CONTRIBUTORS

Preparation
Curriculum Scientific Committee
May Chehab
Hala Al Alem
Abdulelah Yagoub, (Fellow representative)
Review and Approval
Scientific committee
Ayman Al Eyadhy
Fahad Al Jofan
Abdulaziz Al Soqati
Ibrahim AlHelali
Sawsan Al Youssef
Abdullah Al Zahrani
Ahmad Al Barqi
Supervision
Curriculum specialist
Prof Zubair Amin Dr. Sami Alshammari

PEDIATRIC INTENSIVE CARE FELLOWSHIP  1
  

COPYRIGHTS AND AMENDMENTS

All rights reserved. © 2017 Saudi Commission for Health Specialties.

This material may not be reproduced, displayed, modified, distributed, or used in any other
manner without prior written permission of the Saudi Commission for Health Specialties,
Riyadh, Kingdom of Saudi Arabia.

We acknowledge that the CanMEDS framework is a copyright of the Royal College of

Physicians and Surgeons of Canada, and many of the descriptions competencies have been
acquired from their resources.

Any amendment to this document shall be approved by the Specialty Scientific Council and the
Executive Council of the commission and shall be considered effective from the date the
updated electronic version of this curriculum was published on the commission Web site, unless
a different implementation date has been mentioned.

Correspondence:
Saudi Commission for Health Specialties
P.O. Box: 94656
Postal Code: 11614
Contact Centre: 920019393
E-mail: [email protected]
Website: www.scfhs.org.sa

PEDIATRIC INTENSIVE CARE FELLOWSHIP  3
  

ACKNOWLEDGEMENTS
The Pediatric Intensive Care Fellowship team acknowledges the valuable contributions and
feedback from the scientific committee members in the development of this program. We
extend special appreciation and gratitude to all the members who have been pivotal in the
completion of this booklet, especially the Scientific Council, Curriculum Scientific Group, and
the Curriculum Specialists.

4  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
  

TABLE OF CONTENTS
SAUDI FELLOWSHIP BOARD 1
ACKNOWLEDGMENT 4
INTRODUCTION 7
FORWORD 7
CONTEXT OF PRACTICE 8
Historical background 8
Scope of Practice 9
Current Challenges 9
Options of Carrier Paths 9
Future Directions 9
References 9
DIFFERENCES BETWEEN PROPOSED AND EXISTING CURRICULA 11
Criteria for Enrolment 11
Graded Responsibility for Fellows 12
Hospital Program Director Responsibilities 13
Hospital Teaching Staff Responsibilities 13
Scientific Committee Responsibilities 14
Core Curriculum 14
Description of the Three-Year Fellowship Program 14
Independent Learning within a Formal Structure 16
Expanded Range of Competencies 16
Evidence Based Approach 16
Holistic Assessment 18

OUTCOMES AND COMPETENCIES 19

Rationale 19
Overall Goal 19
Learning Outcomes 19
Core Rotations 19
Role#1: Medical Expert
A- Pediatric Intensive Care Rotation 19
B- Cardiac Intensive Care Rotation 32
C- Anesthesia 32
D- Research Rotation 33
E- Elective Intensive Care Rotation 34
1. Neonatal Intensive Care 34
2. Pediatric Emergency Room 34
3. Coronary Care Unit 35
4. Adult Intensive Care Unit 36
F- Elective Rotation 36
1. Medical Imaging and Ultrasonography 37
2. Neuro-anesthesia 37
3. Cardiac Anesthesia 38
4. Pediatric Infectious Disease 39
5. Pediatric Pulmonology 39
6. Critical Care Echocardiography 40

PEDIATRIC INTENSIVE CARE FELLOWSHIP  5
 TABLE OF CONTENTS 

Role#2: Communicator 41
Role#3: Collaborator 42
Role#4: Health Advocate 42
Role#5: Leader 43
Role#6: Scholar 43
Role#7: Professional 44
Top Ten Core Clinical Conditions 44
Continuum of Learning 52
Top Ten Procedures 53
List of Behavioural / Communication Skills 53

LEARNING OPPORTUNITIES 55
General Principles 55
Universal Topics 55
Core Speciality Topics 61
Trainee Selected Topics 75
Examples of Weekly Educational Activities 75
Schedules of Rotations 76

ASSESSEMENT OF TRAINEES 77
Purpose 77
Trainee Support 85
Mentorship 85

6  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
  

INTRODUCTION

Foreword
In this PICU curriculum, we are adopting the CanMEDS framework, as it is an innovative,
competency-based framework that describes the core knowledge, skills, and attitude of
physicians. This curriculum is intended to provide a broad framework for fellows and faculty to
focus on teaching and learning as well as clinical experience and professional development
during the training program. This does not intend to be the sole source of defining what is to be
taught and learned during the fellowship training. Fellows are expected to acquire knowledge
and skills as well as develop appropriate attitude and behaviour throughout their training
program and take personal responsibility in learning. They must learn from every patient
encounter whether or not that particular condition or disease is mentioned in this curriculum.

This curriculum is part of strategic planning of SCFHS to review and update the curricula of the
training programs. The Saudi Commission for Health Specialties, as it is represented by The
Scientific Board, Paediatric Intensive Care Fellowship Committee, and Central Accreditation
Committee are committed to providing full support for the implementation of the curriculum by
way of allocating necessary resources, providing faculty development, and establishing a
monitoring system. Further reinforcements and continuous quality improvement process
through feedback from fellows, trainers and program directors and site visits will be done by the
Central Accreditation Committee and The Paediatric Intensive Care Board Committee.

PEDIATRIC INTENSIVE CARE FELLOWSHIP  7
 INTRODUCTION 

CONTEXT OF PRACTICE

Historical background
The Saudi population is a rapidly growing population with 30% below the age of 14 years.
Health services for the pediatric population have expanded to match the needs for the fast
population growth. The pediatric residency program was one of the earliest training program
established under the umbrella of the Saudi Commission for Health Specialties. Furthermore,
pediatrics subspecialties emerged to reach 13 subspecialties in 2014.

The pediatric ICU and the specialty of pediatric critical care medicine were born from the need
to care for the growing number of critically ill children. Pediatric Intensive Care is a
multidisciplinary subspecialty crossing the boundaries with various pediatric subspecialties. It
(1)
started in the 1960s and kept growing since then in North America and Europe . A similar
momentum of growth of the specialty in Saudi Arabia has been observed where pediatric
intensive care practice started in the major governmental and university hospitals in the mid
1980’s. A better understanding of the underlying pathophysiology and treatment of critical
illnesses, the developments related to the postoperative care of children, especially post
cardiac surgery, the advance in the technologies used in monitoring and treatment, and the
growth in the field of pediatric sedation and pain management have improved the outcome of
critically ill patients.

The concept of the multidisciplinary team in PICU was crucial to enhance the standard of
patient care. The intensivist is the leader of a multidisciplinary team that includes other
subspecialists, nurses, respiratory therapists, clinical pharmacists, dietitians, psychologists,
social workers, physiotherapists, occupational therapists, and religious officers. The need for a
formal training in Pediatric Critical Care became obvious. The intensivist synchronizes complex
and elaborate treatment plans with many specialists towards a better care of critically ill
children.

The Society of Critical Care Medicine in the USA describes the intensivist as a qualified critical
care practitioner who is physically available in the PICU “without competing obligations and
possesses knowledge, skill, judgement, attitude and compassion acquired through training,
experience and focus to achieve the best outcome for patients suffering from critical illness and
injury”(4).

With the increase demands for critical care services for sick children and the need for formally
trained intensivist, the existing PICU curriculum for training pediatric residents in PICU was
developed in 2002. Two centers in Riyadh were accredited in the beginning. Three other
centers from Riyadh joined in 2008. In 2013, one center from Jeddah was accredited. At
present, 60 fellows from various regions of the kingdom and gulf countries have graduated from
the program. The Saudi Critical Care Society (SCCS) was established in 2008 with the
inception of the Pediatric chapter in 2010. The SCCS conducts regularly courses and workshop
to train fellows and to strengthen the skills of intensivist. It also annually an international
symposium to discuss the most recent updates in the specialties.

To further emphasize the importance of training pediatric intensivists, it has been reported in
the literature that the survival of critically ill children has improved in a pediatric ICU with an
intensivist. Moreover, the risk of dying was reduced in a pediatric ICU with a critical care
(2, 3)
fellowship program versus a pediatric ICU without a critical care fellowship program .

8  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
 INTRODUCTION 

Scope of practice
The PICU fellowship program in the Saudi Commission for Health Specialties is committed to:
1. Provide acute care for the critically ill children from early infancy till 14 years of age
2. Provide care for critically ill children with acute and life threatening medical and surgical
illness
3. Monitor post-surgical and transplant patients
4. Train intensivists who will be safe, competent, compassionate, and humane in treating
children with critical illness

Current Challenges
The pediatric intensive care specialty is challenging and demanding. The PICU is a closed unit
with multiple disciplines. The intensivist works long hours and is physically available round the
clock dealing with various stresses in a closed unit. Those stresses include dealing with the
critically ill child and his/her family, orchestrating the various health professionals of the PICU
team, dealing with rapidly evolving technologies, and allocating resources. Those stresses are
contributing factors that lead the “burnout” syndrome and the poor marketing of the professions.
Breaking bad news is a further additive stress that the intensivist has to deal with. The paucity
of well trained nurses and respiratory therapists, who might suffer from the burnout syndrome,
is an ongoing challenge in PICU. Stress coping strategies and improving communication skills
in the intensivist help overcoming those challenges.

Ethical challenges result from the scarce costly resources and the necessity to distribute them
appropriately, end of life care, and futility of treatment. Amid this busy and stressful profession,
the need for research and conducting clinical trials is an added challenge. In comparison to
adult ICU, the literature has fewer clinical therapeutic trials in critically ill children.

Options of Carrier Paths

The intensivist is an enthusiastic and dedicated professional who aspires for continuous self-
improvement and continuous learning throughout his career. Options for career development
include academic involvement, clinical and laboratory research, quality and safety contribution,
simulation based teaching, integrated palliative care service, administrative involvement.

Future Directions
The rapid expansion of the intensive care specialty has improved the outcome of critically ill
children. Future subspecialties in the field of PICU will further improve the outcome. Such
subspecialties may include: cardiac, neuro, trauma and burns, transplant, oncology, and renal
ICU.

References
1-. Epstein D, Brill JE.2005. A History of Pediatric Critical Care Medicine. Pediatr Res 58:
987–996.
2-. Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M. 1994 Impact
of quality-of-care factors on pediatric intensive care unit mortality. JAMA 272:941–946 9.

PEDIATRIC INTENSIVE CARE FELLOWSHIP  9
 INTRODUCTION 

3-. Pollack MM, Patel KM, Ruttimann E. 1997 Pediatric critical care training programs have a
positive effect on pediatric intensive care mortality. Crit Care Med 25:1637–1642.
4-. Editorial. Society of Critical Care Medicine’s vision for critical care. Crit Care Med 1994:
22;1713

10  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
 INTRODUCTION 

DIFFERENCES BETWEEN PROPOSED AND EXISTING CURRICULA

The PICU fellowship program is a well-structured hospital-based clinical program. The program
incorporates education in basic sciences, technical skills training, clinical bedside teaching, and
acquisition of research skills. It teaches the trainee how to integrate basic sciences in
understanding the pathophysiology of diseases and providing optimal care. It also teaches the
trainee how to become a self-disciplined and responsible physician. This updated curriculum
includes major changes as the following:
a-Expanding the program to become of three years’ duration.
b-Adapting to competency based module
c-Updating assessment section to comply with the new regulations of formative assessment.

Criteria for enrolment

To be eligible to enroll in the program, the applicant must conform to the application
requirements established by the Saudi Council of Health Specialties
1-The candidate should have completed a formal residency program in pediatrics and be
certified by the Saudi board of pediatrics or its equivalent.
2-The candidate should have passed successfully the written exam of the Saudi or Arab Board
of Pediatrics.
3-The candidate must pass the interview in the Saudi Commission for Health Specialties.
4-The candidate must pass the interview in the training center.
5-The candidate must provide three letters of recommendation (dated within the last six
months).
6-The candidate must provide a letter of release from his/her sponsoring center for a full-time
commitment for a duration of the fellowship program.
7-The candidate must be registered and classified by the Saudi Commission of Health
Specialties.

PEDIATRIC INTENSIVE CARE FELLOWSHIP  11
 INTRODUCTION 

Graded responsibility for fellows

Two-Year Curriculum
First Year Fellows F1
1-Round every morning on all patients.
2-Join the consultant round.
3-Attend the handover rounds.
4-Do the call duties as per monthly rota.
5-Distribute patients among the residents.
6-Provide consultations to other services in the hospital.
7-Maintain a log book for all procedures performed.
8-Document assessment and plan of management in the medical records daily.
9-Document procedures in the medical record.
10-Document any change in the patient’s clinical condition.
11-Write a social note after counselling the family.
12-Participate in educational and academic activities in the department
13-Participate in a quality project in the department
Second Year Fellows F2
1-Round every morning on all patients.
2-Join the consultant round.
3-Lead the round once weekly.
4-Attend the handover rounds
5-Do the call duties as per monthly rota
6-Distribute patients among the fellows
7-Maintain a log book for all procedures performed
8-Provide consultations to other services in the hospital.
9-Document assessment and plan of management in the medical records daily.
10-Document procedures in the medical record.
11-Document any change in the patient’s clinical condition.
12-Write a social note after counselling the family.
13-Supervise junior fellows and rotating residents in the unit
14-Participate in the educational and academic activities in the department.
15-Perform clinical research/quality projects supervised by senior staff

12  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
 INTRODUCTION 

Approved New Curriculum

Three-year hospital-based clinical and research program

Third Year Fellow F3
1-Round every morning on all patients.
2-Join the consultant round.
3-Lead the round twice weekly
4-Attend the handover rounds
5-Do the call duties as per monthly rota
6-Provide consultations to other services in the hospital.
7-Maintain a log book for all procedures performed
8-Document his assessment and plan of management in the medical records daily.
9-Document procedures in the medical record.
10-Document any change in the patient’s clinical condition.
11-Write a social note after counselling the family.
12-Prepare the call schedule
13-Supervise junior fellows and rotating residents in the unit
14-Participate in the educational and academic activities in the department.
15-Perform clinical research/quality projects supervised by senior staff
16-Publish a research paper
17-Shares administrative responsibilities
18-Writes policies and procedures

Hospital Program Director Responsibilities

 Coordination of the fellowship program
 Planning the rotations of the fellows
 Planning the educational activities of the fellow
 Supervising the research process of the fellows
 Receiving the In-Training Evaluation Reports of fellows after each clinical rotation, and
reporting to the SCFHS scientific committee every three (3) months
 Reporting any concerns about the performance of the fellows to the SCFHS scientific
committee of the fellowship.
 Approval of fellow’s admission to the promotion exam.
 Counseling when needed with fellows, at least once a month and more frequently whenever
possible

Hospital Teaching Staff Responsibilities

 Supervising and teaching fellows during their clinical rotations
 Teaching and debriefing the fellows regarding to their level of performance
 Mentoring the fellows
 Supervising the research projects of the fellows

PEDIATRIC INTENSIVE CARE FELLOWSHIP  13
 INTRODUCTION 

Scientific Committee Responsibilities

 The Scientific Committee will supervise and guide the fellowship program
 The Scientific Committee sets educational standards for the training and certification of
candidates
 The Scientific Committee coordinates with the examination committee to prepare end-of-
year OSCE, final oral and written examinations for candidate fellows
 The Scientific Committee will review the evaluation of In-Training Evaluation Reports every
three months.
 The Scientific Committee develops reference practice guidelines that can be adopted and
modified by local hospitals as needed to promote a unified standard of care within KSA
 The committee members will appoint a chairperson by majority vote
 The members of the committee will be the fellowship program directors of their respective
hospitals

Core Curriculum
Three-year hospital based clinical and research Program

First Year Second Year Third Year

Rotations
Pediatric Intensive Care 8 months 7 months 3 months
Pediatric Cardiac 1 2 1
Intensive Care
Anesthesia 1
Elective ICU related 1
Elective 1 1
Research 1 6
Vacation 1 1 1
Total 12 months 12 months 12 months

Description of the Three-Year Fellowship Program

Core Rotations
1-Pediatric Intensive Care Unit
 Fellows will spend eighteen months in PICU
○ 8 months in the first year
○ 7 months in the second year
○ 3 months in the third year
 Fellows will care for children with critical medical conditions
 Fellows will care for children with critical surgical conditions

2-Pedatric Cardiac Intensive Care

 Fellows will spend four months in Pediatric Cardiac Intensive Care
○ 1 month in the first year
○ 2 months in the second year
○ 1 month in the third year

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 INTRODUCTION 

 Fellows will care for children with critical cardiac conditions

 Fellows will manage the preoperative cardiac patients
 Fellows will manage the postoperative cardiac patients

3-Anesthesia
 Fellows will spend one month in anesthesia during the first year
 Fellows will demonstrate skills in:
○ Airway management
○ Laryngeal mask use
○ Bag-mask ventilation
○ Endotracheal intubation
○ Capnography
○ Inhaled anesthesia use

4-Research
 Fellows will spend 7 months in research
○ 1month in the second year
○ 6 months in the third year
 Second year fellow ( F2) should:
○ Formulate a research question
○ Develop a research proposal
○ Submit the proposal to IRB
 Third year fellow(F3) should:
○ Collect data
○ Analyze data Statistically
○ Write manuscript
○ Present his research project in national or international meetings.

