DAILY ROUNDS IN ICU

Head to Toe examination of critically ill

patient
 Inspection

• Physical examination in the critically ill extends well

beyond the patient.
• It includes the interface of patient and
technology - the lines the monitors, the drains,
even the type of bed the patient is on.
• Accumulating information the second you go into the
patient's room or approach the bed.
• A good intensivist/nurse can walk into the room of any
patient in ICU without any knowledge of the patient,
and within 2 minutes know virtually everything about
the patient without consulting the notes.
Walking up to the bed:
• Look for : Signs
• Placed on isolation precautions (MRSA / Vancomycin
resistant enterococcus (if so make sure you check how
the diagnosis was made and if isolation IS
APPROPRIATE
• What kind of monitors or machines are in the room –
A Ventilator inavasive /non invasive ,
dialysis machine (check the numbers and the
content of the dialysis fluid before you leave),
an intra-aortic balloon pump
an ECMO machine,
high frequency oscillator.
End of bed

• Is the patient moving about, agitated, fighting

the ventilator, or comatose.

• Is the patient pale, jaundiced, cyanosed or diaphoretic? Does the

patient have an extensive skin rash.

• Is the patient lying flat in the bed (more likely to aspirate),

sitting up (better respiratory mechanics) or prone (lung
recruitment).

• What kind of bed is the patient in - a standard bed, a percussion

bed, a rotating bed, a Rotarest or proning bed (this will tell you a
lot about the patient - what is wrong with them, how long they
have been in ICU)?
 Eyeball the monitors
Ensure that the patient is not in physiologic distress
• hypotensive, hypertensive,
• desaturating,
• tachy- or bradycardic or arrhythmic.
• Look at the pressure waveforms - are they damped?
• Do the numbers on display accurately reflect the
physical condition of the patient (measurement error
is frighteningly common in intensive care)?
 Examination of patient

• Check a mental state by talking to the

patient –
• Introduce your self and tell your
role/designation : ICU doctor
• level of consciousness using
AVPU (awake, responding to
verbal stimuli (ideal), responding
to painful stimuli,
unresponsive) /GCS
• Signs of delirium/Sleep
cycle
• Explain, even if the patient is
unresponsive, who you are and that
you are going to examine them.
Examine the patient’s head:

• Are the eyes open?

• Are they too edematous to close
(and thus risk corneal ulceration)?
• Are the pupils equal and reacting to
light?
• Does the patient have a naso- or
oro-gastric tube?
• Does the patient have a
feeding tube? Is the patient
intubated – oral, nasal or
tracheal?
• Have a quick look at the mouth to
ensure that the endotracheal tube
is not causing pressure injury.
Examine the neck:

1. A cervical collar (is it an appropriate

fit?).
2. Tracheostomy (Size ,cuff, Days)
3. Feel for crepitus in the
supraclavicular area (associated with
pneumothorax, important if the
patient was involved with trauma or
is mechanically ventilated),
4. the jugular veins distended
suggesting fluid overload.
5. Does the patient have a neck
or subclavian central line? If so, is it
secured? Is the site infected?
 Examine the chest:
• Is there an old sternotomy or
thoracotomy scar?
• Is there any chest drain (if so
examine the site, the drainage bottle
– how much? Bloodstained? Is there
an air leak present?). 1403/1404
• Does the chest expand evenly?
• Does the patient have a parasternal
heave or a thrusting cardiac apex?
Listen to the heart sounds; are there
any murmurs or evidence of a
pericardial friction rub
(uremia/cardiac surgery)?
• Listen to the lung fields in the apices
and axillae, looking for air entry,
crackles and bronchial breathing.
• Sit the patient forward and
listen to the lower zones of the
lungs. Look for decubitus at
the back of the head and for
sacral edema in this position.
Examine the arms:

