Reviewed and revised 13 January 2020
See below for the daily questions for the Inquiry-Based Learning programme at the Alfred ICU (IBL-ICU). Click the links for the self-directed learning resources for each topic.
TERM 4, 2019
Topic: GI and Nutrition
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)?
Examine an ICU patient on your ward round. What are the signs of ‘cachexia’ or ‘malnutrition’ that you can see?
Review a patient who is at risk of refeeding syndrome. What are the complications of this syndrome? How would you manage their nutritional intake?
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?
Review a patient’s nutrition plan with the ICU dietitian. How have their nutritional requirements been calculated? Is the patient achieving their target requirements?
Assess a patient with (or at risk of) 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?
Assess a patient with (or at risk of) hypernatremia. What are the common causes in ICU for hypernatremia? How do we manage this issue?
Consider a patient with (or at risk of) hyperkalemia. What are your management priorities when managing this acute electrolyte disturbance? How would you determine which treatment options to consider?
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?
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?
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?
Review a patient who has transitioned to end of life care. How are palliative care principles applied in ICU?
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?
Review a patient who has transitioned to end of life care. How is a collaborative request for organ donation handled?
Discuss the process of organ donation. What types of organ donation exist? How are each of these processes facilitated in ICU?
Topic: Sepsis and Septic Shock
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’?
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?
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?
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?
A patient with septic shock has a venous blood gas taken from their femoral central line which shows a 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?
Topic – Mechanical ventilation
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?
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?
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?
Review a patient who is intubated and receiving mechanical ventilation. What can you learn from the ventilator waveforms?
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?
Topic – Resuscitation
As 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?
Review the goals of care of your patients. How can you rapidly find the goals of care in an emergency? Discuss how to determine appropriate goals of care.
For an ACLS drug of your choice, discuss it’s role in the management of cardiac arrest.
Review the ETCO2 waveform of one 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?
Locate the autopulse (mechanical CPR device) in the ICU. What are the characteristics of optimal manual chest compressions in CPR. What are the pros and cons of mechanical CPR?
TERM 3, 2019
Consider a patient who has an acute kidney injury. What are the possible causes and how can they be confirmed or excluded?
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 not receiving CRRT, what would trigger starting? How do you determine when CRRT is no longer required?
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?
Review a patient on CRRT. What variables do you need to consider to prescribe the RRT settings for the day?
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?
Topic – Shock
Q1. Thursday (10/10):
Assess a patient with “shock”. What is the definition of shock? How is it classified?
Q2. Friday (11/10):
Examine a patient who is receiving vasopressors for shock. What are the clinical features that support this diagnosis?
Q3. Saturday (12/10):
Review a patient who is receiving a ‘vasopressor’ or ‘inotrope’. What is the justification for this medication for this patient?
Q4. Sunday (13/10):
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 (14/10):
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?
Topic – Haemodynamics
Q1. Thursday (03/10):
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 (04/10):
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 (05/10):
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 (06/10):
Consider a patient who needs a fluid bolus. How can you assess this patient’s ‘fluid responsiveness’ and does it matter?
Q5. Monday (07/10):
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 7: Pharmacology and Toxicology
Q1. Thursday (12/09):
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 (13/09):
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 (14/09):
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 (15/09):
Review a patient who has renal impairment (+/- renal replacement therapy). How does it affect the dosing and timing of their medications? How does renal replacement therapy alter this?
Q5. Monday (16/09):
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 (such as buprenorphine, tramadol/ tapentadol), pracetamol, NSAIDS, ketamine, and lignocaine infusions)
Q1. Thursday (29/08):
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 (30/08):
Review a patient who is being treated for an infection. How will you determine when to stop antibiotics?
Q3. Saturday (31/08):
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 (01/09):
Consider a patient who has been isolated for infection control. What are the different types of isolation and their indications?
Q5. Monday (02/09):
Attend an ICU Micro round. How does the ICU micro round help patients? What strategies help reduce the emergence of resistant organisms?