MICU Housestaff Manual

Division of Pulmonary and Critical Care Medicine

Northwestern University Feinberg School of Medicine

2009

Table of Contents

Introduction………………………………………………………………………………………..3

MICU Staff………………………………………………………………………………………..4

MICU Day………………………………………………………………………………………...6

Call Responsibilities………………………………………………………………………………7

Presentation and Documentation……………………………………………..…………………...9

Helpful Tips and Guidelines……………………………………………………………………..11Mechanical Ventilation/Respiratory FailureVentilator Weaning ProtocolSevere Sepsis/Septic ShockARDSnet ProtocolIdeal Body Weight/Tidal Volume TablesAdvanced Cardiac Life SupportOpioid Dose Table

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Introduction

Welcome to the Northwestern Medical Intensive Care Unit (MICU). The MICU is considered by many residents to be the highlight of their internal medicine training, offering the most intense, satisfying, and intellectually rigorous rotation during their education. While the MICU can be very busy, and physically and emotionally challenging, it is also an invaluable opportunity to care for gravely ill patients, and learn about disease physiology, diagnosis, and management in an integrated, interdisciplinary, whole-body approach. We hope that you will take full advantage.

The following pages are a basic guide to the structure and function of our unit. They also include some helpful tips about common problems encountered in critical care medicine. One word of caution—the information presented here is a rough sketch of basic principles; it is not meant to substitute for a critical reading of primary research. While this manual contains some of the best understood evidence-based medicine, it does not replicate the knowledge gained from readings articles or weighing the evidence yourself. As a result, we have added a section on the internal medicine residency website, under the critical care curriculum section, that contains a basic syllabus of the seminal articles of critical care medicine, and other relevant topics.

Good luck, and welcome again to the MICU!

The Fellows and Faculty of the Division of Pulmonary and Critical Care Medicine

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MICU Staff

Location/Layout: Feinberg 902-924. This is the primary 23-bed unit where our patients are, although we

commonly overflow into other units (NICU, CCU, CTICU, SICU). Two large and one small nurses’ station Supply rooms at each end (outside 903 and 922, respectively) Two tower cabinets in the hallway that contain central line materials Site-Rite ultrasound for central line placement in the MICU resident workroom Portable CT scanner in neuro ICU that can be used for noncontrast head CTs in a patient

too unstable to travel (ask radiology) Call rooms are located in the cross hall

Procedures: Perform time out prior to all procedures Assist nurses in filling out central line checklist

Physician teams:Two physician teams, each with the following:

Attending. The MICU attending is a physician who is board certified in critical care medicine. He or she is the attending of record for patients on the MICU service, and will round daily with the team to direct work-up and management.

Fellow. The MICU fellow is a trainee in pulmonary and critical care medicine (some fellows are critical care trainees in other departments). The fellow works closely with the attending, and can be a great resource for housestaff in terms of patient care and learning. You should expect the fellow to teach as much as possible depending on how busy the service is. Please don’t hesitate to ask the fellow any question you may have!

2-3 residents 2-3 interns Medical students Pharmacist Day float team

o Comprised of several residents and interns who round with the post-call team and ensure they leave on time

o Start with post-call rounds at 7:30amo When two or more day floats are present, at least one must stay until 7pm when

night float arriveso When one day float is present, must stay until all work on post-call team is done,

and leave no earlier than 5pmo Place orders, call consults, perform procedures, and make sure patients are cared

for once the post-call team has lefto Carry code pager and go to all codeso Sign out between the post-call team and day float team is expected to occur in the

context of work rounds. As a result, when the post-call team is ready to leave, they should just quickly check in with the day floats.

o Check in with the fellow before leaving

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Night float residento 7pm-7amo Cross cover patients on post-call team and post-call sister team patients (half of

entire MICU service). On call and on call sister team patients will be covered by on call team.

o Admit patients over cap (≥9 admissions) and redistribute these patients to other teams (not post-call or on-call teams) at 6:30am

o If necessary, evaluate Prentice patients for MICU admissiono Go to all codeso When not busy, assist admitting team with procedures, transport, etc.

