Dummies Guide to ICU
This is a non-expert opinion from an ED Reg, especially for those who haven’t done anaesthetics.
The following applies to adolescents and adults. Most of it applies to kids as well – but get a big person to help you.
Listen to the senior nurses - they are invaluable.
Let the boss nurse know if you are leaving the unit eg going to a ward, ED or just to lunch - they need to know where you are.
A good website is ccmtutorials.com
If in doubt call the boss day or night. They expect to be called several times a night.
Start your phone call with "I just need some advice ..." or "I think you need to come in" or "We need you here now ..." so the boss knows how urgent the problem is.
Don’t intubate anyone with GCS> 3 unless there is a consultant or experienced ICU or anaesthetics reg at the bedside.
Don’t hesitate to call an anesthetics reg overnight. Usually they are very helpful (much easier to get them to come and help for a tube than trying to get them to ED for a transport).
ICU airways are almost all high risk.
Most should be RSI.
Preparation is the key.
SABI MALE SOD (?the not so sweet transsexual)
Staff: Assign roles so everyone knows what they need to do
Ensure boss nurse knows
Your assistant: drugs / passer of suction/tube / attacher of ambibag
Cricoid person: tell them not to release until told to
Neck immobilizer for traumas
Goffer/chest auscultator (needs stethoscope)
Assess and position airway
Neck mobility (not trauma)
Modified Mallampati: how much of the oropharynx can you see
If any of these look bad move you supervisor a bit closer
Fatties: “ramping” shoulders on pillows, head on more pillows. Tragus above level of manubrium.
Trauma: in line manual stabilization, collar off
Otherwise: “sniffing” head on one thick pillow.
Bougie = get out of jail card #1. Unopened but within reach.
IV access x 2, IV fluid running
Monitoring x 4
Laryngoscope x2 working, usually use a size 3 in adult female, size 4 adult male.
LMA = get out of jail card #2. Size 4 for adult female, size 4-5 adult male.
ETT correct size open, lubed, balloon checked. Another one, 1/2 size smaller, unopened.
Suction working, under the pillow
Scalpel for cric = get out of jail free card 3#. Don’t use a cric kit: takes 5 minutes in expert hands
Oxygen – check it’s flowing and reservoir bag reservoir fills
Etomidate 0.3mg/kg = 20mg = 1 ampoule (0.2mg/kg if shocked, very elderly, chronic renal failure)
Suxamethonium (= succinylcholine) 1-2mg/kg = 100mg = 1 ampoule
Or Rocuronium (1mg/kg = more than one ampoule for RSI) instead of sux if:
Pressor drawn up eg ephedrine see below
Atropine available esp 4 kids
Rocuronium 50mg (if not used for intubation) to keep patient immobile till everything is stabilized (not all patients need this but to start with just paralyse them all)
Propofol infusion15ml/hour initially until long term sedation started. Watch for hypotension. If it occurs stop infusion temporarily and given ephedrine 10mg (3.3ml of 30mg (1 ampoule) made up to 10ml with saline)
If BP dodgy use midazolam 5mg rather than propofol
If patient in pain add an opiate eg fentanyl 50-100µg depending on pain and age.
Washes nitrogen out of lungs giving a bigger reservoir of oxygen in lungs
At least 3 minutes on ambibag – but get sats as high as they will go
Don’t do it. No proven benefit. KISS = less chance of error).
Paralysis and Induction
Rapid push of etomidate immediately followed by rapid push of sux or roc (in that order to avoid a paralysed awake patient if anything goes wrong) then large flush.
Cricoid on. Remind cricoid person not to let go until asked to.
When fasciculation stops (or 45 seconds after roc) open mouth with fingers, remove false teeth, hold laryngoscope in left hand and slide it down right side of tongue, pushing tongue to left.
When you see the epiglottis, ensure the laryngoscope passes anterior to it (posterior if less than say 8 years old) and gently advance as far as it will go. Lift the laryngoscope up and away from you, pulling in the direction of the laryngoscope handle until you get a good view of the cords (= most of the time).
If poor view try repositioning, adjusting cricoid pressure (cricoid off if necessary) or bougie.
Suction if necessary (keep looking in the hole, ask your assistant to pass the suction to your right hand).
