General Cardiologists working as the primary attending in Cardiac ICUs?

[jonathanlikes]

I'm seeing some job openings for Cardiac ICUs where they are willing to take people without any formal critical care training. Is this a frequent situation? Who would be handling the vent? Intubating?

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[chessknt]

View attachment 366641

I'm seeing some job openings for Cardiac ICUs where they are willing to take people without any formal critical care training. Is this a frequent situation? Who would be handling the vent? Intubating?

For a cardiac ICU to exist there is going to be in house anesthesia that can handle procedures for them. The vent is probably being managed by an RT based on protocols designed by a group that knows how to manage a vent. If they have something actually wrong with their lungs or don't get taken care of by a protocol they probably consult pulmonology who will take over.

I find it crazy however that gen cards is all they want. CHF I can get even without the CC because they take care of the sickest cardiology patients but gen cards alone? CHF guys are the only ones who actually seem to show up in the ICU to round on a patient when consulted as opposed to a mid-level since all of the other cardiologists are either in clinic or the Cath lab...

 

[InternistDO]

Where I do residency the CCU is staffed by general cards only (though pulm crit is right down the hallway and anesthesia is in house 24/7). For pure cardiac patients it’s nice, but when the edge cases come up (which is often) then some questionable decisions can be made. This is a fairly large hospital with a big cardiology department but I’m not sure if they could justify a cardiac ICU fully staffed by cardiac intensivists.

The vents are theoretically managed by the cardiologists, which means in practice the residents do it all and call pulm if it’s complicated. Anesthesia intubates.

 

[SpacemanSpifff]

Where I do residency the CCU is staffed by general cards only (though pulm crit is right down the hallway and anesthesia is in house 24/7). For pure cardiac patients it’s nice, but when the edge cases come up (which is often) then some questionable decisions can be made. This is a fairly large hospital with a big cardiology department but I’m not sure if they could justify a cardiac ICU fully staffed by cardiac intensivists.

The vents are theoretically managed by the cardiologists, which means in practice the residents do it all and call pulm if it’s complicated. Anesthesia intubates.

... which in practice means the RT's do it.

I think this situation (nonCCM trained physicians managing critically ill patients) is more common than it should be. The CVICU in residency was split between the surgical and medical patients, with the medical team attending being a cardiologist, usually generally, sometimes with subspecialty training. Fortunately there was a critical care team that co-managed anyone who was on a vent or anyone who the cards attending requested they see.

 

[CCM-MD]

I’m sure they do fine when it’s just the heart that’s the problem, unfortunately that’s usually not the case. I go back and forth between CT surgeon vs. cardiologist when it comes to who’s worse at pretending to be intensivist.

 

[InternistDO]

... which in practice means the RT's do it.

I think this situation (nonCCM trained physicians managing critically ill patients) is more common than it should be. The CVICU in residency was split between the surgical and medical patients, with the medical team attending being a cardiologist, usually generally, sometimes with subspecialty training. Fortunately there was a critical care team that co-managed anyone who was on a vent or anyone who the cards attending requested they see.

Tragically it does not, RTs just execute the vent orders and aren't allowed to adjust at all at my place which sometimes leads to spicy situations.

I agree otherwise, I felt like our cardiac ICU only powered through by giving the senior residents very significant responsibility in the unit for all noncardiac issues, which went fine with good residents and very poorly with a bad team.

 

[gro2001]

I’m sure they do fine when it’s just the heart that’s the problem, unfortunately that’s usually not the case. I go back and forth between CT surgeon vs. cardiologist when it comes to who’s worse at pretending to be intensivist.

The CT surgeons, for sure. No one is more confidently wrong.

 

[jonathanlikes]

For a cardiac ICU to exist there is going to be in house anesthesia that can handle procedures for them. The vent is probably being managed by an RT based on protocols designed by a group that knows how to manage a vent. If they have something actually wrong with their lungs or don't get taken care of by a protocol they probably consult pulmonology who will take over.

I find it crazy however that gen cards is all they want. CHF I can get even without the CC because they take care of the sickest cardiology patients but gen cards alone? CHF guys are the only ones who actually seem to show up in the ICU to round on a patient when consulted as opposed to a mid-level since all of the other cardiologists are either in clinic or the Cath lab...

Yeah I can see how a unit would run very well with a Heart Failure specialist as attending if they had a CCM fellow with them.

 

[McPoyle]

The CT surgeons, for sure. No one is more confidently wrong.

Spend half my time in the CVICU, can confirm nobody I’ve ever met in any area of my life has ever been as confidently wrong as a CT surgeon on any given week describing what his “plan” is for his patient. And somehow even when proven wrong… are still not wrong. Fascinating species they are.

