New to ICU

First, know this:

 (Applies in ICU, A&E and anywhere else you might find yourself with a crashing patient)
1.  How to contact a senior colleague urgently  
2. Where basic airway equipment is kept (bedside set and airway trolley)
3. Where the resuscitation trolley is kept,
4. Where the difficult airway equipment, (and paediatric trolley) is kept,
5. Where the chest drain kit is kept,
6. Where the nearest units of O-negative blood are kept, and how massive transfusion protocol runs,
7. Where the cupboards with metarminol/ephedrine, intralipid and dantrolene is, 
8. Where the transfer bag is kept
9. Your role at arrets and trauma calls, and who else attends these (can attend these)
10. How to get good coffee.

Healthcare assistants often have an encyclopaedic knowledge of equipment whereabouts!

Then work your way down this page…


Other local knowledge

  • Get some idea of your standard ICU day’.
  • Read your unit’s protocols on the admissions process, and the daily review/ward round format.
  • Obtain a summary or protocol for specific post-op management pathways for your unit’s surgical case-mix.

Never events – be aware


Guidelines to be familiar with early (ideally before you start) – ICMWK pdf version here

Endotracheal tube and tracheostomy complications

Periarrest arrhythmias

Major Haemorrhage

Surviving sepsis guidelines




Papers – historic and landmark, and some others

(Based on the ICU top-twenty by Dr J Chantler – with thanks)
Try these ten(ish) first:
EGDT – Rivers E et al.
‘Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock’.
New England Journal of Medicine 345, no. 19 (2001): 1368–1377.
Cook DJ et al..
‘Stress Ulcer Prophylaxis in Critically III Patients’.
JAMA: The Journal of the American Medical Association 275, no. 4 (1996): 308–314.
Cook DJ & Crowther MA.
‘Thromboprophylaxis in the Intensive Care Unit: Focus on Medical-Surgical Patients’.
Critical Care Medicine 38, no. 2 Suppl (February 2010): S76–82. doi:10.1097/CCM.0b013e3181c9e344.
ARDSNET ‘Lower Vt’– De Campos, T et al.
Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. The Acute Respiratory Distress Syndrome Network’.
N Engl J Med342, no. 18 (2000): 1302–130g.
SSC– Dellinger R et al.
‘Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock’.
Critical Care Medicine 41, no. 2 (February 2013): 580–637. doi:10.1097/CCM.0b013e31827e83af.
ABC– Girard TD et al.
‘Efficacy and Safety of a Paired Sedation and Ventilator Weaning Protocol for Mechanically Ventilated Patients in Intensive Care (Awakening and Breathing Controlled Trial): A Randomised Controlled Trial’.
Lancet 371, no. 9607 (12 January 2008): 126–134. doi:10.1016/S0140-6736(08)60105-1.
NICE-SUGAR – Finfer S et al.
‘Intensive versus Conventional Glucose Control in Critically Ill Patients’.
N Engl J Med 360, no. 13 (2009): 1283–1297.
Berenholtz SM et al.
‘Eliminating Catheter-Related Bloodstream Infections in the Intensive Care Unit*’.
Critical Care Medicine 32, no. 10 (2004): 2014–2020.
Cade, J F.
‘High Risk of the Critically Ill for Venous Thromboembolism’.
Critical Care Medicine 10, no. 7 (July 1982): 448–450.
CORTICUS – Sprung C et al.
‘Hydrocortisone Therapy for Patients with Septic Shock’.
The New England Journal of Medicine 358, no. 2 (10 January 2008): 111–124. doi:10.1056/NEJMoa071366.
Knaus WA et al.
‘APACHE II: A Severity of Disease Classification System’.
Critical Care Medicine 13, no. 10 (October 1985): 818–829.
Nolan JP et al.
‘Therapeutic Hypothermia after Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation’.
Circulation 108, no. 1 (2003): 118.
ARDSNET steroids – Steinberg KP et al.
‘Efficacy and Safety of Corticosteroids for Persistent Acute Respiratory Distress Syndrome’.
The New England Journal of Medicine 354, no. 16 (20 April 2006): 1671–1684. doi:10.1056/NEJMoa051693.
TracMan – Young D et al.
‘Effect of Early vs Late Tracheostomy Placement on Survival in Patients Receiving Mechanical Ventilation: The TracMan Randomized Trial’.
JAMA: The Journal of the American Medical Association 309, no. 20 (22 May 2013): 2121–2129. doi:10.1001/jama.2013.5154
TRICC – Hébert, PC et al
‘A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care’.
New England Journal of Medicine 340, no. 6 (1999): 409–417.

