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Therapeutic interventions / Organ system support in single or multiple organ failure

This is an aggregate of the syllabus for all competencies in Domain 4. To view the syllabus for each competence click here.


Principles of prevention of multiple organ failure
Mode of action of drugs (see basic sciences)
Epidemiology and prevention of infection in the ICU
Causes of respiratory failure, their prevention and management
Pharmacokinetics & pharmacodynamics (see basic sciences)
Signs, symptoms and causes of renal failure (acute / chronic / acute on chronic) and indications for intervention
Systemic pharmacology: indications, contraindications, effects and interactions of commonly used drugs including:
hypnotics, sedatives and intravenous anaesthetic agents
simple & opioid analgesics; opioid antagonists
non-steroidal anti-inflammatory agents
neuromuscular blocking agents (depolarising & non-depolarising) & anti-cholinesterases
drugs acting on the autonomic nervous system (inotropes, vasodilators, vasoconstrictors, antiarrhythmics)
respiratory stimulants and bronchodilators
anti-diabetic agents
antibiotics (antibacterial, antifungal, antiviral, antiprotozoal, antihelmintics)
corticosteroids and hormone preparations
drugs influencing gastric secretion & motility; antiemetic agents
local anaesthetic agents
plasma volume expanders
Risk factors for nosocomial infection and infection control measures to limit its occurrence
Pathophysiological consequences, signs and symptoms of disordered fluid, electrolyte, acid-base and glucose balance
Indications for and basic interpretation of haematological tests (including coagulation and sickle tests)
Principles and techniques of cardiac pacing
Signs and symptoms of acute airway insufficiency and acute respiratory failure, and indications for intervention
Investigation of impaired renal function
Methods to assess nutritional status and basal energy expenditure
Adverse effects and interactions of drugs and their management
Requirements for microbiological surveillance and clinical sampling
Principles of right and left ventricular assist devices
Distinguishing features of acute versus chronic renal failure and implications for management
Recognition and management of serious adverse reactions and anaphylaxis
Indications, contraindications, complications and basic principles of intra-aortic counter pulsation balloon pump
Indications, complications and selection of renal replacement therapies (continuous and intermittent)
Fluid & caloric requirements in the critically ill patient including electrolytes, vitamins, trace elements and principles of immunonutrition
Local policies and procedures governing the prescription of drugs and therapies
Indications for and basic interpretation of blood grouping and x-matching
Principles of haemodynamic monitoring - invasive & non invasive methods, indications & limitations, physiological parameters and waveform interpretation
Indications for and methods of invasive and non-invasive mechanical ventilation
Principles of extra-corporeal membrane oxygenation (ECMO)
Placement & management of invasive devices necessary for renal replacement therapy (e.g. temporary haemodialysis catheter)
Indications for and basic interpretation of drug levels in blood or plasma
Indications for, contraindication, risks and alternatives to blood transfusion
Invasive & non-invasive systems available for measuring cardiac output and derived haemodynamic variables, the principles involved and the type and site of placement of the monitoring device
Principles of continuous positive airways pressure (CPAP) and positive end-expiratory pressure (PEEP) and CPAP & PEEP delivery systems
Principles of haemofiltration, haemodialysis, peritoneal dialysis, haemoperfusion and plasmapheresis
Impact of drug therapy on organ-system function
Safe use of therapies which modify the inflammatory response
Local protocols which govern the ordering, storage & verification procedures, monitoring during administration of blood products and reporting of adverse incidents
Indications, limitations and complications of techniques of measurement of cardiac output (e.g. pulmonary artery catheters, oesophageal Doppler, PiCCO, LiDCO) and action to prevent them
Modes of mechanical ventilation - indications, contraindications & expected results of each mode (CMV, IRV, PRVC, HFOV, SIMV, PS, CPAP, BiPAP, NIV)
Function and operation of continuous haemodiafiltration devices (key components & trouble-shooting)
Effects of concomitant treatment and/or co-morbid conditions on an individual patient's response to treatment
Infections from contaminated blood / body fluids; strategy if contaminated (e.g. needle stick injury)
Pathophysiology, detection and management of shock states according to aetiology and in response to physiological data
Operation of at least one positive pressure ventilator, one non-invasive ventilator, and a constant positive airway pressure (CPAP) device
Prophylactic therapies and indications for their use
Coagulation and fibrinolytic pathways, and their associated disorders; clinical and laboratory evaluation of haemostasis
Integration of data from clinical examination and haemodynamic monitoring to characterise haemodynamic derangements
A systematic approach to checking ventilator, breathing circuit and monitoring devices
Patterns of nutritional impairment; consequences of starvation and malnutrition
Principles of nasogastric cannulation in the intubated and non-intubated patient
Concept of risk : benefit ratio and cost effectiveness of therapies
Indications for and interpretation of fluid balance charts
Initial set-up and modification of ventilator settings according to the condition or response of the patient
Alternative routes for enteral feeding: indications, contraindications and complications of post-pyloric and percutaneous feeding tube placement
Complications of specific therapies, their incidence and management
Principles of monitoring ventilation - significance of respiratory rate, tidal volume, minute volume, mean, peak, end expiratory and plateau pressure, intrinsic and extrinsic PEEP, inspired oxygen concentration, arterial blood gas and acid base status; relationship between mode of ventilation and choice of parameters monitored; airflow and airway pressure waveforms
Prevention of stress ulceration
Circumstances when treatment is unnecessary
Principles of plasma exchange
Measures of adequacy of tissue oxygenation
Gut motility: effects of drugs, therapy and disease
Receptor-specific effects of inotropic and vasopressor agents; effects of critical illness and concomitant therapies on receptor function (e.g. down-regulation)
Measurement and interpretation of pulmonary mechanics during mechanical ventilation
Causes of regurgitation and vomiting; prevention and management of pulmonary aspiration
Potential adverse effects and complications of respiratory support and methods to minimise these
Effect of critical illness upon homeostatic mechanisms and causes of homeostatic disturbances
Techniques for preventing gastrointestinal microbial translocation
Prevention and management of constipation and diarrhoea
Treatment strategies for abnormalities of fluid, electrolyte, acid-base and glucose balance
Principles of blood glucose control: indications, methods, monitoring of safety & efficacy
Methods to assess and monitor intravascular volume and state of hydration using clinical signs and modern technology
Fluid therapies: components, physical properties, distribution and clearance of commonly used fluids; indications, contraindications and complications of their administration
Causes of lung injury in ventilated patients; effects and clinical manifestations of pulmonary barotrauma
Theoretical advantages and disadvantages of crystalloid and colloid solutions
Effect of ventilation upon cardiovascular and oxygen delivery parameters, other organ function and how these effects can be monitored (heart-lung interactions)
Principles of physiotherapy in the ICU
Principles of blood and blood component therapy; principles of massive transfusion
Principles of weaning from mechanical ventilation and factors which may inhibit weaning
Distinguishing features of acute versus chronic respiratory failure and implications for management
Indications and contraindications to tracheostomy (percutaneous and surgical) and minitracheostomy
Management of and complications associated with tracheostomy tubes
Safe prescribing of oxygen; manifestations of pulmonary oxygen toxicity
Nephrotoxic drugs and adjustment of drug doses in renal impairment/failure
Risk of bleeding: indications, contraindications, monitoring and complications of therapeutic anticoagulants, thrombolytic and anti-thrombolytic agents
Indications, limitations, methods, and complications of enteral and parenteral nutritional techniques
Nutritional formulations: indications, complications and their management

