Week 1: Ventilators and extubation
Ventilators part 1 and 2
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When to extubate?
Optional Textbook chapters
If you prefer textbook chapters to videos, read these chapters about mechanical ventilation and extubation from the Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink).
If you prefer textbook chapters to videos, read these chapters about mechanical ventilation and extubation from the Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink).
| 39_mechanical_ventilation.pdf |
| 63_weaning_from_ventilation.pdf |
Advanced: Manual for the ventilators in our unit, goes into lots of details about using the vent and how the vent modes really work. In particular, check out page 21 for an explanation of what PRVC mode actually does.
| vent_manual.pdf |
Week 2: Oxygen delivery, intubation
This week will focus on oxygen delivery in non-intubated patient, and intubation. The intubation videos will be most helpful for surgery and junior anesthesia residents.
Oxygen delivery devices
Please note, we don’t use the Oxymizer or Venturia mask in our ICU. Most commonly we use nasal cannula, face mask, and high flow nasal cannula.
Please note, we don’t use the Oxymizer or Venturia mask in our ICU. Most commonly we use nasal cannula, face mask, and high flow nasal cannula.
RSI (Rapid Sequence Induction) Intubation
This video is a good overview of preparation for intubation.
This video is a good overview of preparation for intubation.
Medications for RSI (Rapid Sequence Induction) intubation
This video is intended for pharmacists but is a great review of medications commonly used during intubation in the ICU. During an intubation your attending may choose different combinations of these drugs depending on the circumstances. Also, during intubations in the ICU, the pre-treatment medications discussed in this video are commonly skipped.
This video is intended for pharmacists but is a great review of medications commonly used during intubation in the ICU. During an intubation your attending may choose different combinations of these drugs depending on the circumstances. Also, during intubations in the ICU, the pre-treatment medications discussed in this video are commonly skipped.
Textbook chapter: ICU intubation
This chapter from the excellent Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) focuses on RSI intubation in the ICU setting, rather than intubation in the OR.
This chapter from the excellent Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) focuses on RSI intubation in the ICU setting, rather than intubation in the OR.
| Intubation.pdf |
Take the week 2 quiz on oxygen delivery and intubation!
Week 3: ARDS, tracheostomies
ARDS video: Diagnosis and management
Textbook Chapter: Tracheostomy
This chapter from Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) discussed indications for tracheostomy, technique, and the difficulty in deciding when a patient should get a trachostomy.
This chapter from Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) discussed indications for tracheostomy, technique, and the difficulty in deciding when a patient should get a trachostomy.
| 38_tracheostomy.pdf |
Optional: 2017 American Thoracic Society ARDS guidelines
This set of guidelines contains six high-yield recommendations that everyone should be familiar with. The publication also gives a great literature review for each recommendation.
This set of guidelines contains six high-yield recommendations that everyone should be familiar with. The publication also gives a great literature review for each recommendation.
| ards_guidelines_2017.pdf |
Optional: Textbook Chapter: ARDS
This chapter from Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) goes into a lot more detail about the pathophysiology of ARDS.
This chapter from Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) goes into a lot more detail about the pathophysiology of ARDS.
| 67_ards.pdf |
Take the week 3 quiz on ARDS and tracheostomy!
Week 4: Sedation, pain, delirium
This video from Highland Hospital does a great job discussing sedation and analgesia in ICU patients and the benefits and risks of the sedating medications that we commonly use.
2018 SCCM pain, sedation, and delirium guidelines
These guidelines (full title: Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, or PADIS) focus on thoughtful use of pharmacological and non-pharmacological approaches to keeping patients comfortable while in the ICU and preventing delirium.
These guidelines (full title: Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, or PADIS) focus on thoughtful use of pharmacological and non-pharmacological approaches to keeping patients comfortable while in the ICU and preventing delirium.
| 2018_PADIS_guidelines.pdf |
Take the week 6 quiz on sedation, pain, and delirium!
Week 5: Pressors, shock
This week will focus on the different types of shock and how to distinguish between them, as well as the use of pressors for patients in shock.
Video: Pressors and Inotropes
This lecture from Highland Hospital goes into great detail about the effects and indications for the pressors and inotropes that we use, as well as a good review of relevant studies.