Elective Rotations
Elective rotations allow fellows to gain experience and improve skills in an area of ICU interest.
The elective rotation should be spent in a training program accredited by the SCFHS

1-Elective ICU Rotations

 Fellows will spend one month during the first year in one of the following:
○ Neonatal Intensive Care Unit, NICU
○ Emergency room department
○ Adult General Intensive Care Unit
○ Any other PICU

2-Elective Rotations
 Fellows will have two months of elective
○ 1 month during the second year
○ 1 month during the third year
 The elective should be relevant to the Pediatric ICU specialty

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 INTRODUCTION 

Independent Learning within a Formal Structure

Pediatric Advanced Life Support Course (PALS) Instructor.
Pediatric Fundamental critical care Support) course.
Neonatal and pediatric mechanical ventilation course.
Difficult airway management course.
Ultrasound applications in PICU.
Boot simulation camp.
Research methodology course.
Evidence-based medicine course.
Advanced Trauma Life Support course (ATLS- optional).

Expanded Range of Competencies

Leading round with multi-disciplinary team.
Teaching and supervising residents.
Directing Journal Club.
Presenting academic topic in national and international conferences.
Instructing in different courses e.g. PALS, PFCCS.
Organizing case conference meeting for complex cases.
Participating in Morbidity Discussion.
Participating in Mortality Discussion.
Team leader for quality performance indicator

Profile of the Practice

Evidence Based Approach

Demographic Data
The challenging disease processes most encountered in Pediatric Intensive Care where great
progress has been made include:

I-Respiratory
1-Acute respiratory distress syndrome
2-Bronchiolitis
3-Pneumonia
4-Laryngotracheobronchitis
5-Neuromuscula weakness
6-Sickle cell acute chest syndrome
7-Status asthmaticus
8-Pleural effusion and empyema
9-Postoperative care following tracheostomy

II-Cardiovascular
1-Shock: hypovolemic, distributive, obstructive, neurogenic, and cardiogenic
2-Cardiorespiratory arrest
3-Myocarditis and cardiomyopathy
4-Congenital heart disease
5-Postoperative cardiac surgery

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 INTRODUCTION 

III-Neuromuscular
1-Seizures and status epilepticus
2-Meningitis and encephalitis
3-Spinal muscular atrophy
4-Guillain-Barre syndrome
5-Intracranial hypertension
6-Stroke due to sickle cell disease
7-Postoperative care after tumor resection or ventriculoperitoneal shunt insertion

IV-Fluids and electrolytes disturbances

1-Acute kidney injury
2-Critical abnormalities of sodium, potassium, calcium, phosphate, and magnesium

V-Gastrointestinal
1-Gastritestinal bleeding
2-Acute hepatic failure

VI-Hematology and oncology

1-Sickle cell crisis
2-Tumor lysis syndrome

VII-Endocrine and metabolism

1-Diabetic ketoacidosis
2-Metabolic crisis
3-Diabetes insipidus

VIII-Trauma and burns

1-Non accidental trauma
2-Accidental:
 Traumatic brain injury
 Torso-trauma
 Drowning
 Inhalation injury

IX-Poisoning
IX-Perioperative transplantation management

Practice Data
The advances in the therapeutic technologies include:
1-Airway management
2-Mechanical ventilation
 Invasive
 Non-invasive
 Non- conventional
2-Continuous Renal Replacement Therapy
3-Central venous lines insertion
4-Central and peripheral arterial lines insertion
5-Ultrasound guided procedures
6-Chest tube insertion

PEDIATRIC INTENSIVE CARE FELLOWSHIP  17
 INTRODUCTION 

7-Pleural tap
8-Abdominal tap
9-Extracorporeal membrane oxygenation

Patient Profile
Critically ill inpatients in wards, emergency department, PICU, other ICUs, post-operative
patients.

Catered Towards Future Needs

Support for CODE BLUE team
Support for Rapid Response team

Holistic Assessment
Two-year Curriculum Three-Year Curriculum
2002- 2016
Assessment
Rotation evaluation Fellow level - 1,2 Fellow level - 1,2,3
Quarterly Assessment Fellow level - 1,2 Fellow level - 1,2,3
Structured Oral assessment Fellow level - 1,2
Log-book Fellow level - 1,2
Multidisciplinary Critical Care Fellow level - 1,2,3
Knowledge Assessment
program (MCCKAP)
End of year written Exam Fellow level - 1,2 Fellow level - 1,2
Saudi PICU fellowship Board Fellow level -2 Fellow level - 3
Certifying Exam
End year OSCE Exam Fellow level -2 Fellow level - 3
Research Fellow level 2-3
Specific Academic Task Fellow level -3

18  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
  

OUTCOMES AND COMPETENCIES

Rationale
The rationale of the three-year PICU fellowship program is to ensure the training of safe and
competent intensivist in the care of the critically ill child and to maintain a standard of
excellence in Saudi Arabia and the Gulf countries.

Overall Goal
The aim of the Pediatric Intensive Care Fellowship Program is to provide the fellow with
knowledge, skills, and attitudes to manage critically ill children. The program will emphasize on
the importance of professionalism, clinical ethics, and advanced communication skills for the
intensivist. It will, also, teach the fellow how to conduct research and develop into an
academician.

Learning Outcomes

Educational Objectives of the Program

1. The three-year fellowship program is intended to prepare candidates to practice
independently as experts in the field.
2. Upon successful completion of the program, fellows will master and apply the principles,
knowledge, skills, and ethics of Pediatric Intensive Care discipline.
3. Upon successful completion of the program, fellows must exhibit the Royal College of
Physicians and Surgeons of Canada CanMEDS competencies.

Core Rotations

Role#1: Medical Expert

A. Pediatric Intensive Care Rotation

I. Cardiopulmonary Resuscitation
Fellows must acquire knowledge of the underlying pathophysiology of cardiopulmonary arrest in
children and the skills to resuscitate patients.
1. Science of cardiopulmonary resuscitation
2. Epidemiology of Pediatric Cardiopulmonary arrest
3. Physiologic foundations of cardiopulmonary resuscitation
4. Performance of cardiopulmonary resuscitation in children and infants
a. Circulation and chest compression
b. Airway
c. Breathing
5. Pharmacotherapy
6. Post resuscitation management
7. Other considerations
a. CPR quality
b. Extracorporeal cardiopulmonary resuscitation

PEDIATRIC INTENSIVE CARE FELLOWSHIP  19
 OUTCOMES AND COMPETENCIES 

II. Monitoring
Fellows must be skilful and confident in the use, interpretation, and troubleshooting of
monitoring.
1. Principles of monitoring
a. Utilization, zeroing, and calibration of transducers
b. Trouble shooting equipment
2. Indications for monitoring
3. Non-invasive monitoring
a. Vital signs
b. Capnography and capnometry
c. Pulse oximetry
d. Near infrared spectroscopy
e. Bispectral index spectrometry
f. Continuous electroencephalogram
g. Cardiac output measurement
4. Invasive monitoring
a. Blood pressure monitoring
b. Central venous pressure monitoring
c. Intracranial pressure monitoring
d. Intraabdominal pressure monitoring
e. Cardiac output measurement
5. Ultrasound hemodynamic monitoring
6. ICU Hemodynamic Laboratory
a. Blood gas analysis
b. Calculation of oxygen content, oxygenation index, alveolar-arterial gradients,
P/F ratio, oxygen transport, oxygen consumption
c. Calculation of systemic and pulmonary vascular resistance, and intrapulmonary shunt

III. Skills and Procedures

Fellows must be skilled and well-trained in performing the following procedures as well as
recognise the indications, contraindications, complications, and pitfalls of these interventions.
1. Airway Management
a. Maintaining airway
b. Laryngeal mask airway insertion
c. Endotracheal intubation
d. Use of video-assisted laryngoscopy
2. Breathing and ventilation
a. Use of oxygen delivery systems
b. Bag-mask ventilation
c. Pulse oximetry
d. Suction techniques
e. Chest physiotherapy and incentive spirometry
f. Fiberoptic laryngotracheo bronchoscopy
g. Monitoring of airway pressures
h. Measurement of endotracheal tube cuff pressures
i. Mechanical ventilation
j. Operation of mechanical ventilators
k. Weaning techniques
l. Management of pneumothorax (needle and chest tube insertion drainage systems)

20  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
 OUTCOMES AND COMPETENCIES 

m. Management of pleural effusion (needle and chest tube insertion drainage systems)
n. Interpretation of sputum cultures by smear
o. Principles of performing percutaneous tracheostomy
p. Extracorporeal membrane oxygenation
3. Circulation
a. Arterial puncture and blood sampling
b. Intraosseous insertion
c. Insertion of central lines
1. Femoral, Internal jugular, Subclavian
2. Arterial
d. Hemodialysis line insertion
e. Ultrasound guided procedures
f. Ultrasound goal directed therapy
g. Synchronised cardioversion/defibrillation
h. Cardiac output estimates by thermodilution techniques
i. Application of non-invasive cardiovascular monitoring
j. Pericardiocentesis
k. Use of infusion pumps for vasoactive drugs
l. Infusion of inotropes, vasodilators, inodilators
4. Central Nervous System
a. Lumbar puncture
b. Intracranial pressure monitoring
c. Monitoring and interpretation of modified EEG
d. Application of hypothermia
5. Renal
a. Management of peritoneal dialysis
b. Management of renal replacement therapy
6. GI tract
a. Peritoneal tap
7. Infection
a. ICU sterility techniques and precautions
b. Sampling and staining of blood, sputum, urine, and other body fluids
c. Interpretation of laboratory results
d. Interpretation of antibiotic levels and sensitivities

IV. Respiratory System

The fellow should acquire knowledge in the pathophysiology, anatomy, and the diseases
involving the respiratory system.
1. Anatomic considerations of the upper respiratory system
2. Respiratory monitoring
3. Physiology of the respiratory system
4. Pharmacology of the respiratory system
5. Airway Management
6. Upper Airway Disease
a. Anatomic abnormalities
 Congenital
 Acquired
b. Infections and inflammation
c. Foreign body aspiration
d. Post-operative care

PEDIATRIC INTENSIVE CARE FELLOWSHIP  21
 OUTCOMES AND COMPETENCIES 

7. Lower Airway Disease

a. Pneumonia and bronchiolitis
b. Status asthmaticus
c. Pediatric Acute Respiratory Distress Syndrome
d. Acute chest syndrome
e. Empyema
f. Pulmonary hemorrahage
g. Pneumothorax
h. Foreign body aspiration
i. Pneumonitis
j. Interstitial parenchymal lung disease
8. Neonatal respiratory diseases
9. Apparent Life Threatening Event
10. Non pulmonary conditions associated with respiratory diseases
11. Acute respiratory failure
12. Chronic respiratory failure
13. Pulmonary hypertension

V. Mechanical Ventilation
The fellow should apply and demonstrate skills in applying different modes of mechanical
ventilation
1. Principles of mechanical ventilation
2. Applied physiology
3. Respiratory mechanics
4. Indications for intubation
5. Indications for mechanical ventilation
6. Interpretation of arterial blood gas
7. Weaning and extubation
8. Modes of mechanical ventilation
9. Waveform interpretations
10. Conventional mechanical ventilation
a. Invasive
b. Non invasive
11. High Frequency Oscillatory Ventilation
12. Other new modalities of mechanical ventilation
13. Respiratory dynamics
14. Ventilator Induced Lung Injury
15. Complications of mechanical ventilation
16. Home mechanical ventilation

VI. Cardiovascular System

The fellow should acquire knowledge in the pathophysiology, anatomy, and the diseases
involving the cardiovascular system.
1. Anatomic considerations of the cardiovascular system
2. Physiology of the cardiovascular system
3. Pathophysiology of congenital heart diseases
4. Cardiopulmonary interactions
5. Monitoring of the cardiovascular system
6. Pharmacology of the cardiovascular system

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7. Congestive heart failure

8. Cardiomyopathies
9. Myocarditis
10. Rhythm disturbances
11. Hypertension

VII. Shock
The fellow should acquire knowledge in the pathophysiology, the various types of shock and its
management.
1. Pathophysiology of shock
2. Systemic inflammatory response syndrome
3. Biochemical makers in shock
4. Definition of sepsis and septic shock
5. Classification of shock
a. Hypovolemic
b. Obstructive
c. Distributive
d. Cardiogenic
6. Septic shock
7. Management of shock
8. Reperfusion injury
9. Multiorgan dysfunction syndrome
10. Pharmacology of shock

VIII. Central Nervous System

The fellow should acquire knowledge in the pathophysiology, anatomy, and the diseases
involving the central nervous system.
1. Anatomic considerations of the central nervous system
2. Neurophysiology
3. Neuromonitoring
4. Neuroradiology
5. Neuropharmacology
6. Physiology and management of intracranial hypertension
7. Space occupying lesions
8. Meningitis and encephalitis
9. Infected/obstructed ventriculoperitoneal shunt
10. Hypoxic-ischemic encephalopathy
11. Status epilepticus
12. Coma
13. Metabolic encephalopathies
14. Neuromuscular disease
15. Stroke
16. Brain death
17. Intracranial haemorrhage
18. Critical illness neuropathy
19. Critical illness myopathy

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IX. Renal System

The fellow should acquire knowledge in the pathophysiology, anatomy, and the diseases
involving the renal system.
1. Anatomic considerations of the renal system
2. Physiology of the renal system
3. Monitoring of the renal system
4. Pharmacology of the renal system
5. Acid-base disorders
6. Dysnatremias
7. Acute kidney injury
8. Chronic renal failure
9. Hypertension
10. Renal replacement therapy
11. Peritoneal dialysis
12. Hemodialysis

X. Fluids and electrolytes

The fellow should discuss the physiology of fluids and electrolytes and it application in critically
ill children
1. Body fluid composition
2. Fluids requirements
3. Fluid balance
4. Dysnatremias
5. Disorders of potassium metabolism
6. Disorders of calcium metabolism
7. Disorders of magnesium metabolism

XI. Endocrine and metabolic disorders

The fellow should acquire knowledge in the pathophysiology, anatomy, and the diseases
involving the endocrine system and inborn errors of metabolism.
1. Anatomic considerations of the endocrine system
2. Physiology of the endocrine system
3. Pharmacology of the endocrine system
4. Pathophysiology of inborn errors of metabolism
5. Pharmacology of inborn errors of metabolism
6. Diabetic ketoacidosis
7. Diabetes insipidus
8. Syndrome of inappropriate ADH secretion
9. Cerebral salt wasting syndrome
10. Adrenal crisis
11. Thyroid crisis
12. Hyperammonemia
13. Metabolic crisis

XII. Gastrointestinal System

The fellow should acquire knowledge in the pathophysiology, anatomy, and the diseases
involving the gastrointestinal system.
1. Anatomic considerations of the gastrointestinal system
2. Physiology of the gastrointestinal system

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3. Monitoring of the gastrointestinal system

4. Pharmacology of the gastrointestinal system
5. Abdominal compartment syndrome
6. Gastrointestinal bleeding
7. Acute hepatic failure
8. Hepatic encephalopathy
9. Chronic liver failure
10. Pancreatitis
11. Corrosive injury to the esophagus
12. Gastroesophageal Reflux Disease

XIII. Nutrition
The fellow should acquire knowledge in the importance of feeding and nutritional assessment of
the critically ill child.
1. Nutritional assessment
2. Nutritional requirements
3. Assessing energy expenditure in PICU
4. Metabolic consequences of the stress response
5. Malnutrition in the critically ill child
6. Enteral nutrition
7. Parenteral nutrition
8. Refeeding syndrome

