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Send to a FriendAfter 20 plus years as a cardiothoracic surgeon I decided to shift my focus from surgery to cardiothoracic surgical (CTS) critical care. Even though I directed my own critical care as a cardiothoracic surgeon with the very able assistance of my anesthesiology colleagues and the critical care nursing staff, now that my professional energy is primarily dedicated to this area, I have been impressed with the complexity of the field. Based on this experience I have come to view CTS critical care as an emerging specialty within the larger fields of thoracic surgery and general critical care.
Cardiothoracic Surgical Critical Care: A Specialty
Clearly, CTS critical care is inherent to the specialty of cardiothoracic surgery. The cardiothoracic surgeon provides critical care to his/her patients because of the nature of the surgery. As a reflection of this, a substantial proportion of CTS patients are cared for early postoperatively in intensive care units. From the beginning of a surgeon’s training in cardiothoracic surgery, experience providing critical care is an integral part of the residency or fellowship program.
However, with the increasing complexity of critical care and the involvement of critical care physicians in the care of CTS patients, the question arises whether the critical care of these patients is appropriately considered part of general critical care, or if it is a specialty itself, distinct from general critical care. In support of the latter, it is noted that the clinical situations of cardiothoracic surgery (e.g. cardiopulmonary bypass, cardiac reconstructive procedures, pulmonary resections and esophageal surgery) create unique physiologic changes that require special considerations. In addition, complications associated with CTS procedures may present situations that otherwise would not be encountered in clinical practice.
Accordingly, based on the unique physiologic changes and unique complications associated with cardiothoracic surgery, I believe that CTS critical care should be considered a specialty within the framework of cardiothoracic surgery and critical care.
CTS Critical Care: A Cross-Disciplinary Specialty
It is clear from clinical practice that CTS critical care requires a detailed knowledge of multiple medical and surgical disciplines. Correspondingly, it is now a relatively standard practice for a team of health care professionals to provide CTS critical care. The involved disciplines extend not only across the fields of surgery and medicine, such as cardiothoracic surgery, anesthesiology, cardiology, pulmonology, nephrology, gastrointestinal medicine, neurology, hematology, endocrinology, infectious disease medicine, interventional radiology, and pharmacology, but also extend across paramedical disciplines. These include nursing, extra-corporeal perfusion, respiratory therapy, physical therapy, speech pathology, and nutrition. Practitioners include not only cardiothoracic surgeons, but critical care physicians, other sub-specialty physicians, nurses, nurse practitioners, physician assistants, perfusionists, respiratory therapists, nutritionists, and pharmacists.
Thus, in defining the breadth of the specialty of CTS critical care, and in order to provide for its growth and the education of the team, it is important to recognize that the specialty is cross-disciplinary. Optimal CTS critical care is dependent on members of this multi-disciplinary team “being on the same page” by sharing a broad understanding of the inherent complexities.
In my view, the surgeon should have an important role on this multi-disciplinary team. It is key that one of the leaders of the team caring for a CTS patient understands the details of the individual’s operation and the anticipated response to the procedure(s). It is fundamental that the patient has placed his life in the hands of the cardiothoracic surgeon and, accordingly, expects the surgeon to have an important role in the postoperative care working closely with critical care specialists. This approach preserves the essential element of continuity of care.
Challenges of CTS Critical Care in This Era
The challenges of the specialty are to optimize clinical precision, therapeutic effectiveness, safety, and patient comfort. In this era, the increased acuity of patients undergoing cardiothoracic surgery and the range and complexity of the procedures involved, place increasing and changing demands on the expertise of the CTS critical care team.
Another factor which challenges the expertise of the CTS health care team is the ongoing evolution in maximally supportive technology used both during the surgery and postoperatively. This technology includes, for example, advanced ventilation systems, continuous renal replacement therapy, ECMO, and ventricular assist devices. The complexity of the devices and the on-going improvements in design demand detailed protocols and knowledgeable, experienced bedside professionals.
An additional challenge to the CTS critical care team is the integration of new pharmaceutical agents into management protocols. The new pharmaceuticals have the potential for greater specificity and greater potency and have the potential to avoid important side effects associated with past standard therapies. On the other hand, these new products challenge the team to provide a safe introduction of the associated management protocols.
