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Newsletter October 2020: Anaesthesia versus intensive care medicine: a deleterious debate

Manuel Otero-Lopez, Hôpital Avicenne, AP-HP, Bobigny, France

Pablo Monedero, Clínica Universidad de Navarra, Pamplona, Spain

motero@doctors.org.uk

 

The European Society of Anaesthesiology and Intensive Care (ESAIC) has decided to add explicitly “Intensive Care” to its name. The proposal to change the name of ESA to ESAIC, The European Society of Anaesthesiology and Intensive Care, has been approved with the full support of its members and will be implemented from October 2020 (1).

Shortly after the proposed change, the European Society for Intensive Care Medicine (ESICM) wrote a response letter (2), suggesting that this action goes against their interests. ESICM consider that they are the only, exclusive, and legitimate European voice to represent and defend European intensivists, even though a large proportion of them come from academic training in anaesthesia. This paper is not the place to debate this issue, but indeed these seemingly opposite views of both societies could and should find a place for consensus.

Intensive care medicine (ICM) has changed and progressed deeply in the last 30 years; therefore, any doctor who wants to be competent in ICM needs a central dedication to this field of knowledge, especially to be a leader in this area (3).

In Europe, four countries have ICM partially separated from anaesthesia: Spain (3), Switzerland, the United Kingdom and France. When we look at the evolution in other parts of the world (4,5), we see a strong trend towards a progressive split-up. The main argument expressed to defend this separation is the rapid progression and growth of ICM, incorporating sophisticated routine technologies such as CVVHF or ECMO, and the need to ensure the training of the next generation of ICM physicians to the correct standards and in the necessary numbers (6).

 

Need and advantages of ICM as a supra-speciality of anaesthesiology 

Training in anaesthesia requires a deep understanding of physiology, pathophysiology, and pharmacology, and so it is at first very close to training in ICM. When we teach anaesthesia residents, the ultimate goal of the training is not only to gain knowledge of how to manage a specific condition, or how to perform a practical procedure but also why. This final objective implies an in-depth understanding of the basic sciences.

If we agree with this above statement regarding medical competence for our trainees, then we can admit that there is not a large difference between anaesthesia and ICM. Taking mechanical ventilation as an example, there is not a big difference between knowing how to ventilate a patient for a pulmonary lobectomy and knowing how to ventilate an ICU patient with severe ARDS. The difference will be much smaller between ventilation targets for a patient with severe ARDS and the same patient, in the operating room, with peritonitis developed on day 4 (3). We certainly believe that anaesthesia residents need to acquire a good understanding of pulmonary physiology and pathophysiology.

Proper perioperative anaesthetic management of an ASA 4 patient requires a solid training in ICM. The perioperative management of a frail or elderly patient requires a good knowledge of pathophysiology and ICM to preserve the small organ reserve that the patient possesses and to avoid perioperative morbidity and mortality (7). Therefore, good anaesthetic care for an ASA 4 patient is close to managing an ICU patient.

Operating rooms (OR) are the optimal place to learn and master different skills that are essential for ICU and OR patient management and safety, such as airway management, severe and unexpected bleeding, and life-threatening crises. Besides, working in the OR is a good “scenario” to improve communication skills and to develop the experience and assertive skills necessary for good teamwork.

The challenge we have faced in our hospitals for the COVID-19 pandemic, having to multiply by two or three the number of intensive care beds, has highlighted the relevance and high versatility of the speciality of anaesthesia (8). Anaesthesia is the largest medical speciality in the hospital environment. By increasing the number of places in intensive care units (ICU) run by anaesthesia, and by transforming our post-anaesthesia care units and OR into intensive care areas (9), after postponing scheduled surgeries, we have been able to manage the influx of new COVID-19 patients adequately.

Furthermore, this versatility related to anaesthesia is also relevant when considering hospitals with a small 6-8 bed ICU. This configuration is typical in small 200-bed general hospitals in provincial cities. Providing these units only with intensivists (from an ICM primary medical speciality) 24 hours a day, 7 days a week, will be more expensive for the hospital administration than if anaesthetists, who have adequate training in ICM and who generally work in the operating room, are interested in doing on-call duties in the ICU.

