Division of Pulmonary Medicine

Moses SICU & NICU Fellowship Rotation

Fellowship Rotation 

The objective is to train housestaff in didactic and technical aspects of management of patients with high risk for surgery and those that are critically ill perioperatively. The NCICU team works closely with the adjacent PACU and with specialty Anesthesiology Services in the adjacent OR. The STAT lab is located next to the SICU in the PACU, and provides ABG, co-oximetry, STAT electrolytes (Na/K, glucose, lactate) and coagulation measurements.

The rounds start at 6:00 AM, and evening rounds follow MICU evening rounds. On Mondays, the rounds start at 6:00AM in order for the fellows to attend the Cardiothoracic and Neurosurgery Ground Rounds. The Critical Care team covers this unit on site 24/7. The average night call for fellows on this rotation is every fourth night. The fellows are expected to acquire basic knowledge of intraoperative surgical and anesthetic management through regular visits to the operating room during this rotation. This ICU is the focus of the recently approved liver transplant program.

The most frequent diagnoses at the time of admission to the NCICU are liver transplant surgery cases, major vascular surgery such as abdominal aneurysm resection, major bowel or liver surgery, subarachnoid hemorrhage requiring clipping, and major medical complications of surgery on anesthesia. The fellows are exposed to a large variety of post-operative patients undergoing major cardiovascular and neurosurgical procedures. Patients are admitted from all areas of Montefiore Medical Center.

Goals and Objectives 

Goal:

The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with surgical critical illness.

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.

Fellows are required to attend the Surgery or Neurosurgery Grand Rounds held on Monday morning at 7:00 AM when on this rotation.

Faculty will provide supervision to fellows on site 24/7 every day.

Objectives:

To instruct the fellows in the basic skills to staff and direct a general surgical and neurosurgical intensive care unit in a university hospital setting.

To develop a clinical training program in liver transplant during the 2004-5 year.

  • PATIENT CARE: competent management of a university hospital surgical and neurosurgical intensive care unit
  • MEDICAL KNOWLEDGE: state-of-the-art diagnostic and therapeutic applied knowledge
  • PROFESSIONALISM: ethical and compassionate care delivery in a collaborative practice model
  • INTERPERSONAL SKILLS: highly effective interpersonal communication focused on best practice model under intensivist leadership
  • PRACTICE BASED LEARNING AND IMPROVEMENT: data collection and analysis to allow for highly competitive quality improvement in established and developing areas of surgical practice
  • SYSTEMS BASED PRACTICE: competitive and effective delivery of surgical intensive care with focus on global resource utilization and outcomes
 

