Central Line

Episode Number: 124

Episode Title: Inside the Monitor: Critical Care Medicine

Recorded: February 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ZACH DEUTCH:

Hello and welcome to the Central Line podcast series. I'm your guest host for today's episode, Dr. Zach Deutch. I'm joined by the co-editors of April’s ASA Monitor, Dr. Shahla Siddiqui and Dr, Ashish Khanna. We're going to discuss critical care today, which is a topic we've touched upon a few times recently. However, today we're going to approach the topic a bit differently, and we're going to learn about some of the evolving trends, practices, and procedures that are novel or rapidly evolving in this important field. I'm looking forward to hearing what both of our guests have to say. So welcome to the show.

Let's start off with some introductions. Can each of you tell our listeners a little bit about you and your practice? Let's start off with Dr, Siddiqui, please.

DR. SHAHLA SIDDIQUI:

Hi. Um, I'm an anesthesiologist and intensivist. I work in a tertiary care center in Boston. It's an academic center, and I'm primarily OR, and about one week a month, I do ICU. The type of critical care I cover is cardiovascular as well as trauma and surgical, a lot of liver transplants as well. And my research involves ethics and humanities.

DR. ASHISH KHANNA:

I'm Ashish Khanna, I'm the current chair of the ASA Committee on Critical Care Medicine that Dr. Siddiqui vice chairs. I am currently located in Winston-Salem, North Carolina and at the Wake Forest University School of Medicine and the hospital system known as Atrium Health Wake Forest Baptist. It’s a 900 bedded tertiary care hospital. I work both in anesthesia and critical care medicine, staffing a post cardiac surgery ICU, and also a large mixed ICU in our hospital system.

I have a deep interest in all things perioperative outcomes and large data sets and in clinical trials. I've done a fair amount of clinical trials around shock and vasopressors in the ICU, and some work with perioperative monitoring and improving patient safety in the postoperative period. And I'm excited to be on the podcast today.

DR. DEUTCH:

Thank you both. We're excited to have you. We know that anesthesiologists have made many an important contributions to critical care. Can you start off by telling us about the impact of the specialty on critical care and Dr. Khanna, I’m going to have you answer that one, if you would.

DR. KHANNA:

Sure. Yeah. So if you really look at the impact of the specialty, you'd have to go back to the 1950s, to the times of the, uh, polio epidemic, where in Denmark we first had anesthesiologists who came up with the concept of the most rudimentary ventilators, like the iron lung, and then came up with the concept of, of doing a tracheostomy in these polio patients and providing positive pressure ventilation. In fact, my good friend and colleague Hannah Wunsch has written a lot around it. And the legacy that was established by Bjorn Ibsen and the Danish group of anesthesiologists who truly helped us build critical care in its most basic form in the 1950s, has then carried forward all these years. And I am glad and excited to say that today day critical care and critical care anesthesia has expanded beyond the four walls of the ICU. And we are now much more than just practitioners who round in an ICU. We wear many different hats, and we're diversifying into various areas in the hospital and doing a fabulous job at that.

DR. DEUTCH:

Well, you give an interesting historical perspective, and this episode we really want to touch also on things that are more current and, you know, pertinent to our members today. So I'm going to move on to that topic. Specifically, we want to talk about feeding tubes and fasting. We have about 10,000 critically ill patients per year in the US that have to deal with uncertainty regarding optimal management of perioperative tube feeding. The committee on critical care medicine from the ASA has recently produced updated practice guidelines. Can you inform our listeners about these guidelines, about what changes have been made and what do they need to know for their practices and Dr, Siddiqui, I'd like you to answer this one if you would.

DR. SIDDIQUI:

Sure. So, um, as you said, about 40% of our ICU patients have prolonged fasting preoperatively or for a procedure or for extubation, etc. and sometimes there's uncertainty around those timings and patients are not given their due caloric requirement. As a result, they're weak. And that has been shown to prolong their ICU length of stay and have poorer outcomes. And traditionally, patients are made NPO the night before. Anesthesiologists may even cancel the case if patients are not made NPO. There's a group of physicians who are actually researching this and have just won a very large multi-centered Pcori grant. Uh, we came up with certain guidelines, and there is a good outline of those guidelines in this issue, which basically discuss scenarios where there's unnecessary fasting, for instance, around extubation or even procedures, or delaying fasting for basically just trying to place a post pyloric tube.

