Welcome

to the

Intensive Care Unit

Learning Goals

• To learn to care for critically ill patients• To understand management of respiratory

failure with mechanical ventilation• To develop a better appreciation of

cardiopulmonary physiology• To understand indications for different

modalities of hemodynamic monitoring• To improve on techniques to place invasive

monitors

Learning Goals

• Understand the pharmacodynamics and pharmacokinetics of sedatives

• Learn the communication skills required in the role of the critical care consultant

• Develop a multidisciplinary treatment plan for critically ill patients

• Have a fun and educational month

Organization

• 8/11 ICU – ± intern, ± 1-2 residents, fellows, attending

• 9 ICU – 2 NPs, 2-3 residents, fellows, attending

• 10 ICU – 1 NP, 1 resident, fellows, attending

• 13 ICU – 4 residents, fellows, attending

Housekeeping - call schedule

• Call is approximately every 3-4 nights.

• A non-call resident should be identified and stay until at least 5pm rounds to help with the work.

• Schedule changes are not allowed unless approved by Dr. Shimabukuro (an extremely complex schedule)

Housekeeping - Call rooms

• 13 ICU - L 1351, code 911911

• 8/9/10 ICU - in proximal 9 ICU, no code

• ICU fellow - in distal room of 9ICU, no code

Housekeeping - daily routine

• Lectures start at 8am sharp everyday (except 8:15 on Wednesdays) in room M919

• Check schedule for location and speaker• Rounds start at 9am weekdays and at 8am on

weekends• X-ray rounds immediately follow attending

rounds• Afternoon rounds with fellows start at 5pm

Housekeeping - weekend

• Only on-call and post-call residents round

• Try to pre-round on the sick ICU patients

• Remainder of patients can be discovery rounds

• Please try to write notes either before or after rounds

• Place emphasis on A/P not repeating data

Housekeeping - Lectures

• Everybody will be responsible for 1 lecture during their rotation

• Please check the lecture schedule for assigned topic and date

• Medical students are allowed to pick a topic of their choice

• Read schedule carefully, sometimes lectures are split based on level of training or ICU experience

Housekeeping - paperwork

• List to be described on following slides• Notes• Patient list• Admit Orders• Procedure Note• Central Line Procedure Note

Notes• Do not repeat data that is already listed

elsewhere

• Short and concise notes are the key

• For instance, “wean vent as tolerated” vs. “Patient continues to require a high minute ventilation due to a large dead space fraction. He may not tolerate a rapid wean, so will decrease the rate by 2 today.”

Patient list

• The filemaker database is in the fellow’s office. It should be updated daily

• Post call resident will print out copies for the team

• Do not leave in the ICU (patient confidentiality)

• Make sure to enter morbidities and mortalities

Admit Orders

• There are pre-printed ICU admit orders

• ICU orders are on its own page

• Please make sure you sign these

• Try to use the pre-printed orders since they are compliant with pharmacy regulations

Procedure Notes

• Located in NoteWriter

• Central Line Insertion Procedure Note (CLIP)

• CCM-Procedure Note

Procedure Note for Central Lines

• NoteWriter

• Central Line Insertion Procedure Note (CLIP)

• Attesting provider is Attending of week.

CCM-Procedure Note

• Can check more than one procedure

• Attesting provider is Attending of week

Resident Responsibilities

• Code Blue Coverage (10 ICU team)

• Emergency calls in the ICU

• Co-Managing patient with primary teams

• With special emphasis on:• Airway

• Central lines

• Mechanical ventilation

• Pain and sedative medications

Code Responsibilities

• 10 ICU team will respond to codes during weekdays

• We are responsible for the airway - FIRST• Please make sure that whatever you use in the

CODE bags are refilled immediately• New medication syringes are available from

pharmacy daily (across from M919)• Anesthesia workroom has other supplies – it is

located in the OR on the fourth floor

Emergency Calls

• Calls regarding unstable patients often go to the ICU team

• If situation is truly an emergency, deal with the problem while the primary team is being summoned

• If there is time, discuss with the team, often the night float will be thankful for a friendly word of advice

Communication

• Understanding the primary team’s plans and goals often make it easier to understand the course of action that is planned

• Communication makes it easier for all parties involved and improves patient care

• If there is a disagreement about care, consult your fellow or attending

Airway

• The airway pager (443-4990) will always be with an anesthesiologist (attending or resident)

• Airway backup available:• OR E1 Anesthesia Attending: 3-1581• OR Front Desk: 3-1545• OB Anesthesia Resident: 443-9261• ED: 3-1238

• Do not start sedation/paralysis without someone from anesthesia being present (CA-1 residents should also always get back-up)

Central Lines

• Except for a few services we are responsible for all line placements (CT, cards, vasc)

• All upper body lines must be placed with an ICU attending or fellow present

• Femoral lines are at the discretion of the resident

• 3 line placements will be formally evaluated by fellows (give completed cards to Mitch in M917)

Ventilation

• We are responsible for ALL ventilator orders and extubation (except fast-track CABG – who are on a protocol)

• If the primary team wants something that is unreasonable, please discuss it with the fellow or attending

• DO NOT make changes on the ventilator• Pts should be followed for at least 24 hours

after extubation

Sedation

• We write pain and sedation orders on all patients we follow

• Do what the primary team wants if it is reasonable

• Management of pain in ICU patients with epidural catheters is the responsibility of the acute pain service, but we do keep a close eye on this

Miscellaneous• Radiology does not interpret any studies overnight

unless asked

• Small cards have everybody’s pager and home phone number

• Meal cards are obtainable from Mitch in the office (M917)

• Please don’t hesitate if you identify problems during your rotation to notify your attending

• Please fill out the evaluations. Your comments are confidential and important for future rotation development

Medical Students• Stay late 1 night per week - their choice

• They should read about their patients

• Quality not quantity (2 patients max)

• They are not expected to function as a resident during this rotation

• There should be a resident identified as the supervisor for each patient the students follows

Calls to evaluate patient• Go see the patient in the ER or on the floor

• Discuss ALL ICU admissions with fellow (or attending)

• Any refused admission must be discussed with attending or fellow

• Do not worry about beds, triage attending (443-4443) will take care of that

• Triage covered by 10 ICU fellow

Open and Closed ICU’s

• Most patients in M/L ICU’s are “semi-open” in that primary service still writes some orders, but we co-manage with them.

• Orthopedic surgery, CRI, post-partum OB, ENT/ plastics and Urology are “closed”

• Make sure you know their contact #’s to keep them in the loop

Closed patient issues

• Labs - transfusion, electrolytes, glucose• Nutrition - NPO, tube feeding, TPN• Activity - bedrest, ad lib• IVF - rate, heplock• Studies - radiology, echo, PT - need to

make a phone call• Check patient frequently and

communicate with primary team often

Open and Closed ICU’s• The data:• Multiple studies show that the daily presence of an

intensivist improves outcomes, including mortality and length of stay. There was no advantage to closed units.

• Disadvantages of open units:• Disagreement about management plans• Loss of control

• Advantages of open units• Ability to care for a variety of patients (med, surg, etc)• Ability to focus on critical care issues

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