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ICU 101 with John Galvin and Anne Burgess · Style Points

0:10
and welcome to this month's episode of Style
0:13
Points. Today we're doing something slightly
0:15
different than usual. We're giving a primer on
0:18
how to approach your first day of the ICU with
0:20
soon -to -be CA1 John Galvin and soon -to -be
0:23
CA2 Anne Burgess. They do a great job outlining
0:26
all the different aspects of what we do with
0:28
ICU management. We don't have an RSI this month,
0:32
but I'll give my co -host Nate Moore a pass.
0:35
I suppose that having a beautiful baby and starting
0:37
a family might take precedence over doing a podcast
0:40
segment. Maybe we can get a son Christopher as
0:43
a special guest in a future episode of the podcast.
0:45
Major congratulations and much love to Nate and
0:48
Mary. Without further ado, here's John and Anne
0:51
with ICU 101. Welcome to Style Points. I'm John
1:00
Galvin. I'm a first -year resident here at the
1:03
University of Cincinnati in the anesthesia residency
1:06
program. I'm joined by CA1, one of my seniors
1:10
here in the anesthesia program, and Burgess.
1:13
Happy to be here. Thanks for joining. You're
1:17
interested in critical care. Yes, I am. Awesome.
1:20
Well, today, I think a great topic to talk about
1:24
is starting in an ICU rotation. I think every
1:28
intern... has a little bit of trepidation when
1:32
they're approaching the ICU for the first time.
1:34
Some of us may have never been in an ICU before.
1:38
So I really appreciate you having this conversation.
1:41
What got you interested in critical care? Sure.
1:45
So I'm about at the end of my CA one year. So
1:48
I have a little bit of a rotation under my belt
1:51
at this point. But I actually, my interest started
1:55
in the ICU prior to actually anesthesia. So when
1:59
I was a medical student, I loved rotating in
2:02
the ICU. Sick patients, lots of physiology to
2:06
think through, and it's a high -stakes environment
2:11
that I felt really drawn to. In looking at the
2:15
different paths to critical care, anesthesia
2:19
is the fastest, but I also feel it has the opportunity
2:23
for more balance. The ICU is a very emotionally
2:28
hard place to be. We take care of very sick patients
2:31
and not all of those patients get better. So
2:34
I wanted to think kind of for longevity's sake,
2:38
what's something I could see myself doing forever?
2:42
And anesthesia, I felt like brought a really
2:45
good balance of you get to take care of those
2:48
sick patients in the ICU. And I find a lot of
2:50
satisfaction in taking care of those patients.
2:53
But you also get to kind of temper that with
2:56
general anesthesia, which can also provide some
3:00
similar intellectual stimulation, if you will.
3:03
But you get to bank, I think, easier wins in
3:06
the OR sometimes, which I think for the purpose
3:10
of, you know, having an emotionally balanced
3:12
career, I think is very helpful to have the option
3:15
to do kind of the whole breadth of things. That's
3:19
awesome. Diversifying. getting a lot of different
3:23
experiences. And no better way to do that than
3:28
in an ICU setting where you get to see a lot
3:31
of really sick patients, learn some cool pathologies.
3:35
I think importantly, we need to set up for people
3:41
starting on their first day what to expect. Can
3:46
you talk a little bit about what to expect on
3:49
your first day in the ICU? Sure. And I think
3:51
I'll back up a quick step to kind of talk about
3:54
what our critical care team looks like here at
3:57
UC. Critical care anesthesiologists are going
4:00
to have a different role at every institution.
4:04
I think our role here at UC is very helpful and
4:09
interesting and impactful. We mostly live in
4:14
the cardiovascular ICU. typically working with
4:17
cardiothoracic surgery and cardiology, but also
4:21
have our hands in our burns unit, our ENT unit,
4:24
to help our other colleagues be essentially critical
4:27
care consultants. So we end up getting a lot
4:31
of different hands on different pathologies in
4:35
different places in the hospital and get to continue
4:38
care with surgeons and surgical teams that we
4:42
work with in the OR. We get to continue to help
4:45
their patients post -op with whatever they have
4:48
going on, in addition to very sick cardiology
4:51
patients. As for the first day, first days are
4:55
always really hard. I've always struggled with
4:57
first days. I get very anxious before first days
5:00
just because you have no idea what to expect.
5:03
Tips getting oriented to the unit, what to do
5:07
before your first day, all of that. It's a big
5:08
question. I could talk for a very long time on
5:13
all of the things to do, but ultimately showing
5:17
up ready to learn on your first day. We have
5:21
handoff at 630 here. That may be different depending
5:24
on where you're at, but listening for what's
5:28
going on with your patients. Paying attention
5:31
to kind of the important things that your overnight
5:35
team is telling you. There's no formal handoff
5:38
process that you may have on your medicine rotations.
