Critical Care Goals and Objectives Critical Care Fellowship

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Critical Care Goals and Objectives Critical Care Fellowship Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York

Core Competencies • • • Patient Care Medical Knowledge Professionalism & Ethics Interpersonal Communication Skills Practice-based Learning and Improvement • Systems-based Practice

MICU • • • This 14 -bed North 2 MICU functions as a primary teaching unit and is closed for the purposes of orders and procedures. The unit admits approximately 75 patients per month and maintains a full census. Medical Director is Dr. Daniela Levi and the Nursing Supervisor is Jose Mitre, R. N, medical co-director is Dr. Adam Keene. The unit is staffed with one attending, two fellows, three Medicine PGY-2 s and three Medicine PGY -1 s. The objective is to train housestaff in didactic and technical aspects of management of patients with critical medical illness. 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 9: 00 PM and 10: 00 PM, and the daytime Fellows usually leave by 6 – 7: 00 PM. The average night call for fellows on this rotation is every fourth night. 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. Close relationships exist with the adjacent Echocardiography lab and Coronary Care Unit. The most frequent diagnoses at the time of admission to the Medical ICU are severe respiratory failure, septic shock, endocrine and metabolic emergencies, hemorrhagic shock, oncologic emergencies, and neuromuscular crises. In addition, the unit functions as a primary site for emergency plasmapheresis for patients with TTP. Goal: 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.

Reading List • • 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 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: 34754. 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 (< 6 cc/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,

Reading List • • 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 50 mg HC q 6 and 50 mcg fludrocortisone qd had significantly reduced morality compared to the nonresponders 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.

Reading List • • 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 10 gm/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, 000 U 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 7 gm/dl Hg. B 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. Varon J, 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.

Reading List • • 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 anoxicischemic 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.

Reading List • • • De. Gans 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

Reading List • • comparable to conventional ventilation but was associated with fewer serious complications and shorter ICU stays. Nava S, Carbone G, Di. Battista, 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 Pa. CO 2 > 45 mm. Hg (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.

Reading List • • • Wells PS, 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 Simpli. RED 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

Reading List • • • 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 mm. Hg) in 166 lung transplant candidates and the difference was > 20 mm. Hg 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 O 2 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.

SICU • • • This 12 -bed North 3 MSICU functions as a primary teaching unit and is semi-closed for the purpose of orders; the patients are jointly managed by Neurosurgery - Surgery and Critical Care, with concurrent care by primary surgical services. The unit admits approximately 75 patients per month and maintains a full census. This unit functions as a medical-surgical ICU due to high volume of admissions of surgical patients admitted for medical emergencies, neurointensive care cases requiring medical intensive care and pre-operative admissions of the high risk cardiac patients requiring intensive medical management. The Critical Care team does procedures. The Nursing Supervisor is Sue Martz, RN and Dr. Howard Doyle provides medical direction and coordinates this rotation. . The SICU is staffed with one attending, two fellows, surgical housestaff, and 5 Critical Care PAs. 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, cooximetry, 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: 00 AM 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. The most frequent diagnoses at the time of admission to the NCICU major vascular surgery such as abdominal aneurysm resection, major bowel or liver surgery, subarrachnoid 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. 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. The secondary objective is to develop a clinical training program in liver transplant during the 20045 year. * It is important to note that the North 3 SICU/CSICU has a short call CCM fellow available on weekends from 7 AM – 8 PM, while the CCM fellow on 24 hour on-call takes over responsibility for these units, in addition to the MICU and Consult after 8 PM.

SICU Reading List • • • • 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. 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. 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. 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. Godwin J, Heffner, J. Special Critical Care Considerations in Tracheostomy Management. Clinics in Chest Medicine 1991; 12(3): 573. 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. 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. 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. 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 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. 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. 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. 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. Steer ML: Early events in acute pancreatitis. Clin Gastroenterol 13: 213, 1999.

