The night and weekend call staffing consists of one Medicine PGY-2 and one Medicine PGY-1. The night team consisting of fellows and residents does bedside and order rounds between 6:00 AM and 7:00 AM everyday. The rounds start at 8:00 AM on weekdays and weekends immediately following the daily 7:00 AM Critical Care Service report.
Evening sign-out for Attendings is usually held between 5:30 PM and 6:30 PM, and the daytime Fellows usually leave at 7:00 PM. The night call for fellows follows the night float pattern which garantees reduced fatigue and reduced continuity.
This unit is a model of a university hospital teaching unit in a tertiary referral academic center. In addition to clinical exposure and teaching, fellows will participate in clinical research for study patients admitted or transferred to this unit, development of database and upgrading of computer skills on equipment located in the fellow's office.
One bronchoscope and one metabolic cart are allocated to the MICU; fluoroscopy access is through the adjacent CCU and in the last two beds. An advanced computerized lung mechanics cart is available. The fellow's office/conference room in the unit contains a library, computer system for medical literature search and other necessary educational materials.
Goals and Objectives
The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with medical critical illness in the setting of a tertiary referral voluntary hospital.
The principle teaching method is thorough case management of all patients including history, physical exam, and interpretation of laboratory tests and cardiorespiratory physiology data.
Teaching rounds, unit based conferences for both clinical and administrative management, increased involvement in house staff instruction, and mastery of technical aspects of major required procedures are mandatory. Fellows are required to prepare for teaching rounds by supplementing case based understanding with review of major textbooks and current peer reviewed literature.
Fellows are required to attend all curriculum conferences, and competently prepare their presentations under faculty supervision while on this rotation. Faculty will provide supervision to fellows on site 24/7 every day.
Objective: Instruct the fellow in managing a closed university hospital medical ICU with a large training program.
- PATIENT CARE: competent management of a university hospital medical intensive care unit
- MEDICAL KNOWLEDGE: state-of-the-art diagnostic and therapeutic knowledge
- PROFESSIONALISM: ethical and compassionate care delivery
- INTERPERSONAL SKILLS: highly effective interpersonal communication
- PRACTICE BASED LEARNING AND IMPROVEMENT: data collection and analysis to allow of continuous quality improvement in designated focused areas
- SYSTEMS-BASED PRACTICE: highly competitive and effective delivery of academic medical intensive care
- Ashbaugh DG, Bigelow DB, Petty TL, et al. Acute respiratory distress in adults. Lancet 1967;2:319-323. Original description of ARDS and use of PEEP in treating ARDS.
- ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for ALI and ARDS. NEJM 2000;342:1301-8. Results of ARMA study are basis for low- stretch/low tidal volume ventilation strategy.
- Eichacker PQ, Gerstenberger EP, Banks SM, et al. Meta-analysis of ALI and ARDS trials testing low tidal volumes. AJRCCM 2002;166:1510-14. In this highly controversial analysis, the authors question the validity of the ARDS network study above, arguing that 1) the mortality benefit resulted from excess mortality in the traditional arm, 2) the traditional arm did not receive the standard of care (authors argue the traditional arm received excessively large tidal volumes), and 3) very low tidal volumes are harmful. See links to commentary for rebuttals to all of these points.
- Amato MBP, Barbas CSV, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in ARDS. NEJM 1998;338:347-54. Small, randomized, study famous for using a combination of the lower inflection point of the pressure-volume curve to set PEEP, recruitment maneuvers (CPAP 35-40 cm x 40 sec.), and low-tidal volumes (< 6cc/kg). 28-day mortality was lower in the intervention group, but the conventional group had an unusually high mortality (71%). Patients overall received higher PEEP than in the ARMA study.
- Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical risks for development of ARDS. AJRCCM 1995;151:293-301. Study describes the incidence of ARDS in patients with various clinical risk factors. Also found 1) greater mortality in at-risk patients that develop ARDS and 2) ARDS develops within 48 to 72 hours of the time clinical risk is identified in the vast majority of patients.
