Insights into trauma critical care and cardiosurgical anaesthesiology from Ospedale Di Circolo, Varese

I had the opportunity to visit Ospedala di Circolo E Fondazione Macchi in Varese, Italy, for my ESAIC exchange programme (pic. 1-2). Focus was on trauma critical care, including neurotrauma, and cardiosurgical anaesthesiology with associated cardiac intensive care. Furthermore, at the end of the exchange, I also had some time to acquaint myself with the pre-hospital service in the region by visiting the Como HEMS and the local 112/118 dispatch centre.

I have a general anaesthesiology and intensive care background at a smaller county council hospital in Sweden. Through the ESAIC exchange programme, I would like to gain a broader exposure to and understanding of clinical conditions, treatments, management and organisational structures, which we don’t necessarily have at my domicile hospital in Sweden. Also, comparing differences in traditions regarding the choice of interventions and management can sometimes be an eye-opener, giving you an alternative and more innovative approach to clinical situations when returning to your home department.

Ospedale di Circolo offered exposure to specific clinical cases and a number of clinical cases that I don’t see in my domicile hospital. Trauma casualty numbers per year were about ten times that of my home departments. Road traffic accidents and workplace-related injuries probably represent the main portion of trauma (pic. 3-4). However, the common outdoor sports and recreational activities also have a footprint on the trauma demographic in the region. The cardiosurgical unit performed roughly 500 procedures a year, and some exceptional cases were also presented in the cardiac ICU. For example, ECLS in in-hospital cardiac arrest and surgery for rare conditions such as right atrium myxoma with pulmonary artery embolism. The presence of neuro and ENT-surgery at Ospedale di Circolo likewise contributed to the variation of clinical cases. For example, postoperative care for large meningioma extirpations and, on one occasion, semi-urgent awake, open surgical tracheostomy in a patient with a narrowing upper airway process, where intubation and cricothyroidotomy were regarded futile.

Consequently, the magnitude and width of clinical conditions at Ospedale di Circolo also exposed me to management, treatments and interventions which were either new or just sparsely known to me. I got familiar with new assessment methods and scoring systems in trauma critical care, such as Thoracic Trauma Severity Score (TTSS) and Shock Index (SI), as well as alternative treatment options, for example, serratus anterior block for costa fracture analgesia (pic. 5). Regarding TBI, I was given a deeper understanding of indirect ICP evaluation methods using ultrasonography. Both transcranial Doppler (TCD) and optic nerve sheet diameter (ONSD) measurement was practised in the neuro-ICU (pic. 6). Helmet ventilation as an option for non-invasive ventilation that I earlier only heard about have I now seen practised in real clinical situations in the cardiac ICU. One case for sure, very close-up (pic. 7).

Percutaneous tracheostomy was another intervention commonly used with the so-called Blue Rhino set through the Seldinger technique instead of open surgical access. A pre-scan with airway ultrasound to predict suitability for the percutaneous method was also performed, and for me, a new application of ultrasonography (airway ultrasonography). Moreover, there was an increased disposition for converting an endotracheal airway to a tracheal airway compared with the approach I had been taught back home. Because the percutaneous route provides a sense of simplicity, it is fairly quick and excludes the need to involve a surgeon and resources from the operating theatre. In addition, tracheostomy in neurosurgical patients with long convalescences is a regular practice. Since those patients were common, this experience was also brought into the care of other ICU patient categories.

In the overall ICU practice, one difference that could be detected was the ICU patient turnover rate, which was unrelated to the management and treatment of specific conditions. The average ICU stay for a patient seemed slightly longer compared with the practice I’m used to, even considering the longer stay of neurosurgical patients. Deeper sedation for a longer period, maybe because of a lower nurse-patient ratio and lower use of central and regional blocks in the ICU, with delayed mobilisation and extubation, could be contributors that were in concordance with the slightly extended ICU stays. Related complications such as CLABSI, VAP and thromboembolic events could be expected but hard to state without a closer and more precise analysis. However, there was also a younger patient clientele, who probably would be more resistant to such complications. Furthermore, a higher ICU bed availability might enable an approach with extended evaluation in the ICU instead of frequent ward contacts from the ICU team, which, of course, could be beneficial. Indeed, I saw only two readmissions during my two-month stay in the ICU departments at Ospedale di Circolo.

The exchange programme also gave me a broader understanding of the organisation within the highly specialised ICU departments at Ospedale di Circolo. For example, the set-up and workflow of the trauma team were of particular interest. One striking difference from back home was that the anaesthetist, and not the surgeon, had the trauma leader role. Another fact was the relatively higher individual skillset among the members of the trauma team since more or less daily exposure to trauma casualties did occur. Centralised trauma care, partly enabled by the evolved prehospital system with air transport for time-critical casualties, could probably contribute to the latter (pic. 8-9).

There were, however, also striking similarities in challenges within the organisation and management compared with my workplace back home in Sweden. For example, staff shortages and the need to merge ICU departments during summer periods weren’t unfamiliar. Also, the never-ending need for flexibility when a department deals with both emergency and elective cases was similar to back home.

To summarize, I have learned a lot during my ESAIC exchange programme. Perhaps non-invasive helmet ventilation, serratus anterior block, TCD, ONCD and some particular trauma assessment scores could be suitable in my home department. The insight to another ICU organisation and the Italian healthcare culture as a whole will definitely add another perspective to my future clinical discussions. Ultimately, this experience will become a resource for improvements of my ICU environment back home in Sweden.

Last, one should remember the sociocultural, historical, gastronomic, and outdoor aspects of spending time in the beautiful region of Lombardia (pic. 10-11). I´m very satisfied with my trainee exchange programme in Varese. I want to thank all staff involved in my exchange programme at Ospedale di Circolo for their kind support and introduction, interesting clinical discussions, and genuine sharing of their important work. I especially thank Prof. Severgnini and Prof. Luca Cabrini for hosting me in their departments.

Author

•   Ola Sörensen (MD) – Ospedale di Circolo, Vares, Lombardi, Italy