Nursing: Specially trained in critical care nursing Usually the first to sense and respond to problems Great teachers, always accessible Assigned to 1-2 patients Should always attend and participate on rounds unless patient is crashing Link to patients’ families, as family members commonly seek them out first with

questions. Please include the nurse in any family meeting. Far more than on any other patient unit in the hospital, our nurses are integrated members

of our team Please speak directly with nurse regarding major orders (eg. road trips, urgent meds/labs)

Respiratory: Specially trained to manage mechanical ventilators and other respiratory therapies (eg.

BiPAP, nebs) Perform studies (eg. spontaneous breathing trials, non-bronchoscopic bronchoalveolar

lavages) You can learn a lot about ventilator management from them Please do not change ventilator settings yourself; instead, ask the RT or attending/fellow.

However, you should be there when they make any changes, to see what’s done and to learn.

All ventilator orders/changes must be ordered in Powerchart

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MICU Day

Pre-rounds: Gather overnight information prior to rounds On call team cannot come in before 7am; allow few minutes per patient Non-call teams cannot come in before 6am; allow 10-20 minutes per patient Determine if any patients are especially unstable, and let the fellow know Gather information from:

o Sign-out: overnight changeso Nurse: overall trend, secretions, constipation/diarrhea, family issueso Respiratory sheet/therapist: ventilator settings, peak/plateau pressureso Nursing flowsheet: hemodynamic status, including vitals and vasopressors;

sedation; lines; in/out; latest ABG and central venous O2 sato Labs: especially culture data and lactate

Take a look at any imaging yourself, especially CXR

Rounds: On-call or non-call. Begin at 7:30am Post-call. Attendings will be encouraged to start rounds at 7am The post-call team typically begins rounds with new admissions, although may start with

another patient if they are unstable Rounds begin either at one of the nursing stations in the MICU or in the MICU

conference room in the back hallway. This depends on whether the attending wants to view radiology images in the conference room prior to rounding.

On call resident encouraged not to leave rounds to evaluate a floor/ED patient. Some attendings may require resident to stay on rounds.

After Rounds: The length of rounds obviously varies, but on most days is finished by late morning. The

afternoon, depending on the day, should be spent getting work done, admitting, and sitting down with your attending or fellow to learn something!

Transfer patients to floor, write discharge summaries for discharges and deaths.

Sign Out: Provides continuity of care between day and on-call team Resident-to-resident sign out should include major issues that may come up (ventilator

and hemodynamic issues, fluid goals, road trips to studies, to name a few) Both MICU fellows will conduct quick afternoon rounds with the on-call team

Call: Each team is on call every other night, with each resident-intern pair on call q4. Call runs from 7:30am-7:30am. No new patients can be assigned after 24 hours. Admitting pager must be passed off no later than 7:30am the next day. Post-call team must leave by 1pm.

Work hours: MICU adheres to work hours regulations. No more than 80 hours per week averaged over 4 week period. Cannot accept admissions after 24 hours on call. If you believe work hours are excessive please contact chief residents.

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Call Responsibilities

On Call: MICU resident (“Team Captain”)

o Primary admitting resident. In conjunction with the ED, HOA, and MICU charge nurse, he or she is responsible for finding an ICU bed for each patient admitted to the MICU service.

o First priority is to remain in the MICU to manage admissions and share cross-cover with intern on own/sister team’s patients

Can leave MICU to evaluate non-Prentice floor patients or escort new admissions

If leaving MICU, must take intern with Encouraged not to leave rounds to evaluate a patient. Some attendings

may require residents to stay on rounds.o With the intern, jointly responsible for working up and managing 4 newly

admitted patientso If one intern on call, resident is responsible for 5th through 8th admissionso If two interns are on call, each will admit up to 4 patients with residento Delineate night float responsibilities (opposite team’s cross cover, Prentice

evaluations, procedures, 9th admission and above)o In contact with the MICU fellow regarding all new admissions and any issues

MICU interno First priority is to stay at resident’s side to admit and learn managemento Admit up to 4 patients with MICU residento Responsible for orderso Responsible for sharing own/sister team’s cross-cover

