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MICU student guide common conditions procedures medications monitoring
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π₯ MICU Student Survival Guide
Medical Student Edition
1. ORIENTATION - What the MICU Is
The Medical Intensive Care Unit (MICU) manages the sickest medical patients: septic shock, respiratory failure, multi-organ dysfunction, metabolic emergencies, overdoses, and more. As a student, your goals are:
- Understand the physiologic reasoning behind every order
- Know the Big 5 conditions cold (see below)
- Learn to read the monitors and recognize deterioration early
- Participate in procedures under supervision
- Present concise, organized ICU notes on rounds
2. THE BIG 5 MICU CONDITIONS
A. Sepsis & Septic Shock
Definition (Sepsis-3):
- Sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score increase β₯2)
- Septic shock = sepsis + vasopressor requirement to maintain MAP β₯65 mmHg + lactate >2 mmol/L despite adequate fluid resuscitation
Hemodynamic pattern (distributive shock):
| Parameter | Finding |
|---|---|
| Cardiac Index (CI) | Normal to β |
| SVR | β (vasodilation) |
| ScvO2 | Normal to β (poor O2 extraction) |
| RAP/PAOP | Normal to β |
The 1-hour bundle (Surviving Sepsis Campaign):
- Measure lactate - re-measure if initial lactate >2 mmol/L
- Blood cultures x2 before antibiotics
- Broad-spectrum antibiotics within 1 hour
- 30 mL/kg IV crystalloid (balanced - e.g., Lactated Ringer's) if hypotensive or lactate β₯4
- Start vasopressors (norepinephrine) if MAP <65 mmHg despite fluids
First-line vasopressor: Norepinephrine (alpha-1 dominant, some beta-1). Add vasopressin 0.03 units/min as second agent to spare NE dose. Dopamine is no longer preferred due to higher arrhythmia risk.
Key point for students: Fluid balance matters - multiple trials (ProCESS, ARISE, ProMISe) showed that aggressive EGDT protocols did not improve mortality over standard care. Modern approach: give 30 mL/kg initially, then assess fluid responsiveness (passive leg raise, pulse pressure variation) before more fluid. Positive fluid balance is independently associated with mortality. - Miller's Anesthesia, 10e
B. Respiratory Failure & ARDS
4 types of respiratory failure:
| Type | Mechanism | PaO2 | PaCO2 | Example |
|---|---|---|---|---|
| I (Hypoxemic) | V/Q mismatch, shunt | β | Normal/β | ARDS, pneumonia, PE |
| II (Hypercapnic) | Hypoventilation | β | β | COPD exacerbation, OD |
| III (Periop) | Atelectasis | β | Variable | Post-op patients |
| IV (Shock) | High O2 demand, low delivery | β | Variable | Circulatory shock |
ARDS Berlin Criteria:
- Onset within 1 week of clinical insult
- Bilateral opacities on CXR/CT not explained by effusion or atelectasis
- PaO2/FiO2 ratio: Mild 200-300, Moderate 100-200, Severe <100 (on PEEP β₯5)
- Not fully explained by cardiac failure
Lung-Protective Ventilation for ARDS (ARDSnet):
- Tidal Volume: 4-6 mL/kg predicted body weight (not actual!)
- Plateau pressure β€30 cmH2O
- PEEP: higher PEEP for worse hypoxemia (use PEEP-FiO2 table)
- Allow permissive hypercapnia (pH β₯7.20)
- Prone positioning β₯16 hours/day for severe ARDS (PaO2/FiO2 <150) - reduces mortality
Oxygen delivery options (low to high):
| Device | FiO2 | Notes |
|---|---|---|
| Nasal cannula | 24-44% | 1-6 L/min |
| Simple face mask | 35-50% | |
| Non-rebreather mask | 60-80% | |
| High-flow nasal cannula (HFNC) | Up to 100% | 10-60 L/min, also adds PEEP, reduces intubation need in some cases |
| NIV (BiPAP/CPAP) | Variable | Best for COPD, cardiogenic pulmonary edema |
| Intubation + mechanical ventilation | Variable | Definitive airway |
C. Shock (All 4 Types)
The hemodynamic table is your cheat sheet. Know it cold - Washington Manual of Medical Therapeutics:
| Type | CI | SVR | SvO2 | RAP | PAOP |
|---|---|---|---|---|---|
| Cardiogenic | β | β | β | β | β |
| Hypovolemic | β | β | β | β | β |
| Distributive (septic) | N-β | β | N-β | N-β | N-β |
| Obstructive (PE, tamponade) | β | β-N | N-β | β | N-β |
Goal MAP: β₯65 mmHg in most patients (higher in chronic hypertension - target 70-80 mmHg)
Fluid resuscitation tip: Assess "fluid responsiveness" before giving more fluid:
- Passive leg raise (PLR): Raise legs 45Β° β if SBP increases >10%, patient is fluid-responsive
- Pulse pressure variation (PPV): PPV >13% on controlled ventilation = fluid-responsive
D. Acute Kidney Injury (AKI)
KDIGO Staging:
| Stage | Creatinine Criteria | Urine Output |
|---|---|---|
| 1 | Γ1.5-1.9 baseline, or ββ₯0.3 in 48h | <0.5 mL/kg/h for 6-12h |
| 2 | Γ2.0-2.9 baseline | <0.5 mL/kg/h for β₯12h |
| 3 | Γ3.0 baseline, or Cr β₯4.0, or RRT started | <0.3 mL/kg/h for β₯24h or anuria β₯12h |
Common causes in MICU: Sepsis (most common), nephrotoxic drugs (vancomycin, aminoglycosides, contrast, NSAIDs), hypovolemia, abdominal compartment syndrome.
