Daily Reviews on the ICU

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!

A Assessment
Endotracheal TubeFor patients with artificial airways, check the size and whether there are spare ET tubes/tracheostomies of that size conveniently stored in case of an airway emergency.
TracheostomyKind of tracheostomy – e.g. Portex, Trache Twist.
When the tracheostomy was established; if <7 days old, in the event of an airway emergency, seniors may instead decide to perform endotracheal intubation. If more established, the senior is more likely to be able to reinsert a tracheostomy tube if it needs to be replaced.
As with any examination – look, listen, and feel for threats to airway.
Look- swelling around the face/neck, vomitus, bleeding, see-saw breathing
Listen- stridor (often and easily misidentified as wheeze, but with stridor the chest sounds clear), snoring
Feel/examine – GCS (is this at an airway-protective level?)
Own airwayAs with any examination – look, listen, feel for threats to airway.
Look- swelling around the face/neck, vomitus, bleeding, see-saw breathing
Listen- stridor (often and easily misidentified as wheeze, but with stridor the chest sounds clear), snoring
Feel/examine – GCS (is this at an airway-protective level?)
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?)
B Assessment
Oxygen Requirement (FiO2)How has this changed, and why has it changed?
Some reasons for an increased FiO2 include;-increased secretion burden / respiratory infection-hypoventilation because of pain, sedation or analgesia
Ventilator settingsOne of the forms of organ support which can seem most complex to new starts is ventilation.
Explaining this adequately is beyond the scope of this article, and ventilation decisions are virtually all made either by senior intensivists or specialist chest physiotherapists. 
In a nutshell, look at the type of respiratory support and whether this correlates to;-us breathing for the patient (IPPV, SIMV, BIPAP)-the patient instigating their own breath, with us delivering PEEP to reduce work of breathing or increasing the tidal volume of that breath (PS, CPAP, spont)
Note that in spontaneous ventilation modes, there is a failsafe where if the patient does not trigger a breath in a set amount of time (apnoea), the ventilator delivers a mandatory breath to them. 
Equally, if a patient is on a mandatory ventilation setting but is trying to instigate breaths around those delivered to them, the ventilator will alarm – this is referred to as ventilator dyssynchrony.
These are both important to include in a daily review if it is happening!
If the patient has required a change of ventilation from spontaneous to mandatory, why? Is there a clear reason (e.g. have we sedated them to facilitate a scan), or does this need to be discussed and investigated on the ward round?
While getting accustomed to the vent modes, it is easier to discuss changes in ventilation requirements as opposed to absolute numbers;-has there been an increase or decrease in FiO2, PEEP, ETCO2?
Target tidal volumes for most patients (VT on some ventilators) is 5-8ml/kg; any higher increases the barotrauma burden and may need to be adjusted by a senior. 
Depending on the pathology which has brought them into the ICU, patients may have strict targets / aims of ventilation; for example, lower tidal volumes for patients with ARDS, or strict pCO2 targets for patients with primary neurological pathology.
Chest auscultationAs for any other patient. Air entry in ventilated patients does sound different, so it is easier to compare sides in the same patient than to compare their breath sounds to what you think you should be hearing. 
Strength of cough and secretionsIn ventilated patients, observe the cough stimulated by passing a suction catheter via the endotracheal tube; does this look coordinated and strong, and is it successful in bringing secretions up to a level where they can then be suctioned by nursing staff? This is an important consideration in patients being considered for extubation. 
When secretions are suctioned, these can be seen in the tubing and a chamber at bedside. Nursing staff can help you quantify the volume, tenacity and colour of these.
Secretion burden and weak cough are common reasons for failed extubations, so this is a vital piece of information to guide clinical decisions.
Work of breathingBubbling/swinging, output (volume and colour)
Chest drainsBubbling / swinging, output (volume and colour)
RadiologyRecent CXR / chest CTs

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. 