5:41
You're just showing up and you're listening to
5:43
what your overnight team has said. Things change
5:45
very quickly in the ICU. So things, even if you
5:49
did research on them the night before, things
5:52
are bound to change. So showing up just ready
5:55
and open minded on your first day is kind of
5:58
the biggest obstacle to traverse when showing
6:02
up in the ICU. Thank you for giving some of the
6:05
background. I think I was thrown off because
6:09
I kind of being here at UC, our mascot at University
6:14
of Cincinnati is the Bearcat. So I thought that
6:15
was interesting that this unit is called the
6:19
Seacat. And I wasn't sure if that was just a
6:22
UC specific thing, but. Yes. Critical care anesthesia
6:26
team. Yes. Very UC specific. We love all of our
6:30
cat jokes, but CCAT does stand for critical care
6:33
anesthesia team. And that I believe is a very
6:36
UC specific thing. Very cool. I think it was
6:39
really cool on my first day too, as you mentioned,
6:43
getting to work with all these different teams,
6:44
you really get to build relationships with. people
6:48
that are rotating on different specialties and
6:51
that only serves you better when you're in the
6:53
or when you're working with cardiac surgery residents
6:56
when you're working with the attendings and then
6:58
when you know you're meeting a cardiac surgery
7:01
patient for the first time and you see one of
7:04
your senior residents coming up from the or and
7:06
giving you handoff it's it's a really neat position
7:10
to be in to hear from them and see how things
7:13
work with the transition from the or to the icu
7:16
looks like and what those next steps are. Absolutely.
7:20
Critical care is a team sport. And understanding
7:23
who all is in your unit is a helpful thing to
7:26
know prior to starting your rotation. So here
7:29
at UC, and again, caveat is that this can be
7:32
different at every institution. But our cardiovascular
7:35
ICU here is an open unit, meaning there can be
7:39
multiple different primary teams. And then also...
7:43
With the addition of all your consultant teams.
7:45
So in contrast, our medical ICU here is a closed
7:49
unit, meaning every patient in the MICU is primary
7:53
MICU. Whereas in the cardiovascular ICU here,
7:56
you can have cardiology primary, cardiothoracic
7:59
surgery primary, as well as our own team CCAT
8:02
can be primary as well. So there's a lot more
8:05
of a teamwork dynamic working between all of
8:09
those teams, helping coordinate care for. very
8:12
complex patients who are very sick. So understanding
8:17
that there's several teams that are involved
8:20
and sometimes your rounding structure is going
8:22
to depend on how many shared patients you have.
8:25
We try and round with those teams so we can all
8:30
coordinate that care together. It's not always
8:32
perfect, but understanding that you're going
8:35
to be working with the other teams and you may
8:38
not be the one presenting. You may not be the
8:41
one putting in orders, but your role still very
8:44
much matters. It's helpful to know prior to showing
8:47
up. There's going to be a lot of cooks in the
8:48
kitchen. Okay, so first day, get there early.
8:54
Just to recap, showing up on time, showing up
8:57
a little early is great. That way you can settle
8:59
in a little bit. I liked, you know, on my first
9:01
day, I got there like 10, 15 minutes. Absolutely,
9:04
yeah. Typically the overnight team, they have
9:07
a sheet that... has the census on it and that
9:10
way you can kind of familiarize yourself with
9:12
the organization how morning handoff is going
9:15
to go and then you can listen to rounds kind
9:20
of get oriented by that time you probably know
9:22
if you have a patient that you're going to be
9:25
following and then you can even focus in that
9:27
much more during the handoff let's talk a little
9:31
bit about you know you mentioned the structure
9:33
of the team we have Obviously, if you're an intern
9:38
rotating for the first time, are there other
9:41
anesthesia residents that are rotating with you?
9:43
Who else is going to be taking care of these
9:46
patients with you? Who can you ask for help?
9:48
Tell me a little bit. Absolutely. We have a big
9:51
team, especially depending on the time of year.
9:53
We have two critical care fellows within the
9:57
Anesthesia Critical Care Fellowship. So they
9:59
will be there at any given time. But we also
10:02
have rotating fellows. that come from pulmonary
10:05
correct care, from neuro correct care. Those
10:08
are a great touch point regardless of the time
10:11
of year. And then typically, especially as a
10:15
junior, you'll typically have a senior resident
10:18
alongside with you. I was fortunate to have two
10:21
co -residents on my last rotation up there, which
10:23
was super nice. And then we also have an incredible
10:26
team of advanced practice providers, both nurse
10:29
practitioners and PAs who have been doing this
10:32
for a very long time. and are very familiar with
10:35
our post -op cardiac patients, the unit, and
10:38
are very, very helpful, especially for new learners.
10:41
So do not hesitate to engage them in help. Right.
10:46
A lot of them have worked in the ICU either as
10:49
a nurse or in some other role before. And I thought
10:53
that was really neat because they had even more
10:55
insight into what questions to ask, maybe like
10:59
differentiating different disease states. Yeah,
11:03
their perspective was super useful. Absolutely.
11:08
Okay, now we've talked about the structure of
11:12
the team, what to expect on the first day. And
11:17
I think it's really important after you've gotten
11:20
handoff to organize the rest of your morning.
11:24
You have about an hour, sometimes more than that,
11:28
sometimes less, depending on the attending. you
11:31
know knowing what to expect in terms of what
11:35
kind of patient i'm taking care of and what should
11:39
i be looking for um i have come across a couple
11:43
of mnemonics in anesthesia we use our ms maids
11:46
to help set up our room knowing how to set up
11:51
a case before you know the the surgery happens
11:54
i think there's other mnemonics that are great
11:56
one that i came across was this fast hugs bid
12:00
And we'll have a link to this as well. But the
12:04
F is for feeding and fluids. The A is for analgesia.