SICU Reading List • • • an ST, Lai ECS, Mok FPT, et al: Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 328: 228, 1993. Kusske AM, Rungione AJ, Reber HA: Cytokines and acute pancreatitis. Gastroenterology 110: 639, 1996. Sainio V, Kemppainen E, Puolakkainen P, et al: Early antibiotic treatment in acute necrotizing pancreatitis. Lancet 346: 663, 1995. 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. 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. 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 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. 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. Shires GT, Dineen P: Sepsis following burns, trauma and intra-abdominal infection. Arch Intern Med 142: 2012, 1982. Border JR, Hassett J, La. Duca J, et al: The gut origin septic states in blunt multiple trauma (ISS-40) in the ICU. Ann Surg 206: 42, 1987. Wilson C, Gupta R, Gilmour DG, et al: Acute superior mesenteric ischemia. Br J Surg 74: 279, 1987. Bailey RW, Bulkley GB, Hamilton SR, et al: Pathogenesis of non-occlusive ischemic colitis. Am J Surg 203: 509, 1986. Kaleya RN, Boley SJ: Acute mesenteric ischemia. Crit Care Clin 11: (2)479, 1995. 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. 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. Levy PJ, Kraus z. MM, Manny J: Acute mesenteric ischemia: improved results—a retrospective analysis of ninety-two patients. Surgery 107: 372, 1990. Kron IL, Harman PK, Nolan AP: The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 199: 28, 1984. Burch JM, Moore EE, Moore FA, et al: The abdominal compartment syndrome [review]. Surg Clin North Am 76: 833, 1996. 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. 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. Iberti TJ, Kelly KM, Gentili DR, et al: A simple technique to accurately determine intra-abdominal pressure. Crit Care Med 15: 1140, 1987. Pachter HL, Feliciano DV: Complex hepatic injuries. [Review] [66 refs]. Surg Clin North Am 76: 763, 1996. Elliott D, Kufera JA, Myers RA: The microbiology of necrotizing soft tissue infections. Am J Surg 179: 361, 2000. Eke N: Fournier's gangrene: a review of 1726 cases. Br J Surg 87: 718, 2000. 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. Bilton BD, Zibari GB, Mc. Millan RW, et al: Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg 64: 397, 1998. Lille ST, Sato TT, Engrav LH, et al: Necrotizing soft tissue infections: obstacles in diagnosis. J Am Coll Surg 182: 7, 1996. Elliott DC, Kufera JA, Myers RA: Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg 224: 672, 1996. • Keen RR, Mc. Carthy WJ, Pearce WH, et al: Surgical management of atheroembolization. J Vasc Surg 21: 773, 1995. • • • • • •

SICU Reading List 1. 2. 3. 4. 5. 6. • 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. Mabee JR, Bostwick TL: Pathophysiology and mechanisms of compartment syndrome. Ortho Rev 22: 175, 1993. Robinson JF, Robinson WA, Cohn A, et al: Perforation of the great vessels during central venous line placement. Arch Intern Med 155: 1225, 1995. 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. 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 Labori KJ. Raeder MG. Diagnostic approach to the patient with jaundice following trauma. Scandinavian Journal of Surgery: SJS. 93(3): 176 -83, 2004. Loveland JA. Boffard KD. Damage control in the abdomen and beyond. British Journal of Surgery. 91(9): 1095 -1101, 2004

CSICU • • • MOSES HEART CENTER UNIT (CSICU: This 12 -bed North 3 Heart Center Unit is a teaching unit and is closed for the purposes of orders; Cardiothoracic Surgery, Cardiology and Critical Care jointly manage the patients. Critical Care Medicine is directly responsible for the management and staffing of the CSICU. All procedures are done by Cardiothoracic Surgery or Critical Care housestaff. Nursing Director is Sue Picca, R. N and the Medical Director is Anthony Carlese, MD. Medical Co-director is Dr. Ronald Smith. The unit is staffed with a CCM attending and two CCM fellows, and a CCM PA; Cardiothoracic Surgery fellow and PA staff are also included. The objective is to train housestaff in didactic and technical aspects of postoperative management of patients after cardiothoracic surgery, as well as in acute cardiac medical care. This includes management of surgical complications, pacemakers, arrhythmias, and coagulation disorders and post-operative respiratory and renal insufficiency. The fellows are expected to go to the OR at least once per week, get a working knowledge of the cardiopulmonary bypass for the intra operative and post operative management and of anesthetic techniques applicable to cardiovascular illness. The rounds are at 6: 30 AM and 8: 00 PM everyday. The fellows are encouraged to attend the Chairman's rounds in Moses CSICU on Saturday at 8: 00 AM. The fellows are required to attend the Monday Cardiothoracic Conference is at 7: 00 AM, and are encouraged to attend the Cardiac Cath Conference and Cardiology Grand Rounds. Critical Care Medicine provides a monthly conference on Monday morning dealing with in-depth review of a Critical Care topic relevant to acute cardiac care. The in-house call for this rotation is every fourth night. The most frequent diagnoses at the time of admission to the CSICU are coronary artery bypass graft, valvular surgery and thoracic surgery. In addition, there is a rapidly expanding heart transplant program and a ventricular assist device (VAD) program. The fellows are exposed to management of perioperative cardiac failure and cardiogenic shock, post-operative emergencies including cardiac tamponade and hemorrhage, severe respiratory failure and renal failure. Acute cardiac medical intensive care diagnoses include myocardial infarction, unstable angina, cardiogenic shock and complex arrhthymias. Goal: The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with severe cardiac disease requiring medical and surgical correction and critical care support. 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 from 7 am through 12 midnight every day. Objective: To instruct the fellows in staffing and directing a university hospital heart transplant cardiothoracic ICU using large volume of support technologies including IABP, ECMO, and VAD.

