Urgent intubation of a child with refractory seizures and respiratory distress, analgesia for a neonate with necrotizing enterocolitis, sedation for a child undergoing incision and drainage of a complex abscess at the bedside, pain management in a teenager with refractory cancer pain, preoperative evaluation of a complex patient with cystic fibrosis following liver transplantation, scheduled for liver transplantation. How would our approach to these and other facets of pediatric critical care change if pediatric anesthesiologists formed a core part of the pediatric intensive care teams?
“The necessity to care for all aspects of a child’s critical illness and integrate the knowledge, wisdom, care, and focus of many providers is the key difference between critical care and other specialties.”1 Pediatric intensive care was born from the practice of pediatric anesthesia and rapidly grew to encompass several allied specialties, including adult respiratory care, neonatology, pediatric general surgery, and pediatric cardiac surgery.2 Yet today, pediatric anesthesiologists—and nonpediatricians in general—are largely absent from the pediatric and neonatal intensive care spaces (pediatric intensive care units [PICUs] and neonatal intensive care units). Contributing to this divide are a lack of exposure to pediatric intensive care training and significant credentialing barriers.1 These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We suggest that redesigning the pediatric critical care training pathway for pediatric anesthesiologists may improve care of children both in and out of the operating room (OR) by facilitating further sharing of skills, research, and clinical experience.
INTERDISCIPLINARY CRITICAL CARE
The subspecialties of pediatric anesthesia, neonatology, pediatric cardiology and general surgery have been and should continue to be essential collaborators with pediatric critical care medicine throughout the next century. Continuing interdisciplinary dialogue and education, as well as clinical and research collaboration, will strengthen the effectiveness of each of these subspecialties in caring for sick children. 3
Unlike PICUs, adult intensive care units (ICUs) are staffed by intensivists with heterogeneous residency backgrounds. Surgical ICU training, for example, is available to residents with training backgrounds in anesthesiology, emergency medicine, neurological surgery, obstetrics and gynecology, orthopedic surgery, otolaryngology, plastic surgery, surgery, thoracic surgery, vascular surgery, or urology.4 Medical ICUs (MICUs), in contrast, usually house a more homogenous intensivist staff of physicians with residency training in internal medicine and fellowship training in pulmonary critical care (with some exceptions granted by respective program directors in accordance with Accreditation Council for Graduate Medical Education [ACGME]).5 In the United States, PICUs often operate as concurrent pediatric surgical and MICUs and are staffed by a homogenous mix of physicians with backgrounds in general pediatrics, analogous to adult MICUs.
PEDIATRIC CRITICAL CARE MEDICINE
… anesthesiologists were the first to transfer principles of infant and pediatric physiology and pharmacology from the operating room to the ICU and the first to care for critically ill infants and children outside the operating room. 6
Many definitions of Pediatric Critical Care Medicine (PCCM) exist, particularly because the spectrum of pediatric services available varies greatly among institutions. For example, there are approximately 422 PICUs in the United States.7 Given that there are >5564 hospitals in the United States, <8% of hospitals have a PICU.7 Thus, in the majority of cases, children are either cared for in adult units or transferred. Within institutions that do house PICUs, branches of pediatric care are variably separated, including neonatal intensive care, pediatric cardiac critical care, pediatric medical critical care, and pediatric surgical critical care. With this variability in mind, our working definition of PCCM is an area of the hospital that specializes in the care of critically ill infants, children, and teenagers. Furthermore, the practice of PCCM is in its relative infancy as a subspecialty.
