57 – Training in Cardiothoracic Intensive Care

57 Training in Cardiothoracic Intensive Care

Amy Needham and Chinmay Padvardthan

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.

Sir William Osler The Student of Medicine

A Historical Perspective

From its nascence in the polio epidemic of Copenhagen in 1952 to the foundation of the Faculty of Intensive Care Medicine in 2010, intensive care medicine has made great strides to become one of the fastest growing specialties in hospital medicine. The past 60 years have brought great technological advances in medical devices and we now have better understanding of critical illness pathologies. We have improved the care processes in intensive care, implementing evidence based interventions such as low tidal volume ventilation, bundles of care and critical care outreach. We have introduced better predictors of risk and observed a reduction in mortality of the critically ill.

Developments and progress in anaesthesia and evolution of the concept of ‘intensive care units’ are inexorably linked with the progress of cardiac surgery. John H Gibbon Jr first successfully demonstrated the use of a cardiopulmonary bypass machine to perform open heart surgery in May 1953. Prior to this, cardiac surgery as we know today hardly existed. Surgeons were almost warned against operating on the heart. In the words of Theodor Billroth, the famous Viennese surgeon, ‘Any surgeon who attempts operating on the heart should lose the respect of his colleagues’. Any cardiac surgery prior to Gibbon’s bypass machine was mostly on cardiac trauma, and a few rheumatic mitral repairs. However, since 1953, great strides have been made in cardiac surgery and surgeons now routinely perform a plethora of complex procedures. Albert Starr was one of the early cardiac surgical pioneers who adopted a multidisciplinary team approach to postoperative care after cardiac surgery. He employed cardiologists, an anaesthesiologist, a haematologist, a neurologist, a nephrologist and a psychiatrist to look after his first postoperative case of mechanical aortic valve replacement in 1960. He can be credited as the trailblazer in the concept of cardiothoracic intensive care. The first purpose built, 12 bed cardiac surgery intensive care unit opened in 1964 at Broadgreen Hospital in Liverpool. The catalyst for growth of intensive care units was the growing demands of open heart surgery, which increasingly required specialised haemodynamic and metabolic monitoring.

Another important key change that influenced future cardiac intensive care was the development of coronary care units (CCU) in 1961, dedicated to looking after patients with myocardial infarction and addressing issues of arrhythmias and prompt resuscitation with closed chest compressions. In the late 1960s the second stage in the development of the CCU was ushered in by Bernard Lown and colleagues in Boston, Massachusetts. They described a shift from resuscitation at the time of an arrest to monitoring for early signs of clinical change and prevention of a cardiac arrest.

1978 saw recognition of cardiac anaesthesia as an anaesthetic subspecialty in its own right in North America with establishment of the Society of Cardiovascular Anesthesiologists. It was not until 1984 that the Association of Cardiac Anaesthetists (ACTA) came into existence in the UK. Dedicated cardiac anaesthetists became a vital part of the ‘team’ looking after cardiac surgical patients in the postoperative period. Over the past 40 years the post cardiac surgery care units evolved into the highly specialised cardiothoracic intensive care units of the twenty-first century.

From its humble beginnings, today’s cardiothoracic intensive care unit (CTICU) is a highly complex behemoth. At its heart are the highly trained specialist intensivists, surgeons, cardiologists, specially trained nurses, pharmacists, dieticians, physiotherapists, perfusionists and technicians, all working together with input from almost every medical and surgical specialty in the hospital. The patient population has expanded from postsurgical patients, to include diverse pathologies such as advanced heart failure, severe pulmonary hypertension, mechanical circulatory support, extracorporeal membrane oxygenation (ECMO) support, transplant patients and post cardiac arrest patients. CTICUs now provide long term respiratory weaning, tracheostomy care, renal replacement therapies, plasma apheresis, bronchoscopies and every other form of therapeutic intervention offered on a general intensive care unit. Globally there has been a shift in patient demographics. Patient case mix in intensive care units is increasingly elderly, with multiple comorbidities such as diabetes mellitus, chronic airways disease, hypertension and renal failure. The falling incidence of fatal ST elevation myocardial infarction, on the other hand, has seen a rise in incidence of complications associated with non-ST elevation MI, and complications associated with mechanical support devices. These changes have altered the natural history of cardiovascular illnesses and these have started to resemble the natural history of critically ill patients on general intensive care units with a greater incidence of multiorgan dysfunction requiring organ support. The disease trajectory of a patient admitted after a cardiac complication now resembles that for any other critical illness, bringing with it the complications of prolonged immobility, critical illness neuropathy, resistant infections, renal failure requiring prolonged support, need for specialist nutrition, issues with vascular access, chronic sepsis etc. This means there is a significant effect on resources, bed allocation and availability and in particular need for specialist personnel training.

This need for specially trained medical staff to look after the complex needs of the critically ill patients was first recognised in the USA. The first critical care residency was established at the Presbyterian University Hospital, Pittsburgh in 1962 under the direction of Peter Safar. The residency was initially opened for anaesthesiologists. However, subsequently it became open to different hospital specialties like surgery, internal medicine, paediatrics and pulmonology. Each specialty introduced a different pathway to get into the specialty, with each stipulating their own specific requirements on training and experience. Training in the UK and Australasia, however, took a different pathway with intensive care medicine initially predominantly being the domain of anaesthetists.

Australia and New Zealand introduced a comprehensive subspecialty training programme in critical care in 1996 with the formation of the College of Intensive Care Medicine in 2008. In the UK the Faculty of Intensive Care Medicine was formally established in 2010. The General Medical Council approved the standalone subspecialty training programme for critical care medicine in 2012. The Canadians have a total training requirement which is similar to the rest of North America/Latin America (i.e. 5 years of specialty training); but all base specialties agreed to a 2 year critical care training programme following the primary subspecialty training with a single conjoint examination.

Spain and Latin American countries also went down the same route of requiring a minimum 5 years of base specialty training. The European Society of Intensive Care Medicine (ESICM) was established in 1984 in Geneva to promote education, training and standardisation across Europe in intensive care. ESICM offers a Diploma in Intensive Care Medicine (EDIC) to trainees from various specialties with 2 years of critical care experience.

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Jan 9, 2021 | Posted by in CARDIOLOGY | Comments Off on 57 – Training in Cardiothoracic Intensive Care
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