Guidelines for a training programme in intensive care medicine



## Institutions
An institution offering a training programme in intensive care medicine should fulfil the following requirements 9 Intensive care facilities for patients with acute medical (including cardiac), surgical (including polytrauma), thoracic/cardiac surgical, neurologic/neurosurgical and neonatal/paediatric conditions. Within a hospital, these facilities may be organized either in separate units (i.e. medical ICU, surgical ICU, etc.) working in close collaboration or as one (or more) general ICU(s). All Units should have designated medical and nursing directors. 9 At least four dedicated intensivists; the number of trainees should not exceed the number of intensivists. 9 Full coverage of patient care round the clock. 9 Availability of the expertise of an anaesthesiologist, a cardiologist, a vascular surgeon, a trauma surgeon, a thoracic surgeon, a general surgeon, an orthopaedic surgeon, a paediatrician, a paediatric surgeon, a neonatologist, a neurosurgeon, a neurologist, a nephrologist, a gastroenterologist, a general physician, a haematologist, a pulmonologist, a (neuro) radiologist, a bacteriologist and a pharmacist, all around the clock. 9 Training programme committee with a programme director.

## Programme
The training programme is aimed at trainees with a primary specialty (anaesthesiology, surgery, internal medicine, paediatrics and its subspecialties). 1 Part of the programme can be implemented during the primary specialty training. The programme extends over 24-months period. This period may be divided into sections of not less than 6 months in length. It is possible to complete the programme at different institutions. The content of the programme includes:

## Skills
The programme provides training in practical, attitudinal and procedural skills. These include application of indications and contraindications, recognition of pitfalls, and management of complications of diagnostic and therapeutic procedures, as well as interpretation of data obtained from clinical examination, monitoring and laboratory investigations and determination of the actions to be considered or taken on the basis of this interpretation. The programme provides expert supervision to ensure that adequate experience is obtained in the (procedural) skills listed below.

