SYLLABUS TO THE POSTGRADUATE TRAINING PROGRAM

SYLLABUS TO THE POSTGRADUATE TRAINING PROGRAM FROM THE STANDING COMMITTEE ON EDUCATION AND TRAINING OF THE SECTION AND BOARD OF ANAESTHESIOLOGY

Domain 1.5: Medical and Perioperative Care of the Critically ill / General Intensive Care


a. Knowledge

 Organization of Intensive Care Units and ICU standards including:

o Evaluating and taking into consideration the difficulty and complexity of the tasks in relation to resources, qualifications, as well as local organization.

o Identifying patients with need for treatment beyond local competencies according to national organization and take initiative to organize transport for these patients

o Coordinating the multidisciplinary approach of patients and providing cooperation with all relevant partners, with proper respect for their medical competences and roles in specific situations.

o Contribute to the holistic vision of a homogeneous team interacting both with patients and peers, and providing consensual information.

o Medical auditing in intensive care

 General principles of ICU management:


o Airway management and respiratory support including non-invasive techniques

o Hemodynamic management including advanced cardiovascular monitoring and inotropic and vasoactive therapy

o Fluid and electrolyte support including relevant aspects of blood product transfusion

o Renal replacement therapy

o Neurological management

o Enteral and parenteral nutritional support

o Infectious diseases and antibiotic therapy; antiviral therapy; rules for hospital hygiene

o Prevention of complications such as thromboembolism, ventilator associated injuries, stress ulceration, renal failure and nosocomial infection

o Transportation

o Sedation and pain management including treatment of delirium and anxiety of the critically ill patient using both pharmacologic and non-pharmacologic means

o Appropriate knowledge and use of use scoring systems (APACHE; SAPS; TISS; NEMS)

 Aetiology, pathophysiology, diagnosis and treatment plans according to international standards of specific critical conditions:

o Acute circulatory failure

 Shock

 Cardio-respiratory arrest

 Cardiac arrhythmias

 Ischemic heart disease

 Cardiomyopathy

 Valvular heart disease including endocarditis

 Pulmonary embolism

 Anaphylaxis

o Respiratory failure

 ALI / ARDS

 Pulmonary oedema

 Airway obstruction and stenosis

 Pneumothorax

 Aspiration

 Pneumonia

 COLD/COPD and Asthma

o Renal failure

 Chronic and acute (RIFLE)

o Gastrointestinal failure

 Bleeding

 Ileus

 Peritonitis of various aetiologies (including colitis and intestinal ischemic disease)

 Pancreatitis

 Liver failure

 Digestive fistulas

o Neurological failure

 Delirium and Coma

 Cerebrovascular and bleeding diseases

 Cerebral oedema

 Increased intracranial pressure including monitoring


 Brain stem death

 Seizures

 Guillain Barré syndrome and Myasthenia gravis

o Trauma

 Head/Face injury and spine injury

 Airway and chest injuries

 Aortic injuries

 Abdominal trauma

 Pelvic and long bone injuries

 Massive transfusion

 Burns and electrocution

 Near-drowning

 Hyper- and hypothermia

o Inflammatory diseases

 SIRS/MODS

o Infectious diseases

 Sepsis including sepsis bundle strategy

 Severe community acquired infections (e.g. meningitis)

 Severe nosocomial infections (e.g. MRSA)

 Fungal infections

o Endocrine and metabolic disorders

 Diabetes mellitus and insipidus

 Addison’s disease, Cushing and Conn syndrome

 Thyroid disorders

 Pheochromocytoma

 Malnutrition

 Carcinoid

o Coagulation disorders

 DIC

 Transfusion reaction

o Obstetric complications

 HELLP syndrome, Pre-eclampsia, Eclampsia

 Septic abortion

 Amniotic fluid embolism

o Intoxications

o Organ donor and the transplanted patient

b. Skills

Technical skills:

 Respiratory

o Intubation under emergency situations

o Bronchoscopy (including lavage and sampling)

o Percutaneous tracheostomy

o Pleural drainage

o Ventilation in prone position

 Cardiovascular

o Basic and advanced life support


o Central vascular access (including for haemodialysis)

o Arterial access

o PA catheterization (Swan-Ganz)

 Basic ultrasound techniques for:

o Ultrasound-guided central venous line placement;

o Recognition of severely abnormal ventricular function (right or left ventricle; hypo- or hyperkinesia);

o Measurement of inferior vena cava diameter;

o Recognition of large pericardial, pleural, or abdominal effusion;

o Recognition of urinary retention (distended bladder).

