migraine12

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I will be starting my MICU rotation Aug. 1st as a PGY1. Any practical advice on what I should look over and know very well before starting on this rotation. Any advice on keeping track of patients, quick guides to carry in white coat, presenting a MICU patient during rounds, etc would be greatly appreciated. Basically just need to know how to make this month go as smoothly as possible while learning the most in terms of both patient management and procedural skills. Thanks.
 

bartleby

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Borrow a copy of "The ICU Book" by Marino. All you need to know.
 

12R34Y

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Also starting MICU on Aug 1st. definately a little frightened.
 

bulgethetwine

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12R34Y said:
Also starting MICU on Aug 1st. definately a little frightened.
Well, one good resource is Patrick Neligan's website:

www.ccmtutorials.com

The other thing I would remember is that your presentations on rounds should take the form of systems. Eg.,

Mr. Smith spiked a fever overnight...blah blah blah and the plan for today is:

Cardiovascualar: His BP is well controlled....
Resp: Stable on the vent settings:....
GI/Nutrition: Currently on tube feeds, at goal...
Neuro: blah blah....
Renal: Stable, no new events....
Hematology/Endocrine:
Skin/MSK:
ID: Cultures pending... blah blah
Glucose control: Currently controlled on a drip...
Lines: left ac, 18 ga peripheral, put in 7/23; Right IJ, Triple lumen, put in 7/22. All being used, clean and without signs of infection, no plan for removal.
Dispo: Full Code

The other point is BE ALL OVER THE LINES and VENT! Always know when each line was put in, confirm it is not infected, and confirm that it is still needed. Same as vent: Always know the vent settings, and your plan for getting the patient off (e.g. if weaned to 30% FiO2 with 5 of PEEP will titrate to room and attempt to extubate if ABG remains favorable...).


Oh, that and what the others said about Marino!

If you take one thing away, remember the thing about the lines :)

Good luck.
 

BKN

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bulgethetwine said:
Well, one good resource is Patrick Neligan's website:

www.ccmtutorials.com

The other thing I would remember is that your presentations on rounds should take the form of systems. Eg.,

Mr. Smith spiked a fever overnight...blah blah blah and the plan for today is:

Cardiovascualar: His BP is well controlled....
Resp: Stable on the vent settings:....
GI/Nutrition: Currently on tube feeds, at goal...
Neuro: blah blah....
Renal: Stable, no new events....
Hematology/Endocrine:
Skin/MSK:
ID: Cultures pending... blah blah
Glucose control: Currently controlled on a drip...
Lines: left ac, 18 ga peripheral, put in 7/23; Right IJ, Triple lumen, put in 7/22. All being used, clean and without signs of infection, no plan for removal.
Dispo: Full Code

The other point is BE ALL OVER THE LINES and VENT! Always know when each line was put in, confirm it is not infected, and confirm that it is still needed. Same as vent: Always know the vent settings, and your plan for getting the patient off (e.g. if weaned to 30% FiO2 with 5 of PEEP will titrate to room and attempt to extubate if ABG remains favorable...).


Oh, that and what the others said about Marino!

If you take one thing away, remember the thing about the lines :)

Good luck.
Good advice. I'd add when the patient crashes look at his pumps, lines and vent as well as him. It's often something disconnected or run out or too much of something. Also check his airway pressures - he may have blown a pneumo, It will be tension in no time with his PPV.
 

waterski232002

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The systems based presentations are definitely key. Here are some basic ICU issues to recommend for your patients.... If you include these in your plan, you will be way ahead of the game....

- Recommend daily arousal from sedation
- If the patient's ABG is reasonable, attempt to wean the vent
- If on minimal vent settings (A/C 12/400/5/20%) then recommend SBT (spontaneous breathing trial) for possible extubation
- Put all critically ill patients on an Insulin gtt to maintain glucose between 80-110 (based on NEJM article for decreased morbidity/mortality)
- Know EGDT (early goal directed therapy) like the back of your hand and implement it

Good luck....
 

bulgethetwine

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waterski232002 said:
The systems based presentations are definitely key. Here are some basic ICU issues to recommend for your patients.... If you include these in your plan, you will be way ahead of the game....

- Recommend daily arousal from sedation
- If the patient's ABG is reasonable, attempt to wean the vent
- If on minimal vent settings (A/C 12/400/5/20%) then recommend SBT (spontaneous breathing trial) for possible extubation
- Put all critically ill patients on an Insulin gtt to maintain glucose between 80-110 (based on NEJM article for decreased morbidity/mortality)
- Know EGDT (early goal directed therapy) like the back of your hand and implement it

Good luck....
Our strategy for insulin is:

1. Everybody gets q6h monitoring and SSI. Critical or otherwise.

2. Two consecutive readings >150 obligate an increase in basal insulin dose.

3. Two consecutive readings > 180 obligate starting a drip.

Obviously, skip right to step two if patient is diabetic to begin with and has basal insulin already.

I'll have to check the NEJM article again today. Maybe we're not being agressive based on Waterski's post...
 

waterski232002

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The literature supports starting an insulin drip on any patient who is critically ill if the glucose is above 110. Virtually all patients will have glucoses over 110 in the ICU or otherwise for that matter... I'll bet my glucose is over 110 right now! The study was done on ventillated patients, but it is reasonable to extend this to patients who are septic, in ARDS, in MOSF, but not yet ventillated.

"Intensive Insulin Therapy in Critically Ill Patients"
Volume 345:1359-1367 November 8, 2001 Number 19