Author + information
- Thomas Kulik, MD, Chair,
- Therese M. Giglia, MD, FACC,
- Keith C. Kocis, MD, FACC, FAAP,
- Larry T. Mahoney, MD, FACC,
- Steven M. Schwartz, MD,
- Gil Wernovsky, MD, FACC, FAAP and
- David L. Wessel, MD, FAHA
Although pediatric cardiac critical care, as a distinct field of interest, is a relatively recent development, treating critically ill patients has always been a substantial part of clinical pediatric cardiology. In addition, even pediatric cardiologists who do not provide primary care for critically ill patients will be asked to consult on such patients. It therefore seems appropriate to specify what knowledge and skills relevant to the care of critically ill patients should be taught in a pediatric cardiology fellowship program.
Facilities and environment
Not all pediatric cardiac training programs have a separate pediatric cardiac intensive care unit (ICU), and in some training programs the primary care of hemodynamically compromised cardiac patients is provided by physicians other than pediatric cardiologists. However, this should not preclude trainees from attaining the specified requirements through interaction with pediatric cardiologists, pediatric intensivists, neonatologists, pediatric cardiac surgeons, and other practitioners. Because the advanced practitioner must be board eligible or board certified in pediatric cardiology, it is implied that the pediatric cardiology training be done in an Accreditation Council for Graduate Medical Education (ACGME)-approved training program. The additional nine months of advanced training specified below should take place in an institution in which at least 250 pediatric cardiac procedures per year (this number is by consensus of the authors), utilizing cardiopulmonary bypass, are performed.
Levels of expertise
In formulating the core training requirements, it was expected that all board-certified pediatric cardiologists should be proficient in the following: 1) the evaluation and (at least) initial stabilization of the hemodynamically compromised pediatric patient with heart disease; and 2) consultation with surgeons, pediatric intensivists, neonatologists, and others regarding the medical, and preoperative and postoperative management of pediatric patients with heart disease.
It is unrealistic to expect all pediatric cardiac trainees to be expert (and stay expert) in the most advanced aspects of pediatric cardiac critical care. In many centers the critical care management of pediatric cardiac patients is provided primarily by pediatric intensivists, neonatologists, or pediatric cardiac surgeons, rather than by cardiologists. However, given that most pediatric cardiologists will occasionally be responsible for situations such as those previously noted, it is important that they can provide appropriate care until consultation with those more experienced in pediatric cardiac intensive care can be obtained. In some cases the pediatric cardiologist may be the only source of expertise (e.g., in understanding the limitations of echocardiography in delineating the anatomy/physiology of a hemodynamically compromised postoperative patient). Hence, it is important that the pediatric cardiologist be familiar with critical care-related issues, often specific to a given cardiac lesion, when providing consultation in the context of the critically ill patient. Thus, corerequirements apply to alltrainees seeking board certification in pediatric cardiology.
Advancedrequirements, which are more comprehensive, apply to practitioners who will undertake primary responsibility for the comprehensive management of critically ill pediatric patients with congenital or acquired heart disease.
These documents specify training guidelines in pediatric cardiac critical care for pediatric cardiology trainees. The advanced guidelines specify training requirements only for practitioners who are board eligible/board certified in pediatric cardiology. These guidelines do not address what might be a suitable course of training for cardiac critical care for practitioners with primary training in a discipline other than pediatric cardiology.
Core training: goals and methods
At the end of the pediatric cardiology fellowship, the board-eligible pediatric cardiologist should reliably be able to do the following:
1) Evaluate and treat neonates and infants with critical structural cardiac disease. Evaluation and treatment includes:
a) Establishing an accurate anatomic diagnosis and ascertaining the relevant cardio-pulmonary physiology.
b) Providing appropriate medical therapy to stabilize the patient (provide for adequate oxygen delivery and organ perfusion).
c) Knowing what medical and surgical treatments are appropriate for the condition and what the short- and long-term outcomes of these therapies are.
In particular, the trainee should have sufficient training and experience to be efficient in managing these patients:
∙ Neonates and infants with ductal-dependent left and right-sided obstructive lesions.
∙ Neonates with d-transposition of the great arteries.
∙ Neonates with total anomalous pulmonary venous connection with obstruction.
∙ Infants with anomalous origin of the left coronary artery.
2) Evaluate and treat neonates, infants, and older patients with other forms of critical cardiac disease.
In particular, the trainee should have sufficient training and experience to be efficient in evaluating and treating these patients:
∙ Patients with primary myocardial dysfunction.
∙ Patients with acutely compromised cardiopulmonary status due to myocarditis or cardiomyopathy (including that due to rheumatic fever, Kawasaki disease, and so on).
