ICU

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Before Starting

High Expectations

  • Be prepared. Patients will die during your rotation. More than ever, the patient will depend on your knowledge and skills. This is often the endgame for them, quite literally "life and death." For the patient and family, the ICU may be their last hope. Take ownership of your patients.
  • Arrive early, generally around 6 AM. This is usually the only way to get true sign-out from the night nurse. Everything else will be hearsay from the day nurse. Be ready for rounds with the attending at 8 AM. (Be grateful for this. Rounds often start at 6 or 7 in the morning at major academic centers.)
  • Stay late, if necessary. Sick patients are sick, and sick patients do not care about what time the shift ends when they crash. The patient comes first. Meet the expectations of the profession.
  • Be there. Do not spend significant time away from the unit. You are the ICU resident. Why are you not in the ICU? The attendings frequently abandon ship and entrust the unit to you during long portions of the afternoon. Avoid "hanging out" in the resident's lounge. There is not enough space or computers there anyway, and no one wants you there as a distraction. Examine patients multiple times a day. Show commitment.
  • Absence does not go unnoticed. ICU attendings and nurses have asked numerous times, "Where is the ICU resident?" If you are not in the unit, the perception is that you are not interested, available, or reiliable. The attending or nurse is not necessarily going to track you down. You will miss procedures. More importantly, you will miss critical changes in clinical status.

Recommended Reading

  • The Critical Care section of MKSAP provides an excellent introduction and summary of critical care medicine. This comprises of approximately the last 30 pages before questions.
  • Read the first two chapters of ICU Liberation. This is an excellent evidence-based approach for management of ICU patients. The other chapters have decreased utility as they focus on systems implementation which will generally be out of scope for the learning resident.
  • Marino's The ICU Book and the shorter The Little ICU Book are highly recommended by resident and attending alike.
  • The Ventilator Book by William Owens is a short and easy introduction to mechanical ventilation.

ICU Team

  • ICU relies on a diverse team of players. Get to know these people. Know their names. Let them get to know you.
  • Nurses are the MVP of the rotation. They are extremely well trained and have a wealth of knowledge and experience. They likely know more clinical medicine than you. Respect them. Listen to them. Use them as a resource. Be available as a resource for them. Ask them questions. They will save your butt.
  • Respiratory are like ninjas behind the scenes. They are markedly zen in emergencies. They are essential in monitoring the ventilator. They obtain ABGs, administer nebulizers, perform chest physiotherapy, distribute incentive spirometry, help in BAL, send sputum cultures. For as little as you see them face to face, they do a ton of work. Blink and you will miss them. Know their number by heart.
  • Medications become really complicated really quickly in the ICU. Become close friends with the pharmacists. They do a lot more than dispense medications.
  • Nutrition/dietetics will help to manage all your tube feed needs. They will also help to stave off refeeding syndrome. They know how to officially diagnose severe protein calorie malnutrition. Seriously, they do all the heavy lifting on tube feeds.
  • Palliative care can be an invaluable service in helping to navigate goals of care and potentially redirecting the admission towards hospice or end-of-life care. Often, they will be able to play the role of the "good cop" to your own "bad cop."

Family First

  • Family and loved ones can understandably be quite emotional. Having a loved one in the ICU likely represents a true crisis in their lives. You will not always see people at their best. Remember this. Empathize. Do not take anything personally.
  • Bad things will happen on this rotation. There will be difficult conversations. You may have to deliver bad news. Be prepared to step up and speak with family. Be aware of the current family situation and keep them in the loop with accurate information.
  • Build rapport, but be honest about clinical status and prognosis. Avoid giving false hope. Until you have more clinical experience, exercise restraint in assessments.
  • Often, there will be multiple family members visiting or calling from long distances requesting updates on a patient. Preempt this by designating a spokesperson for the family.
  • If necessary, speak to the charge nurse about enforcing the oft ignored visitation rules.