- Davidson TA, Caldwell ES, Curtis JR, et al. Reduced quality of life in survivors of ARDS compared with critically ill control patients. JAMA 1999;281:354-60. One of the first studies to look at quality of life of ARDS survivors. It found decreased quality of life Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of COPD. NEJM 1999;340:1941-7. Multicenter, double-blind, placebo- controlled study found modest benefit to use of high-dose intravenous steroids. Steroid group had fewer treatment failures (combined endpoint of death, need for intubation, readmission, or intensification of pharmacologic therapy), and shorter hospital stays, but the primary benefit was in decreasing the need to intensify therapy with use of open-label steroids. No benefit from steroids was present at 6 months of f/u, and 2 week and 8 week courses were equally effective. related to severity and complications of ARDS, rather than duration of mechanical ventilation or hospital stay, compared to matched, critically-ill control patients.
- Anthonisen NR, Manfreda J, Warren CPW et al. Antibiotic therapy in exacerbations of COPD. Ann Intern Med 1987;106:196-204. Famous study often cited by proponents of antibiotic use for COPD exacerbations. Randomized, blinded, controlled study found use of antibiotics in the presence of increased dyspnea,
- increased sputum production, and increased sputum purulence improved outcomes. The improvement was no longer significant, however, after controlling for use of oral steroids.
- Poppas A, Rounds S. Congestive heart failure. AJRCCM 2002;165:4-8. Useful, succinct summary of CHF management in the ICU.
- Luce JM. Making decisions about the forgoing of life-sustaining therapy. AJRCCM 1997;156:1715-8. Commentary that summarizes much of the recent research in this area. Emphasizes the need to reaffirm patient autonomy and to be cautious in the use of "futility" as a reason to withdraw care. Truog RD, Cist AFM, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001;29:2332-48. Recommendations for clinical care of dying patients in the ICU derived from data and expert opinion.
- Van Den Berghe, Wouters P, Weekers F, et al. NEJM 2001;345:1359-1377. Landmark RCT found patients in a surgical intensive care unit receiving intensive insulin therapy (blood glucose 80-110 mg/dl) had improved ICU mortality (4.6% vs. 8% in conventional group). Although the study was performed in an SICU population, patients in the ICU > 5 days and patients with multiple-organ failure related to sepsis showed the greatest benefit, suggesting the results may be applicable to the MICU.
- Annane D, Sebile V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288;862-71. Placebo-controlled RCT of 300 septic patients found the subgroup of patients failing to respond to a 250 mccg corticotropin test but receiving 50mg HC q6 and 50mcg fludrocortisone qd had significantly reduced morality compared to the non-responders given placebo (53% vs. 63%). No benefit was seen in giving steroid to corticotropin-responsive patients.
- Marik P Zaloga G. Adrenal insufficiency in the critically ill. A new look at an old problem. Chest. 2002;122:1784-96. Includes discussion of poor sensitivity of tests for adrenal insufficiency and argues for a greater role in random cortisol levels in making diagnosis. See also Marik PE, Zaloga GP. Crit Care Med 2003;31:141-5.
- Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. NEJM 1994;330:377-81. Study found coagulopathy and respiratory failure were the two primary risk factors for clinically important bleeding (3.7% risk if any risk factor present). Use of enteral feeding was not protective. Some high-risk patients (burns, recent diagnosis of PUD etc.) received prophylaxis.
- Hebert P, Wells G, Blajchmann M, et al. A multicenter randomized controlled clinical trial of transfusion requirements in critical care. NEJM 1999;340:409-17. Study found that the transfusion threshold of 10gm/dl may be inappropriately high in patients without cardiovascular disease.
- Corwin HL, Gettinger A, Pearl RG, et al. Efficacy of recombinant human erythropoietin in critically ill patients. JAMA 2002;288:2827-35. Placebo-controlled RCT of 1300 critically-ill patients found weekly administration of 40,000U of recombinant human EPO resulted in a 19% reduction in total units of RBC transfused. No difference seen in morbidity or mortality and the authors estimate EPO cost about $700 more per patient than transfusion. Lack of use of 7gm/dl HgB threshold for transfusion in this study makes relevance of results questionable.