PCCM evolved in the 1950s out of a growing need for pediatric postoperative management, in part, to support the increasing complexity of pediatric surgery, and pediatric cardiac surgery in particular.6 In the beginning, this perioperative care was provided by pediatric anesthesiologists. As PCCM began to take shape as a field, many pediatric anesthesiologists emerged as leaders in the field of PCCM, establishing, directing, and staffing PICUs. The first PICU was established in Sweden in 1955 by the pediatric anesthesiologist, Goran Hoagland. In the United States, the first PICU was established at Children’s Hospital of Philadelphia (CHOP) in 1967 by John Downes, also a pediatric anesthesiologist.6
Before the creation of fellowships in pediatric critical care, pediatricians routinely sought additional training in anesthesia to develop the skills and expertise needed to care for critically ill children. The anesthesia skillset remains a necessary component of pediatric critical care training, and most PCCM fellowships require direct anesthesia OR experience.8 , 9
In 1981, the Society of Critical Care Medicine created a discrete section of pediatric critical care. In 1983–1984, guidelines defining the minimal requirements for PICUs were introduced by the Committee on Hospital Care, the Society for Critical Care Medicine, and the American Academy of Pediatrics. The first certifying examination was offered by the American Board of Pediatrics in 1987, and for the first time, the examination necessitated completion of a 3-year pediatric residency in an ACGME-accredited program to sit for the examination. This was the first divorce of PCCM from allied specialties. Ever since, the proportion of PCCM providers among all pediatricians continues to dwindle, from 7.5% in 2004 to 1.4% in 2015.10 Of these providers, the proportion of pediatric intensivists dual certified in anesthesia and PCCM is exceedingly small; although likely an underestimate, based on the 2016–2017 American Academy of Pediatrics American Board of Medical Specialties Report, only 32 individual members of the American Academy of Pediatrics Section on Anesthesiology and Pain Medicine are boarded in both anesthesia and PCCM.11
An important question is how this relatively small number of PCCM providers reflects the PCCM need in the United States. Recent works have suggested an average of 66,000 admissions per year to PICUs within the Virtual Pediatric Intensive Care Unit Performance System.12 Increasing consumption of hospital resources, in particular, by children with chronic conditions affecting >1 body part, suggesting perhaps an overall sicker population.13 The increased survival of infants with complex disease at birth and increased access of US facilities as international specialty centers for rare, complex diseases may be further driving the need for PCCM providers. The deficit of PCCM care is likely greatest in rural and underdeveloped areas.14
At the same time, there is growing evidence that pediatric intensivists decrease morbidity and mortality of critically ill children.3 Epstein et al6 showed improved survival during hospitalization in a PICU with an intensivist (relative odds of dying, 0.65; 95% confidence interval, 0.44–0.95; P = .027). The risk of dying in a PICU with a critical care fellowship program versus a PICU without a critical care fellowship program is also less (relative risk of dying, 0.714; 95% confidence interval, 0.529–0.964; P = .028).6 Despite this evidence, a study of academic medical centers from 2013 showed that only 33% provided 24/7 PCCM intensivist staffing.15
Taken together, there is cause to rethink our current PCCM training paradigm to encourage more providers to pursue PCCM.
The PCCM Training Pathway
The PCCM fellowship is a 3-year fellowship and requires prior completion of a full 3-year pediatric residency.8 Most PCCM fellowships are composed of ≥1 year of protected research time, with a range based on local training program requirements. Many programs also include 1–2 months of pediatric anesthesia training in the OR.
Under usual circumstances, a pediatric anesthesiologist who decides to pursue dual training in PCCM would be required to undergo ≤6 years of additional training depending on the training program (Figure 1). Additionally, completion of pediatric residency after an anesthesia residency necessitates a protracted break from this intellectually demanding and highly kinesthetic skillset. Furthermore, the financial opportunity cost of pursuing the additional 6 years of training at a fraction of one’s full salary is prohibitive to many. As evidenced by the current paucity of pediatric anesthesiologists certified in PCCM, taken together these barriers appear exclusionary.