XIV. Hematology and Oncology

The fellow should acquire knowledge in the hematologic and oncologic emergencies
1. Anatomic considerations of the hematopoietic system
2. Physiology of the hematopoietic system
3. Pharmacology of the hematopoietic system
4. Massive blood transfusion
5. Transfusion associated lung injury
6. Hemoglobinopathies
7. Coagulation disorders
8. Thrombosis in PICU
9. Hemophagocytic lymphohistiocytosis
10. Tumor lysis syndrome
11. Mediastinal masses
12. Typhlytis
13. Radiation injury

XV. Infections in PICU

The fellow should acquire knowledge in the common infections affecting the critically ill child.
1. Infection prevention/control
2. Intervention bundles
3. Hand hygiene

XVI. Immunology in PICU

The fellow should acquire knowledge in the immunology of the critically ill child and the
diseases affecting the immune system.
1. Anatomical considerations of the immune system
2. Pathophysiology of the immune system

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3. Pharmacology of the immune system

4. Congenital immunodeficiency
5. Acquired immunodeficiency
6. Autoimmune disorders
7. Vasculitis
8. Diagnostic methods
9. Therapeutic modalities

XVII. Trauma and Burns

The fellow should be knowledgeable and well-trained in the management of trauma and burns.
1. Trauma resuscitation
2. Traumatic brain injury
3. Thoracic injuries
4. Abdominal injuries
5. Spinal cord injury
6. Non accidental injury
7. Drowning
8. Inhalation and smoke injuries
9. Burns
10. Thermal injury
11. Electrical injury
12. Rhabdomyolysis

XVIII. Sedation and Analgesia

The fellow should be knowledgeable in the use and the side effects of sedatives and
analgesics.
1. Sedation assessment
2. Sedation scores
3. Pain assessment
4. Pain scores
5. Pharmacokinetics of sedatives and analgesics
6. Pharmacodynamics of sedatives and analgesics
7. Delirium
8. Side effects
9. Withdrawal from sedatives and analgesics

XIX. Toxins and Poisoning

The fellow should be knowledgeable in the clinical presentation of various toxidromes and their
management.
1. Toxidromes
2. Common toxins involved
3. Laboratory tests
4. Toxicology screen
5. Principles of treatment
6. Specific treatment
7. Scorpion sting
8. Snake bite

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XX. Palliative care

Pediatric palliative care is a rapidly growing speciality. Palliative care starts from the admission,
during the stay in PICU, and beyond PICU. The fellow should evaluate and alleviate the child’s
physical, psychological, and social distress. The fellow should comprehend:
1. The necessity of the presence of parents and caregivers at the bedside of the dying patient
2. Values, wishes, and beliefs of parents or guardians
3. Importance of Communication skills
4. Importance of debriefing the PICU team
5. Pharmacologic management of symptoms at end-of-life
6. Withholding and withdrawing ICU interventions
7. Multidisciplinary team involvement and support
8. The delivery of palliative care as:
a. Integrated service
b. Consultation service

XXI. Rehabilitation and Home Health Care

The fellow should be able to identify children who will need rehabilitation and provide
developmentally appropriate and family-inclusive interventions. Rehabilitation will start in PICU
and will continue beyond PICU at home and at school to improve the quality of life of children
discharged from PIU. The fellow should discuss the importance of:
1. Maximising patient’s function and independency
2. Planning discharge to home or rehabilitation facilities
3. Palliative service consultation
4. Home health care services consultation
5. The involvement of a multidisciplinary team
6. The involvement of the family in rehabilitation
7. Prevention and treatment of physical clinical complications
a. Bed ulcers
b. Muscle wasting
c. Musculoskeletal contractures
d. Disuse osteopenia
e. Thromboembolism events
f. Complications of intubation and tracheostomy
g. Complications of long-term mechanical ventilation
h. Swallowing incoordination
8. Prevention and treatment of psychological complications
a. Post- traumatic stress disorder
b. Delirium
c. Depression
9. Prevention and treatment of cognitive complications
a. Learning disabilities
b. Speech disability
c. Special senses
10. Enrolment in special rehabilitation program individualised to each patient

XXII. Simulation training and Team Dynamics

The fellow should recognise the importance of simulation training and its effects on improved
patient care.
1. Standardized patients
2. High-technology mannequins

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3. Virtual simulation
4. Simulation scenarios
5. Teamwork dynamics

XXIII. Ethics
The PICU fellow is likely to face ethically challenging situations on a regular basis. Medical
ethics is the discipline devoted to the identification, analysis, and resolution of value-based
problems in patient’s care.
1. Medical ethics principles
a. Autonomy
b. Beneficence
c. Non maleficence
d. Justice
2. Goal of therapy
a. Cure
b. Care
c. Comfort
3. Family-centred care
 Preparing for and responding to death
○ Anticipating loss
○ Cultural context of death and dying
○ Shared decision of end-of-life care
○ Parental presence
○ Follow up meetings
4. Clinical ethics
a. Informed consent
b. Refusal of treatment
c. End of life care
d. Futility of care
e. Brain death
f. Organ donation
5. Ethics and law

XXIV. Transport
The fellow should recognise the importance of transport on improving patient’s outcome and
demonstrate the skills of safe transport.
1. Physiology relevant to transport medicine
2. Transport team dynamics
3. Transport team responsibilities
4. Communication between
a. Team members
b. Referring hospitals and receiving hospitals
5. Adequate training of team members
6. Availability of optimal transport equipment
7. Safety of transport

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XXV. Quality and safety

The domains of quality in PICU are: safety, effectiveness, patient-centeredness, efficiency.

A- Severity-of-illness scores
The fellow should recognise the use, application, and interpretation of severity-of-illness scores.
The severity-of-illness scores assist in population stratification based on disease burden.
1. Severity-of-illness scores can be used for:
a. Better understanding of clinical performance and resource allocations
b. Providing guidance for quality improvement activities
c. Adjusting for case-mix differences in clinical research and comparative benchmarking
2. Standardized ratios can be used for outcomes of:
a. Mortality
b. Length of stay
c. Infection rates
d. Quality outcome

B- Safety in PICU
1. The fellow should describe the importance of safety in PICU which includes:
a. Risk identification
b. Risk analysis
c. Risk reduction
2. The fellow should discuss safety measures concerning
a. Patient
b. Health information system
c. Environment
d. Health care workers
3. The fellow should discuss
a. How to prevent medical errors
b. How to differentiate medical errors
1. Human errors
2. System errors
c. How to handle medical errors
d. How to disclose medical errors

C- Continuous quality improvement

The fellow should discuss
1. Outcome measures
2. Quality performance indicators
3. Mortality and morbidity meetings

XXVI. Surgery
The fellow should describe the preoperative and postoperative management in the following
specialities.
1. Pediatric surgery
2. Thoracic surgery
3. Neurosurgery
4. ENT and airway surgery
5. Urology
6. Trauma surgery

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7. Spinal surgery
8. Plastic surgery
9. Burns
10. Orthopedic surgery

XXVII. Rapid Response Team

The fellow should recognise the importance of the rapid response team in early recognition and
management of the sick child in the pediatric wards.
1. Rapid response team dynamics
2. Rapid response team responsibilities
3. Communication between afferent and efferent limbs
4. Communication with the family
5. Adequate training of team members
6. Availability of equipment
7. Outcome measures

XXVIII. Organ Donation and Transplantation

The fellow should discuss the importance of organ donation and the management of the
transplanted patients
1. Brain death criteria
2. Cadaveric organ transplantation
3. Living-related transplantation
4. Non-living related transplantation
5. Solid organ transplantation
a. Liver
b. Kidney
c. Heart
d. Lungs
e. Intestines
f. Others
6. Bone marrow transplantation
7. Stem cells transplantations
8. Management protocols
9. Saudi centre for organ transplantation (SCOT)

XXIX. Pharmacology
The fellow should apply the principles of pharmacology to patient care.
1. Pharmacodynamics
2. Pharmacokinetics
3. Drug metabolism
4. Drug monitoring
5. Drug toxicity
6. Dose adjustment for organ dysfunction
7. Application to pediatric intensive care
a. Benzodiazepines
b. Barbiturates
c. Opioids
d. Ketamine
e. Dexmedetomidine
f. Propofol

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g. Neuromuscular blockers
h. Sympathomimetics
i. Vasodilators
j. Inodilators
k. Steroids

XXX. Information Technology

The fellow should be aware of the rapidly developing digital technology
1. Electronic health records
a. Data acquisition
b. Data access
c. Data storage
d. Use of clinical data registries for research
2. Telemedicine
3. Virtual PICU

The fellow should be aware of the potential drawbacks of digital technology

1. Breach to confidentiality
2. Overdependence on technology
3. Reduction of face to face communication
4. Potential increase in human errors

XXXI. Impact of PICU

Excellence in PICU is achieved through a combination of many factors and is dependent on a
healthy work environment. The fellow will recognise the impact of PICU admission on the
family, community, and society.
1. Family-centred care:
 Parental anxiety
 Endorsement parents as capable to deliver care to their children
 Sharing goals and wishes for the good of the child
 Early planning for discharge that include counselling, teaching, and training of the
family.
2. Patient-centred care
 Anxiety/fear at different ages
 Separation anxiety
 Post-traumatic stress disorders
 Withdrawal and delirium
 Reintegration into the family
 Reintegration into schooling
 Need for special care
3. Impact on PICU team
 Increase likelihood of medical error
 Grief experiences
 Burnout
 Self-care strategies

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B. Cardiac Intensive Care Rotation

Role#1: Medical Expert
The fellow should acquire knowledge in the pathophysiology, anatomy, and management of the
diseases involving the cardiovascular system.
1. Anatomic considerations of the cardiovascular system
2. Physiology of the cardiovascular system
3. Physiology of the fetal circulation
4. Cardiopulmonary interactions
5. Principles of invasive and non-invasive hemodynamic monitoring
6. Pharmacology of the cardiovascular system
7. Advanced CPR
8. Interpretation of electrocardiogram
9. Congenital heart diseases
a. Anatomy
b. Physiology
c. Preoperative management
d. Postoperative management
e. Postoperative complications
f. Palliative surgery
10. Congestive heart failure
11. Pulmonary edema
12. Cardiomyopathies
13. Cardiac tamponade
14. Cardiac arrhythmias
a. Pathophysiology
b. Pharmacology
c. Electrical therapy
d. Pacemakers and the indications for and applications of the various modes of temporary
pacing
15. Pericardiocentesis with supervision
16. Mechanical ventilation of the cardiac patients
17. Extracorporeal life support
18. Neurologic risk stratification during cardiopulmonary bypass procedures
19. Current indications and recommendations for SBE prophylaxis
20. Cardiac transplantation
21. Transportation of the child with congenital heart disease

C. Anesthesia Rotation
Role#1: Medical expert
The fellows will recpgnise the anatomic, physiologic, pharmacologic, and psychological
concepts in relation to anesthesia practice.
1. The Respiratory System
 Anatomic differences of the neonate and pediatric airway
 Age differences in control of respiration, compliance, lung volumes, oxygen
consumption
2. The Cardiovascular System
 Anatomy and physiology of transitional circulation
 Maturation of the myocardium and autonomic nervous system

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3. The Central Nervous System

 Age differences: intracranial pressure, cerebral blood flow, autoregulation
4. The Genitourinary System
 Renal Maturation
 Fluids & electrolytes, maintenance requirements, hydration assessment
5. The Gastrointestinal/Hepatic System
 Feeding, fasting guidelines, glucose control
 Maturation of hepatic function
6. The hematological System
 Normal values in infants and children
 Natural history of fetal hemoglobin
 Blood component therapy
7. Thermoregulation
 Body surface area and heat loss
 Differences and ability to thermoregulate
 Heat loss & prevention
 Malignant hyperthermia
8. Psychological Issues
 Anxiety/fear at different ages
 Separation anxiety and parental anxiety
 Use of premeditations
9. Pharmacology
 Pediatric induction techniques, inhalation, intravenous, sedation
 Neuromuscular blockade
 Age differences in: volume of distribution, pharmacokinetics, pharmacodynamics, and
toxicity
10. Pain Management
11. Use of muscle relaxants
12. Anesthesia Equipment
 Sizes of masks, endotracheal tubes, laryngeal mask airways, laryngoscopy blades,
bronchoscopes, GlideScope
 Vascular access and invasive monitoring
 Warming devices

D. Research Rotation
Role#1: Medical Expert
The fellow should learn and discuss the principles of conducting research, reviewing the
literature, writing a proposal, and publishing papers.
1. Identify research areas in pediatric intensive care
2. Perform critical review of the literature
3. Differentiate common statistical principles
4. Differentiate various research methods and designs and their application.
5. Discuss principles of research ethics on humans and animals.
6. Formulate research questions.
7. Write research proposals
8. Comply with the institutional review board(IRB)
9. Demonstrate knowledge of how to prepare protocols involved in hypothesis and
observational research.

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10. Discuss the process of organizing a laboratory research project.

11. Discuss the principles of evidence-based medicine techniques
12. Perform data collection
13. Prepare, organize, and analyze a data base.
14. Write manuscripts
15. Apply principles of publication ethics
16. Submit to internationally recognised journals
17. Learn how to apply for a grant
18. Recognise the importance of teamwork
a. Supervisor
b. Co-investigators
c. Clinical research coordinator
d. Statistician

E. Elective Intensive Care Rotation

1- Neonatal Intensive Care
Role#1: Medical expert
The fellow will acquire knowledge and skills related to the care of the critically ill neonate.
1. Sound knowledge in the principles of Perinatal-neonatal medicine.
2. The understanding of the physiology of common diseases of the premature and low-birth
weight infants.
3. Recognition and management of common disorders in newborn infants
4. Recognition and management of rare disorders in newborn infants
5. Recognition and management of inherited disorders in newborn infants
6. Recognition and management of surgical conditions in newborn infants
7. Recognition and management of duct-dependent cardiac anomalies in newborn infants
8. Interpretation of relevant investigations
9. Acquisition of skills in various diagnostic and therapeutic procedures in NICU
10. Recognition and management of emergency situations
11. Acquisition of skills in procedures
 Umbilical vein catheterisation
 Umbilical artery catheterisation
 Percutaneous intravenous catheterisation
 Exchange transfusions
12. Performing neonatal CPR
13. Consultation to the delivery room for the high-risk deliveries.
14. Participating in neonatal transportation
15. Successful completion of the Neonatal Resuscitation Program (NRP)

2- Pediatric Emergency Room

Role#1: Medical expert
The fellow should demonstrate the skills in the management of the sick child in the emergency
department
1. Early recognition, assessment, and management of medical emergencies
2. Early recognition, assessment, and management of surgical emergencies
3. Early recognition, assessment, and management of polytrauma
 Recognize unique anatomic and physiologic features
 Recognize mechanisms and patterns of injury features

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 Discuss priorities in management

 Recognise the importance of thermal environment
 Evaluation and stabilization
4. Early recognition, assessment, and management of poisoning
5. Early recognition, assessment, and management of burns
6. Early recognition, assessment, and management of non-accidental injury
7. Cardiopulmonary resuscitation
8. Acquisition of skills in:
 Maintaining airways
 Rapid sequence intubation
 Intravenous catheterisation
 Intraosseous cannulation
 Procedural sedation and analgesia
 Wound management and suturing
 Thoracentesis
 Pericardiocentesis
9. Ultrasonography
 Indications for use of ultrasonography for diagnostic emergencies and for guidance
during procedures
 Focused Assessment with Sonography in Trauma (FAST)
10. Triage of patients with major illness or injury
11. Transport of patients with major illness or injury
12. Discuss principles in providing emergency care in disasters, multi-casualty events, and
mass gatherings
13. Recognize the special medicolegal problems
14. Discuss the natural history of illness or injuries
15. Discuss the social and family implication of illness or injury

3- Coronary Care Unit

Role#1 Medical Expert
The fellow should acquire knowledge and experience in the following domains:
1. The common pathophysiology and management of patients admitted to a cardiac critical
care setting who present with:
a. Coronary artery disease, acute myocardial ischemia and infarction, and complications
of myocardial infarction and thrombolytic therapy.
b. Valvular heart disease with familiarity of the pathophysiological alterations induced by
chronic valvular disease in critically ill patients.
c. Shock and the use of volume resuscitation, venodilators/constrictors, inotropes, and
lusitropes.
d. Cardiac tamponade or constrictive pericarditis.
e. Dilated, restrictive, and obstructive cardiomyopathy; congestive heart failure, and
diastolic dysfunction.
f. Aberrant conduction, dysrhythmia, and sudden acute and sub-acute ventricular and
supra-ventricular arrhythmia.
g. Pacemakers and the indications for and applications of the various modes of temporary
pacing.
h. Aortic dissection, thoracic and thoracoabdominal aortic aneurysm.
i. Pulmonary edema.