Management: Treat underlying cause, optimize fluids/MAP, hold nephrotoxins, adjust drug doses, monitor for hyperkalemia/acidosis. Indications for emergency RRT: refractory hyperkalemia, severe acidosis (pH <7.1), uremic complications, fluid overload not responding to diuresis.
E. Altered Mental Status / Delirium
ICU Delirium affects 30-80% of mechanically ventilated patients. Use the CAM-ICU scale to assess.
THINK mnemonic for causes:
- T - Toxic (medications, especially benzos, opioids, anticholinergics)
- H - Hypoxia / Hypoglycemia
- I - Infection / Inflammation
- N - Non-convulsive seizures / Neurologic
- K - K (electrolytes), other metabolic
ABCDEF Bundle (evidence-based ICU bundle):
- A - Assess/manage pain (CPOT or NRS scale)
- B - Spontaneous Breathing Trials (SAT + SBT daily)
- C - Choice of sedation (prefer dexmedetomidine or propofol over benzodiazepines)
- D - Delirium assess/management
- E - Early mobility/Exercise
- F - Family engagement
3. KEY MICU MEDICATIONS
Vasopressors / Inotropes
| Drug | Receptors | Use | Dose Range |
|---|---|---|---|
| Norepinephrine | Ξ±1 > Ξ²1 | 1st line septic/distributive shock | 0.01-3 mcg/kg/min |
| Vasopressin | V1 (smooth muscle) | Add-on in septic shock | 0.03-0.04 units/min (fixed) |
| Epinephrine | Ξ±1, Ξ²1, Ξ²2 | Anaphylaxis, refractory shock | 0.01-1 mcg/kg/min |
| Dobutamine | Ξ²1 >> Ξ²2 | Cardiogenic shock (low CO) | 2-20 mcg/kg/min |
| Dopamine | DA, Ξ²1, Ξ±1 | Rarely used now | 5-20 mcg/kg/min |
| Phenylephrine | Ξ±1 pure | Vasodilatory states (avoid if low CO) | 0.5-6 mcg/kg/min |
Sedation Ladder
- Propofol - first-line for intubated patients; monitor for propofol infusion syndrome (rare, with prolonged high doses - watch for metabolic acidosis, elevated triglycerides)
- Dexmedetomidine (Precedex) - alpha-2 agonist; less delirium, allows wake-up, no respiratory depression; causes bradycardia
- Midazolam/lorazepam - avoid benzodiazepines when possible (β delirium)
- Ketamine - third-line for infusion, 1-5 mg/kg/hr
Analgesia
- Start with scheduled acetaminophen Β± IV fentanyl PRN (preferred over morphine in renal failure)
- Target CPOT <3 or NRS <4
- Analgesia-first approach: treat pain before adding sedation
Common ICU Antibiotics
| Scenario | Empiric Choice |
|---|---|
| Sepsis (unknown source) | Pip-tazo (piperacillin-tazobactam) + consider vancomycin for MRSA coverage |
| CAP requiring ICU | Ceftriaxone + azithromycin OR respiratory fluoroquinolone |
| HAP/VAP | Piperacillin-tazobactam or cefepime + vancomycin if MRSA risk |
| Meningitis | Ceftriaxone + ampicillin (if >50y, immunocompromised) + dexamethasone |
| Neutropenic fever | Cefepime or pip-tazo (add vanc if suspected line infection) |
4. MONITORING - What Every Number Means
Arterial Line (A-line)
- Continuous beat-to-beat BP; also allows frequent ABG sampling
- Placed in radial artery (most common), femoral, or brachial artery
- Waveform: Systolic peak β dicrotic notch (aortic valve closure) β diastolic
- Wide pulse pressure variation with respiratory cycle = fluid-responsive
Central Venous Catheter (CVC)
- Sites: Internal jugular (most common), subclavian, femoral
- Used for: vasopressors, TPN, CVP monitoring, access for multiple drips
- CVP is a poor predictor of fluid status alone - use it as one data point
- Bundle to prevent CLABSI: hand hygiene, chlorhexidine prep, maximal sterile barrier, optimal site (avoid femoral), daily removal assessment
Ventilator Parameters (Know These!)