Reading List 1. 2. 3. 4. 5. 6. • Gilbert TB, Mc. Grath BJ, Soberman M. Chest tubes: indications, placement, management, and complications. J Intensive Care Med 1993; 8: 73 -86. Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. CHEST 1997; 111: 154851. Only randomized trial comparing immediate VATS to tube thoracostomy plus 3 days of daily SK (only 20 patients total). The surgical group had better primary treatment success and earlier hospital discharge, but outcomes of patients randomized to chest tube/lytics was much worse than other reported series, suggesting suboptimal management of those patients. All medical failures were salvageable with VATS. Ashbaugh DG. Empyema thoracis. Factors influencing morbidity and mortality. Chest 1991; 99: 1162 -5. Study of 122 consecutive patients looked at the morbidity and mortality of delaying treatment of empyema. Waiting more than 3 days to place a chest tube, and more than 14 days to proceed to surgical drainage when chest tubes fail, was associated with increased morbidity and mortality. Weinstein G, Parinam S, et al. Serial Changes in Renal Function in Cardiac Surgical Patients. Ann Thorac Surg 1989; 48: 72. Zerr K, Furnary A, et al. Glucose Control Lowers the Risk of Wound Infection in Diabetics After Open Heart Operations. Ann Thorac Surg 1997; 63: 356. Zacharias A, Habib R. Factors Predisposing to Median Sternotomy Complications. Chest 1996; 110: 11731178. Brunet F, Brusset A, et al: Risk factors for deep sternal wound infections after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 111: 1200, 1996.

Reading List 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. • Braxton J, Marrin CA, Mc. Grath PD, et al: Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg 70(6): 2004, 2000. Moulton MJ, Crewsell LL, Mackey ME, et al: Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 111: 1037, 1996. Laub G, Riebman J, et al. The Impact of Aprotinin in Coronary Artery Bypass Graft Patency. Chest 1994; 106: 1370 -1375. Kvetan V, Angus D, Gold J. Cardiac Surgery and Critical Care Medicine. New Horizons 1999; 7(4): 441 -594. Ferraris VA, Ferraris SP: Risk factors for postoperative morbidity. J Thorac Cardiovasc Surg 111: 731, 1996. Higgins T, Estafanous F, Lloyd F, et al: Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients: A clinical severity score. JAMA 207: 2344, 1994. Berger PB, Alderman EL, Nadel A, et al: Frequency of early occlusion and stenosis in a left internal mammary artery to left anterior descending artery bypass graft after surgery through a median sternotomy on conventional bypass: benchmark for minimally invasive direct coronary artery bypass. Circulation 100: 2353, 1999. Force T, Hibberd P, Weeks G, et al: Perioperative myocardial infarction after coronary artery bypass surgery. Circulation 82: 903, 1990. Kajani M, Waxman H: Hematologic problems after open heart surgery, in Kotler M, Alfieri A (eds): Cardiac and Noncardiac Complications of Open Heart Surgery: Prevention, Diagnosis, and Treatment. Mt. Kisco, NY, Futura, 1992, p 219. Bailey JM, Levy JH, Kikura M, et al: Pharmacokinetics of intravenous milrinone in patients undergoing cardiac surgery. Anesthesiology 81: 616, 1994. Lee WA, Gillinov AM, Cameron DE, et al: Centrifugal ventricular assist device for support of the failing heart after cardiac surgery. Crit Care Med 21: 1186, 1993. Oz M, Rose E, Levin H: Selection criteria for placement of left ventricular assist devices. Am Heart J 129: 173, 1995. Chuttani K, Tischler MD, Pandian NG, et al: Diagnosis of cardiac tamponade after cardiac surgery: relative value of clinical, echocardiographic, and hemodynamic signs. Am Heart J 127: 913, 1994. Andrews TC, Reimold SC, Berlin JA, et al: Prevention of supraventricular arrhythmias after coronary artery bypass surgery. A meta-analysis of randomized controlled trials. Circulation 84[Suppl III]: III-236, 1991. Ommen SR, Odell JA, Standon MS: Atrial arrhythmias after cardiothoracic surgery. N Engl J Med 336: 1429, 1997. Chung MK: Cardiac surgery: postoperative arrhythmias. Crit Care Med 28[Suppl]: N 136, 2000. Cameron D: Initiation of white cell activation during cardiopulmonary bypass: cytokines and receptors. J Cardiovasc Pharmacol 27[Suppl 1]: S 1, 1996. Moore FD Jr, Warner KG, Assousa S, et al: The effects of complement activation during cardiopulmonary bypass. Ann Surg 208: 95, 1988. Kellerman PS: Perioperative care of the renal patient. Arch Intern Med 154: 1674, 1994. Kaul TK, Crow MJ, Rajah SM, et al: Heparin administration during extracorporeal circulation. Heparin rebound and postoperative bleeding. J Thorac Cardiovasc Surg 78: 95, 1979. Levi M, Cromheecke ME, de Jonge E, et al: Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant end points. Lancet 354: 1940, 2000. Kreter B, Woods M: Antibiotic prophylaxis for cardiothoracic operations. Meta-analysis of thirty years of clinical trials. J Thorac Cardiovasc Surg 104: 590, 1992. Puskas JD, Winston AD, Wright CE, et al: Stroke after coronary artery operation: incidence, correlates, outcome, and cost. Ann Thorac Surg 69: 1053, 2000. Kuroda Y, Uchimoto R, Kaieda R, et al: Central nervous system complications after cardiac surgery: a comparison between coronary artery bypass grafting and valve surgery. Anesth Analg 76: 222, 1993. Egleston CV, Wood AE, Gorey TF, et al: Gastrointestinal complications after cardiac surgery. Ann R Coll Surg Engl 75: 52, 1993. Crock PA, Ley CJ, Martin IK, et al: Hormonal and metabolic changes during hypothermic coronary artery bypass surgery in diabetic and nondiabetic subjects. Diabetic Med 5: 47, 1988.