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2. Commonly used cardiac drugs, heparin, thrombolytics, and antiplatelet agents and their
appropriate dosages.
3. Ani-fibrinolytic agents and their mechanism of action.
4. Commonly used vasodilators, vasoconstrictors, inotropic and lusitropic agents, their
dosages and effects.
5. Commonly used antiarrhythmic agents.
6. Interpret ECGs for ischemia, infarction, arrhythmias, and paced rhythms.
7. Current indications and recommendations for SBE prophylaxis
8. The basic principles of applying an intra-aortic balloon pump as well as its indications and
contraindications.

Adult Intensive Care Unit

Role#1 Medical Expert
The fellow should:
1. Describe the natural history and clinical expression of critical care illnesses encountered in
the inpatient, ICU, and ER settings.
2. Understand the pathophysiology of commonly observed diseases in critically ill patients.
3. Demonstrate a working knowledge of Critical Care Medicine by actively participating in the
management of critically ill patients.
4. Demonstrate an understanding of the integrative nature of disease in critically ill patients
and the interdisciplinary approach to the management of such patients.
5. Identify at-risk patients, perform appropriate physical examinations, formulate a problem
list, and institute a course of therapy under the direction of senior personnel.
6. Prioritize and summarize approaches to the evaluation of common presentations in Critical
Care Medicine patients.
7. Triage interventions, taking into account clinical urgency, the potential for unexpected
outcomes, and available alternatives.
8. Become comfortable in the management of cardiac arrest and the acute resuscitation of a
traumatized or acutely ill patient.
10. Demonstrate competence in performing common procedures performed in the medical and
surgical ICU, including central and arterial line insertions, orotracheal intubation,
paracentesis, thoracentesis, and lumbar puncture.
11. Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of pulmonary diseases.
12. Effectively interpret diagnostic tests used in the evaluation of ICU patients such as
interpretation of arterial blood gases, chest x-rays, abdominal films, and computerized
tomography (CT) scans.
13. Obtain and document informed consent from patients and explain the risks, benefits, and
rationale for the options discussed.
14. Counsel patients concerning their diagnosis, planned diagnostic testing, and recommended
therapies.

F. Elective Rotation
Objectives: The objectives of the elective rotation are to provide flexibility and opportunities to
explore career possibilities, gain experience in aspects of critical care medicine beyond the core
curriculum, and study certain areas in greater depth. Fellows are free to identify and choose
specific electives in keeping with their individual training objectives, subject to approval by the
program director.

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Role#1: Medical Expert

The fellow should:
1. Provide optimal ethical and patient-centred medical care.
2. Acquire clinical knowledge, skills, and attitudes appropriate to the rotation subject.
3. Use preventive and therapeutic interventions effectively
4. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
5. Seek appropriate consultation from other health professionals, recognizing the limits of
their expertise.

Elective rotation includes but are not limited to:

1. Medical imaging and ultrasonography
2. Pediatric cardiology
3. Pediatric pulmonology
4. Infectious disease
5. Cardiac anesthesia
6. Neuroanesthesia
7. Neurointensive care

1-Medical Imaging and Ultrasonography

Role#1: Medical Expert
The fellow will discuss the applications, indications, and interpretation of various radiological
examinations required in the management of critically ill patients.
1. Develop the skills to interpret chest X-rays and CT scans of the thorax.
2. Discuss the indications for and read abdominal X-rays and CT scans of the abdomen.
3. Discuss the indications for and read skull X-rays and CT scans of the brain.
4. Discuss the indications for:
a) MRI
b) Angiograms/interventional radiology procedures
c) Bone/gallium scans
d) Other nuclear medicine scans
5. Demonstrate knowledge of the causes and ultrasound findings in respiratory failure:
a) Pleural effusion
b) Pneumothorax
c) Alveolar-interstitial syndrome (e.g., congestive heart failure, acute respiratory distress
syndrome)
d) Normal aeration pattern
e) Lobar collapse
6. Demonstrate ability to perform ultrasound-guided procedures.
7. Demonstrate ability to perform FAST exam

2- Neuro-anesthesia
Role#1: Medical Expert
The fellow will discuss the preoperative evaluation, intraoperative management, and
postoperative care of patients undergoing central nervous system and spinal surgeries. The
clinical experience will provide exposure to a variety of basic and complex procedures for
treating patients with neurological disease and will involve graded independence and
responsibility.

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1. Demonstrate knowledge of basic sciences applicable to neuroanesthesia, including

neuroanatomy, neurophysiology, and neuropharmacology.
2. Understand the pathway and physiology of cerebrospinal fluid (CSF) circulation
3. Demonstrate knowledge of the anatomy of cerebral circulation
4. Monitor intracranial pressure
5. Apply the principles of treating increase ICP.
6. Apply safe anesthesia techniques to avoid increases in ICP during induction, intubation,
and emergence from anesthesia.
7. Demonstrate clinical knowledge and skills necessary for the practice of neuroanesthesia
including:
 Preoperative neurological assessment (Glasgow Coma Scale classifications for
subarachnoid hemorrahage, and basic neurological exam)
 Intraoperative support (special positioning, i.e., sitting, prone, lateral, and knee-chest).
 Understanding basic principles of neurophysiologic monitoring
○ EEG
○ Evoked potentials: somatosensory, visual, and brainstem auditory
○ Transcranial Doppler
8. Management of specific perioperative complications;
 Seizures
 Cerebral ischemia
 Intracranial hypertension
 Intraoperative aneurysm rupture
 Air embolism
 Cranial nerve dysfunction
 Neuroendocrine disturbance: diabetes insipidus, syndrome of inappropriate antidiuretic
hormone secretion.
9. Postoperative management of neurological patients

3- Cardiac Anesthesia
Role#1: Medical Expert
The fellow will demonstrate knowledge of the basic sciences as applied to the preoperative,
intraoperative, and postoperative periods of cardiac surgery.
1. Describe common physiological changes occurring in the postoperative period and the
impact they have on end-organ function.
2. Describe the different congenital cardiac anomalies and their surgical management.
3. Describe the altered respiratory physiology of immediate postoperative cardiac cases.
4. Compare common medications for cardiac surgical patients including anesthetic agents,
vasodilators, vasoconstrictors, and inotropic agents.
5. Know the basics of introductory transesophageal echocardiography (TEE), including
techniques of probe insertion and several basic views, and implications and application in
the critical care patient.
6. Know the significance of temperature management in the intraoperative period, including
hypothermic techniques.
7. Recognise the indicators of volume status.
8. Manage metabolic and electrolyte disturbances in the intraoperative period.
9. Differentiate the basic principles of cardiac support devices including the intra-aortic
balloon pump and extracorporeal membrane oxygenation (ECMO).

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4- Pediatric Infectious Disease

Role#1: Medical Expert
The fellow will be trained in the evaluation and management of inpatients with a broad spectrum
of infectious diseases.
1. Discuss the epidemiology, genetics, natural history, and clinical expression of infectious
diseases encountered in the inpatient setting.
2. Discuss the epidemiology, genetics, natural history, and clinical expression of Health-Care
Associate infections.
3. Understand the importance of antimicrobial surveillance.
4. Learn the preventive measures to minimise Health-Care Associated infections and the
importance of implementing the various bundles in PICU.
5. Recognise the interplay of factors related to host defence, microbial infection, and
treatment.
6. Develop a comprehensive approach to the diagnosis of common infectious diseases in
PICU (e.g., AIDS, pneumonia, urinary tract infections, and sepsis).
7. Develop a comprehensive approach to the management of common infectious diseases in
PICU (e.g., AIDS, pneumonia, urinary tract infections, and sepsis).
8. Learn the various type of antimicrobials, their uses, side effects, and indications.
9. Differentiate the mechanisms of action, mechanism of resistance, and spectrum of activity
of antimicrobials used in PICU.
10. Learn how to interpret the therapeutic levels of antimicrobials, the adjustment of the drug
doses, and the special considerations in the presence of organ dysfunction.
11. Select and interpret laboratory, imaging, and pathologic studies used in the evaluation of
infectious diseases.
12. Discuss the importance of PICU and hospital antibiograms and its impact on the choice of
antimicrobials.
13. Develop knowledge of clinical laboratory, the mechanisms by which specimens are
processed, organisms identified, susceptibility testing performed, and test results reported.
14. Apply the biosafety regulations for handling different classes of microbial pathogens.

5- Pediatric Pulmonology
Role#1: Medical Expert
The fellow will be trained in the evaluation and management of inpatients with a broad spectrum
of pulmonary diseases.
1. Effectively obtain a comprehensive history and perform a complete physical examination of
patients with respiratory symptoms or known pulmonary diseases.
2. Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of pulmonary diseases.
3. Develop a comprehensive approach to the diagnosis of common pulmonary diseases in
PICU.
4. Develop a comprehensive approach to the management of common pulmonary diseases in
PICU.
5. Demonstrate the principles of performing flexible bronchoscopy.
6. Assist in performing bronchoscopy.
7. Discuss the indications and basics of interpretation of sleep studies in the clinical context.

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6- Critical Care Echocardiography

Role#1: Medical Expert
The fellow will describe the assessment of critically ill patients by identifying and treating the
underlying causes of hemodynamic instability in a timely manner.
1. Assess critically ill patients using focused and goal-directed cardiac examinations via
appropriate transthoracic echocardiography (TTE).
2. Understand the basic thoracic anatomy.
3. Discuss the importance of proper positioning of the patient for optimal cardiac examination.
4. Apply the basic principles of cardiac transducer orientation and positioning.
5. Discuss the anatomy and orientation of basic echocardiographic views.
6. Obtain a safe and optimal echocardiographic examination via the transthoracic approach in
acutely ill patients.
7. Demonstrate an ability to answer focus questions through focused or goal-directed
examination, which are usually related to
a) Left ventricular size and function
b) Right ventricular size and function
c) Pericardial space for fluid and tamponade
d) Fluid status and responsiveness
8. Demonstrate ability to identify the causes of hemodynamic instability:
a) Cardiogenic
b) Distributive
c) Hypovolemic

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Role#2: Communicator
CanMEDS Key Competencies Methods to achieve competencies
 Provide educational and supportive  Learning from a role model
counselling for patients and their  Simulation-based scenarios
families in simple terms  Communicates with family under
 Express empathy through verbal and supervision of senior fellows and
non-verbal communication consultants
 Identify barriers to effective  Organizing case conference meeting for
communication and modify approach to complex cases
minimize those barriers  Making rounds under the supervision of
 Provide succinct and clear explanation consultant
of life resuscitative measures to  Monitoring the fellow performance when
patient’s family consulted outside unit
 Demonstrate effective communication  Review by the consultant of the fellow note
skills in dealing with terminally ill in the medical record
patients and breaking bad news  Supervise junior residents and fellows
 Resolve conflicts between the family  Present at national and international
and the healthcare professionals conferences
 Document properly in the patient’s  Present at journal clubs
medical record
 Respect the role of each member of the
multidisciplinary PICU team to maintain
a good teamwork spirit in the unit
 Demonstrate effective communication
skills with other subspecialties
 Counsel the junior trainees about their
performance in a constructive manner

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Role#3: Collaborator
CanMEDS Key Competencies Methods to achieve competencies
 Realize the importance of collaboration  Organizing case conference meeting for
and assess the stages of team formation complex cases
 Recognize the unique roles of members  Facilitating simulation-based learning
of the interdisciplinary PICU team  Participating in Morbidity Discussion
 Demonstrates effective collaboration  Participating in Mortality Discussion
among members of the interdisciplinary  Collaborate as a team member for Quality
team and other health care professionals – performance indicator
 Discuss management plan with team  Web based programs
members and ensure that it is well
understood and carried
 Demonstrate integration and
responsibility as a team member

Role#4: Health Advocate

CanMEDS Key Competencies Methods to achieve competencies
 Discuss the long -term consequences of  Application of severity-of-illness
disease in the critical ill children measurement scores
 Discuss the impact of disease on family  Discuss case scenarios with the members
dynamics of the multidisciplinary team which include
 Apply quality improvement measures nurse, respiratory therapists, dietitians,
 Recognise the patterns of disease in the occupational therapists, social workers,
critical ill children in relation to the society clinical psychologists, home health care
 Acknowledge the sociocultural and providers, spiritual counsellors
spiritual preferences in the society  Collaborate in creating support group for
 Coordinate social and financial support the patients and their families
for families  Obtain detailed inform consent under
 Comprehend various ethical and legal direct supervision
issues such as informed consent, end of  Seminars on ethics
life care, and beneficence.  Patient-centred discussion
 Consider appropriate utilisation of
resources to avoid futility of care

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Role#5: Leader
CanMEDS Key Competencies Methods to achieve competencies
 Run the unit in an efficient and smooth  Direct discussion with the consultant after
manner taking decisions related to patients
 Demonstrates the ability to make  Direct supervision of junior colleagues
independent decision on patients with feedback
 Demonstrate skills in time management  Make rounds as a leader once per week
 Demonstrate the ability to function under or as requested
stress  Conduct the monthly mortality and
 Acknowledge signs of burnout morbidity meeting of the unit
 Recognise signs of burnout of other  Collaborate as a team leader for Quality –
members of the team performance indicator
 Demonstrate skills in triage, transfer, and  Workshop for time management
bed allocations  Workshop for stress coping strategies
 Recognise the importance of resource  Workshop for conflict resolution
allocations management
 Attend the monthly unit meeting
 Share administrative responsibilities
 Write policies and procedures
 Get involved in ordering and purchasing
equipment
 Get involved in planning the unit
expansion

Role#6: Scholar
CanMEDS Key Competencies Methods to achieve competencies
 Make evidence-based decision  Participate in all academic activities
 Review literature in solving clinical  Perform clinical research/quality projects
problems supervised by senior staff
 Apply critical appraisal skills to literature  Publish papers
 Provide clinical teaching and mentoring  Attend Research Methodology course
for juniors  Attend Evidence-based medicine course
 Describe the unique challenges of
intensive care research and strategies to
overcome it
 Differentiate principles of qualitative and
quantitative research methodology
 Discuss biostatistics

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Role#7: Professional
CanMEDS Key Competencies Methods to achieve competencies
 Demonstrate integrity, honesty, and  Attend handover round in morning and
compassion in the care of patients evening
 Demonstrate accountability and  Give a comprehensive handover when
punctuality transferring patients
 Guarantee continuity of patient care  Take a comprehensive handover when
 Consider principles of bioethics in daily receiving patients to the unit
practice  Organizing case conference meeting for
 Develop skills in resolving conflicts complex cases
 Discuss the legal and ethical aspects of  Simulation-based teaching
the informed consent
 Adhere to hospital policies and
procedures

Top Ten Core Clinical Conditions

I- Status Asthmaticus
1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the definition, epidemiology,
and risk factors of status asthmatics.
○ The fellow should discuss the pathophysiology of status asthmaticus which is
characterised by airflow obstruction due to airway hyper-responsiveness,
bronchospasm, airway inflammation, mucosal edema, and mucous plugging.
○ The fellow should have a deep understanding ofdiscuss cardiopulmonary interactions,
pulmonary mechanics, and gas exchange abnormalities status asthmaticus.
○ The fellow should be knowledgeable in the use of monitoring tools: pulse oximetry, end-
tidal CO2, arterial blood gas interpretation, waveform interpretation.
○ The fellow should be updated about the advances in the field and the current literature.

2. Patient Care Competencies

○ The fellow should perform a comprehensive clinical assessment of the patient for
optimal management.
○ The fellow should recognise when the patient is not improving on maximal aggressive
therapy in the emergency room.
○ The fellow should know the indications for admission to PICU for a higher level of
monitoring and escalation of therapy
○ The fellow should recognise that clinical interventions for spontaneously breathing
asthmatics is based on clinical evaluation and not on blood gas determination.
○ The fellow should know the standard modalities of therapy: oxygen, fluids, beta-
agonists, anticholinergic agents, corticosteroids, magnesium sulfate, methylxanthines,
helium-oxygen.
○ The fellow should recognise the indications for use of non-invasive ventilation in a
conscious cooperative patient.

