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 Shock (all forms) Cardiac arrhythmias Cardiogenic pulmonary edema Acute cardiomyopathies Hypertensive emergencies Perioperative myocardial infarction Principles of vasoactive and inotropic therapy Arterial, central venous, and pulmonary artery catheterization and monitoring 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 Acute and chronic respiratory failure Status asthmaticus Smoke inhalation and burns Upper airway obstruction, including foreign bodies and obstruction Near drowning Acute respiratory distress syndrome Acute pulmonary embolism Interpretation of pulmonary function studies/ventilator derived measurements, arterial blood gases Oxygen therapy prescription 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 Fluid and electrolytes abnormalities Oliguria and acute renal failure Acid-base disorders Drug dosing in renal failure Fluid and electrolyte therapy in renal failure 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 Coma Drug overdose Acute hypdrocephalus Brain death evaluation Persistent vegetative state Cerebral vascular accidents Status epilepticus Intracranial hypertension Spinal cord injury 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 Acute adrenal insufficiency Diabetes insipidus Diabetic ketoacidosis Diabetes mellitus 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 Sepis Hospital acquired infection (nosocomial pneumonia, opportunistic infection) Intra-abdominal sepsis Urosepsis Principles of antibiotic selection Dosage selection in the critically ill 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 Defects in hemostasis Hemolytic disorders Thrombotic disorders Principles of anticoagulation and fibrinolytic therapy Deep venous thrombosis prophylaxis 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 Gastrointestinal bleeding Stress gastritis prophylaxis in the critically ill Hepatic failure Peritonitis 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 Immunosuppression Infections in the immunocompromised host Organ rejection Organ donation Principles of sedation, analgesia, and neuromuscular blockade in the Critically Ill Accomplish rapid analgesia in patients with acute pain 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 APACHE II Score Respiratory monitoring (SaO2, etCO2, compliance) Hemodynamic monitoring 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 Do not resuscitate orders Principles of informed consent Rights of patients Withholding or withdrawing life support Advance directives Psychosocial issues Understanding the effect of life threatening illness on patients and familes Dealing with death and dying Transport of the Critically Ill Stabilization Monitoring Equipment preperation Trauma 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

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
2 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, 2^nd edition. 1998. Chapter 2: Causation….

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)