Systems-Based Assessments

  • ICU allows for systems-based presentations and documentation. Nursing uses this approach (although some much better than others). Major academic centers almost exclusively rely on a systems-based approach. It is an elegant way of making sense of the complex and critically ill patient. It also ensures that nothing essential is missed. Systems-based assessments are highly recommended.

Open ICU

  • BSWRR runs an open ICU, where critical care is a consult service. This is quite the double-edged sword. It is nice to have the input of multiple physicians. It is also quite awful to have the input of multiple physicians. As a consultant, the ICU does not necessarily have final say over the patient. DO NOT RELY ON THIS AS AN EXCUSE. Often, there will be too many cooks in the kitchen, leading to missed orders, missed consults, and missed details. Communicate effectively. Take control of the situation.

Rapids and Codes

  • Understand foremost, that the resident is a vestigial accessory to the code team. The code team does not necessarily need you or any physician to get their job done. In fact, they will probably perform better without you. Codes essentially run themselves. That being said, you absolutely need to be there.
  • Familiarize yourself with ACLS protocols.
  • ICU team is expected to show up to each rapid and code. The resident team should show up to each event. The attending will not respond to every rapid, but will generally be present for each code.
  • Do not let others kick you out of the room until you have assessed whether this patient is now your patient and whether or not you need to call attending.
  • Silent codes are frequently called in the ICU. I.E. the patient is in a code blue situation and a code is being run, but is not called on the overhead PA. The attending may or may not be there. Call for help if necessary.
  • Residents are not currently authorized to do procedures such as intubation unsupervised. Patient can be bagged indefinitely.

Call

  • Under the current system, ICU residents take call every four days. The resident and intern are not scheduled to take call together. The ICU intern will take call with a floor resident, and the ICU resident will take call with a floor intern. Generally, expect 1 weekend call day every other week, or about twice in one month.
  • Call really has nothing to do with the ICU, as you will usually have to admit patients to the floor. There may be rare occasions where you admit a patient that is also an ICU patient.
  • If things get dicey in the unit, the team will have to divide and conquer, with the upper level managing the more critically ill or crashing patient. This has happened on multiple occasions.

Didactics

  • ICU is excused from morning report. You are expected to attend noon conference, quality improvement, and M&M.

ICU Liberation and the ABCDEF Bundle

ICU Liberation

ICU Liberation is an evidence-based collaborative from the Society of Critical Care Medicine, with the express goal of liberating the patient from the devastating effects of "Pain, Agitation, Delirium" (PAD), thereby increasing ventilator free days, decreasing ICU length of stay, and improving overall mortality. The ABCDEF bundle was created as a systematic approach in achieving ICU Liberation. Be familiar with these concepts and the evidence behind it. There is a copy of ICU Liberation in the unit graciously provided for the residents.

ABCDEF Bundle

  • I am not sure who was in charge of making the acronym, but perhaps they were not paid quite enough.
  • ABCDEF stands for:
    • Assess, prevent, and manage pain
    • Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
    • Choice of analgesia and sedation
    • Delirium: assess, prevent, and manage
    • Early mobility and exercise
    • Family engagement and empowerment

Our ICU

  • Our ICU in the past has particularly struggled with "C", as patients were frequently knocked out by default with fentanyl and midazolam, and less commonly, propofol. There has been a successful acceptance of and increase in the use of Precedex, which comes recommended by ICU Liberation. This is a difficult change as precedex is magnitudes more expensive than its alternatives.
  • Our ICU could likely do a better job with "D", especially in formally assessing delirium using CAM and RASS. This places increased expectations on the resident to be familiar with these assessment scales.
  • It could be argued that our ICU does not even try to implement "E". Many hospitals give ICU patients opportunities to get out of bed or even walk about while intubated. Our hospital simply does not have the therapy resources to mobilize our ICU patients to this extent. The physical therapy team is understandably not familiar with or comfortable working with critical care patients in this way. I would conjecture that this is not likely to change unless the hospital develops a larger unit requiring dedicated resources and closed ICU.