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○ The fellow should recognise the high risks associated with the intubation of the
asthmatic child. The intubation should be performed by the most skilled intensivist, with
appropriate fluid and medications.
○ The fellow should apply the various strategies in mechanical ventilation of the asthmatic
child.
○ The fellow should apply the various ventilatory monitoring and their interpretation.
○ The fellow should recognise the importance of a safe ventilator strategy that aims to
minimize dynamic hyperinflation.
○ The fellow should know the most appropriate drugs for analgesia, sedation, and
neuromuscular blockade that maintain stable hemodynamics and avoid worsening of
bronchospasm.
○ The fellow should consider the use of inhalational anesthetics in nonresponding cases.
○ The fellow should consider the use of ECMO with the failure of all modalities of
treatment.
○ The fellow should recognise the importance of rehabilitation care and pulmonologist
follow-up

II- Pediatric Acute Respiratory Distress Syndrome (PARDS)

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the definition, epidemiology,
and risk factors of PARDS.
○ The fellow should understand the pathophysiology of acute respiratory distress which
include endothelial and epithelia injury, interstitial and intra-alveolar edema,
haemorrhage as well as hyaline membrane formation.
○ The fellow should know the various stages of the disease.
○ The fellow should have a deep understanding of cardiopulmonary interactions,
pulmonary mechanics, and gas exchange abnormalities.
○ The fellow should be knowledgeable in the use of monitoring tools: pulse oximetry, end-
tidal CO2, arterial blood gas interpretation, waveform interpretation.
○ The fellow should be updated about the advances in the field and the current literature.

2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient
○ Recognize the importance of supportive care in the management.
○ Assess the severity of PARDS.
○ Interpret the chest X-ray in PARDS.
○ Describe indications for bronchoscopy and bronchoalveolar lavage.
○ Apply ventilation protective strategies as a mainstay of therapy.
○ Strategically apply permissive hypercapnia, permissive hypoxemia, and their potential
effects on the hemodynamics.
○ Recognize the rational and applications of prone positioning in PARD.
○ Demonstrate a thorough understanding of standard modalities of therapy such as
oxygen, fluids, hemodynamic support, nutritional support, sedation, and neuromuscular
blockade.
○ Consider the use of adjunct therapy: inhaled nitric oxide, surfactant, corticosteroids, and
extracorporeal life support and recognize the indications, contraindication and safe-
usage
○ Anticipate complications of PARDS and predict the outcome in PARDS

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III- Acute Bronchiolitis

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the definition, epidemiology,
and risk factors of acute bronchiolitis.
○ The fellow should know the pathogenesis of acute bronchiolitis.
○ The fellow should know the underlying viral etiology besides respiratory syncytial virus
in acute bronchiolitis.
○ The fellow should know the laboratory testing to be done in acute bronchiolitis.
○ The fellow should know the comorbidities associated with the severity of acute
bronchiolitis: prematurity, chronic lung disease, immunodeficiency, and congenital heart
disease.
○ The fellow should be knowledgeable in the use of monitoring tools: pulse oximetry, end-
tidal CO2, arterial blood gas interpretation, waveform interpretation.
○ The fellow should know that antibiotics and bronchodilators have no proven benefit in
the treatment of acute bronchiolitis.
○ The fellow should know the indication for the use of Respiratory Syncytial Virus
immunoglobulins in high-risk patients.
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient for optimal management.
○ Recognize the PICU admission criteria for acute bronchiolitis.
○ Provide supportive care in acute bronchiolitis management.
○ Provide adequate hydration and oxygenation in acute bronchiolitis management.
○ Practice careful hand washing and other infection control measures necessary to
prevent the spread of viruses.
○ Apply respiratory support in acute bronchiolitis for refractory and recurrent apnea,
progressive hypoxia, refractory hypercapnia, or increasing respiratory distress.
○ Demonstrate a thorough understanding of the standard modalities of therapy: oxygen,
fluids, hemodynamic support, nutritional support, sedation, and neuromuscular
blockade.
○ Demonstrate a thorough understanding of the various modalities of ventilatory
monitoring and their interpretation.
○ Demonstrate a thorough understanding of the importance of a safe ventilator strategy
that aims to minimize dynamic hyperinflation.

IV- Status Epilepticus

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the definition, epidemiology,
and risk factors of status epilepticus.
○ The fellow should know the classification of status epilepticus.
○ The fellow should know the underlying pathophysiology of status epilepticus.
○ The fellow should know the importance of early recognition and aggressive intervention
in status epilepticus.
○ The fellow should know that the outcomes after status epilepticus are primarily related
to the underlying cause of the seizures.
○ The fellow should be knowledgeable in the use of monitoring and diagnostic tools.

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○ The fellow should learn the various type of anticonvulsants, their uses, indications, side
effects, and their mechanisms of action.
○ The fellow should know how monito the therapeutic levels of anticonvulsants.
○ The fellow should understand, and spectrum of activity of antimicrobials used in PICU.
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient for optimal management.
○ Recognize the PICU admission criteria for status epilepticus.
○ Differentiate between convulsive and non-convulsive seizures.
○ Recognize the importance and indications for continuous electroencephalogram
monitoring.
○ Perform the relevant diagnostic tests: serum glucose and electrolytes levels,
anticonvulsants levels, neuroimaging, lumbar puncture, electroencephalogram.
○ Check the serum level of ammonia, lactate, aminoacids and urine level of organic acids
in infants at high risk of inborn errors of metabolism.
○ Perform initial stabilisation: airway protection, oxygen therapy, proper positioning to
avoid aspiration, intravenous access.
○ Treat the underlying etiology of status epilepticus.
○ Use the appropriate anticonvulsants for electrographic seizure termination.
○ Recognize the special considerations in the management of refractory and super-
refractory status epilepticus.
○ Consider other modalities of treatment: immunomodulation, ketogenic diet, surgical
intervention.
○ Recognize the potential resulting functional disabilities.

V- Traumatic Brain Injury (TBI)

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the epidemiology, and risk
factors of traumatic brain injury.
○ The fellow should know and follow the guidelines of pediatric traumatic brain injury.
○ The fellow should know the underlying pathophysiology in pediatric TBI, understand the
mechanisms and pattern of head and brain injury, the impact of primary and secondary
injury in TBI, the pathophysiology of increase intracranial pressure.
○ The fellow should know the age-dependent targets for cerebral perfusion pressure-
directed therapy.
○ The fellow should understand the principles of autoregulation, the importance of an
intact blood barriers, the types of cerebral edema.
○ The fellow should recognize the signs of increase intracranial pressure and pending
herniation and manage it appropriately.
○ The fellow should understand the utilisation and importance of advanced
neuromonitoring and neuroimaging in providing insight into pathophysiology-guided
treatment.
○ The fellow should recognize the importance of adequate hydration and nutrition in
pediatric TBI.
○ The fellow should have a high index of suspicion to recognize non-accidental brain
injury.
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

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2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient for optimal management.
○ Perform a rapid physiological resuscitation as hypoxemia and hypotension are strongly
associated with poor outcomes.
○ Calculate and correlate the Glasgow Coma scale in pediatric TBI.
○ Perform initial resuscitation and stabilisation: airway patency, adequate ventilation,
optimal positioning with immobilisation of the neck fluid resuscitation.
○ Apply the criteria for intubation, the precautions to be followed
○ Use the optimal medications for intubation.
○ Request neuroimaging of the brain.
○ Consider intracranial pressure monitoring after physiologic resuscitation.
○ Apply the first-tier of the recommendations of pediatric TBI guidelines: ventricular
cerebrospinal fluid drainage, osmolar therapy, sedation, analgesia, head position,
hyperventilation.
○ Discuss and apply the second-tier of the Pediatric TBI guidelines: hypothermia,
decompressive craniectomy.
○ Recognize the complications and potential resulting functional disabilities.

VI- Sepsis
1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of
 The epidemiology and risk factors of sepsis
 The pathophysiology of shock, ischemia, and reperfusion injury
 The cellular and molecular mechanisms of injury
 The consensus definitions and classification of shock
 The laboratory tests and biomarkers
○ The fellow should understand that the management of shock depends on the causes of
shock and delivering cause-directed and early goal directed therapies
○ The fellow should know how to calculate oxygen delivery, oxygen content, and mixed
venous oxygen saturation,
○ The fellow should understand the pharmacokinetics, pharmacodynamics of commonly
used medications in sepsis.
○ The fellow should know the consensus definitions, the pathophysiology of Multiorgan
Dysfunction Syndrome (MODS)
○ The fellow should know the high mortality and poor outcome of children with sepsis,
shock, and MODS
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient for optimal management.
○ Perform laboratory tests that include markers such as arterial blood gas, lactate
measurement, and mixed venous oxygen saturation
○ Apply invasive and non-invasive monitoring techniques to guide fluids administration
and use of vasoactive drugs
○ Demonstrate thorough understanding that early normalization of hemodynamic status
can improve outcome.

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○ Master the initial management that focus on interpreting and treating hemodynamic
derangements with targeted therapeutic interventions aimed at improving tissue
perfusion and restoring balance between oxygen delivery and oxygen demand. This
goal-directed therapy includes:
 Prompt fluid resuscitation
 Targeted vasoactive therapy
 Early empiric antimicrobial therapy
 Continuous monitoring of hemodynamic status
○ Recognise the importance of early and prompt goal-directed therapy in preventing the
development of MODS.
○ Recognise that the mainstay of therapy for MODS remains general supportive care.

VII- Diabetic Ketoacidosis (DKA)

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the definition, pathophysiology,
epidemiology, and risk factors of diabetes and diabetic ketoacidosis
○ The fellow should know that cerebral edema is the most frequent serious complication
of DKA and the most frequent cause of morbidity and mortality resulting from DKA
○ The fellow should know that early identification and prompt management of cerebral
edema is crucial in improving the outcome in children DKA.
○ The fellow should know that hyperglycemic hyperosmolar syndrome is underrecognized
in children and may be mistaken for DKA.
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient for optimal management.
○ Perform the relevant diagnostic tests: serum glucose, plasma and urine ketones,
arterial blood gas, serum electrolytes levels, urea, creatinine, osmolarity, calcium, and
phosphorus levels.
○ Perform frequent monitoring of blood sugar and ABG according to protocols
○ Correct rapidly dehydration with isotonic fluids and insulin for optimal management of
DKA
○ Demonstrate thorough understanding that insulin infusion should not be discontinued
until DKA resolves, and that glucose should be provided to avoid hypoglycemia.
○ Perform the optimal clinical management to:
 Correct dehydration and electrolytes deficits
 Correct of acidosis and reversal of ketosis
 Restore of blood glucose to near normal
 Avoid complications of therapy
○ Identify and treat any precipitating condition.

VIII- Acute Kidney Injury (AKI)

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the definition, pathophysiology,
classification, epidemiology, etiologies, and risk factors of AKI
○ The fellow should know that AKI is common during critical illness and is associated with
significant morbidity and mortality

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○ The fellow should realize that the incidence of AKI is rising because of increased use of
intensive care and advanced technologies.
○ The fellow should have a sound knowledge of the biomarkers and laboratory tests to be
done to assess renal function
○ The fellow should understand the importance of prevention of AKI
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Perform a comprehensive clinical assessment of the patient for optimal management
○ Perform the optimal clinical management which includes:
 Adequate fluid management
 Correction of electrolytes deficits
 Use of diuretics
 Use of vasoactive agents
 Correction of acidosis
 Correction of electrolytes
 Avoidance of nephrotoxic medications, proper dosing of medications, and
monitoring of drug levels
 Management of hypertension
 Adequate nutritional support
 Renal Replacement Therapy
○ Demonstrate thorough understanding of renal replacement therapy (RRT)
 The physiology of RRT
 The indications of RRT
 The optimal start time of RRT
 The types of RRT: peritoneal dialysis, intermittent hemodialysis, Continuous renal
replacement therapy (CRRT)
 The technique of RRT
 The anticoagulation used
○ Recognise the impact of short-term and long-term outcome of AKI

IX- Abdominal Compartment Syndrome (ACS)

1. Medical Knowledge Competencies
○ The fellow should have a sound and deep knowledge of the consensus definition,
pathophysiology, epidemiology, etiologies, and risk factors of AKI.
○ The fellow should know that abdominal perfusion pressure is a resuscitation endpoint
with good prediction of outcome
○ The fellow should know that clinical examination is not a reliable substitute to measure
Intraabdominal hypertension
○ The fellow should know that intraabdominal hypertension and ACS can lead to multi-
organ system failure and ae associated with increase morbidity and mortality
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Identify patients at risk to develop ACS
○ Demonstrate the techniques for measuring intraabdominal pressure( IAP)

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○ Apply the important principles for management of ACS

 Serial IAP measurements
 Treat the underlying condition and pre-existing co-morbidities
 Implement IAP lowering interventions
 Optimize systemic mean arterial pressure and abdominal perfusion pressure
 Recognise and support organ dysfunction
 Surgical abdominal decompression

X- Multiple Trauma
1. Medical Knowledge Competencies
○ The fellow should know that trauma is the leading cause of pediatric deaths in
developed countries, and that most children suffer significant morbidity following trauma
○ The fellow should know the mechanisms and pattern of injury:
 Blunt trauma is more frequent than penetrating trauma
 Penetrating trauma is associated with higher mortality
 The mechanisms of injury often predict the pattern of injuries and suggest a
management strategy
○ The fellow should know that the primary survey is a prioritized evaluation and
management on identifying and treating the most life-threatening injuries
○ The fellow should be updated about the advances in the field, the updated guidelines,
and the current literature.

2. Patient Care Competencies

○ Perform the primary survey which includes:
 The ABCDSs: Airway, Breathing, Circulation, Disability
○ Perform the secondary survey to definitively evaluate the injured child:
○ Manage chest trauma:
 Pulmonary contusion, laceration, and hematoma
 Hemopneumothorax
 Rib fractures and flail chest
 Myocardial contusion
 Cardiac tamponade
 Rupture of diaphragm
 Aortic disruption
 Tracheobronchial tears
○ Manage abdominal trauma:
 Liver and spleen
 Kidney and urinary tract
 Gastrointestinal tract
 Pancreas
 Abdominal compartment syndrome
○ Manage skeletal trauma:
 Fractures
 Compartment syndromes
○ Demonstrate thorough understanding of the importance of a multidisciplinary team
involvement
○ Demonstrate a high index of suspicion to rule out non-accidental injury
○ Recognise the potential resulting complications: infections, acute stress, post-traumatic
stress disorder, thromboembolic events

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Continuum of Learning

Competencies milestones
F 1 (Junior Level) F 2, F 3 (Senior Level) Continuing development as
a consultant
Obtains fundamental Applies knowledge to Evaluates ad update
knowledge related to core provide appropriate clinical knowledge
clinical problems of PICU care related to core clinical Modifies clinical care
problems of PICU Enhances patient care
Acquires clinical Analyses and interprets the Evaluates assessment
examination and findings from clinical skills to findings
assessment skills and apply develop appropriate Modifies management plans
it to clinical practice differential diagnoses and
management plan for the
critically ill patient
Provide advanced life Proficient in advanced life May acquire speciality
support support and complex PICU advanced PICU skills
Acquires advanced technical procedures
skills
Performs allocated tasks Plans and prioritises tasks Develop increasing
Begins to plan tasks appropriately expertise
Prioritises tasks
Delegates tasks
Performs allotted teaching Plans and delivers teaching Plans and modifies curricula
tasks to trainees and other Performa assessment and
professionals appraisal
Develops peer mentoring Able to provide mentorship
skills
Aware of management Develops management skills Negotiates and deals with
issues in PICU Able to take responsibility conflicts
Participates in committees Can contribute to and leads
committee
Evaluates and modifies
management structure
Performs allocated audit Designs audit projects Facilitates audit and
projects Understands risk evaluates results
Understands the audit cycle management Evaluate guidelines and
Able to write appropriate ensures implementation of
clinical guidelines appropriate changes

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 OUTCOMES AND COMPETENCIES 

Understands the principles Able to appraise the Able to evaluate critical

of critical appraisal and literature critically and apply appraisal performed by
research methodology to clinical practice others
Proposes a research idea Conducts a research study Able to lead research
and writes a proposal Writes and publish a paper projects
Support juniors in research
Works in a multi- Able to lead a multi- Evaluates and modifies
professional team disciplinary team multi-professional team work

Top Ten Procedures

Procedures Minimum F1 F 2, F 3 Category*
Number
Required
Bag Mask Ventilation 40 30 10 I
Endotracheal Intubation 30 20 10 I
Laryngeal Mask Insertion 10 5 5 I
Glidescope intubation 10 5 5 III
Chest tube 15 10 5 I
insertion/Pleural tap
Arterial Line Cannulation 45 30 15 II
Central venous line 45 30 15 II
insertion
Intraosseous insertion 10 5 5 I
Ultrasound guided 20 15 5 II
Procedures
Resuscitation skills 40 20 20 II

*Procedures list should be divided into three categories

1. Category I: Assumed competent (i.e. previously learned).
2. Category II: Core Procedures. These are the procedures to be learned and certified to be
competent during F 1 and 2.
3. Category III: Mastery level procedures. Trainees are expected to be competent at the end
of F 3

List of Behavioural / Communication Skills

 Behavioral/communication Skills
 Open interview
 Informed consent
 Counselling
 Breaking bad news
 Management of conflict
 Refusing treatment
 End of life care

PEDIATRIC INTENSIVE CARE FELLOWSHIP  53
 OUTCOMES AND COMPETENCIES 

 Clinical Ethics issues

 Research ethics issues
 Administrative skills
 Professionalism

54  PEDIATRIC INTENSIVE CARE FELLOWSHIP 
  

LEARNING OPPORTUNITIES

General Principles
1-Learning is expected to be an active process where fellows participate in teaching, doing
presentations, keeping updated with the recent literature, and reviewing evidence-based
articles.
2-Teaching will be structured, supervised by consultant pediatric intensivists, and self-directed.
3-Fellows will be given protected time, for teaching activities, that will be scheduled on a weekly
and monthly basis.
3-Core Education Program (CEP) includes formal teaching and practice-based learning.
4-Formal teaching time will be conducted over 3 hours, every week. A formal teaching time is
an activity that is planned in advance with assigned tutor, time slots, and venue. Formal
teaching activities include universal topics, core speciality topics, and trainee selected topics.
Formal teaching time excludes bedside teaching.
5-Practice-based learning (PBL) include: morning report, case presentations, morbidity and
mortality reviews, Journal clubs, Systematic reviews, hospital grand rounds and research
presentations.
6-The fellow will be counselled on a monthly basis by the program director and mentor.

