Critical Care Anesthesiologists as Leaders in Cardiovascular and Cardiothoracic Critical Care Medicine

The evolving landscape of cardiovascular critical care necessitates a multidisciplinary approach to effectively manage the increasing complexity of patient cases. In the June issue of the SOCCA Interchange, Karamchandani and Dave highlighted the expanding roles of Critical Care Anesthesiologists (CCAs) beyond traditional ICU settings1. This discussion underscores the potential contributions of CCAs in optimizing patient outcomes, enhancing team dynamics, and advancing cardiovascular medicine, especially as the distinction between surgical and medical cardiovascular intensive care units (CVICUs) patients becomes less pronounced.

In cardiology, the growing demand for proficiency in cardiovascular critical care has led to the development of an ACGME-accredited fellowship recognized by the American Board of Internal Medicine, several non- accredited pathways to achieving competency in the field, as well as the establishment of the Society of Critical Care Cardiology with the membership opening for enrollment in April 2025. The cardiovascular critical care medicine fellowship builds on the skillset attained during three years of cardiovascular medicine fellowship. However, due to workforce shortages, the practical expansion of this staffing model has remained limited2. Similarly, the role of the dual- trained critical care and cardiac anesthesiologist has been described as an ideal training platform for intensivists in the post-surgical cardiothoracic intensive care unit largely due to the clinical experience obtained in managing patients in the perioperative period and attainment of advanced transesophageal echocardiography (TEE) certification. Additionally, anesthesiologist’s involvement in cardiovascular ICUs has withstood the test of time, with nearly 70% of critical care anesthesiologists (CCAs) being the backbone of cardiothoracic/cardiovascular unit staffing3.

However, given ongoing staffing challenges in “ideal” pathways, it is not unusual to operate these ICUs with intensivists from diverse training backgrounds, reflecting the multiple pathways to attaining certification in Critical Care Medicine (e.g., anesthesiology, emergency medicine, internal medicine, general surgery).

In today’s healthcare environment where the value of specialized roles is under constant scrutiny, CCAs must proactively address emerging challenges. Reevaluating and redefining our contributions in cardiovascular critical care is essential to meet the evolving needs of patients and healthcare systems. This discussion will explore the unique skill sets that CCAs bring to the cardiovascular critical care medicine, underscoring their distinctive perspective in patient care.

Expertise in Cardiovascular Physiology
As CCAs, our extensive training during anesthesiology residency and critical care medicine fellowship provides us with a deep understanding of cardiovascular physiology, pathophysiology, and pharmacology. This expertise enables us to manage complex hemodynamic challenges with efficiency and precision. In CVICUs, where patients often experience postoperative instability and severe cardiac dysfunction due to conditions like cardiogenic shock and acute coronary syndrome, our skills are essential for rapid intervention and stabilization. Additionally, the prevention of downstream effects on other organ systems such as central-line associated bloodstream infections, catheter-associated urinary tract infections, ventilator- associated pneumonia, acute kidney injury contribute considerable morbidity and requires a “traditional” critical care medicine lens to be applied along with understanding of the complexities in cardiovascular critical care4.

This expertise also makes CCA’s uniquely positioned to manage critically ill patients requiring temporary mechanical circulatory support, and in some centers, initiate the support. Gutsche and Vernick discuss the role that anesthesiologists can play in mobile Extracorporeal Membrane Oxygenation (ECMO) teams. Our expertise in managing complex cardiovascular and respiratory conditions, along with proficiency in procedures such as cannulation, positions critical care anesthesiologists as valuable contributors to ECMO teams5. 

Management of Cardiovascular Emergencies
In the CVICUs, emergencies such as cardiac arrest, massive pulmonary embolism or acute decompensation of cardiac or respiratory function despite maximal medical therapies are relatively common. Both anesthesiology and CCA training teach a hands-on approach to swift and decisive response in high-pressure situations. Further drawing on our clinical experience and advanced training, we are able to manage advanced life support techniques such as extracorporeal cardiopulmonary resuscitation (ECPR) and Cardiac Surgical Unit Advanced Life Support (CSU-ALS), which requires bedside chest opening within minutes of arrest6. Finally, our expertise in intraoperative crisis management also includes heightened communication skills, ensuring cohesive ICU team function in stressful situations.

Advanced Procedural Skill
CCAs’ procedural expertise includes, but is not limited to, the placement of central venous catheters, arterial lines, pulmonary artery catheters, temporary pacemakers, and at some centers, ECMO cannulations.

Leadership in Perioperative Medicine
The perioperative period for cardiovascular surgery patients is a high-risk and requires seamless coordination between surgical, anesthetic, and critical care teams. CCAs excel in postoperative management precisely because of our role in perioperative medicine. From preoperative optimization of patients with severe cardiac disease to advanced anesthetic management in patients with high risk of adverse cardiac events, to immediate postoperative stabilization, CCA’s ensure continuity of care through a tailored, individualized approach that minimizes complications and promotes recovery when transitioning from the operative room to the intensive care unit7.