This lecture from Highland Hospital goes into great detail about the effects and indications for the pressors and inotropes that we use, as well as a good review of relevant studies.
Video: Shock
This great video from the University of Louisville is an overview of the different types of shock, how to distinguish between them, and basic treatment for each. It doesn't go in depth into management of any one type. The lecturer is a CCU attending and spends time talking about Swann measurements, which we use very rarely in the SICU, but it's still good to understand how to get the Swann numbers and what they mean.
This great video from the University of Louisville is an overview of the different types of shock, how to distinguish between them, and basic treatment for each. It doesn't go in depth into management of any one type. The lecturer is a CCU attending and spends time talking about Swann measurements, which we use very rarely in the SICU, but it's still good to understand how to get the Swann numbers and what they mean.
Optional: Textbook chapter
As an alternative to the above video on shock, you can read this chapter from the Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) that reviews the types of shock and resulting organ failure.
As an alternative to the above video on shock, you can read this chapter from the Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) that reviews the types of shock and resulting organ failure.
| 88_pathohysiology_of_shock.pdf |
Take the week 5 quiz on pressors and shock!
Week 6: Sepsis and Septic Shock
Sepsis is a big topic in the SICU, and many of our patients have some form of sepsis. It's important to know the guidelines and official sepsis definition, although many of our patients are complicated and we may deviate from the official recommendations.
Video: Sepsis
This video from the University of Louisville Department of Medicine is a good review of sepsis and septic shock. The history of how management of sepsis has changed is good to know, especially the famous Rivers trial.
This video from the University of Louisville Department of Medicine is a good review of sepsis and septic shock. The history of how management of sepsis has changed is good to know, especially the famous Rivers trial.
2021 surviving sepsis guidelines
This is the most recent set of surviving sepsis guidelines and everyone should be familiar with them. The main change compared with the 2016 guidelines is that stress dose steroids (hydrocortisone 50 mg q6h) are now recommended for all patients with septic shock and an ongoing pressor requirement (defined as norepinephrine or epinephrine at > 0.25 mcg/kg/min for 4 hours). This is based on three recent RCTs that, in a meta-analysis, showed accelerated resolution of shock with steroids (but no mortality benefit, and worsened neuromuscular weakness).
This is the most recent set of surviving sepsis guidelines and everyone should be familiar with them. The main change compared with the 2016 guidelines is that stress dose steroids (hydrocortisone 50 mg q6h) are now recommended for all patients with septic shock and an ongoing pressor requirement (defined as norepinephrine or epinephrine at > 0.25 mcg/kg/min for 4 hours). This is based on three recent RCTs that, in a meta-analysis, showed accelerated resolution of shock with steroids (but no mortality benefit, and worsened neuromuscular weakness).
| 2021_surviving_sepsis_guidelines.pdf |
Optional: Rivers Trial
This is the famous 2001 paper "Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock," commonly referred to as the "Rivers Trial" based on the first author, Emanual Rivers. Everyone should read this paper at some point because it substantially changed how septic shock is treated.
This is the famous 2001 paper "Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock," commonly referred to as the "Rivers Trial" based on the first author, Emanual Rivers. Everyone should read this paper at some point because it substantially changed how septic shock is treated.
| Rivers_Trial.pdf |
Take the week 6 quiz on sepsis and septic shock!
Week 7: Dialysis in the ICU
Your critically ill patient is stabilized on pressors and on the vent, and you've initiated an appropriate sedation regimen. Unfortunately they have developed anuric renal failure, and will need dialysis. This week will cover dialysis in the ICU- hemodialysis (HD) and continuous renal replacement therapy (CRRT).
This video from Case Western Reserve University discusses different modes of dialysis in the ICU and some technical differences between them. For our purposes, the main distinction is between intermittent hemodialysis (HD) and continuous renal replacement therapy (CRRT, of which CVVH, CVHD, and CVVHDF are subtypes). (Please note that the terms CRRT and CVVH are often used interchangeably).
