The practice of anesthesiology includes provision of care to patients who are critically ill; while critical care medicine has its foundations in perioperative care provided by anesthesiologists, today’s critical care medicine encompasses care beyond traditional intraoperative and routine postoperative care. Critical care medicine includes a wide variety of clinical services provided by the anesthesiologist who possesses special training and experience.
In recent decades, anaesthesiology has steadily expanded from the operating room to post-anaesthesia care units, intensive care units and pain medicine including the development of pain clinics. The speciality has grown to encompass perioperative medical practice in acute pain medicine, and sleep and palliative care medicineas well.
Training in anesthesiology, along with additional advanced training in critical care medicine, uniquely prepares an individual to care for the critically ill by providing important technical skills as well as expertise in physiology, pharmacology and perioperative medicine. The expertise of the critical care anesthesiologist is of particular benefit to patients in the perioperative period; however, the critical care anesthesiologist’s special skills, judgment and training are valuable to all critically ill adults and children.
Anesthesiology-trained intensivists are capable of and practice all aspects of intensive care management in a variety of locations. Provision of an advanced level of health care services for critically ill patients is defined by the expertise and training of the critical care anesthesiologist and not by the location of the delivery of the care. Critical care services are most often provided in designated intensive care units, but may also be delivered in other locations including, but not limited to, the postanesthesia care unit, intermediate care units, and others. Critical care service that is provided by an anesthesiologist should be reimbursed in the same manner as with the same clinical services provided by any other appropriately-trained critical care physicians.
Intensivists are good medicine and anaesthesiologist have the training to be good intensivists.Critical care is a logical extension of anaesthesia practice, and infact anaesthesiologist helped create the discipline.
Anaesthesiologists are uniquely qualified to coordinate the care of patients in the intensive care unit because of their extensive training in clinical physiology/pharmacology and resuscitation. They possess the medical knowledge and technical expertise to deal with many emergency and trauma situations.The practice of anaesthesiology necessitates intimate familiarity with acute pathophysiology and pharmacology.They provide airway management,cardiac and pulmonary resuscitation, advanced life support and pain control, all of which are essential skills to the intensivist.They also play an active role in stabilizing and preparing the patient for emergency surgery. Most importantly, anaesthesiologist have improved safety and outcomes in both the operating room and the ICU.
The anesthesiologist – intensivist provides expertise in the diagnosis and management of disorders of the respiratory system, the cardiovascular system, the neurologic system, the gastrointestinal system (including metabolic and nutritional support) and the renal system (including administration of fluids and electrolytes and management of acid-base disorders). In addition, critical care anesthesiologists are experts in the care of the unconscious patient regardless of etiology, of the patient with a multiple organ injury or disease with multiple organ dysfunction syndrome, and of patients requiring life support. The critical care anesthesiologist effectively coordinates the management of these situations in a comprehensive and appropriate manner.
The fully trained anesthesiologists – intensivist possesses the skills to perform a myriad of diagnostic, monitoring and therapeutic activities. Examples include, but are not limited to, bronchoscopy, invasive and noninvasive hemodynamic and respiratory monitoring, metabolic assessment, airway intubation; institution, management of and weaning from mechanical ventilation; tube thoracostomy; cardiopulmonary resuscitation; cardioversion; electrical cardiac pacing; ultrasonography examination and other usg guided procedures; mechanical and pharmacologic support of the circulation; parenteral and enteral nutrition; fluid, electrolyte and acid-base support; management of extracorporeal membrane oxygenation; hyperbaric oxygen therapy; intra-aortic balloon counterpulsation; and analgesia and sedation for both acute and chronic pain.
Administrative responsibility for the management of the critically ill patient is best directed by an individual, such as an anesthesiologist-intensivist, who is intimately and directly involved with and aware of the impact that administrative decisions can have upon patient care. Examples of appropriate activities include authority for admission to and discharge of patients from intensive care units, triage of critical care services, involvement in budgetary matters and input into constructing, remodeling, equipping, staffing and supplying intensive care units. The anesthesiologist-intensivist is a logical participant and should be a primary negotiator if the hospital becomes involved in the development of local, regional or national guidelines regarding the management of the critically ill and the reimbursement for the provision of services to the critically ill.
Anaesthesiologists are exploring new opportunities to demonstrate value to their hospitals, both inside and outside the operating room. Leadership of the intensive care unit provides an option that some anesthesiologistsmight want to consider. Critical care medicine is, in many ways, a logical extension of anaesthesia practice and can also provides valuable experience for groups interested in making a transition to this field of critical care.
A starting point for assessing the value that an Anaesthesiologist adds to patient care could be critical care outcome measures. Intensive care medicine is expensive and demonstrating favorable value of anesthesiologist-led practices would provide a powerful platform for our speciality .
Dr. Dilip Wasnik
Consultant, Department of Anaesthesiology , Liver Transplant Anaesthesia and Critical Care Alexis Hospital, Nagpur