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Airway Injury During Anesthesia

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Welcome to the Intensive Care Unit Click on Procedure in the left navigator window * Select EITHER Procedure Notes or Create Note * * Moving away ... – PowerPoint PPT presentation

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Title: Airway Injury During Anesthesia


1
Welcome
to the
Intensive Care Unit
2
Learning Goals
  • To learn to care for critically ill patients
  • To understand management of respiratory failure
    with mechanical ventilation
  • To develop a better appreciation of
    cardiopulmonary physiology
  • To understand indications for different
    modalities of hemodynamic monitoring
  • To improve on techniques to place invasive
    monitors

3
Learning Goals
  • Understand the pharmacodynamics and
    pharmacokinetics of sedatives
  • Learn the communication skills required in the
    role of the critical care consultant
  • Develop a multidisciplinary treatment plan for
    critically ill patients
  • Have a fun and educational month

4
Organization
  • 8/11 ICU intern, 1-2 CA-1 residents, 1
    CA-3 resident, fellow(s), attending
  • 9 ICU 2 NPs, 2-3 residents (CA-2, ED, IM),
    fellow(s), attending
  • 10 ICU 1 NP, 1 CA-3 resident, fellow(s),
    attending
  • 13 ICU 4-5 residents (CA-2, ED, IM), fellow(s),
    attending

Fellow(s) Anesthesia, Pulmonary, Neurovascular,
Surgery
5
Housekeeping - call schedule
  • Call is approximately once every 3-4 nights,
    averaged over the entire rotation.
  • Post-call resident leaves before 1100
  • Schedule changes are not allowed unless approved
    by Dr. Shimabukuro (an extremely complex
    schedule)

6
Housekeeping - Call rooms
  • 13 ICU M1318 (outside of ICU, corridor between
    Moffitt and Long, on left side as you walk
    towards Long), use your name badge, use room with
    door labeled ICU resident
  • Shared bathroom (with surgery resident)
  • 8/9/10 ICU - in 9 ICU, use north room (one on
    right when facing both doors), no code or lock
    (ie, DO NOT LEAVE VALUABLES)
  • Shared bathroom (with ICU fellow)
  • ICU fellow in 9ICU, south room.

7
Housekeeping - Call rooms
  • If someone else is using the call room, find out
    what department and/or service and notify Dr.
    Shimabukuro immediately by pagerbox or email.

8
Housekeeping - daily routine
  • Lectures start at 8am sharp every weekday (0815
    on Wednesdays) in room M919
  • Check schedule for topic and speaker (it may be
    you!!!)
  • Rounds start at 0900 weekdays and at 0800 on
    weekends
  • X-ray rounds immediately follow attending rounds
    (at the discretion of the attending)
  • Afternoon rounds with fellow(s) start at 1700
  • DO NOT LEAVE before checking in with the fellow
    or attending

9
Housekeeping weekends/holidays
  • Only on-call and post-call residents round
  • If you are neither, you have the day off
  • Try to pre-round on the sick ICU patients
  • Remainder of patients can be discovery rounds (at
    the discretion of the attending)
  • Notes are written either before or after rounds
    (at the discretion of the attending)
  • Place emphasis on assessment/plan

10
Housekeeping - Lectures
  • Each resident and medical student will be
    responsible for a 30-minute lecture during the
    rotation
  • Please check the lecture schedule for assigned
    topic and date
  • Medical students are allowed to pick a topic of
    their choice
  • Read schedule carefully, lectures are split (ie,
    2 lectures on a day) based on level of training
    or ICU experience

11
Housekeeping paperwork
  • List to be described on following slides
  • General APeX comments
  • Notes
  • Patient list
  • Admit Orders
  • Central Line Procedure Note
  • Procedure Note

12
APeX
  • Context CRITICAL CARE MEDICINE SVC

13
APeX
  • wrenching in flow sheets/reports/accordions

14
APeX
15
APeX
16
APeX
  • Flow Sheets/Reports/Accordions
  • MAR Report/ Med List (if not already there)
  • Comprehensive/Comp (if not already there)
  • Hemodynamics (for those on 10ICC)
  • LDA (current and past central/arterial lines with
    insertion/discontinue dates and locations)

17
APeX
  • Flow Sheets/Reports/Accordions
  • Hematology (Blood products administered)
  • Fever OR ID/Sepsis
  • Insulin/Glucose
  • Labs since admission
  • Radiology
  • Microbiology
  • Critical Care SO/RND

18
APeX
  • Nurses Notes Use Notes Tab All notes

19
APeX
Nurses Notes Comp flow sheet at very bottom or
at top
20
Progress Notes
  • General progress note template is in the
    rounding navigator

