Critical Care

Ventilators, pressors, central lines. MICU gives you a chance to care for some of the hospitals sickest patients with great opportunities to learn. Clink the link below for a pdf copy of the MICU Cram sheet, written by Dr. Doerschug. It’s a nice crash course survival guide.

Download the MICU Cram Sheet

The purpose of this document is to enhance and streamline communication during Morning Rounds.

1. Organize your presentation around “systems”. Systems include: hemodynamic; respiratory; infectious; neurological; hematological; nutrition; preventive cares, etc. Always begin with the most relevant system for that patient at that time, for example, the one that provoked ICU admission or the one that is currently the most acutely deranged or needing of attention. Proceed through each relevant system, omitting any that you judge minimally relevant.

* DO: Prioritize new, impactful results, such as positive blood cultures in a hypotensive patient.

* DON’T: Don’t read laundry lists of lab results and vital signs.

2. For new Admissions/Transfers only, you may begin with a concise HPI leading up to hospitalization; then shift to a systems presentation. You should not present PMH, SH, FH, ROS unless these are crucial to the presentation.

* DO: Present relevant HPI when it informs the differential diagnosis. For example, if a patient is transferred from an outside ICU with hypotension, it is essential to tell me, “The patient was completely well until 2 days ago when she noted mild abdominal cramping, followed by large amounts of black, tarry stools. Yesterday she complained of lightheadedness and, following a syncopal episode, was admitted to XYZ Hospital. She has been taking a daily aspirin as part of general health maintenance (not guided by any physician) but denies other medications, alcohol abuse, or symptoms or history of liver or ulcer disease.”

* DON’T: Don’t relate irrelevant details. In the patient with syncope above, don’t say, “…a head CT at the outside hospital showed no cause for loss of consciousness. An echocardiogram revealed normal LV function.”

3. For each system, present all data essential to understanding that system. For example, for the Respiratory System of a patient with acute lung injury you might say,

“…This morning the ventilator is set on volume assist-control mode with a tidal volume of 380mL and rate of 32 and the patient is sedated and passive. The peak airway pressure is 33 and the plateau airway pressure is 25, both 2-3 lower than yesterday. The SpO2 is now .91 on an FiO2 of 50%, compared to a similar saturation yesterday on 60%. The CXR shows some

clearing diffusely, perhaps related to the net diuresis of 3L. The CVP is 6cm, down from 9cm yesterday. There is no blood gas this morning.”

* DO: Recognize that fluid balance might belong to the respiratory system (as it does in the vignette above) but, alternatively, might belong to the renal system (if, for example, you were dealing with an edematous patient with acute kidney injury).

* DON’T: Don’t present your impressions (see #5) before you’ve communicated the data in support of them.

4. For each system, provide context and a sense of change over time. For example, a mean arterial pressure of 66mmHg can only be interpreted when you also provide doses of vasoactive drug infusions (context). Also, consider how you would interpret a MAP = 66 on norepinephrine 15mcg/min if:

a. yesterday (sense of time) the MAP was 83 on no vasoactive drug;

b. yesterday the MAP was 62 on norepinephrine 25mcg/min.

* DO: Examine your patient’s primary data over several time frames. You may find that a temperature curve yields different conclusions when examined over 3 days rather than over 1 day. EPIC facilitates your ability to examine trends over time.

* DON’T: Don’t present data as a range over 24h. It is not useful, for example, to be told that the heart rate ranged from 88-136. Give the value now and the sense of change over time, not a range.

5. When you conclude a system, give your impression of and plan for that system. For example, continuing with the respiratory presentation described in #3 above, say,

“Measures of respiratory mechanics, gas exchange, and the chest xray all show improvement compared with yesterday, due either to diuresis or to treatment of the underlying sepsis. Today I plan to continue diuresis targeting a CVP less than 4, interrupt the sedatives, and perform a spontaneous breathing trial.”

* DO: Draw conclusions ahead of time as to what you really think. In the vignette above in which all measures of lung function are improving, it’s easy to conclude that the lungs are better and it’s time to liberate. More often data are conflicting or inconclusive. Nevertheless, you must generate a plan. Your plan will make most sense if it’s based on thoughtful inferences from the data you present.

* DON’T: Don’t wait until the Attending asks to begin to process such complex and conflicting information. A few moments of reflection before rounds (“…should I broaden Abx, continue the same Abx, begin to withdraw Abx…”) will make your presentations more efficient and confident.

6. Be efficient: say things once; include only what is essential. Aim to conclude your presentation (including follow up) within 5 minutes.

DO: Arrive at your patient’s bedside prepared by having examined the patient, reviewed the primary data, debriefed the nurse, and reflected on all this sufficiently to have impressions and a plan.

DON’T: Don’t forget the power of an efficient presentation. Your Attending, fellow Residents, the Nurse, and the Therapist will draw a clearer picture from a crisp 2-minute presentation than a 10-minute core dump. Imagine how much better that