Fellowship in Critical Care Medicine
Department of Anaesthesiology and Critical
Care
All India Institute of Medical Sciences (AIIMS)
Jodhpur, Rajasthan, India
Curriculum for Fellowship in Critical Care Medicine
In the Department of Anaesthesiology and Critical Care
The department of Anaesthesiology and Critical Care is managing a six bedded fully
equipped Adult ICU since the IPD services were started in 2014, by AIIMS Jodhpur.
The ICU is equipped with ICU beds, high end mechanical ventilator, advanced
monitoring including invasive haemodynamic monitoring, blood gas analyser,
fiberoptic bronchoscope, bedside ultrasound and transthoracic Echocardiography.
Bedside haemodialysis machine is under the process of procurement. Postoperative
patients and patients from different medical specialities like general onco and GI
surgery, general medicine, pulmonary medicine, cardiology and interventional
radiology are being managed. Till now seven hundred and fortyfive (745) patients
have been admitted and managed in the present ICU.
General Objectives
1. Immediate Assessment and Therapy (Resuscitation): The trainee should be
able to make a quick and accurate assessment of the life threatening problems
in a critically ill patient and apply life supporting therapy.
2. Formal Medical Assessment, Problem Solving and Decision Making
Following resuscitation: The trainee should be able to undertake or contribute
to the continuing management of the acutely ill patient.
3. Consultation and Collaboration: The trainee should understand that
consultation with medical, nursing, support staff and family plays a vital role
in the management of critically ill patients.
4. Management of System(s) Failure: The trainee should be able to manage a
patient with a single or multiple systems failure.
5. Retrieval and Transport: The trainee should be able to supervise the
movement of a critically ill or injured patient to a hospital from another
hospital, place of injury or site of a mass disaster.
6. Disease and Disease Processes - General Medical and Surgical Conditions:
The trainee should have a broad and sound understanding of general medical
and surgical conditions together with a detailed knowledge of medical and
surgical emergencies.
7. Paediatric Knowledge and Skills: The trainee should be able to recognise life
threatening conditions in paediatric age group patients, institute basic or
advanced life support, carry out transportation, stabilise the child in the
intensive care unit or prepare for management during secondary
transportation to a paediatric unit.
8. Anaesthesia: The trainee should understand the preoperative, intraoperative
and postoperative management of patients receiving general, regional or
local anaesthesia.
9. Analgesia: The trainee should be able to provide satisfactory pain relief for
patients.
10. Sedation: The trainee should know how to provide adequate rest and sleep
for patients in the intensive care ward.
11. Therapeutic Agents: The trainee should understand the principles and
practice of the various therapeutic agents used in the critically ill patient.
12. Adverse Reactions to Drugs: The trainee should be able to manage the
adverse effects of drugs.
13. Monitoring, Investigations and Interpretation of Data: The trainee should
have a detailed knowledge of the investigations and monitoring techniques
commonly used in intensive care and a general knowledge of the procedures
in medicine and surgery.
14. Principles of Monitoring and patient equipment: The trainee should
understand the principles of the measurement of biological variables and
have a working knowledge of the practicalities and trouble-shooting of
equipment on which critically ill patients have an everyday dependence.
15. Selection of Monitoring Equipment, etc.: The trainee should know the
indications for and the selection of suitable methods of monitoring or
investigation taking into account their accuracy, convenience, reliability,
hazards, cost and servicing and relevance to the patient's condition.
16. Electrical Safety: The trainee should understand the hazards to patients and
staff from electrical equipment.
17. Ionising Radiation: The trainee should appreciate its uses and hazards in the
practice of intensive care.
18. Interpretation of Data: The trainee should know how to critically evaluate
and use the data that he/she collects.
19. Technical Skills: The trainee should know the indications, contraindications
and complications of procedures commonly performed in intensive care.
20. Attitudes: The trainee should have those attitudes which cause him/her to
act in the best interests of the patients, their relatives and the staff of the
intensive care unit.