Who do I see? AKA Guess Who is ICU?

  • Critical care consultation dramatically increases the costs of an admission for both the individual and the system. Be a mindful and wise steward. Spreading valuable time and resources thin across patients who may not need it, potentially takes away from those who genuinely do. Ask yourself whether the patient truly needs the input of a critical care physician.
  • That being said, determining who you see in the morning is extremely frustrating and takes more time than it should. It will likely be one of your major frustrations with the rotation.

Survey the Board

  • This will generally be the first thing done in the morning. Note or write down any new room numbers written in red marker. These are ICU patients.
  • Note that the board may not be up to date. Some charges are better than others about updating the board.
  • Patients that have a "❤" listed by their room number are CT surgery patients. These will not be your patients.
  • Patients that have a "V" listed by their room number are ventilated patients. These will most likely be your patients.
  • Patients that have neither a "❤" or "V" require further investigation. Ask the charge nurse about these patients.
  • Generally, you will only see patients who are either intubated or require pressor support.
  • Remember, that even the patients you do not see who are admitted to the ICU require an APACHE score.

Check in with the charge nurse

  • This is almost done simultaneously while "surveying the board."
  • The charge nurses will generally start their shift change sign-out anywhere from 600-630 AM. Try to get there early enough to avoid interrupting this. Some of the charge nurses are excessively anal about this and they will get upset if you invade their special time.
  • Obtain the nursing assignment sheet from the charge nurse. This contains all the nursing phone numbers. The day shift sheet may not be ready by the time you arrive.
  • Ask the night charge about any new overnight transfers or admissions. The charge will generally know the basics of the story, the principle problem, why the patient is ICU status and whether the patient is suitable for downgrade.

Patients Admitted as ICU that you will not see

  • Most ❤ related conditions will not need consultation without a pressor or ventilation requirement.
    • Anything CABG related will not need consultation from the resident.
  • Insulin drip is generally not enough to warrant a consultation. These patients are ICU more because of nursing needs such as hourly glucose checks and titration.
    • DKA, HONKH, and pancreatitis will not need consultation without a pressor or ventilation requirement.
  • Non-pressor titrations will not generally need consultation.
    • Hypertensive emergency on a nitro, nicardipine or nitroprusside may need cardiology, but will not likely need critical care without a pressor or ventilation requirement.
    • Precedex is allowed off the unit and without ett up to 0.7 mcg/kg/hr.
  • Stroke s/p TPA is admitted to ICU for 24 hours until repeat of CT head. They do not need consultation without a pressor or ventilation requirement.
  • Thoracentesis or chest tube placement is likely to be a pulmonary consult, not critical care.
  • Sepsis does not require consultation without a pressor or ventilation requirement.
  • Some frustrating caveats:
    • You may actually end up seeing some patients who look "sick as shit."
    • Some attendings will have you see pulmonary consults.
    • "Ventilation requirement" may include patients on NIPPV like CPAP/BiPAP who are tenuous
    • The duration for which you follow an extubated patient is highly provider and patient dependent.

Pre-Rounding

Bedside encounters tend to be shorter in the ICU because patients have limited ability to communicate. If there is no one to talk to, and the patient is sedated, take advantage of this to get in and get out. Take special note of the topics below. For patients who have family disruptive to workflow, examine them first. This can save time if done before the family arrives. Then visit with the family later.

Chart Review and Data Management

  • ICU patients require a lot more information than floor patients. What has worked in the past may not be sufficient for the unit.
  • Use a template, form, rounding sheet, scut sheet, whatever you call it. Do this even even if you have gotten away without doing this on the floor.
  • There are templates shared in Onedrive. Residents also have many personal favorites available.
  • Prioritize recording values directly observed in the room rather than what is recorded in the computer when possible.
  • Lab data may not be available early in the morning. Prioritize laying eyes on the patient in the room before sitting down to record lab data.
  • Pay special attention that you are prepared to interpret any CXR or ABG findings yourself on rounds.