Universal Topics

Intent
These are high-value, interdisciplinary topics of utmost importance to the fellow. The reason for
centralizing these topics is to ensure that every fellow receives high-quality teaching and
develops essential core knowledge. These topics are common to all specialties.

The topics included here meet one or more of the following criteria:
 Impactful: these are topics that are common or life-threatening
 Interdisciplinary: topics that are difficult to teach in a single discipline
 Orphaned: topics that are poorly represented in the undergraduate curriculum
 Practical: topics that trainees will encounter in hospital practice

Development and Delivery: Core topics for the postgraduate curriculum will be developed and
delivered centrally by the SCFHS through an e-learning platform. A set of preliminary learning
outcomes for each topic will be developed. Content experts, in collaboration with the central
team, can modify the learning outcomes. These topics will be didactic in nature and will focus
on the practical aspects of care. These topics will be more content-heavy as compared to the
planned workshops and other face-to-face interactive sessions. The suggested duration of each
topic is 1.5 hours.

Assessment: The topics will be delivered in a modular fashion. At the end of each Learning
Unit, there will be an on-line formative assessment. After completion of all topics, there will be a
combined summative assessment in the form of context-rich multiple choice questions. All
trainees must attain the minimum competency in the summative assessment. Alternatively,
these topics can be assessed in a summative manner within a specialty examination. Some
topics may include case studies, high-quality images, examples of prescribing drugs in disease
states, and Internet resources.

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Module 1 - Introduction
1. Safe drug prescription
2. Hospital-acquired infections (HAIs)
4. Antibiotic stewardship
5. Blood transfusion

1. Safe drug prescription: At the end of the Learning Unit, Fellows should be able to:
 Recognize the importance of safe drug prescription in health care.
 Describe various adverse drug reactions with examples of commonly prescribed drugs
that can cause such reactions.
 Apply the principles of drug–drug, drug–disease, and drug–food interactions in common
situations.
 Apply the principles of prescribing drugs in special situations such as renal failure and
liver failure.
 Apply the principles of prescribing drugs for the elderly, children, and pregnant or
lactating women.
 Promote evidence-based, cost-effective prescription.
 Discuss the ethical and legal framework governing safe drug prescription in Saudi
Arabia.

2. Hospital acquired infections (HAIs): At the end of the Learning Unit, Fellows should be
able to:
 Discuss the epidemiology of HAIs with special reference to HAIs in Saudi Arabia.
 Recognize HAIs as one of the major emerging threats in health care.
 Identify the common sources and set-ups of HAIs.
 Describe the risk factors of common HAIs such as ventilator-associated pneumonia,
methicillin-resistant Staphylococcus aureus, central line-associated bloodstream
infections, and vancomycin-resistant enterococcus.
 Identify the role of HCWs in the prevention of HAIs.
 Determine appropriate pharmacological (e.g., selected antibiotic) and non-
pharmacological (e.g., removal of indwelling catheter) measures in the treatment of
HAIs.
 Propose a plan to prevent HAIs in the workplace.

4. Antibiotic stewardship: At the end of the Learning Unit, Fellows should be able to:
 Recognize antibiotic resistance as one of the most pressing public health threats
globally.
 Describe the mechanism of antibiotic resistance.
 Determine what constitutes appropriate and inappropriate use of antibiotics.
 Develop a plan for safe and proper antibiotic usage including the indications, duration,
types of antibiotic, and discontinuation.
 Appraise local guidelines in the prevention of antibiotic resistance.

5. Blood transfusion: At the end of the Learning Unit, Fellows should be able to:
 Demonstrate knowledge of the different components of blood products available for
transfusion.
 Recognize the indications and contraindications of blood product transfusion.
 Discuss the benefits, risks, and alternatives to transfusion.
 Undertake consent for specific blood product transfusion.

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 Perform steps necessary for safe transfusion.

 Develop an understanding of special precautions and procedures necessary during
massive transfusions
 Recognize transfusion-associated reactions and provide immediate management

Module 2 - Cancer
8- Management of Oncologic emergency: At the end of the Learning Unit, Fellows should
be able to:
 Enumerate important oncologic emergencies encountered both in hospital and ambulatory
settings
 Discuss the pathogenesis of important oncologic emergencies
 Recognize the oncologic emergencies
 Institute immediate measures when treating a patient with oncologic emergencies
 Counsel the patients in anticipatory manner to recognize and prevent oncologic
emergencies

Module 3: Diabetes and Metabolic Disorders

4. Abnormal ECG: At the end of the Learning Unit, Fellows should be able to:
 Recognize common and important ECG abnormalities
 Institute immediate management, if necessary

Module 4 – Medical and Surgical Emergencies

7. Management of altered level of sensorium
8. Management of hypotension and hypertension
9. Management of upper GI bleeding

For all the above; following learning outcomes apply.

At the end of the Learning Unit, you should be able to:
a) Triage and categorize patients
b) Identify patients who need prompt medical and surgical attention
c) Generate preliminary diagnoses based history and physical examination
d) Order and interpret urgent investigations
e) Provide appropriate immediate management to patients
f) Refer the patients to next level of care, if needed

Module 5 - Acute Care

12. Postoperative care
13. Acute pain management
14. Chronic pain management
15. Management of fluid in the hospitalized patient
16. Management of electrolyte imbalances

12. Postoperative Care: At the end of the Learning Unit, Fellows should be able to:
 Devise a postoperative care plan including monitoring of vitals, pain management, fluid
management, medications, and laboratory investigations
 Handover patients properly to appropriate facilities
 Demonstrate knowledge of the process of postoperative recovery in a patient
 Identify common postoperative complications
 Monitor patients for possible postoperative complications
 Institute immediate management for postoperative complications

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 LEARNING OPPORTUNITIES 

13. Acute pain management: At the end of the Learning Unit, Fellows should be able to:
 Demonstrate knowledge of the physiological basis of pain perception
 Proactively identify patients who might be in acute pain
 Assess patients with acute pain
 Apply various pharmacological and non-pharmacological modalities available for acute
pain management
 Provide adequate pain relief for uncomplicated patients with acute pain
 Identify and refer patients with acute pain who can benefit from specialized pain
services

14. Chronic pain management: At the end of the Learning Unit, Fellows should be able to:
 Demonstrate a knowledge of the biopsychosocial and physiological basis of chronic
pain perception
 Discuss various pharmacological and non-pharmacological options available for chronic
pain management
 Provide adequate pain relief for uncomplicated patients with chronic pain
 Identify and refer patients with chronic pain who can benefit from specialized pain
services

15. Management of Fluid in Hospitalized Patients: At the end of the Learning Unit, you
should be able to:
a) Review physiological basis of water balance in the body
b) Assess a patient for his/her hydration status
c) Recognize a patient with over and under hydration
d) Order fluid therapy (oral as well as intravenous) for a hospitalized patient
e) Monitor fluid status and response to therapy through history, physical examination and
selected laboratory investigations

16. Management of Acid-Base Electrolyte Imbalances: At the end of the Learning Unit, you
should be able to:
a) Review physiological basis of electrolyte and acid-base balance in the body
b) Identify diseases and conditions that are likely to cause or associated with acid/base
and electrolyte imbalances
c) Correct electrolyte and acid-base imbalances
d) Perform careful calculations, checks, and other safety measures while correcting acid-
base and electrolyte imbalances
e) Monitor response to therapy through history, physical examination and selected
laboratory investigations

Module 7 - Ethics and Healthcare

21. Occupational hazards of health care workers.
23. Patient advocacy
24. Ethical issues: transplantation/organ harvesting and withdrawal of care
25. Ethical issues: treatment refusal and patient autonomy
26. Role of doctors in death and dying

21. Occupation hazards of health care workers (HCWs): At the end of the Learning Unit,
Fellows should be able to:
 Recognize common sources and risk factors of occupational hazards among HCWs
 Describe common occupational hazards in the workplace

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 Develop familiarity with legal and regulatory frameworks governing occupational

hazards among HCWs
 Develop a proactive attitude towards promoting workplace safety
 Protect themselves and colleagues against potential occupational hazards in the
workplace

23. Patient advocacy: At the end of the Learning Unit, Fellows should be able to:
 Define patient advocacy
 Recognize patient advocacy as a core value governing medical practice
 Describe the role of patient advocates in the care of patients
 Demonstrate a positive attitude towards patient advocacy
 Be a patient advocate in conflicting situations
 Demonstrate a knowledge of local and national patient advocacy groups

24. Ethical issues: transplantation/organ harvesting; withdrawal of care: At the end of the
Learning Unit, you should be able to:
a) Apply key ethical and religious principles governing organ transplantation and
withdrawal of care
b) Be familiar with the legal and regulatory guidelines regarding organ transplantation and
withdrawal of care
c) Counsel patients and families in the light of applicable ethical and religious principles
d) Guide patients and families to make informed decision

25. Ethical issues: treatment refusal and patient autonomy: At the end of the Learning
Unit, Fellows should be able to:
 Predict situations where a patient or family is likely to decline the prescribed treatment.
 Describe the concept of a “rational adult” in the context of patient autonomy and
treatment refusal.
 Analyze key ethical, moral, and regulatory dilemmas in treatment refusal.
 Recognize the importance of patient autonomy in the decision-making process.115
 Counsel patients and families who decline medical treatment in light of patient’s best
interests.

26. Role of doctors in death and dying: At the end of the Learning Unit, Fellows should be
able to:
 Recognize the importance of doctors’ roles in the dying process.
 Provide emotional and physical care to a dying patient and his/her family.
 Provide appropriate pain management to a dying patient.
 Identify and refer suitable patients to palliative care services.

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 LEARNING OPPORTUNITIES 

Universal topics Year of training

st
Module 1 - Introduction 1 year
1. Safe drug prescription (F1)
2. Hospital-acquired infections (HAIs)
4. Antibiotic stewardship
5. Blood transfusion
Module 3: Diabetes and Metabolic Disorders
4.Abnormal ECG
nd
Module 2 - Cancer 2 year
8-Management of Oncologic emergency (F2)
Module 4 – Medical and Surgical Emergencies
7. Management of altered level of sensorium
8. Management of hypotension and hypertension
9. Management of upper GI bleeding

Module 5 - Acute Care

12. Postoperative care
13. Acute pain management
14. Chronic pain management
15.Management of fluid in the hospitalized patient
16.Management of electrolyte imbalances
rd
Module 7 - Ethics and Healthcare 3 year
21. Occupational hazards of health care workers. (F3)
23. Patient advocacy
24. Ethical issues: transplantation/organ harvesting and withdrawal of
care
25. Ethical issues: treatment refusal and patient autonomy
26. Role of doctors in death and dying

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 LEARNING OPPORTUNITIES 

Core Speciality Topics: Case Discussions; Interactive Lectures

Topics Learning outcomes
Fundamentals of Gas Exchange and 1-Apply the alveolar gas equation
Assessment of Oxygenation and Ventilation 2-Define and quantify dead space (alveolar
and anatomic)
3-Understand the distribution of ventilation
and pulmonary blood flow and their coupling
4-Describe and calculate alveolar/arterial
oxygen gradient
5-Understand the hemoglobin/oxygen
dissociation curve and carbon dioxide
transport
6-Describe the mechanics of, uses, and
limitations of pulse oximetry, end tidal
carbon dioxide monitoring and
transcutaneous oxygen and carbon dioxide
measurement
Oxygen Delivery and Oxygen Consumption 1-Calculate oxygen delivery
in Pediatric Critical Care 2-Dicus cardiopulmonary interactions
3-Describe the mechanisms for
measurement of oxygen consumption
4-Discuss the use of and limitations of the
Fick equation in the evaluation of the
adequacy of oxygen delivery
5-Define the oxygen extraction ratio
6-Recognise the difference between aerobic
and anaerobic metabolism touching
Upper Airway Obstruction 1-Describe the anatomic differences in the
airway of a child as compared to an adult
2-Recognize the signs and symptoms of a
child with upper airway obstruction
3-Recognise the approach to safe diagnostic
evaluation of the infant or child with upper
airway obstruction
4-Recognise the differential diagnosis of a
child with upper airway obstruction
5-Apply the approach to stabilization and
management of the child with upper airway
obstruction
6-Differentiate the indications for
endotracheal intubation and tracheostomy in
a child with upper airway obstruction.
Acute Asthma 1-Review the pathophysiology of status
asthmaticus 2-2-Evaluate the child admitted
to the PICU with status asthmaticus
3-Identify the major therapies for status
asthmaticus:

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 LEARNING OPPORTUNITIES 

Inhaled beta agonists, inhaled

anticholinergic agents, corticosteroids,
magnesium, Helium/Oxygen mixture,
intravenous beta agonists, methylxanthines,
ketamine and inhalational anesthetics, non-
invasive ventilation
4-Review the theoretical and practical
difficulties with mechanical ventilation in
patients with status asthmaticus
5-Discuss the complications that may occur
with status asthmaticus during positive
pressure ventilation
Acute Respiratory Distress 1-Be updated with the most recent
Syndrome(ARDS) consensus on pediatric acute respiratory
distress syndrome
2-Recognize the importance of the integrity
of the alveolar-endothelial barrier
3-Discuss the mechanisms of pulmonary
edema in ARDS
4-Describe the pathophysiology of ARDS
5-Identify how changes in compliance and
functional residual capacity lead to
intrapulmonary shunting and hypoxemia
seen in ARDS.
6-Recognize the distinct temporal pathologic
changes in ARDS necessitating specific
targeted therapies
6-Describe how the “open lung model”
maximizes oxygen exchange while
minimizing ventilator induced lung injury.
7-Discuss the roles of adjunct therapies: for
prone positioning, HFOV, APRV,
corticosteroids, surfactant and nitric oxide in
the treatment of ARDS.
Acute Pulmonary Infections 1-Learn the epidemiology of acute
pulmonary infections that require pediatric
intensive care.
2-Understand the pathophysiology of
bronchiolitis and pneumonia in children.
3-Identify the common etiologies, signs and
symptoms of bronchiolitis
4-Identify the common etiologies, signs and
symptoms of pneumonia
5-Review host defense mechanisms during
acute pulmonary infections
6-Discussthe treatment options, including
modes of ventilation, for bronchiolitis and
pneumonia
7-Apply an effective management strategy
for parapneumonic effusions and empyemas

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 LEARNING OPPORTUNITIES 

Non-conventional Mechanical Ventilation 1-Discuss the indications and

contraindications of noninvasive mechanical
ventilation
2-Discuss the advantages and
disadvantages of noninvasive mechanical
ventilation
3-Describe the indications, advantages, and
disadvantages for use of high frequency
oscillatory ventilation (HFOV)
4-Understand the “open-lung” concept.
5-Describe the mechanics of airway
pressure-release ventilation (APRV)
6-Define the concept, indications, and
limitation of use of Neurally Adjusted
Ventilatory Assistance (NAVA)
Conventional Mechanical Ventilation 1-Describe the differences between negative
and positive pressure ventilation
2-Describe the effects of positive pressure
ventilation on preload and afterload
3-Recognize the effects of the ventilator
circuit on gas exchange and the importance
of humidification
4-Describe the differences between
pressure and volume ventilation
5-Discuss the advantages and
disadvantages of each mode of mechanical
ventilation these choices
6-Discuss the concept of ventilator
triggering, cycling
7-Describe the methods of delivering
assisted breaths
8-Interpret waveforms on the ventilator
9-Dicuss static and dynamic compliance and
their calculations
10-Describe the mechanism of ventilator-
induced
11-Apply protective ventilation strategy
12-Understand the application of permissive
hypercapnia and permissive hypoxemia
13-Discuss weaning and extubation criteria
and strategies
14-Interpret Arterial Blood Gas