Clinical and case management skills:

Trainees are expected to understand relevant principles, apply knowledge in practice and to demonstrate clinical skills and management in the following areas grouped by organ systems:

 General

o Proper and clear documentation including list of differential diagnosis and priorities

o Transportation both inter and intra-hospital of the critically ill patients

 Cardiovascular

o Basic and advanced life support including resuscitation decisions and appropriate fluid-strategy

o Use of vasoactive/catecholamine drugs and agents

o Management of arrhythmias including pacemaker and cardioversion

o Application of advanced hemodynamic monitoring (i.e. pulmonary artery catheter, less invasive monitoring such as ultrasound techniques)

o Prevention of thromboembolism

 Respiratory

o CPAP

o Mechanical ventilation including NIV (Modes of mechanical ventilation, indications, contraindications, protective strategy etc)

o Blood gas analysis

o Prevention of lung injuries associated with mechanical ventilation

o Prevention of aspiration

 Renal

o Application of renal replacement therapy

o Prevention of renal function deterioration

o Drug-administration in according to renal function

 Neurological

o Maintenance of cerebral perfusion

o Management of the unconscious patient

o Management of brain stem death

o Management of organ donation

o Management of critically ill polyneuropathy

 Gastrointestinal

o Nutritional support

o Prevention of stress ulceration

o Management of gastroparesis, paralytic ileus, diarrhoea, constipation both pharmacologic and non-pharmacologic.

 Trauma


o Systematic priority-based approach to severe trauma

o Control of bleeding and management of complications

 Endocrinology

o Management of critical illness-induced hyperglycaemia

o Management of over- and under-activity of thyroid

o Management of adrenal and pituitary disorders and sepsis-induced relative adrenal insufficiency

c. Specific attitudes

 Establishing effective communication and interaction with ICU colleagues and other specialists

 Establishing effective communication and interaction with ICU patients and their relatives.

 Recognizing psychological issues relevant to ICU patients and their relatives.

 Strategies to provide informed consent and disclosure of risk when consulting with ICU patients and their relatives.

POSTGRADUATE TRAINING PROGRAM FROM THE STANDING COMMITTEE ON EDUCATION AND TRAINING OF THE SECTION AND BOARD OF ANAESTHESIOLOGY

POSTGRADUATE TRAINING PROGRAM FROM THE STANDING COMMITTEE ON EDUCATION AND TRAINING OF THE SECTION AND BOARD OF ANAESTHESIOLOGY

The 10 domains of general core competencies identified are:

1.5 Medical and perioperative care of critically ill patients / General Intensive Care

El programa de formación para los residentes de Anestesia en Europa, reconoce los cuidados intensivos como una competencia general central-principal de todos los anestesiólogos.
Esto responde a la pregunta: ¿deben todos los anestesiólogos ser intensivistas? La respuesta es que sí en su formación inicial, aunque luego profesionalmente se decanten por otra área de la especialidad.

A multidisciplinary approach to intensive care medicine

Carta de la Junta Directiva de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología sobre la situación de los cuidados intensivos en España y Europa y la conveniencia de un acceso multidisciplinar. Cfr. Peyro R, Monedero P; the Executive committee of the Intensive Care Section of the Spanish Society of Anaesthesiology. A multidisciplinary approach to intensive care medicine. Eur J Anaesthesiol. 2011 Jul 7. [Epub ahead of print]