Keep looking in the hole, ask assistant to pass ETT to your R hand.
Pass the ETT from the R corner of mouth (ask your assistant to pull the corner of the mouth out if necessary).
Pass tube through cords until 24cm at the teeth.
Hold the tube.
Get your assistant to attach ambibag (+ filter + capnography) and start bagging. Ask the goffer to inflate the cuff until the leak stops.
Look for fogging of the tube.
Look at the capnography trace.
Get the goffer to auscultate lateral upper chest bilaterally.
If you’re happy “cricoid off” and get someone to tie the tube in.
Post intubation management
Sedate and paralyse as above (“Drugs”)
Attach to ventilator (see “Breathing” below)
Urinary catheter early.
Check cuff pressure with manometer (lives on main airway trolley): get pressure in the green zone.
Other Airway Issues
If one falls out
Trache less than a week old: reintubate orally with ETT as above. Then someone can redo the trache later.
Trache more than a week old: sedate eg Infuserite (see Sedation later) or propofol 15ml/hour and insert a new trache through the hole.
Bleeding from trache: fresh blood may = tracheo-inominate fistula = huge mortality. D/w boss even if bleeding stopped. If actively bleeding incr pressure in trache cuff to attempt to tamponade.
Get the nurses to show you how to suction ETTs and traches. An important skill we need to be comfortable with.
Generally done during day shift, unless immediately post-op, FIO2 0.3, able to lift head off pillow, squeeze your hand x3 and keep eyes open.
Incr FIO2 to 1.0 for a few minutes.
Airway trolley handy.
Part of challenge is stinky secretions above cuff.
Sit pt up at least 30° (if spine allows). Put "bluey" on chest for stinky tube and secretions to go on.
Suction down ETT. Suction mouth.
Attach syringe to cuff balloon.
Undo tube holder/tape.
Turn PEEP up to 15cm (to help blow crud out).
Get pt to take deep breath in, deflate cuff, pull ETT out.
Turn ventilator off.
O2 via hudson mask (occassionally CPAP used post extubation (if needed more than 5cm PEEP prior to extubation)
They seldom listen to backs of chests in ICU.
One approach to ventilation is to consider oxygneation; ventilation and lung mechanics separately:
Oxyenation: FIO2 + PEEP determines oxygneation. "The patient is able to maintain an O2 sat of 97% with an FIO2 of 0.35 and a PEEP of 5: they are oxygenating well"
Ventilation: What is the minute ventilation (L air moved per minute) and what CO2 does this achieve. "We are only getting a minute ventilation of 4L/minute and the PCO2 is 50: we are underventilating the patient.
Lung mechanics: "We are requiring 20 of pressure support and causing plateau pressures of 34cmH20. The patient has stiff lungs and at the moment our airway pressures are too high"
Important marker of lung badness.
Know the RR of all patients.
Starting rate for ventilator: 16. Go as low as 6 for an asthmatic. Patients breathing at 25+/minute, even if supported, will fatigue. You either need to increase their manditory ventilation or sedate +/- paralyse to allow them to tolerate a higher CO2.
A good marker of lung health.
Generally, if the patient has a high FIO2 it means lung badness eg pneumonia; ARDS.
In ICU they don’t generally drop the FIO2 below 0.3 (for no good reason).
The patient generally won’t be ready to extubate till FIO2 is 0.30 or 0.35.
Generally start at 0.6 and titrate down to the lowest that will keep the patient at “normoxyia” for them. Tolerate SaO2s as low as 88-89% in ARDS
Generalised lung badness not due to the heart.
Stiff wet lungs.
Definition: bilateral infiltrates on CXR. PaO2/FIO2 < 200mmHg with normal pulmonary artery and left atrial pressures (in practice the vascular pressures are a clinical guess).
Managed with low tidal volume ventilation. See below.
Acute Lung Injury
Like ARDS but not quite so bad. Definition: as for ARDS but PaO2/FIO2 < 300mmHg.
Positive end expiratory pressure.
Pressure maintained in lungs at the end of expiration to keep airways open.
Usually start off with 5cm H20.
NB PEEP can reduce venous return, so if BP low may need to reduce PEEP.
