Junior Doctor Notes 🩺

Intensive Care Unit

11 min read

Common Conditions and Presentations

Medications to Know

Approach to Ward Round

  • Team member capabilities
    • ensure all team members know where emergency equipment is (e.g. airway and resus trolleys)
    • explicitly discuss how the ward round will run
    • determine the order of patients
      • e.g. unstable patients first, patients ready for discharge/ extubation, new admissions, the other patients
      • if possible coordinate with nursing staff breaks, etc
    • identify team member capabilities and learning needs prior to the ward round to ensure appropriate tasks are allocated and that appropriate teaching opportunities are taken
  • For each patient
    • ask the bedside nurse what issues they are concerned about or need to be addressed (check their ‘to do’ list)
    • review the history (talk to patient and/or family if possible!)
    • review the labs and imaging
    • review documentation
      • ICU chart (observations, infusions, fluid balance, etc)
      • medication chart
      • clinical notes (including letters, notes by visiting teams, and notes by other ICU team members such as dieticians and physiotherapists)
    • perform the physical examination
    • review the checklist
      • e.g. Systems A to I: airway, breathing, circulation, disability, exposure (incl skin, sec survey if trauma, temp), fluid/ renal, GI, Haematology, Infection; lines, labs (and other investigations), meds, micro
      • FAST HUGS IN BED Please
    • document a plan with appropriate targets (e.g. MAP, SpO2, etc), end-points for therapy, and explicit criteria for notification of the medical team
    • highlight learning points / provide teaching to the team
    • communicate the plan verbally and always ask “does anyone have any questions or concerns?” before leaving the patient’s bedside

FAST HUGS IN BED Please

  • Mnemonic to aid in recall the key issues to review when looking after a critically ill patient
    • Fluid therapy and feeding
    • Analgesia, Antiemetics and ADT*
    • Sedation and Spontaneous breathing trial
    • Thromboprophylaxis, Tetanus prophylaxis
    • Head up position (30 degrees) if intubated
    • Ulcer prophylaxis
    • Glucose control
    • Skin/eye care and suctioning
    • Indwelling catheter
    • Nasogastric tube
    • Bowel care
    • Environment (e.g. temperature control, appropriate surroundings in delirium)
    • De-escalation (e.g. end of life issues, treatments no longer needed)
    • Psychosocial support (for patient, family and staff)

Documentation

  • Title & summary
  • Issues list
  • Progress
    • Things that may have happened since the last time you or your day/night team documented a ward round note
  • Examination
    • A/B:
      • Ventilator modes, inhaled agents
    • CVS:
      • Also include any vasoactive agents and the rate they are running at
    • CNS
      • Neurological examination relevant details
      • Also any sedative agents/analgesia infusions or PCA running
      • EVD height and outputs, colour
    • GIT
      • NG/PEGs as well as other drains, diet intake, bowel status
    • GUT
      • Renal stuff (including CRRT)
    • Other
      • Temperature, fevers
    • Lines
      • Current lines and where they are placed
  • Investigations
  • FAST HUGS IN BED Please
  • Plan
    • Try and be systematic about the plan (e.g. A → E)

EXAMPLE

ICU AM WR – Nickson / Pearlman / Blogs 67M day 8 ICU with necrotising gallstone pancreatitis with multi-organ dysfunction.

Issues

  • Necrotising gallstone pancreatitis
  • Type 1 respiratory failure
  • Septic shock
  • Renal failure on CRRT

Progress Night team administered 2 units of red cells, 300mg loading of amiodarone administered for AF now rate controlled

Examination A/B: ETT remains at 23cm at the teeth. SIMV-VC 500×12, FiO2 0.6, PEEP 10 / PS 10. Scant secretions. Good AE Throughout chest, no added sounds CVS: noradrenaline stable at 12mL/h (of 4mg in 50mL) with BP meeting targets of >100 / MAP >65, AF rate controlled between 80-100, amiodarone infusion running. Peripherally warm and well perfused. Dependent peripheral oedema. CNS: E4VTM6, RASS (Richmond Agitation and Sedation Score) 0, comfortable on Prop of 2mL/h, dexmedetomidine at 0.5microgs/kg/min and fentanyl of 10microgs/h. No new focal neurology. PEARL 3mm. GIT: NG feeds Nutrison Protein Plus running at 60mL/h, minimal aspirates, bowels opening daily, abdomen soft and not tender GUT: IDC, oliguria remains with concentrated / cola coloured output ~10-20mL/h. CRRT ongoing, no issues running on CiCa (Citrate-Calcium) circuit, fluid balance close to -ve 2 litres.