• Are they equal in size –

• is there unilateral edema
(suggestive of axillary vein
thrombosis)?
• Does the patient have an arterial
line? Examine the site – any
inflammation or pus?
• Carefully look at the fingers
of that hand (any blanching
or ischemic changes). Then
examine the fingers of the
other hand
Examine the abdomen
• Is it distended,
• is there a wound, drains or
dressings. If so, take down the
dressings and examine the wound and
drain sites – are the sites red and
inflamed, or dry and healing? Is there
any pus?
• If there are drains, look at the
drainage bottles – what do they
contain – blood, serous fluid? How
much? 1401/1414/1409
• Palpate the abdomen feeling for
masses and hepato-splenomegaly.
• Percussion the abdomen to
confirm organ enlargement,
bladder distension, or the
presence of ascites (shifting
dullness) or bowel air
(tympanic).
Examine the groin area

• Are there any femoral

lines (including arterial
sheaths and intra-aortic
balloon pumps)?
• Is there any material oozing along
the urinary catheter from the
ureteral meatus or evidence of
gential or flexure candidal
infection.
• How much is in the urinary catheter
bag, and what color is it (light or
dark yellow – dehydration – or red
(myoglobin)
Examine the legs:

• Are they equal in size.

• Does the patient have compression
stockings or sequential compression
devices (SCDs - are they switched on?)
for DVT prophylaxis?
• Is there any evidence of deep venous
thrombosis or thrombophlebitis?
• Is there any ankle edema?
• Are there any lines in the feet?
• Are there any mottled or ischemic
toes?
Roll the patient on his/her • Are there any pressure sores?
side and examine the • Is there any evidence of skin
posterior aspect of the or deep tissue infection?
body . • Surgical scar ?
Look at the monitor

• What is the heart rate? Is it regular?

What is the blood pressure?
• Does the arterial line correlate with the
blood pressure cuff?
• What is the central venous pressure
(CVP)? Is there a good trace?
• Is there a PA catheter present?
• What are the pressure and check
transducer position?
• Then flush the line and check the
reading again.
• If the patient is ventilated, have a look
at the ventilator: what settings is the
patient on? Is the patient breathing
spontaneously?
• is there any evidence of dysynchrony
or gas trapping?

• Before leaving the bedside, look at all

of the infusion pumps – what is
running and at what rate?
Systematic Data Interpretation & Interventions

• Now that you have assembled observational

information it is time to address the recorded data
and assemble a problem list.
• The way to write your note is to write down what
you have found (examination),
• what has been recorded (data observation),
• what you are doing (interventions)
• what you are planning to do along a continuum.
• An isolated blood pressure of 110/70 is irrelevant if
you are not informed that the patient is requiring
20mg/minute of norepinephrine to maintain it
 The most effective method of exploring patient data is
to use a head-to-toe systems approach.

The following mnemonic :

• New (nervous system)
• Residents (respiratory)
• Can (cardiovascular)
• Get (gastrointestinal tract, liver and
nutrition),
• Killed (kidneys),
• Even (endocrine),
• Surgeons (skin, extremities and
wound),
• Lives (laboratory studies),
• Are (analgesia),
• In (infectious diseases),
• Danger (devices).
Neurological (clinical and imaging)
• Is the patient awake? If not – why
not?
• Quantified the neurological status
using AVPU,The Glasgow Coma
Score (GCS),
• Sedation Agitation Scale (SAS).
• The interventions in this system
usually involve the use of sedatives,
with or without pain killing
properties :
• “the patient responds to verbal
stimuli, his GCS is 11, his
Ramsay score is 3 on propofol
10mg/minute, and fentanyl
25mg/hour.”
• Sedation Scales
Respiratory System

• You have multiple layers of

pulmonary information
• The examination in a ventilated
patient may be less valuable than
hard information such as the
blood gas measure, the ventilator
settings and the chest x-ray.

