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    Contents Contents Document Transcript

    • BIDMC ICU Curriculum Schedule of Teaching Sessions Week One Day 1: Introduction and Expectations Day 2: Ventilator Basics Day 3: Shock Part I - When and How to Resuscitate: Case Based Day 4: Resident Led Journal Club Week Two Day 1: Shock Part II - Fluids and Pressors Day 2: ARDS Day 3: Subspecialty Topic of Relevance to Unit Players Day 4: Resident Led Journal Club Week Three Day 1: Sepsis Day 2: Acid Base Day 3: Subspecialty Topic of Relevance to Unit Players Day 4: Resident Led Journal Club Week Four Day 1: Hypercarbic Respiratory Failure Day 2: Liberation from Mechanical Ventilation Day 3: Family Meetings/ End of Life Day 4: Resident Led Journal Club
    • Subspecialty Topics Basic Physiology – O2 Carrying Capacity & Delivery Blood Product Usage DKA Glucose Control in the ICU Hepatic Failure Hyponatremia Liberation from Ventilation Line Placement NIPPV Nosocomial infection – Lines and VAP Prophylaxis in the ICU Sedation & Paralysis Severe Asthma
    • Vent Basics Learning Objectives 1. Distinguish controllers of oxygenation vs. ventilation a. PEEP & FiO2 b. Minute Ventilation 2. Modes of Ventilation – understand independent & dependent variables a. AC b. PSV c. PCV 3. Resistance vs. Compliance a. Calculation of both b. Trouble-shooting vent when there is a change in either Supplemental articles 1. Hess & Kacmarek, Essentials of Mechanical Ventilation, selected chapters 2. Hess. Ventilatory Modes Used in Weaning. Chest 2001; 120: 474S. Also Include
    • Shock – Part 1: Basics and Assessment Learning objectives 1. Understand that shock is a state of tissue hypoxia and may exist even when the blood pressure is normal (“occult hypoperfusion” or “compensated shock”) 2. Recognize that delaying intervention in shock may markedly increase mortality 3. Understand basic pathophysiologic that lead to shock and the clinical syndromes that go with them a. Hypovolemia b. Vasodilation c. Cardiogenic 4. Review exam and monitoring techniques for assessing whether a patient in shock has hypovolemia a. JVP & CVP b. Arterial pulse pressure variation c. PCWP Supplemental articles 1. Michard F and Teboul JL. Predicting Fluid Responsiveness in ICU Patients: A Critical Analysis of the Evidence. Chest 2002; 121:2000–2008. 2. Michard F et al. Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid Responsiveness in Septic Patients with Acute Circulatory Failure. AJRCCM 162:134–138, 2000. 3. Claridge JA, Crabtree TD, Pelletier SJ, Butler K, Sawyer RG, Young JS. Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. J Trauma. 2000 Jan;48(1):8-14; discussion 14-5. 4. Landry D. W., Oliver J. A. Mechanisms of Disease: The Pathogenesis of Vasodilatory Shock. NEJM 2001; 345:588-595, Aug 23, 2001 5. Hochman JS. Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm. Circulation. 2003 Jun 24;107(24):2998-3002.
    • Shock – Part 2: Treatment Learning objectives 1. Understand the endpoints one follows to gauge the success of resuscitation in shock a. Urine output b. Lactate c. Mental Status 2. Know how to treat hypovolemic shock. a. What is a bolus? i. 1000 cc/hr (pump), vs. ii. “wide open” without a pump, vs. iii. Rapid infuser b. Flow rates through various IVs, CVLs, Cordis, etc. c. Types of fluids and their indications – NS, LR, albumin, hetastarch, etc. 3. Understand the effects of various pressors, a. Dopamine b. Dobutamine c. Norepinephrine d. Epinephrine e. Know that there is little evidence to guide the choice of one pressor over another 4. Know how to target hemodynamic therapies of shock toward the pathophysiologic problem that underlies the shock Supplemental articles 1. The SAFE Study Investigators. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. NEJM 2004; 350:2247-2256, May 27, 2004. 2. Mullner M et al. Vasopressors for shock. Cochrane Database Syst Rev. 2004(3):CD003709 3. Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF, Heard SO, Martin C, Napolitano LM, Susla GM, Totaro R, Vincent JL, Zanotti-Cavazzoni S. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. CCM. 2004 Sep;32(9):1928-48.