PEEP is good for CCF, ARDS, atalectasis. Not good for localised pneumonia.
For ARDS use 15 cm H20.
Peak Airway Pressure and Plateau Pressure
Too higher pressures are believed to do a lot of damage to lungs and cause/exacerbate ARDS.
Generally we like to have both the peak pressure and the plateau pressure (the airway pressure during most of inhalation) < 30cmH20
d/w boss if getting above 30. Often intial management is to reduce tidal volume. Sometimes a pressure limited mode of ventilation is used
When the patient breathes in, the ventilator helps push air in under pressure.
Pressure support is the extra pressure above the patient inspiratory pressure.
More pressure support generally results in deeper breaths ie greater tidal volume.
Always set to a minimum of 5cm H20 to overcome the resistance of the circuit.
Generally start with 500ml for an adult male, 400-450ml for a adult female.
For someone with dodgy lungs, eg ARDS; asthma, use a “lung protective strategy” of 6-8ml/kg ideal body weight (based on height). You will need a table/calculator, eg Archimedes, to work this out)
Synchronised intermittent mandatory ventilation.
The ventilator breathes for the patient at a set rate. If the patient breathes faster than the set rate, the machine will assist the spontaneous breaths.
Use this initially for all patients and all patients who are paralysed.
Assisted Spontaneous Breathing.
Incorrectly called CPAP by many of the nurses, and lablelled CPAP on some of the ventilators, just to confuse you.
The patient is breathing spontaneously and the ventilator is just giving a bit of help with each breath.
“SIMV, 500 by 16, on 60% with 5 and 5”
NB notes on Tidal volume above.
This applies to portable vents as well as the ones in the unit.
As in ED.
10cm H20 to start with.
“Breathing up” / “Poor synchronisation with the ventilator” / "fighting the ventilator
Patients with losts of rapid irregular spontaneous breaths need there ventilator settings adjusted, there sedation increased &/or to be paralysed. d/w boss. Also check for bronchospasm.
Adjusting Ventilator Settings
For the first few months speak to the boss before fiddling with the vent. Vent generally shouldn’t be adjusted overnight.
Looks like a pneumothorax but it aint. During/immediately after being turned in bed, ICU patients often drop their sats, and may have decr air entry on the new dependent side. This is probably due to lung secretions moving to the new dependent side.
Often just need suctioning and an increased FIO2 for a few minutes till they sort themselves out.
Occasionally need increased PEEP or hand-bagging to reinflate them.
Sometimes need a bronchoscopy to suck the snot out of the bronchi. These ones will have a lobe or lung whited out on CXR. d/w boss.
Pneumothoraces do happen but are rare (usually post trauma).
If in doubt get urgent CXR.
Unlikely to need “stat” needle decompression in ICU - but tension pneumothoraces do happen. If you get the above picture + falling BP treat as tesnion penumothorax
“Swing in the art line”
This beastie is a believed to be a marker that the patient needs more volume. The arterial line blood pressure trace swings with ventilation. In an under-filled patient a high intrathoracic pressure decreases venous return and decreases cardiac output and therefore blood pressure.
Art lines and central lines.
One of those skills that just takes time, and many failed attempts, to master. Be patient with yourself. Use the ultrasound. It’s great when you get the hang of it.
This unit likes volume = Normal Saline (sometimes plasmalyte is used if the patient has a hyperchloraemic acidosis)
Patient is normally on maintenance fluid (male 80ml/hr, female 60ml/hr, cardiothoracic surgery 20ml/hr).
If the patient may be under-filled eg
We usually give 1L normal saline stat for any adult (no matter how old and crumbly) and monitor the results.
If still looks under-filled repeat.
Patients occassionally get 15 litres of fluid over 4 hours but NB Pressors below.
Used sparingly after cardiothoracic surgery.
Otherwise considered evil.
Used sparingly. Transfuse if Hb < 70 (or patient is exsanguinating).
With massive transfusions have a low threshold for giving FFP and platelets as urgent coag results take an hour to come back. d/w with the boss. Recommendations vary: 1 FFP:1 RBC; 1FFP:2RBC
If you think your patient is well filled, eg 3 litres of crystalloid, but still they look like they are under-perfused (partly given by the indices under volume above) or you are getting no response from your fluid boluses d/w the boss. They will usually be given noradrenaline 2mg made up to 50ml with D5W starting at 2ml/hour. When they get to 20ml/hr they change to 4mg/50ml = “double strength norad” and will often have vasopressin added.