• His chest x-ray reveals low lung

volumes, bilateral infiltrates
and small bilateral pleural
effusions. He requires hourly
suctioning and his sputum is
thick and purulent.”
• Several factors are influencing
the PaO2 on the ventilator
alone:
• “the patient’s blood gas on an
FiO2 of 0.4 and PEEP of
10cmH2O is PaO2 77, PaCO2
44, pH 7.38, HCO3 27,
Saturation 95%. His ventilator
settings are pressure control of
22cmH20, inspired time of 1.5
seconds rate of 14 breaths. His
tidal volumes are 450ml.
• the CPAP/PEEP level, the peak
pressure level, duration of
inspiration and the fraction of
inspired oxygen (FiO2).
• The blood gas reveals two types of
information: the PaO2 /PCO2and
the patient’s acid-base status.
• Cause ??
 Cardiovascular
• Heart rate, blood pressure, CVP,
PA catheter measurements.
• “...his pulse rate is 100, in atrial
fibrillation, on amiodarone, his
blood pressure is 90/50 on
noradrenaline
0.5mcg/kg/minute,
• his CVP is 12,
following volume loading of 2.5
liters, our target BP is MAP of 60
and
• CVP of 14cmH20.
• He has a PA catheter in situ: is
PAP is 38/18, wedge pressure of
14cmH20, which correlates well
with the CVP,.
 The mean arterial pressure is the
principle perfusion pressure of all
major organs except the heart.
Coronary filling is determined by the
diastolic pressure. The heart rate
determines the time available for
diastolic filling and the myocardial
oxygen consumption.
The CVP is indicative of venous
return, and intravascular volume. The
numeric value of CVP is influenced by
venoconstriction and intrathoracic
pressure, particularly when CPAP is
applied. Thus CVP is not an isolated
value, but a trend.
• The urinary output is the most useful
direct measure of end organ
perfusion.
• Pulmonary artery catheters (PAC)
are inserted in order to measure
cardiac performance, stroke volume,
in response to cardiac muscle
loading, end diastolic pressure
Gastrointestinal System & Nutrition
• This involves evaluation of
abdomen, the gut and the liver.
• It is necessary to refer to
the examination of the
abdomen, including the
wound site, if present,
• Data relating to inputs and
outputs,
• qualitative data regarding liver
function.
• “On examination of the
abdomen, there is a midline
laparotomy wound, which is
healing well. Nasogastric
suction is minimal. He is being
fed thru a gastric /post-pyeloric
feeding tube, using enteral feed
at 80ml/hour, which The feed is
well tolerated and he is passing
stool. His liver function has
been normal since admission.”
• It is essential to defend
the absence of enteral
feeding, which may
require a discussion
about the presence or
absence of bowel sounds,
which are insensitive
markers of the presence
or absence of ileus.
• You must also discuss
whether or not the patient
is passing flatus or bowel
motion: a patient who is
having bowel movements
does not have an ileus.
Renal Function and Fluid Balance
• The kidneys control overall fluid
balance and excrete products of
metabolism.
• Two surrogate markers of renal
function are used –
• urea (which is
determined by protein
catabolism, and is
reabsorbed in part by
the nephron,)
• creatinine the serum
concentration of which is
determined by muscle mass
and muscle turnover.
• “the patient is 8 litres positive
since admission, 500ml positive
over the last 24 hours. His urinary
output is on average 35ml/hour.
His urea is 20 and his creatinine is
1.8, up from 1.4 over the past 24
hours. We have sent a urine
routine ,cultures, urinary sodium
and creatinine in order to
determine the nature of the renal
injury ”
The patient may be on continuous
hemodiafiltration (CVVHDF) or
intermittent hemodialysis