    • ARDS Learning Objectives 1. Understand basic pathophysiology of hypoxemic respiratory failure 2. Know different causes of ARDS 3. Understand the ARDS Net ventilation strategy c. Low tidal volumes d. PEEP 4. Review novel approaches to treatment of severe hypoxemia a. Prone position b. Recruitment maneuver c. NO d. Lack of data to support a mortality benefit Supplemental articles 1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. NEJM 2000; 342:1301. 2. Amato, MB, Barbas, CS, Medeiros, DM, et al. Effect of a protective- ventilation strategy on mortality in the acute respiratory distress syndrome. NEJM 1998; 338:347. 3. Meduri, GU, Headley, S, Golden, E, et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome. JAMA 1998; 280:159. 4. Gattinoni, L, Tognoni, G, Pesenti, A, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. NEJM 2001; 345:568. Also Include Vent Weaning Protocol
    • Sepsis Learning Objectives 1. Know the definition of sepsis/SIRS 2. Understand the basic pathophysiology of sepsis 3. Know the various therapeutic strategies with mortality benefit a. Early aggressive resuscitation b. Activated Protein C c. Steroids Supplemental Articles 1. Rivers EN, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345: 1368. 2. Bernard GR et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. NEJM 2001; 344: 699. 3. Annane D et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000;283:1038. 4. Hotchkiss RS. Karl IE. The pathophysiology and treatment of sepsis. NEJM 348:138. Also Include MUST Protocol
    • Acid/Base Disorders Learning Objectives 1. Recognize the presence of an acid/base disorder a. Define normal values i. pH ii. PaCO2 iii. serum bicarbonate b. Check for internal consistency c. Recognize a primary metabolic or respiratory disorder 2. Understand the importance of the anion gap a. Know when to report the anion gap b. Correct the anion gap for serum albumin c. Determine if it is a gap or non-gap acidosis d. Know the differential for gap and non-gap acidosis e. Understand urine electrolytes and why are they important 3. Determine if the disorder is acute or chronic and if there is a mixed disorder a. Recognize “compensation” b. Recognize what is appropriate compensation, use the DFK rule, (1 to 1, 10 to 7, 1, 4, 2, 5) 4. Strong Ion
    • Hypercarbic Respiratory Failure Learning Objectives 1. Understand underlying causes of hypercarbic respiratory failure a. Increased dead space (intrinsic lung disease) b. Central control issue (meds, head trauma, obesity hypovent) c. Respiratory muscle weakness/fatigue d. Increased CO2 production (rare) 2. Understand the use of an ABG to assess acute vs. chronic hypercarbia… BUT… ultimately use the clinical condition to assess need for intubation ( i.e. not just the absolute PCO2) 3. Recognize unique Issues to watch for in ventilating asthma/COPD a. AutoPEEP b. Manage I: E ratio/Flow Rates c. Don’t overcorrect – think of their baseline PCO2 4. Understand the role of NIPPV Supplemental articles 1. Brochard Non invasive ventilation for acute exacerbations of COPD NEJM 1995 333: 817. 2. Antonelli NEJM 1998 339: A comparison of NIPPV versus conventional mechanical ventilation in pts with acute respiratory failure C 429.
    • Weaning Learning Objectives 1. Recognize the need to “fix” the original issue requiring intubation 2. Understand different modalities of weaning a. T piece vs. PSV vs. IMV b. Daily Wake Ups 3. Understand you to assess readiness a. RSBI b. NIF c. White Card 4. Recognize barriers to weaning a. Sedation b. Nutrition c. Positioning Supplemental articles 1. Withdrawal from Ventilatory Support when Weaning from Mechanical Ventilation AJRCCM 1994 Oct 150 (4) 893-903. 2. Esteban Comparison of 4 Different Methods of Weaning Patients from Mechanical Ventilation NEJM 332(6) pp345-250.