21. Administration, Organisation and Education: By the end of training, the
trainee should have some knowledge and skill of the administration and
organisation of an intensive care unit so that clinical care, research and
teaching are carried out optimally.
Training schedule:
This is a full time, one-year training programme with emphasis on adult critical care.
The training shall comprise of rotation as follows:
ICU (Multispecialty: Surgical/ Medical/ Neuro/ Cardiac) – 9 months
Pulmonary Medicine, and Microbiology – 15 Days each (For Anaesthesiologist)
Anaesthesiology, and Microbiology – 15 Days each (For physicians/Pulmonary
Physicians)
Trauma & Emergency area- 30 days
Pediatric and Neonatal ICU- 10 days
Dialysis Unit-10 Days
Radiology – 10 Days
Programme content:
The candidate must gain experience in the diagnosis and treatment of patients with
acute, serious, and life-threatening medical and surgical diseases. The present
document defines the core curriculum of cognitive knowledge and procedural skills
that an intensivist is expected to be equipped with to effectively approach the complex
problems encountered in the critically ill patient.
TEACHING METHODOLOGIES AND DUTIES
1. Lectures
2. Discussion
3. Student Directed Learning
4. Case Based Learning
5. Role Playing
6. Simulators Based learning
7. Web Based learning
Teaching components will consist of
1 Didactic learning (theory lectures, seminar and journal club sessions),
2 Non-didactic/practical/clinical learning - (bed-side, treatment procedure,
clinical demonstration, case discussion, laboratory observation sessions).
3 Combined Round/ Grand round
4 Mortality/ Morbidity meetings
5 Quality Assurance meeting
6 Radiology conferences
CLINICAL POSTING
1. Academic and practical training commences in the Critical Care.
2. Second month of training, identification of project and synopsis submission for
Ethics approval.
3. Didactic and clinical training within the unit
4. Learning the good clinical practice skills pertaining to the curriculum
5. Team work, bed-side practice, out-patient care understanding by the end of 8
months duration
CURRICULUM
(A) Theoretical Knowledge
The critical care specialist (Intensivist) must understand the pathophysiology,
construct a differential diagnosis and apply the appropriate prophylactic and
therapeutic interventions in the following disorders. The list is not comprehensive and
can be modified from time to time.
1. Cardiovascular Physiology, Pathology, Pathophysiology and Therapy
a. Shock and its complications
b. Myocardial infarction and its complications
c. Cardiac rhythm and conduction disturbances; indications for and types of
pacemakers
d. Pulmonary embolism—thrombus, air, fat, amniotic
e. Pulmonary edema; cardiogenic, noncardiogenic
f. Cardiac tamponade and other acute pericardial diseases
g. Acute and chronic life-threatening valvular disorders
h. Acute aortic and peripheral vascular disorders, including A-V fistulas
i. Acute complications of cardiomyopathies and myocarditis
j. Vasoactive and inotropic therapy
k. Pulmonary hypertension and corpulmonale
l. Complications of angioplasty
m. Principles of oxygen transport and utilization
n. Hemodynamic effects caused by ventilatory assist devices
o. Thrombolytic and anticoagulant therapy
p. Perioperative management of patient undergoing cardiovascular surgery
q. Recognition, evaluation, and management of hypertensive emergencies and
urgencies
2. Respiratory Physiology, Pathology, Pathophysiology, and Therapy
a. Acute respiratory failure
i. Hypoxemic respiratory failure including acute respiratory distress
syndrome
ii. Hypercapnic respiratory failure
iii. Acute on chronic respiratory failure
b. Status asthmaticus
c. Smoke inhalation, airway burns
d. Aspiration
e. Flail chest, chest trauma, pulmonary contusion
f. Bronchopulmonary infections
g. Upper airway obstruction
h. Near drowning
i. Pulmonary mechanics and gas exchange
j. Oxygen therapy
k. Hyperbaric oxygenation
l. Mechanical ventilation
i. Pressure and volume ventilators