For example, if the patient is on

CVVHDF,

1. the blood flow rate,

2. the dialysis flow rate,
3. the amount of fluid removed per
hour,
4. the agent used for
anticoagulation,
5. and the dialysate formula.
Endocrine
• Most intensivists are only
interested (perhaps wrongly) in
glucose control and adrenal
function.
• It is important to note the serum glucose
level, as this may become dangerously
high in this patient population, and
hyperglycemia is associated with worse
outcome.
• If the blood sugar is normal due to
insulin therapy, this must be projected.
Likewise, patients may have absolute or
relative adrenal insufficiency, usually due
to chronic steroid therapy. It is essential
to evaluate whether sufficient quantities
of adrenal hormones are being given.
• “The patient’s blood sugar is 240mg/dl,
controlled on an insulin drip, currently at
5 units per hour. He is being treated
with hydrocortisone at 50mg q8hours,
due to chronic steroid use, related to
COPD.”
Extremities, wound and skin
Critically ill patients are catabolic, wounds heal poorly.
• surgical sites are frequent sources of misadventure.
• Interventions aimed at the patients extremities must be
described and discussed.
• On examination of the skin and extremities, the patient has a
stage 2 decubitus ulcer on his sacrum. There is some
peripheral edema and the patient is being treated with
sequential compression devices and enoxparin for DVT
prophylaxis. The laparotomy wound site is clean and
granulating.”
Labs and Hematology
• The ability to make
blood cells and
platelets is an
important prognostic
factor in critical illness.
• Likewise it is essential to
know if the patient has
being requiring multiple
transfusions to maintain
normal homeostasis.
• The measurement and
supplementation of
electrolytes should be
documented.
• “His hemoglobin is 9.2 following
transfusion of 4 units of red cells.
His platelet count is 230 and his
prothrombin time (to control)
ratio is 1.2 (the INR is used only to
guide warfarin treatment).
Sodium is 142, potassium was 3.4,
this has been supplemented,
magnesium, calcium and
phosphate are all within normal
limits.”
• Microbiology report and cultures
report informed and documented
Infectious Diseases (microbiology)
The patients temperature is 38.6, his white cell count is 19. He
has an infiltrate on the right lower zone of his chest x-ray. A
broncho-alveolar lavage was performed 2 days ago, and
Pseudomonas grew. He is being treated with ciprofloxacin (dose)
and gentamycin (dose). He has a penicillin allergy, and is on day
3 of 10 of treatment. We have also sent blood, urine and stool
cultures.”
Devices
One of the inevitable
consequences of critical illness
is
• Lines
• drains
• hardware.
You must know what
devices are inserted into
your patients, why they are
there and for how long.
There is no evidence that routine
changing of lines reduces the incidence
of sepsis, and indeed may increase the
risk of complications (e.g.
pneumothorax).
This does not excuse you from
monitoring the age and condition
of your lines and drains.
• “The patient has a right radial arterial
line, which is 6 days old, a right sided
subclavian line, which is 4 days old,
and two abdominal drains, which
drained 300ml and 200ml of sero-
sanguinous fluid over the past
24hours. All of the sites look clean.”
•
The following is a quick checklist for all the points
discussed before

Primary diagnosis
Differential If any
Comorbidities:
check home medications.
Assess the extent of the disease process/their control
Intake:

Target: all inclusive Oral liquids

IV Fluid: ml/hour. Total/24h PN
Albumin Transfusions
Infusions: expected total amount/24h Electrolytes
Medications
Paracetamol ABX/AFX/Others

Diet

Calorie Protein

Supplements Vitamins Prokinetics Probiotics

Calorie balance Total debt

Output
Urine: ml/hr. Total in last 6hrs. 24 hrs. any deviation from average

Drain(s): last hour. Last 6 hrs. Last 24 hrs. any deviation from average/normalcy UF, Net

balance in CRRT

Interventional drainage Probable/insensible/loss

Bleeding if any

I/O: daily
Cumulative balance

Daily body weight trend

CXR

Tissue condition IVC

Arterial swings
Organ supports & Monitored parameters
Respiratory:
Mode. FIO2. P/F ratio.
Escalation of mode/support.
CXR.
I/O balance.
Airway pressures/Compliance-resistance.
Breath sounds.
Respiratory patterns.
P 0.1, cuff leak , secretion , cuff pressure, duration of ett /tt, speaking valve,
duration of intermittent niv, loops, pressure ulcers on nose and angle of
mouth.
VV ECMO- fio2 on E-, flow, rpm, sweep, act.
CVS:
Vasopressors/Inotropes/NO/Methylene Blue.
Escalation of Support?
Wean off.
MAP.
Hourly urine output.
Peripheral circulation & Pulse.
ABG & Lactate.
ECG St=t Changes, Rate & Rhythm
IABP: Trigger. Augmentation. Support. Escalation or descalation?
Peripherial pulse. Position.
Check xray.
Urine outPUT
pacing
.

