ICU Orientation
What You Need to
Know
The Six COMPETENCIES
Patient care
Medical knowledge
Communication
Professionalism
Practice based learning
System based practice
Patient Care: Cognitive Skills
 Improve the skills to provide optimal methodology to work
up and deliver care to critically ill patients
 Communicate effectively with and demonstrate empathy
and respectful behavior when interacting with patients and
their families
 Ensure relevant and accurate information about their
patients
 Oversee diagnostic and therapeutic plans for their patients
based on history, physical examination and laboratory
data tempered with evidence-based medicine, clinical
judgment and patient preference
 Ensure management plans are implemented
 Counsel and educate patients and their families
Patient Care: Technical skills
 Insertion of and instruction in the insertion
of intra-arterial (radial, femoral, axillary)
and central venous catheters (internal
jugular, subclavian, femoral)
 Insertion of and the instruction in the
insertion of pulmonary artery catheters
(internal jugular, subclavian and femoral)
 Emergency airway management
 Insertion of chest tubes (optional)
 Percutaneous tracheostomies (optional)
Medical Knowledge
Master the following:
 Physiology
 Pharmacology
 Clinical Knowledge and
Management:
 Respiratory

Mechanical Ventilation

Management of acute lung
injury and the acute

respiratory distress
syndrome

Weaning from mechanical
ventilation
 Cardiovascular
Hemodynamic monitoring
 Oxygen transport
 Use of inotropes and
vasopressors

 Pharmacokinetics and
pharmacodynamics
 Management of Increased ICP
 Management of renal
insufficiency
 Liver failure
Acute
 Chronic


Care of the liver transplant patient
 Massive bleeding and
transfusion
 Nutrition
 Infectious diseases
Microbiology
 Antimicrobials