Reading List 

  1. Coplin WM, Pierson DJ, Cooley KD, et al. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. AJRCCM 2000;161:1530-1536. Prospective cohort study found patients with "delayed" extubation had increased incidence of nosocomial pneumonia, longer ICU and hospital stays, and greater hospital charges.
  2. Mansel JK, Norman JR. Respiratory complications and management of spinal cord injuries. CHEST 1990;97:1446-52. Summarizes the impact of cervical injuries on pulmonary mechanics over time and interventions to minimize pulmonary morbidity and mortality and optimize chances of successful weaning from the ventilator.
  3. Allen CH, Ward JD. An evidence-based approach to management of increased ICP. Crit Care Clin 1998;14:485-495. The title is an oxymoron, but the article does a nice job summarizing what is known.
  4. Peerless JR, Snow N, Likavec MJ, et al. The effect of fiberoptic bronchoscopy on cerebral hemodynamics in patients with severe head injury. CHEST 1995;108:962-5. Small study found the transient elevation of ICP associated with bronchoscopy was matched by increased MAP, and hence cerebral perfusion pressure was maintained.
  5. Godwin J, Heffner, J. Special Critical Care Considerations in Tracheostomy Management. Clinics in Chest Medicine 1991; 12(3): 573.
  6. Sandham J, Hull R, et al. A Randomized, Controlled Trial of the Use of Pulmonary-Artery Catheters in High-Risk Surgical Patients. NEJM 2003; 348(1): 5-14.
  7. Strong EB, Bell DA, Johnson LP, et al: Intractable epistaxis: transantral ligation vs. embolization: efficacy review and cost analysis. Otolaryngol Head Neck Surg 113:674, 1995.
  8. Eagle KA, Brundage BH, Chaitman BR, et al: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 93:1278, 1996.
  9. Polanczyk CA, Rohde LE, Goldman L, et al: Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 286:309, 2001
  10. Mangano DT, Layug EL, Wallace A, et al: Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 335:1713, 1996.
  11. Poldermans D, Boersma E, Bax JJ, et al: The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 341:1789, 1999.
  12. Bradley EL: A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 128:586, 1993.
  13. Dervenis C, Johnson CD, Bassi C et al: Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini consensus conference. Int J Pancreatol 25:195, 1999.
  14. Steer ML: Early events in acute pancreatitis. Clin Gastroenterol 13:213, 1999.
  15. an ST, Lai ECS, Mok FPT, et al: Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 328:228, 1993.
  16. Kusske AM, Rungione AJ, Reber HA: Cytokines and acute pancreatitis. Gastroenterology 110:639, 1996.
  17. Sainio V, Kemppainen E, Puolakkainen P, et al: Early antibiotic treatment in acute necrotizing pancreatitis. Lancet 346:663, 1995.
  18. Folsch OR, Nitsche R, Ludtke R, et al: Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis. N Engl J Med 336:237, 1997.
  19. Nathens AB. Curtis JR. Beale RJ. Cook DJ, et al. Management of the critically ill patient with acute pancreatitis. Crit Care Med 32(12):2524-36, 2004.
  20. Maher MM, Lucey BC, Gervais DA, Mueller PR. Acute pancreatitis: the role of imaging and interventional radiology. Cardiovascular & Interventional Radiology. 27(3):208-25, 2004
  21. Freeny PC, Hauptmann E, Althous S, et al: Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol 170: 969, 1998.
  22. Morali GA, Braverman DZ, Shemesh D, et al: Successful treatment of pancreatic pseudocysts with a somatostatin analogue and catheter drainage. Am J Gastroenterol 86:515, 1991.
  23. Shires GT, Dineen P: Sepsis following burns, trauma and intra-abdominal infection. Arch Intern Med 142:2012, 1982.
  24. Border JR, Hassett J, LaDuca J, et al: The gut origin septic states in blunt multiple trauma (ISS-40) in the ICU. Ann Surg 206:42, 1987.
  25. Wilson C, Gupta R, Gilmour DG, et al: Acute superior mesenteric ischemia. Br J Surg 74:279, 1987.
  26. Bailey RW, Bulkley GB, Hamilton SR, et al: Pathogenesis of non-occlusive ischemic colitis. Am J Surg 203:509, 1986.
  27. Kaleya RN, Boley SJ: Acute mesenteric ischemia. Crit Care Clin 11:(2)479, 1995.
  28. Moneta GL, Yeager RA, Dalman R, et al: Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion. J Vasc Surg 14:511, 1993.
  29. Iberti J, Salky B, Omefrey D: Use of bedside laparoscopy to identify intestinal ischemia in post-operative cases of aortic reconstruction. Surgery 105:686, 1989.
  30. Levy PJ, Kraus zMM, Manny J: Acute mesenteric ischemia: improved results—a retrospective analysis of ninety-two patients. Surgery 107:372, 1990.
  31. Kron IL, Harman PK, Nolan AP: The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 199:28, 1984.
  32. Burch JM, Moore EE, Moore FA, et al: The abdominal compartment syndrome [review]. Surg Clin North Am 76:833, 1996.
  33. Schein M, Wittmann DH, Aprahamian C, et al: The abdominal compartment syndrome. The physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 180:745, 1995.
  34. Chang MC, Miller PR, D'Agostino R Jr, et al: Effects of abdominal decompression on cardiopulmonary function and visceral perfusion in patients with intra-abdominal hypertension. J Trauma 44:440, 1998.
  35. Iberti TJ, Kelly KM, Gentili DR, et al: A simple technique to accurately determine intra-abdominal pressure. Crit Care Med 15:1140, 1987.
  36. Pachter HL, Feliciano DV: Complex hepatic injuries. [Review] [66 refs]. Surg Clin North Am 76:763, 1996.
  37. Elliott D, Kufera JA, Myers RA: The microbiology of necrotizing soft tissue infections. Am J Surg 179:361, 2000.
  38. Eke N: Fournier's gangrene: a review of 1726 cases. Br J Surg 87:718, 2000.
  39. Sudarsky LA, Laschinger JC, Coppa GF, et al: Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg 206:661, 1987.
  40. Bilton BD, Zibari GB, McMillan RW, et al: Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg 64:397, 1998.
  41. Lille ST, Sato TT, Engrav LH, et al: Necrotizing soft tissue infections: obstacles in diagnosis. J Am Coll Surg 182:7, 1996.
  42. Elliott DC, Kufera JA, Myers RA: Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg 224:672, 1996.
  43. Keen RR, McCarthy WJ, Pearce WH, et al: Surgical management of atheroembolization. J Vasc Surg 21:773, 1995.
  44. Weaver FA, Comerota AJ, Youngblood M, et al: Surgical revascularization versus thrombolysis for nonembolic extremity native arterial occlusions: results of a prospective randomized trial. The STILE Investigators. Surgery versus Thrombolysis for Ischemia of the Lower Extremity. J Vasc Surg 24(4):513, 1996.
  45. Mabee JR, Bostwick TL: Pathophysiology and mechanisms of compartment syndrome. Ortho Rev 22:175, 1993.
  46. Robinson JF, Robinson WA, Cohn A, et al: Perforation of the great vessels during central venous line placement. Arch Intern Med 155:1225, 1995.
  47. Lucas CE. Resuscitation through the three phases of hemorrhagic shock after trauma. Can J Surg 33:451-456; 1990. A little dated, but nevertheless a good review for those without a surgical background regarding fluid shifts in the post-trauma period (this includes elective surgery). It will explain to you why it is so incredibly silly to try to diurese a patient in the immediate post-operative period, while third spacing is at its maximum.
  48. Girard TD. Philbrick JT. Fritz Angle J. Becker DM. Prophylactic vena cava filters for trauma patients: a systematic review of the literature. Thrombosis Research. 112(5-6):261-7, 2003
  49. Labori KJ. Raeder MG. Diagnostic approach to the patient with jaundice following trauma. Scandinavian Journal of Surgery: SJS. 93(3):176-83, 2004.
  50. Loveland JA. Boffard KD. Damage control in the abdomen and beyond. British Journal of Surgery. 91(9):1095-1101, 2004

Calendar

Pulmonary Fellowship Conferences occur regularly throughout the year.

info and schedule  

Contact Us

Albert Einstein College of Medicine
Price Center for Genetic & Translational Medicine
1301 Morris Park Avenue
Bronx, NY 10461

Tel: 718.678.1040
Fax: 718.678.1020

 
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