Renal Neuro:
Risk factors. gcs,/avpu scoring,
Nephrotoxic drugs.
pupils, reflexes,
Creatinine Clearance.
icp monitoring,
BUN,Ur.Cr,Na,K,PO4,Mg, Ca,
D3 drain output,
,HCO3, Anion Gap. PSA. tcd, rass ,
Urine-R/E.M/E. ct/mri, carotid doppler,
Hourly urine output.
apnea test
USG
GI- Hemato-Coag-
tenderness, guarding, rigidity, hb, platelet,
abdominal girth, peripheral smear,
bowel sound, b12 level,
rbc folate assay,
fluid thrill/shifting dullness,
serum iron profile,
stoma/ drain output, usg abdomen ,
rt/jt/peg/flatus tube, retic count,
iap pressure monitoring, pt, inr, apt, fibrinogen,
stool r/m culture fibrinogen degradation product,
d dimer,
teg/ rotem,
bone marrow report,
massive transfusion protocol
Analgesia
– assess pain score using verbal scale and cpot tool.

-Pcm , nsaids , oral opiods,

--Epidural- drug, dose , rate , day of epidural and side effects

-v pca- drug, dose, boluses rate, and side effects------------

transdermal patch

-Transcutaneous blocks
-Need for pain reference???
Medications Microbiology
ABX ,AFX -blood culture
- urine culture
PPI sputum/bal -culture
APT - stool culture
-fluid culture
ACX -last biofire report-
Procalcitonin
CVS, Statins beta d glucon / galactomannon
Eltroxin
Need for ID physician???
Immunosuppresants
Diuretics
ACD
Lines /site/days HGT
- IV line
- Central line Glycemic Control
- Arterial line Ketones
- HD catheter
- IABP Insulin / OHA
- ECMO

Inhalational therapy
Spirometry
Chest Physio
Positioning : Head up position
Out of bed Mobilisation

DVT prophylaxis ACX

Pump Stockings Mobilisation

Referrals Raised Visited

Notes updated/Read Feedback informed to primary Suggestions integrated

Investigations

Daily
Special
Periodic
Where are we going
• There comes a point in any patient evaluation when a we must formulate
his or her own opinion on the patient’s status.
• The quality of this opinion is obviously determined by the amount of
training and experience of the doctor.
• The clinical impression – a “state of the patient” declaration is a useful
way of assessing the problems presented to you prior to your assessment,
the new problems that you discovered, and whether these are resolving or
not.
• “My impression of the problems:
• For eg
• 1) The acute lung injury is not resolving, we are unable to wean, but do
have a treatable cause – the nosocomial pneumonia.
• 2) The patient’s heart rate remains too high . In addition, the patient
should be reviewed for possible antiarrythmatics .
3) The hyperbilirubinemia remains unexplained – it may be
caused by AKT induce hepatits ,hemolysis, the patient did
have a massive transfusion, but may also be due to sepsis or
cholestasis. I feel that we should be overly concerned about
this problem at this time.