Weiler CICU • • • This 15 -bed 4 West Heart Center Unit (10 CT Surgery; 5 Cardiology/CHF) is a teaching unit and is closed for the purposes of orders; the patients are jointly managed by Cardiothoracic Surgery, Cardiology and Critical Care Medicine is directly responsible for the management and staffing of the CSICU. The unit is in the process of expanding to a 18 -bed new Heart Center Unit with an adjacent 8 -10 -bed intermediate care unit. All procedures are done by Cardiothoracic Surgery or Critical Care housestaff. Scott Monrad, M. D. is the Director of Cardiology, Robert Foreman, M. D. is the Director of CCU, Jamshid Shirani, and M. D. is the Director of Cardiology Fellowship Program and of Echocardiology. Abe Deanda, MD and Joe Derose. MD. are the full-time on-site Cardiothoracic Surgery Attendings. Nursing Director is Pat Bernes, R. N and the Medical Director is Jose Yunen, MD. The unit is staffed with a CCM attending and two CCM fellows, as well as a Cardiology and Cardiothoracic Surgery fellow and PA staff. The objective is to train housestaff in didactic and technical aspects of postoperative management of patients after cardiothoracic surgery, as well as in acute cardiac medical care. This includes management of surgical complications, pacemakers, arrhythmias, and coagulation disorders and post-operative respiratory and renal insufficiency. The fellows are expected to go to the O. R. at least once per week, get a working knowledge of the cardiopulmonary bypass for the intra operative and post operative management and of anesthetic techniques applicable to cardiovascular illness. The rounds are at 6: 30 AM and 8: 00 PM everyday. The fellows are encouraged to attend the Chairman's rounds in Moses CSICU on Saturday at 8: 00 a. m. The fellows are required to attend the Monday Cardiothoracic Conference, and are encouraged to attend the Cardiac Cath Conference and Cardiology Grand Rounds. Critical Care Medicine provides a monthly conference on Monday morning dealing with in-depth review of a Critical Care topic relevant to acute cardiac care. The in-house call for this rotation is every fourth night, and is integrated with the call for the adjacent MSICU. Dr. Shirani directs the Cardiology fellowship program, and directs an echocardiography laboratory located directly in the CSICU/CCU, which instructs the Critical Care fellows in echocardiography. The most frequent diagnoses at the time of admission to the CSICU are coronary artery bypass graft, valvular surgery and thoracic surgery. The fellows are exposed to management of perioperative cardiac failure and cardiogenic shock, post-operative emergencies including cardiac tamponade and hemorrhage, severe respiratory failure and renal failure. Acute cardiac medical intensive care diagnoses include myocardial infarction, unstable angina, cardiogenic shock and complex arrhthymias. Goal: The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with severe cardiac disease requiring medical and surgical correction and critical care support. 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 from 7 am through 12 midnight every day. Objective: To instruct the fellows in the requirements to staff and direct a general cardiac ICU with surgical and medical case mix.