∙ Patients with acutely symptomatic arrhythmias.
∙ Patients with acutely compromised cardiopulmonary status due to endocarditis.
∙ Patients with pericardial effusion.
∙ Patients having a hypercyanotic episode (“tet spell”).
∙ Neonates and infants with increased pulmonary vascular resistance, with or without structural abnormality of the heart.
3) Provide care, or consultation for those providing primary care, for cardiac patients with illness of non-cardiac origin.
For example, a cyanotic patient with respiratory syncitial virus pneumonitis requires care somewhat different than a patient with a normal heart.
4) Provide consultation for those caring for postoperative cardiac patients.
In particular, the pediatric cardiologist should be able to do the following:
∙ Provide interpretation of diagnostic studies, such as echocardiograms and heart catheterization, including clearly delineating the limitations of such studies.
∙ Diagnose and treat acutely symptomatic arrhythmias.
∙ Provide consultation regarding therapies to maximize oxygen delivery and cardiac output.
∙ Provide consultation regarding pharmacologic and other therapies for patients with “single ventricle” physiology.
∙ Provide consultation regarding therapy for patients with increased pulmonary vascular resistance.
Specific areas of knowledge and competence
The following section lists certain areas of special importance.
1. Cardiopulmonary physiology, especially as it applies to cardiac patients in the ICU setting.
a) Determinants of, and means of influencing, oxygen delivery, cardiac output, and vascular resistance.
b) The physiology of the patient with a single ventricle, including determinants of, and means of influencing, systemic arterial oxygen saturation, systemic perfusion, and myocardial work.
c) The physiology of the patient with a ductal-dependent left-sided obstructive lesion, including determinants of, and means of influencing, systemic arterial oxygen saturation, systemic perfusion, and myocardial work.
d) The physiology of the patient with a fixed restriction of pulmonary blood flow, including determinants of, and means of influencing, systemic arterial oxygen saturation, systemic perfusion, and myocardial work.
e) The physiology associated with d-transposition of the great arteries.
f) The physiology of cardiopulmonary interaction, including how mechanical ventilation affects cardiac output.
2. Cardiovascular pharmacology.
The trainee should learn the actions, mechanisms of action, side effects, and clinical use of:
a) Inotropic agents (e.g., digoxin, adrenergic agonists, phosphodiesterase inhibitors).
b) Vasodilators/antihypertensive agents (e.g., alpha adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel antagonists, beta adrenergic antagonists).
c) Commonly used antiarrhythmic drugs (e.g., digoxin, procainamide, lidocaine, amiodarone).
d) Inhaled nitric oxide.
e) Prostaglandin E1.
f) Neuromuscular blocking agents (e.g., pancuronium, succinylcholine).
g) Analgesics and sedatives (e.g., morphine, fentanyl, ketamine, benzodiazepines).
h) Anticoagulants (unfractionated and low molecular weight heparin, warfarin).
i) Diuretics (e.g., furosemide, chlorothiazide).
j) Prostacyclin and other pulmonary vasodilators.
3. The relationship between cardiac structure, function, and clinical state.
The trainee should learn:
a) How cardiac structural abnormalities (e.g., obstruction of the atrial septum in hypoplastic left heart syndrome) affect cardiopulmonary function, physiology, and hence the clinical state of the patient.
b) Methods (e.g., echocardiography, invasive pressure measurements, arterial blood gas analysis, magnetic resonance imaging) to determine and measure cardiac structure, function, and physiology in the ICU patient, and the limitations of these techniques.
c) Indications for remedy of structural lesions (in both unoperated and operated patients), and appropriate means of therapy (surgical, catheter-based intervention).
4. Diagnosis and therapy of arrhythmias, especially those occurring in ICU patients.
In particular, the trainee should be familiar with the use of atrial and ventricular pacing leads or transesophageal electrocardiography for diagnosing and treating arrhythmias, and the diagnosis and therapy of junctional ectopic tachycardia.
5. Airway management skills.
6. Provision of analgesia and sedation.
7. Conduct of cardiopulmonary resuscitation.
8. Commonly used modes of mechanical ventilation and their application in patients with heart disease.
9. Common complications that occur in cardiac patients in the ICU, and how they may be prevented and treated.
The trainee should be familiar with factors that predispose to common postoperative complications (e.g., catheter-related sepsis, pathological thrombosis, surgically-induced heart block), appropriate diagnostic techniques, and therapy for these complications.