 Shock
Evaluation
 Management

Practice-based Learning
 By appraising and assimilating scientific evidence,
residents must be able to investigate, evaluate and
improve their patient care practices. The resident will be
able to:
 Locate, appraise and assimilate evidence from scientific studies
that are relevant to their patients' health problems;
 Use evidence-based medicine methodology to ascertain the utility
and effectiveness of certain diagnostic tests and therapeutic
strategies in the care of their patients;
 Use information technology to manage information, access on-line
medical information and support their own education;
 Assist in the teaching of CA-2 residents, medical students and
allied health personnel.
Communication
 Residents must be able to demonstrate interpersonal and
communication skills that result in effective exchange of
information and provide a framework for the development
of a cohesive critical care team. Residents are expected
to:
 Create and sustain a therapeutic and ethically sound relationship
with their patients;
 Use effective communication techniques to provide and elicit
information:
o Efficient and effective presentations during daily rounds;
o Timely, complete and legible progress and procedure notes;
o Effective dissemination of information to consultants and allied health
care providers
o Providing updates to family members;
o As part of the CCM team, discuss end-of-life issues with families
Professionalism
 Residents must demonstrate a commitment to completing
their professional responsibilities, adhering to ethical
principles and being sensitive to a diverse patient population.
Residents are expected to demonstrate:
 Respect, compassion and integrity;
 Responsiveness to the needs of patients and society that
supersedes self-interest
 Accountability to patients, society and the profession;
 Commitment to excellence;
 On-going professional development;
 Commitment of ethical principles:
o Provision/withholding of care;
o Patient confidentiality;
o Informed consent;
o Business practices
 Sensitivity and responsiveness to patients' age, culture, gender
and disabilities.
System-based Practice
 Residents must demonstrate an awareness of and
responsiveness to the larger context and system of health
care and the ability to effectively call on system resources
to provide care that is of optimal value. Residents are
expected to:
 Understand how their patient care and other professional
practices affect other health care, the health care organization
and the larger society and how these elements of the system
affect their own practice;
 Practice cost-effective health care and resource allocation that
does not compromise quality of care;
 Advocate for quality patient care and safety;
 Know how to partner with health care managers and providers
to assess, co-ordinate and improve health care and know how
these activities can affect system performance.
Educational Goals
 80 hour work week must be adhered w/o exception
 Didactic activities: lectures 7:00-8:00 Tuesdays
and Thursdays only!
 Anesthesia (first week)
 Trauma (second week)
 Neuro Critical Care (third week)
 Resident Lecture
 Multidisciplinary critical care conferences 4pm on
Wednesdays
 Patient bedside teaching rounds: Friday at 1PM
Educational Goals
 Evaluation and Feedback:
 Monthly evaluation by attendings
 Evaluation by selected nurses & Affiliate
Practitioners
 Evaluation of each attending by
residents
 Evaluation of rotation
 Work hour documentation
Resident “Call Out ” Procedure
Anesthesia
1.
2.
3.
Resident attempts to cover
with fellow residents
Failing#1: resident notifies
Administrative Chief and
Clinical Director
Failing #1 & #2: Program
Director is notified
Emergency Medicine
Resident calls their
administrative Chief, who