Now try these:
 Bickell WH et al.
‘Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries’.
The New England Journal of Medicine 331, no. 17 (27 October 1994): 1105–1109. doi:10.1056/NEJM199410273311701.
PROSEVA – Guérin C et al.
‘Prone Positioning in Severe Acute Respiratory Distress Syndrome’.
The New England Journal of Medicine 368, no. 23 (6 June 2013): 2159–2168. doi:10.1056/NEJMoa1214103.
CHEST – Gattas DJ et al.
‘Fluid Resuscitation with 6 % Hydroxyethyl Starch (130/0.4 and 130/0.42) in Acutely Ill Patients: Systematic Review of Effects on Mortality and Treatment with Renal Replacement Therapy’.
Intensive Care Medicine 39, no. 4 (14 February 2013): 558–568. doi:10.1007/s00134-013-2840-0.
Dowdy DW et al.
‘Quality of Life in Adult Survivors of Critical Illness: A Systematic Review of the Literature’.
Intensive Care Medicine 31, no. 5 (1 April 2005): 611–620. doi:10.1007/s00134-005-2592-6.
Esteban A et al
‘Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation’.
New England Journal of Medicine 350, no. 24 (2004): 2452–2460.
Goldfrad, C, and K Rowan.
‘Consequences of Discharges from Intensive Care at Night’.
Lancet 355, no. 9210 (1 April 2000): 1138–1142. doi:10.1016/S0140-6736(00)02062-6.
Gray A et al.
‘Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema’.
New England Journal of Medicine 359, no. 2 (2008): 142–151.
MIDEX & PRODEX – Jakob SM et al.
‘Dexmedetomidine vs Midazolam or Propofol for Sedation during Prolonged Mechanical Ventilation: Two Randomized Controlled Trials’.
JAMA: The Journal of the American Medical Association 307, no. 11 (21 March 2012): 1151–1160. doi:10.1001/jama.2012.304
Kress JP et al.
‘Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation’.
The New England Journal of Medicine 342, no. 20 (18 May 2000): 1471–1477. doi:10.1056/NEJM200005183422002.
Lightowler JV et al
‘Non-Invasive Positive Pressure Ventilation to Treat Respiratory Failure Resulting from Exacerbations of Chronic Obstructive Pulmonary Disease: Cochrane Systematic Review and Meta-Analysis’.
BMJ 326, no. 7382 (25 January 2003): 185–185. doi:10.1136/bmj.326.7382.185.
ACCEPT – Martin CM et al.
‘Multicentre, Cluster-Randomized Clinical Trial of Algorithms for Critical-Care Enteral and Parenteral Therapy (ACCEPT)’.
CMAJ: Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne 170, no. 2 (20 January 2004): 197–204.
McQuillan P et al.
‘Confidential Inquiry into Quality of Care before Admission to Intensive Care’.
BMJ (Clinical Research Ed.) 316, no. 7148 (20 June 1998): 1853–1858.
ARDSNET PAC – Wheeler AP et al.
Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute Lung Injury’.
The New England Journal of Medicine 354, no. 21 (25 May 2006): 2213–2224. doi:10.1056/NEJMoa061895.
Palevsky PM et al.
Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury’.
N Engl J Med 359, no. 1 (2008): 7–20.
MENDS – Pandharipande PP et al.
Effect of Sedation with Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients: The MENDS Randomized Controlled Trial’.
JAMA: The Journal of the American Medical Association 298, no. 22 (12 December 2007): 2644–2653. doi:10.1001/jama.298.22.2644.
CESAR – Peek G et al.
‘Conventional Ventilatory Support vs Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure’.
BMC Health Services Research 6, no. 1 (2006): 163.
Simpson F & Doig GS.
‘Parenteral vs. Enteral Nutrition in the Critically Ill Patient: A Meta-Analysis of Trials Using the Intention to Treat Principle’.
Intensive Care Medicine 31, no. 1 (January 2005): 12–23. doi:10.1007/s00134-004-2511-2.
Sud, SM et al.
‘Effect of Mechanical Ventilation in the Prone Position on Clinical Outcomes in Patients with Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis’.
Canadian Medical Association Journal 178, no. 9 (22 April 2008): 1153–1161. doi:10.1503/cmaj.071802.

A standard ICU day

(Download page as docx)   Sample daily routine on the ICU   Example time Activity   0800 Handover   0830-1200   Ward round Format depends on unit and consultant Patient review 1200 Radiography round Depends on unit whether these happen at all 1230 Microbiology round 1300 Lunch Whenever you can 1330   Post-ICU clinic etc …

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Core papers

Historic and landmark – a broad sample (Based on the ICU top-twenty by Dr J Chantler – with thanks) Try these ten(ish) first: EGDT – Rivers E et al. ‘Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock’. New England Journal of Medicine 345, no. 19 (2001): 1368–1377. Bottom line review   Cook DJ …

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Fluid resuscitation in a nutshell

From Myburgh and Mythen’s marvellous monograph  Myburgh, John A., and Michael G. Mythen. ‘Resuscitation Fluids’.  New England Journal of Medicine 369, no. 13 (26 September 2013): 1243–1251. doi:10.1056/NEJMra1208627.  Principles Fluid requirements change over time in critically ill patients. Fluids should be administered with the same caution that is used with any intravenous drug. Consider the type, …

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Never events on ICU

Serious incidents that are wholly preventable Potential to cause serious patient harm or death (whether or not harm actually happened) Protective national recommendations should have been implemented by all healthcare providers   (From the NHS 2015 updated never-events list.) Many of these may seem ridiculously obvious but the point is that they happen, and should never. …

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Resources for new starters

Key Topics Airway problems (particularly good for the non-anaesthetist, and me) – the VORTEX free ebook Acute fluid guidance – Fluid resuscitation in a nutshell Doing less harm – FAST HUG explanation Mechanical ventilation – ccmtutorials website (This is either temporarily down or gone as of 29/2/16) Respiratory failure algorithm – GSTT severe respiratory failure protocol Trachesotomy information and algorithms – …

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Top guidelines

Endotracheal tube and tracheostomy complications NAP4 algorithms Periarrest arrhythmias Refresh your knowledge (Resus UK) Major Haemorrhage European trauma haemorrhage guidelines 2013 Surviving sepsis guidelines initial resuscitation haemodynamic support other supportive therapy (kids) Brain trauma BTF guidelines 2016 summary Generic elevated ICP algorithm

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