The development of a specialty: an interview with Dr. Mark C. Rogers,a pioneering pediatric intensivist

Dr. Mark C. Rogers (1942–), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long‐term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.     

Outstanding contribution to pediatric anesthesiology: An interview with Dr. Robert H. Friesen

Dr. Robert H. Friesen, (1946–) Professor of Anesthesiology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, has played a pivotal and pioneering role in the development of pediatric and congenital cardiac anesthesiology. His transformative research included the study of the hemodynamic effects of inhalational and intravenous anesthetic agents in the newborn and the effects of anesthetic agents on pulmonary vascular resistance in patients with pulmonary hypertension. As a model clinician‐scientist, educator, and administrator, he changed the practice of pediatric anesthesia and shaped the careers of hundreds of physicians‐in‐training, imbuing them with his core values of honesty, integrity, and responsibility. Based on a series of interviews with Dr. Friesen, this article reviews a career that advanced pediatric and congenital cardiac anesthesia during the formative years of the specialties.     

Breaking the glass ceiling: an interview with Dr. Shirley Graves,a pioneering woman in medicine

Shirley Graves M.D., D.Sc. (honorary) (1936), Professor Emeritus of Anesthesiology and Pediatrics at the University of Florida, was one of the most influential women in medicine in the 1960 and 1970s, a time when the medical profession was overwhelmingly male‐dominated. In today's society, it is hard to believe that only 50 years ago, women were scarce in the field of medicine. Yet Dr. Graves was a pioneer in the fields of pediatric anesthesia and pediatric critical care medicine. She identifies her development of the pediatric intensive care unit and her leadership in the Division of Pediatric Anesthesia at the University of Florida as her defining contributions. Through her journal articles, book chapters, national and international lectures, and leadership in the American Society of Anesthesiology and the Florida Society of Anesthesiology, she inspired a generation of men and women physicians to conquer the unthinkable and break through the glass ceiling.     

Pediatric transport medicine and the dawn of the pediatric anesthesiology and critical care medicine subspecialty: an interview with pioneer Dr. Alvin Hackel

Dr. Alvin ‘Al’ Hackel (1932‐) Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine, and Pediatrics at the Stanford University School of Medicine, has been an influential pioneer in shaping the scope and practice of pediatric anesthesia. His leadership helped to formally define the subspecialty of pediatric anesthesiology (‘who is a pediatric anesthesiologist?’) and the importance of specialization and regionalization of expertise in both patient transport and perioperative care. His enduring impact on pediatric anesthesia and critical care practice was recognized in 2006 by the American Academy of Pediatrics when it bestowed upon him the profession's highest lifetime achievement award, the Robert M. Smith Award. Of his many contributions, Dr. Hackel identifies his early involvement in the development of pediatric transport medicine as well as the subspecialty of pediatric anesthesiology as his defining contribution. Based on a series of interviews held with Dr. Hackel between 2009 and 2014, this article reviews the early development of transportation medicine and the remarkable career of a pioneering pediatric anesthesiologist.     

The need for maternal critical care education,point-of-care ultrasound and critical care echocardiography in obstetric anesthesiologists training

Globally, the increase in medically complex obstetric patients is challenging the educational approach and clinical management of critically ill obstetric patients. This increase in medical complexity calls into question the educational paradigm in which future physicians are trained. Obstetric anesthesiologists, physician experts in the perio-perative planning and management of complex obstetric patients, represent an essential workforce in the strategies to address maternal mortality. Unfortunately, the development of peri-operative medicine and maternal critical care curricula has only received minor attention in most countries.Proposed guidelines and models highlight the existing need for tiered maternity care services in which critical care infrastructure plays a central role in the delivery of high-risk peripartum care. Therefore, the development of maternal critical care models designed to prepare obstetric anesthesiologists for the clinical challenges of a medically complex patient are warranted. Key critical care topics such as advanced ultrasonography, with the inclusion of quantitative echocardiographic assessments into obstetric anesthesiology educational curricula, will serve to better prepare physicians for the realities of an increasingly complex pregnant patient population, and further reinforce the critical care infrastructure detailed in the Levels of Maternal Care consensus.Despite an increasingly complex obstetric patient population, heterogeneity of maternal critical care practices exists across the globe, warranting standardization and further development of proposed curricula.     

The time is now: addressing the need for training in maternal critical care medicine

Amongst many high-income countries, indirect medical conditions (e.g. cardiovascular disease, sepsis) now account for the majority of maternal deaths. In response to this concerning rise in indirect causes of maternal deaths, professional societies have developed guidelines that regionalize high-risk obstetric care and prioritize critical care expertise as a requirement for designated ‘top’ maternity hospitals. Critical care proficiency is mandated by the Accreditation Council for Graduate Medical Education for graduating obstetric anesthesiology fellows. Despite these requirements, no formal obstetric critical care educational curricula or fellowship pathways, combining critical care medicine and obstetric anesthesiology, currently exist. Dual subspecialty training in both obstetric anesthesiology and critical care medicine represents one strategy to improve the care of critically-ill obstetric patients and reduce maternal mortality and morbidity, which is one of the pressing healthcare issues of our time.     