21
Progress Notes
22
Progress Notes
  • Problems added to the Problem List are seen by
    all providers
  • Assessment and plan added to each problem are
    seen by all but ONLY appear in the CCM SVC notes
    (ie, what a surgery resident writes under the
    same problem will NOT appear in your note)

23
Progress Notes
24
Progress Notes
25
Progress Notes
Attending of the week
26
Progress Notes
27
Progress Notes
Progress Note
28
Progress Notes
  • If using anothers template or your own

29
Progress Notes
  • Using copy forward

30
Notes
  • Using copy forward

31
Notes
  • Using copy forward

32
Notes
  • Be very careful about copy-forwarding notes.
    Always review the entire note for accuracy. (ie,
    a patient cannot be POD2 for 5 days in a row)

33
Notes
  • Be as specific as possible for the assessment/
    problem list
  • Altered mental status versus ICU delirium
  • COPD Exacerbation versus acute hypercarbic
    respiratory failure from pneumonia on (and) COPD
  • UTI with hypotension versus septic shock from
    (and) UTI

34
Notes
  • Be specific as possible with the plan
  • For instance, wean vent as tolerated vs.
    Patient continues to require a high minute
    ventilation due to a likely large dead space
    fraction from resolving ARDS. He is not
    tolerating a rapid wean. Failed SBT yesterday
    due to sustained respiratory rate in the 40s
    with desaturation. Will try again today.

35
Notes
  • Co-sign Required should be checked unless
    otherwise specified by your attending
  • Title of note should have
  • Critical Care Medicine Progress Note
  • Critical Care Medicine Admission Note

36
Admission Notes
37
Admission Notes
Remember the tabs
38
Admission Notes
39
Admission Notes
HP Note
40
Admission Notes
  • You are allowed to use your own/others HP
    template via a dot-phrase.
  • Dont forget about co-signature and title/header
    of note
  • Chose the correct note type

41
Patient list
  • The filemaker database is in the fellows office.
    It should be updated daily. The password is
    m917icu
  • Post call resident will print out copies for the
    team
  • Do not leave in the ICU (patient confidentiality)
  • Make sure to enter morbidities and mortalities

42
Admit Orders
43
Admit Orders
IP Adult Core Admission Orders
44
Orders
  • Other order sets of interest
  • IP Adult Core Admission Orders
  • IP Adult ICU Addendum
  • IP Adult Sepsis
  • IP Adult Continuous Neuromuscular Blocking Agent
  • IP Adult Blood Product Transfusion
  • IP Adult PCA

45
Orders
  • The IP Adult ICU Addendum Order Set needs to be
    completed by the ICU resident for every patient
    admitted to 9/13 ICU. On 8/11 and 10, they only
    need to be completed for patients the service is
    following
  • The IP Adult Core Admission Order Set may also
    need to completed. Ask your fellow.

46
Orders
  • Use Order Management to modify/discontinue
    existing orders and/or add new orders

47
Orders
  • Mechanical Ventilation
  • There is NO order set
  • Search under ventilation or use IP Adult ICU
    Addendum Order Set

ARDSNet Protocol
PSV/CPAP
48
Orders
  • Mechanical Ventilation
  • Dont forget to write for oxygen titration orders
    under admin instructions
  • When changing between modes, dont forget to
    discontinue the old one
  • SBT search under SBT

49
Procedure Notes
50
Procedure Notes
51
Procedure Notes
52
Procedure Notes
53
Procedure Notes
54
Procedure Notes
55
Procedure Notes
56
Procedure Notes
57
Procedure Notes
58
Procedure Note
59
Procedure Notes
60
Procedure Notes
61
Procedure Notes
62
Procedure Notes
63
Procedure Notes
64
Procedure Notes
65
Procedure Notes
  • Person who is primarily responsible for the
    patient has first dibs on the procedure
  • Person who performs the procedure is responsible
    for the note
  • Cosign Required MUST be checked
  • Cosigner is your attending of the week

66
Moving away from APeX
67
Resident Responsibilities
  • Code Blue Coverage (next slide)
  • Emergency calls in the ICU
  • Co-Managing patient with primary teams
  • With special emphasis on
  • Airway
  • Central lines
  • Mechanical ventilation
  • Pain and sedative medications

68
Code Blue Coverage
  • 10 ICC team will respond to codes during weekdays
    (M-F 0800-1700) everyone should go outside these
    times
  • We are responsible for the airway - FIRST
  • Please make sure that whatever you use in the
    CODE bags are refilled immediately

69
Code Blue Coverage
  • New medication syringes are available from
    pharmacy (across from M919) bring label of
    patient for which the prior drugs were used
  • Anesthesia workroom has other supplies it is
    located in the OR on the fourth floor
  • Place ET tubes with subglottic suctioning, if
    length of mechanical ventilation is expected to
    be longer than 48 hours