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 LEARNING OPPORTUNITIES 

Hemodynamics 1-Discuss the importance of cardiac

histology and anatomy as it relates to the
normal cardiac cycle
2-Relate chemical and cellular events in the
myocardium to the normal cardiac cycle
3-Describe how pathologic states can alter
the normal chemical and cellular events in
the heart.
4-Discuss how chemical and cellular
changes affect the overall function of the
heart and cardiac output.
5-Discuss the components of cardiac output
and the response to low cardiac output
states at different ages.
6-Understand the cardiovascular response
to alterations in intravascular pressure and
volume.
7-Discuss afterload physiology and the
effect of changes in afterload on cardiac
function.
8-Recognize the cardiopulmonary
interactions
9-Recognize how positive and negative
pressure ventilation affect cardiovascular
physiology
Assessment of Cardiovascular Function 1-Describe focused physical examination in
assessing the cardiovascular status of the
critically ill child.
2-Discuss arterial pressure measurements
and waveforms and how they are affected
by various disease states.
3-Understand central venous pressure
measurements and waveforms and how
they are affected by various disease states.
4-Understand what is meant by the
assessment of “functional hemodynamics”.
5-Describe invasive and non-invasive
techniques for estimation of cardiac output
in critically ill children.
6-Identify and describe biochemical markers
of cardiovascular function: mixed venous,
central venous saturations, lactate and brain
natriuretic peptide measurements

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The Inflammatory Response 1-Discuss the mechanism of the

inflammatory response
2-Describe innate and adaptive immunity
and the role of the cellular elements
involved in inflammation
3-Learn about key proinflammatory and
antiinflammatory 4-Discuss the roles of Toll-
like receptors and NFkappaB on the
regulation of cytokine production
5-Describe the role of humoral factors in
inflammation
6-Identify and describe the major
modulatory factors on inflammation
7-Recognize how the genetic makeup of the
host may alter the inflammatory response
8-Describe possible therapeutic strategies to
control the inflammatory response
9-Describe the concept of immunoparalysis
during critical illness
Sepsis 1-Discuss the epidemiology of sepsis
2-Discuss the inflammatory cascade
3-Discuss the cellular responses to systemic
infection
4-Recognize the clinical signs and
symptoms that result from generalized and
organ specific inflammation and injury
5-Recognize the role of appropriate empiric
antibiotic coverage, adequate fluid
resuscitation and pharmacologic
hemodynamic support
6-Discuss the treatment of sepsis
7-Appreciate the role of genetic regulation
immunologic and physiologic responses
Health Care Associated Infections 1-Describe the epidemiology, risk factors,
potential sources of nosocomial infections in
the PICU
2- Describe the specific identification,
treatment and outcomes of nosocomial
infections: blood stream Infection, ventilator
associated infection, urinary tract infection,
infections in surgical patients
3-Identify of the general principles of
infection control measures in the PICU
4-Apply the infection bundles

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Circulatory Failure/Shock 1-Define shock

2-Describe the pathophysiologic changes
that occur with the different classifications of
shock
3-Understand the molecules that mediate
the changes in the cardiovascular system in
shock
4-Recognize the role of cardiovascular
monitoring in circulatory failure
5-Apply goal-directed therapies (including
use of lactate levels and venous saturations)
to improve outcome in children with
circulatory failure
6-Define and understand the
pathophysiology of multiple organ
dysfunction syndrome
Multiple Organ Dysfunction Syndrome 1-Discuss the presentation and course of
multiple organ dysfunction syndrome
2-Discuss outcomes, and the criteria used to
predict them, in multiple system organ
failure
3-Discuss the cellular mechanisms that lead
to multiple organ dysfunction syndrome
4-Plan a course of therapy in a patient with
multiple organ dysfunction syndrome.
Drugs in Hemodynamic Instability 1-Review the anatomy and physiology of the
autonomic nervous system
2-Describe the various adrenergic receptors,
their agonists and specific relationships with
G proteins.
3-Describe the mechanism of action, clinical
uses, metabolism and potential adverse
effects of: Norepinephrine, Epinephrine,
Dopamine, Dobutamine, Isoproterenol ,
Vasopressin, and Milrinone
4-Keep updated with the current
recommendations for use of cardiovascular
agents in shock
Disorders of Cardiac Rhythm 1-Understand the physiology of the cardiac
action potential
2-Discuss the mechanism of action of
antiarrhythmic medications
3-Discuss the various mechanisms that
generate tachyarrhythmias
4-Identify and treat common pediatric
tachyarrhythmias
5-Describe the causes and treatment of
bradycardia
6-Learn basic pacemaker functionality

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Post-operative Cardiac Care 1-Understand the techniques for and

pathophysiology of cardiopulmonary bypass
and oxygenation and carbon dioxide
removal
2-Describe the complications and therapies
used in the post-operative care of patients
3-Discuss the roles of temporary
pacemakers
4-Discuss the principles of respiratory
support after cardiac surgery
5-Describe the post-operative care problems
after total repair of acyanotic disease
6-Describe the post-operative care problems
after total repair or palliative surgery of a
cyanotic lesion
Assessment of Neurologic Function 1-Perform a detailed neurologic assessment
2-Differentiate upper motor neuron
pathology from lower motor neuron
pathology.
3-Recognize the utility and limitations of the
Glasgow coma scale.
4-Appreciate dermatomal distribution of
peripheral nerves.
5-Recognise in herniation syndromes
6-Describe spinal syndromes
7-Describe the components of a brain death
examination.
8-Describe the technique, clinical
applications and limitations of intracranial
pressure monitoring in the child with
intracranial hypertension.
9-Discuss the differences between
intracranial monitoring devices.
10-Discuss indications, contraindications
and analysis of cerebrospinal fluid and
opening pressure measurement.
11-Review the indications for the use of
electroencephalography and evoked
potentials in the neurologically compromised
child.
11-Review indications and limitations of
neuroimaging techniques.

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Cerebral Resuscitation and Traumatic Brain 1-Recognizes the difference between

Injury primary and secondary brain injury
2-Understand the pathophysiology of global
cerebral ischemia and reperfusion
3-Describe the modalities and indications for
clinical monitoring in brain injured patients
4-Discuss the outcome of a patient with
hypoxic ischemic encephalopathy
5-Describe the care of a patient with hypoxic
ischemic encephalopathy
6-Describe the initial evaluation of a patient
with closed head injury: presumptive neck
injury, Glasgow Coma Scale Score,
assessment for other injuries
7-Discuss the management of severe head
injury including respiratory, hematologic and
nutritional issues
8-Discuss the outcome of moderate and
severe head injury in the pediatric patient
Neurologic Disease in PICU 1-Discuss the differential diagnosis of coma
2-Develop a management plan for
investigation and treatment of coma
3-Discuss the differential diagnosis of
neuromuscular weakness in an infant
4-Discuss acquired disorders of
neuromuscular weakness in older children
5-Describe the typical presentation,
diagnostic evaluation, and treatment of
Guillain-Barre Syndrome
6-Discuss the causes, treatment, and
outcome of status epilepticus in the pediatric
patient
7-Recognise the epidemiology, presentation,
diagnosis, treatment, and outcomes of CNS
Infections in children
8-Understand the pathophysiology,
neuroimaging
findings, and potential triggers for posterior
reversible encephalopathy syndrome
9-Review the most commonly used
guidelines for determining brain death in the
pediatric patient
10-Discuss the role of ancillary testing
(cerebral angiography, nuclear medicine
flow scans, electroencephalography, evoked
responses) in determining brain death in
children

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Overview, Structure and Function of the 1-Understand the structure and function of
Nephron the nephron; know the roles of the
glomerulus, proximal tubule, loop of Henle,
distal tubule and collecting ducts on urine
formation and composition
2-Understand the basis for the concentration
of urine (counter-current)
3-Discuss the regulation of renal blood flow
4-Discuss the role of the kidney in the
maintenance of circulating blood volume
5-Understand the roles of the
renin/angiotensin system, Atrial Naturetic
Factor, and ADH in maintaining circulating
blood volume and electrolyte (sodium)
homeostasis
6-Discuss the renal role in acid–base
homeostasis
7-Discuss the age related changes in normal
renal function and biochemical markers of
renal function
8-Define the actions of commonly used
diuretics on the renal “unit”
Fluid/Electrolyte/Acid–Base Abnormalities 1-Describe the major causes of dehydration
2-Apply the principles of rehydration therapy
3-Classify the causes and treatment of hypo
and hypernatremia
4-Describe the pathophysiology, diagnosis
and treatment of diabetes insipidus
5-Describe the pathophysiology, diagnosis
and treatment of Syndrome of Inappropriate
Anti Diuretic Hormone secretion
6-Describe the pathophysiology, diagnosis
and treatment cerebral salt wasting
7-Describe the causes, symptom,
electrocardiographic changes and treatment
of hypocalcemia
8-Discuss the cause, clinical manifestations,
electrocardiographic changes and treatment
of hypo and hyperkalemia
9-Discuss the cause, clinical manifestations,
and treatment of hypo and
hypermagnesemia
10-Describe the symptoms and the
treatment of high and low serum phosphorus
11-Describe the pathophysiologic effects
caused by metabolic acidosis
12-Describe the clinical conditions
associated with high anion gap and their
management

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13-Describe the pathophysiologic effects

caused by metabolic alkalosis
14-Identify the major causes of acute and
chronic metabolic alkalosis
15-Describe the general treatment of
metabolic alkalosis
Acute Kidney Injury 1-Discuss the interpretation and limitations
of serum creatinine levels as an indicator of
renal function
2-Describe the major causes and etiology of
acute kidney injury
3-Distinguish between pre-renal, intrinsic,
and post-renal causes of acute kidney injury
using appropriate laboratory tests and
imaging studies
4-Describe the major manifestations of
acute kidney injury
5-Discuss the management of acute kidney
injury and the controversies surrounding
some of the traditional interventions in acute
kidney injury, such as diuretics and low-
dose dopamine infusion
6-Discuss the indications for renal
replacement therapy
7-Discuss interventions that may prevent or
modify the course of acute kidney injury
8-Discuss the effect of acute kidney injury
on the choice and dosing of drugs
9-Discuss the prognosis of children with
acute kidney injury.
Renal Replacement Therapies 1-Discuss the importance of renal
replacement therapy in the care of critically
ill children with acute renal failure.
2-Discuss the mechanisms of peritoneal
dialysis, hemodialysis, and continuous renal
replacement therapy
3-Discuss the indications, advantages, and
complications of peritoneal dialysis
4-Discuss the indications, advantages, and
complications of hemodialysis
5-Discuss the indications, advantages, and
complications of continuous renal
replacement therapy

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Acute Liver Injury and Failure in Children 1-Learn the varied etiologies of acute liver
injury and failure in children
2-Formulate an initial management plan for
the child with acute liver injury and failure
3-Initiate an appropriate diagnostic workup
for acute liver failure
4-Plan the transport of children with
progressive liver dysfunction to transplant
centres in a timely manner prior to clinical
deterioration
5-Recognize, prevent, and treat
complications of acute liver failure
6-Identify the prognostic indicators in acute
liver injury.
Hematology and Oncology in Critical Illness 1-Understand the pathophysiology, the
causes, and the hemodynamic
consequences of severe anemia in critically
ill children
2-Categorize anemia according to the
underlying pathophysiology, whether
decreased production versus increased
destruction or loss and their red blood cell
indices
3-Understand the pathophysiologic basis of
disseminated intravascular coagulation
(DIC) and detail the common precipitating
causes of this condition
4-Discuss the differential diagnosis of
thrombocytopenia in the critically
5-Discuss the factors and conditions
associated with an increased risk of
thromboembolism in children
6-Describe the pathophysiology, clinical
presentation, an complications of sickle cell
disease
7-Describe the pathophysiology and
management of acute chest syndrome in
sickle cell disease
8-Describe the pathophysiology and
management of stroke in sickle cell disease
Use of Blood Products 1-Recognize the indications for transfusion
of various blood products
2-Recognize the indications for irradiated,
filtered, and/or leukoreduced blood products
3-Define the types of transfusion reactions
and their treatment
4-Recognize the adverse effects of massive
blood transfusion
5-Discuss the pathophysiology of
Transfusion Associated Lung Injury

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Critical Care Endocrinology 1-Recognize the signs and symptoms of

endocrine and metabolic disturbances
2-Discuss the important mechanisms in
maintaining glucose homeostasis
3-Identify the common causes of
hypoglycemia in infants and children
4-Assess and manage hypoglycaemia
5-Discuss the pathophysiology, clinical
symptomatology, monitoring, and
management of diabetic ketoacidosis
6-Discus the pathophysiology, causes,
laboratory monitoring, and management of
adrenal insufficiency in a critically ill child
7-Discuss the biochemical and
pathophysiological differences between
thyroidal and non-thyroidal illnesses
8-Identify the causes and treatment of
disorders of calcium homeostasis
9-Recognize disturbances of osmoregulation
encountered with tumors of the central
nervous system both pre and
postoperatively
Metabolic Crises 1-Review the physiologic basis and patterns
of inborn errors of metabolism
2-Review the most common clinical and
biochemical presentations of children with
metabolic diseases
3-Identify the screening laboratory tests to
help guide the further diagnostic work up of
a child with suspected metabolic disease
4-Recognize potential pitfalls when
analyzing the results of metabolic testing
5-Outline initial treatment strategies for
managing a child during a metabolic crisis.
Trauma/Burn 1-Apply the ATLS approach to evaluation
and initial treatment of the injured child
2-Evaluate and clear the axial skeleton in an
injured child
3-Know the current treatment of common
thoracic, abdominal and orthopedic injuries
in children
4-Apply the comprehensive management of
burn

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Toxicology for the Pediatric Intensivist 1-Understand the epidemiology of pediatric

poisonings
2-Appreciate unique pediatric considerations
when approaching the poisoned child
3-Identify the important points in the history,
physical examination and laboratory
evaluation of the poisoned child; including
the recognition of a “toxidrome”
4-Describe the limits and benefits of
toxicological drug screening
5-Identify key management strategies in
treating the poisoned child
6-Review toxic ingestions of particular
importance to the pediatric intensivist
The Approach to the Critically Ill Infant 1-Appreciate the unique physiologic state of
transition that occurs in the neonatal period
2-Describe key anatomic and physiologic
differences between the small infant and
older child and how they may affect critical
care management
3-Describe the rapid cardiopulmonary
assessment and stabilization of the infant
4-Develop a quick differential diagnosis to
allow the timely initiation of specific
therapies
5-Develop an initial laboratory and imaging
assessment in critically ill infants
6-Recognize the pathophysiology, clinical
presentation, and therapy of diseases that
may present in neonates and infants:
neonatal sepsis, congenital heart disease,
abusive head trauma in infancy, inborn
errors of metabolism, infantile botulism,
hemorrhagic shock and encephalopathy
syndrome
Sedation and Analgesia 1-Emphasize the psychological and
physiologic necessity of providing sedation
and analgesia in the PICU
3-Review the pharmacology, physiology and
rationale for use of the major sedative
agents in the PICU
4-Review the pharmacology, physiology and
rationale for use of the major narcotic
agents in the PICU
5-Discuss the risk factors and treatment for
the development of opioid and
benzodiazepine dependence and withdrawal
in the PICU.
6-Apply different scores for sedation and
pain.

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Neuromuscular Blockade 1-Identify the indications for and

pharmacology of neuromuscular blockade in
PICU
2-Discuss the physiology of the
neuromuscular junction and how it is
affected by neuromuscular blockade
3-Describe the various neuromuscular
blocking agents used in the PICU including
their pharmacokinetics, pharmacodynamics,
and adverse effects.
4-Discuss the interactions and adverse
effects of neuromuscular blockade including
ICU myopathy.
5-Understand the monitoring of
neuromuscular blockade
6-Know the agents used for the reversal of
neuromuscular blockade
7-Recognize the importance of providing
sedation and analgesia to paralyzed patients
Nutrition in Critical Illness 1-Identify the nutritional requirements of
healthy children and critically ill children
2-Calculate caloric and protein needs in
PICU
3-Make appropriate choices for the provision
of nutritional support to patients based on
their disease state and clinical status.
4-Discuss the principles of nutritional
support for patients with specific disease
states
5-Recognise the importance of enteral
nutrition and its early use
6-Identify the indications and side effects of
parenteral nutrition

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Core Speciality Topics: Workshops/Simulation

Pediatric Advanced Life Support course Mandatory upon starting fellowship
Pediatric Advanced Life Support Instructor The fellow should develop as an instructor
course Recommended for F2 AND F3
Pediatric Fundamental critical care Support Mandatory
course (PFCCS)
Mechanical ventilation course Mandatory
PICU Ultrasound applications course Mandatory
Difficult airway management course Mandatory
Research Methodology course Mandatory
Evidence-based medicine course Mandatory

Trainee Selected Topics

Trainee will be given choice to develop a list of topics on their own. All these topics must be
planned and need to be approved by the local education committee. Institution might work with
trainees to determine the topics as well.

