SNICU Education

Upon completion of the residency training, the physician should have achieved proficiency in the recognition and initial management of sepsis, acute respiratory failure, acute renal failure, hemodynamic failure, acute neurologic illness, and endocrine emergencies.

All housestaff should have Advanced Cardiac Life Support (ACLS) training. Fundamentals in Critical Care Support (FCCS), Pediatric Advance Life Support and Advanced Trauma Life Support training are encouraged.

These are our current goals for training. It is recognized that the rotating resident during the one to two month rotation may or may not experience all of the listed areas. Supplementary reading is always encouraged.

Management of Cardiovascular Emergencies

  1. Shock (all forms)
  2. Cardiac arrhythmias
  3. Cardiogenic pulmonary edema
  4. Acute cardiomyopathies
  5. Hypertensive emergencies
  6. Perioperative myocardial infarction
  7. Principles of vasoactive and inotropic therapy
  8. Arterial, central venous, and pulmonary artery catheterization and monitoring
  9. Deep venous thrombosis prophylaxis

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Sections III, IV, and V. Marino PL. The ICU Book. 2nd edition. 1998 Williams & Wilkins
  • Martin C et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock? Chest 1993:103:1826-1831.
  • Raper R et al. Mislead by the wedge? The Swan-Ganz catheter and left ventricular preload. Chest 1986;89:427-434.

 

 

Management of Respiratory Emergencies

  1. Acute and chronic respiratory failure
  2. Status asthmaticus
  3. Smoke inhalation and burns
  4. Upper airway obstruction, including foreign bodies and obstruction
  5. Near drowning
  6. Acute respiratory distress syndrome
  7. Acute pulmonary embolism
  8. Interpretation of pulmonary function studies/ventilator derived measurements, arterial blood gases
  9. Oxygen therapy prescription
  10. Mechanical ventilation (invasive and non-invasive), including indications, modes, complications, and weaning

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Handbook of Mechanical Ventilatory Support. Stock and Perel
  • Section VII: Mechanical Ventilation. Marino PL. The ICU Book. 2nd edition. 1998. Williams and Wilkins
  • American College of Chest Physicians' Consensus Conference on Mechanical Ventilation. Chest 1993:104:1833-1859
  • Glauser FL, Polatty RC, Sessler CN. Worsening oxygenating in the mechanically ventilated patient: causes, mechanisms, and early detection. Am Rev Respir Dis 1988:138:458-495.
  • Meyer TJ and Hill NS. Noninvasive positive pressure ventilation to treat respiratory failure. Ann Intern Med 1994:120:760-770.
  • Feihl F et al. State of the art: permissive hypercapnia-how permissive should we be? Am J Respir Crit Care Med 1994:150:1772-1737.

 

Management of Acute Renal Pathology

  1. Fluid and electrolytes abnormalities
  2. Oliguria and acute renal failure
  3. Acid-base disorders
  4. Drug dosing in renal failure
  5. Fluid and electrolyte therapy in renal failure
  6. Dialysis

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Section X. Fluid and electrolyte disorders. Marino PL. The ICU Book. 2nd Edition. 1998. Williams & Wilkins.
  • Section XIV. Pharmaceutical considerations. Marino PL. The ICU Book. 2nd edition. 1998. Williams & Wilkins.
  • Kaczmarczyk G. Pulmonary-renal axis during positive-pressure ventilation. New Horizons 1994:2:512-517.

 

Acute Central Nervous System Pathphysiology

  1. Coma
  2. Drug overdose
  3. Acute hypdrocephalus
  4. Brain death evaluation
  5. Persistent vegetative state
  6. Cerebral vascular accidents
  7. Status epilepticus
  8. Intracranial hypertension
  9. Spinal cord injury
  10. Hyperosmolar coma

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Section XIII. Neurologic disorders. Marino PL. The ICU Book. 2nd edition. 1998. Williams & Wilkins.
  • Traumatic Brai Injury Guidelines. American association of Neurologic Surgeons and Braintrauma Foundation. (Revised 2003)

 

Management of metabolic and endocrine emergencies

  1. Acute adrenal insufficiency
  2. Diabetes insipidus
  3. Diabetic ketoacidosis
  4. Diabetes mellitus
  5. Principles of alimentation
    - Enteral
    - Parenteral

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Section XII. Nutrition and metabolism. Marino PL. The ICU Book. 2nd edition. 1998. Williams & Wilkins.

