The day started with clinical lectures:
1)Airway : difficult airway management in ICU with ASA recommendations and Difficult airway society guidelines. Use of short handle laryngoscope and specially angulated blade to manoeuvre the scope in pregnant women should be a norm and in ICU we should have it on the airway trolley.
2)Haemodynamic monitoring by Dr David Bihari, who gave an excellent lecture, more of historical aspects of haemodynamic monitoring, Shomaker’s goals, River’s goals and currently used methods in ANZ (PiCCO, and PAC) and the newer ones like LiDCO
Unipolar leads are no longer used routinely. Bipolar leads are norm. But unipolar leads are still good if problem with capture still persists after trouble shooting common causes. Unipolar for capture and bipolar good for sensing.
Pacemaker mediated tachycardia is managed by increasing Absolute refractory period – Adjust this setting with the dial on the pulse generator box .
Pacemaker syndrome a clinical constellation NOT an ECG diagnosis alone.
Common ECG patterns that recur in the exam: failure to sense, failure to capture, and oversensing.
CVC lines : the newer ones with Rifamicin and minocycline coated : decreased incidence of CRBSI but stiff. Coated both internally and externally. The common blue CVC coated with silversulphadiazine and clorhex but only externally.
Newer pacing PA catheters: advantage to pace both atrium and ventricle in DDD mode, more flexible guidewires decreasing the incidence of myocardial perforation. Also PA catheters with new rapid response thermistor sensors, good for Right heart function evaluation.
Bronchoscopy : helpful tip on manipulating along passages -> use a redundant loop of scope tubing to manoeuvre the bronchoscope – extremely useful point. Risk of fracturing fibreoptic cables lessened with use of LED camera at the tip of the scope.
Active heated waterbath humidifier: Fisher Paykal : 100 % relative humidity , temperature at tube end 41 C if IPPV and NIV 31C at face mask.
Portable ECMO console available. ANZ results extremely encouraging with ECMO in general as compared with CESAR trial. ( possibly due to transport on ECMO from referring hospital rather than ECMO after transfer, 5 patients in CESAR trial randomised to ECMO group but never got ECMO confounded the results, protective lung ventilation was not the norm in all hospitals in CESAR trial). Early referral is essential!
Salem sump, tiger tubes, fine bore NG tube : indications and criteria to choose
ICP monitoring , Codman and EVD with the newer ones which can monitor ICP and drain continuously.
Intra-abdominal pressure measurement the volume instilled is 25 m l and not 50 or 100 ml as previously recommended
The newer IABP consoles with fibreoptic rapid response sensors can be used in patients with AF, use Auto PILOT mode. To check for timing in IABP, 1:3 or 1:4 ratio is the best
(Rajiv Singhal – ICU senior registrar, Wollongong ICU)