DR. DEUTCH:

Do you think that based on this, that we can come to sort of a consensus and it won't be, um, you know, each provider has their own, my level of comfort is this or I usually do that. Could this kind of close that gap and solve that problem?

DR. SIDDIQUI:

I think so. I think that to be consensus. And this review article talks about the various papers that have been published on it, the literature on 7000 patients that have shown no adverse outcome without fasting. However, this study that Dr. Negrebestky is proposing is such a large study that it should produce some sort of level one evidence. However, this article is a good review of all the literature that's around this.

DR. DEUTCH:

Excellent. So hopefully our Monitor readers will read it, absorb it, and incorporate it into their practice.

Moving on to another topic, which is pertinent but a little bit more complex. That's the use of mechanical circulation support devices, which also have been abbreviated as MCS. So MCS patients are obviously complex and care for these patients, often by necessity revolves around interdisciplinary teams or multidisciplinary teams. What considerations should anesthesiologists be thinking about when they're providing anesthetic care for patients with these devices?

DR. SIDDIQUI:

Right. So this article has a very nice table in it which talks about, uh, mechanical circulatory support devices. For instance, you have ECMO devices or patients coming in with Lvads or Impella fives. Uh, in my center, for instance, we have a large volume of these patients. And sometimes these patients may be coming to the noncardiac anesthesiologist in the middle of the night or coming to a noncardiac ICU as well. So I think it's very important that all anesthesiologists should be familiar with these devices.. These patients are generally very sick. And that's why they're requiring the mechanical circulatory support. Their comorbidities should be known. But it's not just the device and the support that the device is providing, but also get to know what the clinical condition is of the patient and how to tailor your anesthetic around it. So I think if people are more familiar with it and know what the details of the device are, they will feel more comfortable in providing anesthesia care, which is of good standard.

DR. DEUTCH:

Okay, I have a question for Dr. Khanna. This is regarding point of care ultrasound, which is another very, very pertinent and very, uh, hot topic in perioperative medicine in all of medicine right now. So this is being used in addition to other applications in resuscitation efforts in real time. How might point of care ultrasound be used to differentiate types of shock and to help institute appropriate management strategies in patients who are critically ill with this type of diagnosis?

DR. KHANNA:

Yeah. It's um, great question. You know, I always say that not all shock is created equal, whether in the operating room or the perioperative period or in the ICU. And, um, unfortunately, shock doesn't come in one flavor. It usually comes as a multi-dimensional problem. So patients could have mixed shock as well. And sometimes even the best clinicians would struggle with establishing an early diagnosis and a correct diagnosis that would guide appropriate therapy, all of which is really important. So again, we well know how pocus has revolutionized this field. Gone are the days when people used to feel that sense of being technologically deficient, or needing to call an ultrasound tech or even a cardiologist to do their bedside echoes. Now, most trainees are facile with using point of care ultrasound, and I think that that is really changing the way we're taking care of our patients. Uh, we are able to truly take ownership of our patients, uh, hemodynamic assessment starting sometimes in the preoperative holding room to the intraoperative world, the post-operative space and the recovery room, and also in the ICU and on the general hospital floors when we're confronted with a with a rapid response. It's become really simple. For example, in my program, uh, all of our anesthesia residents get a portable ultrasound device that that they can keep, um, and they use at liberty during their, uh, training.

The four views, uh, which I feel that are the essential backbone and that everyone should know how to acquire are the parasternal long axis, the mid papillary short axis, the apical view, and also the, uh, the subxiphoid view. And I really feel that, you know, the Subxiphoid view is one which I use commonly. It's an easy to acquire view. It gets you a quick look at the heart and and contractility and both sides of the heart. Um, the other one is looking at the IVC. I think every critical care anesthesiologist, or in fact, I say every anesthesiologist, should be facile with looking at the IVC and getting a quick estimate of, uh, volume status.