Admissionso Source: Emergency Department, floor, another ICU or outside hospital (decided

by MICU fellow)o Default is to accept all admissions. If there is disagreement after evaluating a

patient and discussing with floor/ED team, must call fellow.o Admission Caps

1-4: jointly admitted and managed by intern and resident 5-8: solely admitted and managed by resident ≥9: admitted and managed by night float, redistributed to non-call/non-

post-call team in amo Floor “Evaluations”

The default position of the MICU resident should be to accept all floor transfers and ED admissions

Resident cannot leave rounds to evaluate a patient (except for code) If there is concern about the appropriateness of an admission, resident can

quickly see the patient on the floor Prentice patients to be evaluated by night float (not admitting resident) Intern must go with resident to floor evaluations if it would be admission

#1-4

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If there is disagreement after evaluating a patient and discussing with floor/ED team, must call fellow

o ED “Evaluations.” The MICU resident is not responsible for “signing off” on an ED patient being admitted to the floor.

If requested, ask ED attending to call fellow If conflict regarding admission, must call fellow

Cross Covero On-call and on-call sister teams’ patients cross covered by admitting teamo Opposite team patients cross covered by night float

Post Call: Pre-rounding shared between intern and resident Rounds encouraged to start at 7am Post-call notes shared between intern and resident Day float responsible for orders, consults, and procedures If notes are not completed by 1pm, they must be taken over by day float

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Admission Presentation and Documentation

The following is the preferred structure for the presentation and note of a new MICU admission. We are working on making a template in Powerchart so the MICU Admit Note will follow this format.

Name/Room Number

Critical Care Chief Complaint. The reason the patient was admitted to intensive care (eg. septic shock or hypoxemic respiratory failure, NOT cough, fever, or dyspnea). This should provide a hook to draw in the team to focus on the rest of the presentation or note.

History of Present Illness. This should include a pertinent review of systems and ED/hospital course.

Past Medical History (include prior MICU admissions)

Allergies

Meds

Family History

Social History

Physical Exam. This should include admission vitals, any ventilator settings, including respiratory mechanics, and any vasoactive drips and their rates. All admissions must be evaluated for skin breakdown. This can be accomplished by helping the nurse evaluate for ulcers on admission, and charting it in the admission note.

Labs

Imaging

Assessment. This should include a full discussion of the differential diagnosis, including less likely diagnoses (you’ll be surprised how many critical care diagnoses are unclear on admission!). It should be more than a mere restating of the primary diagnosis.

Plan. The critical care plan should be issue-based, not by organ system. The reason for this is that many critical care diagnoses affect more than one organ system. For example, septic shock can include hemodynamics, pneumonia (ID), respiratory failure (pulm), acute kidney injury (renal), demand ischemia (cardiac), and lethargy (neuro). By saying “Issue #1, septic shock,” you can then separate out these other, secondary issues. Also, issue order can change on a daily basis.

Due to the multitude of data and organ-systems affected by critical illness, “copy-forwarding” of inaccurate or outdated information is unacceptable. Every day, the plan should be rewritten and updated.

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Daily Presentation

Name/Room Number

ICU Day #, Intubated Day #

Subjective

Objective Nurse will present vitals, drips, sedation, secretions, in/out, lines Ventilator settings, including peak/plateau pressures Physical exam Include skin assessment in daily progress note

Labs

Studies

Assessment/Plan

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Helpful Tips and Guidelines

(or, what do I do when…?)

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Mechanical Ventilation/Respiratory Failure

Indications for intubation and mechanical ventilation Respiratory/cardiac arrest Hypoxemic respiratory failure Hypercarbic respiratory failure Airway protection Increased work of breathing/shock

Ventilator Parameters Respiratory rate: number of breaths delivered or taken in one minute. Tidal volume: volume delivered or taken with each breath Minute ventilation: respiratory rate times tidal volume FiO2: fraction of inhaled oxygen delivered with each breath PEEP: positive end-expiratory pressure to prevent alveolar atelectasis Peak inspiratory flow rate: speed with which each breath is delivered Waveform: pattern with which peak flow rate is attained (“square” or “ramp”) Trigger: how the ventilator senses a patient-initiated breath (eg. flow or pressure trigger) Inspiratory pressure: during pressure-controlled or supported ventilation, the inspiratory

pressure that is delivered with each breath

Modes of Mechanical Ventilation

AC—Assist Control: most common in MICU

Set Tidal Volume (Vt) for ALL breaths Minimum set respiratory rate, but patient gets a FULL Vt breath for making efforts above

this If patient does not breathe over minimum RR, this is called controlled mechanical

ventilation (CMV) Set FiO2 and PEEP Good: rests respiratory muscles, so oxygen can be diverted elsewhere Bad: may cause hyperventilation, dysynchrony, auto-PEEP/breath stacking