Weiler MSICU • • This 14 -bed 4 West ICU functions as a primary teaching unit and is closed for the purposes of orders and procedures. The unit admits approximately 100 patients per month and maintains a full census. Medical Director is Dr. Peter Dicpinigaitis and the Nursing Supervisor is TBD The medical co-director is Dr. jim Gasperino. The unit is staffed with one attending, two fellows, two senior anesthesia residents and five Critical Care PA. The objective is to train housestaff in didactic and technical aspects of management of patients with critical medical and surgical illness. The night and weekend call staffing consists of a CCM attending from 7: 00 AM to 12 midnight daily plus 24 hour coverage by a CCM fellow and a CCM PA. The rounds start at 8: 00 AM on weekdays and weekends immediately following the daily 7: 00 AM Critical Care Service report. The average night call for fellows on this rotation is every fourth night. This unit is a model of a university hospital teaching unit in a tertiary referral academic center, and is structured as a combined medical-surgical ICU which is the predominant national model of critical care practice for hospitals of this size. 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. Fluoroscopy access is through the adjacent CCU and in the last two beds. The Critical Care fellow's office/conference room is shared with the P. A. team, and contains a library, computer system for medical literature search and other necessary educational materials. Close relationships exist with the adjacent Echocardiography lab and Coronary Care Unit. The most frequent diagnoses at the time of admission to the MSICU are severe respiratory failure, septic shock, endocrine and metabolic emergencies, hemorrhagic shock, oncologic emergencies, and neuromuscular crises. The major surgical diagnoses are extensive vascular and intraabdominal procedures, thoracic surgery and spine surgery. Goal: The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with medical-surgical critical illness in the setting of a tertiary referral voluntary hospital in a closed unit setting. The combined medicalsurgical format is crucial for administrative and management training of the fellows, who also have a major role in administering the post-anesthesia care unit under the supervision of Critical Care faculty. 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 from 7 am through 12 midnight every day. Objective: To instruct the fellows in the requirements to staff and direct a general community hospital medical-surgical ICU, which is the primary model of critical care, practice in the U. S. Additional experience in managing patients with obstetric-gynecologic emergencies.

Reading List 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. • Maternal Mortality and Morbidity Review Committee. Pregnancy-associated mortality. Medical causes of death 1995– 1998. Matern Mortal Morb Rev Mass (1): 1, 2000. Donaldson JO: Neurologic emergencies in pregnancy. Obstet Gynecol Clin North Am 18(2): 199, 1991. Barton JR, Sibai BM: Care of the pregnancy complicating HELLP syndrome. Obstet Gynecol Clin North Am 18(2): 165, 1991. Masson RG. Amniotic fluid embolism. Clin Chest Med 1992; 13: 657 -665. Nelson-Piercy C. Asthma in pregnancy. Thorax 2001; 56(4): 325 -328. Position Statement: The use of newer asthma and allergy medications during pregnancy. Ann Allergy Asthma Immunol 2000; 84: 475 -480. Ginsberg JS, Greer I, et al. Use of antithrombotic agents during pregnancy. Chest 2001; 119(Supp 1): 122 S-131 S. Greer IA. Thrombosis in pregnancy: maternal and fetal issues. Lancet 1999; 353: 1258 -1265. Deblieux PM, Summer WR. Acute respiratory failure in pregnancy. Clin Obstet Gynecol 1996; 39(1): 143 -152. Ramsey PS, et al. Pneumonia in pregnancy. Obstet Gynecol Clin North Am 2001; 28(3): 553559. Andres RL, Miles A et al. Venous thromboembolism and pregnancy. Obstet Gynecol Clin North Am 2001; 28(3): 613 -630.

St. Barnabas Hospital Trauma ICU • • The ACGME requirement for Trauma/Critical Care management training of fellows is met in this 16 bed ICU that is an integral part of the ACGME CCM accredited fellowship program of Mount Sinai Medical Center Program (ACGME # 0453521020). Medical Director is Daryll Adler, MD, & The Departmentb of Surgery is Dr. Di. Rossi, with the head of Trauma & Critical Care being Dr. Davis. There are 900 major Trauma cases per year admitted to Elmhurst Hospital, and 250 -300 is admitted to the Trauma ICU each year. At least 50% of patients in this ICU has suffered from critical injury due to penetrating or blunt trauma. Some 50% of the trauma patients have significant neurosurgical critical illness. This service is fully integrated with the program of Department of Surgery under Dr. Di. Rossi. The Critical Care fellow calls alternates Monday through Fridayplus Friday night, with Monday through Saturday plus Saturday night. In addition to excellent surgical critical care training, the focused programs in this unit allows fellows to gain experience in being part of the trauma team. Also, they participate in Anesthesia operating room procedures, perform procedures not routinely done in Montefiore such as percutaneous tracheotomy, and are responsible for CRRT techniques such as CVVH and SLED. The CCM fellows will participate in the trauma case conferences, grand rounds and core curriculum lectures including the trauma journal club and M&M conferences as required by ACGME. Goals: The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with severe traumatic injury requiring medical and surgical correction and critical care support. 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 from 7 am to 7 pm every day.