But, um, really looking at how things have evolved over the last some years. I'm happy to say that, uh, pocus is now no longer something that is a moonshot. It is totally within our reach, and it is being done on a daily basis. And things can only get better for us as a specialty as we adopt, uh, the use of pocus, not just for the heart, but but also for, uh, you know, basic lung views and the quick diagnosis of a pneumothorax or a pleural effusion and so on and so forth. The opportunities are endless here.

DR. DEUTCH:

So the trainees are all getting, you said, their own portable devices. What type of devices are those?

DR. KHANNA:

Well, those devices are pretty much portable, uh, devices where they can carry them around and they can easily do point of care ultrasound. The quality of the images is is excellent and is only improving. And they're specifically using them sometimes in the preoperative holding area when they're, uh, worried about a patient, sometimes in the post anesthesia recovery room when someone's worried about the hemodynamic status. And sometimes also and I've seen them be creative about it that they've used it for, like an emergency airway that they are called for at a remote location where they're unsure of the hemodynamic status of a patient. So like I said, the opportunities are endless. I'm just glad to see that there is a level of comfort with these things that that is on a trajectory of improvement and that is continuously evolving to be better every day.

DR. DEUTCH:

Yes. And this type of very impressive incorporation into the curriculum will allow these people to bring this technology forward into their own practice. And honestly, they're going to end up teaching people like me. That's how it works.

DR. KHANNA:

And me.

DR. DEUTCH:

Yeah, it's been great talking with two critical care experts so far and getting a lot of insight from the front lines. Right now. We need to take a short patient safety break. Please stay with us. We have some more questions for both of these doctors.

(SOUNDBITE OF MUSIC)

DR. JEFF GREENE:

The bed-to-bed transfer that occurs at the start and end of nearly every surgical procedure is an often under-recognized hazard that can cause patient harm. Patient falls and the accidental removal of tubes, lines, or drains can lead to injury. Checklists and protocols are available for optimal lateral transfer and supine to prone transfer, but steps can be omitted in the busy OR. Using a simple, standardized, verbal memory tool where questions are posed to the team can help ensure safe patient transfers. For example, on the count of one, the team is asked that lines, drains, and tubes are able to move with the patient, on the count of two, the team is asked that both beds are locked.

Verbalizing safety concerns during transfer helps the entire team work as one identify issues before they cause problems that threaten patient safety.

VOICE OVER:

For more patient safety content, visit asahq.org/patientsafety.

DR. DEUTCH:

Welcome back. We're going to resume our discussion with our two experts, Dr. Khanna and Siddiqui. As our patient population ages and comorbidities increase, end of life discussions in the perioperative period are becoming more common and obviously more important. What is the role of anesthesiologists in these conversations? What do we bring to those conversations and scenarios that makes us particularly effective and what might make us ineffective in those? And Dr. Siddiqui, I'd like you to answer that if you would.

DR. SIDDIQUI:

Thank you. This is a particularly important area to me. My master's in medical ethics thesis was around end of life care in elderly ICU patients. So this is the area of research that I focus on. As you know, when patients are brought for procedures and if their previous wishes have been to limit end of life care or to limit aggressive care, these wishes are often reversed for the procedure, for example in the GI suite or before surgery, etc. and although these are reversed and the anesthesiologist just goes and picks up, the patient brings them to the Or. Very often these decisions have a huge amount of impact on the patient and their families.

