Interventional radiologists are increasingly being called upon to perform potentially life-saving procedures on extremely ill patients. Multi-organ trauma, respiratory arrest, severe hypotension, and sepsis are management dilemmas that are confronted regularly in the interventional suite. It is imperative that the interventional radiology team be prepared for these challenges, write Deepak Sudheendra and Joshua Adams.
Interventional radiologists have been the pioneers in developing minimally invasive procedures that often obviate the need for patients to undergo high-risk surgery. As the field has continued to advance, the scope of practice has widened to include more critically ill patients who often were treated by surgery before. In many hospitals, interventional radiology has become the “go to” specialty for procedures such as chest tube and abscess drain placement, cholecystostomy tube placement, and venous access. These procedures were historically done by medicine and surgery residents or attending physicians at the bedside. Today, it is not uncommon for critically ill patients who are on the verge of death to be brought to the interventional suite for a procedure that was previously done at the bedside.
Because of the increased level of clinical acumen needed to care for critically ill patients, it is imperative that the interventional radiology team be prepared for the potential challenges that can arise in the suite. To help think about these issues, a new workshop was offered at the Society of Interventional Radiology’s annual scientific meeting in Atlanta, USA, called “What every interventional radiologist should know about critical care”.
The objective of the workshop was to present interventional radiologists with various clinical scenarios involving critically ill patients and ask them how they would manage the medical problems of the patient in addition to the interventional radiology issue at hand, knowing that a code team may not be immediately available to bail them out. Our goal of this workshop was not to turn interventional radiologists into critical care doctors but rather to educate physicians on the importance of having a methodical plan in caring for extremely sick patients and not just focusing on the intervention alone.
Management dilemmas such as concomitant thoracic and pelvic trauma, respiratory arrest, massive blood loss, and sepsis were discussed. Attendees were asked how they would manage the “crashing patient” in the absence of a code team. The use of inotropes, pressors, and antibiotics were also discussed to exemplify the importance of being “captain of the ship” in such dire circumstances.
We designed this workshop based on our surgical training backgrounds and current scope of practice. (Adams is a dual boarded vascular surgeon and interventional radiologist. Sudheendra is an interventional radiologist who also works as a surgical critical care attending.) The panel also included James F Calland, a trauma and critical care surgeon at the University of Virginia, Charlottesville, USA.
Interventional radiology has often been criticised for not being able to manage patients. It is not uncommon for other clinicians to say “the last place to have a code is in radiology”. However, this would not be stated if the patient was in the operating room or interventional cardiology. If interventional radiology is to be taken seriously as a true clinical specialty, we need to be responsive to the acute medical issues of the patient. While interventional radiology fellowship has not traditionally included critical care training, the new diagnostic radiology/ interventional radiology (DR/IR) dual pathway in the USA will be a positive step in preparing future interventional radiologists to be on the same playing field as surgeons and other clinicians when it comes to clinical management.
Critical care interventional radiology
As interventional radiologists continue to treat an ever increasing number of high acuity patients, it begs the question; will there be a need for a “critical care interventional radiologist” in the future? This individual would work exclusively with the intensive care unit (ICU) and be responsible for performing all of the interventional radiology procedures needed for the critically ill patients in a timely manner, either at the bedside or in an angiography suite attached to the ICU. This would provide safer, more efficient care of the unstable ICU patient and also allow the “regular” interventional radiologists to focus on the myriad of other procedures that are needed in the hospital.
With interventional radiology continuing to evolve into a field that is more reminiscent of surgery than diagnostic radiology, the training of future interventional radiologists will need to include more focus on patient management skills. In the meantime, our hope is that interventional radiology will continue to blaze new trails in improving patient care.
Deepak Sudheendra is an assistant professor of Clinical Radiology and Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA. Joshua Adams is an assistant professor of Surgery and Radiology and the head of Endovascular Surgery, Medical University of South Carolina, Charleston, USA. The authors have reported no disclosures pertaining to the article.