12:09
The S is for sedation. The T is for thromboprophylaxis.
12:14
The H in HUGS is for head of bed elevation. The
12:20
U is for ulcer prophylaxis. G is for glycemic
12:24
control. And S is for SAT, SBT, which stands
12:29
for spontaneous awakening trial or spontaneous
12:32
breathing trial. And then lastly, the BID is,
12:35
B is bowel regimen, I is indwelling catheters,
12:39
and D is de -escalation of antibiotics and delirium.
12:42
So we can go into this a little bit more. I think
12:47
maybe we can just talk about why each of these
12:50
things is important to look for. um but before
12:54
we dive in do you have any thoughts about what
12:56
mindset you should be in after you've gotten
12:59
handoff and you're about to go see your your
13:01
first patient what you should be looking for
13:03
so i think whenever you're seeing patients either
13:08
in the icu or on the floor or wherever having
13:11
a process that is familiar to you consistent
13:14
to you is going to be the best thing you can
13:17
do for yourself we have Kind of similar paradigms
13:21
even in the pre -op evaluation. If you do it
13:24
the same way every time, you're less likely to
13:26
miss things. What I would immediately start with
13:31
is, is this patient stable? If they are not stable,
13:36
then you loop and help. You talk to your fellow.
13:40
You say, hey, I have this concern. I see this
13:42
hemodynamic trend. Can you come with me to go
13:45
see the patient? And then you can kind of go
13:48
through your same list. But if they're stable,
13:50
then you can kind of take a minute. You have
13:52
like an hour and a half. It's more than enough
13:54
time, even if it doesn't feel that way at first,
13:57
to go assess your patients or start by chart
14:02
reviewing. You can kind of go either direction.
14:04
But as long as it's the same for you every time,
14:06
that's all that matters. Okay. Do you, I mean,
14:10
what is your preference? Do you like to chart
14:13
review first? What's the first thing you look
14:15
at when you're looking into a patient? Is it
14:18
their last progress note? Is it their history?
14:23
What do you think? I know it's probably patient
14:26
specific, but tell me a little bit about your
14:29
process when you're taking care of a new patient
14:33
on your first day. I'm a little bit of an anomaly
14:35
because I like to go see the patient first. I
14:39
think there's a lot of benefit in going to lay
14:42
eyes on a patient to see what they look like,
14:45
to see what drips they have running, what their
14:48
ventilation settings look like. I just want to
14:50
see all of that first. The information in the
14:54
chart may not be the most up -to -date information,
14:56
and it will change quickly in the ICU. Not a
14:59
lot of people have that method. I like it because
15:03
especially at the time of day, By the time you
15:06
get to go see the patient, oftentimes the night
15:07
nurse is still there. So you can very quickly
15:11
get their understanding about what their concerns
15:13
have been over the last 12 hours, which I think
15:16
is a very helpful starting point, especially
15:18
if you're brand new to this unit. They have a
15:20
lot of information. Utilize your resources. I
15:23
discovered that a weekend when I was getting
15:26
there first thing and I could catch the night
15:30
nurse and it felt like I just had. I had all
15:33
of the secrets on my presentation. I felt like
15:36
I knew exactly what was going on. So I wasn't
15:39
guessing. I wasn't getting it secondhand from
15:41
somebody that was like, oh, I thought this was
15:43
maybe important. But now you're hearing it right
15:46
from the source. Yeah. I find that very helpful,
15:50
both to engage with the care team, look at the
15:53
patient. You have an understanding from handoff,
15:57
kind of what things you should be looking for
15:59
in a physical exam. So I like starting there
16:02
and then bringing one of our computer on wheels
16:05
and just pre -charting right outside of the room.
16:08
The disadvantage of that is that you're not in
16:10
the workroom. You can't, you know, immediately
16:13
bounce ideas off the fellow. But also if the
16:17
patient's sick, your fellow is probably there.
16:19
So they're around anyway to talk to. They're
16:22
pretty easy to find. That is my method. Not a
16:26
lot of people do that, but it works well for
16:27
me because I just, I want to see stuff. I want
16:31
to touch stuff. I want to be able to see it with
16:34
my own eyes because far too many times as an
16:37
intern, especially I would chart review. I had
16:40
this great idea of a presentation for this patient
16:43
and then I show up and things are totally different.
16:45
They have to say, well, my presentation does
16:47
not matter because everything is different. So
16:51
we're just going to restart and start from square
16:53
one. And that's part of what I actually love
16:55
about the ICU is things change quickly and you
16:57
learn to adapt. That's great advice. I think
17:02
something that helped me as I got more familiar
17:06
with how rounds and presentations worked. I could
17:11
actually tailor here at UC, we use Epic. I could
17:14
actually tailor some of the tabs in the morning.
17:17
And this is a great question you can ask a senior
17:19
or a fellow. You can ask how to organize your
17:24
tabs so that when you're doing chart review,
17:26
you can see vitals. We have this great tab called
17:30
the comp and it shows drips, what they're running
17:33
at. But again, sometimes those are not up to
17:36
date. So it's good to go see in person and have
17:39
an idea. Because then, again, that number may
17:42
change by the time you're presenting the patient.
