Special article
Intensive Care of Anaesthesia: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology
Cuidados Intensivos de Anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología
P. Monedero
, D. Paz-Martín, J. Cardona-Pereto, F. Barturen, L. Fernández-Quero, L. Aguilera-Celorrio, J. Canet, J.I. Gómez-Herreras, R. Peyró, C. Sánchez, J.C. Valía
Corresponding author
Comisión Ejecutiva de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología y Reanimación, Madrid, Spain
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Monedero, D. Paz-Martín, J. Cardona-Pereto, F. Barturen, L. Fernández-Quero, L. Aguilera-Celorrio, J. Canet, J.I. Gómez-Herreras, R. Peyró, C. Sánchez, J.C. Valía" "autores" => array:11 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Monedero" "email" => array:1 [ 0 => "pmonedero@unav.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Paz-Martín" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Cardona-Pereto" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Barturen" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Fernández-Quero" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Aguilera-Celorrio" ] 6 => array:2 [ "nombre" => "J." "apellidos" => "Canet" ] 7 => array:2 [ "nombre" => "J.I." "apellidos" => "Gómez-Herreras" ] 8 => array:2 [ "nombre" => "R." "apellidos" => "Peyró" ] 9 => array:2 [ "nombre" => "C." "apellidos" => "Sánchez" ] 10 => array:2 [ "nombre" => "J.C." "apellidos" => "Valía" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Comisión Ejecutiva de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología y Reanimación, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuidados Intensivos de Anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">European guidelines for specialized training in anaesthesiology are drawn up by the European Board of Anaesthesiology (EBA UEMS) through its Standing Committee on Education and Professional Development.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> In these guidelines, which are approved by the UEMS Council, intensive care is defined as a core competency in the field of anaesthesiology.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> Unlike other specific competencies, “Medical and perioperative care of critically ill patients/General Intensive Care” is considered one of the general core competency domains that should be achieved by anaesthesiologist in Europe. The “European Standards of Postgraduate Medical Specialist Training” in their “Training Requirements for the Specialty of Anaesthesiology, Pain and Intensive Care Medicine” establish a minimum training time of 5 years to reach the competencies required to become a specialist in anaesthesiology, of which up to 1 year can be specifically focussed on Intensive Care Medicine training.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Unlike most European countries, anaesthesiologists in Spain receive just 4 years of training, which is insufficient to fully acquire the competencies required by the specialty. Constant, though unheeded, demands to increase the training period to 5 years prompted the former National Anaesthesiology Committee (CNEA, in its Spanish acronym) to petition for the speciality to be included in medical residency training programme in order to extend training time and provide more training in intensive care medicine.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,5</span></a> The current core residency curriculum has given the CNEA, for the first time in its history, the opportunity to develop a specific specialty training programme based on competencies described by the EBA UEMS<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> and the Competency Based Training Programme in Intensive Care Medicine for Europe, or Cobatrice,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> curricula, albeit at the expense of extending the training period. Although intensive care in Spain is not recognized as a multidisciplinary competency, as it is in Europe,<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7–9</span></a> it must become as much part of the specialty of anaesthesiology as it is in cardiology. In a recent editorial, the Spanish Society of Cardiology defined its official position regarding the care of acute and critically ill cardiac patients in Spain,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> stating that “the care of patients with acute, critical cardiovascular disease is an essential part of the specialty of cardiology”, proposing the creation of critical and acute cardiovascular care units attended and led by cardiologists. As an interim, short-term measure, the Society calls for the creation of intermediate cardiac care units, and highlights the need to “come to an understanding with intensive care unit managers to create organizational models that would enable intensivists and cardiologists to share the care of patients with acute heart disease”.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Intensive Care Section of the Spanish Society of Anaesthesiology, following the recent elections to the board,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> has evaluated the situation in Spain and proposed measures to improve critical care provided by specialists in Anaesthesiology. The recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology include measures consistent with the speciality's intrinsic commitment to intensive care, and the use of appropriate terms that accurately described the reality of the situation (see <a class="elsevierStyleCrossRef" href="#sec0010">Appendix</a>). The aim of these recommendations is to raise awareness among all anaesthesiologists of the need to: 1) accept intensive care as an essential part of our specialty; 2) ensure the availability of excellence training in intensive care, particularly for residents who are the future of our specialty, and 3) improve the care provided to critically ill patients through research and the implementation of the quality standards recommended by the Ministry of Health.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The situation with regard to Intensive Anaesthesia Care in Spain varies greatly, as shown in the analysis published by the previous CNEA.