Before You Start

  • Revise ventilator terminology: tidal volume, PEEP, FiO2, plateau pressure, driving pressure
  • Know the major vasopressors: noradrenaline/norepinephrine, vasopressin, phenylephrine — mechanisms and typical doses
  • Review arterial blood gas interpretation — a core daily skill in ICU
  • Understand sepsis (Sepsis-3 criteria) and septic shock definitions

The ICU Daily Structure

ICU runs differently from ward medicine. The day typically follows:

  1. Handover: SBAR format per patient — current status, overnight events, active problems, plan
  2. Morning labs: ABG, FBC, U&Es, LFTs, coagulation, lactate, cultures reviewed early
  3. Ward round: Systematic head-to-toe review for each patient; ABCDEF bundle assessment
  4. Procedures: Lines, bronchoscopies, imaging, family meetings
  5. Documentation: ICU daily progress note — problem-based, plan for each system
  6. Evening review: Second consultant round; update plan

ABCDEF Bundle

  • A: Assess, prevent and manage pain
  • B: Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)
  • C: Choice of sedation — lightest effective sedation; avoid deep sedation where possible
  • D: Delirium — assess daily (CAM-ICU), prevent, manage
  • E: Early mobility and exercise — physio on board from day one
  • F: Family engagement and empowerment — daily communication, open visiting where possible

Ventilator Basics

  • Tidal volume: Target 6 mL/kg ideal body weight (not actual weight) in ARDS
  • PEEP: Typically 5–15 cmH2O; higher in ARDS to recruit alveoli
  • FiO2: Target SpO2 94–98% (or 88–92% in COPD) — do not over-oxygenate
  • Plateau pressure: Keep <30 cmH2O to avoid ventilator-induced lung injury
  • Daily SBT: Pressure support trial to assess readiness for extubation

Family Communication

ICU is a high-stress environment for families. Key principles:

  • Introduce yourself to families early in the rotation — they will be present daily
  • Use plain language — avoid jargon, give realistic but not brutal prognostic information
  • Document family meetings in notes — what was said, who was present
  • Know your hospital's process for DNAR/DNACPR decisions and escalation planning
  • Never estimate a specific time-to-death — it is almost always wrong