So previous guidelines did exist at the ASA which talked about required reconsideration, where the anesthesiologist, the primary team physicians should actually have a discussion with the family or the patient if they are still awake and alert and are able to participate to actually discuss what their preferences, goals, and wishes are around end of life care or limiting such care, including the resuscitation they would receive during an anesthetic, for instance. However, just for efficiency and in order to get the patients to the OR and back, and for the comfort of nurses or physicians in the operating room, these orders are often blanket rescinded, and patients are actually not allowed to come to the OR unless the DNR order is reversed. So the ASA is now, the ethics Committee is actually looking at these guidelines again to recommend and enforce a required reconsideration. And as perioperative physicians, anesthesiologists are situated in a very important position because they are bridging the link between the operating room as well as the primary team, sometimes the ICU, the Intensivists are important physicians here who are actually the point of contact for the family as the patient goes to the operating room, and for the anesthesiologist who comes to pick up that patient. And so it's important that we should not just blanket reverse these orders, but actually have that conversation with these families and patients, because these decisions have come about after a great deal of thought and emotional upheaval. And there's a lot of consideration that has gone into these decisions. And just to reverse them without any discussion with the family, in my opinion, is not really ethical. And as a result, this should be done, of course, upstream not at the time when the physician is going to pick up the patient for a procedure. People have to be trained for this kind of conversation and they have to have a multidisciplinary discussion as well. So communication skills are very important. I think our trainees need to know this and need to be aware of what the ethical principles are around end-of-life decisions that are made and how to handle these patients, not just in the ICU but also in the operating room.

DR. DEUTCH:

So I am not a critical care trained physician, and I'm wondering if your guys training, I'm assuming, includes some of these either practical or didactic modules about end of life issues, number one. And number two, do you feel on that basis that anesthesiologists who function in critical care role possibly have a more effective role in dealing with these situations because of our background?

DR. SIDDIQUI:

Absolutely. So, yes, we do have training. In fact, our boards have a large section on this sort of communication of breaking bad news or goals of care discussions, etc. At my center, we do have ethics teaching modules. I'm part of the ethics committee. I'm the co-chair here of the ethics committee. So we do have regular discussions and drills where we actually do role play, and we have simulation around this kind of conversation. Trainees are encouraged to sit in in these conversations as well. And I feel that as intensivists our link and our bond with the families and the patients themselves is a very important part of our clinical care. The communication that we do is not just the words that we speak or document in our charts, but also how we treat the patient, how we treat their families and and understand what their goals actually are around the care that they're receiving. So they may choose to to rescind the DNR and to be full code around a procedure, but that should come after a very deliberate conversation and discussion around it, focusing on the patient's autonomy and their worldview rather than a blanket rule that has to be abided by. So I think Intensivists are trained to do this. Uh, it comes with a little bit of compassion and emotional intelligence that is person dependent as well. But we try and reinforce this within our trainees, not just the fellows, but also the residents who come through the ICU, that these are not just patients that are going to the operating room, they are family units. And their decisions that we make today have a huge impact on the entire family. And so that that has to be taken into consideration when we make these decisions.

DR. DEUTCH:

And these are very difficult situations and scenarios. And my hat's off to people that are approaching that in a very thoughtful way that's patient centered, because so often we're just, you know, our instinct is just to plow through, get it done, get through it. And that's not necessarily the best thing. So your comments are very pertinent, I think, to our practice both operationally and ethically.

DR. SIDDIQUI:

Yeah. And I always encourage people to go back and think about a situation in their life, which can sort of reflect on the scenario that they're facing with the patient. And until you personalize things, and I'm not saying take your work home and grieve over it because we don't want to increase, uh, burnout amongst our physicians. But unless something touches a chord within you, it can't be genuine and sincere. So like in anything else in life, you have to personalize it to a point where you can actually have sincere empathy rather than just, you know, fill the boxes and, and go through the motions. So I do encourage people to try and put yourself in the other person's shoes as much as possible, rather than just literally.

DR. DEUTCH:

So speaking of putting yourself in someone else's shoes, we're going to shift gears a little bit. And Dr. Khanna, I'm going to give you an opportunity to be a salesman and to hype your specialty. So talk to us and to trainees and possible future intensivists as well. What's unique about critical care? Why should they consider taking a role as an intensivist, a career in critical care? What would the days look like for them when they're working? What would be the pros and cons of that of the job that they might do?

