Transcript Airway Injury During Anesthesia

Welcome
to the
Intensive Care Unit
Learning Goals
• To learn to care for critically ill patients
• To understand management of respiratory
failure with mechanical ventilation
• To develop a better appreciation of
cardiopulmonary physiology
• To understand indications for different
modalities of hemodynamic monitoring
• To improve on techniques to place invasive
monitors
Learning Goals
• Understand the pharmacodynamics and
pharmacokinetics of sedatives
• Learn the communication skills required
in the role of the critical care consultant
• Develop a multidisciplinary treatment plan
for critically ill patients
• Have a fun and educational month
Organization
• 8/11 ICU – ± intern, ± 1-2 residents,
fellows, attending
• 9 ICU – 2 NPs, 2-3 residents, fellows,
attending
• 10 ICU – 1 NP, 1 resident, fellows,
attending
• 13 ICU – 4 residents, fellows, attending
Housekeeping - call schedule
• Call is approximately every 3-4 nights.
• A non-call resident should be identified
and stay until at least 5pm rounds to help
with the work.
• Schedule changes are not allowed unless
approved by Dr. Shimabukuro (an
extremely complex schedule)
Housekeeping - Call rooms
• 13 ICU - L 1351, code 911911
• 8/9/10 ICU - in proximal 9 ICU, no code
• ICU fellow - in distal room of 9ICU, no
code
Housekeeping - daily routine
• Lectures start at 8am sharp everyday (except
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8:15 on Wednesdays) in room M919
Check schedule for location and speaker
Rounds start at 9am weekdays and at 8am on
weekends
X-ray rounds immediately follow attending
rounds
Afternoon rounds with fellows start at 5pm
Housekeeping - weekend
• Only on-call and post-call residents round
• Try to pre-round on the sick ICU patients
• Remainder of patients can be discovery
rounds
• Please try to write notes either before or
after rounds
• Place emphasis on A/P not repeating data
Housekeeping - Lectures
• Everybody will be responsible for 1 lecture
during their rotation
• Please check the lecture schedule for assigned
topic and date
• Medical students are allowed to pick a topic of
their choice
• Read schedule carefully, sometimes lectures
are split based on level of training or ICU
experience
Housekeeping - paperwork
• List to be described on following slides
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Notes
Patient list
Admit Orders
Procedure Note
Central Line Procedure Note
Notes
• Do not repeat data that is already listed
elsewhere
• Short and concise notes are the key
• For instance, “wean vent as tolerated” vs.
“Patient continues to require a high
minute ventilation due to a large dead
space fraction. He may not tolerate a rapid
wean, so will decrease the rate by 2
today.”
Patient list
• The filemaker database is in the fellow’s
office. It should be updated daily
• Post call resident will print out copies for
the team
• Do not leave in the ICU (patient
confidentiality)
• Make sure to enter morbidities and
mortalities
Admit Orders
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There are pre-printed ICU admit orders
ICU orders are on its own page
Please make sure you sign these
Try to use the pre-printed orders since
they are compliant with pharmacy
regulations
Procedure Notes
• Located in NoteWriter
• Central Line Insertion Procedure Note (CLIP)
• CCM-Procedure Note
Procedure Note for Central Lines
• NoteWriter
• Central Line Insertion Procedure Note
(CLIP)
• Attesting provider is Attending of week.
CCM-Procedure Note
• Can check more than one procedure
• Attesting provider is Attending of week
Resident Responsibilities
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Code Blue Coverage (10 ICU team)
Emergency calls in the ICU
Co-Managing patient with primary teams
With special emphasis on:
• Airway
• Central lines
• Mechanical ventilation
• Pain and sedative medications
Code Responsibilities
• 10 ICU team will respond to codes during
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weekdays
We are responsible for the airway - FIRST
Please make sure that whatever you use in the
CODE bags are refilled immediately
New medication syringes are available from
pharmacy daily (across from M919)
Anesthesia workroom has other supplies – it is
located in the OR on the fourth floor
Emergency Calls
• Calls regarding unstable patients often go
to the ICU team
• If situation is truly an emergency, deal
with the problem while the primary team is
being summoned
• If there is time, discuss with the team,
often the night float will be thankful for a
friendly word of advice
Communication
• Understanding the primary team’s plans
and goals often make it easier to
understand the course of action that is
planned
• Communication makes it easier for all
parties involved and improves patient
care
• If there is a disagreement about care,
consult your fellow or attending
Airway
• The airway pager (443-4990) will always be with
an anesthesiologist (attending or resident)
• Airway backup available:
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OR E1 Anesthesia Attending: 3-1581
OR Front Desk: 3-1545
OB Anesthesia Resident: 443-9261
ED: 3-1238
• Do not start sedation/paralysis without
someone from anesthesia being present (CA-1
residents should also always get back-up)
Central Lines
• Except for a few services we are responsible for
all line placements (CT, cards, vasc)
• All upper body lines must be placed with an ICU
attending or fellow present
• Femoral lines are at the discretion of the
resident
• 3 line placements will be formally evaluated by
fellows (give completed cards to Mitch in M917)
Ventilation
• We are responsible for ALL ventilator orders
and extubation (except fast-track CABG – who
are on a protocol)
• If the primary team wants something that is
unreasonable, please discuss it with the fellow
or attending
• DO NOT make changes on the ventilator
• Pts should be followed for at least 24 hours
after extubation
Sedation
• We write pain and sedation orders on all
patients we follow
• Do what the primary team wants if it is
reasonable
• Management of pain in ICU patients with
epidural catheters is the responsibility of the
acute pain service, but we do keep a close eye
on this
Miscellaneous
• Radiology does not interpret any studies
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overnight unless asked
Small cards have everybody’s pager and home
phone number
Meal cards are obtainable from Mitch in the
office (M917)
Please don’t hesitate if you identify problems
during your rotation to notify your attending
Please fill out the evaluations. Your comments
are confidential and important for future rotation
development
Medical Students
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Stay late 1 night per week - their choice
They should read about their patients
Quality not quantity (2 patients max)
They are not expected to function as a resident
during this rotation
• There should be a resident identified as the
supervisor for each patient the students follows
Calls to evaluate patient
• Go see the patient in the ER or on the floor
• Discuss ALL ICU admissions with fellow (or
attending)
• Any refused admission must be discussed with
attending or fellow
• Do not worry about beds, triage attending (4434443) will take care of that
• Triage covered by 10 ICU fellow
Open and Closed ICU’s
• Most patients in M/L ICU’s are “semiopen” in that primary service still writes
some orders, but we co-manage with
them.
• Orthopedic surgery, CRI, post-partum OB,
ENT/ plastics and Urology are “closed”
• Make sure you know their contact #’s to
keep them in the loop
Closed patient issues
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Labs - transfusion, electrolytes, glucose
Nutrition - NPO, tube feeding, TPN
Activity - bedrest, ad lib
IVF - rate, heplock
Studies - radiology, echo, PT - need to
make a phone call
• Check patient frequently and
communicate with primary team often
Open and Closed ICU’s
• The data:
• Multiple studies show that the daily presence of an
intensivist improves outcomes, including mortality
and length of stay. There was no advantage to closed
units.
• Disadvantages of open units:
• Disagreement about management plans
• Loss of control
• Advantages of open units
• Ability to care for a variety of patients (med, surg, etc)
• Ability to focus on critical care issues
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