ii. Positive end-expiratory pressure, intermittent mandatory ventilation,
continuous positive airway pressure, high-frequency ventilation, inverse
ratio ventilation, pressure-support ventilation, negative pressure
ventilation, differential lung ventilation, pressure control, and
noninvasive ventilation
iii. Indications for and hazards of mechanical ventilation
iv. Barotrauma and volutrauma
v. Criteria for weaning and weaning techniques
vi. Extracorporeal membrane oxygenation
vii. Permissive hypercapnia
viii. Liquid ventilation
m. Airway maintenance
i. Emergency airway management
ii. Endotracheal intubation
iii. Tracheostomy—open and percutaneous
iv. Long-term intubation vs. tracheostomy
n. Ventilatory muscle physiology, pathophysiology, and therapy, including
polyneuropathy of the critically ill, and prolonged effect of neuromuscular blockers
o. Pleural diseases
i. Empyema
ii. Massive effusion
iii. Pneumothorax
iv. Hemothorax
p. Pulmonary hemorrhage and massive hemoptysis
3. Renal Physiology, Pathology, Pathophysiology, and Therapy
a. Renal regulation of fluid balance and electrolytes
b. Renal failure: Prerenal, renal, and postrenal
c. Derangements secondary to alterations in osmolality and electrolytes
d. Acid-base disorders and their management
e. Principles of hemodialysis, peritoneal dialysis, ultrafiltration, continuous
arteriovenous hemofiltration (CAVH), and continuous veno-venous hemofiltration
(CVVH)
f. Interpretation of urine electrolytes
g. Evaluation of oliguria
h. Drug dosing in renal failure
i. Rhabdomyolysis
4. Central Nervous System (CNS) Physiology, Pathology, Pathophysiology, and
Therapy
a. Coma
i. Metabolic
ii. Traumatic
iii. Infectious
iv. Mass lesions
v. Vascular-anoxic or ischemic
vi. Drug induced
b. Hydrocephalus
c. Psychiatric emergencies
d. Perioperative management of patient undergoing neurologic surgery
e. Brain death evaluation and certification
f. Diagnosis and management of persistent vegetative states
g. Management of increased intracranial pressure (ICP), including ICP monitors
h. Status epilepticus
i. Neuromuscular disease causing respiratory failure
i. Guillian-Barré
ii. Amyotropic Lateral Sclerosis
iii. Myasthenia Gravis
j. Nontraumatic intracranial bleed: Subarachnoid, Intracerebral and Others
5. Metabolic and Endocrine Effects of Critical Illness
a. Colloid osmotic pressure
b. Alimentation
i. Enteral and parenteral
ii. Evaluation of nutritional needs including indirect calorimetry
c. Endocrine
i. Disorders of thyroid function (thyroid storm, myxedema coma, sick
euthyroid syndrome)
ii. Adrenal crisis
iii. Disorders of antidiuretic hormone metabolism
iv. Diabetes mellitus
(1) Ketotic and nonketotic hyperosmolar coma
(2) Hypoglycemia
v. Pheochromocytoma
vi. Insulinoma
vii. Disorders of calcium and magnesium balance
6. Infectious Disease Physiology, Pathology, Pathophysiology, and Therapy
a. Antibiotics
i. Antibacterial agents
ii. Antifungal agents
iii. Antituberculosis agents
iv. Antiviral agents
v. Agents for parasitic infections
b. Infection control for special care units
i. Development of antibiotic resistance
ii. Universal precautions
iii. Isolation and reverse isolation
c. Anaerobic infections
d. Systemic Inflammatory Response Syndrome (SIRS)
e. Tetanus
f. Hospital acquired and opportunistic infections in the critically ill
g. Adverse reactions to antimicrobial agents
h. Intensive care unit (ICU) support of the immunosuppressed patient
i. Acquired Immunodeficiency Syndrome (AIDS)
ii. Transplant
iii. Oncologic
i. Infectious risks to healthcare workers
J Evaluation of fever in the ICU patient
7. Physiology, Pathology, Pathophysiology and Therapy of Acute Hematologic
and Oncologic Disorders
a. Acute defects in hemostasis
i. Thrombocytopenia/thrombocytopathy
ii. Disseminated intravascular coagulation
b. Anticoagulation; fibrinolytic therapy
c. Principles of blood component therapy
i. Platelet transfusion
ii. Packed red blood cells
iii. Fresh frozen plasma
iv. Specific coagulation factor concentrates
v. Albumin, plasma protein fraction
vi. Stroma-free hemoglobin
