In the intensive care unit, junior medical staff conduct and present daily reviews of their patients to seniors to guide the planning of care on the ward round.
This may well seem daunting given how unwell and complex the patients might be but a thorough, well-structured A-E will give you most of the information you need to progress that patient’s care.
While you won’t be expected to have an in-depth understanding of all of the seniors’ decisions, some insight will make your job a lot easier- for example, when vetting scans, updating relatives or seeking information from other specialities. 
Below is a guide taking you through an A-E for a patient in the ICU- if you use electronic patient records, it may help to import in an acronym expander with the items below in a checklist until you find your feet.
Of course, this should be used in conjunction with local checklists at your hospital. While I love intensive care medicine and have tried to make this as helpful as possible, your seniors remain the best source of information when clinical uncertainty arises.

Patient Details

Check the patient details, check the head-of-bed sign is correct and that any emergency guidelines (e.g. tracheostomy emergency algorithm) are at the head of bed.

A – Airway

This will vary depending on what kind of airway the patient has!

B – Breathing

The general questions your B assessment should address are;

• Is the patient’s current level of respiratory support appropriate?
• Does this need to be escalated (is there evidence of respiratory failure necessitating intubation/ high flow oxygen delivery), or stepped down (is this ventilated patient fit for an extubation trial?)
• Is there any evidence this patient has sustained a respiratory complication from their illness or from the respiratory support they have been given? (Ventilator-associated pneumonia, pneumothorax, ARDS?)

Your plan from your B assessment may be;

• Chest physiotherapy, saline nebulisers, and sputum cultures if secretions are an issue
• Chest imaging if concerned about a respiratory tract infection, or a pneumothorax (does one side seem more easily ventilated than the other?)
• Some hospitals have ‘bundles’ that should be prescribed for patients with artificial airways, with reminders for nursing staff to complete certain toileting tasks for that airway- this is to reduce the incidence of ventilator-associated pneumonia.

C – Circulation

The main themes you want to use the points below to answer are;

• What level of cardiovascular support and monitoring is the patient receiving- is their level of cardiovascular support increasing or decreasing?
• Does the patient seem sufficiently perfused?

Assessing a patient’s cardiovascular status and whether we need to manipulate any aspects of it is disease process-specific and patient-specific. It is worth looking through previous documentation to see whether the patient’s team or senior intensivists have set any individual cardiovascular targets. 

D- Disability

• Does the patient have compromised neurology?
• Is this because of something we are doing to them (sedation), because of their initial insult that brought them into hospital or the ICU (e.g. focal neurology in a patient with a traumatic brain bleed), or does this seem like a secondary development (e.g. delirium, evolving focal neurology, evolving GCS drop or pupil signs?)
• Do they need further neuroimaging?

E – Exposure / Enteral

H – Haematinics

I – Infection

Patients in critical care units are at increased risk of infection, for several reasons;

• by virtue of being in an environment where patients have infections
• increased number of invasive lines and devices; endotracheal tubes, urinary catheters, peripheral and central vascular access
• immune suppression as a result of their critical illness
• higher rates of antibiotic necessity predisposing to multi-drug-resistant organisms

Senior intensivists, pharmacists, and critical care microbiologists can all help to guide you in whether antibiotics are indicated and which, as well as any samples they might require to achieve adequate insight into the likelihood of infection.

Marry the below with their blood results above; white cells (including neutrophil: lymphocyte ratio), lactate +/- CRP (some critical care units don’t include this in their standard daily bloods to encourage dependence on clinical gestalt)

SLAVED Assessment

Another checklist used in some intensive care units, to ensure the following domains are checked daily.

Impression and Plan

• Do they need to remain on CCU and why- organ support, intensive monitoring, management of e.g. EVDs, tracheostomy?
• When were their family members last updated? It is good practice to update them as frequently as possible, but absolutely needs to happen when the patient’s clinical status changes, any decisions are being made that change the trajectory of care or any ceilings of care are being applied

• What is the parent team’s plan, for example, any upcoming procedures?

Resources and References

Singer, M. and Webb, A.R. (2009) Oxford Handbook of Critical Care. Oxford: Oxford University Press. 

Allman, K.G. and Wilson, I.H. (2016) Oxford Handbook of Anaesthesia. 4th edn. Oxford: OUP. 

Brown, S. Bratanow, S. Appelboam, R. Systematic assessment of an ICU patient. Update in Anaesthesia. Available at: https://resources.wfsahq.org/wp-content/uploads/uia28-Systematic-assessment-of-an-ICU-patient.pdf 

Written by Dr Eva Kerr, FY2
Kindly reviewed by Dr James Dunning, ST4 Anaesthetics