C Assessment
BP and MAPInvasive reading (via an arterial line) or non-invasive (via a BP cuff)?
Augmented/ artificially lowered:-vasopressors-antihypertensives-sedation
Does the patient have a target MAP or BP they should be meeting and are they meeting this? 
Heart rate / rhythmBest practice to check in all 4 limbs.
Patients receiving vasopressors may feel peripherally shut down as their peripheral vasculature constricts.
Capillary refill timeClinical assessment of perfusion is made by looking at the above parameters, plus the function of the end organs. For example,
Brain/ cerebral vasculature – is there any abnormal neurology e.g. pronator drift? Is the patient ‘cerebrating’ – are they awake and alert?
Heart / coronary vasculature – is there any chest pain? Troponin rise?
Kidneys / renal vasculature – is the patient passing adequate amounts of urine? (See below)
PerfusionAccept a minimum of 0.5-1ml/kg/hour
On the other end of the spectrum, if the patient is producing high volumes of urine (e.g. >200ml/hr for 2 consecutive hours), there are a few potential explanations;
-they may be appropriately excreting any excess fluid they had previously been given (de-resuscitating)- for example, were they given 5 litres of crystalloid in resus the day prior?
-could represent a complication of their admitting pathology; for example DI, SIADH, post-obstructive diuresis
Sending paired serum and urine osmolalities will help you to differentiate.
BloodsNot just urea and creatinine;-If Hb, HCT, electrolytes (especially Na) high → consider whether they might be dry
Fluid balanceClinical fluid status; mucous membranes, peripheral oedema etc. 
Any insensible losses not being accounted for – for example, is the patient febrile or tachypnoeic?
Weight Another useful index of fluid status for patients who have been in for a few days – have they gained 4kg in a week? Some of this may be attributed to water weight
Urine outputMurmurs may manifest for several reasons;-patients brought up post-ACS or cardiac arrest may have new valvular incompetence or cardiomyopathy-invasive lines = increased risk of infective endocarditis
Heart soundsMurmurs may manifest for a number of reasons;-patients brought up post-ACS or cardiac arrest may have new valvular incompetence or cardiomyopathy-invasive lines = increased risk of infective endocarditis
TTE/ FICEPatients may have echocardiography as indicated.
You may see ‘FICE / FUSIC’ scans documented – this is an accredited senior making use of ultrasound scanning to answer specific basic questions – for example, significant ventricular dilatation or impairment, assessment of preload or scanning for pleural or pericardial fluid collections.
This should be followed up with formal echocardiography as soon as possible.
TroponinDepending on the primary pathology, some patients with a critical illness may have a raised troponin; it is the overall trend and clinical picture that is important.
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?
D Assessment
PupilsEqual and reactive?
Blood sugar and HbA1cImportant both because blood sugars may affect consciousness levels, and tight glycaemic control is important in care for patients with neurological injuries in the ICU. 
GCSIt is possible to observe for signs of focal neurology even in sedated patients or those with a low GCS; for example, do they only ever localise to pain with one arm?
ICU-associated weakness/ neuromyopathy;-common but not fully understood-a combination of reduced muscle mass due to metabolic changes and deconditioning, plus reduced muscle function following a critical illness and its associated inflammation, disturbed blood supply and ischaemia-generally symmetrical, global, maximally affecting proximal limb muscles and respiratory muscles, with reduced tone-risk factors include the severity of the critical illness, poor glycaemic control, prolonged immobilisation and certain drugs used in the ITU.-this is important because it makes patients harder to get off ventilation, extubate, rehabilitate and discharge home-managed by the MDT by firstly avoiding predisposing factors where possible and after the fact with physiotherapy, nutritional optimisation
Invasive devicesIn tertiary neurocritical care units, patients may have intracranial pressure bolts (ICP bolts) or extraventricular drains (EVDs). 
These are briefly described below for students and foundation doctors rotating through tertiary neurological centres; feel free to skip this section if it does not apply. 
The Monro-Kellie doctrine states that the cranium is a fixed compartment made up of three basic materials; blood, brain parenchyma and CSF. 
If the volume of one increases, the volume of the others must reduce to maintain the same intracranial pressure.
If the ICP increases, this implies an increase in the volume of one of these three materials, that cannot be compensated for by a reduction in the others. 
Neurosurgeons can help ICP management by inserting an extraventricular drain, which drains CSF into an external chamber. If there is a sudden spike in CSF output, this implies attempts at compensating for something which is now taking up more volume in the cranium than previously – for example, a new bleed or worsening cerebral oedema. 
Neurological exam and ICU-associated weaknessDelirium in the ICU is both common and can be distressing for patients – many, after their discharge from hospital, recall upsetting sensory disturbance as a result of their delirium.
As with delirium on the wards, this can be hyper- or hypoactive or mixed.
If your patient seems delirious on your review or there is documentation from previous shifts suggesting delirium (acute change or fluctuation in conscious level +/- other disturbances), PINCHME is a useful checklist to identify any potential triggers or exacerbating factors. 
DeliriumDelirium in the ICU is both common and can be distressing for patients – many, after their discharge from the hospital, recall upsetting sensory disturbance as a result of their delirium.
As with delirium on the wards, this can be hyper- or hypoactive or mixed.
If your patient seems delirious on your review or there is documentation from previous shifts suggesting delirium (acute change or fluctuation in conscious level +/- other disturbances), PINCHME is a useful checklist to identify any potential triggers or exacerbating factors. 
E – Exposure / Enteral
E Assessment
Bowels opening?Check when they last opened
Most critical care patients will be on laxatives regardless to compensate for the lack of mobility and often being on constipating medications. 
Route of feeding and medicationsPatients who are not yet established on an enteral route of feeding are put on a PPI to reduce the risk of gastric ulceration.
When their enteral feeding is commenced, the PPI should be reviewed and stopped as this influences the microbiome and can contribute to Clostridioides infections.
Exceptions include;-patients on other drugs that indicate a PPI, e.g. steroids / SSRI plus NSAID-patients who require a PPI by the parent team, e.g. upper GI surgery
PPI?At a minimum, whether the abdomen is soft, distended, whether bowel sounds are present
If the patient is awake, can also assess for tenderness
Abdominal examination At a minimum, whether the abdomen is soft, distended, whether bowel sounds are present
If the patient is awake, can also assess for tenderness
H – Haematinics
H Assessment
HbVirtually all ICU patients will be anaemic, by virtue of the critical illness that brought them to the unit. 
That said, it is still important to detect any evidence of bleeding.
For example;-Hb drop, with rise in urea but not in creatinine, and some dark aspirates from their NG tube?-Hb downtrend, with a distended abdomen and tachycardia on the monitor when you palpate?-Hb drop, with bloodstaining of the CSF from their EVD and a difficult-to-manage ICP?
HCT is a useful indicator of the extent the Hb drop can be contributed to haemodilution- as well as looking at their fluid balance for the past few days.
Clinical evidence of bleedingIncluding, but not limited to;-bruising/ petechiae-blood in catheter bag / EVD draining system / abdominal or chest drains / NG tubes / sputum aspirate-PR bleeding, or blood in stool
Jaundice in the absence of obvious liver pathology should also raise suspicion for bleeding (bilirubin being produced as a result of RBC haemolysis)- examine the sclerae even of sedated patients!
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)