10. Familiarity with extracorporeal membrane oxygenation and other cardiac support systems.
11. Indications for, and general principles, for providing “end-of-life” or “palliative” care.
Required training period for core training
In training programs where pediatric cardiology fellows provide primary care of pediatric cardiac patients in the ICU (generally programs that have a separate cardiac ICU), a minimum of two months’ full-time experience in the ICU is recommended. For programs where pediatric cardiology fellows act as consultants for cardiac patients in the intensive care setting, at least four months’ experience providing such consultation is recommended.
Trainees will be evaluated by the appropriate supervising faculty, and both written and oral feedback will be provided to the trainee. Written evaluations, addressing specific areas of competence, will be developed at each training site.
Advanced training: goals and methods
Advanced training in pediatric cardiac intensive care is intended to prepare practitioners who will undertake primary responsibility for the comprehensive management of critically ill patients with congenital or acquired heart disease. Because this discipline stands at the nexus of pediatric cardiology and pediatric critical care, some physicians with primary training in fields other than pediatric cardiology work in this area. This document describes an appropriate advanced practitioner training program only for physicians board eligible or board certified in pediatric cardiology; it does not specify what an appropriate training program should be for those trained in other disciplines (e.g., critical care medicine [CCM] or pediatric anesthesiology).
1. The advanced practitioner must be board certified/board eligible in pediatric cardiology.
2. Advanced practitioners must have (at least) nine months of clinical training beyond the core training as outlined in the previous text. (This excludes practitioners doubly boarded in pediatric cardiology and pediatric CCM.) Practitioners with training in (only) pediatric cardiology are therefore expected, in addition to having three years of pediatric cardiology training, to have one month of training in anesthesia, four months’ experience predominantly in general pediatric CCM, and at least four months’ experience caring for pediatric cardiac patients in the ICU setting (a total of 9 months).
The practitioner must have sufficient experience in managing term and pre-term neonates both preoperatively and postoperatively.
Specific areas of knowledge and competence
Specific requirements for advanced training include all of those for core training (listed in the previous text), as well as the following:
1. Mechanical ventilation.
a) Indications for and utilization of commonly employed modes of mechanical ventilation, as well as more advanced modes of ventilation (e.g., high-frequency oscillatory ventilation).
b) Optimal ways of providing gas exchange for patients with congenital heart disease, taking into account factors such as the effect of airway pressure on venous return, the impact of fiO2on pulmonary vascular resistance, arterial O2saturation, and systemic perfusion.
c) Pulmonary toxicity related to barotrauma, volutrauma, and high levels of inspired oxygen, and how to minimize such toxicity.
2. Indications for, application of, and complications related to mechanical support for the failing cardiopulmonary system. Current systems that provide such support include extracorporeal life support, ventricular support devices, and intra-aortic balloon pumps. Expertise in at least one form of mechanical support should result from advanced-level training.
3. Performance of invasive procedures often required in managing critically ill cardiac patients. These procedures include advanced techniques for intravascular access (e.g., subclavian vein and internal jugular venous cannulation), insertion of chest tubes, pericardiocentesis, and so on.
4. Utilization of more advanced cardiovascular pharmacologic therapy (e.g., esmolol for therapy of hypertension, vasopressin for therapy of hypotension).
5. Advanced skills in evaluation and treatment of arrhythmias (e.g., utilization of epicardial electrodes and transesophageal leads for diagnosis and treatment of rhythm abnormalities, use of pharmacologic agents to treat arrhythmias, and so on).
6. Advanced management of pulmonary hypertension.
7. Diagnosis and treatment of less frequently encountered/more complex postoperative complications, including lesion-specific complications. Such complications include significant residual cardiac lesions, paralyzed hemi-diaphragm(s), large airway obstruction, compartment syndrome following femoral arterial cannulation for cardiopulmonary bypass, prolonged chest tube drainage, and so on. The practitioner should be familiar with indications for invasive evaluation (e.g., heart catheterization or bronchoscopy) and invasive therapy (e.g., additional cardiac surgery, interventional catheterization, tracheostomy).
8. Evaluation and management of multisystem organ failure.
9. Postoperative management of orthotopic heart transplant patients, and management of acute rejection.
10. Diagnosis and management of renal failure, including indications for renal replacement therapy.
11. Diagnosis and management of forms of neurological dysfunction, sometimes seen in patients with critical heart disease (seizures, stroke, global ischemia, increased intracranial pressure).
12. Available means of providing nutritional support, and the most appropriate means for a given patient.
13. Transfusion management, and recognition and treatment of common transfusion-related complications.
Dr. David L. Wessel declared that he had the following relationships with industry relevant to this topic—Pfizer (consultant and research grant); INO Therapeutics (consultant and scientific advisory board). The other authors of this report declared that they have no relationships with industry pertinent to this topic.
- American College of Cardiology Foundation