SIMV—Synchronized Intermittent Mechanical Ventilation: most common in SICU

Set Tidal Volume (Vt) for MINIMUM number of breaths Minimum set respiratory rate Breaths taken above minumum rate are patient driven (Vt set by patient drawing in air

instead of machine blowing it into the lungs) Good: patient assumes some work of breathing, negative flow can increase venous return

to heart Bad: greater work of breathing (not so great in septic patient with high metabolic

demand), not physiologic, dysynchrony

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PCV—Pressure Control Ventilation: used in ARDS to prevent barotrauma (lower mean airway pressure)

Minimum set respiratory rate Inspiratory pressure and PEEP determine Vt (similar to BiPAP) with variable flow and

fixed I:E ratio Can be used to transition to inverse ratio ventilation (I>E) to help open alveoli

PSV—Pressure Support Ventilation: see weaning below No set rate or Vt Requires spontaneous breathing Continuous Positive Airway Pressure (CPAP): ventilator controls a continuous airway

pressure throughout respiratory cycle (eg. CPAP 5)

Initial Settings Vt: 8cc/kg based on IDEAL body weight (see chart below) Respiratory rate (RR): based on clinical picture, target for pH and minute ventilation FiO2: 100% to start, wean to non-toxic levels (≤60%) ASAP Positive End-Expiratory Pressure (PEEP): at least 5 to overcome resistance of ETT Asthma patients need higher flow, more PEEP, lower RR, and square waveform to

prevent auto-PEEP

Ventilator Mechanics: know the peak and plateau every day Peak—end inspiration

o pressure to overcome airway resistance AND elastic properties of lung and chest wall

Plateau—pause at end of inspiration with NO airflowo pressure to overcome ONLY elastic properties of lung and chest wall; best

estimate of alveolar pressureo calculated with inspiratory pause maneuvero goal < 30

Resistance = peak – plateau; normally ≤ 10 (for 8 Fr ETT)o requires measurement on 60L/min square waveformo increased by: biting/kinked tube, bronchospasm, mucus secretionso decreased by: tension PTX, atelectasis/PNA, R mainstem intubation, auto-PEEP

Compliance = Vt/(plateau – PEEP); normally 60-80o decreased by (think stiff lungs): dysynchrony, auto-PEEP, PTX, atelectasis/PNA,

pulmonary edema, PE, ARDS

ARDS—Acute Respiratory Distress Syndrome Bilateral pulmonary infiltrates in the absence of CHF (i.e. PCWP < 18) PaO2/FiO2 < 200 (< 300 for ALI—acute lung injury) Often from sepsis, but also caused by: trauma, aspiration, embolism (fat, air),

burns/inhalation/toxins, massive transfusion, eclampsia, radiation, pancreatitis Small Stiff Lungs: airway collapse, decreased surfactant, decreased compliance Treatment: Low Tidal Volume Strategy (see below)

o Goal Vt 6cc/kg based on ideal body weight to prevent barotrauma

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o Increase RR to keep goal pH>7.20 as you decrease Vto Goal SpO2 (O2 sat) 88-95% (PaO2 55-80) by using higher PEEP to decrease

FiO2o Watch out for auto-PEEP: air trapping by breath stacking at end of exhalation;

will see start of next breath before waveform returns to baseline on the ventilator If no improvement with above consider: paralytics, steroids, prone positioning, nitric

oxide

TRALI—Transfusion Related Acute Lung Injury Clinical picture of ARDS within 6 hours of blood transfusion Low BP, fever, tachycardia, SOB Related to HLA antibody reaction Treatment: supportive