Last May, a questionnaire was published in Anesthésie & Réanimation among recently graduated French doctors (10), on the professional reasons that motivated them to choose the speciality of anaesthesia.  Around 90% of the residents answered the questionnaire, and 55% of them reported having a future goal of practising a mixed activity of anaesthesia and ICM.

The European Union of Medical Specialists (UEMS) contradicts itself when it approves ICM as a domain of general core competence of anaesthesia with at least one year of training in ICU (11), but requires a minimum of 3 years of intensive care training to be recognised for qualification in ICM (12). Any broad speciality, such as anaesthesia, requires in-service training after completion of initial medical training and continuous improvement with specific professional practice to enrich both the number and level of competencies (11). However, anaesthetists do have recognition of their qualification and possess free movement as intensivists in Europe.

The confrontation between ESAIC and ESICM opens a debate that is deleterious for the future of ICM in Europe that needs to avoid useless and harmful conflicts between specialities and scientific societies. ICM is a domain of competences of multiple primary specialisations and especially of anaesthesia. Any anaesthetist must be competent in ICM. Multidisciplinary access is an even better solution than a primary speciality for promoting ICM in Europe (3). Anaesthesia needs to increase dedication and training in ICM, with the use of CoBaTrICE as a tool for progress and evaluation of competences (13).

 

References

  1. ESA will become ESAIC. ESA webpage. Available from: https://www.esahq.org/esa-news/esa-will-become-esaic/ [accessed 20 September 2020].
  2. “Together we are Intensive Care Medicine”: A statement from the ESICM President – ESICM webpage. Available from: https://www.esicm.org/together-we-are-intensive-care-medicine/ [accessed 20 September 2020].
  3. Monedero P, Paz-Martín D, Barturen F, et al. Rev Esp Anestesiol Reanim 2020; 67:147–52.
  4. Bion J, Rothen HU. Am J Respir Crit Care Med 2014; 189:256–62.
  5. Rubulotta F, Moreno R, Rhodes A.. Intensive Care Med 2011; 37:1907–12.
  6. Rhodes A, Chiche JD, Moreno R.. Intensive Care Med 2011; 37:377–9.
  7. Hubbard RE, Story DA.. Anaesthesia 2014; 69:26–34.
  8. van Klei WA, Hollmann MW, Sneyd JR. Br J Anaesth. 2020; S0007-0912(20)30661-9. doi:10.1016/j.bja.2020.08.014
  9. Peters AW, Chawla KS, Turnbull ZA.. N Engl J Med 2020; 382: e52.
  10. Mikol X, Rouaux J, Gouzien L, et al. Anesthésie & Réanimation 2020; 6:307–12.
  11. European Board of Anaesthesiology (EBA UEMS). Anaesthesiology European Training Requirements (new UEMS European Training Requirements Anaesthesiology 2018. Available from: http://www.eba-uems.eu/resources/PDFS/EPD/ETR-Anaesthesiology-2018.pdf [accessed 20 September 2020].
  12. Requirements for the Core Curriculum of Multidisciplinary Intensive Care Medicine. European Standards of Postgraduate Medical Specialist Training. EBICM. Available from: https://ebicm.esicm.org/training/ and https://www.uems.eu/__data/assets/pdf_file/0007/19753/Item-3.2.1-ETR-Training-requirements-in-ICM-final-26-sept-2014.pdf [accessed 20 September 2020].
  13. Bion JF, Barrett H.. Intensive Care Med 2006; 32:1371–83.

 

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1 reply

Nicolas Pavez
Hi. Internist and Intensivist here. During my training as an intensivist, I learned to admire my fellow anesthesiologists when they quickly resolved an airway or helped the nurse with a complex venous line. They also had a deep knowledge of pharmacology, something far from my basic training. However, they forgot to adjust the antibiotic for resistant microorganisms, they made the diagnosis of systemic vasculitis late, the weaning of COPD was complex because they did not start their chronic treatment on time or they forgot the management of cirrhosis or decompensated diabetes, as well as the care of end of life (common in internal medicine and ICU and unusual in the operating room); all these examples much closer to my training. We learned to share our knowledge and we grew together. Today I see no difference in patient care between "them" and "me". I believe that intensive medicine is a unique specialty, the complexity of which requires solid background training, both in internal medicine and anesthesia. "Maintain homeostasis and reach the diagnosis, to allow life and avoid death. But also to know when we have reached the end." Nico Pavez, Chile.
8 days ago

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