![3D"NU%20Header"](3D"CriticalCare_files/image001.jpg")
Updated 2009Critical Care Medicine
Educational
Plan: A competency based
development of knowledge and skills in Pulmonary and Critical Care Medicine
through clinical experience, bedside teaching, didactic conferences and rea=
dings
to achieve competence, proficiency and the foundation for mastery.
Educational
Methods:
Clinical Information and Didactics:
- 4 week rotation with q4 call
schedule. The MICU is split between 2 attendings.
- Each attending team consists =
of 1
fellow and 2 residents. Each resident will have 1 to 2 interns.
- Resident and intern clinics a=
re
canceled for the block. Confirm this before starting the
rotation. (Float residents maintain their clinics).
Intern Role (PG=
Y-1) Pre-rounding for
Interns
- Discuss events that happened
overnight with on-call intern
- Review flowsheet to obtain
vitals, including Tmax, O2 sats, Ventilator
settings, In’s/Out’s, daily weight, medications and drips =
- Examine your patient
- Review pt.’s telemetry
events, new x-rays/imaging
Resident Role
(PGY-2,3)
- Residents on call admit from =
- Post-call
MICU teams will be paged by one of the chief residents at
- Please
page one of the chief residents when you are leaving to ensure work ho=
urs
compliance.
- The
post-call MICU team should be out of the hospital by
- It
is the responsibility of the MICU resident to ensure their intern(s) a=
re
out by
- The
admission cap for a MICU resident is 10 patients. Any admissions over 8
should be redistributed to other MICU teams in the morning. Redistribu=
tion
can also be considered if the difference between two teams is >6 an=
d should
occur if the difference is >8.
MICU Float
- MICU
day float will occur everyday of the week
- MICU
nightfloat will be from
- The
MICU nightfloat will admit any patients over 10 and can help out by
admitting other patients that are set to be redistributed in the AM. T=
his
should be clearly communicated to MICU nightfloat when they arrive.
- Generally,
float residents maintain their clinics. However, if only one senior
resident is on for that week, their clinics will be cancelled.<=
span
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";mso-farea=
st-font-family:
Calibri'>
- MICU
day float’s primary responsibility is to get the post-call team =
out
by
· =
7am Lectures: A=
ll
residents in the MICU, including floats, are required to attend all 7am lec=
tures
that occur 3 times a week.
Post-call teams and housestaff with scheduled days off are excused.<=
b>
Evalu=
ation
Tools: Click
here
Goals
and Objectives: Review the 6 core competencies that apply to your clinical rotatio=
ns. Click
here
PGY1
· &=
nbsp;
Initiate an evaluation of a critica=
lly
ill patient
· &=
nbsp;
Formulate a differential diagnosis =
and
treatment plan for a critically ill patient
· &=
nbsp;
Describe methods of initial resusci=
tation
and stabilization of critically ill patients
· &=
nbsp;
Review the criteria for transfer in=
and
out of the ICU
· &=
nbsp;
Residents
should be familiar with and perform radial artery and central venous
catheterization and naso/gastric intubation. Sepecifically they should describe=
the:
o =
;
indications for vascular catheteriz=
ation
o =
;
landmarks and techniques for succes=
sful
and safe catheterization
o =
;
pros and cons of gastric and small =
bowel
intubation
o =
;
contraindications and complications=
to
these procedures
· &=
nbsp;
Review
ventilator management. Specif=
ically
interns should describe the:
o =
;
indications for intubation and mech=
anical
ventilation
o =
;
specifics of volume-cycled ventilat=
ion
and pressure-controlled ventilation
o =
;
means for activating the machine br=
eath
including:
§ &nbs=
p;
controlled mechanical ventilation
§ &nbs=
p;
assist/control ventilation
§ &nbs=
p;
synchronous intermittent mandatory
ventilation
§ &nbs=
p;
pressure support ventilation
o =
;
specifics and utility of measuring =
airway
resistance, static compliance of the respiratory system and auto-PEEP
o =
;
indications for and risks of machin=
e set
PEEP
o =
;
relationship between ventilator set=
tings
and hemodynamics
o =
;
relationship between ventilator set=
tings
and arterial blood gases
