The Adult CV ICU

I believe that a well and appropriately trained cardiac surgeon is capable of delivering quality care in the adult CV ICU and that he should be primarily responsible for the management of these patients. The cardiac surgeon should not abdicate the care of his patients to the intensivist. The presence of an intensivist may be helpful in the CV ICU, but is not essential. It is erroneous to believe that the only way to acquire the experience and skills to care for CV ICU patients is by becoming and being an intensivist. How has it come about that intensivists at some institutions have gained control of the CV ICU? We have been neglectful and, perhaps, lazy. And now we have to deal with some intensivists that treat us with contempt and who undermine our authority.

I propose that cardiac surgeons understand cardiovascular physiology better that any intensivist. This understanding is essential for the competent, rational, and pathophysiologic-based care of cardiac surgical patients. Cardiac surgeons alter cardiovascular physiology in the operating room and experience it in a way that is more real than any ICU training or experience can provide. Cardiac surgeons also must be, and are, familiar with cardiovascular pharmacology, and see the effects of drug manipulation on the cardiovascular system first hand in the operating room. Of necessity, cardiac surgeons must also be familiar with hemostasis, ventilatory management, and fluid management, because these are relevant considerations in the operating room. These experiences in the OR translate to the CV ICU and the CV ICU is merely an extension of the operating room.

As the "Most Responsible Physician", the cardiac surgeon is the most motivated to ensure a positive outcome for his patient. If a mortality occurs it is the surgeon, not the intensivist, who is held accountable by Colleges, hospitals, and the patient's family. This results in a level of commitment to the patient that is not equaled by anyone else because, at the end of the day, the surgeon must stand alone to explain the outcome of the patient, good or bad. Others have the option of walking away, and many do.

Cardiac surgeons are also doctors. This means that they will have knowledge of the other body systems. This enables them to care of the whole patient in the CV ICU. However, the cardiac surgeon must realize that he is not expert in all body systems and should consult when appropriate. BUT, it is the responsibility of the surgeon to not blindly accept the advice of another consultant. Any new treatment must make pathophysiologic sense and should be applied taking into account the patient's history and overall condition. The surgeon should be willing to question the opinions of other consultants and is entitled to question the advice given.

The training of a cardiac surgeon should include the constant responsibility for, and primary care of, CV ICU patients so that enough experience is gained to care for these patients and the problems that arise. Operating on and caring for cardiac surgical patients in the ICU (and the ward) should be considered equal aspects of cardiac surgery. It is ALL cardiac surgery. This paradigm I experienced at the Mayo Clinic during my fellowship, where I also truly learned to care for CV ICU patients. I found my Canadian training to be deficient in this regard.

Critics of this model of care will state that cardiac surgeons are not able to be in the operating room and care for patients in the ICU at the same time. There are many practical arrangements that can solve this problem, such as hired intensivists that answer to the surgeons, resident coverage 24/7, and other cardiac surgeons being present in the ICU when their colleagues are operating. The primary surgeon remains responsible for the patient and determines the plan of care along with the details of such plan.

The same critics will argue that surgeons cannot be experts in ICU because they have not been trained as intensivists and they cannot keep up with the ICU literature. Training of a CV Surgeon has been addressed above. I would also add that overall training in ICU is not necessary because CV ICU is a niche where a cardiac surgeon, trained as mentioned, can gain enough experience to be competent at it. Much of the ICU literature does not directly apply to the CV ICU patient. What is more, the relevant ICU and CV ICU advances and controversies will likely be published in cardiac sciences literature, which will be followed by the surgeon. Resources, such as Literature Watch in CTSNet and SESATS can help keep the surgeon abreast of the significant advances in intensive care that apply to cardiac patients.

Intensivists will point out that cardiac surgeons are not capable or trained for a multisystem approach to the ICU patient. The reality is that the majority of cardiac patients have 1 or 2 system problems and most of them will have a brief ICU stay, and they can even be managed by a competent nurse practitioner or physician assistant under the direction of a cardiac surgeon. For the minority of patients that develop multisystem problems, the surgeon, by virtue his training and practice in the ICU, should be able to recognize these problems and request consultations in a timely and appropriate manner. What I must stress again is that the surgeon remains in control of the patient's care and should not blindly follow the advice of other consultants or relinquish to others the care of his patient. The surgeon is ultimately responsible and must ultimately decide what he feels is in the best interest of the patient.

Cardiac surgery is not only surgery, but also cardiac intensive care. They are one in the same. I do not agree with the fractionation of the practice. Sometimes we complain about the manner in which intensivists are managing our patients but we are not willing to re-establish our authority in the CV ICU.