Alternative training pathways exist that modestly reduce portions of this training, resulting in significant variability in program length by institution. For example, in 2013, the combined anesthesia–pediatric residency was created to help minimize total duration of training. Beginning in 2013, select programs offered the opportunity to concurrently complete residencies in pediatrics and anesthesiology in 5 years. This reduces the total training time by 1–2 years, depending on whether the pediatrics residency is completed first, and therefore satisfies the anesthesia preliminary year requirement. Importantly, the combined training stipulates that all graduates must complete a fellowship in anesthesia or pediatrics to practice in that respective field. In 2017, 7 programs in the United States offered the combined training program, for a total of 9 positions nationally. These programs include University of California (Irvine), Stanford University School of Medicine, Children’s Hospital Boston, Johns Hopkins Medicine, University of North Carolina, University of Pittsburgh Medical Center, and Medical College of Wisconsin. Although a positive step, barriers remain. The combined length of training remains 9 years if one hopes to practice both pediatric anesthesia and PCCM after completing the 2 respective full-length fellowships. Furthermore, this combined training route must be chosen and pursued during the third and early fourth years of medical school, requiring a significant degree of subspecialization in 2 fields before developing significant knowledge of PICU or pediatric anesthesia. Therefore, this pathway offers no utility to residents who choose to specialize based on meaningful clinical experiences in residency and may force medical students to make an unreasonable commitment for their level of exposure, as evidenced by the observation that no combined program graduate has ultimately pursued PCCM to date.
A small number of outlier programs offer different options for combined training. For example, the Stanford PCCM training program advertises a reduced 2-year fellowship tract for those who have “completed scholarly activity in a prior ACGME-accredited subspecialty program,” such as pediatric anesthesiology.16 Similarly, Johns Hopkins offers a training path by which individuals may pursue a 5-year combined anesthesia and PICU training path after completion of a complete pediatric residency.17 Based on publicly available information, these pathways seem to reduce the total research and scholarly time, which preserving the total clinical time required for training. These observations beg the question, can a pediatric anesthesiologist achieve the core competencies of PCCM without completing 6 additional training? The shared core competencies among these allied training programs are highlighted in Figure 2 to help guide design of an ideal alternative pediatric intensivist training track.
THE PEDIATRIC ANESTHESIA SKILLSET AND PCCM
There are many reasons to strive for increased collaboration between the disciplines of PCCM and anesthesia. In addition to the significant overlap of skillsets (pediatric advanced life support, critical airway management, interpretation of critical laboratory data, resuscitation, postoperative care, pain management, central and peripheral access, etc), pediatric anesthesiologists also bring an expertise in various areas of critical care. For example, a recent study of PCCM fellows at CHOP found that fellows performed an average of 42 intubations (range, 39–60).18 Anesthesiologists, in contrast, often complete >1500 intubations during the course of their residency training and are required to care for at least ≥100 children under 13 years of age to meet ACGME requirements.4 Significant additional experience is garnered during a pediatric anesthesia fellowship, providing substantial expertise in management of the difficult airway.19 Therefore, attendings with backgrounds in anesthesia undoubtedly have much to offer with respect to management of the pediatric airway.
Pediatric anesthesiologists are experts in sedation both in and out of the OR and are largely responsible for the pediatric sedation literature.20 For example, the Procedural Sedation Research Consortium, overseen by pediatric anesthesiologists, has vastly expanded our knowledge of sedation of children outside the OR. This skillset is critical in the ICU, where it has been reported that up to one-third of children are inadequately sedated.6 Pediatric anesthesiologists can provide additional anesthetics outside of the OR, vastly increasing the ability to perform procedures at the bedside, improving access, safety, and both patient and family comfort.
The field of pediatric pain continues to evolve to better meet the complex pharmacology of infants and children, including the potential negative effects of both pain and analgesics on the developing brain. Some important innovations in acute and chronic pain management, including regional anesthesia, have been relatively slow to translate from the OR to the PICU. It is our hope that both questions and innovations in the field of pediatric pain would be approached more effectively with increased collaboration between pediatric anesthesiologists and intensivists.
