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The anaesthesiologist

The unsung hero of peri-operative intensive care

Martin, Claude; De Robertis, Edoardo; De Hert, Stefan

European Journal of Anaesthesiology (EJA): June 2019 - Volume 36 - Issue 6 - p 387–389
doi: 10.1097/EJA.0000000000000982
Editorial
Free
SDC

From the Department of Anaesthesiology and Intensive Care and Trauma Centre, Nord University Hospital, Marseille, France (CM), Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Italy (EDR) and Department of Anaesthesiology, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH)

Correspondence to Prof Claude Martin, Department of Anaesthesiology and Intensive Care and Trauma Centre, Nord University Hospital, Marseille, France E-mail: Claude.martin@ap-hm.fr

For many, if not all patients and nonanaesthesiologist physicians, anaesthesia consists of putting patients to sleep, controlling pain, providing muscle relaxation and stabilisation of oxygen saturation, body temperature and blood pressure (BP). In fact, anaesthesia is much more than that, has multiple faces and is one of the most complex medical specialities (Fig. 1).1,2

Fig. 1

Fig. 1

Today, anaesthesiology is a comprehensive medical speciality that, in daily practice, deals with the care of complex vital functions. The Helsinki Declaration on Patient Safety in Anaesthesiology, jointly launched in 2010 by the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology (EBA) of the Union Européenne des Médecins Spécialistes (UEMS), states that ‘Anaesthesiology shares responsibility for quality and safety in Anaesthesia, Intensive Care, Emergency Medicine and Pain Medicine, including the whole peri-operative process and also in many other situations inside and outside the hospital where patients are at their most vulnerable’.3

The concept of peri-operative medicine has emerged recently, emphasising the fact that anaesthesiologists are in charge of all medical problems occurring during the peri-operative period.4,5 The concept is large, from situations as simple as optimising a chronic β-blocker treatment in a stable patient with a long history of chronic hypertension, to the complex management of unstable patients, with one or more organ dysfunctions, with a risk of death within minutes or hours. For those patients, the concept of peri-operative intensive care must be individualised. Anaesthesiologists are those saving the lives of these patients by providing up-to-date intensive care, outside the ICU.

The current Editorial focuses on the role of anaesthesiologists in peri-operative intensive care and will not analyse their role in the pre-operative assessment and optimisation of the surgical patient.

To nonanaesthesiologists, this is an unknown, or poorly recognised, side of anaesthesia, but peri-operative intensive care is an integral part of the anaesthesiologist's role.

For many, including hospital physicians, intensive care starts from admission to an ICU, and finishes with discharge from the unit.6,7 Patients are admitted to ICUs after transfer from hospital wards, emergency departments or operating/recovery rooms. In the ICUs, there are medical staff specialised in intensive care, nurses specialised in intensive care, sophisticated monitoring systems, and organ dysfunction support. But in the pre-operative, the operative period and the recovery room, patients with acute organ dysfunction and needing intensive care are managed by anaesthesiologists.

For surgical patients, the need for intensive care may begin before surgery and continue during surgery, during the stay in the recovery room and of course also after transfer to the ICU (Table 1, Fig. 1).6–9

Table 1

Table 1

As well as intensive care physicians, anaesthesiologists are experts in many aspects of diagnosis of many diseases/syndromes currently treated in ICUs. Indeed, iconic syndromes treated in ICUs are also treated during the peri-operative period.

  1. Acute respiratory distress syndrome (ARDS): Patients with ARDS may need emergency surgery and be managed according to up-to-date guidelines (protective ventilation, optimal driving pressure, optimal positive end-expiratory pressure).
  2. Sepsis/septic shock: This is the case for patients with, for example, peritonitis, cellulitis or purulent pleuritis who need emergency surgery.
  3. Haemorrhagic shock in patients who need emergency haemostatic surgery.

The same is true for anaesthesiologists providing up-to-date and optimal intensive care treatments by prescribing intensive care drugs and organ support techniques. Sophisticated concepts developed in ICUs are also applied in the peri-operative period, such as goal-directed therapy (to optimise oxygen metabolism) or lung-protective ventilation.10,11

During the stay in the pre-anaesthesia unit, during surgery and in the recovery room, anaesthesiologists and nurses diagnose critical illnesses and organ dysfunction, monitor vital functions (from BP to cardiac output), recognise and treat deviations by:

  1. Use of vasoactive drugs, antibiotics, resuscitation fluids.
  2. Control and/or treat hypovolaemia, body temperature, oxygenation, hypercapnia, anaemia (Table 1).
  3. Use of sophisticated techniques such as Doppler, echocardiography, pulmonary catheter or transpulmonary thermodilution.
  4. Anaesthesiologists are trained to provide peri-operative intensive care and can bring their enormous expertise to give rescue therapy to surgical patients, present these patients in the best condition possible for surgery and to control and treat organ dysfunction during surgery and beyond.12,13

As briefly indicated in Table 1, there are several steps to salvage, stabilisation, optimisation and deresuscitation.

  1. Salvage is the phase in which the aim is to save life by providing at least a perfusion pressure to the brain and the heart, sometimes at the expense of blood flow and perfusion of organs such as the kidneys, the lungs and the splanchnic organs.
  2. Stabilisation is the phase in which, by using vasoactive drugs, resuscitation fluids and blood, normovolaemia is restored and flow to the organs is improved.
  3. Optimisation is the phase in which oxygen metabolism is optimised and surrogate markers such as serum lactate, central venous oxygen saturation (ScvO2 and PCO2 gap) are optimised.
  4. Deresuscitation will be done in the ICU: less aggressive fluid infusion, weaning from vasoactive drugs, initiating narrow spectrum antibiotic therapy.

The European Training Requirements in Anaesthesiology (ETR) have been recently licensed by the EBA and approved in April 2018 by the UEMS Council (https://www.uems.eu/__data/assets/pdf_file/0004/44428/UEMS-2013.18-European-Training-Requirements-Anaesthesiology.pdf) (ETR). In this official European document, it is clearly stated that the practice of anaesthesiology has significantly changed towards more holistic competencies in the peri-operative period, in intensive care medicine, critical emergency medicine and pain medicine which in many countries are integrated parts of the clinical speciality. Implications of the EBA/UEMS ETR update are aimed also at the content of the European Diploma in Anaesthesiology and Intensive Care.

An adequate training in intensive care medicine is needed to fulfill the above goals. For those who graduated years ago, continuous medical education is needed and the European Journal of Anaesthesiology and Euroanaesthesia, the yearly scientific meeting of the ESA, are the sources to provide state-of-the art knowledge.

Peri-operative intensive care is a reality and should be recognised by all hospital physicians as part of intensive care medicine (Fig. 1). Peri-operative intensive care offers flexible and ‘tailored’ intensive care assistance, with a better allocation of resources, limiting admission to intensive care or intermediate care units. This of the greatest benefit for surgical patients to minimise postoperative complications and to maximise the chance of survival after surgical procedures.14,15

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Acknowledgements relating to this article

Assistance with the Editorial: none.

Financial support and sponsorship: none.

Conflict of interest: none.

Comment from the Editor: this Editorial is based on the 2018 Sir Robert MacIntosh lecture ‘Anaesthesia in the 21st century: from the IV Doctor to the Intensivist-Anaesthesiologist’, delivered by CM on 2 June 2018 at the Euroanaesthesia meeting in Copenhagen, Denmark. This article was checked and accepted by the Editors, but was not sent for external peer-review.

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