I. INTENSIVE CARE UNIT TRAINING PROGRAM
LEARNING OBJECTIVES FOR ROTATING ICU RESIDENT
An 8 week rotation in the ICU is intended to provide residents in Medicine, Surgery, Anesthesia,
Emergency Medicine, and Family Medicine with experience in the evaluation and initial
management of critically ill patients. We encourage you to identify specific learning objectives for
yourself, and bring them to our attention. We expect that you will achieve the following specific
educational objectives.
At the end of this rotation you will be able to:
1. Use a question/hypothesis testing approach in diagnosis and management of patients. Use
knowledge of pathophysiology as a foundation for understanding clinical presentation and
management of patients.
2. Recognize the patient who is in shock or who has significant cardiopulmonary compromise.
Demonstrate the appropriate use of clinical information: history, physical examination, basic
laboratory and radiographic investigations to develop a reasonable differential diagnosis and
management plan for such a patient.
List the indications and contraindication for invasive hemodynamic monitoring.
Provide central venous access from the internal jugular, subclavian and femoral veins, and
arterial access from the radial and femoral arteries.
Place and use a pulmonary arterial catheter to obtain cardiac output, intracardiac pressures,
and venous oxygen content analysis.
Demonstrate the use of this information to modify hemodynamic function and treat shock
states using appropriate fluids and vasoactive drugs (including dopamine, dobutamine,
nitroglycerin, nitroprusside and noradrenaline).
3. Identify the patient who has respiratory failure.
Demonstrate the appropriate use of clinical information: history, physical, radiographic and
laboratory to develop a reasonable differential diagnosis and initial management plan for
such a patient.
Use and recommend oxygen delivery devices appropriately (nasal prongs, low and high-flow
masks).
Provide effective bag-mask ventilation.
Describe and identify the indications for intubation and mechanical ventilation.
Describe and contrast basic modes of ventilation (assist control ventilation, pressure support
ventilation, continuous positive airway pressure, PRVC), and select ventilator settings (rate,
tidal volume, Fi02, PEEP) appropriate for specific patients. 10
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Evaluate a patient's potential for weaning and initiate a weaning program.
Demonstrate correct placement of a chest tube and evaluate its function using a closed
drainage system.
Utilize radiographs to identify the correct placement of a venous and pulmonary arterial
catheter, chest tube, pacer wire, feeding tube and endotracheal tube. Recognize major
abberations in chest radiographs including pneumothorax, lobar collapse, consolidation or
pleural effusion, and have a practical differential of common radiographic abnormalities.
Demonstrate the management of patients after major vascular, abdominal, and cardiac
surgery in discussion with the surgical services.
Demonstrate the evaluation of a patient with reduced level of consciousness, list a differential
diagnosis of coma, and outline a plan to investigate it.
Describe the principles of monitoring and manipulation of intracranial pressure and
demonstrate the application of this knowledge to the patient's care.
List the criteria for the diagnosis of brain death.
Identify and differentiate common coagulopathies including those due to factor deficiency,
liver disease, platelet deficit or dysfunction, DIC, fibrinolysis, and consequences of massive
transfusion. Use of blood products, protamine, and vitamin K appropriately.
List the common sites and organisms responsible for infections in critically ill patients.
Identify and investigate patients with suspected sepsis and select appropriate initial antibiotic
therapy.
Describe the nutritional needs of critically ill patients, recommend and monitor appropriate
nutritional support.
Correctly place and monitor venous access for TPN and feeding tubes for enteral feeds.
Describe the basic pharmacology of common sedatives, analgesics, and neuromuscular
blocking agents. Select and monitor the use of these drugs appropriately.
Describe the normal distribution of fluids and electrolytes. Demonstrate an appropriate
choice of fluid therapy for patients who have shock, cardiac, or renal failure, and after major
surgery.
Identify the patient who has significant renal dysfunction. Monitor and manage anticipated
disturbances of fluids and electrolytes, including identifying the need for urgent dialysis.
Identify, anticipate, and demonstrate the appropriate management of common electrolyte
disturbances.
Identify the patient who has a significant acid-base disturbance, and describe a reasonable
differential diagnosis and management plan.Plan the transport of a critically ill person and
demonstrate this ability in arranging the transport of such a patient to or from this centre.
Discuss the factors determining the prognosis of critically ill patients. Demonstrate this
knowledge in arriving at and discussing patient care decisions with fellow caregivers and
family members.
Describe the condition of a critically ill patient to his/her family and address their concerns in
a compassionate and therapeutic manner.
Demonstrate interacting with other physicians and health care workers in a collaborative way
to arrive at a plan for patient care.
Demonstrate knowledge of ethical principles in decision making.