- Marrero J, Martinez FJ, Hyzy R. Advances in critical care hepatology. AJRCCM 2003;168:1421-6. Excellent concise review of the evaluation and management of fulminant hepatic failure, ascites, hepatorenal syndrome, hepatic encephalopathy, and hepatic dysfunction in sepsis.
- Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. NEJM 1999;341:403-9. RCT found addition of albumin to cefotaxime vs. antibiotic alone in above population preserved renal function and reduced mortality. Study does not provide information on volume resuscitation in the antibiotic-alone group, however, making it less clear whether albumin has additional benefit beyond what could be achieved with aggressive IVF.
- Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996;276:889-897. This famous prospective cohort study found worse outcome with use of PACs in the critically ill, instantly becoming a source of enormous controversy.
- Marik PE. The diagnosis and management of hypertensive crises. CHEST 2000;118:214- 27. Excellent review of the topic.
- Marini JJ, Pierson DJ, and Hudson LD. Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy. Amer Rev Resp Dis 1979;119:971-8. This could be useful in fending off suck bronchs. Study found FOB followed by RT no better than RT alone at 24-48 hours.
- Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. NEJM 1996;335:1864-9. RCT found protocol of daily weaning parameters followed by trials of spontaneous breathing in appropriate patients and subsequent notification of physicians of successful trials reduced the duration of mechanical ventilation compared to usual care (daily weaning parameters only).
- Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. NEJM 1995;332:345-50. Prospective, randomized study found once-daily or multiple daily trials of spontaneous breathing (T-piece or CPAP <5 cm) resulted in more rapid successful extubation than gradual weaning of pressure support or IMV.
- Murray P, Hall J. Renal replacement therapy for acute renal failure. AJRCCM 2000;162:777-81. Concise review of continuous vs. intermittent use of hemodialysis, ultrafiltration, and hemofiltration in hemodynamically stable and unstable patients with ARF.
- Tepel M, van der Giet M, Scwarzfeld C, et al. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. NEJM 2000;343:180-4. Randomized trial comparing IVF to IVF plus acetylcysteine found significantly fewer patients with stable CRI had significant bumps in Cr at 48 hrs in the intervention group. There were no significant differences in clinical outcomes; role in acute renal failure not known.
- Siegal RE, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate. JAMA 2004;292(12): 1428.
- Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomized trial. ANZICS Clinical Trials Study Group Lancet 2000;356:2139-43. 324 patients with at least 2 criteria for SIRS and evidence of early renal dysfunction were randomized to 2 mcg/kg/min dopamine or placebo. Dopamine did not attenuate elevation in creatinine, reduce the need for dialysis, shorten ICU and hospital stays, or decrease mortality.
- Levy DE, Caronna JJ, Singer BH, et al. Predicting outcome from hypoxic-ischemia coma. JAMA 1985;253:1420-6. Oft-cited landmark study of the prognostic information provided by physical examination.
- Zanbergen EGJ, de Haan RJ, Stoutenbeek CP, et al. Systematic review of early predictors of poor outcome in anoxic-ischemic coma. Lancet 1998;352:1808-12. Focuses on the utility of physical exam, EEG, and evoked potentials in hypoxic and traumatic coma. Most studies on this topic limited by self-fulfilling nature of withdrawing support based on prognostic criteria.
- DeGans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. NEJM 2002;347;1549-56. High quality RCT including 301 patients found early administration of 10 mg dexamethasone q 6 hrs for 4 days reduced the risk of poor outcome (score of 5 vs. score of 1-4 on Glasgow Outcome Scale) [relative risk 0.59] and was associated with a relative risk of death of 0.48.
- Deem S, Lee CT, Curtis JR. Acquired neuromuscular disorders in the ICU. AJRCCM 2003;168:735-9. Succint overview of common causes of weakness associated with critical illness. There are few large prospective studies performed in this area to date.
- Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of COPD. NEJM 1995;333:817-22. Landmark prospective, randomized study found use of NIPPV in selected patients with COPD exacerbations resulted in fewer intubations, complications, days in hospital, and lower in-hospital mortality compared to standard treatment.
