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