Ventilator Weaning Patient is ready to wean IF:

o Reason for intubation has been correctedo Acceptable minute ventilation (<10 L/min)o Good oxygenation (FiO2 < 40%, PEEP 5, PO2 > 60)o Minimal pressors, stable HR and BPo No significant respiratory acidosis or anemia, okay lyteso Able to follow commands

Hold sedation every day to gauge mental status, restart at half of previous level SBT: Spontaneous Breathing Trial—T-piece or Pressure Support

o T piece Disconnect patient from ventilator and let them breathe on their own More work for the patient (have to overcome resistance of the ETT), but if

successful a better predictor of successful extubation than PSVo PSV: Pressure Support—has two parts

1) Extra support with each breath, patient determines volume 2) Baseline PEEP to overcome tubing Equivalent to BiPAP Tolerating 5/5 for >1-2 hours is good predictor of successful extubation

Signs of weaning failure: hypertension, tachypnea, dropping sat, low TV and minute ventilation

Weaning Parameterso Cuff leak: occlude ETT with cuff down, listen for air movement around tube; no

movement could mean laryngeal edemao NIF (Negative Inspiratory Flow), goal >30o RSBI (Rapid Shallow Breathing Index): RR/Vt >105 predicts failure

Consider tracheostomy if not close to extubation by intubation day 7o Prolonged intubation leads to tracheomalacia, tracheal stenosis, and mucosal

ulcerations

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Severe Sepsis and Septic Shock

Definition Systemic Inflammatory Response Syndrome (SIRS): at least 2/4 of the following: hypo-

or hyperthermia (T > 38°C or < 36°C), tachycardia (HR > 90/min), tachypnea (RR > 20 or pCO2 < 32), and leukocytosis or leucopenia (WBCs > 12,000 or < 4,000 or > 10% bands)

Sepsis: SIRS plus documented or suspected source of infection Severe sepsis: sepsis plus evidence of end-organ dysfunction/hypoperfusion (eg. acute

kidney injury, encephalopathy, lactic acidosis) Septic shock: severe sepsis plus hypotension refractory to initial volume resuscitation

Management Infection source control

o Culture everything (at least peripheral blood x 2, each port of indwelling lines, urine, CXR, resp cx/NBBAL; if needed LP, stool, biliary, wound)

o Broad-spectrum antibiotics: commonly vancomycin/zosyn/tobramycin if no history to guide you

Early goal-directed therapyo Hemodynamic management (see algorithm below)o Vasopressors

Norepinephrine (Levophed): alpha and beta 1 agonist, titrate to 20mcg vasoconstricts, watch out for tachyarryhthmias

Vasopressin: ADH analog on renal V2 receptors, on or off (0.04mcg) may decrease requirement for other pressors by up to 50%

Phenylephrine (Neosynephrine): alpha 1 agonist, titrate to 300mcg improve SVR and therefore MAP

Dopamine: D agonist at low dose (0-10mcg/kg/min), beta agonist at moderate dose (10-20mcg/kg/min), alpha agonist at high dose (> 20mcg/kg/min)

o Intubation: consider if increasing pressors even if respiratory status appears ok Other therapy

o “Stress” dose steroids History of steroid use refractory shock despite volume and pressors Hydrocortisone 50mg IV q6h or 100mg IV q8h

o Activated Protein C (Xigris) Reduce thrombin and tissue factor, decrease inflammation induced by

clotting cascade Proven mortality benefit if APACHE ≥ 25 (can calculate this on the web) Long list of contraindications (mostly related to bleeding)

Treat ARDS (see below) Sedation: bolus or gtt; ideally keep sedated for first 24-48h

o Propofol: fast acting but potential for toxicity (hypotension, high TG) and withdrawal

o Fentanyl: long acting but beware in liver patients

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o Ativan: long acting, good for EtOH withdrawal Do No Harm: Prophylaxis

o DVT: lovenox or heparin, SCDso GERD: PPI, HOB > 30%o Surveillance: Cx for VRE, examine skin for ulcerso Feed: OGT or DPT, consult nutrition for TF recs

Goals of Care: talk to next of kin or power of attorney about hospital course and code status

Also make sure to get EKG, troponin, and order TTE to gauge cardiac function

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Advanced Cardiac Life Support

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Sedation

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