The volume vs pressor balance is part of the fine art of ICU, ie we don’t know which approach works better.
If you are in ED or on the wards use the “poor man's pressor” 1 mg of adrenaline in 1 L normal saline and run it at about 120ml/hr (= 8 hour bag) till you get a response (do 2 minutely BP) then titrate up or down.
Or use ephedrine (alpha and B agonist) 30mg (1 ampoule) made up to 10ml with normal saline. 10mg boluses prn every few minutes. Lasts about about 10 minutes.
In Australia: metaraminol (alpha>Beta) 0.5-1mg prn q 3 minutes
(another, less often used, pressor in phenylephrine (pure alpha) but KISS)
Many cardiac surgery patients come back from theatre on milrinone. It is a long acting phospodiesterase inhibitor => incr levels of cAMP. d/w boss when to stop it.
Non-cardiacs will sometimes have dobutamine added to their cocktail when norad and vasopressin aren’t working.
Cardiac surgery patients
Often precarious. Keep the ICU Registrar Guidelines handy and follow them. Call the bosses early and often.
Know how to use the defib – you’ll be using it lots.
Know how to drive a pacemaker – get someone to talk you through the control box.
= cardiac surgery in CICU, not theatre. This happens fairly frequently. Don’t take it personally. When the boss decides to reopen you call the operator “reopen please”. Keep the patient alive (may require every blood product, CPR, adrenaline infusions) till the anaesthetist comes to take over from you.
A very expensive, unproven, cardiac function monitor.
Arterial pressure and temperature sensing cathether.
Different sized catheters for brachial vs femoral.
Uses thermodilution to work out cardiac output. Cold saline is injected into central venous line. The temperature drop at near-central arterial line tells you how much blood the cold saline has been diluted in. Then with some magical assumptions the machine will tell you from the shape of the pressure and temperature change curves whether the patient needs more volume, more squeeze or some frusemide.
Put the lines in. Nurses do the cold saline bit. Machine spits out numbers which you tell the boss. He scratches his chin and says give more fluids.
Treated with BiPAP or invasive ventilation and nitrates.
Frusemide is not used acutely for CCF.
Frusemide is sometimes used to dry out an overloaded patient who is over the acute phase of an illness.
Short stay, eg overdose: TEDS
Post op: TEDS, enoxaparin as directed by surgeon
Other: TEDS, enoxaprin 40mg od, or 20mg od if moderate renal impairment (arbitrary cut off)
First line: correct K and Mag. Give Mag even if Mag in normal range – often helps.
Second line: Amiodarone for just about everything.
Sedation is required so patients can tolerate ETTs.
Different ICU have different methods. Commonly infusions of midazolam and fentanyl are used for long term intubations and propofol if the patient will be intubated for < 24H
After long periods of sedation it may take hours or days to clear body stores of sedative.
Use fentanyl 600µg rather than morphine in renal failure.
Watch for hypotension with propofol.
For procedural sedation give 2ml boluses of propofol or an infusion as above, but ICU patients are often extremely sensitve to sedatives/analgesics and will drop their BP. If BP dodgy safer to use midazolam 1-5mg depending on how nasty the procdure is and whether they’re being ventilated or not.
Most of the long term oldies wake up delirious and agitated. Rx haloperidol 0.5 – 5 mg prn. Nurses will often tie the patients’ hands to stop the patient removing tubes and lines.
Nurses will take blood, sputum and urine cultures.
Antibiotics seldom started empirically. D/w boss before starting Abs – they’re very particular about them.
Over 39°: paracetamol, actively cool: damp sheet, fan.
Over 40°: may need paralysis to reduce heat generation.
Unconscious post cardiac arrest: Sedate with propofol (they are unconscious now, but they potentially could wake in a hurry and pull their ETT out. Cool: 24 hours @ 32-34° (international guidelines are vague): 2 litres cold normal saline (out of fridge in ED or ICU), damp sheet, fan.
