INTENSIVE CARE UNIT

Clinical Rotation Goals for IR Trainees

Written by: Shantanu Warhadpande MD
Edited by: Amanjit Baadh MD

GENERAL

Be proficient in all aspects of BLS and ACLS

Know DVT prophylaxis measures (SCDs, SQ heparin, etc.)
Know stress ulcer prophylaxis measures (PPIs)
Be comfortable with fluids, pressors, sedation, pain regimens, and other drips

RESPIRATORY FAILURE
Know the two overarching types of respiratory failure (hypercapnic, hypoxemic)
Be able to recognize each type using physical exam clues, an ABG, and vital signs
Identify the common causes of respiratory failure and the pathogenesis/management of each:
o ARDS
o Pneumonia
o COPD/asthma exacerbation
o Massive pulmonary embolism
o Decreased respiratory drive
Know when supplemental oxygen is indicated and be able to recognize a shunt
Know when to use NIPPV/High Flow O2
Know when to intubate
Recognize the general ventilator settings (PEEP, FiO2, Tidal Volume, respiratory rate) and when to adjust
them
Know the criteria used to wean a patient from a ventilator

SHOCK
Identify the types of shock (cardiogenic, septic, anaphylactic, neurogenic, hypovolemic, distributive)
using vitals, physical exam, LA wedge pressure, central venous pressure
Be able to manage each type of shock and know when to use fluids, pressors, antibiotics, inotropes,
invasive (Swan-Ganz) and biochemical monitoring (lactate)
Recognize when a patient is bleeding and be able to identify the source of the bleed (fecal occult blood
stool, FAST scan, etc.)
Know routine transfusion and massive transfusion protocols
Know when to use cryoprecipitate, fresh frozen plasma, platelets, pRBCs
Know how to reverse commonly used anticoagulants and how to monitor response

HEART FAILURE
Recognize the signs, symptoms of heart failure
Be able to identify the physical exam findings of HF: JVD, hepatomegaly, ascites, lung base crackles, LE
pitting edema
Know the medications to use for symptomatic therapy (diuretics) and for long-term therapy (ACE-
I/ARBs, beta blockers, spironolactone) in patients with HF
Know how to use patients weight to evaluate progress
Be able to correct electrolyte abnormalities seen in HF patients
Identify when a patient is acutely decompensating
Identify, manage and follow up massive and submassive PE

ACUTE CORONARY SYNDROME

Know the difference between stable angina, unstable angina, NSTEMI, STEMI
Recognize when a patient is suffering from an ACS and know which labs/imaging studies to order (i.e.
ECG, troponin/CK-MB, etc.)
Know the initial pharmacological management of each presentation
Recognize an NSTEMI, STEMI using an ECG
Identify the major causes of mortality and what complications to monitor for in a post-MI patient
(recurrent MI, ventricular rupture, papillary muscle rupture, etc.)
Have familiarity at recognizing commonly seen ECG rhythms and arrhythmias

ACUTE RENAL FAILURE

Know the different etiologies of pre-renal acute renal failure and how to manage them
Know the different etiologies of intra-renal causes of acute renal failure and how to manage them
Know the different etiologies of post-renal causes of acute renal failure and how to manage them
Be able to diagnose acute renal failure and the specific cause using laboratory findings (BUN/Cr,
electrolyte abnormalities, urine output, urinalysis, vital signs, etc.)

CHRONIC KIDNEY DISEASE

Identify the most common causes of chronic kidney disease (HTN, DM, etc.)
Know the sequelae of CKD (anemia, HTN, electrolyte abnormalities, hyperparathyroidism, etc.)
Be able to manage fluids/electrolytes in a patient with CKD
Identify the indications for emergent dialysis
Identify the indications for long-term dialysis

ACID-BASE DISTURBANCES
Be able to recognize using an ABG and laboratory findings, metabolic acidosis/alkalosis, respiratory
acidosis/alkalosis
Recognize the appropriate compensatory changes for each disturbance
Known common causes of each disturbance and the initial management
Be able to calculate an anion gap in patients with metabolic acidosis
Know when to use serum osmolarity gap

ELECTROLYTES
Identify electrolyte abnormalities and common causes:
o Hyperkalemia
o Hypokalemia
o Hypercalcemia
o Hypocalcemia
o Hyperphosphatemia
o Hypophosphatemia
o Hypernatremia
o Hyponatremia
Recognize the red-flag sequelae for each electrolyte disturbance and know how to manage these
complications (i.e. Peaked T-waves in hyperkalemia, QT prolongation in hypocalcemia, etc.)
Know the common clinical pearls in the correction of each electrolyte disturbance (i.e. avoid rapid
correction of Na in patient with hyponatremia)

FLUID MANAGEMENT

Know the difference between crystalloids and colloids

Know the commonly used fluids (0.9% NaCl, 0.45% NaCl, 3.0% NaCl, LR, D5W)
Identify the electrolyte composition and osmolarity of each
Know the common indications and contraindications for each
Know the commonly used infusion rates and hydration status indicators
Know how to assess a patients fluid status using physical exam, Chem 7, UA, ultrasound
Know how to manage fluids in a euvolemic patient
Identify the most common causes of hypervolemia
Know the fluid management and hydration goals in a hypervolemic patient
Identify the most common causes of hypovolemia
Know the fluid management and hydration goals in a hypovolemic patient

INFECTIOUS DISEASE

Know the commonly encountered infections in the ICU setting (HA-PNA, UTIs, sepsis, C. Diff etc.)
Know the criteria for sepsis and its variants (SOFA)
Know the antibiotic regimens used to treat these infections
Identify the preventative measures used to avoid PNA, line-involved infections, UTIs, etc.

DIABETIC MANAGEMENT

Be able to use the sliding scale insulin to control a patients glucose

Know how to manage fluids in a patient with diabetic nephropathy/CKD
Know how to manage electrolyte abnormalities in a patient with diabetic nephropathy/CKD
Recognize when a patient is in DKA or hyperosmolar hyperglycemic state (HHS)
Know the initial management and monitoring of patients in each (normal saline, insulin + glucose,
bicarbonate, potassium replenishment, etc.)

ICU PROCEDURAL GOAL

Know the indications and post-procedure complications for the following IR procedures commonly
performed on ICU patients:
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Tunneled Catheter Insertion / Removal

Port Removal
Percutaneous Cholecystostomy Tube Placement
Percutaneous transhepatic cholangiogram (PTC) and biliary drainage catheter placement (PTBD)
Abscess Drainage
Image-guided Thoracentesis, Paracentesis or Lumbar Puncture (in difficult patients)
IVC filter placement and retrieval
G/J-tube placement / exchange
Percutaneous nephrostomy tube placement / exchange
Visceral angiography and embolization for post-op hemorrhage or trauma
Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement / revision
Participate in, know each step of, and/or perform the following procedures:
Intubation / Extubation
Arterial Line Placement (Radial and Femoral)
Central Venous Catheter Placement (Jugular, Subclavian and Femoral)
Arterial and Venous Blood Gas Sampling
Lumbar Puncture
Thoracentesis
Paracentesis
NG/OG/Dobhoff Tube Placement