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INTRODUCTION TO PICUThe PICU rotation can be a difficult one. When residents work together as a team and help one another, the rotation becomes much easier and patient care improves. If there are ever any problems or concerns, the Attendings/PNP are ALWAYS available to discuss such issues.GENERAL RULES PICU patients are your patients: you are responsible for them and, so, need to practice as such. In order to ensure the best care you must follow the rules below.You must read the PICU syllabus and it is strongly recommended that you do so before you start the rotation. The Attendings assume that you will have a baseline amount of ICU knowledge. In addition, if you want to be able to do a procedure, and the opportunity arises, you must have read and/or seen a video dealing with the procedure. If no attempt has been made to learn about the procedure, then you will not be allowed to do the procedure.All residents must know the daily and global plans for every patient. On call residents need to know everything about all patients. That includes ventilator settings, caloric intake, etc. Ignorance is no excuse – if you don’t understand something, ask your attending.If a patient has a physiologic change that has not been addressed by the Attending on rounds, the Attending needs to be called and an SBAR form or note needs to be completedConsultants consult – you, not they, are the primary doctors in the PICU through which all information/plans funnel. If another service wants to do something or orders something on your patient that is a change from the PICU team’s plan, find out why and discuss it with the PICU Attending.If a patient’s clinical status is acutely evolving, the expectation is that the resident will be consistently present at the patient’s bedside, even if the Attending is present– not writing orders or notes at the communication station. Please utilize the Computer on Wheels and write orders and follow up on labs, at the bedside Find your PALS card and keep it with you. This will be some of your first experiences with 24 hour call. Prepare by having ongoing good sleep habits, drink lots of water, and have a well-balanced diet. Sleep when you can in the unit. Patients will be split as evenly as possible. How you split up the patients is up to your group. You may follow the same patient throughout or split the list according to acuity with the sickest patient going to the 24 hour call resident.Remember – you are in charge of your education. Read during downtime, ask questions of all participants in the PICU: the attending, the nurses, the nutritionist, the pharmacist, the chaplain. The PICU team has a wealth of knowledge so ask questions. GOALS AND OBJECTIVESObtain an understanding of the pathophysiology of various critical illnesses in childrenLearn to recognize, triage, and stabilize critically ill children and to realize one’s own limits of knowledge, skills, and stressorsBecome familiar with invasive procedures and monitoring in the PICUBecome familiar with ethical issues within the PICULearn to read, critique, and apply medical literature appropriatelyParticipate as an integral member of the PICU teamCURRICULUM CONTENTRespiratory Failure Pathophysiology of different types of respiratory failure and their treatments Bag mask ventilation and various modes of invasive and noninvasive positive pressure ventilation;Interpretation of arterial blood gassesCirculatory Failure 1. Types of shock and their manifestations Evaluation and resuscitation of children in shockMonitoring of shock statesUse of Vasopressors and InotropesRepair of Congenital Heart DiseaseTypes and post-operative management issues Acute Brain Injury 1. Causes and pathophysiology of various types of brain injury2. Clinical signs of high intracranial pressure3. Monitoring and management of high ICPSedation, Analgesia and Paralysis Strategies and pharmacology of various sedatives and analgesics Use and complications of paralytic agentsMetabolic/Endocrinologic Abnormalities Pathophysiology and treatment of critically ill patients with endocrinologic diseases such as diabetic ketoacidosis, congenital adrenal hyperplasia, etcHematologic and Oncologic AbnormalitiesEvaluation and management of bleeding disordersManagement of oncologic emergenciesRenal FailurePathophysiology and treatment of renal dysfunction and fluid managementEthics/Palliative CareDiscussion of relevant ethical issues seen with the critically ill childLECTURES: Please refer to the Teams site for your scheduleMondayTuesdayWednesdayThursdayFridayWeek 11-2PM Chief Rounds1-2PM Lecture PICUWeek 21-2PMLecture PICU1-2PM Chief Rounds1-2PM Lecture PICUWeek 31-2PM Lecture PICU1-2PM Chief Rounds 1-2PM Lecture PICUWeek 41-2PMLecture PICU1-2PM Chief Rounds1-2PM Lecture PICUWeek 51-2PMLecture PICUThe major teaching method is case-based instruction/discussion at the bedside. In addition, core lectures will be given by the PICU Attendings and supporting staff. Information about these lectures is available on the Teams site. Attendance is mandatory for all residents not in clinic. The attending will handle