Accurately communicate your diagnostic and therapeutic plans verbally and in writing in the
medical record.
Identify your own strengths and limitations, and appropriately seek guidance and
consultation.
The following is a list of topics that will be addressed during the Housestaff rotation through the
MRICU. Teaching methods will include bedside teaching and discussion on teaching rounds,
didactic instruction of an informal (freeform or chalkboard) or more formal (PowerPoint slides)
nature, discussion of important medical literature, demonstration, supervision, and performance
of procedures, textbook review, and self-study using PowerPoint slide sets, reprints of key
articles, other written and instructional materials on the computer.
1. Ethics—understand principles of advanced directives, terminal care and conflict
resolution in the context of the ICU
2. Assessment of severity of illness: understand the rationale, applications, and limitations
of severity of illness scoring systems
3. Hemodynamic monitoring: know indications, contraindications, techniques, and potential
complications for arterial catheterization, central venous catheterization, and pulmonary
artery catheterization. Be able to interpret hemodynamic data and analyze waveforms.
4. Pharmacology in the ICU: understand the basic principles of pharmacokinetics and how
organ dysfunction and critical illness can influence it. Understand the indications and
potential complications of vasopressors, ionotropes, sedatives and paralytic agents.
5. Airway management: know principles of airway management including the indications,
contraindications, techniques, and potential complications for orotracheal and
nasotracheal intubation as well as the alternatives to endotracheal intubation.
6. Mechanical ventilation including principles of positive pressure ventilation; resistance
and compliance, common modes, settings, alarms and monitors; application in ARDS;
mechanisms, risk factors, recognition and management of barotrauma and pneumothorax;
principles of weaning; indication, contraindications, techniques and potential
complications of noninvasive ventilation.
7. Arterial blood gas and pulse oximetry interpretation including techniques, limitations,
and principles of acid-base physiology and interpretation.
8. Hypoxemia and Respiratory failure—causes pathophysiology, and management of
various forms including hypoxemic and hypercapneic respiratory failure. Understands the
pathophysioligical differential diagnoses of hypoxemia and application of A-a gradient
9. ARDS—defining characteristics, causes, pathophysiology, and management.
10. Pneumonia—agents and antibiotics for severe community acquired pneumonia;
pathophysiology, manifestations, prevention, diagnostic testing and management of
ventilator-associated pneumonia.
11. Life-threatening asthma—principles of mechanical ventilation and pharmacologic
management options.
12. Shock—mechanisms of hypovolemic, maldistributive, cardiogenic and obstructive;
principles of resuscitation and monitoring; indications and characteristics for common
vasopressors and ionotropic agents.
13. Hypertensive crisis—criteria for hypertensive urgency and emergency; treatment agents
including indications, contraindications and potential adverse effects.
14. Acute renal failure—differential diagnosis, management principles, indications for
dialysis.
15. Fluid and electrolyte disorders—understand pathophysiology, manifestations of
disorders; advantages and disadvantages of crystalloid vs. colloid fluids
16. Endocrine disorders in the ICU—manifestations, diagnostic tests and management of
adrenal insufficiency, thyroid storm, hypothyroidism, and DKA.
17. Principles of enteral and parental nutrition.
18. Gastrointestinal disorders—differential diagnosis, evaluation and management of upper
and lower GI bleeding, acute pancreatitis, cirrhosis and its complications, and fulminant
hepatic failure.
19. Hematology/oncology—causes and management of bleeding disorders, including proper
use of blood products; management of neutropenic and immunocompromised patient;
complications of bone marrow transplantation and their management.
20. Nervous system disorders—causes, evaluation and management of coma, cerebrovascular
accidents, status epilepticus, delirium and other psychiatric disorders, weakness and
neuromuscular disorders. Criteria and testing for brain death. Understand the application
of post-arrest hypothermia.
21. Infectious diseases in the ICU—including principles of infection control and prevention
of nosocomial infection; spectrum of activity and potential adverse effects of
antimicrobial agents; causes and evaluation of fever in the ICU; criteria, causes,
evaluation and management of septic shock.
22. Manifestations, evaluation and management of poisoning and drug overdose.
23. Disorders of temperature control including evaluation and management of hypo- and
hyperthermia.
24. Recognition and management of acute allergic reactions, anaphylaxis, and immunecompromise disorders
How Learning Objectives are met:
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One-on-one interaction with ward attending during teaching and work rounds.
Direct patient care
Interaction with consultants and support staff
Participation in regularly scheduled MRICU core conference
Literature searches to answer clinical questions that arise on rounds or during patient
care.
6. Interaction with the interdisciplinary health care team
7. Participation in daily radiology rounds