4) The wound site is granulating nicely

5)The pressure sore is of some concern. The patient had this on

admission, he came from a nursing home, we have obtained an
air bed, but the ulcer, if anything, is getting worse.”
 What is thePlan?
• One of the major weaknesses exhibited by residents is their
unwillingness to lay out a plan of care for ICU patients.
• This is a far easier undertaking than most realize.
• Again the methodology is to follow the systems
approach. Here is an example of a plan of care for a patient:
• “Neuro – the plan is to discontinue all sedation, and wake the patient
up and assess him neurologically. We will address agitation at that
stage if necessary.
• Respiratory – the plan is to switch him over from pressure control
ventilation to pressure support and wean the peak pressure level.
• Cardiovascular – the plan is to increase beta blockade to 10mg
metoprolol q6hourly. Consult cardiology for possible PCI

• GIT/nutrition – the plan to advance feeds to goal and to administer a

phosphate enema to treat fecal impaction.
• Renal/fluids – the plan is to reduce maintenance fluids to KVO (keep the
vein open) once enteral feeds have reached goal.

•Endocrine – the plan is to switch the patient over from i.v. insulin to
subcutaneous – 10units of NPH q12 with a 4 hourly sliding scale of regular
insulin
• .

• Extremities / Skin – no change in treatment is planned.

• Heme and labs – the plan is no transfusion unless the hemoglobin falls
below 7.0g/l or platelets fall below 50,000.

• Analgesia – the plan is to convert the morphine infusion to PCA as the

patient wakes up.

• ID – the plan is to discontinue all antibiotics today, and re-culture if he

spikes a new temperature.

• Devices – the plan is to remove the IJV CVC line, which is no longer
needed.”
Writing a Note

• Your daily ICU update note can be as long or as short as you

deem it to be.
• Time available for writing notes can be
extremely short…………
ICU PROGRESS NOTE

13/07/19 8.15am
Mr vyas age 49y
Day 1 post left lung decortication, complicated by 1. Resp Failure
2, ARF 3. septic shock 4. Multiple transfusion
Background: DM, IHD
Current Problems
1, Failure to wean
2.oliguria renal failure
3.arrhythmias
4.Hemodynamic instability
5.Increased creatinine
6.ICD care
• Neuro – Ramsay 4 on midazolam 4mg/hr, morphine 2mg/hr.

• Resp – FiO2 40%, PaO2 78 on PC 20 PEEP 5, rate 12. Not weaning.

ABG 7.46/78/48/+2/94%, Crackles audible throughout, dull in bases.
CXR – bilateral infiltrates (ARDS).
• CVS – BP 120/70, HR 92 (metoprolol 5mgq6h), CVP 8, normal HS, No
murmurs, ECG T-wave iversion across anterior leads.

• GI – abdomen soft, non tender, wound open but clean, post-pyeloric

feed started (30ml/hr), no stool, Bilirubin has increased to 12.6,
transaminases are normal.
• Renal – balance -500ml (x24h), overall +ve 8l. Creatinine 2.4 (down from
2.6). Hourly outpur 80-120ml.
• Endocrine – no problems
• Extremities – mild ankle edema, SCDs, enoxaparin 40mg q24 large (6 x
6cm) grade 2 pressure sore over sacrum

• Labs - 138/3.2/111/29 Hb 9.0 (1 unit RCC overnight), plat 230, PTR 1.5
• ID - Temp 38.2, WCC 19.2, pseudomonas in BAL x 2/7, tx piptaz 4.5gm
8hlry
• Devices – R IJV , RRAL
 Impression
• ALI not resolving – infectious component. Blood pressure and Heart rate
remains a little fast in setting of ischemia – cardiology should review . His
low HB may be due to I/O bledding. Renal function is worsening and
setting a oliguric AKI with Puffiness of face is present .

• Plan
• Neuro – Decrease fentanyl today and assess neurologically
• Resp – wean fio2 and peep
• CVS – amiodarone / metoprolol to 5mg q8h, cardiology to see ?
• GI – feeds to goal 50ml/ 2hrly,
• Renal – electrolytes correction and nephorlogy to revive
• Endocrine – glycemic control withSGT of 150-180 mg/dl
• Extremeties – wound care to see
• Heme/labs – transfuse if Hb < 8,
• ID – continue antibiotics
• Devices – central line care n arterial care
THANK YOU