8] [9] [10] [11] Beyond direct clinical care in the frontlines of the pandemic, anesthesiologists are also leading operations for surge planning, educating physicians about ventilator management, and designing guidelines for sedation and analgesia in patients with COVID-19. [10] [11] [12] As of 2018, less than 4% of anesthesiologists in the United States had board certification in critical care. 13 As a comparison, over 10% of were board certified in pain medicine and 6% were board certified in pediatric anesthesiology. 13 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 less than 2% of anesthesiologists had subspecialty certification in critical care. 13 The focus on critical care due to the coronavirus pandemic might further stimulate an inteest in board certification in this specialty, given the inspiring roles of anesthesiologists in leading and providing care on the frontlines. 14 Table 1 ). Notably, a major themes is the ongoing expansion of critical care anesthesiologists into cardiothoracic critical care with concomitant integration of extracorporeal membrane oxygentation into the practice of perioperative medicine. [14] [15] As the coronavirus crisis continues, the roles of anesthesiologists outside the operating room environment will expand and add value across their halth systems. The response to the crisis will likely 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. 21 Furthermore, there are also opportunities for adult cardiothoracic anesthesiology to learn from the European experience in fellowship development as the evolution in this subspecialty continues. 22 The challenges ahead for fellowships in adult cardiothoracic anesthesiology include board certification and better integration with cardiothoracic critical care. [23] [24] This dynamic interface between cardiothoracic anesthesiology and critical care offers multiple opportunities for both subspecialites to harmonize, to thrive and to strengthen their clinical impact and delivered value.

24. Troianos CA. The time is now for board certiifcation inc ardiac anesthesia. J Cardiothorac Vasc Anesth 34: 573-574, 2020 

• "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"

• "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"

• "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"

• "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"

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