Rules of thumb for the ICU

1. When a patient deteriorates suddenly, think of the ABC's, resuscitate and stabilize the patient. Once the patient is stable, try to determine the underlying cause for the episode. Do what the patient needs done at that moment, but always try to determine the cause later.
2. There should be only one person in charge of cardiopulmonary resuscitation. Resuscitation team members must accept delegation of tasks and remain focused on those duties.
3. Familiarity with ACLS recommendations is necessary for all members of the team.
4. Don't slow down a sinus tachycardia with medications. Treat the cause.
5. Shock is about perfusion not the BP. Always assess for signs of adequate or inadequate perfusion; warm extremities, good urine output, normal mental status.
6. When you are uncertain whether a patient has sepsis or not, ask yourself how sick the patient is. Begin presumptive antibiotic therapies immediately if the patient is very sick (hemodynamically unstable or potentially unstable). If not, pan culture and wait and see how he or she progresses and what the culture results will be.
7. When called to assess a patient with new agitation, confusion, or altered mental status always consider possibilities of hypoxia, hypercarbia, hypoglycemia, inadequate cerebral perfusion, and medication reactions (among other causes) before simply sedating the patient.
8. When faced with a patient with declining renal failure or oliguria of uncertain etiology, it is usually more prudent to assume that the cause is pre-renal and give a fluid challenge, unless there are already signs of volume overload with respiratory compromise.
9. When faced with a patient with an acute brain injury (trauma, SAH, CVA, ICH, etc), try to minimize the possibility of secondary brain injury. Avoid hyperglycemia, hypoglycemia, hypoxia, hypotension, fever, and electrolyte abnormalities.
10. Remember that most therapies have adverse as well as beneficial effects. It is important to titrate therapy to a desired positive therapeutic endpoint, with titration against negative effects.
11. It helps to be smart in the ICU but it is more important to pay attention to the small details.
12. Treat the patient not the monitor.
13. Never assume the obvious.
14. Nothing in medicine stays constant.
15. Before ordering a test, decide what you will do if it is positive and what you will do if it is negative. If the answers to each are the same, then don't do the test.
16. No organ ever fails in isolation.
17. Remember the three cardinal rules of Anaesthesia; trust no-one, believe nothing, and give oxygen.

Central lines, catheters, and monitoring

1. Remember that central lines are invasive and thus have risks associated with insertion. Make sure that the benefits outweigh the risks before inserting one.
2. Remember that central lines are invasive and carry a risk of infection each day they remain. Examine every central line site each day for signs of infection and remove the line immediately if signs of infection are present.
3. Remember that central lines are invasive and carry a risk of infection each day they remain. Consider whether your patient still requires a central line each and every day. Remove them as soon as possible.
4. Any time a catheter is not functioning properly, the first question you should ask is "Does the patient still need this?"
5. Pulmonary artery catheters provide data, not judgment.
6. Trends are more important than single values.

Communication

1. Listen to the nurses and respect what they have to say. Like you, they are sometimes right and sometimes wrong.
2. Never ignore an ICU nurses observation.
3. Be kind to the nurses and they will be kind to you. Be unkind to the nurses and they will make your life miserable.
4. The nurses, respiratory technicians, pharmacists, and dieticians in the ICU all have an agenda. You also have an agenda. Communicate well with all of them to ensure that you and everyone else are pursuing the patient's agenda.
5. If a patient who is intubated is awake and alert, make an effort to talk with him on rounds.
6. Speak to the patient's family members at least once per day.
7. If it cannot be read, don't write it.
8. Any order that can be misunderstood, will be misunderstood.

Complications

1. Wash your hands.
2. Make sure you are doing all you can to decrease common ICU complications such as nosocomial pneumonia, GI stress ulcers, deep venous thrombosis, bedsores, and catheter-related infections.
3. Many patients in the ICU have lost their ability to regulate their serum sodium level. The patient who comes into the ICU with a normal serum concentration and experiences hyponatremia or hypernatremia is usually the victim of iatrogenesis. Pay close attention to the volume and composition of intravenous fluids given each day.

Medications

1. Review the patient's antibiotics and culture results each day. Always try to narrow antibiotic coverage rather than broaden it. Initial antibiotic coverage should only be broadened when the patient is deteriorating. Discontinue antibiotics as soon as possible.
2. Review all patient medications each day. Look for medications that can be discontinued and discontinue them. Look for medications whose doses should be adjusted because of a recent change in renal or hepatic function.
3. Whenever a patient deteriorates, consider the possibility of an adverse drug reaction.
4. There is no manifestation that cannot be caused by a given drug.
5. It is much easier to add drugs than to subtract them.
6. If a drug is not working, stop it.

Airway

1. Maintain a healthy respect for the airway. Airway problems are the greatest source of preventable disasters.
2. The indications for intubation are to maintain airway patency (bypass an upper airway obstruction), to protect the airway, to provide positive pressure ventilation and oxygenation, or to provide tracheobronchial toilet. Be aware of what the indication is every time you intubate a patient and always ask yourself if the indication is gone before you extubate the patient.
3. Anybody (almost) can be oxygenated and ventilated with a bag and mask.
4. The art of bagging should be mastered before the art of intubation.
5. The first response to failure of bag-mask ventilation is always better bag-mask ventilation.
6. If fail on your first intubation attempt, come out, bag the patient, and think about why you failed (large tongue, small mouth, anterior larynx, etc) and plan carefully how you are going to change your second approach to increase your chance of success.
7. Confirmation of ETT position cannot be made reliably on clinical grounds in all cases. ETCO2 monitors are considered standard of care in the controlled environment of the OR, thus they should be standard of care in the ED or the ICU as well.
8. Placement of the ETT within the esophagus is an accepted complication of endotracheal intubation, failure to recognize it is not.
9. If you "can't intubate, can't ventilate" prepare to cut the neck.
10. Call for help early.
11. Not all airway failures are avoidable, Always have a back-up plan for the failed airway.

Mechanical ventilation

1. Most patients receiving mechanical ventilation do not require neuromuscular blockade. The ones that do rarely require it for more than 48 hours. Make a point of discontinuing NMB's as soon as possible.
2. A patient who is intubated and ventilated that suddenly becomes agitated should never be sedated until the following have been checked: tube patency, breath sounds, airway pressures, and oxygen saturation.