INTRODUCTION TO PICU
The PICU rotation can be a difficult one. When residents work together as a team
and help one another, the rotation becomes much easier and patient care
improves. If there are ever any problems or concerns, the Attendings/PNP are
ALWAYS available to discuss such issues.
GENERAL RULES
PICU patients are your patients: you are responsible for them and, so, need to practice as
such. In order to ensure the best care you must follow the rules below.
1.
You must read the PICU syllabus and it is strongly recommended that you do so
before you start the rotation. The Attendings assume that you will have a baseline
amount of ICU knowledge. In addition, if you want to be able to do a procedure,
and the opportunity arises, you must have read and/or seen a video dealing with
the procedure. If no attempt has been made to learn about the procedure, then you
will not be allowed to do the procedure.
2.
All residents must know the daily and global plans for every patient. On call
residents need to know everything about all patients. That includes ventilator
settings, caloric intake, etc. Ignorance is no excuse – if you don’t understand
something, ask your attending.
3.
If a patient has a physiologic change that has not been addressed by the Attending
on rounds, the Attending needs to be called and an SBAR form or note needs
to be completed
4.
Consultants consult – you, not they, are the primary doctors in the PICU through
which all information/plans funnel. If another service wants to do something or
orders something on your patient that is a change from the PICU team’s plan, find
out why and discuss it with the PICU Attending.
5.
The entire PICU uses the Electronic Medical Record for all aspects of patient
care. You will be educated by the prior month’s residents or by one of the PICU
attendings on the use of the EMR.
6.
If a patient’s clinical status is acutely evolving, the expectation is that the resident
will be consistently present at the patient’s bedside, even if the Attending is
present– not writing orders or notes in the core. The residents have a laptop that
should be used to write orders and follow up on labs, at the bedside.
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7.
Find your PALS card and keep it with you.
8. This will be some of your first experiences with overnight call. Prepare by having
ongoing good sleep habits, drink lots of water, and have a well-balanced diet.
Sleep when you can in the unit.
9. Patients will be split as evenly as possible, with the sickest children going to the
resident on call, as they will spend 24 hours at their bedside. It is important to as
evenly as possible distribute the sick children, to each ER resident, anesthesia
resident and the pediatric residents. Even if you don’t have the sickest patient
you can still examine them and talk with the team about the plans. The senior
most resident is in charge of distribution of the patient.
10. Remember – you are in charge of your education. Read during downtime, ask
questions of all participants in the PICU: the attending, the nurses, the nutritionist,
the pharmacist, the chaplain. The PICU team has a wealth of knowledge so ask
questions.
GOALS AND OBJECTIVES
1. Obtain an understanding of the pathophysiology of various critical illnesses in
children
2. Learn to recognize, triage, and stabilize critically ill children and to realize
one’s own limits of knowledge, skills, and stressors
3. Become familiar with invasive procedures and monitoring in the PICU
4. Become familiar with ethical issues within the PICU
5. Learn to read, critique, and apply medical literature appropriately
6. Participate as an integral member of the PICU team
CURRICULUM CONTENT
Respiratory Failure
1. Pathophysiology of different types of respiratory failure and their
treatments
2. Bag mask ventilation and various modes of invasive and noninvasive
positive pressure ventilation;
3. Interpretation of arterial blood gasses
Circulatory Failure
1. Types of shock and their manifestations
2. Evaluation and resuscitation of children in shock
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3. Monitoring of shock states
4. Use of Vasopressors and Inotropes
Repair of Congenital Heart Disease
1. Types and post-operative management issues
Acute Brain Injury
1. Causes and pathophysiology of various types of brain injury
2. Clinical signs of high intracranial pressure
3. Monitoring and management of high ICP
Sedation, Analgesia and Paralysis
1. Strategies and pharmacology of various sedatives and analgesics
2. Use and complications of paralytic agents
Metabolic/Endocrinologic Abnormalities
1. Pathophysiology and treatment of critically ill patients with
endocrinologic diseases such as diabetic ketoacidosis, congenital
adrenal hyperplasia, etc
Hematologic and Oncologic Abnormalities
1. Evaluation and management of bleeding disorders
2. Management of oncologic emergencies
Renal Failure
1. Pathophysiology and treatment of renal dysfunction and fluid
management
Ethics
1. Discussion of relevant ethical issues seen with the critically ill child
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LECTURES
Monday
Tuesday
12-1PM case
presentation
Wednesday
Thursday
12-1PM
Lecture
PICU
Friday
12-1PM
Lecture
Equipment
12-1PM
Lecture
PICU
12-1PM
Lecture
PICU
12-1PM
Nutrition
Lecture
1-2PM
Lecture
PICU
1-2PM
Lecture
Pharmacy
12-1PM
Lecture
PICU
12-1PM
Lecture
PICU
12-1PM
Lecture
PICU
Week 1
Week 2
Week 3
Week 4
Week 5
12-1PM
Ethical case
presentation
The major teaching method is case-based instruction/discussion at the bedside. In
addition, core lectures will be given by the PICU Attendings and supporting staff.