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12,13</span></a> Particularly striking is the existence of teaching hospitals with no Intensive Anaesthesia Care Units. This prevents future anaesthetists from acquiring a fully comprehensive understanding of the specialty and acquiring the intensive care competencies they will need to put into practice both in the operating room and other settings. In addition to its key role in defining the curriculum and duration of training in anaesthesia, the CNEA can also shape the future of the specialty by changing the way anaesthesia teaching units are accredited. Since the development of the core curriculum involves re-accreditation of teaching units, we ask the CNEA to demand compliance with current accreditation requirements that include, in addition to a post-anaesthesia care unit (PACU), a “recovery unit with 1 bed for every 1.5 operating rooms,” which “will be attended round the clock,” and where intensive care is given to “high-risk or unstable patients or those at high risk of presenting complications”.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> The fact that the availability of an Intensive Anaesthesia Care unit is a pre-requisite for accreditation as a teaching hospital should compel managers to approve requests for setting up such units.</p><p id="par0025" class="elsevierStylePara elsevierViewall">All anaesthesiologists need to show their commitment to the specialty by working towards developing intensive care competencies in their own hospital. Today, thanks to the Royal Decree regulating the Specialised Care Register,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> recovery units have been recognized as intensive care units, provided they contain permanent beds and are subject to admission formalities. All anaesthesia services should request that their permanent beds be subject to specific admission formalities in order to be classified as “intensive care units”. Any units that are not recognized as such should advise the hospital management of the potential negative impact this could have on the case mix index (CMI) and on funding; failing to properly encode the type of care given, the procedures in place and their complexity would reduce the hospital's weight in the database used to obtain diagnostic-related groups (DRG). Formally admitting patients to the Intensive Anaesthesia Care unit in hospitals in which these beds are not considered part of the Intensive Care Unit would increase the centre's average weighting in terms of DRG, and with it the CMI, thus making the hospital eligible for additional funding. Hospital admission services and coding departments play a pivotal in obtaining official recognition of beds in the Intensive Anaesthesia Care and the proper classification of the different levels of intensive care provided.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The steps needed to allocate beds to an Intensive Anaesthesia Care unit will vary, depending on the characteristics of each unit. Services in which only a PACU is available will first have to ensure the unit is open round the clock and has the appropriate number of medical and nursing staff on hand. This is will make it possible to provide night-time mechanical ventilation to certain surgery patients, and thus justify the creation of specific admission formalities to these special care beds. Long-term mechanical ventilation is one of the criteria used in Europe to define an intensive care unit.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">16,17</span></a> Once they have obtained recognition, intensive anaesthesia care units should then expand their portfolio of services to include support for critically patients ill with multiple organ failure, thus eliminating admission restrictions due to time constraints or organ failure. This objective can only be achieved with ongoing efforts to improve training and quality of care, in accordance with the guidelines recommended by the Spanish National Health System Quality Agency.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> In addition, partnership agreements should also be reached with surgery services in order to create synergies, develop preoperative enhanced recovery after surgery (ERAS) programmes, and avoid surgical cancellations.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Making the required investment to train anaesthesia residents in intensive care medicine is essential if we are to change the future of our specialty. The 6-month rotation in intensive care required by current guidelines<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> does not give residents the skills needed to work without supervision. These can only be obtained with additional training after the residency period, as is required in practically all other specialty fields, in which specific competencies and subspecialization after residency are required to quality as a specialist. Services that do not have an Intensive Anaesthesia Care unit should arrange for their residents to be rotated in hospitals equipped with these specialist units in order to give trainees a better, more comprehensive understanding of the speciality.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally, as names express the nature of the realities they describe, we must all undertake to use the correct terminology. We must not permit some common terms, such as intensivist or intensive care, to unjustifiably become the exclusive prerogative of a primary specialty, and so lose their multimodal identity. Accordingly, we include here a glossary (see <a class="elsevierStyleCrossRef" href="#sec0010">Appendix</a>) with definitions of the most common terms used in intensive care.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, it is the responsibility of all anaesthesiologists to promote intensive care as a part of our specialist field, using appropriate terminology and encouraging hospitals to improve quality of care by setting up Intensive Anaesthesia Care units and providing appropriate training. The CNEA plays a key role in defining and developing our specialty, particularly in the field of intensive care.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-14" "fechaAceptado" => "2016-12-19" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Monedero P, Paz-Martín D, Cardona-Pereto J, Barturen F, Fernández-Quero L, Aguilera-Celorrio L, et al. Cuidados Intensivos de Anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología. Rev Esp Anestesiol Reanim. 2017;64:282–285.