With respect to pediatric perioperative care, anesthesiologists are poised to form an ideal bridge between medical and surgical management. Preoperatively, anesthesiologists are trained to help assess surgical risk and thereby help guide families and teams in critical decision making.21 To further support perioperative decision making, pediatric anesthesia has developed the concept of the “surgical home” to help evaluate perioperative risk for complex pediatric patients, including the flagship program implemented at Boston Children’s Hospital through the department of pediatric anesthesia (Boston Children’s Hospital).22 Such anesthesia-led perioperative centers speak to the benefit of more closely involving the operative providers with the perioperative evaluation and treatment of the patient.
With respect to postoperative management, the field of PCCM was born from the tradition of Dr Downes at CHOP, by which anesthesiologists would take responsibility for the postoperative management of their own surgical patients.24 While this may not be practical in most current systems, dual training would enable reimagining systems in which this optimal level of care continuity could be emulated.
The most common unplanned PICU presentations are respiratory, trauma, postsurgical care, infection, and fluid and electrolyte derangements.25 To each of these pathologies, pediatric anesthesiologists also bring a valuable skillset. Other common presentations familiar to anesthesiologists include anaphylaxis and burn management. Even status asthmaticus, a classic pediatric presentation, is an illustrative example of the potential for knowledge sharing, with the use of volatile anesthetics as an innovative part of ICU management in refractory cases.26 One can imagine more such innovations evolving by simply increasing collaboration between these allied fields.
WHAT PCCM CAN TEACH PEDIATRIC ANESTHESIOLOGISTS
Educating anesthesiologists about pediatric patients is essential if children are to receive the most effective and efficient anesthesia care. 27
Whereas significant exposure to adult critical care training is required for licensure (a minimum of 2 months during internship and 3 months during residency), no formal PICU training is required to perform anesthesia for children. This limited exposure is a significant weakness of practice, particularly given that in communities without major pediatric academic centers, the majority of pediatric cases are done by general anesthesiologists without additional training in pediatrics. For this reason, PICU training should be incorporated into the residency training of all anesthesia residents.27 We contend that critically ill children would receive better operative care if PCCM were a part of anesthesia training.
In addition, while pediatric anesthesiologists generally provide episodic care, appreciation for the longitudinal impact of decisions via PCCM exposure can significantly inform perioperative management. Examples include the impact of intraoperative fluid boluses on postoperative recovery or the choice of intraoperative sedatives and the subsequent need for long-term sedation in the unit. Finally, the longitudinal experience of interacting with a child and a family as they evolve through a critical illness may be career changing. If residents were routinely exposed to the PICU, more residents might consider dual training in pediatric anesthesia and PCCM.
SUMMARY AND RECOMMENDATIONS
An excellent pediatric critical care unit goes further – it inculcates a culture of positive continual change targeted at improving the care it delivers and innovation around that care. 1
Measuring the impact of excluding multidisciplinary providers from pediatric critical care is challenging; however, imagining ways in which we might support each other and grow the field is both intuitive and exciting. We suggest the following changes:
- The pathway to becoming a pediatric intensivist should be reconsidered to further enable residents from allied specialties, including anesthesia, to enter the field. To facilitate this, an abbreviated pediatric experience should be available to residents who have completed an anesthesia residency, consisting of only the necessary training to become an effective PCCM provider. We propose that an effective way of providing this experience is to create a focused pediatric transitional year that includes experiences such as general inpatient pediatrics, inpatient pediatric subspecialty experiences, pediatric and neonatal intensive care, and pediatric emergencies. This could exist as a stand-alone year or in place of 1 year of research time allocated within the 3-year PCCM fellowship, at the discretion of the institution. Preliminary evidence for the feasibility of this pathway is the existing combined pediatric anesthesia program, in which the total training time is also reduced by 2 years, by reducing the total amount of elective and scholarly concentration time. However, a significant benefit of the proposed model over the existing training dual residency design is that it would allow residents to choose niche subspecialization after adequate clinical exposure, rather than in the third or early fourth year of medical school when exposure to the subspecialties of pediatric critical care and pediatric anesthesia is likely minimal.