issues within the unit if necessary to ensure the participation of all other team members. Residents on a 5 person rotation will also participate as “Nurse for a Day” with an experienced PICU nurse along with time either in the sedation unit and/or on the code team. This will be assigned by the director of the PICU residency rotation and listed in your Teams rotation block site. EVALUATION METHODSThe resident will be evaluated on his or her clinical and procedural skills, interest in learning and reading, organizational skills, and interactions with other members of the medical staff as well as patients and their families. These evaluations will occur via direct observation by the PICU Attendings/PNP and will be reported on departmental evaluation forms at the end of each rotation. The PICU Attendings also provide written mid-rotation feedback. If a resident wishes feedback earlier in the rotation, he or she can ask an Attending/PNP for this information at any time during the rotation. CLINICAL RESPONSIBILITIESMorning Rounds7:30 AM Every patient should be seen and examined and appropriate lab values and radiographic studies’ results should be obtained prior to morning rounds. During your PICU rotation, your work hours are officially 6:30am - 4pm signout, Morning rounds template-This template should be followed for rounds. Resident introduction: 1 line about the patientInterval history or HPI: What happened overnight? Bedside RN Overnight eventsVital signs: Give ranges for this patient and talk about the abnormal vital signs. Urine output in(in cc/kg/hour) with 24hour I/O balance–attention should be paid to the last 8-12 hours if there has been a change. System review and quality (Braden, CAPD, WAT)RN and family concernsRT: Respiratory settings and IssuesPharmacy: Medications and issuesResidentExam: short and focused on pertinent positivesLabsRadiologyAssessment: one liner that shows you can synthesize what is going on with this patientPlans: Review by SystemsRespiratory – include vent settings or other O2 delivery devices; blood gas; meds (i.e. albuterol, heliox, steroids, etc.), CV – inotropes/pressors or other meds such as antihypertensives; lines; Neuro – sedatives, analgesics, and other meds (anti-epileptics – with drug levels); FEN/GI – nutrition/IVF/TPN; ideally, H/O – most recent CBC or other labs; medications; consults calledI/D – most recent cultures; list abx with levels; consults calledRenal –; medications; imaging; consults calledEndocrine – medications and labs; consults calledSocial – pertinent findings; consults calledIT IS ESSENTIAL FOR THE RESIDENTS TO EXAMINE EACH VENTILATOR AND IV PUMP TO ENSURE THE PROPER SETTINGS ARE IN PLACE AND BEING RECORDED Afternoon Rounds3 PM, Post-call residents and residents in clinic are not required to attend PM roundsDaytime Responsibilities Residents should frequently round on their patients in addition to completing the day’s tasks prescribed during roundsOrdersMajority of order writing should be done on rounds before moving onto the next patient. You should notify the patient’s nurse of ANY new or discontinued orders, especially if the order is written as STAT.Lexi-Comp online () is our hospital-approved reference for medication. There are links to Lexi-Comp directly from Powerchart and also from the main hospital intranet page.It is prudent and necessary to check every order every day to make sure that you haven’t hit a soft stop or fallen off of the pare active orders to what the patient should be getting to exactly what the patient is getting (MAR) every day.Admissions All PICU admissions are admitted under the PICU Attending’s name, unless they are a trauma patient. The trauma patients are admitted under the trauma attendings, co-managed by us. The Attending must be notified of all admissions by the ER, Peds senior resident, etc prior to acceptance. The PICU resident will contact the Attending once the new admission is evaluated and the resident has a treatment plan. It is the responsibility of the admitting resident to contact the patient’s PMD of the PICU admission either at the time of admission or the following morning.Transfer/Discharge NotesAny patient transferred or discharged from the PICU is to have a transfer/discharge summary and appropriate orders. It is the responsibility of the transferring resident to sign out to the accepting resident and primary pediatrician. This transfer/discharge note can be the daily progress note as well, with a detailed course for the accepting teamCommunicationPICU attending coverage is 24 hours in-house. The attending pagers and cell phones are on the back wall of the communication station and with the unit clerk. The attendings expect communication with any organ system change. It is better to over-communicate than to under communicate. One of the most important things the Attendings expect is a plan. So remember to have one when you call!Communication with the surgery team should go through the chief or most senior resident. If you aren’t getting an answer from any consulting service, let your attending know. ................
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