Cardiac and lung point‐of‐care ultrasound in pediatric anesthesia and critical care medicine: Uses,pitfalls, and future directions to optimize pediatric care

Point‐of‐care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed.     

Futility and inappropriate care in pediatric intensive care: a cross-sectional survey

BACKGROUND: Over recent years, there have been increasing concerns regarding an increase in the number of futile and inappropriate admissions to pediatric intensive care units (PICUs) in the United Kingdom (UK). METHODS: A prospective cross-sectional survey was carried out using a data collection form distributed by mail to the directors of all PICUs in the UK. Respondents were asked to give details of all patients on their unit on a specific day including age, reason for admission and any preexisting medical conditions. An assessment was made by respondents of whether the care being provided in each case was, in their opinion, appropriate, futile or inappropriate according to standard definitions. RESULTS: We received responses from 21 units (68%) who reported the details of 111 patients. Care was felt to be appropriate in 88 of these cases (79%), futile in nine cases (8%) and inappropriate in 14 cases (13%). Futile cases were most commonly admitted with respiratory failure and all had preexisting medical conditions, most commonly developmental delay. Where care was felt to be inappropriate, respiratory failure was again the most common reason for admission and all had a preexisting medical condition, most commonly cardiovascular disease. CONCLUSIONS: The care being provided in 21% of the PICU cases, described in this study, was felt to be either futile or inappropriate by the directors of those units. There is an urgent need to, accurately, establish the resource consumption associated with these patients and to establish a standard approach to futility and inappropriate care in PICU in the UK.     

Malignant hyperthermia in the early days of pediatric anesthesia: an interview with anesthesiology pioneer,Dr. John F. Ryan

Dr. John F. Ryan (1935 ‐ ), Associate Professor of Anaesthesia at the Harvard Medical School, influenced the careers of hundreds of residents and fellows‐in‐training while instilling in them his core values of resilience, hard work, and integrity. His authoritative textbook, A Practice of Anesthesia for Infants and Children, remains as influential today as it did when first published decades ago. Although he had had many accomplishments, he identified his experiences caring for patients with malignant hyperthermia and characterizing the early discovery of this condition as his defining contribution to medicine. Based on a series of interviews with Dr. Ryan, this article reviews a remarkable career that coincides with the dawn of modern pediatric anesthetic practice.     

The thoracic surgical intensivist: the best critical care doctor for our thoracic surgical patients

The recognition of cardiothoracic critical care as a separate and integral component of the care of the thoracic surgical patient is emerging. We review the recent exciting emergence of this area of specialization and its important future.     

Anaemia among intensive care unit survivors and association with days alive and at home: an observational study

Anaemia is highly prevalent at the time of intensive care unit discharge and is persistent for a high proportion of intensive care unit survivors. Whether anaemia is a driver of impaired recovery after critical illness is uncertain. The aim of this study was to test the hypothesis that, in adult intensive care survivors, anaemia at the time of intensive care unit discharge independently predicts decreased days at home-90. This retrospective cohort study was conducted in a tertiary intensive care unit in Perth, Western Australia. All patients aged ≥ 16 years, discharged alive from their index intensive care unit admission and without documented treatment limitations were included. Median (IQR [range]) age of the 6358 participants was 61 (46–72 [16–95]) years and included 3385 (53.2%) unplanned admissions. Intensive care unit discharge with a haemoglobin concentration < 100 g.l^-1 occurred in 2886 (45.4%) patients, a threshold that identified a cohort with significantly lower days at home-90 (median (IQR [range]) 80 (64–85 [0–90]) days vs. 85 (77–88 [0–90]) days (median difference 5 days, 95%CI 4.4–5.5, p < 0.0001). The association followed a severity-response relationship with more severe anaemia predicting lower days at home-90. When accounting for prespecified covariates including admission haemoglobin concentration and red blood cell transfusion, anaemia at intensive care unit discharge remained a significant predictor of decreased days at home-90, relative risk 0.96 (0.93–0.98), p < 0.002. These findings support the need for interventional trials investigating whether this risk is modifiable.     

The development of pediatric fluid resuscitation: an interview with Dr. Frederic A. ‘Fritz’ Berry

Dr. Frederic A. ‘Fritz’ Berry (1935), Professor Emeritus of Anesthesiology and Pediatrics at the University of Virginia, has played a pioneering role in the development of pediatric anesthesiology through training generations of anesthesiologists. He identifies his early advocacy of balanced electrolyte solution for perioperative fluid resuscitation as his defining contribution. Based on his clinical experiences, he pushed to extend the advances in adult fluid resuscitation into pediatric practice. He imparted these and other insights to his colleagues although textbooks, book chapters, original journal publications, and decades of Refresher Course Lectures at the American Society of Anesthesiologists' annual meetings. A model educator, clinician, and researcher, he shaped the careers of hundreds of physicians‐in‐training while advancing the field of pediatric anesthesiology.     