This textbook chapter from Textbook of Critical Care (2017, Vincent, Abraham, Moore, Kochanek, Fink) discusses indications for dialysis in the ICU in general, and some differences between HD and CRRT. Please note that the chapter uses the term renal replacement therapy (RRT) to refer to all modes of dialysis.
| renal_replacement_therapy.pdf |
Week 8: Nutrition and ICU prophylaxis
Your patient is more stable and it's time to think about nutrition as well as prophylaxis against DVT and stomach ulcers.
Review of nutrition guidelines
Nutrition in the ICU is a very complicated topic, and there are a lot of important things that we still don't really know. It seems that every time a new study comes out, it contradicts prior studies. A good place to start is the ASPEN (American Society for Parenteral and Enteral Nutrition) guidelines. They do a great job at summarizing the literature and give concise recommendations that we can apply to our patients in the ICU.
This video nicely summarizes the key points from the 2016 ASPEN guidelines for ICU nutrition.
Nutrition in the ICU is a very complicated topic, and there are a lot of important things that we still don't really know. It seems that every time a new study comes out, it contradicts prior studies. A good place to start is the ASPEN (American Society for Parenteral and Enteral Nutrition) guidelines. They do a great job at summarizing the literature and give concise recommendations that we can apply to our patients in the ICU.
This video nicely summarizes the key points from the 2016 ASPEN guidelines for ICU nutrition.
2016 ASPEN guidelines on ICU nutrition
Here is the actual set of guidelines. It does a great job at dispelling some persistent nutrition "myths" that you will encounter. Some of the most interesting and useful recommendations are:
B3 (starting enteric nutrition)
B4a and B4b (gastric feeds for most patients)
B5 (nutrition in patients on pressors)
D2a and D2b (not using gastric residuals)
L3b (gastric or jejunal feeding in pancreatitis)
O2 (start nutrition soon after surgery)
Q8 (nutrition and hydration in end-of-life care)
Here is the actual set of guidelines. It does a great job at dispelling some persistent nutrition "myths" that you will encounter. Some of the most interesting and useful recommendations are:
B3 (starting enteric nutrition)
B4a and B4b (gastric feeds for most patients)
B5 (nutrition in patients on pressors)
D2a and D2b (not using gastric residuals)
L3b (gastric or jejunal feeding in pancreatitis)
O2 (start nutrition soon after surgery)
Q8 (nutrition and hydration in end-of-life care)
| 2016_aspen_guidelines.pdf |
Stress Ulcer Prophylaxis
Many patients in the ICU are at risk for developing gastric and duodenal ulcers (stress ulcers). However, not all patients in the ICU require prophylaxis against ulcers, and it is easy to overuse stress ulcer prophylaxis. ICU patients should receive prophylaxis (pantoprazole or famotidine) if they have a risk factor for ulcers: mechanical ventilation, coagulopathy, traumatic brain injury, major burns, sepsis, high-dose steroid use, NSAID or anti-platelet use. This does not apply to patients with active or recent GI bleed. Read this UpToDate article for more more in-depth discussion.
Many patients in the ICU are at risk for developing gastric and duodenal ulcers (stress ulcers). However, not all patients in the ICU require prophylaxis against ulcers, and it is easy to overuse stress ulcer prophylaxis. ICU patients should receive prophylaxis (pantoprazole or famotidine) if they have a risk factor for ulcers: mechanical ventilation, coagulopathy, traumatic brain injury, major burns, sepsis, high-dose steroid use, NSAID or anti-platelet use. This does not apply to patients with active or recent GI bleed. Read this UpToDate article for more more in-depth discussion.
| stress_ulcer_prophylaxis_uptodate.pdf |
DVT prophylaxis
ICU patients are at very high risk for DVT and should all receive chemical DVT prophylaxis (subcutaneous heparin or enoxaparin) unless there is a strong and specific contraindication.
In these 2019 guidelines, the American Society of Hematology recommends chemical DVT prophylaxis for most patients after major surgery, with a few exception for certain neurosurgery and urology procedures.
ICU patients are at very high risk for DVT and should all receive chemical DVT prophylaxis (subcutaneous heparin or enoxaparin) unless there is a strong and specific contraindication.
In these 2019 guidelines, the American Society of Hematology recommends chemical DVT prophylaxis for most patients after major surgery, with a few exception for certain neurosurgery and urology procedures.
| 2019_hematology_dvt_guidelines.pdf |