Investigations

Plan

  • Wean ventilation across to PSV today if able / tolerates same
  • Send sputum sample
  • If noradrenaline >20mL/h and ongoing AF, commence vasopressin as secondary agent
  • If ongoing AF:
    1. Ensure K+ >4.0 / Mg2+ >1.0 (yes, I know that there is now less evidence for targeting higher potassium targets (extrapolated from cardiac surgery), alas… we persist)
    2. Further 150mg amiodarone over 30mins
    3. if ongoing, to commence amiodarone infusion 900mg/24 hours
  • Aim to wean and cease propofol, and continue dexmedetomidine as primary agent.
  • Aim fluid balance -ve 2500mL today
  • If CRRT circuit clots today, not to restart unless urgent indication
  • If Hb <75, please transfuse unit of red cells
  • Chase sensitivities from sputum and blood cultures, and adjust antibiotics if able
  • Family meeting tomorrow planned for 2pm, need to ensure surgical / medical team + family members + SW coming

Principles

  • DVT prophylaxis
    • All ICU patients should receive DVT prophylaxis unless there is a contraindication1
      • Haemorrahge
      • Thrombocytopenia (platelet count <~30,000 or <~50,000 and falling
      • Planned procedure (e.g. lumbar puncture, IR procedure)
    • GFR >30 ml/min: Generally enoxaparin 40 mg daily
      • Weight <50 kg: use enoxaparin 20 mg daily
      • Weight >120 kg: consider ~0.25 mg/kg q12hr
      • Monitor anti-factor Xa levels for patients with unusual weight, pregnancy or borderline renal function; check four hours after the third dose
    • GFR <30 ml/min: Use heparin 5,000 IU TDS/BD
  • GI prophylaxis
    • As a simple rule of thumb, use GI prophylaxis only for intubated patients
    • Preferred agent is pantoprazole 40 mg PO/IV daily
  • Medications to avoid in ICU
    • NSAIDs (renal failure, bleeding).
    • ACEi/ARBs (avoid unless there is a specific strong indication for them, such as Sympathetic crashing APO or severe systolic heart failure)
    • Fluoroquinolones2
    • Benzodiazepines, zolpidem, diphenhydramine (delirium). (However, for patients on these medications chronically they often must be continued)
      • Should be restricted to use in:
        • Status epilepticus.
        • Ketamine re-emergence, procedural sedation.
        • Patients who are chronically on benzodiazepines as a home medication.
        • Palliative sedation.
        • Occasional cases of complicated alcohol withdrawal
      • Better alternatives:
        • For insomnia: quetiapine, guanfacine.
        • For acute agitation: haloperidol, olanzapine, dexmedetomidine.
        • For sedation: dexmedetomidine, propofol, possibly quetiapine.
    • Tramadol
  • Anaemia
    • Avoid transfusions if hemoglobin is >70
    • Only transfuse one unit at a time (unless hemodynamically unstable, or severe anaemia)
  • Volume Status & Hypotension
    • ICU patients usually retain fluid and develop volume overload.
    • Avoid giving fluid boluses unless the patient is clearly volume depleted.
    • Follow I/O balance daily and avoid progressive volume overload (e.g., with diuresis)
    • LR is generally the fluid of choice in the ICU with the following two exceptions:
      1. Patients with elevated intracranial pressure (normal saline may be preferable).
      2. Patients with metformin-induced lactic acidosis (optimal fluid in this situation is hotly debated, but it’s not LR
  • Hyponatraemia
    • Hypernatraemia should not be tolerated, as it will make patients delirious and miserable (thirsty) (One exception = intracranial pressure elevation)
    • Calculate the amount of free deficit (otherwise we tend to underestimate water requirements)
    • Provide free water in the form of oral water (e.g., via enteral tube) or as D5W intravenously
  • Hypokalaemia
      • Generally target K>3.5 (not >4, this makes your life easier!)
    • Whenever possible use enteral potassium (it’s safer and doesn’t sclerose veins)
    • Be cautious in renal failure
  • Hypocalcaemia
    • Most critically ill patients are hypocalcemic, and the best thing is usually to ignore it.
    • Avoid administration of IV calcium in response to a low calcium level unless the patient is symptomatic or the ionized calcium is extremely low (e.g., perhaps <0.8 mM). IV calcium is primarily useful for massive transfusion protocols or hyperkalemia
    • IV calcium is relatively contraindicated in hyperphosphatemia (risk of calciphylaxis)
  • Trops and Ischaemic evaulation
    • Screen for ischemia with a good history and careful evaluation of the ECG
    • Don’t measure troponin unless there is a legitimate concern for MI based on history and/or ECG and/or echocardiogram.
    • Most critically ill patients will have elevated troponin levels. Checking troponin on every patient will generate false-positive results and lead to iatrogenic harm
  • Sedation
    • Propofol
      • Easily & rapidly titrated.
      • May cause hypotension, but this can be counteracted with an infusion of low-dose norepinephrine (e.g. ~0-8 mcg/min).
      • Use of high propofol doses for prolonged periods of time may cause hypertriglyceridemia and a risk of propofol infusion syndrome. Over extended periods of time, it’s ideal to wean the dose down to <50 mcg/kg/min.