Skills & Behaviours

Obtain informed consent/assent from the patient where appropriate
Identify and correct haemostatic and coagulation disorders
Measure and interpret haemodynamic variables (including derived variables)
Correct electrolyte disorders (e.g. hyperkalaemia, hyponatraemia)
Order, check, verify and administer blood products according to local protocols
Institute and manage a regimen to control blood glucose within safe limits
Collaborate with microbiologists / infectious diseases clinicians to link clinical, laboratory and local (hospital / regional / national) microbiological data
Administer and monitor response to repeated fluid challenges
Identify and treat underlying causes for a metabolic acidosis
Supervise the provision of continuous renal replacement therapy
Resuscitate a patient with septic shock using appropriate monitoring, fluid therapy and vasoactive agents
Set appropriate exchange and fluid balances for renal replacement therapies
Select an appropriate inotrope / vasopressor - dose, physiological endpoint, rate and route of administration
Modify fluid and electrolyte therapy according to clinical features and fluid balance charts
Identify surgical and other contraindications to enteral feeding
Recognise and manage emergencies; seek assistance appropriately
Use infusion pumps to administer drugs and fluids
Prescribe and supervise safe administration of a standard / customized parenteral (TPN) preparation
Prevent hypokalaemia
Collaborate with nursing staff / clinical dietician in monitoring safe delivery of enteral and parenteral nutrition
Select the appropriate type and mode of ventilation for an individual patient
Identify and correct ventilator mis-assembly and disconnections
Liaise with clinical dieticians / medical team to plan feeding regimens after discharge from the ICU
Stabilise a patient on a constant positive airway pressure (CPAP) device
Stabilise a patient on a non-invasive ventilator (NIV)
Stabilise a patient on a positive pressure ventilator
Interpret data from an arterial blood gas sample
Prioritise therapy according to the patient's needs
Confirm adequate oxygenation and control of PaCO2 and pH
Establish a management plan based on clinical and laboratory information
Set and interpret data from ventilator alarms
Consider potential interactions when prescribing drugs & therapies
Construct, monitor and review a weaning plan
Consider risk-benefit and cost-benefit of alternative drugs & therapies
Critically appraise the evidence for and against specific therapeutic interventions or treatments
Set realistic goals for therapy (independently or in collaboration with other teams)
Define targets of therapy and review efficacy at regular intervals
Consider modifying diagnosis and/or therapy if goals are not achieved
Recognise when treatment is unnecessary or futile
Administer intravenous drugs (prepare, select route and mode of administration and document)
Prescribe appropriate antimicrobial therapy based on history, examination and preliminary investigations
Choose appropriate fluid, volume, rate and method of administration
Consider and exclude unknown pathology if goals of fluid therapy are not achieved (e.g. continued bleeding)
Identify and avoid factors contributing to impaired renal function
Prescribe and manage anticoagulation therapy
Prescribe an appropriate standard enteral feeding regimen
Lead, delegate and supervise others appropriately according to experience and role


Appreciates the importance of timely institution of organ-system support
Appreciates the differences between organ system support and specific treatment
Recognises the need for supportive care for all organ systems whether failing / injured or not
Responds rapidly to acute changes in monitored variables
Consults, communicates and collaborates effectively with patients, relatives and the health care team
Demonstrates compassionate care of patients and relatives
Desire to minimise patient distress
Respects the ideas and beliefs of the patient and their family and their impact on decision making (does not impose own views)
Respects the expressed wishes of competent patients
Recognises personal limitations, seeks and accepts assistance or supervision (knows how, when and who to ask)

Basic Sciences also underpin the competencies within this domain. These are presented in full in the Basic Sciences Syllabus.

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