- Nava S, Ambrosino N, Clini E, et al. Non-invasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. Ann Intern Med 1998;128:721-8. Oft-cited RCT included 50 patients intubated for a COPD exacerbation who failed a T-piece trial. Patients randomized to immediate extubation to NIPPV had decreased duration of mechanical ventilation and improved survival compared to the control group undergoing PS wean with twice daily spontaneous breathing trials.
- Declaux C, L'Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with CPAP delivered by face mask. JAMA 2000;284:2352-60. Prospective, randomized, multicenter study compared oxygen to oxygen plus CPAP in this population (123 patients;17% cardiac etiology, 83% ALI). Study found no difference in the need for intubation, lenghth of hospital stay, or hospital mortality, and the CPAP group had an increased incidence of adverse events.
- Antonelli M, Conti G, Rocco M, et al. A comparison on NIPPV and conventional mechanical ventilation in patients with acute respiratory failure. NEJM 1998;339:429-35. Randomized study compared NIPPV with immediate intubation and conventional ventilation in 64 patients with acute, non-hypercapnic, hypoxemic respiratory failure (19% cardiogenic and 25% ARDS). Use of NIPPV resulted in gas exchange and survival
- comparable to conventional ventilation but was associated with fewer serious complications and shorter ICU stays.
- Nava S, Carbone G, DiBattista, N, et al. Non-invasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. AJRCCM 2003;168:1432-7. This larger study (130 patients) found non-invasive pressure support did not improve outcomes compared to conventional therapy. Mask ventilation reduced intubations in the 64 patients with PaCO2 > 45 mmHg (6% vs. 29%), but this difference was not significant after regression analysis.
- Lapinsky SE, Kruczynski K, Slutsky AS. State of the art: Critical care in the pregnant patient. AJRCCM 1995;152:427-55. Comprehensive review covering the normal physiologic changes that occur with pregnancy, fetal monitoring, fetal risk of radiologic procedures, drug therapy, and critical illness specific and not specific to obstetrics.
- Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132:641-8. Study found a course on central venous catheter placement for residents emphasizing the use of full-size drapes reduced catheter-related infections. This article is a motivator to teach housestaff to do the job right when the unit gets busy and there is the temptation to cut corners.
- Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the management of intravascular catheter- related infections. Clin Infect Dis 2001;32:1249-72. Comprehensive, reader-friendly.
- PIOPED Investigators. Value of the ventilation/perfusion scan in pulmonary embolism: results of the PIOPED. JAMA 1990;263:2753-2759. This ubiquitously-cited study found that VQ scans are useful when they are high probability and normal, but that most of the time PE can't be ruled in or out by VQ scan. Includes a useful table comparing clinical suspicion and VQ scan result relative to PA gram result.
- Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997-1005. Study used a "minimally invasive" approach to managing patients with suspected PE, emphasizing use of serial dopplers rather than PA grams in patients with a non-diagnostic initial work-up. Approach is comparable to the 1999 ATS guidelines; it does not include CT angiography. A particular strength of the study was the use of set criteria to establish clinical suspicion.
- Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001;135:98-107. Large prospective cohort study using the SimpliRED d-dimer assay (which has sensitivity lower than, and specificity higher than, most other d-dimer tests) found the combination of a low clinical suspicion for PE and a negative d-dimer safely ruled out pulmonary embolism without additional testing.
- Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical CT in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med 2000;132:227-32. This systematic review concluded 1) the methodology of published studies is poor. 2) compared to pulmonary angiography, sensitivity of helical CT ranged between 53 and 100% and specificity 81 to 100%. 3) studies had limited follow-up of patients with a negative CT. 4) CT can provide alternative diagnosis in up to 33% of cases. 5) abnormal scans effectively rule in P.E.
- Konstantinides S, Geibel A, Heusel G, et al. Heparin plus altepase compared with heparin alone in patients with submassive pulmonary embolism. NEJM 2002;347:1143-50. Randomized, double-blind study found lytic therapy in submassive PE did not improve mortality. Patients randomized to lytics were significantly less likely than the placebo group to require escalation of therapy, which primarily entailed administration of lytics. The indication for rescue therapy was worsening respiratory symptoms, short of intubation, two-thirds of the time.
- Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-77. Excellent review of the data available on each of the commonly placed filters, including efficacy and rate of complications. A more recent update on the use of retrievable filters is needed. The author notes the paucity of randomized trials and lack of long-term follow-up in existing studies, addresses the controversies surrounding caval filters, and offers recommendations.
- Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal DVT. NEJM 1998;338:409-15. This is the only randomized trial involving filters. All patients were aniticoagulated and LMW and unfractionated heparin were equally effective. 4.8% of patients receiving anticoagulation alone had PE vs. 1.1% in filter + anticoagulation group at
- study day 12. There was no difference in rate of PE after anticoagulation was discontinued, but the filter group had significantly more recurrent DVT.
- Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. AJRCCM 2003;167:735-40. The cardiology literature indicates echocardiography-derived estimates of pulmonary artery pressures are accurate. This study found 52% of echo estimates were inaccurate (off by > 10 mmHg) in 166 lung transplant candidates and the difference was > 20 mmHg in 28%. In patients without hypertension, echo was more likely to overestimate pressures while in patients with pulmonary hypertension, it was as likely to over as underestimate. Accuracy and ability to obtain an estimate varied with the underlying disease.
- Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill patient. Crit Care Med 2002;30:119-41. Combines expert opinion and literature review to make updated recommendations.
- Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. NEJM 2000;342:1471-7. RCT found daily interruption of sedation in a MICU population resulted in shorter duration of mechanical ventilation and ICU stay, less total dose of sedation, and less use of diagnostic tests to work-up impaired mental status compared to the control group. No increase in short term adverse outcomes in the intervention group identified but patients were not evaluated for subtle or long term adverse outcomes.
- Kollef MH, Levy NT, Ahrens TS, et al. Use of continuous vs. bolus IV sedation. Chest 1998;114:541-8. Surveillance study of 157 patients on ventilator found bolus sedation resulted in shorter duration of mechanical ventilation, and ICU and hospital stays.
- Bernard GR, Vincent JL, Laterre PE, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. NEJM 2001;344:699-709. Large, phase III multicenter RCT found patients randomized to APC had an absolute mortality reduction of 6%, but may have a greater risk of bleeding.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368-77. This RCT of 263 patients found benefit from early (in E.D.) aggressive resuscitation (in-hospital mortality of 30% in the goal-directed group compared to 46% in the standard therapy group). The intervention arm was noteworthy for prn use of blood transfusion and/or intotropes to maintain central venous O2 sat >70%. Authors speculate the earlier aggressiveness accounts for better outcomes than previous studies of goal-directed hemodynamic optimization.
- management of suspected ventilator-associated pneumonia. Ann Intern Med 2000;132:621-30. Randomized study found use of BAL or PSB to dictate antibiotic treatment in suspected VAP resulted in lower mortality at 14 days and less antibiotic use compared to standard approach of clinical impression coupled with endotracheal aspirates. Initiation of antibiotic treatment for VAP was withheld until after obtaining specimens and antibiotics were stopped if cultures were negative.
- Kirtland SH, Corley DE, Winterbauer RH, et al. The diagnosis of VAP: a comparison of histologic, microbiologic, and clinical criteria. CHEST 1997;112:445-57. Study with a similar design to the Chastre study but without restrictions on use of antibiotics or recent pneumonia. Authors found poor correlation between histologic findings and quantitative cultures from bronch specimens. Tracheal aspirates were 87% sensitive but 31% specific compared to biopsy culture. A sterile BAL had a PPV of 91% for sterile lung parenchyma.
- Kollef MH. The prevention of ventilator-associated pneumonia. NEJM 1999;340:627-634. Makes recommendations for or against known preventive strategies and grades the quality of data supporting each intervention.
- Drakulovic MB, Torres A, Bauer TT, et al. Semirecumbancy to prevent VAP. Lancet 1999;354:1851-8. Study found supine position is an independent risk factor for VAP and positioning at 45 reduces the risk, especially if patient receiving tube feeds.
- Gooch JL, Suchyta MR, Balbierz JM, et al: Prolonged paralysis after treatment with neuromuscular junction blocking agents. Crit Care Med 19:1125, 1991.