17:44
So it sounds overwhelming because you want to
17:48
stay as up to date as you can. But just remember,
17:51
you know, there's multiple places where you can
17:54
find information. And I think at the end of the
17:57
day, if you have a concern or if you just don't
18:02
know what to do, it's more than OK to ask, especially
18:04
in your first days in the ICU. Let's talk a little
18:09
bit about this FAST -HUGS BID mnemonic. I think
18:14
knowing what to look for, you talked about your
18:18
approach to the physical exam, seeing the patient
18:20
for the first time, pre -charting. Let's talk
18:23
about maybe why some of these things are important
18:25
and what's going to come up, what you may get
18:27
questions about when you're presenting on rounds.
18:31
For FAST, the first letter is F for feeding and
18:35
fluids. We typically want our patients to eat
18:41
by mouth. We don't want them to be getting TPN.
18:45
Ideally, the sooner they're able to eat by mouth,
18:49
the better. Sometimes that means an NG tube.
18:52
And then as far as fluids, they may need maintenance
18:57
fluids. But also in the cardiac ICU, these are
19:01
patients that may struggle with volume overload.
19:04
So you want to opt for volume overload. Any thoughts
19:07
on feeding fluids? You're absolutely right. Early
19:11
enteral feeding is shown to have mortality benefit
19:15
in the ICU. So we really want to provide, even
19:18
our sick patients, there's evidence to show that
19:20
they have benefit from getting nutrition. I think
19:26
a very key point to kind of tack on to the nutrition
19:29
piece is your access for nutrition. because NGs
19:37
don't just get magically placed. So even if,
19:42
you know, they're coming in flaming hot, they're
19:44
really sick, there's a lot going on, you have
19:47
to think about, we want to feed them eventually.
19:52
So we should probably set things in motion to
19:56
set them up for that. So thinking about your
19:58
access for nutrition is important. And you're
20:02
absolutely right with the fluids. Volume status
20:04
is going to be one of the first things you talk
20:07
about for almost all of these patients. And how
20:09
you assess that is definitely a learning curve
20:14
because you're going to have your exams, you're
20:18
going to have invasive devices that help show
20:20
you kind of what central pressures are. And everybody
20:23
has kind of a different approach to how they
20:25
systematically walk through that. But you will
20:28
certainly be asked about volume and what you
20:32
want to do with those patients. And it is a very
20:34
important part of their care and recovery. Yeah.
20:38
Okay, let's move on. The next letter is A for
20:42
analgesia. How do we assess pain in the ICU?
20:47
Some of these patients are intubated. What's
20:50
going on? How's the patient feeling? There are
20:54
standardized scores that our ICU nurses will
20:56
have. Typically for our intubated sedated patients,
21:00
we like to keep them comfortable. So they keep
21:03
all of the lines and things and tubes where they
21:05
need to be. So you'll typically see things like
21:09
your CPOT scores, your RAS scores for sedation.
21:16
If you just look up what the tools are and what
21:18
kind of comprises them, it's a helpful way to
21:20
understand what the ICU nurses are evaluating
21:22
and kind of help direct whether they need more
21:27
sedation, less sedation, because ultimately you
21:30
want to keep them in a place where you can also
21:33
wean that to get an appropriate neuro exam, to
21:36
do appropriate spontaneous awake trials, see
21:39
how they do with SPTs and things like that. Awesome.
21:41
And you already alluded to the next letter, which
21:43
is sedation. Yeah, the RAS score, the CPOT, those
21:48
are also things that you can find in the chart.
21:50
Typically, the nurse will be updating that throughout
21:55
their shift. So you can see if things are getting
21:59
progressively better, things are getting progressively
22:00
worse. So you know, do we need to adjust this
22:04
person's sedation? Do we need to adjust this
22:08
person's pain? We've been talking about the RAS
22:12
score. So the RAS score is the Richmond Agitation
22:15
Sedation Scale. It basically is just a subjective
22:20
measure of a patient's awakeness or sedation
22:24
going from super combative, which is up in like
22:29
the plus four range, all the way to they're unarousable,
22:33
which would be a negative four or five with kind
22:37
of neutral being your zero. Okay. So we're typically...
22:42
shooting for like a negative one to zero, which
22:44
is comfortable, but also arousable. You can get
22:48
them to maybe move in extremities like that.
22:51
Yes. But it also depends on the patient, which
22:55
is going to be the answer to almost every patient
22:57
in the ICU. But if you have a patient with really,
23:00
really sick lungs and you're having trouble ventilating
23:03
them and they're on like a infusion of a paralytic,
23:08
for example, their RAS score is going to be much,
23:10
much deeper. because you don't want them arousable
23:13
and paralyzed right the next letter is going
23:16
to be t for thromboprophylaxis obviously very
23:21
important for us to prevent blood clots but also
23:24
something to consider when you're thinking about
23:26
anticoagulation is the bleeding risk and some
23:29
of these patients have just had surgery and They
23:33
may have sutures and wounds and things that could
23:36
possibly bleed. So that's an important consideration.