70
Resident Responsibilities
  • 8/11 ICU
  • Residents not taking call should rotate staying
    late to sign out to NP at 1900
  • Residents need to take sign out from overnight NP
    by 0700
  • CA-3 resident should have greater responsibility
    running team and teaching

71
Emergency Calls
  • Calls regarding unstable patients often go to the
    ICU team
  • If situation is truly an emergency, deal with the
    problem while the primary team is being summoned
  • If there is time, discuss with the team, often
    the night float will be thankful for a friendly
    word of advice

72
Communication
  • Understanding the primary teams plans and goals
    often make it easier to understand the course of
    action that is planned
  • Communication makes it easier for all parties
    involved and improves patient care
  • If there is a disagreement about care, consult
    your fellow or attending

73
A Word from the NPs
  • We can be a resource for you. Ask and we will
    try to help
  • Be prepared for sign out by knowing the
    ventilator and sedation plan for patients.
  • If you cant restock the code bag before sign
    out, let us know. We will help you.
  • The list (filemaker) is our life line. It needs a
    thorough update before 6AM/6PM every day.

74
Airway
  • The airway pager (443-4990) will always be with
    an anesthesiologist (attending, fellow or
    resident)
  • Airway backup available
  • OR E1 Anesthesia Attending 3-1581 (Spectralink)
  • OR Front Desk 3-1545
  • OB Anesthesia Resident 443-9261
  • ED 3-1238
  • Do not start sedation/paralysis without someone
    from anesthesia being present (CA-1 residents
    should also always get back-up)

75
Central Lines
  • Except for a few services (CT surgery and
    Cardiology) we are responsible for all line
    placements
  • At the request of the CT Surgery or Cardiology
    Fellow/Attending, we will assist with line
    placement
  • All central lines placed above the diaphragm must
    have an ICU attending or fellow at the bedside

76
Ventilation
  • We are responsible for ALL ventilator orders and
    extubation (For those on 10ICC, please clarify
    with your attending for each CT surgery
    non-fast-track CABG patient)
  • If the primary team wants something that is
    unreasonable, please discuss it with the fellow
    or attending
  • DO NOT make changes directly on the ventilator
  • Patients should be followed for at least 24 hours
    after extubation

77
Sedation
  • We write pain and sedation orders on all patients
    we follow (For those on 10ICC, please clarify
    with your attending for each CT surgery
    non-fast-track CABG patient)
  • Do what the primary team wants if it is
    reasonable
  • Management of pain in ICU patients with epidural
    catheters is the responsibility of the acute pain
    service, but we do keep a close eye on this

78
Miscellaneous
  • Radiology does not interpret any studies
    overnight unless asked
  • Small cards have everybodys pager and home phone
    number
  • Please dont hesitate if you identify problems
    during your rotation to notify your attending
  • Please fill out the evaluations. Your comments
    are confidential and important for future
    rotation development

79
Medical Students
  • Stay late 1 night per week - their choice
  • They should read about their patients
  • Quality not quantity (2 patients max)
  • They are not expected to function as a resident
    during this rotation
  • There should be a resident identified as the
    supervisor for each patient the students follows
  • Residents should be writing their own note as
    well

80
Open and Closed ICUs
  • Most patients in M/L ICUs are semi-open in
    that the primary service still writes the
    majority of the orders, but we co-manage with
    them.
  • Orthopedics, Ortho-Spine, CRI, OMFS, post-partum
    OB, OHNS, Gynecology, Gyn-Oncology, and Urology
    are closed THE ICU SERVICE IS THE PRIMARY
    SERVICE
  • Make sure you know their contact s to keep them
    in the loop

81
Closed patient issues
  • Labs - CBC, electrolytes, glucose
  • Nutrition - NPO, tube feeding, TPN
  • Activity - bedrest, ad lib
  • IVF - rate, heplock
  • Transfusions triggers, CMV negative, irradiated
  • Studies - radiology, echo, PT - need to make a
    phone call
  • Check patient frequently and communicate with
    primary team often

82
Open and Closed ICUs
  • The data
  • Multiple studies show that the daily presence of
    an intensivist improves outcomes, including
    mortality and length of stay. There was no
    advantage to closed units.
  • Disadvantages of open units
  • Disagreement about management plans
  • Loss of control
  • Advantages of open units
  • Ability to care for a variety of patients (med,
    surg, etc)
  • Ability to focus on critical care issues

83
Wear your name tags
84
Questions?
85
Calls to evaluate patient
  • Go see the patient in the ER or on the floor
  • Discuss ALL ICU admissions with fellow (or
    attending)
  • Any refused admission must be discussed with
    attending or fellow
  • Do not worry about beds, triage attending
    (443-4443) will take care of that
  • Triage covered by 10 ICU fellow
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