Reading List • • • • • • • Zipnick RI, Scalea TM, Trooskin SZ, et al: Hemodynamic responses to penetrating spinal cord injuries. J Trauma 35: 578– 582, 1993. Chang MC, Meredith JW: Cardiac preload, splanchnic perfusion, and their relationship during resuscitation in trauma patients. J Trauma 42: 577– 584, 1997. Chang MC, Blinman TA, Rutherford EJ, et al: Preload assessment in trauma patients during large-volume shock resuscitation. Arch Surg 131: 728– 731, 1996. Miller PR, Meredith JW, Chang MC: Randomized, prospective comparison of increased preload versus inotropes in the resuscitation of trauma patients: effects on cardiopulmonary function and visceral perfusion. J Trauma 44: 107– 113, 1998. Cheatham ML: Right ventricular end-diastolic volume measurements in the resuscitation of trauma victims. Int J Crit Care 1– 6, 2000. Abramson D, Scalea TM, Hitchcock R, et al: Lactate clearance and survival following injury. J Trauma 35: 584– 589, 1993. Choi PTL, Yip G, Quinonez LG, et al: Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med 27: 200– 210, 1999. Kellum JA, Decker J: Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med 29: 1526– 1531, 2001. Goodnough LT, Brecher ME, Kanter MH, et al: Transfusion medicine: first of two parts—blood transfusion. N Engl J Med 340: 438, 1999. Matsuoka T, Wisner DH: Resuscitation of uncontrolled liver hemorrhage: effects on bleeding, oxygen delivery, and oxygen consumption. J Trauma 41: 439, 1996. Mann CN, Mullins RJ, Mac. Kenzie EJ, et al: Systematic review of published evidence regarding trauma system effectiveness. J Trauma 47: S 25, 1999. Bullock R, Chestnut RM, Clifton G, et al: Guidelines for the Management of Severe Head Injury. New York, Brain Trauma Foundation, 1995. Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34: 216, 1993. Muizelaar JP, Marmarou A, Ward JD, et al: Adverse effects of prolonged hyperventilation in patients with severe head injury. J Neurosurg 75: 731, 1991. Temkin NR, Dikman SS, Wilensky AJ, et al: A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med 323: 497, 1990. Hsiang JK, Chesnut RM, Crisp CB, et al: Early, routine paralysis for intracranial pressure control in severe head injury: is it necessary? Crit Care Med 22: 1471, 1994. Robertson CS, Gopinath SP, Goodman JC, et al: Sj. VO 2 monitoring in head-injured patients. J Neurotrauma 12: 891, 1995. Amar A, Levy M: Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal injury. Neurosurgery 44: 1027– 1040, 1999. Lu J, Ashwell K, Waite P: Advances in secondary spinal cord injury. Spine 25: 1859– 1866, 2000. Harrop J, Sharan A, Vaccaro A, et al: The cause of neurologic deterioration after acute cervical spinal cord injury. Spine 26: 340– 346, 2001. Marino R, Ditunno J, Donovan W, et al: Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems. Arch Phys Med Rehab 80: 1391– 1396, 1999. Maynard F, Bracken M, Creasey G, et al: International standards for neurological and functional classification of spinal cord injury. Spinal Cord 35: 266– 274, 1997. Bracken M: Methylprednisolone and spinal cord injury. J Neurosurg 96: 140– 141, 2002. Deep K, Jigajinni M, Mc. Lean A, et al: Prophylaxis of thromboembolism in spinal injuries—results of enoxaparin used in 276 patients. Spinal Cord 39: 88– 91, 2001. Velmahos G, Kern J, Chan L, et al: Prevention of venous thromboembolism after injury: an evidence-based report—Part II: analysis of risk factors and evaluation of the role of vena caval filters. J Trauma 49: 140– 144, 2000. Nagy KK, Krosner SM, Joseph KT, et al: A method of determining peritoneal penetration in gunshot wounds to the abdomen. J Trauma 43(2): 242, 1997. Zantut LF, Ivatury RR, Smith RS, et al: Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma—a multicenter experience. J Trauma 42(5): 825, 1997.