then arranges coverage
Surgery
Resident attempts to
cover with fellow
residents: switches, etc.
2. Failing #1: Resident
notifies Surgery Chief
Resident on-call at that
campus. He/she gauges
impact and acts
accordingly
3. Failing #1 & #2: Chief
Resident notifies Dr.
Anne Larkin to decide if
other resources needed
1.
SICU Team
 ICU Attendings: Rotate weekly Monday through
Sunday
 ICU Fellow - intermittently
 E ICU
 After 6pm review all new admissions
 Nocturnal bed triage
 Affiliate Practitioners
 SICU
 Neuro Critical Care
 Pharm D
 PA Residents
 Students – Medical, NP, PA
eICU
 24 hour Intensivist and Affiliate
Practitioner to assist with patient
management
 Present all nocturnal (19:00-07:00)
admissions to eICU attending
 Review unexpected patient
deterioration
 Remember: covering Intensivist may
need to know also!
Work Flow
 Get sign out from previous shift
 Pre round on pts
NOTE: Vascular Rounds in 3ICU at 0630 AM
 AM lecture
 Finish pre-rounding
 Round with attending, team
 Verify, allocate the work to be done
 Do the work
 Afternoon Rounds
 Sign out
Lectures / Reading List
 Morning conference includes post-call resident
 7:00 – 8:00 Tuesdays and Thursdays: L2
 Residents responsible for one lecture per
month (last week)
 End of month written test
 Critical care conference: Wednesdays at 4pm
(anesthesia conference room)
 Reading list: select chapters in Irwin & Rippe’s
“Manual of Intensive Care Medicine” (2010)
Rounds
 Vascular rounds in 3ICU at 6:30 AM
 Weekend/holidays rounds 8:00
 Top priorities:
 A good exam
 Know what has happened in past 12 hours
 Review studies
 We can make plan as a group and note can
be completed later
Upon Completion of Rounds:
 SICU team gathers to run list
 Ensures we’re all on same page
 Delegate tasks
 Assign procedures
 First - Call consults
 Arrange procedures
 Sit-down rounds with SICU attending 4-5pm
Admissions:
 All admissions accepted by Attending only
 All admission cleared through eICU
 eICU calls unit ATTENDING for acceptance
 Must present all admits to eICU attending after hours
 All admission orders reviewed by ICU resident/mid-
level; changes made as needed
 See patients in PACU as soon as notified of arrival
 Attending decides which unit covers SICU patients
in PACU (if necessary)
 Notify EICU of admissions - can put in pre-admit
bed so note can be started prior to pt arrival
Discharges:
 Discharges out of SICU determined by
Attending/Surgery team
 Delay in transfer d/t bed availability requires re-
evaluation prior to transfer
 All patients that have been in SICU > 48 hours
will need dictated transfer summary (exception:
trauma patients)
 Receiving teams write transfer orders.
When this can not be completed in a timely
fashion holding orders can be written.
Deaths
 Before making CMO notify NEOB
 Notify family and attending
 Review what needs to be called to Medical Examiner
 Review new Brain death criteria on intranet
 Final note in chart
 Circumstances of death
 Death summary dictation (trauma does their own)
 Pronouncement and time of death: Mid-levels can pronounce
but can’t sign death certificate
Printing SICU List “TEAMNOTES”
 Salar “TeamNotes”
 Update daily : add new patients
Daily SICU Notes
 Start notes after 1pm in VISICU
 Update as needed and at 4am: preround
information inserted
 Separate event notes and notes for line
insertion/procedures as well as a postop
check
 Notes saved as open draft until ready to
sign/print. Notes expire after 24 hours
SICU Routine Orders
 Stress ulcer prophylaxis
 Restraint orders
 TPN
 CWAS
 Sedation protocol with daily holiday
 Ventilator wean protocol
 Low tidal volume protocol
 Glycemic protocol: All patients except
pancreatic transplants or HHNK or DKA
SICU Routine Orders: Writing Orders
VISICU: Orders-Create