o =
;
complications of mechanical ventila=
tion
§ &nbs=
p;
ventilator-induced lung injury
§ &nbs=
p;
laryngeal and tracheal injury
§ &nbs=
p;
nosocomial infections: sinusitis and
ventilator associated pneumonia
o =
;
approach to patients with obstructi=
ve
lung disease and ARDS
o = ; approach to weaning and extubation<= o:p>
o =
;
timing of tracheostomy
PGY2,3<=
span
style=3D'font-size:11.0pt'>
· &=
nbsp;
Develop
a fundamental knowledge of respiratory failure including the:
o =
;
differential diagnosis and treatmen=
t of acute
hypoxiemic respiratory failure (pneumonia, pulmonary edema, alveolar
hemorrhage, lobar collapse)
o =
;
differential diagnosis and treatmen=
t of
ventilatory failure (status asthmaticus, COPD exacerbation, neuromusclar
weakness)
o =
;
causes and treatment of upper airway
obstruction
· =
Describe
the pathophysiology, hemodynamic profiles and treatment of shock:
o =
;
hypovolemic shock
o =
;
septic shock (including definition =
of
SIRS, sepsis and severe sepsis)
o =
;
cardiogenic shock
o =
;
obstructive shock
· =
Review
the use of right heart catheters and alternative noninvasive measures of
cardiac output (e.g. lithium
dilution)
o =
;
Describe the pathophysiology and
treatment of patients with multiple organ dysfunction syndrome (MODS)
o =
;
Contrast simple and mixed acid-base
disorders
· =
Diagnose
and treat supraventricular and ventricular arrhythmias
o =
;
List protocols for CPR
o =
;
Review the ethical and legal aspect=
s of
withdrawal and withholding of life support
o =
;
Develop an approach to fever in the
intensive care unit including:
o =
;
the diagnosis and treatment of hosp=
ital
acquired infections
o =
;
a comprehensive list of noninfectio=
us
causes of fever
· =
Review
the differential diagnosis and treatment of patients with hyper and hypothe=
rmia
o =
;
Review the etiology and management =
of
patients with common electrolyte and mineral abnormalities including:
o =
;
hyper and hyponatremia
o =
;
hyper and hypokalemia
o =
;
hyper and hypocalcemia
· =
Review
the management of endocrine diseases in the ICU including patients with:
o &nb=
sp;
adre=
nal
insufficiency
o &nb=
sp;
diab=
etic
ketoacidosis
o =
;
thyroid storm
o =
;
hypothyroidism
o =
;
sick euthyroid syndrome
· =
Describe
nutritional issues in critically ill patients including;
o =
;
recommendations regarding protein c=
aloric
supplementation
o =
;
the differences between enteral and
parenteral nutrition
· =
Manage
patients with gastrointestinal bleeding and review:
o =
;
the approach to upper and lower GIB=
o =
;
the approach to stress ulcer prophy=
laxis
· =
Describe
the diagnosis and prevention of venous thromboembolism in the ICU
· =
Review
the differential diagnosis and management of thrombocytopenia in the ICU
· =
Define
the assessment and management of poisoned patients in the ICU including:
o =
;
the general approach to the poisoned
patient
o =
;
the specifics of acetaminophen pois=
oning
o =
;
the specifics of non ethanol alcohol
poisoning
o =
;
the specifics of anticholinergic
poisoning
o =
;
the specifics of carbon monoxide
poisoning
o = ; the specifics of cyanide poisoning<= o:p>
· =
Review
the diagnosis and treatment of anxiety, agitation, pain and delirium in the=
ICU
including the:
o =
;
use of appropriate sedation and/or
paralysis
o =
;
identification and treatment of
drug/alcohol withdrawal syndromes
· =
Describe
the differential diagnosis and management of patients with neuromuscular
problems in the ICU including patients with:
o =
;
metabolic encephalopathy
o =
;
status epilepticus
o =
;
CVA
o =
;
Steroid/paralytic myopathy
o =
;
Critical illness polyneuropathy
o =
;
Guillain-Barre syndrome
o =
;
Anoxic encephalopathy
o &nb=
sp;
Pers=
istent
vegetative state
o &nb=
sp;
Coma=
o =
;
Increased intracranial pressure
· =
Define
the approach to patients with acute liver failure
· =
Review
the approach to patients with acute renal failure
· =
Demonstrate
an understanding of the effect of the severity of acute illness, age and pr=
ior
health on the ability of patients to tolerate critical illness. Understand the utility of the APAC=
HE II
scoring system and be able to calculate&nb=
sp;
an APACHE II score.