- An abbreviated 2-year PCCM fellowship track should be available to candidates with dual training in pediatrics and anesthesia. In these cases, the first year of PICU fellowship should focus on clinical exposure to relevant areas of pediatrics, including pediatric emergency medicine, pediatric critical care, and neonatal intensive care. Other applicable experiences may include subspecialty services such as pediatric cardiology, pediatric pulmonology, and pediatric surgery. This additional clinical pediatric exposure may be in place of 1 year of research time otherwise protected within the PICU fellowship. In this way, fellows may gain relevant exposure to pediatric-specific pathophysiology and management, and greater familiarity with the culture of inpatient pediatric care.
- PICU exposure should be an integral part of anesthesia training to complement the required pediatric anesthesia training to improve the overall quality of pediatric anesthesia provided and to encourage the sharing of information among allied specialties.
- PICU fellows (with backgrounds in pediatrics) should be allowed to pursue additional experiences in pediatric anesthesia, including use of analgesics and anesthetics in and out of the OR.
- To further promote partnership between the 2 specialties, additional joint educational conferences and joint morbidity and mortality conferences are needed.
- At the attending level, PICU attendings should spend scheduled time in the OR (eg, 1–2 days twice yearly), and anesthesia attendings should spend scheduled time in the PICU (1–2 days twice yearly) to further familiarity and collaboration with the respective allied specialty.
- The applicability of these recommendations to other pediatric subspecialties, including pediatric surgery, should be explored. A similar synergy is likely to result from removing barriers from pediatric surgeons also providing intensive care, as is common in adult critical care.
- Further data are needed to help assess the impact on trainee preparedness and patient care of accelerated pediatric anesthesia training. Factors to consider include patient care, retention, research output, interdisciplinary collaboration, and clinical innovation. A survey of thoughts and concerns regarding an integrated training track by current pediatric anesthesiologists, PCCM providers, and respective fellowship directors could provide valuable input going forward.
CRITICISM AND CONCERNS
We contend that pediatric anesthesiologists should be allowed to pursue abbreviated PCCM training after an abbreviated and applicable pediatric experience. We also contend that providers who have completed dual training should be allowed to complete a 2-year PCCM fellowship by reducing research time, not clinical time. We anticipate several criticisms of this proposal. Broad exposure to nonacute children is necessary for holistic, contextualized, and compassionate management of children and their families. For this reason, the American Board of Pediatrics has historically been reluctant to consider reducing the 3-year minimum for all pediatric fellowship tracts. In this case, we suggest that PCCM has enough in common with adult critical care and pediatric anesthesia that, even after reducing the length of PCCM training by 1 year, new dual-training attendings would be sufficiently prepared to safely manage critically ill children. Furthermore, what is lost in sacrificing training in general pediatrics is traded for a different and highly applicable set of experiences that can be shared with the respective clinical team.
Another potential criticism is that the anesthesia training does not adequately prepare physicians for the care of critically ill medical patients. However, from the adult literature, we know that there is no statistically significant difference in mortality between patients managed by intensivists with core training in internal medicine and those managed by intensivists with training in surgery/anesthesiology.34
In 1 recent work, Davis35 suggested that anesthesiologists are not interested in participating in longitudinal patient care. Just as there is a wide range of practices within the field of pediatrics, so too are there myriad anesthesia providers with diverse clinical passions. At present, 2042 anesthesiologists participate in adult critical care, suggesting significant interest in longitudinal practice and critical care specifically.36 Other longitudinal fields within anesthesia include chronic pain, perioperative care, and palliative care. Furthermore, for those anesthesiologists who choose a career with less longitudinal patient care, PCCM exposure during training is all the more important to enhance the operative care of the same patient population.
Finally, one might contend that the same discussion could be had with respect to anesthesia and the neonatal intensive care unit. Although beyond the scope of this article, we hope that others more fully explore this topic in the future.