Nurse Report

  • There is no hand-off from an overnight provider for our ICU. Speak to the night nurse directly. Their report is invaluable.
  • If unavailable near bedside, call the number from the nursing assignment sheet. Otherwise, speak to the day nurse who received sign-out from the night nurse.

Telemetry Monitor

  • Record values that you see in the room rather than what is recorded in the computer. Live telemetry data is also available at the nurse station.
  • Note EKG wave form and heart rate. Verify the current rhythm.
  • Observe the venous, arterial, and O2 saturation wave forms, verify that these readings are accurate.
  • Note blood pressure including systolic, diastolic, and mean arterial pressure (MAP). Ignore cuff pressure if there is an arterial line and the measurement is in agreement.
  • Note central venous pressure (CVP) if CVP monitoring is being monitored through a central line.
  • Note cardiac output (CO) and cardiac index (CI) if available.
  • Note oxygen saturation, but ABG oxygen saturation is what should be reported in rounds if available.

Infusions

  • Has the patient undergone a Spontaneous Awakening Trial (SAT)? I.E., has sedation been weaned? If no, then investigate why not.
  • Note all continuous infusions including pain/sedation, pressers, insulin, amiodarone, anti-hypertensives, fluids, blood products, tube feeds, etc.
  • Know the current rate of infusion and whether there was any change overnight.
  • Make special note when a pressor is running through a peripheral line. Ask whether the patient needs a central line?
  • Make sure tube feeds are held in the morning if anticipating extubation.

Ventilator

  • Is the patient undergoing a spontaneous breathing trial (SBT)? If no, investigate why not.
  • Note current ventilator settings. Check and verify any overnight changes.
  • Ventilator settings by convention are presented as Mode/TV/rate/PEEP/FiO2.
  • Observe and note peak pressure. This should generally not exceed 30 cm H2O and should almost never exceed 35 cm H2O.
  • If on CPAP/SBT, also note the rapid shallow breathing index (SBI), and pressure support (e.g. 5 cm H2O over 5 cm H2O).

Daily Checklist

The following items must be reviewed and accounted for daily in your pre-rounds, rounds, and notes.

  1. Pain and sedation orders.
  2. Invasive devices.
  3. Prophylaxis, both DVT and GI.
  4. Nutrition and diet orders.
  5. Glucose management.
  6. Current duration and expected end date of antibiotics.

Physical Examination

Generally the physical exam should be similar to a standard physical exam with the following notable exceptions.

Tubes, Lines, and Drains

  • Make note of all invasive devices attached to the patient. Know when each item was placed. Always ask if this item is still needed.
  • Central lines: Know the route of entry. Examine for any signs of infection or bleeding.
  • Arterial line. Is there good waveform? Is there agreement with cuff pressure? Arterial lines frequently clot.
  • Endotracheal tube: Tube should be patent and without kink. Be aware of the tube size and distance at the teeth.
  • Nasogastric and orogastric tube: Is there active suction? Examine any fluid collections. Is the patient receiving tube feeds and/or free water? Have oral medications been restarted and changed to feeding tube?
  • Chest tubes and surgical drains: Note the volume and character of output. Is it serous, sanguinous, purulent, bilious? Is there air leak?
  • Foley: Is the drainage dark, bloody, or transparent? Is there thick sediment? Is the insertion site clean?
  • Rectal tube: Some degree is leakage is normal, but the patient should not be covered in excrement. Stool should not be pooling in the bed.
  • If duration of intubation and OGT placement is approaching 1 week, ask whether the patient will need tracheostomy or PEG.

Neurologic

  • Is the patient awake and alert?
  • Can the patient follow commands? Have the patient squeeze your hands and wiggle their toes.
  • If too weak to do this, have patient move head or blink eyes.
  • Comatose patient
    • Assess response to painful stimuli.
      • Sternal rub, finger and toe nail pinch are appropriate.
      • Decorticate = flexor response, "towards the core". Absence of cortex function.
      • Decerebrate = extensor response. Absence of cerebral function. Implies brainstem function only. Worse than decorticate.
    • Evaluate GCS
    • Assess gag and corneal reflex.