vii. White blood cell transfusion
viii. Cryoprecipitate
d. Acute hemolytic disorders including thrombotic microangiopathies
e. Acute syndromes associated with neoplastic disease and antineoplastic therapy
f. Sickle cell crisis
g. Plasmapheresis
h. Prophylaxis against thromboembolic disease
8. Physiology, Pathology, Pathophysiology, and Therapy of Acute
Gastrointestinal (GI), Genitourinary (GU), and Obstetric-Gynecological (Ob-
Gyn) Disorders
a. Acute pancreatitis with shock
b. Upper gastrointestinal bleeding including variceal bleeding
c. Lower gastrointestinal bleeding
d. Acute and fulminant hepatic failure
e. Toxic megacolon
f. Acute perforations of the gastrointestinal tract
g. Ruptured esophagus
h. Acute inflammatory diseases of the intestine
i. Acute vascular disorders of the intestine, including mesenteric infarction
j. Obstructive uropathy, acute urinary retention
k. Urinary tract bleeding
l. Toxemia of pregnancy; amniotic fluid embolism, HELLP (hemolysis, elevated
liver function tests, and low platelet count) syndrome, ovarian hyperstimulation
m. Hydatidiform mole
n. Perioperative management of surgical patients
o. Stress ulcer prophylaxis
p. Drug dosing in hepatic failure
q. Acalculouscholecystitis
r. Postoperative complications including fistulas, wound infection, and evisceration
9. Intensive care management of polytrauma patients
10. Environmental Hazards
a. Drug overdose and withdrawal
i. Barbiturates
ii. Narcotics
iii. Insecticides and pesticides
iv. Alcohols
v. Cocaine
vi. Tricyclic Antidepressants
vii. Acetaminophen
viii. Others
b. Temperature-Related Injuries
i. Hyperthermia
ii. Hypothermia
c. Envenomations
11. Immunology and Transplantation
a. Principles of transplantation (organ donation, procurement, maintenance of organ
donors, preservation, transportation, allocation, implantation, national organization
of transplantation activities)
b. Immunosuppression
c. Organ transplantation: Indications and postoperative care
12. Monitoring, Bioengineering, Biostatistics
a. Prognostic indices, severity, and therapeutic intervention scores
b. Principles of electrocardiographic monitoring, measurement of skin temperature
and resistance, transcutaneous measurements
c. Invasive hemodynamic monitoring
i. Principles of strain gauge transducers
ii. Signal conditioners, calibration, gain, adjustment
iii. Display techniques
iv. Principles of arterial, central venous, and pulmonary artery pressure
catheterization and monitoring
v. Assessment of cardiac function and derived hemodynamic parameters
d. Noninvasive hemodynamic monitoring
e. Thermoregulation
f. CNS brain monitoring (intracranial pressure, cerebral blood flow, cerebral
metabolic rate, electroencephalogram, jugular venous bulb oxygenation,
transcranial Doppler)
g. Respiratory monitoring (airway pressure, intrathoracic pressure, tidal volume,
pulse oximetry, dead-space-tidal volume ratio, compliance, resistance,
capnography, pneumotachography)
h. Metabolic monitoring (oxygen consumption, carbon dioxide production,
respiratory quotient)
i. Use of computers in critical care units
j. Research Methodology
K. Electrical safety
(B) General Interventions and Procedures
The intensivist must be able to perform a number of specific procedures; for all
candidates experience is desirable but not mandatory in the following areas:
- Maintenance of open airway
- Endotracheal intubation (oral and nasal)
- Intermittent positive pressure ventilation on resuscitation bag
- Setting and turning on the respirator with various modes of ventilation
- Chest physiotherapy and suctioning of airway
- Titration of oxygen therapy and assessment and measurement of arterial and mixed
venous blood gas analysis
- Assessment of gas exchange and respiratory mechanics
- Various modes of weaning from mechanical ventilation
- Placement of intercostal drainage tube
- Fibreoptic bronchoscopy and bronchoalveolar lavage
- Cricothyrotomy, minitracheotomy and percutaneous dilational tracheostomy
- Placement of central venous catheter through various approaches.