    • Dexmedetomidine
      • The major advantage of dexmedetomidine is that it doesn’t suppress respiration, making it safe to use in a non-intubated patient
        • Therefore, dexmedetomidine may be continued throughout the weaning process (unlike propofol, which must be shut off prior to extubation)
        • This is an excellent option for patients who develop anxiety and tachypnea whenever sedation is lifted, making it difficult to extubate them
      • Dexmedetomidine may cause hypotension due to bradycardia, but this can be counteracted with an infusion of low-dose epinephrine if the use of dexmedetomidine is critical
  • Ventilation
    • etCO2
      • etCO2 will always underestimate blood pCO2, because gas in the trachea dilutes CO2 as it travels from the alveoli to the ventilator.
        • If the etCO2 is >45 mm, then the patient is definitely hypercapneic.
      • The gap between etCO2 and pCO2 depends on how healthy the lungs are:
        • In healthy lungs, this gap is usually <15 mm.
        • In patients with lung disease (e.g., COPD, pneumonia, ARDS, PE, pulmonary contusion) the gap will widen.
      • For most patients, after intubation the respiratory rate should usually be adjusted to achieve an etCO2 of ~30 mm. This should put the pCO2 in a safe range (~35-50 mm).
        • One exception would be in patients with severe metabolic acidosis, in whom the respiratory rate should initially be maximized in efforts to provide a compensatory respiratory alkalosis
    • Titrating NIV settings
      • Cardiogenic pulmonary edema
        • Key here is the expiratory pressure (this increases the mean airway pressure and thereby decreases preload & afterload).
        • Ramp up expiratory pressure until the patient improves (e.g. 10/5 > 15/10 > 18/15), It’s also fine to simply use continuous positive airway pressure (CPAP). In that case, escalate CPAP pressure from 5 > 10 > 15 cm.
      • Hypercapnia (e.g., COPD or obesity hypoventilation syndrome)
        • The key here is driving pressure (inspiratory pressure minus expiratory pressure), which supports the work of breathing.
        • Ramp up the driving pressure until the patient improves (e.g. 10/5 > 15/5 > 18/5)
  • Fevers
    • Causes
      • Infection: (~50% of cases)
        • Pneumonia.
        • C. difficile, Acalculous cholecystitis.
        • Line infection.
        • Surgical site infection.
      • Non-infectious: (~50% of cases)
        • Procedure-related (hemodialysis, bronchoscopy, 1-3 days post-surgery).
        • Drug fever.
        • Febrile transfusion reaction.
        • Sterile inflammation (pancreatitis, aspiration pneumonitis, ARDS).
        • Pulmonary embolism.
        • Alcohol withdrawal.
        • Central fever (intracranial hemorrhage).
    • Workup
      • Physical examination, focusing on:
        • Sites of any intravascular catheter or surgical incision.
        • Abdomen (distension or tenderness)?
        • Sputum quality and volume.
      • Chest radiograph if intubated or symptoms of pneumonia.
      • Blood cultures:
        • At least two sets of cultures from different venipuncture sites, with at least one peripheral culture.
        • Any line in place >48 hours should be cultured.
      • C. difficile testing, if diarrhea.
      • Further testing per clinical judgement (e.g. abdominal CT scan, CT angio for PE).
  • Transferring patients out of ICU (Very Lazy Rabbits Rarely Make Lemonade)
    • Vitals:
      • Evaluate vital signs for any worrisome trends (especially unexplained/worsening tachycardia or tachypnea).
      • Vital signs don’t need to be normal for patients leaving the ICU. However, abnormalities should be adequately investigated and not deteriorating.
    • Labs:
      • Look at the latest labs for any values that require intervention before transfer.
      • Labs most likely to hold up a transfer: potassium, lactate, hemoglobin, and blood gas values.
      • Like vitals, labs don’t need to be normal. However, abnormalities should be appropriately investigated and managed.
    • RN:
      • Discuss with the bedside RN whether there are any barriers to transferring to the floor.
      • RNs know precisely how much care the patient requires and whether they are floor-appropriate.
    • RT:
      • Discuss with the RT whether the respiratory care needs can be met on the floor.
      • (Only necessary for patients with respiratory dysfunction.)
    • Meds:
      • Review the medication list.
      • Remove any ICU-specific medications (e.g., GI prophylaxis).
      • Remove PRN medications that could be misused.
    • Lines:
      • Remove any arterial lines.
      • Remove central lines or HD catheters if possible. If the line must remain, ensure that another service is aware of the line and is responsible for removing it promptly

Footnotes

  1. Patients with cirrhosis and elevated INR are generally not coagulopathic and generally do require DVT prophylaxis ↩

  2. See here PulmCrit - Six reasons to avoid fluoroquinolones in the critically ill ↩

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