23:39
But again, they're not moving. We need to make
23:43
sure that they're not throwing clots, things
23:45
like that. Yeah. What I'll add for this bit is
23:49
a lot of our post -surgical cardiac patients
23:52
specifically, a lot of our anticoagulation is
23:56
going to be a very cooperative discussion between
23:59
us and the cardiac surgery team. And they will
24:03
have opinions, rightfully so, for when it's safe
24:06
and appropriate because there's a very, very
24:09
important risk -benefit conversation specifically
24:11
for those patients. H is the next letter on this
24:16
fast hugs mnemonic. H is for head of bed elevation.
24:20
Why do we want the head of the bed to be a little
24:23
bit elevated? And how, I mean, are we sitting
24:26
these patients straight up or what are we doing
24:29
with the head of the bed? They tend to be at
24:31
about 30 degrees -ish as best we can, and it's
24:36
all to protect lungs for the most part. We care
24:39
very much about lungs in the ICU. It's one of
24:42
our ways to prevent pneumonia and kind of help
24:48
mitigate any reflex issues that we may have with
24:54
our important airways. Which is a great segue
24:58
into the next letter. U is for ulcer prophylaxis.
25:01
We are constantly trying to keep patients from
25:05
getting stomach ulcers, peptic ulcers. What are
25:09
some of the risk factors for getting peptic ulcers?
25:12
Why is it so important? One of the biggest things
25:15
that we think of with our GI ulcer prophylaxis
25:20
population, anybody who's mechanically ventilated
25:24
is going to be high risk. So pretty much anybody
25:28
who has an endotracheal tube will also have GI
25:32
ulcer prophylaxis. Some institutions will have
25:36
different policies as well, which is always going
25:39
to be the case, especially in ICUs. Our cardiac
25:43
surgery population, for example, will get GI
25:47
ulcer prophylaxis even after they've been extubated.
25:51
Um, for reasons that I won't necessarily get
25:54
into, but, um, I've certainly been there and
25:56
we're like, we're going through the checklist
25:57
at the end of the presentation. I'm like, do
25:59
they actually have an indication? Their indication
26:01
is that they have cardiac surgery. Um, and I
26:04
don't have a great explanation for that, uh,
26:06
beyond they have their studies, uh, they have
26:11
their reasons. Uh, so we, we keep them. My understanding
26:14
is also being on steroids can increase your risk
26:18
in a lot of these patients. again after surgery
26:20
they may need to reduce inflammation so they
26:22
may be on a steroid regimen what's great about
26:26
the rounds just taking a pause here is that you'll
26:30
have a pharmacist typically so they'll also be
26:33
helping you you alluded to the checklist at the
26:35
end of some of these presentations that's in
26:38
our notes they'll help us know what medications
26:41
are on know what the risk factors, why we may
26:45
need to be on anticoagulation in the first place,
26:48
whether or not that's indicated. They're very,
26:51
very helpful. So if you have questions about
26:52
what medications, what is indicated or not, they're
26:56
constantly thinking about these things. Absolutely.
26:59
Like I said earlier, it's a team sport up there,
27:02
and you have so many helpful teammates beyond
27:06
just your critical care team. You know, we have
27:09
pharmacists, we have perfusionists and ECMO specialists,
27:12
we have respiratory therapists, and your nurses
27:14
are incredible. There's so many incredible resources
27:16
to help you understand what's going on with patients
27:20
and to help you think through kind of what they
27:22
may need next. The next letter in our fast hugs
27:27
BID mnemonic is glycemic control, which is G.
27:33
What is our goal? glucose level in these patients?
27:39
Typically, we like to keep them below 180. And
27:43
our cardiac surgery patients specifically, there's
27:47
evidence that within at least the first 24 hours,
27:50
and I don't remember exactly, but having very
27:53
tight glycemic control does improve outcomes
27:55
for them. It kind of depends on the attending,
27:59
but I'm a big fan of insulin infusions if they're
28:03
needed. I think it's a very efficient way to
28:07
keep people very tight and then can give you
28:09
a very quick understanding of what their need
28:12
is going to be to transition them off an infusion
28:15
to long acting things. But for most people, below
28:19
180 is the goal. And the ICU experience for the
28:24
human body is stressful. So you will see some
28:27
hyperglycemia just in the setting of stress.
28:29
There was one. trial that I think gets brought
28:33
up over and over again so you can earn brownie
28:35
points with your attending is the NICE sugar
28:38
trial. So that's a good one to look up. That's
28:41
where some of this data has been. That's where
28:45
some of this data comes from. And it's just a
28:49
great resource when you're giving your presentations
28:52
to maybe cite one of these. When you're giving
28:59
your presentation, it's helpful to give your
29:03
citations it may be helpful to get brownie points
29:07
the next letter is s for spontaneous awakening
29:11
trial and spontaneous breathing trial um we need
29:15
to wake these patients up they need to get out
29:17
of the icu at some point so this is this seems
29:20
a little bit like an art almost because we want
29:23
the patient to be comfortable but we also want
29:26
to make sure that they're heading in the right
29:28
direction, that they can wake up, that they're
29:30
able to breathe on their own at some point. Tell
29:33
me a little bit about what constitutes a spontaneous
29:36
awakening trial or a spontaneous breathing trial.