 

Diagnosis and Treatment of nosocomial Infectious Complications

  1. Sepis
  2. Hospital acquired infection (nosocomial pneumonia, opportunistic infection)
  3. Intra-abdominal sepsis
  4. Urosepsis
  5. Principles of antibiotic selection
  6. Dosage selection in the critically ill
  7. Infection risk to health care workers

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Selected references from Mendell's Infectious Diseases
  • Section VII. Infections and inflammatory disorders. Marino PL. The ICU Book. 2nd edition. 1998. Williams & Wilkins.
  • American Thoracic Society Consensus Statement. Hospital acquired,Ventilator acquired pneumonia and Healthcare associated pneumonia in adults: . Am J Respir Crit Care Med 2005:171:388-416

 

Hematologic Disorders

  1. Defects in hemostasis
  2. Hemolytic disorders
  3. Thrombotic disorders
  4. Principles of anticoagulation and fibrinolytic therapy
  5. Deep venous thrombosis prophylaxis
  6. Blood component therapy

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Section IX. Blood component therapy. Marino PL. The ICU Book. 2nd edition. 1998. Williams & Wilkins.

 

Gastrointestinal diseases

  1. Gastrointestinal bleeding
  2. Stress gastritis prophylaxis in the critically ill
  3. Hepatic failure
  4. Peritonitis
  5. Pancreastitis

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Chapter 6. Gastrointestinal prophylaxis. Marino PL. The ICU Book. 2nd edition. 1998. Williams & Wilkins.

 

Principles of Transplantation

  1. Immunosuppression
  2. Infections in the immunocompromised host
  3. Organ rejection
  4. Organ donation

Principles of sedation, analgesia, and neuromuscular blockade in the Critically Ill

  1. Accomplish rapid analgesia in patients with acute pain
  2. List the benefits and complications of epidural analgesia

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Shapiro BA et al. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Crit Care Med 1995:23:1596-1600.
  • Shapiro BA et al. Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary. Crit Care Med 1995L23L1601-1605.
  • Chapter 8: Analgesia and sedation. Marino PL. The ICU Book. 2nd edition. Williams & Wilkins 1998.

 

Monitoring and Biostatistics

  1. APACHE II Score
  2. Respiratory monitoring (SaO2, etCO2, compliance)
  3. Hemodynamic monitoring
  4. Pulse contour analysis and Lithium thermodilution cardiac output measurement.

 

References:

  • Textbook of Critical Care: Mitchell Fink, J-l Vincent
  • Tobin MJ. Principles and practice of intensive care monitoring. McGraw Hill. 1998.

 

Ethical and Legal Aspects of Critical Care

  1. Do not resuscitate orders
  2. Principles of informed consent
  3. Rights of patients
  4. Withholding or withdrawing life support
  5. Advance directives

Psychosocial issues

  1. Understanding the effect of life threatening illness on patients and familes
  2. Dealing with death and dying

Transport of the Critically Ill

  1. Stabilization
  2. Monitoring
  3. Equipment preperation

Trauma

  1. Assessment and management of the trauma patient

 

Essential References:

  • Marino PL. The ICU Book. 2nd edition. Williams & Wilkins. 1998.
    - Current and concise with a very reasonable bibliography.
  • Hall J. Principles of Critical Care. 2nd edition. McGraw Hill. 1998.
    - A complete encyclopedia of all aspects of critical care
  • Tobin MJ. Principles and practice of mechanical ventilation. McGraw Hill. 1994.
    - Everything one wants to know about mechanical ventilation. "if we don't have it, you don't need it."
  • Tobin MJ. Principles and practice of intensive care monitoring. McGraw Hill. 1998.
    - A superb collection on ICU monitoring chapters.
  • Chernow B. The pharmcologic approach to the critically ill patient. 3rd edition. Williams & Wilkins.
    - A good source to review drug interactions with respect to the critically ill.
  • Mandell GL. Principles and practice and infectious diseases. 4th edition. Churchill Livingstone. 1995.
    - An encyclopedia of infections and antibiotics
  • Guidlines for the Management of Severe Traumatic Brain Injury.  3rd edition. Mary Ann Liebert, Inc. 2007