The executive committee of the Intensive Care Section of the Spanish Society of Anaesthesia would like to thank Van Aken et al. for their editorial in favour of a multidisciplinary approach to intensive care medicine (ICM).
The editorial is timely and highly needed in these times of increasing pressure for the recognition of a primary speciality of ICM in Europe. The arguments in the editorial against this proposal can be further expanded considering the situation of ICM in Spain and Europe.
In Spain, we have the broadest and longest European experience of a primary speciality in ICM. Other countries can learn from our bad experiences in order not to repeat our mistakes. The existence of a primary speciality constitutes an obstacle against the multidisciplinary access to ICM, because primary intensivists try to achieve exclusive attention over the critical patient. They progressively extend their scope of action, coming into conflict with anaesthesiologists in post-operative care, cardiologists in coronary units, emergency physicians, pneumologists and so on.
The existence of a primary speciality of ICM in Spain has meant an impoverishment in the training of all the specialities involved in the attention of critical patients, particularly anaesthesia. Training in anaesthesia has been limited to only 4 years to the detriment of ICM training, compromising the acquisition of competencies during the period of residency. Although more than 41% of intensive care beds in Spain are under anaesthesia-intensivists, since 2009 training in ICM during anaesthesia residency lasts only for a minimum of 6 months, up from 3 months previously. This inappropriate situation has become possible, as ICM has become a primary speciality. Anaesthesia-intensivists now need to make an extra effort in order to acquire competency in ICM. Competencies for ICM have been cut down on all primary specialities that attend critically ill patients and training in this field is practically nonexistent in Spain.
The Spanish system is inefficient, and probably not sustainable, due to the duplication of services, huge staffing, conflicts and rivalries not only in new openings but also in almost all hospitals where primary intensivists try to extend their dominance. Spanish primary intensivists have started to perform sedation for endoscopies and to control post-anaesthesia care units in small hospitals to increase their numbers and gain access to private practice.
The situation of medical specialities in Europe also advises against the recognition of a new primary speciality. In Europe there are 72 different primary specialities, including ICM. Only 48 of them are recognised by
the European Union because they exist in at least two fifths of the countries, and ICM is not one of them. The European Union of Medical Specialists (UEMS) recognises few, only 38 specialities existing in at least one third of the member states. European recommendations for free movement of professionals require progressive unification with a reduction in the number of medical specialities. We must stop fragmenting an already over fragmented system. Recognition of a focused practice does not require the creation of a new primary speciality. The road map for the recognition of ICM as a particular competence is the most appropriate way not to make the present problem worse.
The question is not on the convenience of a new primary speciality but on whether we need a multidisciplinary access for ICM. Those who defend a primary speciality are in fact rejecting a multidisciplinary access to ICM. The key aspects of ICM are not speciality-unique. The Competency-Based Training in Intensive Care Medicine (CoBaTrICe) program allows education and certification in a speciality-independent fashion, so that multiple speciality trainees can receive inter-speciality education. A multidisciplinary approach allows faculty and trainees to learn from counterparts outside of their base speciality.
Anaesthesia specialists had the generosity and broad outlook to recognise ICM as part of the training and work of different primary specialities through the creation of the UEMS Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM). However, if this multidisciplinary access is not recognised due to the expansion of a primary speciality, we claim that ICM belongs to anaesthesia. Historically, ICM is a sub-speciality of anaesthesia and anaesthesia is the primary speciality with most affinity and similarity to ICM.  In fact, the new postgraduate UEMS/European Board of Anaesthesia (EBA) training guidelines identify medical and perioperative care of critically ill patients – general intensive care – as one of the 10 domains of general core competencies of anaesthesia training.
In summary, the proposal to expand a primary speciality in Europe will not improve ICM and, instead, will create a barrier to the multidisciplinary approach to ICM. In that case, it would be preferable to expand anaesthesia sub-specialisation in ICM, as it already is in 17 European countries.

Development of the faculty of intensive care medicine.

Vale la pena leer la editorial del BJA acerca de los intensivos en UK (Nightingale P. Development of the faculty of intensive care medicine. Br J Anaesth. 2011;107: 5-7) porque contiene informacion relevante para la medicina de cuidados intensivos.
En concreto el Dr. Nightingale afirma lo siguiente:

1. Que aunque los intensivos es parte necesaria de la formación de un anestesista no todos quieren dedicarse a ello, como es conocido:

It was reiterated frequently that all anaesthetists need critical care skills and this will always be so. Training in ICM is done over 9 months in a pattern of ?spiral learning? to a higher level than any other specialty. However, it is accepted that although anaesthetists may need critical care skills when caring for patients in the Operating Theatre and Emergency Department, not all will wish to deliver continuing care to critically ill patients within the intensive care unit (ICU). This ongoing responsibility is accepted by those consultants who wish to dedicate a significant part of their working week to the ICU, and requires a different training over and above that obtained by all anaesthetists.


2. Que la Medicina de Cuidados Intensivos debe mantenerse de acceso multidisciplinar:

In the 14 years, it has been in place the Intercollegiate Board has exemplified the wish of intensivists to be part of a multidisciplinary training programme; that desire has seen it through a number of difficulties over the years. The Board has been hugely successful in bringing together those, from whatever background, who wish to raise the standard of training and practise within the specialty. The wisdom and foresight of those who saw that the specialty will essentially remain multidisciplinary are to be congratulated.

3. Que lo óptimo es que los intensivistas tengan una especialidad primaria que les permita un trabajo distinto de la UCI:

It is the general expectation that most contemplating a career in ICM will choose Dual CCTs, predominantly with anaesthesia. As in many parts of the world, medical training and workforce development remains problematical. The current Coalition Government in England, in the face of a severe financial crisis, is consulting on how medical careers will be structured in the future. It is likely that consultants will be expected to deliver more service directly and, at the same time, be expected to work past the age of 65. Although ?burnout? is less of a problem than previously, it remains a worry for intensivists. Many consider that trainees should have skills in another specialty (e.g. anaesthesia) where their workload can be adjusted in later years.


4. La mayoría de los intensivistas serán siempre anestesistas:

The Royal College of Anaesthetists can be proud of its vision and support of those who have laboured to improve the care that patients can expect when admitted to an ICU. By developing a career structure with a specific training and assessment programme, ICUs will more and more be staffed by consultants who want to be there. Most of them will be anaesthetists.


Me parece que es una editorial muy positiva que demuestra las discrepancias importantes entre lo que sucede en  UK y en España.