Surroundings

The ICU environment provides several clues to diagnosis and severity of illness. Key regions include:

Bedspace

  • Isolation room
    • Positive pressure
    • Negative pressure
  • Infection control and PPE
  • Waste disposal
    • Cytotoxic
  • Room temperature
    Burns.
  • Medications
    • Antibiotics
      Implications for causative organism or resistance patterns.
    • Pathognomonic medications
  • Long-stay
    • Photographs/art
    • Physical therapy equipment
    • Activity plans
  • Equipment
    • Wheelchair
    • Walking aids
    • Handweights
    • Splints
    • Cooling blanket

Monitor

  • ECG
    Rate and rhythm.
    • HR <30-35 may lead to critical coronary hypoperfusion, independent of blood pressure
  • Pressure monitoring
    • Alignment to haemodynamic supports
    • MAP <35mmHg (+/- 10mmHg) is usually the critical threshold for coronary perfusion, below which heart rate and cardiac output fall rapidly
  • EtCO2
    • Level
    • Trace
    • PaCO2 gradient and dead space
  • Temperature
  • ICP
    If transduced from EVD, ensure monitor is leveled appropriately.

Integration

Patterns:

Information from the monitor, ventilator, and medications should be combined to form a clinical impression.

e.g. “The SpO2 is 93% with an FiO2 of 50% - there is evidence of a raised A-a gradient”.

Or, “The patient is in AF, I note the heparin infusion and wonder if this is the sole indication for anticoagulation.”

  • Cushing Triad
    ↑ ICP leads to a sympathetic surge aimed to maintain cerebral perfusion, which manifests as:
    • Arterial hypertension
    • Bradycardia
    • Irregular respiration
Integration of Haemodynamic Data
Type of Shock MAP CVP CI/ MPAP PCWP
Hypovolaemic ↓/- ↓ ↓ ↓ ↓
Obstructive ↓ ↑ ↓ ↑ ↑/-
Distributive ↓ ↓ ↑ ↓ ↓
Cardiogenic: LV failure ↓/- ↑/- ↓ ↓/- ↑
Cardiogenic: RV failure ↓/- ↑ ↓ ↑/-/↓ -

Ventilator

  • Mode
  • Oxygenation
    • FiO2
    • PEEP
    • Quick assessment of A-a gradient based on SpO2 and FiO2
  • Ventilation
    • Minute ventilation
    • Dynamic compliance
      • Peak pressure
      • Plateau pressure
    • Consider assessing plateau pressure to determine static compliance if dynamic compliance is ↓
  • Disease-specific ventilation strategies
  • “Extubatable settings?”
  • Airway suction
    • Yellow, brown, green, or creamy
      Infection.
    • Foamy or foamy-bloody
      Pulmonary oedema.
    • Bloody
      Tracheal suction trauma or haemorrhage.
    • Brown
      Enteral nutrition or infection.

The colour of purulent secretions does not accurately predict the causative organism. However, in general, secretions that are:

  • Yellow, brown, or putrid
    Suggest bacterial infection of the lower airways or parenchyma.
  • Foul-smelling and yellow or dark-green
    Suggest lung abscesses or bronchiectasis.

Infusions

  • IV fluid
  • Vasoactives
  • Heparin
  • Pathognomonic drugs
    • Octreotide/terlipressin
    • Hypertonic saline
    • Hypertonic dextrose
    • Nimodipine
    • Mannitol
    • IVIG
  • TPN
  • Blood

Drains

Urine

Many abnormalities of urine colour are also visible in RRT effluent.

  • Quantity
  • Colour
    • Clear
      • Polyuria
        • Diabetes insipidus
        • Hyperglycaemia
        • Diuretic therapy
    • Concentrated
      May indicate:
      • Hypoperfusion or hypovolaemia
        Classically low-volume.
    • Turbid/purulent
      Pyuria suggesting infection.
    • Sediment
      • UTI
      • AKI
      • Presence of IDC
    • Foamy
      • Proteinuria
        Albuminuria secondary to nephrotic syndrome.
      • Urobilinogen
        Dark and foamy urine secondary to hyperbilirubinaemia.
    • Dark red
      Frank blood suggesting macrohaematuria due to to prostate, bladder, or urethral trauma.
    • Rose-coloured
      Suggests microhaematuria due to intravascular haemolysis.
    • Tea-coloured
      • Glomerulonephritis
      • Haemolytic crisis
      • Myoglobinuria
    • Blue-green
      • Methylene blue
      • Propofol
    • Bright red without blood
      Drug effects, including:
      • Rifampicin
      • Ibuprofen
      • Hydroxocobalamin
      • Porphyria
    • Clear
      Diuretic therapy.

Small volumes of light urine are concerning for obstruction.

Concentrated Urine

Pyuria

Urobilinogen

Urobilinogen in RRT Effluent

Propofol

Methylene Blue

Rifampicin

Nasogastric

  • Brown aspirates
    Commonly occur with small bowel ileus or obstruction.
  • Feculent aspirates
    Indicate lower intestinal obstruction or severe ileus.
  • Bilious aspirates
    Exclude upper GI haemorrhage.
  • Pure nasogastric feed aspirates
    Indicate gastroparesis.
Bilious Nasogastric Aspirates

Aspirated Nasogastric Feed

External Ventricular Drain

  • Set height
  • Open or closed
  • Colour of CSF

Stool

  • Faecal management system
    • Stool colour
      • Acholic stool indicates biliary obstruction due to lack of stercobilin
      • Haematochezia
      • Melaena
        Black, tarry, malodorous stool.
        • Indicates recent (4-20 hours) upper GI, small bowel, or caecal haemorrhage
        • Typically becomes bloodier the more distal the bleeding source
Acholic stool

Surgical Drains

Chest:

  • Location
    • Pleural
    • Mediastinal
  • Size
  • Output
    • Blood
    • Serous
  • Behaviour
    • Swinging
    • Bubbling

Abdominal:

Faeculent Abdominal Drainage

  • Location
  • Size
  • Output
    • Blood
    • Serous
      • Turbidity
    • Bile
    • Faeculent

Ancillary Equipment

  • CRRT
    • Mode
    • Dialysate/buffer
    • Dose
    • Anticoagulation
  • Active cooling
  • IABP

References

  1. Foot C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine. Elsevier Australia; 2011. (Examination series).
  2. Dünser MW, Dankl D, Petros S, Mer M. Clinical Examination Skills in the Adult Critically Ill Patient. Springer International Publishing; 2018.