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <span class="elsevierStyleInterRef" id="intr0010" href="http://www.elsevier.es/redar">www.elsevier.es/redar</span></p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">∘</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthesiology and Intensive Care:</span> A primary specialty in Spain,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> known in Europe as Anaesthesiology, Pain and Intensive Care Medicine.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">∘</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthesiologist or anaesthetist:</span> Specialist in Anaesthesiology and Critical Care medicine.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">∘</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Care or Critical Care Medicine:</span> Medical field specializing in the care of critically ill patients,<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> being a patient whose life is in danger due to presence or risk of organ failure requiring organ failure care and support, and who must be monitored round the clock to enable timely intervention if his or her condition deteriorates. In Europe, intensive care competence is acquired in a multidisciplinary setting following primary specialization in anaesthesiology, cardiology, cardiovascular surgery, general surgery, internal medicine, pulmonology, neurosurgery; in Spain, it is also a primary specialty.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">∘</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensivist:</span> Physician who has acquired competence in Intensive Care Medicine. The term must not be used in an exclusive sense, and should not be confused with a specialist in “Intensive Care Medicine”, who should be called a “primary intensivist”.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">∘</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthetist intensivist or intensivist anaesthetist:</span> Specialist in “Anaesthesiology and Intensive Care” who has acquired competence in Intensive Care Medicine.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">∘</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Primary intensivist:</span> Specialist in “Intensive Care Medicine”.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">∘</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Care Medicine:</span> See Intensive Care.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">∘</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Medicine:</span> Primary specialty in Spain,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> which is not recognized in Europe, which provides non-specialist physicians with training in “Intensive Care Medicine”.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">∘</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthetist:</span> See Anaesthesiologist.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">∘</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensivist physician:</span> See Intensivist.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">∘</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recovery room:</span> See post anaesthesia care unit (PACU).</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">∘</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Critical Care Unit:</span> Term to be withdrawn, equivalent to “Anaesthesia Critical Care Unit”.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">∘</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Care Unit:</span> Specific hospital area staffed by health professionals providing multidisciplinary care, which complies with certain functional, structural and organizational requirements needed to guarantee the conditions of safety, quality and efficiency required to aid in the recovery of patients who need respiratory support or basic respiratory support together with support for at least 2 organs or systems; and all complex patients requiring support for multiple organ failure.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> They can be managed by primary intensivists (Intensive Care Unit) or by anaesthetist intensivists (Intensive Anaesthesia Care Unit).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">∘</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Anaesthesia Care Unit:</span> “Intensive Care Unit” managed by intensivist anaesthesiologists. This term should replace the confusing terms “Critical Care Unit” or “Recovery Unit”. It can be abbreviated as IACU.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">∘</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intermediate Care Unit:</span> Specific hospital area that treats patients requiring a higher level of a care than that given on the hospital ward, but less than the Intensive Care Unit. Patients requiring invasive mechanical ventilation or renal replacement therapy are usually excluded from these units.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">∘</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Medicine Unit:</span> “Intensive Care Unit” managed by primary intensivists. They could be called “Intensive Medicine Intensive Care Units”, or be abbreviated to IMU.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">∘</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recovery Unit:</span> Term to be withdrawn, equivalent to “Intensive Anaesthesia Care Unit”, due to it being confused with emergency room resuscitation cubicles, and due to their recognition as intensive care units in Royal Decree 69/2015 of 6 February, regulating the Specialised Care Register</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">∘</span><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Post anaesthesia care unit (PACU):</span> Specific hospital area, within the surgical suite,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> where patients who have undergone an anaesthetic procedure that does not require a high level of care are treated and monitored. The PACU is part of the intensive care unit.</p></li></ul></p>" "etiqueta" => "Appendix" "titulo" => "Glossary" "identificador" => "sec0010" ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "European Board of Anaesthesiology (EBA UEMS). Education and Professional Development (EPD) Standing Committee. Available from: <a href="http://www.eba-uems.eu/Education/education.html">http://www.eba-uems.eu/Education/education.html</a> [accessed 06.12.16]" ] ] ] 1 => array:3 [ "identificador" => "bib0125" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Anaesthesiology, Pain and Intensive Care Medicine. Syllabus to the postgraduate training program. 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