- Arterial catheterisation
- Placement of pulmonary artery (Swan Ganz) catheter and measurement &
interpretation of hemodynamic variables
- Implementation of cardiovascular support and antiarrhythmic therapy and
thrombolysis.
- Bedside Ultrasound screening of lungs & abdomen
- Bedside Echo screening (TTE/TEE)
(C) Speciality Specific Interventions and Procedures
The intensivist must be able to perform a number of specific procedures; for all
candidates experience is desirable but not mandatory in the following areas:
• Neurological
Basic interpretation of brain CT/MRI Scan
Monitoring of intracranial pressure
Lumbar puncture and sampling of CSF
• Metabolic and Nutritional
Implementation of intravenous fluid therapy
Enteral and parenteral nutritional therapy
• Haematological
Correction of haemostatic and coagulation disorders
Interpretation of coagulation profile including thromboelstograph
Implementation of thrombolysis
• Renal
Urinary bladder catheterization
Renal support techniques including peritoneal dialysis, SLED, CRRT
• General
Measurement of severity of illness and outcome assessment
Exposure to clinical research, ethical and legal aspects of critical care
(D) Assessment Procedures:
The candidates would maintain 1 logbook of procedures performed /assisted which
would be countersigned by the departmental faculty members.
(E) Professional Duties and Ethics
Obligation and responsibilities in medical practice; knowledge of relevant laws of the
country governing the practice of medicine; knowledge of medical ethics and
principles of good practice; doctor-patient relationship, doctor-doctor relations,
relationship with medical organisation and hospitals, para-medical services,
including pharmacists and druggists.
(F) Medico-legal aspects of critical care
Knowledge of health legislation and duties of doctor attending to cases, certification
court evidence, expert advice; medical negligence and Consumer Protection Act.
(G) Palliation and communication in critical care – The various methods of
communication like breaking bad news, handling workplace conflict, handling an
aggressive relative will be taught to the trainee.
Research:
1. See 20 cases of quality analysing and discussing which will be certified
by the faculty of the department.
2. Present at one regional and one national conference.
Textbooks/Reference books/Journals:
TEXT BOOKS:
1. Intensive Care Medicine: Rippe, Irwin Alpert & Funk, Little Brown.
2. Textbook of Critical Care: Shoemaker Ayres Grekvik, Holbrook & Thompson
Saunders.
3. Critical Care: Civetta. Taylor & Kirby, J.B. Lippincott
4. Principles of Critical Care: Hall, Schmidt & Wood, McGraw Hill.
5. Cardiopulmonary Critical Care: Dantzker, Saunders.
6. Pharmacologic Approach to the Critically Ill patient: Chernow, Williams &
Wilkins
7. Respiratory Physiology - The Essentials: West, Williams Wilkins.
8. Textbook of advanced cardiac life support. American Heart Association.
POCKET MANUALS:
1. Critical Care Secrets: Parsons, Wiener-Kronish, Jaypee Brothers
2. Washington Manual of Critical Care
JOURNALS:
1. Critical Care Medicine
2. Journal of Trauma
3. Intensive Care Medicine
4. Anaesthesia & Intensive Care
5. Critical Care & Resuscitation
6. Current Opinion in Critical Care Medicine
7. American Journal of Respiratory & Critical Care Medicine
8. Critical Care Clinics
9. Critical Care
10. Chest
11. Journal of Enteral & Parenteral Nutrition
EXIT EXAM—
As per Institute policy