H Assessment
TemperaturesWhat day of treatment are they on- is there any indication this should be changed, for example, new culture results or persistent evidence of clinical infection despite current antibiotic therapy?
Scoring systemsMany infections have scoring systems that can be used to determine what action is needed, for example;- CPIS score for pulmonary infections- VIP scores for cannula / line-related phlebitis. 
Previous investigations and samplesCulture samples may be available from;-sputum (or non-directed bronchoalveolar lavage in intubated patients)-blood (either peripheral or line cultures)-urine
Current antibioticsWhat day of treatment are they on- is there any indication this should be changed, for example new culture results or persistent evidence of clinical infection despite current antibiotic therapy?
SLAVED Assessment

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

SLAVED Assessment
SedationAny indwelling/invasive devices.
Include what they are, where they are, how old they are, whether they look clean (VIP score for cannulae), and whether they are required
For chest drains – bubbling / swinging, output (amount and colour)
Surgical drains – location, output (amount and appearance)
For brachial arterial lines, always check distal perfusion (no collateral blood supply – end artery)
LinesWhat is prescribed
Include all modes of analgesia; enteral, IV, epidurals, wound catheters, and regional blocks.
How frequently they require PRNs.
Ask the patient if their current analgesic regime is working for them; if sedate, look for physiological indicators of pain e.g. high BP and HR
AnalgesiaRoom air/oxygen / high flow / ventilation (spontaneous or mandatory)
Gas exchange on ABGs
VentilationEating & drinking / NG fed / TPN / NBM?PPI prescribed/ not prescribed depending on whether they are not / are established on enteral feeding? Bowels opening? Weight changes? Consider whether calorie requirements have changed (are they on less propofol today vs yesterday- propofol has 1 calorie per ml!)
EnteralEating & drinking / NG fed / TPN / NBM?PPI prescribed/ not prescribed depending on whether they are not / are established on enteral feeding? Bowels opening?Weight changes? Consider whether calorie requirements have changed (are they on less propofol today vs yesterday- propofol has 1 calorie per ml!)
Drugs / DVT prophylaxisOn LMWH- if not, why not?
For LMWH;-dose still appropriate for weight?-any upcoming events that would warrant suspending LMWH e.g. upcoming surgeries?-LMWH adjusted for creatinine clearance? (needs enoxaparin if <30)
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

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