Standard Order : free text

Medication: pick list/formulary

Add /Stop

Formulary
USE IT !!
o Allergy checking
o Med Compatibility checking
o Visible to nurse/Pharm D


Other
Hardcopy of Verbal order
Not available
With
“free texting”
SICU Procedures
 Informed consent for elective
 Inform Intensivist !!
 Nurse in room and time-out
 Radial arterial lines only:
Gloves/mask/cap
 Central lines : Chlorhexadine prep and
full barrier precautions
 Procedure note after
all procedures
(no matter how they turned out)
General Responsibilities
 Discharges to home are the exception
 PDI in Soarian
 Dictations
 Prescriptions
 Night duties
 Restraint forms
 TPN started – not faxed – attendings to
review prior to faxing
 Dictate patients every 14 days
 Dictate prior to moving to other ICU or off
service (except traumas)
Critical Care Clinical Practice
Guidelines
 Developed by dedicated team of critical
care providers at UMMHC
 Evidenced based
 Available on intranet under
CCOC
 Includes specific order sheets
CPG’s include:
 Transfusion “trigger”
 ARDS/ALI
 Sepsis
 Hypothermia s/p VF arrest
 Analgesia and sedation
 Ventilator Weaning
 VAP: prevention of
 Glycemic Control
 Electrolyte replacement
Blood Transfusion Threshold CPG
 Conservative transfusion trigger in
euvolemic, non-bleeding, critically ill
patient is proven superior regarding
hospital mortality, pulmonary and cardiac
complications
 Applies to all critically ill patients @
UMMMC except:
 Actively bleeding
 Post/pre-op resuscitations
 Pregnant patients
 NICU patients
Transfusion CPG
 Transfusion trigger: Hgb < 7gm/dl
 Subgroup patient populations
 Transfusions require attending approval
unless patient actively bleeding
 Consider repeat Hgb/Hct if there have not
been any sign or symptoms
 Transfuse 1 unit RBC at time unless
bleeding.
Transfusion Surgical/Trauma
 Post-op patient Hgb BID goal Hg 8mg/dl
 If not adequately resuscitated transfuse to
Hg 10 mg/dl
Transfusion: Surgical/Trauma
 Consider patient’s operative state:
 Pre-op
 Post-op
 Non-op
 Consider adequacy of resuscitation
 Acid-base balance
 Hemodynamic stability
o CI > 2.2; FtC 350; CV02 > or equal 70%
o No or decreasing vasopressor requirements
o No unexplained tachycardia
o Restoration UOP > .5ml/kg
Transfusion: Acute Coronary Syndrome
 Transfusion trigger Hct < 25
 Patients > 65 years old may transfuse at a
HIGHER Hct at discretion of attending
 Remember: a “troponin leak” is
NOT ACS
Transfusion: Sepsis
 Early Severe Sepsis: must meet all
criteria:
o Suspected/confirmed infection
o 2/4 SIRS criteria
o SBP < or equal to 90 or lactate > 4
o Sv02 < or equal to 70% after CVP > 8
and MAP > or equal to 65mmHg
Transfusion: Renal Failure
 Patients who are requiring RRT either chronic
or acute
 Transfusion trigger Hgb < 9 at the discretion
of nephrologist/intensivist
Transfusion: SAH
 Subarachnoid hemorrhage with active
vasospasm
 Transfusion trigger < 7
 There is evidence to support a more
liberal threshold Hgb 10 in severe
spasm: this is at discretion of the
neurointensivist
Use of Erythropoietin
 Most recent studies do not support routine
use of erythropoietin
 Exception is patient with chronic renal failure
on hemodialysis
Sepsis CPG
 In USA, severe sepsis/septic shock effects >
750,000 with overall mortality 29%
 A systematic and organized approach to
early goal directed therapy to be provided to
all our adult patients with sepsis
 Goal: early identification and use of sepsis
packet with antibiotics within 3 hours in ED
and 1 hour in ICU
Sepsis CPG
 Key elements:
 Central access within 2 hours for
CVP/fluid/CV02 monitoring
 Ultimate goal to be achieved within first
6 hours:
o CVP 8-15
o CV02 > or equal to 70%
o MAP 65-110
o Lactate < 4
Antibiotics
 Review restricted antibiotics
 VAP treatment based on ATS and IDSA
guidelines: MRSA and GNR
 Vanco trough for MRSA PNA 15-20
 Coverage for pseudomonas PNA with pip/tazo
or cefepime and tobramycin or quinolone (5
days)
 1st dose of any antibiotic can be given stat w/o
ID approval
 De-escalate once cultures back
Central Venous and Arterial Catheter
Management
 Mandatory education on E Learning
 Standardized line carts
 2nd person present during insertion to
assist/monitor and halt procedure if necessary:
ensure Intensivist aware!
 Standard catheter dressings
 Standard documentation
 Need for lines reassessed daily on rounds
 DC “high risk” lines ASAP
Therapeutic Hypothermia for
Comatose Survivors of Cardiac Arrest
 Intubation
 Sedation/analgesia
 Consider paralysis to prevent shivering
 Supportive measures
 Induce hypothermia to 32-34 degrees
within 2 hrs and continue total 24 hrs
 Evaluate and address potential medical
problems
 Address family concerns
Pain Management
 Fentanyl drug of choice
 Hydromorphone or fentanyl with renal insufficiency
 Rarely use propofol w/o pain control
 No systemic narcotics with epidural unless instructed
by anesthesia service managing epidural
 Rarely use narcotic/sedative gtts after extubation,
but must be reordered
 Consider ketorolac if no significant bleeding
concerns and normal renal function (48 hours only)
Sedation Protocol CPG
 Standardized monitoring of pain,
agitation and delirium in mechanically
intubated patients
 Excludes patients receiving
neuromuscular blockade and induced
coma for ICP control
 Standard order form to be completed
include RASS goal and frequency
Sedation Protocol
 Sedation holiday performed daily on all
patients unless contraindicated
 Restart analgesic/sedation at 50% dose if
agitated
 Delirium assessment daily (CAM-ICU)
Sedation Protocol
 Fentanyl preferred analgesic in
hemodynamically unstable or severe renal
impairment
 Remember to include bowel regimen
 Consider tolerance/withdrawal issues in
patients with heavy opioid requirements
and those on narcotic/sedation for a
week or more who are at risk for
withdrawal
Paralytics
 Requires critical care Attending or fellow
approval
 Must use SICU NMB protocol order sheet
 Patient must be heavily sedated and have
adequate pain control
 Avoid if also receiving immunosuppresive
doses steroids
ARDS/ALI - Low Tidal Volume
CPG
 Institution-wide guidelines for adults with
ARDS/ALI includes Order Sheet
 Multiple randomized control studies
demonstrate use of lower TV in ARDS/ALI
 Decreased mortality with use of 6ml/kg TV
(IBW)
Ventilator Weaning CPG
 Applies to any patient intubated for >48 hours
 RRT to discuss with SCIU team who shall be
weaned
 Patients to consider weaning
 Evidence of some reversable of cause of respiratory