ENT

  • Is patient on NIPPV or intubated?
  • Is there excessive drooling or secretions?
  • If patient is sedated, suction for secretions and check gag reflex.
  • Check for thrush.
  • Comatose patients may have abnormal self-inflicted trauma.

Pulmonary

  • Usually it is not possible to listen to the back of the intubated patient.
  • Auscultate at the apices, anterior lung fields, and sides near mid-axillary line.
  • Often it will be difficult to hear above the coarse sounds of mechanical ventilation, but with experience, you will be able to recognize abnormal findings.

Extremities

  • Assess distal pulses, DP and radial at a minimum.
  • Always assess that extremities are warm.
  • Check for edema. Edema in ICU patients may be more proximal in the legs or thighs due to positioning.

Skin

  • Skin breakdown and pressure ulcers are common in ICU patients.
  • It is not possible or reasonable to check every square inch, but be aware of any ulcers.
  • Double check with nursing on skin checks. Make sure the patient is being turned.

Rounds and Tasks

Attending Rounds

  • Be prepared for rounds to start around 0800 - 0830 AM
  • Presentations tend to be more formal.
    • Give an appropriate one liner.
      • E.G. *Name* is a *age* year old *sex* admitted for ___. ICU status due to ___. Hospital day ___. ICU day ___. Intubated *date*.
    • Give an updated subjective history. As ICU patients cannot really talk, this tends to be more a summary of significant events, nursing report, and family. It is ok to include updates on family. Try not to linger on this too long.
      • E.G. No acute events overnight. Patient denies pain. Family was concerned about ___. Nursing reports ___.
    • From here there are multiple options:
      • Proceed with an integrated systems based approach where relevant vitals, exam, labs, imaging, assessment, plan, and daily checklist are reviewed within the appropriate system. (Highly recommended)
      • Proceed with a mixed SOAP format that includes objective findings (including vitals, exam, labs imaging), followed by a systems based assessment and plan.
      • Proceed with a standard SOAP format starting with OBJECTIVE (including vitals, exam, labs, imaging) ASSESSMENT (including focused problem list), and PLAN (try to focus on changes and most relevant treatments).
    • Make sure you include the items of the daily checklist either separately or in an integrated model.

Orders

  • Orders should be put in as soon as possible, either while rounding, or immediately after.
  • The resident and intern should feel a certain degree of freedom to order many labs and medications independent of the attending.
  • Orders that the resident should feel comfortable placing, changing, or renewing without the immediate supervision of the attending. (IE, the attending should not be routinely following up on you to address these items):
    • Restraints. Need to be renewed daily.
    • Foley, rectal tube, and NGT placement.
    • Electrolyte replacement including K, Mg, P.
    • Long and short acting insulin or insulin drip.
    • GI and DVT prophylaxis.
    • Morning studies including labs, ABG, and CXR.
    • IV Fluids.
  • Orders that the resident should learn to feel confident in ordering or adjusting on their own:
    • Transfusion of PRBC.
    • Weaning of sedation for SBT
    • Cdiff stool testing
    • Repeating cultures
    • Broadening and narrowing of antibiotics
    • Administration of short acting pain medication, anti-psychotics, and PRN benzodiazepines. Use with caution as these medications are associated with increased mortality.
    • In the ICU there is a low threshold to order stat CXR, ABG, or EKG, and residents should feel comfortable about knowing when to order and not order these tests.
    • Starting a patient on NIPPV like BiPAP
    • Giving bolus medications including including lasix, hydralazine, metoprolol, labetalol, diltiazem
  • Orders that you should not change without first discussing with the attending or until you have reached a high level of experience, unless in emergent situation:
    • Any procedure. This goes without saying.
    • Ventilator settings. Do not adjust the ventilator without telling the RT. Do not adjust PEEP settings until you become familiar with ventilator settings. Loss of PEEP can undo hours of positive pressure ventilation.
    • Pressors. Do not transition or change pressors without permission. If there is an emergent need you can default to nor-epinephrine in a non-coding patient. A patient who is actively coding will likely receive epinephrine. Do not discontinue the pressor order immediately after patient has been weaned as there may be changing requirements.
    • Sedation. Be wary about changing attendings' preferred choices for pain or sedation. Remember that benzodiazepines are associated with a higher degree of mortality. Propofol can lower BP.
    • Continuous infusions including lasix/bumex, nitro, nifedipine, nimbex, amiodarone, esmolol, etc.
    • Do not give atropine unsupervised unless truly emergent.
    • Advanced imaging including CT or MRI.
    • Dietitian will generally adjust diet orders, although there is room for discretion in stopping or resuming the diet.