 

[chessknt]

Spend half my time in the CVICU, can confirm nobody I’ve ever met in any area of my life has ever been as confidently wrong as a CT surgeon on any given week describing what his “plan” is for his patient. And somehow even when proven wrong… are still not wrong. Fascinating species they are.

Bro they cut the heart open and they held it in their hands, it gives them unparalleled insight in to the physiology of that patient you can never have. It means they need to give esmolol and epinephrine, insulin and dextrose, lasix and fluids because the heart told them that's what it needs.

 

[Redpancreas]

I’m sure they do fine when it’s just the heart that’s the problem, unfortunately that’s usually not the case. I go back and forth between CT surgeon vs. cardiologist when it comes to who’s worse at pretending to be intensivist.

I see Cardiology attendings complain about a lack of evidence from ICU attendings. Any response?

 

[RemyMcswain]

I see Cardiology attendings complain about a lack of evidence from ICU attendings. Any response?

The main housekeeping interventions are evidenced based. But as you know, the majority of decisions are not. ICU is interesting because youre making decisions based on physiology, not meta analysis

 

[CCM-MD]

I see Cardiology attendings complain about a lack of evidence from ICU attendings. Any response?

Don’t understand, are you saying cardiologists are complaining about lack of evidence based practice from intensivists? I just had a cardiologist tell me yesterday: “we should be getting q4h labs in these unstable patients please”. And a different one demanded 2 units of FFP be transfused for an INR of 1.4 prior to impella removal. Ridiculous.

 

[SpacemanSpifff]

I see Cardiology attendings complain about a lack of evidence from ICU attendings. Any response?

Sure: high quality evidence is lacking in most disease states that affect the critically ill. Look no further than cardiogenic shock trials.

 

[Redpancreas]

Sure: high quality evidence is lacking in most disease states that affect the critically ill. Look no further than cardiogenic shock trials.

Makes sense.

 

[Radetzky]

Lol cardiologists running an ICU. You mean the folks that start b blockers on their acutely EF 20% pts and then wonder why they crap out? Makes me nauseated.

 

[Splenda88]

The CT surgeons, for sure. No one is more confidently wrong.

So it's like that everywhere.

These people run my hospital... not only the CVICU.

 

[gulmohr]

Lol cardiologists running an ICU. You mean the folks that start b blockers on their acutely EF 20% pts and then wonder why they crap out? Makes me nauseated.

This happened yesterday. Decompensated HF w/ EF 10%, intubated for florid pulmonary edema after failing NIV in the ED. Cardiologist starts B-blockers because tachycardia.

 

[lymphocyte]

I've had one tell me I was going to kill their patient with sodium nitroprusside. Is it really that controversial?

 

[SurfingDoctor]

I've had one tell me I was going to kill their patient with sodium nitroprusside. Is it really that controversial?

That sh-t is the life saver…

Unironically, if you asked the average intensivist what guanylate cyclase does… I guarantee you’d be met by blank stares.

And people wonder why their is mid-level creep.

 

[chessknt]

I've had one tell me I was going to kill their patient with sodium nitroprusside. Is it really that controversial?

Are you using it in shocked hypotensive patients with pressors or just decompensated bad CHF?

 

[lymphocyte]

Are you using it in shocked hypotensive patients with pressors or just decompensated bad CHF?

Not the one where I'm actually killing the patient. And also the one where the patient miraculously starts to pee.

 

[lymphocyte]

Are you using it in shocked hypotensive patients with pressors or just decompensated bad CHF?

Also so called "pressors" can make cardiogenic shock worse. More than a few times I've had to turn off Norad and started SNP. The look on the nurses faces is priceless when the MAP goes UP.

 

[chessknt]

Also so called "pressors" can make cardiogenic shock worse. More than a few times I've had to turn off Norad and started SNP. The look on the nurses faces is priceless when the MAP goes UP.

I can't say I have ever seen that effect personally.

So if you have someone on a moderate dose norepi and vaso with EF 8% with MAP running in the 50s you add nipride and turn the vaso and norepi off? Ive definitely tried to turn down supercharged norepi in a bad right heart failure case (though never get the effect I am hoping for) but I have never cold turkey killed pressors and added a potent vasodilator in a patient near death--kudos to you if that worked.

 

[lymphocyte]

I have never cold turkey killed pressors and added a potent vasodilator in a patient near death--kudos to you if that worked.

I haven't either.

I think you're taking a very extreme case to create a strawman.