Reading List • • • Boyle EM, Maier RV, Salazar JD, et al: Diagnosis of injuries after stab wounds to the back and flank. J Trauma 42(2): 2660, 1997. Velmahos GC, Demetriades D, Foianini E, et al: A selective approach to the management of gunshot wounds to the back. Am J Surg 174(3): 342, 1997. Hodgson NF, Stewart TC, Girotti MJ: Open or closed diagnostic peritoneal lavage for abdominal trauma? A meta-analysis. J Trauma 48(6): 1091, 2000. Blow O, Bassam D, Butler K, et al: Speed and efficiency in the resuscitation of blunt trauma patients with multiple injuries: the advantage of diagnostic peritoneal lavage over abdominal computed tomography. J Trauma 44(2): 287, 1998. Scalfani SJ, Shaftan GW, Scalea TM, et al: Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. J Trauma 39(5): 818, 1995. Myers JG, Dent DL, Stewart RM, et al: Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma 48(5): 801, 2000. Shatz DV, Schinsky MF, Pais LB, et al: Immune responses of splenectomized trauma patients to the 23 -valent pneumococcal polysaccharide vaccine at 1 verses 7 versus 14 days after splenectomy. J Trauma 44(5): 760, 1998. Croce MA, Fabian TC, Menke PG, et al: Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Ann Surg 221(6): 744, 1995. Richardson JD, Franklin GA, Lukan JK, et al: Evolution of hepatic trauma: a 25 -year perspective. Ann Surg 232(3): 324, 2000. Timaran CH, Martinez O, Ospina JA: Prognostic factors and management of civilian penetrating duodenal trauma. J Trauma 47(2): 330, 1999. Takishima T, Sugimoto K, Hirata M, et al: Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 221(1): 70, 1997. Allen GS, Moore FA, Cox CS, et al: Delayed diagnosis of blunt duodenal injury: an avoidable complication. J Am Coll Surg 187(4): 393, 1998. Stapfer M, Selby RR, Stain SC, et al: Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 232(2): 191, 2000. Fang JF, Chen RJ, Lin BC, et al: Small bowel perforation: is urgent surgery necessary? J Trauma 47: 515, 1999. Frick EJ, Pasquale MD, Cipolle MD: Small-bowel and mesentery injuries in blunt trauma. J Trauma 46: 920, 1999. Bozorgzadeh A, Pizzi WF, Barie PS, et al: The duration of antibiotic administration in penetrating abdominal trauma. Am J Surg 177: 125, 1999. Murray JA, Demetriades D, Colson M, et al: Colonic resection in trauma: colostomy verses anastomosis. J Trauma 46: 250, 1999. Santucci RA, Mc. Aninch JW: Diagnosis and management of renal trauma: past, present, and future. J Am Coll Surg 191(4): 443, 2000. Sinnott R, Rhodes M, Brader A: Open pelvic fracture: an injury for trauma centers. Am J Surg 163: 283, 1992. Kale IT, Kuzu MA, Berkem H, et al: The presence of hemorrhagic shock increases the rate of bacterial translocation in blunt abdominal trauma. J Trauma 44: 171, 1998. Swank GM, Deitch EA: Role of the gut in multiple organ failure: bacterial translocation and permeability changes. World J Surg 20: 411, 1996. Kirton OC, Windsor J, Wedderburn R, et al: Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU. Chest 113: 1064, 1998. Kshettry VR, Bolmon RMI: Chest trauma: assessment, diagnosis, and management. Clin Chest Med 15: 137– 146, 1994. Branney SW, Moore EE, Feldhaus KM, et al: Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma 45: 87– 94; discussion 94– 95, 1998. Wall MJ, Granchi T, Liscum K, et al: Penetrating thoracic vascular injuries. Surg Clin North Am 76: 749– 761, 1996. • Nagy KK, Lohmann C, Kim DO, et al: Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 38: 859– 862, 1995. • • • • •

Reading List • • • • , Moore EE, Ilke DN, et al: Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1, 561 patients. J Trauma 48: 673– 682; discussion 682– 683, 2000. Smith MD, Cassidy JM, Souther S, et al: Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 332: 356– 362, 1995. Minard G, Schurr MJ, Croce MA, et al: A prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta. J Trauma 40: 225– 230, 1996. Ziegler DW, Agarwal NN: The morbidity and mortality of rib fractures. J Trauma 37: 975– 979, 1994. Freedland M, Wilson RF, Bender JS, et al: The management of flail chest injury: factors affecting outcome. J Trauma 30: 1460– 1468, 1990. Ahmed Z, Mohyuddin Z: Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 110: 1676– 1680, 1995. Allen GS, Coates NE: Pulmonary contusion: a collective review. Am Surg 62: 895– 900, 1996. Sharma S, Mullins RJ, Trunkey DD: Ventilatory management of pulmonary contusion patients. Am J Surg 172: 529– 532, 1996. Bertinchant JP, Polge A, Mohty D, et al: Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma 48: 924– 931, 2000. Fabian TC, Richardson JD, Croce MA, et al: Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma 42: 374– 383, 1997. Luchette FA, Barrie PS, Oswanski MF, et al: Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: the EAST practice management guidelines work group. J Trauma 48: 758– 759, 2000. Reed WJ, Doyle SE, Aprahamian C: Tracheoesophageal fistula after blunt chest trauma. Ann Thorac Surg 59: 1251– 1256, 1995. Hargens AR, Mubarak SJ: Current concepts in the pathophysiology, evaluation, and diagnosis of compartment syndrome. Hand Clin 14: 371, 1998. Whitesides TE, Heckman MM: Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg 4: 209, 1996. Andermahr J, Helling HJ, Tsironis K, et al: Compartment syndrome of the foot. Clin Anat 14: 184, 2001. Block EF, Dobo S, Kirton OC: Compartment syndrome in the critically injured following massive resuscitation: case reports. J Trauma 39: 787, 1995.