DR. KHANNA:

Yeah. You know, um, I often look at this as a challenge for myself because I know that in the, in the broad world of anesthesia, across its varying specialties, critical care is probably ranked the lowest when it comes to or the number of days I'd spend home with my family over a weekend, or a holiday, or the number of nights spent at home. But I'll say this, and I know that it sounds cliche. Time flies when you love what you're doing. So if trainees want to ask me, is there great work life balance in critical care, I'd very honestly answer them. Well, you know, if you're looking for a life where you know, you have very regulated work hours and you don't have to work any weekends and you don't have to work holidays and you don't have to work nights, then if that is a huge issue in your mind, then maybe you need to rethink. On the other hand, I will say that it is the passion that drives the work, and it is the ability to make a meaningful difference, to have that sense of gratification when you are at work and that sense of fulfillment that overcomes you, that takes over and goes beyond that work life balance, and I mean it when I say it. And Dr. Siddiqui can endorse what I'm saying, and so can the rest of the critical care fraternity, that when we're working the night of Christmas or the night of a holiday or a Friday night where that we could have spent with our family and we end up saving a life or making a difference in another family's life, whose mom or dad are critically ill and in the ICU, we do go back home very satisfied individuals and there is difficult to put into words what that satisfaction is unless you have a chance to experience it. So, um, I'll say this to the trainees. You have the opportunity of being with a family at the most and the biggest crisis moments of their lives. When a family is looking for answers, when they have their loved ones who are struggling, you are the focal point of their universe at that time. And not many other specialties will give you the opportunity to live that, and live that again and again. And yes, not all outcomes will be great outcomes, but it is you who is going to be that person who is not only going to rejoice with the families when you will bring their loved ones back from a really poor outcome, but also work with these families in their grief and their understanding of disease when they have to let go. That, you know, Dr. Siddiqui has done so well during her career and that all of us need to learn from. So, you know, I can go on all day trying to sell the specialty, but I can say what I said when I started this. You love what you're doing, then it's not work. Time flies. And that becomes the essential meaning of of your of your life. And then you don't regard holidays and weekends as time spent away.

DR. DEUTCH:

Dr. Siddiqui, I'd like to give you an opportunity to hype your specialty as well. If you have anything to add on this subject.

DR. SIDDIQUI:

Yeah. And, um, as Dr. Khanna said, we could just go on about this. But as Steve Jobs said that, uh, when this is your passion, it's not even a day of work. So I don't even call it work life. I call it work life synchrony. Because what I'm doing at work is actually part of my life. And I wouldn't. I wouldn't even dream. I've been doing this for 25 years and I'm a mom. I have two kids, and I think I've spent the most important times, uh, at work. But also I've never--and my mother was a surgeon as well, so--I've never felt that I've deprived my kids of anything that was important. So it is possible to do things that you love in balance and in synchrony. It is really, really possible. But you have to derive that passion and that vigor out of it. And even if we stay back late, as Doctor Khanna was mentioning, or it takes into a vacation or you have to cancel some dinner plans, etc., it doesn't feel like it's, um, a sacrifice. It feels like an honor. So I feel that critical care is the most honorable thing that that I do. And I feel that it's a duty that I'm performing. So it really feels I feel very passionate about this. I feel very rewarded in every single day and very privileged that I can make a differencet.

DR. DEUTCH:

That's well said by both of you and clearly very, very sincere. Dr. Khanna I'm going to come back to you. Um, we've talked in the field of anesthesiology in leadership is important in perioperative medicine. It's also important in other areas. What sorts of non traditional non critical care roles are intensivists playing at this point. And how do you see that evolving in the future?

DR. KHANNA:

Yeah, I think Intensivists are rapidly stepping out of their, uh, traditional roles. And I have seen evolution into various different roles and opportunities. Um, to name a few. I've seen Intensivists who have sort of developed a vision and a pathway around perioperative optimization, around perioperative outcomes research, around leadership, and establishing perioperative medicine programs that closely interdigitate with with critical care. I've seen um, intensivists rapidly stepping into the world of perioperative monitoring and rapid response teams. I'll say personal pitch - I'm very passionate about enhanced monitoring for patients on the hospital general care floor. And someone would say, well, you know, what is a what is an anesthesiologist or an intensivist doing on a general care floor? But I truly believe that we improve monitoring of patients on the general care floor. We avoid a lot of unplanned ICU admissions and downstream, uh, morbidity and mortality. And that drives me to that nontraditional area. I've also seen folks have a sort of a deep interest in clinical informatics and sort of evolve themselves into as CMIOs or CIOs, uh. Others I've seen lead, for example, IQR programs, pocus programs that we just talked about. I've seen people get into the post-surgical rehabilitation space. And then, you know, there's this huge opportunity with, uh, post ICU recovery. Uh, we, uh, you know, we we look at our ICU patients and we, you know, we follow them to when they come in through the doors of the ICU and then we follow them to the doors of the ICU, and we generally just leave them there saying, okay, you know, now it's a hospitalist’s job or back to the surgeon. And then the patient at some stage goes home and continues to, um, struggle. And that is where post ICU clinics are coming in in a big way. Uh, they're giving Intensivists the opportunity to then, uh, sit in a, um, on almost an outpatient clinic environment, get these patients back with their post ICU problems and offer solutions. And I think that really rounds it out for the cycle of care here. And I'm very excited to say that, uh, some of our colleagues from within the ASA committee on critical care medicine are doing a remarkable job with, uh, post ICU recovery. So, again, you know, opportunities are endless. And, um, excited to say that people have been really successful with all of these opportunities that I've just cited.

DR. DEUTCH:

And it sounds like whether it's the enhanced monitoring on the floor to prevent, uh, either admission or readmission to ICUs or post discharge optimization of medical conditions, there is some significant traction to be gained here based on saving of health care dollars for hospitals and health system, which is obviously obviously always very attractive. So, uh, that's very intriguing what you mentioned.

Um, we're coming to the end here. I have one more question for the both of you and Dr. Siddiqui, I'd like to hear from you first. What do you hope people will take away from the issue of the Monitor that you guys have co-edited?

DR. SIDDIQUI:

Um, I think this issue is a very broad cover of things that we do and the new advances and, um, consensus that we're reaching about our usual practice. So this issue is modern. It brings to, uh, the focus of the readership what kind of interventions that are now being practiced. What is the literature behind it? Critical care is a field where we're constantly reinventing ourselves. Since I've graduated in 2002 from my fellowship, we've come such a long way. Ecmo, pocus, um, intensivists are doing global health, we're doing work in disparities. There's so much that we can achieve. And this issue adds to what has been added in the past decade and what is the literature around it. So I think it's a very informative issue. I think it also opens the door for new and novel ways that intensivists and anesthesiologists can contribute to the sickest of the patients in the hospital.

DR. KHANNA:

Yeah, and I agree with all of what Dr. Siddiqui just said. And specifically, I'd, um, leave a message for medical students, uh, residents and, uh, with with a future interest in critical care and, and even the more junior attendings please stay inspired. We were the ones who introduced critical care to the world. So live and believe in that legacy and believe that our future is bright and work towards that bright, shining future and everything else will will fall in place.

Finally, um, quickly wearing my vice chair research hat that I do within my institution, I always encourage my fellows and my junior attendings to find a question and try and seek an answer to that scientific question. Once you start doing that, then you find a bigger meaning and a reason to practice critical care, and it becomes fun rather than being monotonous in any way.

DR. DEUTCH:

Well, it's been wonderful speaking with both of you. I really appreciate y'all's expertise and your obvious, conscientious, thoughtful, and informed approach to your work, which is so important. For the listeners who want to learn more about this topic and anything else related to critical care, please check out the ASA Monitor at asamonitor.org and we hope to see you back in the future for more centralized podcasts.

(SOUNDBITE OF MUSIC)

VOICE OVER:

Evidence based learning, industry innovations, global networking. It's all happening at ANESTHESIOKOGY 2024. Join us in Philadelphia October 18th through the 22nd for everything new in anesthesiology. For more details, please visit asahq.org.annualmeeting.

Subscribe to Central Line today wherever you get your podcasts, or visit asahq/org/podcasts for more.