I think you're saying obvious things to make an obvious point.

I think so called pressors are over used in this population and afterload reduction isn't used enough. I'm happy to give it a whirl with a MAP of 55-60 depending. Do you disagree?

This intervention has more evidence to justify it than most ICU interventions, including the Cleveland Clinic's experience published in NEJM and JACC, especially in the setting of critical AS, which seems completely counter-intuitive but works great. Some of the data go back to the 70s.

I mean, there are even some suggestions about using SNP in cardiac arrest, correct? The Minneapolis folks and so-called SNPeCPR.

I guess I'm still trying to figure out what your point is.

https://www.nejm.org/doi/full/10.1056/nejmoa022021

https://www.jacc.org/doi/abs/10.1016/j.jacc.2008.02.083

https://www.nejm.org/doi/full/10.1056/NEJM197409192911201

https://www.jacc.org/doi/abs/10.1016/j.jacbts.2019.11.010

 

[chessknt]

I haven't either.

I think you're taking a very extreme case to create a strawman.

I think you're saying obvious things to make an obvious point.

I think so called pressors are over used in this population and afterload reduction isn't used enough. I'm happy to give it a whirl with a MAP of 55-60 depending. Do you disagree?

This intervention has more evidence to justify it than most ICU interventions, including the Cleveland Clinic's experience published in NEJM and JACC, especially in the setting of critical AS, which seems completely counter-intuitive but works great. Some of the data go back to the 70s.

I mean, there are even some suggestions about using SNP in cardiac arrest, correct? The Minneapolis folks and so-called SNPeCPR.

I guess I'm still trying to figure out what your point is.

https://www.nejm.org/doi/full/10.1056/nejmoa022021

https://www.jacc.org/doi/abs/10.1016/j.jacc.2008.02.083

https://www.nejm.org/doi/full/10.1056/NEJM197409192911201

https://www.jacc.org/doi/abs/10.1016/j.jacbts.2019.11.010

Well the post I was originally responding to made it sound like nipride shouldn't be controversial in a CHF patient which is why I asked if you were using it in a shocked patient because I can absolutely see that being problematic in quite a few scenarios which is why I was asking if that was something you did regularly since I had never seen it done, not to illustrate an 'obvious point.'

Ultimately I think medical management in this population is generally futile when they are that sick--they need mechanical support. I use nipride a fair bit but if they are hypotensive with crappy urine output and need volume off I go straight to crrt although I've never actually seen someone pull out of a tailspin when it gets that bad without a mechanical intervention.

 

[Radetzky]

I don’t use nipride if they’re hypotensive. There was a paper somewhere I can’t remember looking at the benefit in terms of afterload reduction compared to the harm from reduced coronary perfusion pressure and the sweet spot seemed to be a MAP of 70 (as in CO actually dropped even as more dilation occurred)

I’m sure sometimes you give dilator and the BP goes up but the effect is unpredictable

 

[lymphocyte]

Well the post I was originally responding to made it sound like nipride shouldn't be controversial in a CHF patient which is why I asked if you were using it in a shocked patient because I can absolutely see that being problematic in quite a few scenarios which is why I was asking if that was something you did regularly since I had never seen it done, not to illustrate an 'obvious point.'

Ultimately I think medical management in this population is generally futile when they are that sick--they need mechanical support. I use nipride a fair bit but if they are hypotensive with crappy urine output and need volume off I go straight to crrt although I've never actually seen someone pull out of a tailspin when it gets that bad without a mechanical intervention.

That's fair. But I use SNP in shocked patients all the time. Shock is not synonymous with hypotension.

Plenty of shocked patients with "normal" blood pressures, and hence me stopping vasopressors and starting vasodilators rather than continuing to circle down the drain by chasing a MAP target. One of the goals in a sick heart is of course to unload the ventricle to improve the CI. Are they peeing? Are they getting warmer? Is the heart rate coming down? Don't really care about the MAP per se, which is only crude measure of organ perfusion and microcirculation.

Obviously this is not someone needing multiple vasoactive agents or floridly hypotensive. But even the exclusion criteria in the JACC paper for example was a MAP of 60. Pretty low. Lower than most would intuit for starting vasodilators.

I'm not telling you this in particular. Just making a general point.

 

[Tipsy McStagger]

For my cardiogenic shock patients I typically will do dobutamine + Levo (if dobutamine makes them hypotensive) if their BP is low. If their BP is normal or high I’ll either go with dobutamine or cleviprex/nipride and follow their clinical (or PA cath guided) progress.

Typically I don’t start IV afterload acutely if the BP is low and they’re in shock.