TERM 2, 2021

Reviewed and revised 11 June 2021 by G Brogan

Week 7: Topic – Communication

Q1. Thursday (10/6):

How would you manage a family meeting where you are breaking bad news to relatives? How might this differ if you were giving bad news over the phone?

Q2. Friday (11/6):

What phrases and strategies could you use when discussing treatment limitations and goals of care with patients and families?

Q3. Saturday (12/6):

How are organ donation conversations managed in ICU?

Q4. Sunday (13/6):

What attributes and behaviours make someone a good team leader? What are the equivalent requirements for good followership? What communication strategies might they employ in a crisis?

Q5. Monday (14/6):

What strategies do you have to manage conflict within your team and with other inpatient teams?

Week 6: Topic - Coma, Seizures and Weakness 

Q1. Thursday (3/6):

a. Perform a neurological examination on an intubated patient. How can you assess focal neurology if the patient is sedated?

b. Assess a patient’s pupillary responses on your ward round. What are the common causes of mydriasis and miosis in ICU patients?

Q2. Friday (4/6):  

Assess a patient who is not ‘waking up’. What is your broad differential diagnosis list for this patient? What investigations should you order to investigate this?

Q3. Saturday (5/6):

Assess a patient who is being considered for extubation. How would you assess his neuromuscular strength and likelihood of successful extubation?

Q4. Sunday (6/6):

Assess a patient who is obtunded. How can you rule out a seizure diagnosis in this patient?

Q5. Monday (7/6):

Assess a patient who might have critical illness polymyoneuropathy. What are the clinical features of this disease? How can you confirm your diagnosis?

Week 5: Topic - Mechanical Ventilation

Q1. Thursday (27/5):

Review the ventilator settings on your intubated patients during your ward round. Are they receiving “protective lung ventilation”? What is the justification for the choice of mode, tidal volume and PEEP?

Q2. Friday (28/5):

Assess an intubated patient and determine their PF ratio. What does the PF ratio tell you? What ventilator and non-ventilator strategies can be used to improve oxygenation?

Q3. Saturday (29/5):

Perform an inspiratory hold and an expiratory hold on a stable mechanically ventilated patient. What information does this give you about your patient’s respiratory condition?

Q4. Sunday (30/5):

Review a patient who is intubated and receiving mechanical ventilation. What can you learn from the ventilator waveforms?

Q5. Monday (31/5):

Review a patient who is intubated and receiving mechanical ventilation. How can you assess their lung compliance on the ventilator? What factors affect lung compliance?

Week 3: Topic - End of Life and Organ Donation

 Q1. Thursday (13/5):

Observe an ICU family meeting. What are the important considerations in preparing for the meeting? How was bad news conveyed? How was the meeting documented?

Q2. Friday (14/5):

Review a patient who has transitioned to end of life care. How are palliative care principles applied in ICU?

Q3. Saturday (15/5):

Review a newly admitted patient. Are their goals of care formally documented? How is/should this be discussed with the patient or their medical treatment decision maker?

Q4. Sunday (16/5):

Consider a patient who has transitioned to end of life care. How is a collaborative request for organ donation handled?

Q5. Monday (17/5):

Discuss the process of organ donation. What types of organ donation exist? How are each of these processes facilitated in ICU?

Week 2: Topic - Resuscitation

Q1. Thursday (6/5):

As a team, locate the defibrillator in your pod. How would you set up the defibrillator and use it to safely and effectively defibrillate a patient in VF? How is synchronised cardioversion different?

Q2. Friday (7/5):

Review the goals of care of your patients. How can you rapidly find the goals of care in an emergency? Discuss what factors to consider when determining appropriate goals of care.

Q3. Saturday (8/5):

For an ACLS drug of your choice, discuss its role in the management of cardiac arrest.

Q4. Sunday (9/5):

Review the etCO2 waveform of one of your intubated patients. How would this waveform change in the event of a cardiac arrest? What is the role of etCO2 monitoring in the management of cardiac arrest?

Q5. Monday (10/5):

What ALS modifications are currently recommended at the Alfred for suspected or confirmed COVID patients during the COVID-19 pandemic?

TERM 1, 2021

Week 13: Topic - Electrolytes and Metabolic Crises

Q1. Thursday (22/4):

Assess a patient with hyponatremia. What is the cause of their hyponatremia and does assessing fluid balance help differentiate the cause? What other investigations can you order to determine the diagnosis?

Q2. Friday (23/4):

Assess a patient with hypernatremia. What are the common causes in ICU for hypernatremia? How do we manage this issue?

Q3. Saturday (24/4):

Consider a patient with hyperkalemia. What are your management priorities when managing this acute electrolyte disturbance? How would you determine which treatment options to consider?

Q4. Sunday (25/4):

Review a patient with a metabolic acidosis. How can you determine the cause of this acid-base imbalance? Is there an additional respiratory component or metabolic alkalosis?

Q5. Monday (26/4):

Review a patient with a metabolic alkalosis. What are the common causes of a metabolic alkalosis in ICU? What rules can help determine if respiratory compensation is appropriate?

Week 12: Topic - Sepsis and Septic Shock

Q1. Thursday (15/4):

Consider a patient with suspected sepsis. How is sepsis defined and diagnosed? What are the difficulties in diagnosing sepsis? What are the diagnostic criteria for ‘septic shock’?

Q2. Friday (16/4):

Consider a patient with suspected sepsis. What are the key management interventions that need to be provided at a MET call for suspected sepsis at Alfred Health? Why are these important?

Q3. Saturday (17/4):

Consider a patient with suspected sepsis. How would you decide if further fluid therapy is required? Is there a role for monitoring each of these: CVP? Lactate? ScvO2? “Fluid responsiveness” assessments?

Q4. Sunday (18/4):

Consider a septic shock patient on moderate-to-high dose noradrenaline. What diagnoses or complications should you consider? What are the roles of adjunctive therapies to support the circulation?

Q5. Monday (19/4):

A patient with septic shock has a venous blood gas taken from their femoral central line which shows an oxygen saturation (ScvO2) of 50%. How should we interpret this ScvO2? Would this number to be lower/higher/unchanged if the central line was in a jugular vein?

Week 10: Topic – Sedation and Delirium (Neuro I)

Q1. Thursday (1/4):

What is the definition and prevalence of delirium in ICU?

Q2. Friday (2/4):

What is CAM-ICU? Do you know any other delirium diagnostic tools?

Q3. Saturday (3/4):

What are the complications of delirium in ICU?

Q4. Sunday (4/4):

What treatments can be used for delirium in ICU?

Q5. Monday (5/4):

How do we assess the level of sedation in ICU? Is there any evidence for daily sedation breaks in ICU?

Week 7: Topic – Renal Replacement Therapy

Q1. Thursday (11/3):

Consider a patient who has an acute kidney injury. What are the possible causes and how can they be confirmed or excluded?

Q2. Friday (12/3):

Review patients on your ward round with acute kidney injury. If they are receiving continuous renal replacement therapy (CRRT), what was the indication to start? If they are not receiving CRRT, what would trigger starting? How do you determine when CRRT is no longer required?

Q3. Saturday (13/3):

Examine a CRRT circuit with the bedside nurse in the ICU. Compare the circuit with this simplified image below. Are there any differences between the two?

Image from DerangedPhysiology.com (Source: CVVHDF circuit diagram)

Q4. Sunday (14/3):

Review a patient on CRRT. What variables do you need to consider when prescribing the RRT settings for the day?

Q5. Monday (15/3):

Review a patient on CRRT. What is the anticoagulation strategy being used? What are the pros and cons of this strategy compared to other options

Week 5: Topic – Shock and Vasoactive Agents

Q1. Thursday (25/2):

Assess a patient with “shock”. What is the definition of shock? How is it classified?

Q2. Friday (26/2):

Examine a patient who is receiving vasopressors for shock. What are the clinical features that support this diagnosis?

Q3. Saturday (27/2):

Review a patient who is receiving a ‘vasopressor’ or ‘inotrope’. What is the justification for this medication for this patient?

Q4. Sunday (28/2):

Review a patient on a Noradrenaline and/or Vasopressin infusion. What is the evidence for the use of Noradrenaline? What is the evidence for the use of Vasopressin?

Q5. Monday (1/3):

Review a patient with an elevated Lactate level. Does hyperlactatemia always mean a patient is shocked? What are the causes of hyperlactataemia and why does it occur in patients with shock?

Week 4: Topic - Haemodynamics 

Q1. Thursday 18/2

Clinically assess a patient on your daily ward round. What clinical and biochemical parameters can you consider when deciding on a daily fluid balance aim?

Q2. Friday 19/2

Review a patient with a central line in situ. What information can you obtain from a central venous pressure (CVP) trace? Does the CVP help you assess a patient’s haemodynamic status?

Q3. Saturday 20/2

Review a patient with an arterial line in situ. What information can you obtain from the arterial waveform? What factors affect the accuracy of its measurement?

Q4. Sunday 21/2

Consider a patient who needs a fluid bolus. How can you assess this patient’s ‘fluid responsiveness’ and does it matter?

Q5. Monday 22/2

Assess a patient who might have a low cardiac output state. How can we measure cardiac output? How would we choose which approach to use?

Week 3: Topic - Trauma ICU

Q1. Thursday (11/2)

What are the mechanisms for coagulopathy in a trauma patient? What is haemostatic resuscitation and what clinical endpoints do we target to achieve this?

Q2. Friday (12/2)

Review a trauma patient who has been haemodynamically unstable. What are the causes of hypotension in major trauma? How would you approach diagnosis at the bedside?

Q3. Saturday (13/2)

What are the possible mechanisms of bleeding in pelvic trauma? In broad terms, what would be your approach to a patient with pelvic trauma who was haemodynamically unstable?

Q4. Sunday (14/2)

What specific management issues do we need to consider in a patient with a spinal cord injury in ICU?

Q5. Monday (15/2)

Which traumatic injuries might affect our ventilation strategy in an intubated patient? How would we adjust our strategy in these circumstances?

Week 2: Topic - Post-Cardiac Surgery

Q1. Thursday (4/2):

What are the complications associated with cardiopulmonary bypass?

Q2. Friday (5/2):

What are your differential diagnoses and management plan for a patient who is hypotensive in ICU 1 hour after cardiac surgery?

Q3. Saturday (6/2):

How would you diagnose tamponade following cardiac surgery?

Q4. Sunday (7/2):

How do you manage a patient who is bleeding following cardiac surgery?

Q5. Monday (8/2):

What does “off-pump” surgery mean? What are the theoretical advantages and disadvantages?

TERM 4, 2020

Week 13: Topic – GI and Nutrition

Q1. Thursday (21/1):

Review your patient’s drug charts on the morning ward round. Which patients are receiving ulcer prophylaxis? What is the justification for prescribing a proton-pump inhibitor (PPI)?

Q2. Friday (22/1):

Examine a critically unwell patient on your ward round. What are the signs of ‘cachexia’ or ‘malnutrition’ that you can see?

Q3. Saturday (23/1):

Review a patient who is at risk of refeeding syndrome. What are the complications of this syndrome? How would you manage their nutritional intake?

Q4. Sunday (24/1):

Review a patient who is ‘not absorbing feeds’. What is the Alfred ICU’s guideline for the use of prokinetic agents? What are the adverse effects of these prokinetic agents?

Q5. Monday (25/1):

Review a patient’s nutrition plan with the ICU dietitian. How have their nutritional requirements been calculated? Is the patient achieving their target requirements?

Week 12: Topic - Electrolytes and Metabolic Crises

Q1. Thursday (14/1):

Assess a patient with hyponatremia. What is the cause of their hyponatremia? Does assessing fluid balance help differentiate the cause? What other investigations can you order to determine the diagnosis?

Q2. Friday (15/1):

Assess a patient with hypernatremia. What are the common causes in ICU for hypernatremia? How do we manage this issue?

Q3. Saturday (16/1):

Consider a patient with hyperkalemia. What are your management priorities when managing this acute electrolyte disturbance? How would you determine which treatment options to consider?

Q4. Sunday (17/1):

Review a patient with a metabolic acidosis. How can you determine the cause of this acid-base imbalance? Is there an additional respiratory component or metabolic alkalosis?

Q5. Monday (18/1):

Review a patient with a metabolic alkalosis. What are the common causes of a metabolic alkalosis in ICU? What rules can help determine if respiratory compensation is appropriate?

Week 11: Topic - Transfusion & Blood Products

Q1. Thursday (7/1):

What are the causes of anaemia in ICU?

Q2. Friday (8/1):

What are the haemoglobin targets in ICU? Is there any evidence for these targets?

Q3. Saturday (9/1):

What are the complications (acute and chronic) of massive transfusion?

Q4. Sunday (10/1):

What are the causes of thrombocytopenia in ICU? How would you manage this?

Q5. Monday (11/1):

Which blood products require cross matching and which blood products don’t?

Week 7: Topic – Communication

Q1. Thursday (10/12):

How would you manage a family meeting where you are breaking bad news to relatives? How might this differ if you were giving bad news over the phone?

Q2. Friday (13/12):

What phrases and strategies could you use when discussing treatment limitations and goals of care with patients and families?

Q3. Saturday (14/12):

How are organ donation conversations managed in ICU?

Q4. Sunday (15/12):

What attributes and behaviours make someone a good team leader? What are the equivalent requirements for good followership? What communication strategies might they employ in a crisis?

Q5. Monday (16/12):

What strategies do you have to manage conflict within your team and with other inpatient teams?

Week 6: Topic - Coma, Seizures and Weakness 

Q1. Thursday (3/12):

a. Perform a neurological examination on an intubated patient. How can you assess focal neurology if the patient is sedated?

b. Assess a patient’s pupillary responses on your ward round. What are the common causes of mydriasis and miosis in ICU patients?

Q2. Friday (4/12):  

Assess a patient who is not ‘waking up’. What is your broad differential diagnosis list for this patient? What investigations should you order to investigate this?

Q3. Saturday (5/12):

Assess a patient who is being considered for extubation. How would you assess his neuromuscular strength and likelihood of successful extubation?

Q4. Sunday (6/12):

Assess a patient who is obtunded. How can you rule out a seizure diagnosis in this patient?

Q5. Monday (7/12):

Assess a patient who might have critical illness polymyoneuropathy. What are the clinical features of this disease? How can you confirm your diagnosis?

Week 5: Topic - Mechanical Ventilation

Q1. Thursday (26/11):

Review the ventilator settings on your intubated patients during your ward round. Are they receiving “protective lung ventilation”? What is the justification for the choice of mode, tidal volume and PEEP?

Q2. Friday (27/11):

Assess an intubated patient and determine their PF ratio. What does the PF ratio tell you? What ventilator and non-ventilator strategies can be used to improve oxygenation?

Q3. Saturday (28/11):

Perform an inspiratory hold and an expiratory hold on a stable mechanically ventilated patient. What information does this give you about your patient’s respiratory condition?

Q4. Sunday (29/11):

Review a patient who is intubated and receiving mechanical ventilation. What can you learn from the ventilator waveforms?

Q5. Monday (30/11):

Review a patient who is intubated and receiving mechanical ventilation. How can you assess their lung compliance on the ventilator? What factors affect lung compliance?

Week 3: Topic - End of Life and Organ Donation

Q1. Thursday (12/11):

Observe an ICU family meeting. What are the important considerations in preparing for the meeting? How was bad news conveyed? How was the meeting documented?

Q2. Friday (13/11):

Review a patient who has transitioned to end of life care. How are palliative care principles applied in ICU?

Q3. Saturday (1411):

Review a newly admitted patient. Are their goals of care formally documented? How is/should this be discussed with the patient or their medical treatment decision maker?

Q4. Sunday (15/11):

Consider a patient who has transitioned to end of life care. How is a collaborative request for organ donation handled?

Q5. Monday (16/11):

Discuss the process of organ donation. What types of organ donation exist? How are each of these processes facilitated in ICU?

Week 2: Topic - Resuscitation

Q1. Thursday (5/11):

As a team, locate the defibrillator in your pod. How would you set up the defibrillator and use it to safely and effectively defibrillate a patient in VF? How is synchronised cardioversion different?

Q2. Friday (6/11):

Review the goals of care of your patients. How can you rapidly find the goals of care in an emergency? Discuss what factors to consider when determining appropriate goals of care.

Q3. Saturday (7/11):

For an ACLS drug of your choice, discuss its role in the management of cardiac arrest.

Q4. Sunday (8/11):

Review the etCO2 waveform of one of your intubated patients. How would this waveform change in the event of a cardiac arrest? What is the role of etCO2 monitoring in the management of cardiac arrest?

Q5. Monday (9/11):

What ALS modifications are currently recommended at the Alfred for suspected or confirmed COVID patients during the COVID-19 pandemic?

TERM 3, 2020

Reviewed and revised 1 October 2020

Week 12: Topic Infectious Diseases and Microbiology

Q1. Thursday (22/10):

Review a patient who has had a fever in the last 24 hours. How do you define fever? What are the potential infectious and non-infectious causes of fever in ICU patients?

Q2. Friday (23/10):

Review a patient who is being treated for an infection. How will you determine when to stop antibiotics?

Q3. Saturday (24/10):

Review a patient who is being treated with antibiotics. How do you decide if the patient is failing to respond to treatment? What are the possible causes of failure to respond to antibiotic therapy?

Q4. Sunday (25/10):

Consider a patient who has been isolated for infection control. What are the different types of isolation and their indications?

Q5. Monday (26/10):

Attend an ICU Micro Round. How does the ICU Micro Round help patients? What strategies help reduce the emergence of resistant organisms?

Week 11: Topic – Toxicology and Pharmacology

Q1. Thursday (8/10):

Review a patient’s drug chart with the ICU pharmacist. What are the potential drug interactions to be aware of? What are the common ICU drug interactions?

Q2. Friday (9/10):

Discuss the dosing and frequency of administration of important ICU medications with the ICU pharmacist. What factors affect the pharmacokinetics (absorption, distribution, metabolism and excretion) of these medications in critically ill patients?

Q3. Saturday (10/10):

Discuss a patient who may benefit from therapeutic drug monitoring (TDM). When should we perform TDM – which drugs and in which patients? What practical issues affect TDM?

Q4. Sunday (11/10):

Review a patient who has an acute kidney injury. How does it affect the dosing and timing of their medications? How does renal replacement therapy alter this?

Q5. Monday (12/10):

Review a patient with complex analgesia needs. Discuss the advantages and disadvantages of different pharmacological therapies for this patient (e.g. opioids, partial opioid agonists, paracetamol, NSAIDS, ketamine, lignocaine)

Week 10: Topic – Sedation and Delirium (Neuro I) Sedation and Delirium (Neuro II)

Q1. Thursday (1/10):

What is the definition and prevalence of delirium in ICU?

Q2. Friday (2/10):

What is CAM-ICU? Do you know any other delirium diagnostic tools?

Q3. Saturday (3/10):

What are the complications of delirium in ICU?

Q4. Sunday (4/10):

What treatments can be used for delirium in ICU?

Q5. Monday (5/10):

How do we assess the level of sedation in ICU? Is there any evidence for daily sedation breaks in ICU?

Week 8: Topic - Sepsis and Septic Shock

Q1. Thursday (17/9):

Consider a patient with suspected sepsis. How is sepsis defined and diagnosed? What are the difficulties in diagnosing sepsis? What are the diagnostic criteria for ‘septic shock’?

Q2. Friday (18/9):

Consider a patient with suspected sepsis. What are the key management interventions that need to be provided at a MET call for suspected sepsis at Alfred Health? Why are these important?

Q3. Saturday (19/9):

Consider a patient with suspected sepsis. How would you decide if further fluid therapy is required? Is there a role for monitoring each of these: CVP? Lactate? ScvO2? “Fluid responsiveness” assessments?

Q4. Sunday (20/9):

Consider a septic shock patient on moderate-to-high dose noradrenaline. What diagnoses or complications should you consider? What are the roles of adjunctive therapies to support the circulation?

Q5. Monday (21/9):

A patient with septic shock has a venous blood gas taken from their femoral central line which shows an oxygen saturation (ScvO2) of 50%. How should we interpret this ScvO2? Would this number to be lower/higher/unchanged if the central line was in a jugular vein?

Week 6: Topic – Renal Replacement Therapy

Q1. Thursday (10/9):

Consider a patient who has an acute kidney injury. What are the possible causes and how can they be confirmed or excluded?

Q2. Friday (11/9):

Review patients on your ward round with acute kidney injury. If they are receiving continuous renal replacement therapy (CRRT), what was the indication to start? If they are not receiving CRRT, what would trigger starting? How do you determine when CRRT is no longer required?

Q3. Saturday (12/9):

Examine a CRRT circuit with the bedside nurse in the ICU. Compare the circuit with this simplified image below. Are there any differences between the two?

Image from DerangedPhysiology.com (Source: CVVHDF circuit diagram)

Q4. Sunday (13/9):

Review a patient on CRRT. What variables do you need to consider when prescribing the RRT settings for the day?

Q5. Monday (14/9):

Review a patient on CRRT. What is the anticoagulation strategy being used? What are the pros and cons of this strategy compared to other options

Week 5: Topic – Shock and Vasoactive Agents

Q1. Thursday (27/08):

Assess a patient with “shock”. What is the definition of shock? How is it classified?

Q2. Friday (28/08):

Examine a patient who is receiving vasopressors for shock. What are the clinical features that support this diagnosis?

Q3. Saturday (29/08):

Review a patient who is receiving a ‘vasopressor’ or ‘inotrope’. What is the justification for this medication for this patient?

Q4. Sunday (30/08):

Review a patient on a Noradrenaline and/or Vasopressin infusion. What is the evidence for the use of Noradrenaline? What is the evidence for the use of Vasopressin?

Q5. Monday (31/08):

Review a patient with an elevated Lactate level. Does hyperlactatemia always mean a patient is shocked? What are the causes of hyperlactataemia and why does it occur in patients with shock?

Week 4: Topic - Haemodynamics

Q1. Thursday 20/8

Clinically assess a patient on your daily ward round. What clinical and biochemical parameters can you consider when deciding on a daily fluid balance aim?

Q2. Friday 21/8

Review a patient with a central line in situ. What information can you obtain from a central venous pressure (CVP) trace? Does the CVP help you assess a patient’s haemodynamic status?

Q3. Saturday 22/8

Review a patient with an arterial line in situ. What information can you obtain from the arterial waveform? What factors affect the accuracy of its measurement?

Q4. Sunday 23/8

Consider a patient who needs a fluid bolus. How can you assess this patient’s ‘fluid responsiveness’ and does it matter?

Q5. Monday 24/8

Assess a patient who might have a low cardiac output state. How can we measure cardiac output? How would we choose which approach to use?

Week 3: Topic - Trauma ICU

Q1. Thursday (13/8)

What are the mechanisms for coagulopathy in a trauma patient? What is haemostatic resuscitation and what clinical endpoints do we target to achieve this?

Q2. Friday (14/8)

Review a trauma patient who has been haemodynamically unstable. What are the causes of hypotension in major trauma? How would you approach diagnosis at the bedside?

Q3. Saturday (15/8)

What are the possible mechanisms of bleeding in pelvic trauma? In broad terms, what would be your approach to a patient with pelvic trauma who was haemodynamically unstable?

Q4. Sunday (16/8)

What specific management issues do we need to consider in a patient with a spinal cord injury in ICU?

Q5. Monday (17/8)

Which traumatic injuries might affect our ventilation strategy in an intubated patient? How would we adjust our strategy in these circumstances?

Week 2: Topic - Post-Cardiac Surgery

Q1. Thursday (6/8):

What are the complications associated with cardiopulmonary bypass?

Q2. Friday (7/8):

What are your differential diagnoses and management plan for a patient who is hypotensive in ICU 1 hour after cardiac surgery?

Q3. Saturday (8/8):

How would you diagnose tamponade following cardiac surgery?

Q4. Sunday (9/8):

How do you manage a patient who is bleeding following cardiac surgery?

Q5. Monday (10/8):

What does “off-pump” surgery mean? What are the theoretical advantages and disadvantages?

TERM 2, 2020

Reviewed and revised 23 July 2020

Week 14: Topic – Renal Failure & Renal Replacement Therapy

Q1. Thursday (23/7):

Consider a patient who has an acute kidney injury. What are the possible causes and how can they be confirmed or excluded?

Q2. Friday (24/7):

Review patients on your ward round with acute kidney injury. If they are receiving continuous renal replacement therapy (CRRT), what was the indication to start? If they are not receiving CRRT, what would trigger starting? How do you determine when CRRT is no longer required?

Q3. Saturday (25/7):

Examine a CRRT circuit with the bedside nurse in the ICU. Compare the circuit with this simplified image below. Are there any differences between the two?

Image from DerangedPhysiology.com (Source: CVVHDF circuit diagram)

Q4. Sunday (26/7):

Review a patient on CRRT. What variables do you need to consider when prescribing the RRT settings for the day?

Q5. Monday (28/7):

Review a patient on CRRT. What is the anticoagulation strategy being used? What are the pros and cons of this strategy compared to other options

Week 13: Topic - Coma, Seizures and Weakness 

Q1. Thursday (16/7):

a. Perform a neurological examination on an intubated patient. How can you assess focal neurology if the patient is sedated?

b. Assess a patient’s pupillary responses on your ward round. What are the common causes of mydriasis and miosis in ICU patients?

Q2. Friday (17/7):  

Assess a patient who is not ‘waking up’. What is your broad differential diagnosis list for this patient? What investigations should you order to investigate this?

Q3. Saturday (18/7):

Assess a patient who is being considered for extubation. How would you assess his neuromuscular strength and likelihood of successful extubation?

Q4. Sunday (19/7):

Assess a patient who is obtunded. How can you rule out a seizure diagnosis in this patient?

Q5. Monday (20/7):

Assess a patient who might have critical illness polymyoneuropathy. What are the clinical features of this disease? How can you confirm your diagnosis?

Week 10: Topic - GI and Nutrition

Q1. Thursday (2/7):

Review your patient’s drug charts on the morning ward round. Which patients are receiving ulcer prophylaxis? What is the justification for prescribing a proton-pump inhibitor (PPI)?

Q2. Friday (3/7):

Examine a critically unwell patient on your ward round. What are the signs of ‘cachexia’ or ‘malnutrition’ that you can see?

Q3. Saturday (4/7):

Review a patient who is at risk of refeeding syndrome. What are the complications of this syndrome? How would you manage their nutritional intake?

Q4. Sunday (5/7):

Review a patient who is ‘not absorbing feeds’. What is the Alfred ICU’s guideline for the use of prokinetic agents? What are the adverse effects of these prokinetic agents?

Q5. Monday (6/7):

Review a patient’s nutrition plan with the ICU dietitian. How have their nutritional requirements been calculated? Is the patient achieving their target requirements?

Week 9: Topic - Electrolytes and Metabolic Crises

Q1. Thursday (25/6):

Assess a patient with hyponatremia. What is the cause of their hyponatremia? Does assessing fluid balance help differentiate the cause? What other investigations can you order to determine the diagnosis?

Q2. Friday (26/6):

Assess a patient with hypernatremia. What are the common causes in ICU for hypernatremia? How do we manage this issue?

Q3. Saturday (27/6):

Consider a patient with hyperkalemia. What are your management priorities when managing this acute electrolyte disturbance? How would you determine which treatment options to consider?

Q4. Sunday (28/6):

Review a patient with a metabolic acidosis. How can you determine the cause of this acid-base imbalance? Is there an additional respiratory component or metabolic alkalosis?

Q5. Monday (29/6):

Review a patient with a metabolic alkalosis. What are the common causes of a metabolic alkalosis in ICU? What rules can help determine if respiratory compensation is appropriate?

Week 7: Topic - Infectious Diseases and Microbiology

Q1. Thursday (11/6):

Review a patient who has had a fever in the last 24 hours. How do you define fever? What are the potential infectious and non-infectious causes of fever in ICU patients?

Q2. Friday (12/6):

Review a patient who is being treated for an infection. How will you determine when to stop antibiotics?

Q3. Saturday (13/6):

Review a patient who is being treated with antibiotics. How do you decide if the patient is failing to respond to treatment? What are the possible causes of failure to respond to antibiotic therapy?

Q4. Sunday (14/6):

Consider a patient who has been isolated for infection control. What are the different types of isolation and their indications?

Q5. Monday (15/6):

Attend an ICU Micro Round. How does the ICU Micro Round help patients? What strategies help reduce the emergence of resistant organisms?

Week 6: Topic - End of Life and Organ Donation

Q1. Thursday (4/6):

Observe an ICU family meeting. What are the important considerations in preparing for the meeting? How was bad news conveyed? How was the meeting documented?

Q2. Friday (5/6):

Review a patient who has transitioned to end of life care. How are palliative care principles applied in ICU?

Q3. Saturday (6/6):

Review a newly admitted patient. Are their goals of care formally documented? How is/should this be discussed with the patient or their medical treatment decision maker?

Q4. Sunday (7/6):

Consider a patient who has transitioned to end of life care. How is a collaborative request for organ donation handled?

Q5. Monday (8/6):

Discuss the process of organ donation. What types of organ donation exist? How are each of these processes facilitated in ICU?

Week 5 : Topic - Mechanical Ventilation

Q1. Thursday (28/5):

Review the ventilator settings on your intubated patients during your ward round. Are they receiving “protective lung ventilation”? What is the justification for the choice of mode, tidal volume and PEEP?

Q2. Friday (29/5):

Assess an intubated patient and determine their PF ratio. What does the PF ratio tell you? What ventilator and non-ventilator strategies can be used to improve oxygenation?

Q3. Saturday (30/5):

Perform an inspiratory hold and an expiratory hold on a stable mechanically ventilated patient. What information does this give you about your patient’s respiratory condition?

Q4. Sunday (31/5):

Review a patient who is intubated and receiving mechanical ventilation. What can you learn from the ventilator waveforms?

Q5. Monday (1/6):

Review a patient who is intubated and receiving mechanical ventilation. How can you assess their lung compliance on the ventilator? What factors affect lung compliance?

Week 3: Topic – Resuscitation

Q1. Thursday (14/5):

As a team, locate the defibrillator in your pod. How would you set up the defibrillator and use it to safely and effectively defibrillate a patient in VF? How is synchronised cardioversion different?

Q2. Friday (15/5):  

Review the goals of care of your patients. How can you rapidly find the goals of care in an emergency? Discuss what factors to consider when determining appropriate goals of care.

Q3. Saturday (16/5):

For an ACLS drug of your choice, discuss its role in the management of cardiac arrest.

Q4. Sunday (17/5):

Review the etCO 2 waveform of one of your intubated patients. How would this waveform change in the event of a cardiac arrest? What is the role of etCO 2 monitoring in the management of cardiac arrest?

Q5. Monday (18/5):

What ALS modifications are currently recommended at the Alfred for ALL patients

during the COVID-19 pandemic?

TERM 1, 2020

Reviewed and revised 5 May 2020

Week 13: Topic – Communication

Q1. Thursday (23/04):

How would you manage a family meeting where you are breaking bad news to relatives? How might this differ if you were giving bad news over the phone?

Q2. Friday (24/04):

What phrases and strategies could you use when discussing treatment limitations and goals of care with patients and families?

Q3. Saturday (25/04):

How are organ donation conversations managed in ICU?

Q4. Sunday (26/04):

What attributes and behaviours make someone a good team leader? What are the equivalent requirements for good followership? What communication strategies might they employ in a crisis?

Q5. Monday (27/04):

What strategies do you have to manage conflict within your team and with other inpatient teams?

Week 12: Topic – Sedation and Delirium (Neuro II) Sedation and Delirium (Neuro II)

Q1. Thursday (16/4):

What is the definition and prevalence of delirium in ICU?

Q2. Friday (17/4):

What is CAM-ICU? Do you know any other delirium diagnostic tools?

Q3. Saturday (18/4):

What are the complications of delirium in ICU?

Q4. Sunday (19/4):

What treatments can be used for delirium in ICU?

Q5. Monday (20/4):

How do we assess the level of sedation in ICU? Is there any evidence for daily sedation breaks in ICU?

Week 10: Topic – COVID Modifications to Standard Procedures (Alfred Guidelines)

Q1. Thursday (2/04):

What ALS modifications are currently recommended at the Alfred for all patients during the COVID-19 pandemic?

Q2. Friday (3/04):

What modifications to intubation are currently recommended at the Alfred for suspected or confirmed COVID patients?

Q3. Saturday (4/04):

What modifications to extubation are currently recommended at the Alfred for suspected or confirmed COVID patients? How should a circuit disconnection be safely performed in this patient group?

Q4. Sunday (5/04):

What workflow changes are required for sterile procedures in the COVID area of
ICU?

Q5. Monday (6/04):

What workflow changes are required for transporting suspected or confirmed COVID patients?

Week 9: Topic – COVID Infection Control (Alfred Guidelines)

Q1. Thursday (26/3):

What are the current PPE recommendations for the ICU, considering

Location: COVID vs. non-COVID zone, inside vs. outside cubicle

Activity: general patient care, aerosol generating procedures

Q2. Friday (27/3):

What procedures and interventions are considered aerosol generating? Which procedures require (standard) airborne precautions in non-COVID patients?

Q3. Saturday (28/3):

What are the criteria for COVID testing in hospitalised patients? How can suspected cases be declared negative? How are confirmed cases cleared?

Q4. Sunday (29/3):

Which staff must not look after a COVID-19 patient? What are our current guidelines for Alfred staff who are feeling unwell or have risk factors for COVID-19?

Q5. Monday (30/3):

What is the ICU policy on equipment use and cleaning in COVID areas? What is the ICU policy on patient visitors? What about visiting clinical teams?

Week 7: Topic – Renal Failure & Renal Replacement Therapy

Q1. Thursday (12/03):

Consider a patient who has an acute kidney injury. What are the possible causes and how can they be confirmed or excluded?

Q2. Friday (13/03):

Review patients on your ward round with acute kidney injury. If they are receiving continuous renal replacement therapy (CRRT), what was the indication to start? If they are not receiving CRRT, what would trigger starting? How do you determine when CRRT is no longer required?

Q3. Saturday (14/03):

Examine a CRRT circuit with the bedside nurse in the ICU. Compare the circuit with this simplified image below. Are there any differences between the two?

Image from DerangedPhysiology.com (Source: CVVHDF circuit diagram)

Q4. Sunday (15/03):

Review a patient on CRRT. What variables do you need to consider when prescribing the RRT settings for the day?

Q5. Monday (16/03):

Review a patient on CRRT. What is the anticoagulation strategy being used? What are the pros and cons of this strategy compared to other options?

Week 6: Topic – Transfusion & Blood Products 

Q1. Thursday (5/03):

What are the causes of anaemia in the ICU?

Q2. Friday (6/03):

What are the haemoglobin targets in ICU? Is there any evidence for these targets?

Q3. Saturday (7/03):

What are the complications (acute and delayed) of massive transfusion?

Q4. Sunday (8/03):

What are the causes of thrombocytopenia in ICU? How would you manage this?

Q5. Monday (9/03):

Which blood products require cross-matching and which don’t?

Week 4: Topic – Shock

Q1. Thursday (20/02):

Assess a patient with “shock”. What is the definition of shock? How is it classified?

Q2. Friday (21/02):

Examine a patient who is receiving vasopressors for shock. What are the clinical features that support this diagnosis?

Q3. Saturday (22/02):

Review a patient who is receiving a ‘vasopressor’ or ‘inotrope’. What is the justification for this medication for this patient?

Q4. Sunday (23/02):

Review a patient on a Noradrenaline and/or Vasopressin infusion. What is the evidence for the use of Noradrenaline? What is the evidence for the use of Vasopressin?

Q5. Monday (24/02):

Review a patient with an elevated Lactate level. Does hyperlactatemia always mean a patient is shocked? What are the causes of hyperlactataemia and why does it occur in patients with shock?

Week 3: Topic – Haemodynamics

Q1. Thursday (13/02):

Clinically assess a patient on your daily ward round. What clinical and biochemical parameters can you consider when deciding on a daily fluid balance aim?

Q2. Friday (14/02):

Review a patient with a central line in situ. What information can you obtain from a central venous pressure (CVP) trace? Does the CVP help you assess a patient’s haemodynamic status?

Q3. Saturday (15/02):

Review a patient with an arterial line in situ. What information can you obtain from the arterial waveform? What factors affect the accuracy of its measurement?

Q4. Sunday (16/02):

Consider a patient who needs a fluid bolus. How can you assess this patient’s ‘fluid responsiveness’ and does it matter?

Q5. Monday (17/02):

Assess a patient who might have a low cardiac output state. How can we measure cardiac output? How would we choose which approach to use?