Aim for BSL 8-10 for all ICU patients
NG feeding (Glucerna (Jevity if diabetic/hyperglycaemic) 0-80ml/hour adjusted by the nurse) starts on admission to ICU unless very short stay eg overdose.
If 2 blood sugars > 10 the patient will have blood sugar controlled with an insulin infusion as per the ICU protocol
Insert a vas cath or niagra as directed by the boss. Same technique as central line, just scary bigger catheter. Make a big skin incision. Have lots of gauze ready as they bleed ++ when you pull the dilator out.
Dialysis has some heparin in the filter which shouldn’t affect the patients coags too much, but often does.
Dialysis may or not remove volume from the patient – the boss decides.
We don’t prescribe dialysis enough to know what we’re doing – admit defeat and ask the boss what to write down.
A sample standard prescription enclosed.
Chest XRay after insertion of central line, ETT or NG tube. Further chest XRays only if clinically indicated. Radiographers do a round about 7am each day, so nightshift docs need to think about who needs an XRay that day.
Retrievals from wards or ED, transporting patients to CT.
Potential disaster around every corner.
To start with take a budy and boss nurse with you.
Get someone to show you how to drive the portable ventilator
Take every drug you think you may need (intubation drugs, post intubation drugs, ephedrine and adrenaline) and one of the red airway bags (ambibag, airways, PEEP valve for doing CPAP) (on the wall opposite the loos the reg room) with you. You have to ask nurses to get etomidate for you especially cos it’s not in the transport box for some stupid reason.If the patient isn't tubed take some good sedatives with you eg haloperidol + midazolam for agitation clasutrophobia (especially in the CT) and antiemetics if flying or travelling by road.
Usually leave art lines and central lines till you get back to ICU. Any drugs can be given peripherally for a short time – just watch for extravasation of pressors.
OK to tube people in ED, otherwise, where possible, bring patients back to ICU to be tubed.
Don’t move patients till you are happy with them. Don’t let any one rush you. It’s better to stabilise where you are rather than have a disaster in the lift or CT.
Have full monitoring (sats, ECG, art line or BP cuff set to go q5min, capnography if tubed) on before you move.
For tubed patients paralyse for transport to decrease risk of patient pulling out tubes or lines en route.
Beware of propofol and morphine for anyone with a dodgy BP. Safer to use midazolam (and fentanyl if analgesia needed).
Resist taking unstable traumas to CT if they need to go theatre.
Be assertive during trauma resuscitations.
ICU admission from ED/Ward/Theatre
76 male, mentally sharp, lives alone at home, independent with ADLs but has to stop every 100 metres on flat due to SOB
7 days of productive cough. Started on Abs 2/7 ago by GP. Found by neighbour tonight unconscious. BIBA. In ED febrile, confused.
Type 2 DM/glycaemic control
MI 1997, stent. No angina since
COPD FEV1 75%
A: own, quiet breathing but GCS M3, E2, V2 = 7
B: RR 36, O2 sat 90% on reservoir mask on 15L, bronchial breathing + coarse creps L
C: Mottled, cold peripheries, HR 130, BP 90/30 MAP 50. UO 10ml/hour
E: temp 38.5
G: BSL 12.3, abdo soft non tender
I: Gravely unwell 76 man with LLL pneumonia and septic shock
D/W Dr …..
ETT, etomidate 10mg, sux 100mg, Grade 1 view, easy intubation, 5mg midazolam for transport
ventilate SIMV, 500 by 16, on 60% with 5 and 5
4 litres normal saline
blood, urine and sputum cultures
augmentin and clarythromycin
NG feed – Glucerna
M+M sedation via infuserite
TEDS, enoxaparin 40mg od
Ward round notes
ICU WR Dr …
Day 1 in ICU
LLL pneumonia with septic shock
type 2 DM
etc as above
B SIMV, 16x 350ml, 5/5, FIO2 0.5, O2 sat 100% Decr ae and bronchial breathing L base
F = early enteral Feeding
A = Analgesia
S = Sedation
T = Thromboembolic prophylaxis
H = Head of bed elevation
U = stress Ulcer prophylaxis
G = Glycemic control lycemic control
increase PEEP to 10, FIO2 decr to 0.4
reduce enoxaparin to 20mg od