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Intensive care patient review [advanced]

Case review

  • Background (pre-admission)
    • Age
    • Baseline function
    • Co-morbidities
  • Reason for hospital and ICU admission (admission)
    • Day in ICU
    • Reason admitted to hospital and ICU
    • Major management (e.g. operations etc.)
  • Other main issues and management (post-admission)

Examination (top-to-toe)

A to I (+ L)

  • Airway
    • Own or type of airway
    • If intubated: correct position on CXR (below clavicles, but above the carina)? Any air leaks?
    • If tracheostomy: correct position on CXR? Type? Cuffed or non-cuffed? Innertube or single lumen? Size? When inserted? Why inserted (e.g. weaning, supraglottic airway obstruction)? Any air leaks?
  • Breathing
    • Ventilation
      • Self-ventilating or ventilator settings?
      • FiO2 (and requirement trend)
      • Tidal volumes/airway pressures (whichever is not set)
      • Respiratory rate/pattern
    • Saturations and latest ABG (pH, pCO2, pO2)
    • Secretion load
    • Chest exam
    • Chest drains in situ: Swinging? Bubbling? Output?
    • Last CXR/CT
  • Circulation
    • HR, BP/MAP
    • Vasopressors/inotropes: requirements; increasing/decreasing?
    • Perfusion (capillary refill time, peripheral temperature, lactate)
    • Heart sounds
    • Peripheral oedema
    • ECG/rhythm abnormalities
    • TTE if done
  • Disability
    • GCS
    • Sedation ± paralysis (check RASS score if paralysed)
    • Neurological exam if relevant
    • Pain control (e.g. PCA, opiates etc.)
  • Everything abdomen (nutrition, GI, abdominal exam)
    • NG/NJ/PEG/PEJ tubes (feeding/free drainage or spiggoted ± 2/4/6 hourly drainage)
    • Nutrition
      • Oral – note any oral restriction e.g. NBM, sips, clear fluids limited to ml/h, clear free fluids, free fluids, light/soft diet, normal diet
      • Enteral/parenteral nutrition (ml/h and kcal/kg/day) – note administration method e.g. NG, NJ, PEG
    • Absorbing feed? (normally nurses will aspirate every 4 hours – concern about absorption if >100ml; not absorbing if >250ml)
    • Stools (when bowels last opened, type, laxatives)
    • Abdominal exam (inc. bowel sounds)
    • Drains
    • Relevant results e.g. LFTs
    • Stress ulcer prophylaxis (pantoprazole 40mg IV OD)
  • Fluids and renal
    • Fluid balance
      • 24 hour target
      • Fluid balance so far today and last 1-2 days
      • Urine output (ml/kg/h) – catheterised?
    • NB: if giving maintenance fluids, remember to also take into account the volume of any infusions going in
    • Electrolyte results
    • Renal function
    • Acid-base balance
    • Renal replacement therapy (if so: type, e.g. CVVH, CVVHDF; anticoagulant – heparin (systemic) or citrate (filter); current net fluid removal in ml/h, i.e. fluid removed after accounting for input; 24 hour fluid balance target; effluent rate ml/h)
  • Glucose
    • Glucose level
    • Insulin requirements/VRII
  • Haematology
    • Hb, platelets
    • Clotting
    • VTE prophylaxis (heparin 5000 units BD S/C + IPCs/TEDs)
  • Infection
    • Temperature
    • WCC, CRP, PCT (and trend)
    • Microbiology results
    • Antibiotics (day)
  • Lines
    • Vascular access (+ day post-insertion (usually replaced every 7-10 days)? Clean? Any erythema/discharge?)
      • Central line/Vascath/Hickmann/PICC (position confirmed with CXR?)
      • Arterial line

Conclusion

  • Current issues/problem list
  • Plan
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