## General/attitudinal
9 Identification and management of life-threatening or other emergency situations 9 Identification of essential elements and assignment of priorities in diagnostic procedures and treatment in complex clinical situations 9 Application of pathophysiological concepts in individual patient problems 9 Assessment of the pros and cons of diagnostic and therapeutic options 9 Responsibility for comprehensive patient care 9 Search for ways of improving daily patient care 9 Awareness of and ability to cope with the psychological and social effects of life-threatening illness on patients and their relatives 9 Compassion for and humane approach to the critically ill and their relatives 9 Ability to work in a multidisciplinary team 9 Awareness of costs (and cost/benefit ratios) of ICU procedures Respiratory: recognition, assessment and management of respiratory distress and failure Mandatory 9 Oxygen therapy 9 Ventilation by bag and mask 9 Use of mask ventilation (with PEEP) 9 Mechanical ventilation (setting and tuning) : assist/controlled (pressure-cycled, volume-cycled), inversed ratio, (S) IMV, pressure support; use of PEEP and CPAP 9 Assessment of proper endotracheal tube cuff pressure 9 Airway suction techniques 9 Weaning techniques (several modes) 9 Management of pneumothorax (needle, chest tube insertion, drainage systems) 9 Monitoring of airway pressures and other respiratory variables 9 Interpretation of arterial (and mixed venous) blood gases and assessment of pulmonary gas exchange (A-a gradients, shunt fraction, VD/VT, etc.) 9 Implementation of respiratory pharmacological support (intravenous, inhalation, etc.) 9 Basic interpretation of a bed chest X-ray 9 Interpretation of sputum cultures and results of bronchoalveolar lavage and protected brush specimens in the diagnosis of lower respiratory tract infections Advisable 9 Performance of bedside pulmonary function tests and assessment of pulmonary mechanics 9 Chest physiotherapy, incentive spirometry 9 Other modes of mechanical ventilation Optional 9 Fibre-optic laryngotracheobronchoscopy 9 Extracorporeal respiratory assist devices For neonatal/paediatric intensive care the added: 9 Choice of adequate endotracheal tubes 9 Prevention of subglottic/tracheal stenosis 9 High-frequency ventilation following items are Cardiovascular: recognition, assessment and management of acute circulatory problems and crises and basic and advanced cardiopuImonary resuscitation Mandatory 9 Assessment of ECG abnormalities and rhythm disturbances 9 Arterial puncture and blood sampling 9 Insertion of monitoring lines -Arterial (A radialis, A. femoralis) -Central venous (V. jugularis interna, V. subclavia, V. femoralis -Pulmonary artery catheters 9 Cardiac output determination by the thermodilution technique 9 Calculation of derived haemodynamic and oxygen transport variables 9 Implementation of anti-arrhythmic therapy and fibrinolysis 9 Cardioversion 9 Implementation of cardiovascular support (fluid therapy, vasoactive and inotropic drugs) 9 Use of infusion pumps 9 Transcutaneous pacing Advisable 9 Pericardiocentesis 9 Echo-Doppler cardiovascular techniques including transoesophageal echocardiography (interpretation of results) 9 Application and regulation of intra-aortic assist devices 9 Transoesophageal pacing Optional 9 Insertion of A. axillaris catheter 9 Application of cardiovascular echo-Doppler techniques 9 Use of ventricular assist devices Neurological/Psychiatric: recognition, global assessment and management of common acute neurological and psychiatric problems Mandatory 9 Assessment of coma depth 9 Assessment of brain death 9 Lumbar puncture 9 Intracranial pressure monitoring 9 Management of cerebral edema (including sedation and positioning) 9 Basic interpretation of brain CT scan 9 Monitoring of neuromuscular blockade Optional 9 EEG monitoring 9 Interpretation of brain and brain stem evoked potentials 9 Measurement of jugular venous oxygen saturation 9 Measurement of cerebral Doppler velocities and cerebral blood flow For neonatal/paediatric intensive care the following item is added: 9 Ventricular drainage Renal: recognition, assessment and basic management of acute renal failure Mandatory 9 Establishment of a fluid and electrolyte balance 9 Insertion of haemodialysis catheters 9 Management of continuous renal replacement techniques (CAVH, CAVHD, CVVH, CVVHDF)
Advisable 9 Insertion of a peritoneal (dialysis) catheter 9 Management of acute peritoneal dialysis
Metabolic." recognition, assessment and treatment of(common) acute metabolic and endocrine crises (diabetic keto-acidosis, metabolic coma, etc.) Mandatory 9 Monitoring and assessment of nutritional support 9 Implementation of fluid therapy 9 Interpretation of acid-base abnormalities 9 Implementation of enteral and parenteral nutrition 9 Maintenance of temperature homeostasis 9 Management of hypothermia and hyperthermia Monitoring and life-support devices Mandatory 9 Utilization, zeroing, calibration of transducers 9 Use of amplifiers and recorders 9 Assessment of reliability of measured data 9 Operation of ventilators 9 Trouble-shooting equipment Pharmacology Mandatory 9 Implementation and control of adequate sedation and analgesia 9 Implementation of most commonly used drugs (also in renal, hepatic failure) 9 Implementation of muscle relaxants Advisable 9 Management of techniques of loco-regional analgesia Ethical Mandatory 9 Exposure to ethical aspects of intensive care 9 Ability to appreciate and implement patient's expressed wishes/will 9 Implementation of ethical guidelines of the hospital 9 Ability to consider/discuss (dis)continuation or restriction of treatment (also with relatives) 9 Implementation of DNR and treatment limitation For neonatal/paediatric intensive care the following item is added: 9 Integration of the family's wishes into the treatment plan Organizational Mandatory 9 Structure of daily patient care 9 Structured patient file with strategies for diagnostic procedures and management of individual patients 9 Quality management (use of scoring systems, outcome measures, etc.) 9 Adequate and timely reports to the primary care/referring physician 9 Allocation of human, spatial and technical resources 9 Implementation of cost containment 9 Management and risk estimation of transport of critically ill patients (radiology department, transfer, etc.) 9 Coordination of activities of the intensive care team Advisable 9 Use of advanced data management systems For neonatal/paediatric intensive care the following item is added: 9 Use of neonatal/paediatric transport systems Theoretical knowledge
The programme provides ample opportunities to increase or acquire theoretical knowledge in the field of intensive care medicine. Clearly structured theoretical courses are part of the training programme. These include (when applicable) physiology, pathophysiology, pathology, symptomatology, complications, diagnosis and differential diagnosis, prophylaxis, and, in addition to theoretical knowledge of the practice of intensive care medicine, therapy of the following kinds and for the following disorders.

## General
Mandatory 9 Basic and advanced life-support (CPR), including several variants, as well as cerebral resuscitation 9 Multi-organ system failure

## Respiratory
Mandatory 9 Upper airway obstruction 9 Airway maintenance -Emergency airway management -Endotracheal intubation (and its risks) -Tracheostomy (vs long-term intubation) 9 Acute respiratory (hypoxaemic/hypercapnic) insufficiency (ventilation, pulmonary circulation, gas exchange, acid-base balance, oxygen transport, lung mechanics, respiratory muscle disorders) 9 Pulmonary function tests 9 Acute cardiogenic pulmonary oedema, ARDS, neurogenic pulmonary oedema 9 Smoke inhalation, airway burns 9 Near-drowning 9 Status asthmaticus 9 Aspiration, chemical pneumonitis 9 Acute (broncho)pulmonary infection 9 Chest trauma, flail chest 9 Oxygen therapy (including delivery systems) 9 Mechanical ventilation -Pressure-and volume-cycled ventilators -Ventilation modes: IPPV, PEEP ventilation, (S) IMV, CPAP, inversed-ratio ventilation, pressure support ventilation, highfrequency ventilation, differential lung ventilation