Information about these lectures is available on the website. Attendance is
mandatory for all residents not in clinic. The resident on call will handle issues
within the unit if necessary to ensure the participation of all other team members.
Residents will also participate as “Nurse for a Day” with an experienced PICU
nurse. This will be assigned by the pediatric chief resident.
EVALUATION METHODS
The resident will be evaluated on his or her clinical and procedural skills, interest in
learning and reading, organizational skills, and interactions with other members of the
medical staff as well as patients and their families. These evaluations will occur via direct
observation by the PICU Attendings/PNP and will be reported on departmental
evaluation forms at the end of each rotation. The PICU Attendings also provide verbal
mid rotation feedback. If a resident wishes feedback earlier in the rotation, he or she can
ask an Attending/PNP for this information at anytime during the rotation.
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CLINICAL RESPONSIBILITIES
Morning Rounds
7 AM on weekdays
7 AM on weekends and holidays
Every patient should be seen and examined and appropriate lab values and
radiographic studies’ results should be obtained prior to morning rounds.
During your PICU rotation, your work hours are officially 7am - after 4pm
signout, or 5 PM signout on Thursday nights. The resident who was on Saturday
overnight call will report after 24 hours on Monday morning.
Morning rounds signout template-This template should be followed for rounds.
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1 line about the patient
Interval history or HPI: What happened overnight?
Vital signs: Give ranges for this patient and talk about the abnormal vital
signs. Urine output in(in cc/kg/hour) with 24hour I/O balance–attention
should be paid to the last 8-12 hours if there has been a change. Basically,
we want to know that you know what normal is and then talk about the
outliers.
Exam: short and focused on pertinent positives
Review by Systems
Respiratory – include vent settings or other O2 delivery devices; blood
gas; meds (i.e. albuterol, heliox, steroids, etc.), CXR findings; consults
called
CV – inotropes/pressors or other meds such as antihypertensives; lines;
consults called
Neuro – sedatives, analgesics, and other meds (anti-epileptics – with drug
levels); EEG findings or recent neuro-imaging findings; consults called
FEN/GI – nutrition/IVF/TPN; ideally, for little babies, kcal/kg/day; most
recent electroytes/LFT’s/pancreatic enzymes, etc.; medications; consults
called
H/O – most recent CBC or other labs; medications; consults called
I/D – most recent cultures; list abx with levels; consults called
Renal – most recent labs; medications; imaging; consults called
Endocrine – medications and labs; consults called
Social – pertinent findings; consults called
Medications: As read by the pharmacist. We have a pharmacist on rounds
and we will use her. We can talk about utility, dosing, think about drugs
that are nephro or hepatotoxic, etc
Assessment: one liner that shows you can synthesize what is going on
with this patient
Plans: Depending on the attending, this can be done by system or by
reiterating plans discussed during the review of systems
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IT IS ESSENTIAL FOR THE RESIDENTS TO EXAMINE EACH
VENTILATOR AND IV PUMP TO ENSURE THE PROPER SETTINGS
ARE IN PLACE AND BEING RECORDED
Afternoon Rounds
4 PM, except Thursday which is at 5 PM
Post-call residents and residents in clinic are not required to attend PM rounds
Daytime Responsibilities Residents should frequently round on their patients in
addition to completing the day’s tasks prescribed during rounds
Orders
All order writing is done electronically through CPOE. You should notify the
patient’s nurse of ANY new or discontinued orders, especially if the order is
written as STAT.
Lexi-Comp online (http://online.lexi.com/crlonline) is our hospital-approved
reference for medication. There are links to Lexi-Comp directly from Powerchart
and also from the main hospital intranet page.
It is prudent and necessary to check every order every day to make sure that you
haven’t hit a soft stop or fallen off of the MAR.
Compare active orders to what the patient should be getting to exactly what the
patient is getting (MAR) every day.
Tuesday is order renewal/revision day in PICU.
Admissions
All PICU admissions are admitted under the PICU Attending’s name, unless they
are a trauma patient. The trauma patients are admitted under the trauma
attendings, co-managed by us. The Attending must be notified of all admissions
by the ER, 11 North senior resident, etc prior to acceptance. The PICU resident
will contact the Attending once the new admission is evaluated and the resident
has a treatment plan. It is the responsibility of the admitting resident to contact
the patient’s PMD of the PICU admission either at the time of admission or the
following morning.
Transfer/Discharge Notes
Any patient transferred or discharged from the PICU is to have a
transfer/discharge summary and appropriate orders. It is the responsibility of the
transferring resident to sign out to the accepting resident and primary pediatrician.
This transfer/discharge note can be the daily progress note as well, with a detailed
course for the accepting team
Communication
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PICU attending coverage is now 24 hours in-house. The attending pagers and cell
phones are posted on the board in the back or the clerk has them. The attendings
expect communication with any organ system change. It is better to overcommunicate than to under communicate. One of the most important things the
Attendings expect is a plan. So remember to have one when you call!
Communication with the surgery team should go through the chief or most senior
resident. If you aren’t getting an answer from any consulting service, let your
attending know.
Unit Coverage
A resident must be in the PICU at all times. Exceptions to this are during resident
administrative meetings and when an Attending/PNP is present within the PICU.
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