Introductory Material for New Starters

Dr Tamara Tajsic (FY2 NCCU), Dr Sam Cook (FY2 NCCU), Dr Jacob Low (FY2 NCCU).

If you do not have any prior ICU or, specifically, NCCU experience, you might find the following useful. We have compiled the list as ICU naïve foundation doctors.

Firstly, two websites with a wide range of invaluable resources.

The Life in the Fast Lane Critical Care Compendium

Critical Care Reviews


General approach to ICU patients

As a foundation doctor with little to no ICU experience, assessing patients during a junior ward round was slightly daunting. Writing ‘obs stable, apyrexial’ in the notes after flicking through the observations is not sufficient, however, finding an easy system was not easy – it seems that everyone has their own approach.

After completing a week NCCU it became clear that as long as all systems are reviewed on the ward round, we would have at least achieved the very basics of what is expected of us as foundation trainees. We have found the A-M and FASTHUG mnemonics below useful, they allowed us to maintain a structure on daily ward rounds. The key thing to remember is that these systems merely act as aide memoirs and all patients should be reviewed in the context of their pathologies and the trajectory of their critical illnesses. They also remind us that doing the basics right is essential, when reviewing patients it is important to think about why physiology is abnormal and what needs to be done, if anything, to correct those abnormalities. After that, making a plan is perhaps the most important thing can do for our patients.

Airway: Self ventilating, intubated, or tracheostomy –  comment on any positive pressure ventilation.

Breathing: HR, SpO2, ventilatory support, examination, imaging.

Cardiac: BP, HR, MAP cardiovascular support, cardiac pathology, imaging.

Disability: GCS, pupils, sedation, sedation holds, agitation.

Environment: Temperature and pattern of temperature changes, active cooling – recall that patients in renal replacement may be afebrile due to cooling by the extracorporeal circuit.

Fluids: Fluid balance, daily and total, IV fluid prescriptions and strategy, renal function, renal support.

Gastrointestinal: Abdominal examination, commenting on recent bowel movements, feeding – route, aspirates – requirement for prokinetics, calorie and protein intake.

Haematology: Hb, platelets, clotting, DVT prophylaxis, therapeutic anticoagulation.

Infection: Temp, WCC, neutrophils, CRP, PCT, and antibiotic regime. It is important to also note the number of days they have been on this antibiotic regime and any culture results.

Jaundice: Liver function

Kidneys: to remind to to think about renal function and support if not assessed during electrolytes

Lines: Include any lines that the patient may have, such as CVC, PICC or peripheral cannulas. Also include the number of days it has been in.

Medicines: Chart review, drug interactions, allergies, stop antibiotics?

In addition there are some key components of critical care which need to be delivered and assessed each day. We have tried to build the tab on EPIC (our electronic patient record) around these but two mnemonics may also be useful.

Give your patient a fast hug (at least) once a day 

Critically ill patients need “FAST HUGS BID”


Specific clinical focus

Cardiovascular

The use of inotropes/vasopressor and cardiac output monitoring is rather unfamiliar when first starting. This is a brief summary of the main agents, mostly in table form. This is more comprehensive with particular detail of the pharmacology.

Mechanical Ventilation

Difficult to find something basic enough to be accessible but comprehensive enough to be useful, this is probably the best we have found so far.

Sedation

This first link is quite short and has emphasis on NCCU, the second is probably more comprehensive (quite long), although quite readable, addressing general principles of sedation and analgesia in ICU.


Specific Diseases

These reviews  serve as a general introduction to pathologies most frequently met on the unit, a base that you can build on. Also, they are not axioms and should be subject to continuous review – so if you find something that might be more useful, more up to date, or comprehensive, by all means please update the list.

  1. Traumatic brain injury – intensive care management from our very own Prof. A. Gupta and Mr A. Helmy.
  2. Raised intracranial pressure – monitoring and management strategies.
  3. Multimodal monitoring in traumatic brain injury.
  4. Subarachnoid haemorrhage – multimodal monitoring and management. Before starting on NCCU you might not have appreciated the impact of “vasospasm” on the morbidity and mortality of patients following sub-arachnoid haemorrhage. It is a complex, poorly understood disease and is better thought as being part of a large group of  processes termed delayed cerebral ischemia (DCI). Try a brief overview with management strategies here and a lovely, free, review of the wider DCI concept in the BJA.
  5. Intracerebral haemorrhage.
  6. Ischaemic stroke. Also have a look at a series David Menon edited in Critical Care, all open access.
  7. Epilepsy – a broad subject – I chose a review on the epilepsy and nonconvulsive status in the context of coma.
  8. Clearing the spine in the unconscious patient.

All of the above should be freely available.