Examples of Trainee Topic

1- Advanced Communication skills
2- Medical ethics
3- Research ethics
4- Formulating a proposal
5- Writing scientific papers
6- Authentic Leadership skills
7- Administrative skills
8- Palliative care
9- Family counselling
10- Coping strategies
11- Presentation skills
12- Passing the MCQs
13- What is after the fellowships
14- Career path

Examples of Weekly Educational Activities

Sunday Monday Tuesday Wednesday Thursday
8 am-9 am Morning Morning Morning Trainee topic Morning
report report report Presentation report
st
1pm-3 pm Core topics 1 : JC Grand
nd
2 : M&M Round
rd
3 :
Research
activity

JC: Journal Club

M&M: Mortality and Morbidity review

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Schedules of Rotations
Three-year hospital based clinical and research Program:

First Year Second Year Third Year

Rotations
Pediatric Intensive 8 months 7 months 3 months
Care
Pediatric Cardiac 1 2 1
Intensive Care
Anesthesia 1
Elective 1
ICU related
Elective 1 1
Research 1 6
Vacation 1 1 1
Total 12 months 12 months 12 months

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ASSESSMENT OF TRAINEES

A. Purpose
Assessment plays a vital role in the success of postgraduate training. Assessment will guide
trainees and trainers to achieve the targeted learning objectives. On the other hand, reliable
and valid assessment will provide excellent means for training improvement as it will inform the
following aspects: curriculum development, teaching methods, and quality of learning
environment. Assessment can serve the following purposes:
a. Assessment for learning: As trainers will use information from trainees’ performance to
inform their learning for improvement.
b. Assessment as learning: As assessment criteria will drive trainees’ learning.
c. Assessment of learning: As assessment outcomes will represent a quality metrics that can
improve learning experience.

Ideally assessment should be aligned with learning objectives (that was explicitly described
early) which can be summarized as the following:
I- Knowledge and Academic Activity
1. Basic sciences knowledge
2. Clinical Knowledge
3. Current Literature
4. Participation in Scientific Activities
5. Research

II- Clinical and Technical Skills

1. Organisation of Work
2. Records and Reports
3. Interpretation and Utilisation of Information
4. Clinical Judgement and Decision Making
5. Indications of Procedures
6. Procedures and Operative Skills
7. Performance in Emergencies
8. Supervision and Consultation

III- Attitudes and Ethics

1. Discipline and Reliability
2. Patient Relations
3. Inter-professional Relations
4. Ethical Standards

For the sake of organization, assessment will be further classified into two main categories:
Formative and Summative

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Formative Assessment
Trainees, as an adult learner, should strive for feedback throughout their journey of competency
from “novice” to “mastery” levels. Formative assessment (also referred to as continuous
assessment) is the component of assessment that is distributed throughout the academic year
aiming primarily to provide trainees with effective feedback. Input from the overall formative
assessment tools will be utilized at the end of the year to make the decision of promoting each
individual trainee from current-to-subsequent training level. Formative assessment will be
defined based on the scientific committee recommendations (usually updated and announced
for each individual program at the start of the academic year). According to the executive policy
on continuous assessment (available online: www.scfhs.org), formative assessment will have
the following features:
a. Multisource: minimum four tools and should be continuous in nature, judgment should be
based on holistic profiling of a trainee rather than individual traits or instruments.
b. Comprehensive: covering all learning domains (knowledge, skills, and attitude).
c. Relevant: focusing on workplace-based observations.
d. Competency-milestone oriented: reflecting trainee’s expected competencies that matches
trainee’s developmental level (please refer to “Continuum of Learning” mentioned earlier in
this curriculum).

Trainees should play an active role seeking feedback during their training. On the other hand,
trainers are expected to provide timely and formative assessment. SCFHS will provide an
e-portfolio system (currently One45) to enhance communication and analysis of data arising
from formative assessment.

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Tools and Criteria for Formative Assessment

Domains Knowledge Skills Behavior
Specific SOE Multidisciplinary Promotion Log Book Research ITER
Academic Critical Care Exam
Tasks Knowledge
Assessment
program
(MCCKAP)
F1 to F2 √ Requirement √ √ √
F2 to F3 √ Requirement √ √ Approved √
proposal
F3 Requirement Requirement Completed √
completion report with
of training results

1. In Training Evaluation Rotation (ITER)

To fulfil the CanMEDS competencies based on the end of rotation evaluation, the fellow’s
performance (F1, F2, and F3) will be evaluated by the PICU consultants for the following
competencies:
1. Performance of the trainee during daily work
2. Performance and participation in academic activities
3. Performance in a 10–20 minute direct observation assessment of trainee-patient
interactions
4. Trainers are encouraged to perform at least one assessment per clinical rotation,
preferably near the end of the rotation
5. Trainers should provide timely and specific feedback to the trainee after each assessment
of a trainee-patient encounter
6. Performance of diagnostic and therapeutic procedural skills by the trainee. Timely and
specific feedback for the trainee after each procedure is mandatory
7. The CanMEDS-based competencies end of rotation evaluation form must be completed
within two weeks following the end of each rotation (preferably in an electronic format) by
at least two consultants.
8. The fellow’s in-training evaluation should be signed by the program director who will
discuss it with the fellow.
9. The fellow should sign the evaluation form.
10. The evaluation form will be submitted to the PICU fellowship committee at the SCFHS
within four weeks following the end of the rotation.

2. Multidisciplinary Critical Care Knowledge Assessment program (MCCKAP)

The Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP) online
examination assesses critical care fellowship programs. The annual MCCKAP examination
helps program directors:
a. Prepare fellows for the subspecialty board examinations in critical care
b. Identify specific areas of strength and weakness for each fellow with lists of references and
key terms for missed questions
c. Assess results for each individual fellow and the overall program as well as the institution’s
national ranking
d. F 1,2,3 should sit for the exam to be promoted to the next level

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3. Structured Oral Assessment (SOE)

a. A performance assessment method using case scenarios with PICU consultants
questioning a candidate in a structured and standardized manner.
b. This exam format assesses the “know how” of clinical decision-making and the
application or use of medical knowledge with realistic patient scenarios.
c. F1 and F 2 have to sit for the exam
d. It will be considered as a midyear assessment.

F1, F2 Blue print for PICU Structured Oral Exam

Domain for Patient Pathophysiology Communication and
integrated clinical management professional
encounter behavior
Central nervous √
system
Respiratory system √ √
Cardiovascular √
system
Infectious and √ √
hematology system
Psychosocial √
aspects

4. Log Book
1. The logbook will be electronically filled and monitored for the performance of the
procedures for F1, F2.
2. Trainee and faculty must meet together to review portfolio and logbook once every two
months and at the end of a given rotation.
3. The purposes of the logbook are to:
a. Monitor trainees’ performance on a continual basis
b. Maintain a record of procedures and technical intervention performed
c. Enable the trainee and supervisor to determine the learning gaps
d. Provide a basis of feedback to the trainee

5. End of year written Promotion Exam

a. End of year examination will be limited to F1and F2.
b. The number of exam items, eligibility, and passing score will be the responsibility of the
PICU scientific committee
c. The fellow who fails the yearly evaluation will not be allowed to sit the written exam

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F1, F2 End of Year Written Promotion Exam

Blue Print

Sections – Acute MCQs Domain 1 Domain 2 Domain 3 Domain 4

numbers
Subsection : for each Pathophysiology Investigation Management outcome
subsection & Etiology & Diagnosis

Cardiovascular 12

Respiratory 12

Neurology/ 10
Neuromuscular

Infectious Diseases/ 11
Immunology/
inflammation

Renal and Electrolyte 6

Metabolism / 4
Endocrinology

Hematology/Oncology 4

Gastroenterology 6
/Nutrition

Poisoning/ 4
toxin/overdose

Trauma/ Burn 5

pharmacology 6

Anesthesia/ 4
postoperative care

Procedures/ 5
Monitoring/ special
critical care issues

Quality/safety 5

Ethics/research 6

TOTAL 100

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6. Research
a. The second year fellow should submit an IRB approved proposal to be promoted
b. The third year fellow cannot sit for theSaudi PICU fellowship Board Certifying Exam unless
the following criteria are fulfilled:
1. A completed research with an IRB approval, or a research study published, accepted
for publication, or presented at a national or international meeting, or an abstract/poster
published or presented at a national or international meeting
2. A letter of recommendation from the program director testifying active involvement of
the fellows in research

7. Specific Academic Tasks

a. The third year fellow should do an oral presentation in a conference or during the fellow
day. This is a mandatory task
b. The third year fellow should choose one optional activity of the following:
1. To lead PICU quality improvement project, or
2. To Be a qualified Instructor in PFCCS or PALS course

- Criteria for promotion

a. Scoring a minimum of borderline pass (BP) in all formative assessment tools will allow the
fellow to be promoted to the next level.
b. In case the fellow scored borderline failure (BF) in one of the assessment tools he/she can
be considered for promotion to the next training level provided that he/she compensated
that by scoring clear pass (CP) in at least another assessment tool after getting the
required recommendations from program director and the approval of the supervisory
committee (in accordance with the executive policy).
c. Scoring clear failure (CF) in one assessment tool will not allow the fellow to be promoted to
the next level.
d. Scoring borderline failure in more than one assessment tool will not allow the fellow to be
promoted to the next level.

Clear Failure Borderline Borderline Pass Clear Pass

Failure >70%
ITER <50% 50-59.4% 60-69.4% >70%
SOE <50% 50-59.4% 60-69.4% >70%
Not sitting
for exam
Log Book <50% 50-59.4% 60-69.4% >70%
MCCKAP Not sitting Sitting for exam
for exam
Promotion <50% 50-59.4% 60-69.4% >70%
exam
Specific None Completed Completed only Completed the
Academic only one of the mandatory mandatory task
Task the optional task (Oral (Oral presentation)
tasks presentation) plus one of the
optional tasks

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Research F2 No proposal Incomplete Submitted IRB approved

proposal proposal to IRB proposal
Research F3 Incomplete Incomplete Initial report with Completed report
report report full results ready to submit
No results Partial
results

C-Summative Evaluation
The fellow should pass the final written exam and final OSCE to be certified in the specialty.

In order to be eligible to set for final specialty examinations, each trainee is required to obtain
“Certification of Training-Completion”. Based on the training bylaws and executive policy
(please refer to www.scfhs.org) trainees will be granted “Certification of Training Completion”
once the following criteria is fulfilled:
a. Successful completion of all training rotations.
b. Completion of training requirements as outlined by scientific committee of specialty
(e.g. logbook, research, others).
c. Clearance from SCFHS training affairs, that ensure compliance with tuitions payment and
completion of universal topics. “Certification of Training-Completion” will be issued and
approved by the supervisory committee or its equivalent according to SCFHS policies.

1-Saudi PICU fellowship Final Written Board Certifying Exam

a. This examination assesses the theoretical knowledge base (including recent advances)
and problem-solving capabilities of candidates in the specialty of
b. It is delivered in an MCQ format and held at the end of the training.
c. The number of exam items, eligibility, and passing score will be in accordance with the
Commission’s training and examination rules and regulations
d. The fellow must pass the written exam to sit for the final OSCE

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F3 Final Written Exam Blueprint Template for PICU

Sections – Acute MCQs Domain 1 Domain 2 Domain 3 Domain 4
Subsection : numbers Pathophysiology Investigation Management outcome
for each & Etiology & Diagnosis
subsection
Cardiovascular 14
Respiratory 14
Neurology/ 10
Neuromuscular
Infectious Diseases/ 11
Immunology/
inflammation
Renal and 6
Electrolyte
Metabolism / 3
Endocrinology
Hematology/ 4
Oncology
Gastroenterology 5
/Nutrition
Poisoning/ 4
toxin/overdose
Trauma/ Burn 5
pharmacology 5
Anesthesia/ 4
postoperative care
Procedures/ 5
Monitoring/ special
critical care issues
Research and 10
Ethics
TOTAL 100

2-Objective Structured Clinical Examination (OSCE)

a. A standardized way of assessing clinical competencies.
b. It provides a mean to assess:
1. The “shows how” of physical examination and history taking skills.
2. The communication skills with patients and family members.
3. The breadth and depth of knowledge and cognitive skills.
4. The ability to summarize and document findings.
5. The ability to make a differential diagnosis and treatment plan.

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F3 Blue print for PICU Final OSCE exam

Domain for Patient Procedure and Communication # station
integrated clinical management technical skills and professional
encounter behavior
Central nervous 1 1
system
Respiratory 1 1 2
system
Cardiovascular 1 1 2
system
Infectious and 1 1
hematology
system
Psychosocial 2 2
aspects
Total station 4 2 2 8

Trainee Support
1-Each trainee must have an assigned supervisor
2-A clinical supervisor must not have more than 3 trainees in any given point of time
3-Assigned supervisor must follow the trainee for at least one year

Mentorship
Post-graduate residency training is a formal academic program for residents to develop their full
potentials as future specialists. This is potentially the last substantial training program before
they become an independent specialist. However, unlike the undergraduate program with well-
defined structure, residency training is inherently less organized. Residents are expected to be
in the clinical settings delivering patient care. They are rotated through multiple sites and sub-
specialties.

Goals
1. Guide residents towards personal and professional development through continuous
monitoring of progress
2. Early identification of struggling residents as well as high achievers
3. Early detection of residents who are at risk of emotional and psychological disturbances
4. Provide career guidance

Roles of the Mentor

1. The primary role of the mentor is to nurture a long-term professional relationship with the
assigned residents.
2. Mentor is expected to provide an ‘academic home’ for the residents so that they can feel
comfortable in sharing their experiences, express their concerns, and clarify issues in a
non-threatening environment.
3. Mentor is expected to keep sensitive information about the residents in confidence.
4. Mentor is also expected to make appropriate and early referral to Program Director or
Head of the Department if s/he determines a problem that would require expertise or
resources that is beyond his/her capacity.

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5. Example of such referral might include

a. Serious academic problems
b. Progressive deterioration of academic performance
c. Potential mental or psychological issues
d. Personal problems interfering with academic duties
e. Professional misconduct

6. The following are NOT expected roles of a mentor

a. Provide extra tutorials, lectures, or clinical sessions
b. Provide counselling for serious mental and psychological problems
c. Being involved in residents’ personal matters
d. Provide financial or other material supports

Roles of the Fellow

1. Submits resume at the start of the relationship
2. Provide mentor with short term and long term goals
3. Takes primarily responsibility in maintaining the relationship
4. Schedule monthly meeting with mentor in a timely manner; do not request for ad hoc
meeting except only in emergency
5. Recognize self-learning as an essential element of residency training
6. Report any major events to the mentor in a timely manner

Frequency and duration of Meetings

1. The recommended minimum frequency is once every 4 weeks.
2. Each meeting might take 30 minutes to 1 hour.
3. It is also expected that once assigned, mentor should continue with the same fellow
preferably for the entire duration of the training program

Tasks during the meeting

1. Discuss overall clinical experience of the fellow with particular attention to any concerns
raised
2. Review logbook or portfolio with the fellow to determine whether the fellow is on target of
meeting the training goals
3. Revisit earlier concerns or unresolved issues, if any
4. Explore any non-academic factors seriously interfering with training
5. Document excerpts of the interaction in the logbook

Mandatory reporting to Program Director

1. Consecutive absence from three scheduled meetings without any valid reasons
2. Unprofessional behaviour
3. Consistent underperformance in spite of counselling
4. Serious psychological, emotional or health problems that may potentially cause unsafe
patient care
5. Any other serious concerns by the mentor

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REFERENCES
th
1. Fuhrman, BP, Zimmerman JJ, et al, 2017. Pediatric Critical Care. 5 ED Philadelphia:
Elsevier.
TH
2. Nichols DG, Shaffner DH, 2016. Rogers’ Textbook of Pediatric Intensive Care. 5 ED.
Baltimore: Wolters Kluwer.
st
3. Lucking SE et al, 2012. Pediatric Critical Care Study Guide. 1 ED. Springer

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