Consult • • • This crucial rotation covers all Critical Care activity outside of the main teaching units, and is concerned with medical intensive care management of patients in the ER, on the medical/surgical floors and in the surgical specialty areas, such as the Surgical Special Care Unit and Recovery Rooms at Moses. The Service sees approximately 450 patients per month at both sites, with the total exceeding 5, 000 consultations per year, which are equally divided between the ER and other services. The fellows are expected to follow high acuity discharges during the first 24 -48 hours, as well as making regular rounds with Respiratory Therapy on ventilator patients outside of the ICUs. The fellows acquire skills in rapid critical care assessment and management in a less technologically intense environment. The Consult fellow is responsible for critical care early intervention and triage throughout the institution. The rotation is covered by the CCM attending in the primary target units and occasionally, an Emergency Medicine resident assigned to CCM. The fellow starts rounds at 7: 00 a. m. with the CCM Chief of Service Report, and is responsible for coordinating evening continuous triage rounds for Moses MICU and MSICU, as well as Weiler MSICU and CSICU/CCU. The Consult fellow assists the Chairman of the Critical Care Q. I. Committee in preparing the monthly meeting, acquires skills in triage decision making and ethics, gains exposure in management of O. R. scheduling. The fellow on call or the second fellow performs the consult function in one of the two site units as designated by the faculty. Scope of this service is expanding to include insertion of all CVP lines and senior coverage of the CAC team. Goal: Educational purpose of this rotation is to develop expertise in evaluation and management of critically ill patients outside of the ICU environment. The fellows are required to perform thorough evaluation, and develop management and triage plan under direct supervision of a faculty member. The principle teaching method is case based learning, which includes assessment of severity of illness and outcome, aggressive early intervention, critical care transport and, when appropriate application of palliative care. Follow up to selected patients discharged from main intensive care units is provided. Faculty will provide supervision to fellows on site 24/7. With 7 am to 4 pm weekday coverage being dedicated with a separate attending. Objective: To instruct the fellows in the requirements to function as the institutional triage officer, as well as an early intervention intensivist delivering rapid competent care to critically ill patients outside of the ICU along the ICU without walls concept.

Reading List 1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. 2. Nugyen HB, Rivers EP, Havstad S, Knoblich B, Ressler JA, Muzzin AM, Tomlanovich MC: Critical care in the emergency department: Aphysiologic assissment and outcome evaluation. Acad Emerg Med. 2000 Dec; 7(12): 1354 -61. 3. Shoemaker WC, Wo CC, Yu S, Farjam F, Thangathurai D: Invasive and noinvasive haemodynamic monitoring of acutely ill sepsis and septic shock patients in the emergency department. Eur J Emerg Med. 2000 Sep; 7(3): 169 -75. 4. Truog RD, Cist AF, Brackett SE, Burns JP, Curley MA, Danis M, De. Vita MA, Rosenbaum SH, Rothenberg DM, Sprung CL, Webb SA, Wlody GS, Hurford WE. Recommendations for end-of-life in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001 Dec; 29(12): 2332 -48. 5. Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A, Oppenheim A, Epstein L, Cotev S. Evaluation of triage decisions for intensive care admission. Crit Care Med. 1999 June; 27(6): 1073 -9. 6. Metcalfe MA, Sloggett A, Mc. Pherson K. Mortality among appropriately referred patients refused admission to intensive care units. Lancet. 1997 July 5; 350(9070): 7 -11. 7. Morales IJ, Peters SG, Afessa B. Hospital mortality rate and length of stay in patients admitted at night to the intensive care unit. Crit Care Med. 2003 Marcgl 31(3)L 858 -63, 8. Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001 Mar; 29(3): 635 -40. 9 Afessa B. Triage of patients with acute gastroinestional bleeding for intensive care unit admission based on risk factors for poor outcome. J Clin Gastroenterol. 2000 Apr; 30(3): 281 -5. 10 . Morales IJ, Peters SG, Afessa B. Hospital mortality rate and length of stay in patients admitted a night to the intensive car unit. Crit Care Med. 2003 Mar; 31(3): 858 -63. 11. Rosenberg AL, Hofer TP, Strachan C, Watts CM, Hayward RA. Accepting critically ill transfer patients: adverse effect on a referral cneter’s outcome and benchmark measures. Ann Intern Med. 2003 June 3; 138(11): 882 -90. 12 Higgins TL, Mc. Gee WT, Steingrub JS, Rapoport J, Lemeshow S, Teres. Early indicators of prolonged intensive care unit stay: impact of illness severity, physician staffing, and pre-intensive care unit length of stay. Crit Care Med. 2003 Jan; 31(1): 45 -51. 13 Rocker G, Cook D, Sjokvist P, Weaver B, Finfer S, Mc. Donald E, Marsh J, Kirby A, Levy M, Dodek P, Heyland D, Guyatt G; Level of Care Study Investigators; Canadian Critical Care Trials Group. Crit Care Med. 2004 May; 32(5): 1149 -54. Nasraway SA, Button GJ, Rand WM, Hudson-Jinks T, Gustafson M. Surviors of catastrophic illness: outcome after direct transfer from intensive care to extended care facilities. Crit Care Med. 2000 Jan; 28(1): 19 -25.

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