Thread by @jholloway_MD

ICU pre-rounding tips:
I feel like early on, knowing what matters in the ICU is REALLY tough. So here’s what I typically do:
A 🧵 inspired by @akhadilkarMD’s pre-round thread (you should check that one out too!)

#MedTwitter #MedEd #CritCare #ICU #medicine #criticalcare

1. If you can get at least some of this information automated for a printout, that can be invaluable. Whether that’s an updateable .dotphrase or a printable page from EPIC/Cerner etc. — save the carpal tunnel for later and just make notes on the data!

2. Start with a page that allows you to trend vitals. Particularly helpful is one with vitals and vasoactive gtts :
Is the MAP the same all night but the levo is down OR struggle to get a MAP >65 & escalate to a second pressor?
The #’s are important, but the TREND is essential.

Write down ranges, but make note of the vitals trends and the gtts trend.

Also note any info from advanced cardiac monitoring if present (eg PA values/trends, CO values/trends/inotropic gtts).

Conversely, if you’re working to keep a BP ⬇️, this is when you can note prns given.

Also as part of reviewing gtts, look at their sedation meds. Up? Down? Was something added overnight? These are important neuro clues for agitation or mental status changes in patients who are on a vent.

2. Vent settings:
Know the mode, oxygenation settings (eg PEEP/FiO2), ventilation settings (eg Pins or Vt, RR). + note set vs. actual RR - they may be different, & that is important.

Again note trends. (Eg increasing FiO2 is important even if SpO2 is recorded as 90 all night.)

3. I/Os:
You’ll want to note the overall ins/outs, but UOP and drain/chest tube output are king. Good to note where large fluid ins might come from (eg unconcentrated infusion) and make sure nothing stands out as crazy (eg huge NGT output).

4. Labs etc:
Again, trends are important. ICU patients have labs more frequently drawn than your floor patients. A hgb of 8 is important in a fresh post-op whose hgb was 12 two hours ago.

Note ABGs & correlate this to the vent and vitals info you’ve gathered.

Check micro data.

5. Imaging:
If a CXR is done, look at it. Never order imaging you don’t intend to use for decision making (eg daily CXR just because they’re in the ICU). If the TTE was read overnight, make note of that. If there was a stroke concern and the MRI brain was read, make notes.

6. Notes review:
Check to see if consultants have dropped their notes. Peep to see if the overnight team wrote about an event that was forgotten at handoff. Look through any nursing notes from overnight.

7. Do a final double check through meds administered and current orders:
Make sure nothing was missed or note why it was. Take a look at an insulin gtt and consider switching to SSI. D/c inactive drips.

8. Finally, make sure you TALK TO THEIR OVERNIGHT NURSE.

Nurses are invaluable to patient success in the ICU and know more about their night than you can gather from the chart. If you have to postpone pre-rounding to make sure you talk to them before night shift leaves, DO IT.

Honorable mentions:
- ECMO patients - review ECMO setting changes (flow, FiO2, sweep)
- Impella - note P-level changes, flow
- CRRT - know how much is being pulled (or not), extra credit for checking solution (eg 4k bath vs no K, citrate?)

Etc.

At the end, sit and organize this data in context of problems or systems (presentation format will differ by ICU/attending preference).

Thoughts? Anything missed? Use a different order for ICU pre-rounding? Drop a comment!