Crème de la Misc: essential reading for random topics

Because CICM have historically asked written questions an impressively diverse range of miscellaneous topics, and then basically never repeated them, the trainee is somewhat adrift with regards to what might be expected from them in the future. What follows is an attempt to use the experience of the past to predict future examiner behaviour, and arm the exam candidates with some basic tools to help them revise in preparation for the unpredictable. Wherever overlap exists between these topics and other chapters, links are used to redirect the reader and keep the length of this inventory to a manageable minimum.

Trials and guidelines on ICU "housekeeping"

Protocolised bundles of supportive care in general

• CHECKLIST-ICU - 2016 - daily checklist and goal setting bundle; n=6877 in Brazil. No difference in mortality ((32.9% vs 34.8%) but a few secondary outcomes were better (use of low tidal volumes, avoidance of heavy sedation, use of central venous catheters, use of urinary catheters, perception of team work, and perception of patient safety climate)
• 2018 SCCM guidelines on, basically, FASTHUG

Nutrition trials and guidelines

• Covered in the nutrition trials and guidelines chapter

Analgesia and sedation

• Covered in the sedation trial and guidelines chapter

Thromboprophylaxis trials and guidelines

• 2020 Australian (ACQSHC) guidelines for VTE prevention
• 2018 European (ESA) guidelines on VTE prophylaxis in perioperative ICU patients
• 2018 American (ASH) guidelines on VTE prophylaxis

Patient mobility and positioning 

• As fas as relevant to VAP prevention:
  • 2008 Candian VAP prevention guidelines
  • 2014 Spanish "Zero-VAP" guidelines
• General position and mobility:
  • 2019 Brazilian guidelines for early mobility in the ICU
  • 2017 Australian (ACI) guideline for the mobilisation of critically ill patients
  • 2015 German guidelines for positioning and mobility
  • One good systematic review of them all: Lang et al, 2020

Physiotherapy for the critically ill

• 2015 Belgian guidelines on physiotherapy in the ICU
• 2008 ERS/ESICM guidelines on physiotherapy in the ICU

Pressure area prevention

• 2020 intenational consensus guidelines on pressure area prevention in ICU
• 2014 ACI guidelines for pressure area prevention in the critically ill

Ulcer prophylaxis

• The evidence for this is discussed in the chapter on ulcer prophylaxis
• Those SUP guidelines that have been published after SUP-ICU (2019) include:
  • 2020 international consensus guidelines
  • 2019 Portuguese (SPCI) guidelines

Glycaemic control in the ICU

• The evidence for this is discussed in the chapter on glycaemic control
• 2016 American (ADA) guidelines for glucose targets in the critically ill
• 2012 Australia (ADS) guidelines for glucose control in hospital patients
• 2010 international recommendations (by the French, SFAR/SRLF) 

Physical examination findings

CICM have asked a lot of weird questions in the past, for example about the non-cardiorespiratory causes of cyanosis, or how to tell the difference between a kidney and a spleen using nothing but the crude sensitivity of your fingers (like you'd make a surgical referral on the basis of those findings). Most of these questions appear to have come from the pre-2010 exam, which helps delineate the year in which the examiner who insisted on them had retired. A system of checks and balances in exam design has since replaced the lawlessness of those earlier papers, but just in case, it would not hurt to be familiar with the content of Talley & O'Connor's Clinical Examination of whatever second-hand edition, as this is likely to have the highest yield in terms of mark density per gram of printed paper. Those morally above resorting to online piracy may be able to score a cheap copy from a final-year medical student about to embark on a career in pathology.

Radiology and ultrasound

• ACR appropriateness criteria for routine chest Xrays in ICU patients
• 2016 SCCM guidelines for bedside ultrasound in the ICU - Part 1 and Part 2

Transport of the critically ill patient

• 2015 ANZCA guidelines for Transport of Critically Ill Patients
• 2010 CICM minimum Standards for Transport of Critically Ill Patients (IC-10, 2010) 

Frailty, ageing, and functional outcomes in critical care

• 2019 ICFSR international frailty (detection and management) guidelines 
• 2017 Asia-Pacific frailty clinical practice guideline
• ACI frailty resources

Rare or multisystem diseases in the CICM Part II exam

Rheumatological, systemic autoimmune and generally congenital conditions which have appeared in the exam have included rheumatoid arthritis, systemic sclerosis, Down syndrome, myotonic dystrophy, acromegaly, ankylosing spondylitis, Parkinson's disease, and SLE. The questions on these have generally consisted of "outline" and "discuss" style questions about how these diseases influence the care of the patient who has them, who ends up in the ICU for whatever reason. Obviously, trainees cannot protect themselves from such questions in the future with revision, as the range of possible conditions is vast, and repeated SAQs are unpredictable. Instead it is recommended that they adopt and practice a systems-based structure which might help them construct and answer with some headings, and hopefully help recall vague snippets of information about a half-forgotten systemic weirdopathy. One such system could be:

• A - airway issues and concerns about intubation (or prognosis-related concerns about offering intubation or tracheostomy)
• B - lung involvement, weaning, pulmonary circulatory problems
• C - and acquired or congenital cardiac problems, and  peripheral circulatory problems (including any issues with vascular access)
• D - neurological involvement, neuromuscular problems
• E - tendency towards specific endocrine electrolyte derangement (whether due to the condition or due to the treatment for it, such as steroids)
• F - renal involvement which could be also genitourinary
• G - Gastrointestinal, hepatic or metabolic/nutritional problems, including things like difficulty placing NG tubes into uncooperative intellectually disabled patients
• H - haematological and bone-marrow-related considerations, including the consequences of therapy (eg. bone marrow suppression)
• I - immunological and infectious complications (including things like impaired wound healing or immunosuppressive therapy)
• K - knowledge gaps which call for superspecialised investigations,  consultations or cultural advice
• L - the need to discuss the prognosis with loved ones (as often these conditions may culminate in a protracted course of ICU stay)

This is obviously not the only possible system and the author of it is acutely conscious of the fact that he is not an expert and anyway writing these notes at 3am, which places him in a uniquely stupid position. Trainees are advised to generate their own systems and compare with each other to improve them.

Critical care dermatology - this covers the narrow overlap between dermatology and intensive care that can broadly be described as "things were your skin is falling off". There is obviously no way to rapidly become an expert in such things for the CICM fellowship exam. The best thing one can do is get a good review such as Badia et al (2020)