Notes

  • Notes should be completed after orders have been placed.
  • There are many individualized note templates.
  • Can use a SOAP based template or a system based template.
  • Needs to include the daily checklist.
  • Do not be offended if the attending does not immediately sign your notes or prefers to write their own note. This also does not absolve you of the responsibility to write your own note.

Unit Based Rounds

  • ICU multidisciplinary rounds take place every morning at 10:30 AM.
  • They usually start in the CABG patch.
  • Attendees include nursing, RT, diet, pharmacy, chaplain, case management, social work, and pharmacy.
  • Avoid HIPPA violations by being mindful of family wandering the halls. Try to keep patient doors closed for the same reason.
  • Residents will be expected to present patients depending on the attending.
    • Follow the lead from what you observe from nursing.
    • This is not a medicine based presentation, this is meant to coordinate auxiliary services. Address each service as appropriate.
    • Give a one-liner, events, and jump into a brief systems based presentation. Cover all check list items.
    • This differs from other UBR/MDR in that family needs should be discussed and addressed.
    • SW/CM will generally address disposition.

Procedures

  • Be prepared for possible procedures from day one.
  • Review the video links on the Procedures page.

APACHE Scores

APACHE IV is a national ICU metric that helps predict mortality and ICU length of stay. It is based on mortality data from ICU patients from hospitals all over the US.

  • Residents are expected to submit APACHE IV scores within 24 hours of ICU admission.
  • The upper level resident has the responsibility for completing APACHE IV scores.
  • Score is required on all patients admitted to ICU >4 hours and must be completed by 48 hours after discharge from the ICU.
  • All patients admitted to the ICU, regardless of whether they receive an ICU consult, require an APACHE IV score.
  • ICU patients are designated in RED on the white board.
  • Add 'APACHE IV LOS NON-CABG' and 'APACHE IV HM NON-CABG' on patient lists for a real-time reminder of whether a score has been documented.
  • This helps encourage smart use of the ICU. If patient does not need ICU, then utilize IMC.

Score Submission

  1. Make sure EPIC login context is "RRH ICU".
  2. Navigate to APACHE IV on left hand menu. If not visible, it can be found under "More" or "Rarely Used". It can be added using the customization wrench.
  3. Once the APACHE IV menu opens, navigate to the "documentation" section.
  4. The overwhelming majority of the score module will autofill.
  5. Selecting "No" to the question "Is this a CABG patient?" will populate the remainder of required questions.
    Apache01.png
  6. Fill in all the questions with the appropriate answers.
  7. Selecting "Non-Operative" under "APACHE IV Diagnosis" will open a new window. Select the appropriate system for the main diagnosis and click OK. This will generate a drop-down menu with the specific diagnoses.
    Apache02.png
  8. Select the appropriate specific diagnosis. Note that many diagnoses are not always listed under the most intuitive source. For example, sepsis is listed under "Cardiovascular" in the system menu.
  9. Once this has been completed return to the "Score Report" section.
  10. Click "File" for the "Hospital Mortality Score" and "Length of Stay Score".
    Apache03.png