Beyond the operating room: Integrating pediatric cardiac anesthesiology and critical care in India – Towards a collaborative model

Dear Sir, The care of children with congenital heart disease in India has grown substantially, yet the perioperative and critical-care phases remain vulnerable links in the chain of outcomes. Pediatric cardiac anesthesiologists, long regarded primarily as intraoperative physicians, are increasingly pivotal in bridging physiology between the operating room and the intensive care unit (ICU). Acknowledging this expanded role and utilizing it appropriately are crucial for optimizing patient outcomes, reducing the unit’s financial burden, and ensuring a healthy work–life balance for the anesthesiologist. Existing data from India has demonstrated clear benefits when anesthesiologists are actively involved in structured postoperative critical care. In a prospective study conducted over 634 consecutive children undergoing congenital heart surgery, establishment of a dedicated pediatric cardiac ICU led to a significant reduction in mechanical ventilation duration (42.9 ± 74.2 h to 32.2 ± 52.0 h, P = 0.04), ICU stay (3.43 ± 3.80 days to 2.69 ± 2.90 days, P = 0.001), and bloodstream infection (9.18%–5.03%, P = 0.04). Pediatric cardiac anesthesiologists contribute to these improvements through postcardiopulmonary bypass stabilization, protocol-driven hemodynamic optimization, focused ventilator strategies including fast-track extubation when appropriate, and perioperative echocardiography. Their expertise in vasoactive pharmacology, complex airway management, extracorporeal circuits, and rapid crisis response provides real-time diagnostic and therapeutic advantages in resource-constrained environments.1 In addition, they ensure continuity from intra-operative care to the immediate postoperative phase, facilitate structured handovers, and coordinate multidisciplinary inputs. This perioperative continuity can allow earlier recognition and management of residual lesions or evolving hemodynamic instability and may improve throughput and resource utilization in high-volume programs.2 High-intensity ICU models with dedicated intensivist leadership are generally associated with improved outcomes, but the evidence does not consistently show differences in outcomes based solely on the attending physician’s background (medicine vs. anesthesia vs. surgery). This suggests that structured critical-care training, protocolized care pathways, and protected ICU leadership time may be stronger determinants of outcomes than the base specialty alone.3 A global evaluation identified pediatric cardiac critical care (PCCC) as one of the most understaffed and least formally trained domains, particularly across parts of Asia.4 Although pediatric critical care fellowships are available nationally, a structured subspecialty curriculum dedicated to PCCC is still in its early stages of development.5 Recruitment into pediatric cardiac anesthesia remains limited nationally. Addressing this requires active measures such as developing defined fellowship programs, pediatric cardiac-focused research and mentorship during residency, academic encouragement of participation in pediatric cardiac anesthesia conferences, and professional society endorsement of competency frameworks. Certain critical-care domains, such as total parenteral nutrition and broader nutritional management, renal replacement therapies, and advanced ventilatory modalities such as high-frequency oscillatory ventilation, are less emphasized in standard anesthesiology training. Incorporating simulation-based learning and multidisciplinary rotations in pediatric and neonatal intensive care, nephrology, and clinical nutrition can provide early exposure and encourage motivated trainees to pursue advanced fellowship training in pediatric cardiac anesthesia and critical care. These curricular additions are intended as preparatory steps that complement, rather than replace, the dedicated pediatric cardiac critical-care fellowships. Importantly, the proposed role for anesthesiologists is collaborative and complementary rather than substitutive. Even in well-established centers with certified pediatric cardiac intensivists, multidisciplinary collaboration, with timely and appropriate contributions from pediatric cardiologists, cardiac surgeons, and pediatric cardiac anesthesiologists, is equally important as the leadership provided by the intensivist. In established pediatric cardiac units, an anesthesiologist can serve as a perioperative consultant or cointensivist, contributing unique perioperative insights that enhance continuity of care. In resource-limited or transitional centers, trained anesthesiologists with competency-based intensive care skills can provide high-quality perioperative and immediate postoperative ICU dedicated intensivist services are available. This collaborative framework distributes workload, leverages complementary skills, and ensures consistent, physiology-based management across care phases. Dual operating room and ICU responsibilities can be stressful and often discourage anesthesiologists from opting for this career path. Institutional measures such as fixed ICU shifts, spaced duty schedules, rotation-based postings, accompanying on-call duties, and wellness initiatives are practical steps to minimize fatigue, stress, and burnout. Formal recognition through clear job descriptions, appropriate remuneration increments, and career progression pathways further supports retention. To enable sustainable implementation of the hybrid or collaborative models, institutions should develop structured policies for credentialing, allocate protected time for ICU duties, define transparent compensation frameworks, and recognize critical care contributions in academic promotion criteria. Prospective multicenter outcome studies and collaborative policy dialogues are necessary to determine the most effective staffing patterns, credentialing standards, and wellness safeguards tailored to the Indian healthcare context. It is time to recognize that the pediatric cardiac anesthesiologists play a pivotal role in bridging the entire perioperative spectrum – an essential component in advancing PCCC in India. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.