29:39
Sure. And this could certainly be its own series
29:42
of lectures. It absolutely is an art. Most importantly,
29:46
coordinating these two things together, I think,
29:48
is really important. A patient will likely fail
29:52
a spontaneous breathing trial if they're sedated
29:55
to Mars. Um, and similarly, uh, you know, it's
30:02
not exactly comfortable to have an endotracheal
30:05
tubing. Um, so if you're not trying to put them
30:08
on some kind of pressure support mode through
30:10
a breathing trial while you're weaning sedation,
30:13
that can also be really uncomfortable and you're
30:15
more likely to fail. Um, cause I would probably
30:18
freak out. Um, so understanding kind of the dance
30:24
of those two things happening together and understanding
30:27
the time it takes for sedation to be formally
30:32
weaned. A lot of these patients are on some kind
30:36
of combination of propofol, fentanyl, etc. So
30:40
making sure you're giving them a fair shot at
30:43
properly waking up, but also maybe layering medicines
30:46
like we use Presidex sometimes to kind of smooth
30:50
the process of keeping them chill, but awake
30:55
enough to get an appropriate neuro exam, to feel
30:57
like you have a good understanding of if they
30:59
could properly protect their airway without an
31:01
endotracheal tube. Coordinating those things
31:04
is certainly an art, but working with your respiratory
31:07
therapists and the members of your team who are
31:09
very familiar with this process is going to be
31:12
the best thing that you can do to help understand
31:15
this process. And ultimately, Even if you're
31:20
like, there's no way we're going to extubate
31:21
this person today, their lungs still want an
31:24
SBT. It's still important to give them the chance
31:27
to kind of exercise those muscles and to get
31:30
stronger rather than just parking them on a vent
31:32
and leaving them there. Because otherwise, you
31:34
just don't have a good way to get them off. Right.
31:36
And that, you know, leaving people intubated
31:39
for longer periods of time predisposes them to
31:42
a higher risk for pneumonia. All the things.
31:46
Not good things. So, and now there's a difference
31:52
between, is there a difference between spontaneous
31:56
breathing trial and fast track extubation? Because
31:59
that was something that came up even in my first
32:02
day. Sure. And fast track extubation may be a
32:07
Cincinnati specific term, I'm unsure, but typically
32:10
we refer to our patients who did pretty well
32:15
post cardiac surgery. We think we can probably
32:19
get successfully extubated post -surgery. Most
32:24
of our cardiac patients, with a select few exceptions,
32:27
will come to the ICU still intubated. But if
32:30
we feel like they'll be able to be extubated
32:32
within, I think it's four or six, maybe six to
32:36
eight hours, they can qualify for what we call
32:40
fast track extubation, which is kind of... escalating
32:44
the process of getting them weaned off sedation,
32:48
getting them to a point where they could complete
32:51
a spontaneous breeding trial. And there's a very
32:54
specific protocol that our respiratory therapists
32:56
will run. So we're less involved with that than
33:00
what we are in the OR, because we kind of do
33:03
our own SBT, air quotes, in the OR before we
33:08
extubate people. But it's much more formal in
33:10
the ICU. So they have to do the 30 -minute trial,
33:15
make sure they can ventilate and oxygenate appropriately
33:19
before extubating. Very cool. I remember watching
33:23
this process happen, and the nurse is there kind
33:27
of monitoring how the patient's doing. The respiratory
33:30
therapist is in and out of the room. They may
33:32
be running one or two spontaneous breathing trials
33:36
at the same time. But as you mentioned, it's
33:39
a time intensive process. They want to make sure
33:42
that it's safe before they're pulling the tube.
33:44
Absolutely. And sometimes family's in the room
33:46
too. So I've gotten in the process of if I'm
33:50
popping in and there's family there, I'll talk
33:52
them through what we're doing as well. Because
33:54
it can be pretty alarming maybe isn't the right
33:58
word. Definitely jarring to watch somebody trying
34:01
to breathe off with assistance and then trying
34:05
to wean off of it. Yeah. So trying to, you know,
34:09
set expectations both for the patient and for
34:12
their family, I think is, I mean, it's a helpful
34:14
lesson in the ICU in general, but specifically
34:17
having family watch an SBT for sure. The last
34:22
three letters are BID. The B is for bowel regimen.
34:26
Obviously good to keep people regular. And making
34:31
sure that when they're on medications, these
34:34
opioids, things that can slow down their gut
34:37
motility, you know, think about anticholinergics
34:39
as well. Just making sure that that's not causing
34:43
issues as well, because that can get you into
34:45
a lot of trouble in the ICU when patients aren't
34:47
able to get up, move, exercise, and keep themselves
34:51
regular. Absolutely. And it swings the other
34:53
direction too. If they're going too much, you
34:56
can miss things like if they're high risk for
35:01
C. diff or things like that. You have to kind
35:03
of keep a tally on those things as well. I is
35:08
for indwelling catheters. What can you tell me,
35:12
what kind of catheters are we talking about?