Journal Club

The fellowship didactics include monthly Journal Clubs. The Journal Clubs are usually at 710hrs on the second and fourth tuesdays of the month. The topics are decided in advance and the articles are usually emailed to the residents and attending faculty members about one week in advance. The topics are from current critical care literature and the articles are archived for future references. The Journal Club is in a short powerpoint format highlighting the essential facts and inferences. All fellows are encouraged to present at Journal Club on a regular basis. Arrangements to attend relevent Journal Clubs with the Pulmonary Critical Care Group, Trauma Surgery, or other sub-speciality departments can be arranged and is encouraged.

To maximize the benefit of presenting an article at the SICU journal club, the following points should be considered and accounted for in the presentation. Below is an example of a study that was presented at a SICU journal club some time in the recent past.

Name of Article: Kim, DH. INCREASES IN CARDIAC OUTPUT CAN REVERSE FLOW

DEFICITS FROM VASOSPASM INDEPENDENT OF BLOOD PRESSURE: A STUDY USING XENON COMPUTED TOMOGRAPHIC MEASUREMENT OF CEREBRAL BLOOD FLOW. Neurosurgery 2003:53:1044

 

 

Grading Considerations

Comments

A. Description of evidence

Concise, clear, accurate

 

1 Exposure

1. Hypervolemia
2. Increase MAP
3. Increase CI

 

Outcome

Cerebral blood flow measured in terms of ml/100 gm/min.

 

3 Design

Prospective, observational trial

 

4 Study population

16 patients with non-traumatic SAH on mechanical ventilation

 

5 Main result

Induced hypertension with alpha agonist increases CBP

Increased CO without increase MAP increases CBF

 

B. Non-causal explanations

Each sub-topic is addressed

 

6 Information/misclassification bias

All patients had cerebral vasospasm by arteriography after TCD screen.

 

7 Confounding

Define confounding

CO2 levels

8 Chance

Significant p values

CVP without Power

C. Positive features of causation

Relevant sub-topics are addressed

20

9 Time relationship

Yes: 30 to 60 minutes

 

10 Strength

Signficant strength of association

 

11 Dose-response

No dose response curve

 

12 Consistency

Other studies (lLevey)

 

13 Specificity

Cause leads to a specific effect

 

Summary of internal validity:

Except for CO2

 

D. External validity

Applicable to Iowa patients

 

14 To the eligible population

Yes

 

15 To the source population

Yes, but temporal consistency unknown

 

16 To other populations

Unknown

 

E. Other evidence

 

10

17 Consistency

Yes

 

19 Plausibility

This study is biologically plausible.

What happens over time?

20 Coherence

Yes

 

Conclusion about the study:

This is an important addition to the medical literature.

Clinical outcomes

Writing:

Clarity of purpose (rich use of examples, quotes and explanations)

Organization and structure (topic sentences, relation to appraisal outline topics clear)

Writing conventions (word usage, grammar, sentence structure, precision of language)

   
  • Use the Lecture Handout as a guide

Excellent reference: Rothman, KJ & Greenland, S. Modern Epidemiology, 2nd edition. 1998. Chapter 2: Causation….

Educational Links

Journals

Advances in Sepsis

American Journal of Respiratory & Critical Care Medicine

Anesthesia & Analgesia

Anesthesiology

British Journal of Anaesthesia

British Medical Journal (Full Text)

Chest

Critical Care Medicine

Intensive Care Medicine

JAMA

Journal of Trauma

Postgraduate Medicine

The New England Journal of Medicine

Critical Care Links

American College of Cardiology

American College of Chest Physicians

American Society for Parenteral and Enteral Nutrition

Infectious Diseases Society of America

National Guidelines Clearinghouse

Organizations

American Board of Anesthesiology (ABA)

American Society of Anesthesiologists

Society of Critical Care Medicine (SCCM