Collaboration and Interdisciplinary Teamwork Best patient-centered outcomes in cardiovascular critical care medicine occurs in a collaborative environment that depends effective teamwork among physicians, nurses, respiratory therapists, pharmacists, dieticians, physical and occupational therapists and case management/ social work among other healthcare team members8 . CCAs are experts in communicating under high-pressure perioperative environments and our ability to translate this skillset across traditional specialty boundaries is an asset that should be leveraged when searching for the ideal staffing model in CVICUs. This expertise should also be considered in discussions regarding the ideal leaders for lung rescue or cardiogenic shock teams4.

Contributions to Education, Research and Innovation
Anesthesiology as a specialty has responded to the increasing needs of critical care by innovating and organizing efforts. In response to the predicted shortage of critical care physicians, anesthesiologist increased the number of fellowship programs and positions, as well as educational paths a trainee can take to become an intensivist. One such path is offering residency spot that guarantee automatic CCM fellowship position. Similarly, societal organizing efforts have also been underway, such as SOCCA’s workgroups including MCS/ECMO/CTICU workgroup. Finally, there are also grassroots efforts lead by anesthesiologists designed to elevate CVICU medicine by organizing educational and research activities, such as the Cardiothoracic Surgical Critical Care Consortium (C4).

Role in Quality Improvement and Patient Outcomes
Critical care anesthesiologists (CCAs) are champions of quality, patient safety, and patient experience throughout the perioperative period. Given our pivotal role in managing hemodynamic stability, pain control, and ventilator support, we have a direct impact on patient outcomes, recovery times, and satisfaction. Our training and expertise uniquely position us to identify gaps in care and develop targeted enhanced recovery protocols for cardiovascular patients, aligning with hospital quality goals such as reducing length of stay and readmissions.

For instance, in lung transplant patients, the integration of critical care and anesthesiology has facilitated the use of thoracic epidurals, paravertebral blocks, and other regional techniques in post-surgical cardiothoracic ICUs. These approaches are based on the premise that they enhance respiratory mechanics while minimizing the risks of respiratory depression and delirium associated with excessive postoperative opioid use in this vulnerable population9. By combining technical expertise with a focus on patient safety and quality of life, CCAs ensure that patients receive the highest standard of care.

The unique skillset of critical care anesthesiologists (CCAs)—encompassing advanced knowledge of cardiac and respiratory physiology, perioperative care, procedural expertise, and leadership in crisis—positions us as ideal leaders in cardiovascular critical care medicine. These skills are more critical now than ever. As the demand for high-quality care in cardiovascular critical care continues to grow, our role is becoming increasingly apparent. Our ability to adapt to the evolving needs of this complex field, combined with our specialized training, ensures that our expertise will remain invaluable in shaping the future of cardiovascular critical care.

REFERENCES:

1. Dave, S., & Karamchandani, K. (2024). Critical Care Anesthesiologists: Their Expanding Role Outside of the ICU [Letter to the editor]. Society of Critical Care Anesthesiologists Newsletter, 35(2).
2. Gage, A., Higgins, A., & Lee, R. (2022). Cardiac critical care: The evolution of a novel subspecialty. Methodist DeBakey Cardiovascular Journal, 18(3), 24–29.
3. Shaefi, S., Pannu, A., Mueller, A.L., et al (2023). Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists. Anesth Analg. 2023 Feb 1;136(2):295-307. doi: 10.1213/ANE.0000000000006160. Epub 2022 Aug 10. PMID: 35950751; PMCID: PMC9840646.
4. Shelton, K.T., & Wiener-Kronish, J.P. (2020). Evolving role of anesthesiology intensivists in cardiothoracic critical care. Anesthesiology, 133(5), 1120–1126.
5. Shelton, K.T., Crowley, J., & Wiener-Kronish, J. (2021). Prevention of complications in the cardiac intensive care unit. Journal of Cardiothoracic and Vascular Anesthesia, 35(7), 1930–1932.
6. Gutsche, J.T., & Vernick, W.J. (2016). Cardiac and critical care anesthesiologists may be ideal members of the mobile ECMO team. Journal of Cardiothoracic and Vascular Anesthesia, 30(6), 1439–1440.
7. Gu, Y., Panda, K., Spelde, A., et al(2024). Modernization of Cardiac Advanced Life Support: Role and Value of Cardiothoracic Anesthesiologist Intensivist in Post-Cardiac Surgery Arrest Resuscitation. Journal of cardiothoracic and vascular anesthesia, S1053-0770(24)00646-3.
8. Fleisher, L.A., Fleischmann, K.E., Auerbach, A.D., et al (2014). 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(22), e77–e137.
9. Weissman, C., Damuth, E., & Halpern, N.A. (2016). Team-based care in the cardiovascular ICU: The anesthesiologist as a team leader. Critical Care Clinics, 32(1), 95–109.
10. Feltracco, P., Barbieri, S., Milevoj, M., et al (2010). Thoracic epidural analgesia in lung transplantation. Transplantation Proceedings, 42(5), 1265–1269

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