35:15
Are we just talking about Foley catheters or
35:17
are there other types of catheters that we need
35:19
to be addressing every day? There's so many lines
35:24
that you see in the ICU. And that part can certainly
35:27
be overwhelming at first. You're going to have
35:29
vascular access lines. You're going to have Foley
35:33
catheters. You're going to have endotracheal
35:34
tubes. And you should be evaluating any invasive
35:37
line every single day. They have more stringent
35:42
rules on how long we like to keep lines in. So
35:46
you have to review when things were placed, how
35:49
long they've been there, if they really need
35:50
them. We try and take as many tubes out as possible
35:54
to normalize patients, reduce the risk for delirium,
35:57
and then ultimately trying to normalize these
36:00
patients as quickly as possible to get them out
36:03
of the ICU. But you're going to be evaluating
36:05
central lines, whether they're supposed to be
36:09
for continuous renal replacement or pressors.
36:14
If they have an invasive PA catheter, colloquially
36:19
known as SWANs. We love SWANs here at UC, but
36:22
that's an institution to institution thing. So
36:25
whether you really need that invasive monitoring
36:28
is a question we should be asking every day.
36:31
Similar with arterial lines and then making sure
36:35
you have enough vascular access as well. All
36:38
of those are things that you should be going
36:39
through every single day to try and, you know.
36:44
The more attached they are to things, the more
36:47
likely they are to suffer from things like delirium
36:49
and the longer they're going to stay in the ICU.
36:53
I remember walking into a post -cardiac surgery
36:59
patient's room, seeing this tower with all of
37:03
these pumps, all the infusions, all the lines
37:07
going to the patient. If being in the OR and
37:11
having to learn all of the cord organization
37:14
isn't overwhelming enough, you're in the ICU
37:18
setting and so many of these drips are very important.
37:21
But as you said, getting out of the ICU is a
37:25
goal that every patient has. And we want to figure
37:29
out how we get them detached from the machines
37:32
and the pumps and the medications and all those
37:35
different things. Yeah. And I will certainly
37:37
add for... All of those things, I don't think
37:41
I got there at the end of my intern year. But
37:43
after I did my month of cardiac, I was much more
37:46
comfortable with the infusions that were running,
37:49
the kind of access that you have, and why you
37:52
need it. A lot of that didn't really click until
37:54
after I was the one doing the cardiac case. And
37:58
conveniently, with the way my schedule worked,
38:00
I went straight from cardiac into my next round
38:02
of CCAN. So I kind of got to see the full picture,
38:05
which was a hard two months, but a very, very
38:07
good two months to really understand what are
38:11
we doing for these patients? Why do we have the
38:13
access that we have? What infusions are we running
38:15
for? Why? All of that clicked much more later
38:19
in training. So if you don't get it all as an
38:21
intern, that is very normal. That's reassuring.
38:25
I think one thing just on the note about lines,
38:30
sometimes these lines can... go bad or they stop
38:34
working you know you'll hear things like oh this
38:38
a -line is over dampened or under dampened those
38:42
are things that you know it takes time to understand
38:45
a little bit more i will say you know this is
38:48
a good opportunity to mention there's procedures
38:50
that you can do in the icu occasionally so certainly
38:54
during rounds when you're talking about reevaluating
38:56
lines you may hear somebody say hey this person
38:59
actually needs a new a -line because this one
39:02
isn't working as well. That may be an opportunity
39:04
for you to do a procedure. Do you have any comments
39:08
or thoughts about doing lines, doing your first
39:11
line, things like that? Our fellows are awesome.
39:14
They're typically going to be the ones that are
39:16
walking you through it. It's very different doing
39:18
lines in the ICU than the OR. The procedure is
39:22
the same, but it just feels very different. I
39:24
don't have a good explanation for why. And patients
39:27
are just sicker in the ICU than typically what
39:30
we'll find in the OR, I feel, or at least they've
39:34
had attempts at access. So the access itself
39:36
may be more difficult. So cut yourself some slack
39:38
if it doesn't go super well. If it's an A -line
39:43
that people have had trouble with, it's also
39:45
okay if you struggle at first, but we're all
39:47
there to learn. So always asking for help, being
39:51
very proactive in asking to do things is only
39:54
going to do you good. Being an enthusiastic learner
39:57
is how you learn quickly. So I would certainly
40:02
emphasize that. This is the kind of rotation,
40:05
as with any rotation, the more you put into it,
40:08
the more you show up and want to learn and want
40:10
to do things, the more you're going to get out
40:13
of it. And the better physician you're going
40:14
to end up being. So things like arterial lines,
40:17
central lines. Intubations, typically, we won't
40:22
really participate in just because the fellows
40:25
will typically do that here. And truthfully,
40:28
we get plenty of them in the OR that I don't
40:31
feel that's a place you need to take your energy.
40:34
But I did get to do my first brunk in the ICU
40:36
as an intern on a healthy patient, which felt
40:42
really cool at the time. And now that we're a
40:44
little bit deeper, it's not quite as novel. You
40:48
certainly get exposure to all of those things,
40:51
not quite in the volume that you get down in
40:53
the OR, but it's nice to see how things are done
40:56
a little bit differently. I was really impressed
40:59
and grateful that so many of the specialists,
41:04
the respiratory therapist, the perfusionist,
41:07
you know, if you want to learn a little bit more
41:09
about how a ventilator works. and you're watching
41:13
how things get set up before a patient gets intubated.
41:15
You see the respiratory therapist bring all that
41:17
equipment in. It's great to maybe spend some
41:20
time talking to the respiratory therapist how
41:21
things work. I actually remember doing a learning,
41:25
like a lecture with one of the respiratory therapists.
41:29
And this may be an opportunity for you where
41:30
you actually get to feel what it's like for that
41:34
mechanical ventilator to be blowing air into
41:39
your body. and just how uncomfortable that can
41:42
be. And then, you know, if you want to learn
41:44
more about ECMO, there's perfusionists. They
41:46
can tell you how the machine works. It's just
41:49
really great that the ICU has people that are
41:53
willing to teach. And as you said, you know,
41:57
being open to education, asking questions, you're
42:00
going to pick up a lot during this rotation.
42:04
Absolutely. The intensive care unit is a very
42:08
overwhelming place. But you're not there alone.
42:12
And that's, you know, if you hear nothing else,
42:14
that's what I want people to really take home
42:17
is you're not taking care of this patient alone.
42:20
You're on a team that's working with other teams,
42:23
that's working with a whole set of professionals
42:25
within the ICU. So you're certainly not alone.
42:30
And there's plenty of help should you need it.
42:33
And asking questions is going to be the best
42:36
way that you figure those things out. So always
42:38
communicating. What you know, what you don't
42:42
know, asking questions. That's all we really
42:45
need from you, especially as an intern. That's
42:48
really helpful. We didn't get to talk a ton about
42:52
D, but in a way we actually did. We talked about
42:55
de -escalation. There's all kinds of things that
42:57
we de -escalate. The other D being delirium.
43:00
You alluded to that as well and some strategies
43:02
to mitigate in -hospital delirium, keeping patients.
43:08
um safe keeping them alert and and liberating
43:13
them from the icu and i want to thank you so
43:17
much for this conversation i love the passion
43:21
that you bring to critical care and i really
43:24
appreciate you taking time to help you know this
43:28
next set of interns get oriented to the unit
43:31
um any other pearls that you wanted to share
43:34
i'd probably just leave you with uh My most consistent
43:41
piece of advice, and this baby applies outside
43:44
of the ICU as well, but honestly, communicating
43:48
with everyone is what is going to keep patients
43:54
safe. Being very honest about what you think
44:00
is going on and talking through your thought
44:02
process is going to help both your team and...
44:07
the rest of the care team. So I've certainly
44:09
been in situations where, you know, a nurse has
44:12
a huge concern. I don't share the concern, but
44:15
if you talk through it and be honest about kind
44:20
of where you're at, what you're thinking, oftentimes
44:23
you can diffuse all sorts of tension within the
44:26
unit and getting help is easy. But you have to
44:32
ask for it. Those are some great style points,
44:35
Anne. Really appreciate that. I'll leave you
44:39
with a couple of references that I found helpful
44:41
as well. Obviously, this Style Points podcast,
44:45
we have other episodes. There's one with Dr.
44:49
Zadie, who is an ECMO specialist. So I would
44:52
recommend listening to that episode if you want
44:55
to learn a little bit more about how ECMO works,
44:57
what kind of patients are on ECMO, because you'll
44:59
for sure see one or two during your month in
45:02
the CVICU. There's also a great lecture from
45:07
Dr. Jones about liver transplant, because you
45:10
may see some liver transplant patients in the
45:12
ICU as well. Outside of this podcast, there is
45:17
ACRAC, the Anesthesia and Critical Care Reviews
45:20
and Commentary podcast by Jed Wolpaw. He has
45:24
a couple of great episodes. There's one on ERAS,
45:27
or Enhanced Recovery After Surgery, for cardiac
45:31
surgery patients. And I would just use the search
45:36
bar to find those episodes. But if you have questions,
45:40
as you mentioned, Anne, there's all sorts of
45:43
resources. You'll be getting emails, I'm sure,
45:45
before these rotations start. So never fear.
45:48
There's more information to come, always. Yeah.
45:51
Thanks again. Of course. I'd probably tack on
45:53
the ICU one -pagers to the references. Oh, yes.
45:57
There's one for like almost everything. And they're
45:59
super helpful from ECMO, Impella's. Ventilators.
46:03
Yes. Even just evaluation of shock. They're all
46:06
super helpful. I would highly recommend. ICU
46:09
one pagers. Good tip. That's it for this month's
46:14
episode of Style Points. Thanks to John and Anne
46:16
for putting it together. They did a great job
46:18
of running through a lot of the basics. Something
46:21
like this would have definitely been helpful
46:22
to me when I was starting in the ICU. If you're
46:26
a fan of the show. please consider giving us
46:28
a five -star rating or review, or just tell your
46:31
friends about the podcast. If you want to email
46:33
us, please reach out at stylepointspodcast at
46:36
gmail .com. Lastly, there's no way I was going
46:40
to end the podcast without congratulating my
46:42
NBA team, the Oklahoma City Thunder, on winning
46:44
their first title in a hard -fought battle with
46:47
the very respectable Indiana Pacers. I did my
46:50
residency in Oklahoma City, and I've been a big
46:52
fan ever since. Take a deep breath. Open your
46:56
eyes. We're all done.