Name: Mckenna M. Longacre, MD, MM.
Contribution: This author helped generate the idea and compose the original draft of the manuscript.
Name: Brian M. Cummings, MD.
Contribution: This author helped provide essential guidance, oversight, and editing to the body of the text.
Name: Angela M. Bader, MD, MPH.
Contribution: This author helped provide essential guidance, oversight, and editing to the body of the text.
This manuscript was handled by: James A. DiNardo, MD, FAAP.
1. Ross PA, Bart R, Wetzel RC. Pediatric intensive care. Gregory’s Pediatric Anesthesia. 2012:5th ed. Hoboken, NJ: Blackwell Publishing Ltd; 946–992.
2. Hanson CW III, Durbin CG Jr, Maccioli GA. The anesthesiologist in Critical Care Medicine: past, present, and future. Anesthesiology. 2001;95:781–788.
3. Downes JJ. The future of Pediatric Critical Care Medicine. Crit Care Med. 1993;21:S307–S310.
6. Epstein D, Brill JE. A history of Pediatric Critical Care Medicine. Pediatr Res. 2005;58:987–996.
7. American Hospital Association. American Hospital Association Hospital Statistics. 1993.Chicago, IL: American Hospital Association.
11. Riefe J. Personal communication. American Academy of Pediatrics. August 30, 2017.
12. McCrory MC, Gower EW, Simpson SL, Nakagawa TA, Mou SS, Morris PE. Off-hours admission to pediatric intensive care and mortality. Pediatrics. 2014;134:e1345–e1353.
13. Berry JG, Hall M, Hall DE. Inpatient growth and resource use in 28 children’s hospitals: a longitudinal, multi-institutional study. JAMA Pediatr. 2013;167:170–177.
14. Anand KJ. Pediatric critical care: grand challenges for a glowing future. Front Pediatr. 2014;2:35.
15. Riley C, Poss WB, Wheeler DS. The evolving model of pediatric critical care delivery in North America. Pediatr Clin North Am. 2013;60:545–562.
18. Ishizuka M, Rangarajan V, Sawyer TL, et al. National Emergency Airway Registry for Children Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network. The development of tracheal intubation proficiency outside the operating suite during Pediatric Critical Care Medicine fellowship training: a retrospective cohort study using cumulative sum analysis. Pediatr Crit Care Med. 2016;17:e309–e316.
19. Yamamoto S, Tanaka P, Madsen MV, Macario A. Analysis of resident case logs in an anesthesiology residency program. AA Case Rep. 2016;6:257–262.
20. Holzman RS, Mason KP. Anesthesia and sedation outside the operating room. Gregory’s Pediatric Anesthesia. 2011:5th ed. Hoboken, NJ: Blackwell Publishing Ltd; 919–945.
21. Weinberg AC, Huang L, Jiang H. Perioperative risk factors for major complications in pediatric surgery: a study in surgical risk assessment for children. J Am Coll Surg. 2011;212:768–778.
22. Ferrari LR, Antonelli RC, Bader A. Beyond the preoperative clinic: considerations for pediatric care redesign aligning the patient/family-centered medical home and the perioperative surgical home. Anesth Analg. 2015;120:1167–1170.
24. Downes JJ. Wheeler D, Wong H, Shanley T. Development of pediatric critical care medicine: how did we get here and why? In: Science and Practice of Pediatric Critical Care Medicine. 2009:London, UK: Springer; 1–28.
26. Carrié S, Anderson TA. Volatile anesthetics for status asthmaticus in pediatric patients: a comprehensive review and case series. Paediatr Anaesth. 2015;25:460–467.
27. Schwartz AJ. Educating pediatric anesthesiologists: what’s best for the kids? Gregory’s Pediatric Anesthesia. 2012:5th ed. Hoboken, NJ: Blackwell Publishing Ltd; 27–39.