The development of pediatric anesthesia and intensive care in Scandinavia

The initiation and development of pediatric anesthesia and intensive care have much in common in the Scandinavian countries. The five countries had to initiate close relations and cooperation in all medical disciplines. The pediatric anesthesia subspecialty took its first steps after the Second World War. Relations for training and exchange of experiences between Scandinavian countries with centers in Europe and the USA were a prerequisite for development. Specialized pediatric practice was not a full‐time position until during the 1950s, when the first pediatric anesthesia positions were created. Scandinavian anesthesia developed slowly. In contrast, Scandinavia pioneered both adult and certainly pediatric intensive care. The pioneers were heavily involved in the teaching and training of anesthetists and nurses. This was necessary to manage the rapidly increasing work. The polio epidemics during the 1950s initiated a combination of clinical development and technical innovations. Blood gas analyses technology and interpretation in combination with improved positive pressure ventilators were developed in Scandinavia contributing to general and pediatric anesthesia and intensive care practice. Scandinavian specialist training and accreditation includes both anesthesia and intensive care. Although pediatric anesthesia/intensive care is not a separate specialty, an ‘informal accreditation’ for a specialist position is obtained after training. The pleasure of working in a relatively small group of devoted colleagues and staff has persisted from the pioneering years. It is still one of the most inspiring and pleasant gifts for those working in this demanding specialty.     

Anesthesiology critical care medicine: a fellowship and faculty recruitment program

Study Objective

To review national data on anesthesiology critical care medicine (ACCM) fellowship program enrollment and to describe a program that successfully recruited ACCM fellows and faculty at a single academic medical center.

Design

An incentive program known as the Mayo Clinic Scholar program, designed to recruit ACCM fellows and faculty, was reviewed. Interviews were conducted to assess the impact of the Mayo Clinic Scholar program.

Setting

Academic health center.

Measurements

ACCM fellowship program enrollment data were compared with similar data for critical care medicine fellowship programs in internal medicine, pulmonary medicine, pediatrics, and surgery.The results of a program to recruit ACCM fellows and faculty were reviewed.

Main Results

Only 89 of 147 (60.5%) ACCM fellowship positions available nationally were filled during the 2010-2011 academic year, and only 89 of the 896 (9.9%) critical care medicine fellows anticipated to graduate in 2011 were in ACCM programs. The Mayo Clinic ACCM fellowship enrolled 28 fellows from January 1, 2000 through July 1, 2010 (range 0-6 per yr). Ten of the 28 (35.7%) were United States medical graduates (USMGs) and 6 of the 10 (60.0%) USMGs who were graduates of the Mayo Clinic residency were appointed as Mayo Clinic Scholars. All 6 Mayo Clinic Scholars were retained as ACCM faculty. Only two of the 6 (33.3%) Mayo Clinic Scholars would have completed ACCM training without a Mayo Clinic Scholar appointment. All recommend ACCM training to others and plan to continue to practice ACCM.

Conclusions

The Mayo Clinic Scholar program effectively recruited ACCM fellows and faculty in a single institution. Incentive-based programs should be considered to support the involvement of anesthesiologists in perioperative medicine.     

Systematic overview and critical appraisal of meta‐analyses of interventions in intensive care medicine

Rationale

Meta‐analysed intervention effect estimates are perceived to represent the highest level of evidence. However, such effects and the randomized clinical trials which are included in them need critical appraisal before the effects can be trusted.

Objective

Critical appraisal of a predefined set of all meta‐analyses on interventions in intensive care medicine to assess their quality and assessed the risks of bias in those meta‐analyses having the best quality.

Methods

We conducted a systematic search to select all meta‐analyses of randomized clinical trials on interventions used in intensive care medicine. Selected meta‐analyses were critically appraised for basic scientific criteria, (1) presence of an available protocol, (2) report of a full search strategy, and (3) use of any bias risk assessment of included trials. All meta‐analyses which qualified these criteria were scrutinized by full “Risk of Bias in Systematic Reviews” ROBIS evaluation of 4 domains of risks of bias, and a “Preferred Reporting Items for Systematic Reviews and Meta‐Analyses” PRISMA evaluation.

Results

We identified 467 meta‐analyses. A total of 56 meta‐analyses complied with these basic scientific criteria. We scrutinized the risks of bias in the 56 meta‐analyses by full ROBIS evaluation and a PRISMA evaluation. Only 4 meta‐analyses scored low risk of bias in all the 4 ROBIS domains and 41 meta‐analyses reported all 27 items of the PRISMA checklist.

Conclusion

In contrast with what might be perceived as the highest level of evidence only 0.9% of all meta‐analyses were judged to have overall low risk of bias.

     

The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation*

Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri-operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one-quarter of all surgical activity was lost, with paediatric and non-cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one-third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID-19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics.