IBL-ICU

Reviewed and revised 13 November 2019

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

Week 3

Topic – Mechanical ventilation

Thursday 14/11:

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?

Friday 15/11:

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?

Saturday 16/11:

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?

Sunday 17/11:

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

Monday 18/11:

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 2

Topic – Resuscitation

Thursday 07/11:

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?

Friday 08/11:

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.

Saturday 09/11:

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

Sunday 10/11:

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?

Monday 11/11:

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

Week 13

Topic – Renal failure and Renal Replacement Therapy

Thursday (24/10):

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

Friday (25/10):

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?

Saturday (26/10):

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?

CVVHDF circuit
Image from DerangedPhysiology.com (Source: https://derangedphysiology.com/main/required-reading/renal-failure-and-dialysis/Chapter%203.1.7/cvvhdf-circuit-diagram)

Sunday (27/10):

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

Monday (28/10):

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 11

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?

Week 10

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)

Week 5: Infectious diseases and Microbiology

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?