failure
Pa02/Fi02 > 150
PEEP < 8
Fi02 < 0.5
Arterial pH 7.3 - 7.5
No evidence of active cardiac ischemia
Hemodynamic stability
Some indication of inspiratory effort
Weaning Protocol
 If patient fails weaning evaluate barriers to
weaning
 Cardiac ischemia / LV dysfunction
 Volume overload
 Pulmonary / systemic infection
 Malnutrition
 Neurologic dysfunction including over sedation
 Pain / anxiety
 Pre-existing pulmonary disease
 Inappropriate ETT size
 Electrolyte abnormalities
 Thyroid disease
Weaning Protocol
 Daily worksheet done by RRT
 Spontaneous breathing trial with CPAP 5 to 8 cm
H2O of PEEP
 If CPAP successful for 2 hours evaluate for
extubation
 Termination of SBT
 New onset diaphoresis / arrhythmias
 SBP > 180 or > 20% increase baseline
 HR > 120 or > 30 from baseline
 Sa02 < 90% or Fi02 > .6
 If ABG obtained: pH < 7.3; paO2 < 60; sa02 < 90% or
pC02 > 10 above baseline
VAP CPG
 Preventable cause of morbidity/mortality and excess cost
in ICUs
 Steps in Prevention
 HOB elevation to 30 degrees unless contraindicated
 Oral intubation
 OGT
 Rapid extubation as able and adherence to weaning






protocol
Sedation protocol
Minimization of self-extubation
Prevention gastric over distention by checking residuals
q 4 hours
Oral hygiene with chlorhexidine @ least q 8 hours
Vaccinate for influenza/pneumococcus
Avoid contamination respiratory circuit
Venous Thromboembolism CPG
 All patients to receive prophylaxis unless
contraindicated (i.e. bleeding or head injury /
hemorrhage)
 Chemical prophylaxis preferred over mechanical
 Enoxaparin
o 40mg daily
o 30mg BID
o Unfractionated heparin in patients with somewhat elevated
risk bleeding or creat clearance < 30. Smaller doses can be
used. Higher doses for morbidly obese
o SCD to be utilized unless contraindicated
o In case of inadequate prophylaxis of 3 or more days in high
risk surgical/trauma patients doppler screening LE
o Consider IVC filter if unable to adequately prophylax high
risk patient
Glycemic Control CPG
 To ensure safe and effective management of
tight glycemic control
 Goal 80-140 mg/dl
 All ICU patients placed on glycemic control
protocol and BS monitored for effectiveness
 Evaluate for transition to sliding scale/long
acting insulin coverage
 PO diet
 Clinical condition stabilizes
 Stable insulin gtt dose
 Stable caloric intake
 Approaching transfer
Increased ICP CPG
Six step process
1. Assess at-risk population
2. Assess for hyperosmolar therapy
3. Initiate hyperosmolar therapy
4. Deep Sedation
5. Pharmacologic coma
6. Paralysis
Always
Consider
Need
For
Surgery
Therapeutic Hypothermia for Comatose
Survivors of Cardiac Arrest
 2005 AHA Guidelines indicate instituting
mild hypothermia improves neurologic
outcome
 Scope: All patients 18 and older who remain
comatose post-VF cardiac arrest, with return
of pulse pressure
 Excluded: major head trauma, recent major
surgery, sepsis, bleeding, pregnancy
Pressure Ulcer Care CPG
 PREVENTION including ordering air
mattress/specialty bed on high risk patients
 Daily skin assessment with report to clinical
staff by nursing with weekly PU reports
 Education for residents, midlevels and
nursing staff
Pressure Ulcer Care CPG
 1.3 to 3 million adults affected with
incidence of up to 38% hospitalized
patients
 Aim is to reduce/eliminate hospital
acquired pressure ulcers
 Pressure Ulcer Risk/Assessment
completed with 24 hours of admission
(Braden Scale)
 Ongoing skin assessment on ECare
Manager Flow Sheet
SICU Rotation:
 Is a GREAT learning opportunity
 Has GREAT Faculty
 Has GREAT NP/PA support
 Is only what you make of it
Intellectual Curiosity