Intensive care patient review [advanced]

Clerking and reviewing patients > Reviewing inpatients

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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