New diagnostic technologies available for CTS critical care further challenge the CTS team. Examples are the use of advanced hemodynamic catheter devices, impedance cardiography, and bedside portable ultrasonography. These technologies provide the means to help achieve the goal of extending the inherent precision of cardiothoracic surgery from the operating room to the critical care unit.
Clearly, modern technology and pharmacology have the ability to increase the effectiveness and safety of care. However, the implementation of these advances requires the fluid coordination and education of the multi-disciplinary team as a unit.
Conferences Dedicated to CTS Critical Care
To help fill the educational requirements of this new specialty, I have directed 2 previous continuing medical education conferences that emphasize the surgeon’s partnership with the multi-disciplinary team in directing CTS critical care. The conferences have provided a unique platform for all team members to have a voice in the sharing of ideas, experience, and expertise. Our recent conference in June was attended by about 300 participants from 31 states and 11 countries. We are now finalizing plans for our 3rd annual CME conference, "Cardiothoracic Surgical Critical Care 2006: Innovative Concepts and Technology to Increase Precision, Effectiveness, Safety, and Patient Comfort." It is being held in Washington, DC, April 27th- midday April 29th and now incorporates a 19-member multi-disciplinary Board of Advisors to guide and participate in the program agenda. Specific conference details and registration can be found at www.ctscriticalcare.ws.
At this year's conference, we will not only be addressing the latest concepts, controversies and technologies, but provide the opportunity for all participants to have a voice in shaping the future of CTS critical care. Based on the groundswell of support at last year’s conference, we will begin to shape a new organization that will strictly focus on the needs of CTS patients and team members.
In this regard, the Foundation for the Advancement of CTS Care (FACTS-Care) was created to serve as a platform for the new International Society for CTS Critical Care. The Society’s relatively small size will allow a direct focus on the unique aspects of the specialty and a sense of ownership by the multi-disciplinary members. The new organization will truly be complementary with the existing excellent large organizations and will work closely with them to the benefit of all.
The Future of CTS Critical Care
I believe it is important for thoracic surgeons to stay in the forefront as leaders in the specialty of CTS critical care. The multi-disciplinary Society and conferences focused on the specialty provide an excellent opportunity for cardiothoracic surgeons to stay updated in this rapidly evolving field and to support their leadership role in the multi-disciplinary patient care team. Leading cardiothoracic surgeons have had a major role in the newly created CTS critical care conferences mentioned above.
Important questions to be addressed involve how CTS critical care should be organized. For example, who should provide the day-to-day and hour-to-hour leadership in the ICU for CTS patients? How should cardiothoracic surgery residents and fellows receive training in CTS critical care? With the recognition that extension of the thoracic surgery residency to three years is advantageous to provide for the new techniques and complexity of the specialty, a 3-year format does provide the opportunity for increasing training of CTS residents in the area of critical care. At the conclusion of the thoracic surgery residency, should the graduates of the programs be eligible to take certification board examinations in critical care?
It is evident that some cardiothoracic surgeons have an interest in making a transition to this specialty as a primary professional activity. Questions have been raised about the need for certification. It would seem that a cardiothoracic surgeon who has been certified by the American Board of Thoracic Surgery is qualified to provide the critical care of cardiothoracic patients, as this is inherent in the discipline. Nevertheless, with evolving critical care knowledge and technology, there is the need for updates of knowledge and expertise and perhaps additional certifications. These issues should be addressed by cardiothoracic surgeons and the organizations of thoracic surgery, surgery and critical care.
Conclusion
In my opinion, cardiothoracic surgical critical care is a new specialty that has emerged as a reflection of the unique physiologic changes and unique complications associated with cardiothoracic surgery and the rapid evolution in the surgical techniques and critical care for CTS patients. The specialty crosses multiple disciplines of medicine and surgery and involves a spectrum of health care professionals. Cardiothoracic surgeons have an important role in the specialty and in maintaining the continuity of care by working closely with the multi-disciplinary team. The new International Society of CTS Critical Care provides the unique opportunity for all members to share in the development of CTS critical care.