=
References: Top Ten Reference=
s
1.
ARDS Network. Ventilation with lower tidal volumes as compared with traditi=
onal
tidal volumes for ALI and ARDS. NEJM
2000;342:1301-8.
- Results
of ARMA study are basis for low- stretch/low tidal volume ventilation
strategy.
2.
Connors AF, Speroff T,
- This famous prospective cohort study found worse outcome with use of PACs i= n the critically ill, instantly becoming a source of enormous controversy. <= o:p>
3.
Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of
trials of weaning from mechanical ventilation. NEJM 1991;324:1445-50. (=
Available
in the journal stacks at the Galter Library).
- Study
in a VA population found the rapid shallow breathing index (RSBI =3D
RR/Vtidal) was the single best predictor of weaning success (sensitivi=
ty
0.97, specificity 0.64).
4.
Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative
infusions in critically ill patients undergoing mechanical ventilation. NEJM
2000;342:1471-7.
- RCT
found daily interruption of sedation in a MICU population resulted in =
shorter
duration of mechanical ventilation and ICU stay, less total dose of
sedation, and less use of diagnostic tests to work-up impaired mental
status compared to the control group. No increase in short term adverse
outcomes in the intervention group identified but patients were not
evaluated for subtle or long-term adverse outcomes.
5.
Bernard GR, Vincent JL, Laterre PE, et al. Efficacy and safety of recombina=
nt
human activated protein C for severe sepsis. NEJM
2001;344:699-709.
- Large,
phase III multicenter RCT found patients randomized to APC had an abso=
lute
mortality reduction of 6%, but may have a greater risk of bleeding.
6. Rivers E, Nguyen B, Havstad S, et al. Early
goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM
2001;345:1368-77.
- This
RCT of 263 patients found benefit from early (in E.D.) aggressive
resuscitation (in-hospital mortality of 30% in the goal-directed group
compared to 46% in the standard therapy group). The intervention arm w=
as
noteworthy for prn use of blood transfusion and/or inotropes to mainta=
in
central venous O2 sat >70%. Authors speculate the earlier aggressiv=
eness
accounts for better outcomes than previous studies of goal-directed
hemodynamic optimization.
7.
The Safe Study Investigators. A comparison of albumin and saline for fluid
resuscitation in the intensive care unit. NEJM
2004;350:2247-56.
- A high-quality study involving 6997 patients assigned to recei=
ve
albumin or saline found no difference in 28-day mortality, single or
multiple organ dysfunction, days spent in ICU, days spent in the hospi=
tal,
mechanical ventilation days, and days spent on renal replacement thera=
py.
Although the debate over the use of crystalloids vs. colloids will lik=
ely
rage on, these results make a strong case against the routine use of
colloids given their expense.
8.
Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia: Official statem=
ent
of ATS and IDSA 2004. AJRCCM 20=
05;171:388-416.
- This
in-depth evidence-based guideline on the management of nosocomial
pneumonia emphasizes early collection of lower respiratory tract sampl=
es,
early institution of antibiotics, a shorter duration of antibiotics for
uncomplicated pneumonia, and use of linezolid, colistin, inhaled
antibiotics, and combination therapy.
9.
Effect of Treatment with Low Doses of Hydrocortisone and Fludrocortisone on
Mortality in Patients with Septic Shock. JAMA 2002; 7 n=
o.
288; 862-871
10.
Intensive Insulin Therapy in Critically Ill Patients. NEJM 2001; 34=
5;19;
1359-1367
Collection
by Dr. Joseph Weber
For an = extended list of references with direct article links, sign in to the Galte= r Health Library website at:
http://www.galter.northwestern.edu/guides/expand/resident-reading-lis= ts
The ATS has also developed a excellent reference= list that is posted online: www.thoracic.org/go/atsr= eadinglist