| Parameter | What It Tells You |
|---|---|
| FiO2 | Fraction of inspired oxygen - try to wean to β€60% to avoid O2 toxicity |
| PEEP | Keeps alveoli open - watch for barotrauma if high |
| Tidal Volume (Vt) | Keep 4-6 mL/kg IBW in ARDS |
| Plateau Pressure (Pplat) | Lung compliance marker - keep β€30 cmH2O |
| Driving Pressure | Pplat - PEEP - keep <15 cmH2O; stronger mortality predictor |
| PaO2/FiO2 ratio | ARDS severity - calculate from ABG |
ABG Interpretation (Systematic Approach)
- pH: acidosis (<7.35) or alkalosis (>7.45)?
- PaCO2: respiratory component (βCO2 = respiratory acidosis)
- HCO3-: metabolic component (βHCO3- = metabolic acidosis)
- Compensation: is it appropriate? (Winter's formula for metabolic acidosis: expected PaCO2 = 1.5ΓHCO3- + 8 Β± 2)
- PaO2: is oxygenation adequate?
- AG = Na - (Cl + HCO3-); normal 8-12 mEq/L
5. COMMON PROCEDURES (Student Role = Observe & Assist)
| Procedure | Indication | Key Points to Know |
|---|---|---|
| Endotracheal intubation | Respiratory failure, airway protection | RSI: succinylcholine or rocuronium + propofol/ketamine; confirm with end-tidal CO2 + CXR |
| Central line placement | Vasopressors, access, CVP | Ultrasound-guided, sterile technique, confirm with CXR |
| Arterial line | Continuous BP, ABGs | Radial artery; Allen's test; watch for distal ischemia |
| Thoracentesis/chest tube | Large pleural effusion, pneumothorax | Ultrasound-guided; watch for pneumothorax, re-expansion edema |
| Bronchoscopy | VAP diagnosis, mucus plugging, hemoptysis | BAL sample for culture |
| Lumbar puncture | Meningitis/encephalitis, SAH | Check platelets, INR; CT head first if papilledema/focal neuro signs |
| Dialysis (CRRT) | Renal failure, fluid overload, toxin removal | Continuous renal replacement therapy preferred in hemodynamically unstable |
6. THE ICU NOTE / DAILY ASSESSMENT
Pre-rounding Checklist (Check BEFORE rounds)
- Vital signs trend: HR, BP, MAP, RR, SpO2, Temp, UO/hr
- Latest labs: CBC, BMP, lactate, coags, LFTs if relevant
- ABG if intubated
- Vent settings and any changes overnight
- Blood cultures + culture results
- Lines: Dates of central lines/arterial lines (removal when no longer needed)
- Medications: drip rates, new orders, held meds
- Inputs/Outputs: fluid balance (daily and cumulative)
- Imaging: any new CXRs, CT scans overnight
- Nursing notes: any acute events overnight
ICU Note Format (SOAP or Systems-Based)
One-liner: "Mr. X is a 65M with septic shock from pneumonia, now HD day 3, intubated on AC/VC, NE 0.15 mcg/kg/min."
Systems review:
- Neuro: Mental status/sedation level (RASS score), pain (CPOT), delirium (CAM-ICU)
- Cardiovascular: HR, BP, MAP, vasopressor requirements, fluid balance
- Respiratory: Vent mode, settings (FiO2, PEEP, Vt, RR), SpO2, last ABG, latest CXR
- Renal: UO, Cr trend, electrolytes, fluid balance, need for RRT?
- GI/Nutrition: Bowel function, tube feeds (rate, tolerance), residuals
- Heme: Hgb, platelets, anticoagulation, VTE prophylaxis
- ID/Micro: Fever curve, WBC, culture results, antibiotic day and duration
- Lines/Tubes/Drains: All invasive lines, dates, necessity review
- Prophylaxis: DVT (SQ heparin or LMWH vs SCDs), GI (PPI or H2 blocker), skin integrity
7. RAPID FIRE MNEMONICS
| Mnemonic | Meaning |
|---|---|
| SOFA | Sepsis-related Organ Failure Assessment (resp, coag, liver, cardio, CNS, renal) |
| RASS | Richmond Agitation-Sedation Scale (-5 unarousable β +4 combative); target -1 to 0 |
| CAM-ICU | Confusion Assessment Method for ICU; checks acute change + inattention + altered consciousness/disorganized thinking |
| FAST HUG BID | Daily ICU checklist: Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of bed elevation (30Β°), Ulcer prophylaxis, Glycemic control, Breathing trial, Indwelling catheter review, De-escalate antibiotics |
| DDD | For metabolic acidosis: Diarrhea/Renal tubular acidosis (non-AG); Diabetic ketoacidosis/Lactic acidosis/Toxins (AG) |
8. MUST-KNOW TARGETS IN MICU
| Parameter | Target |
|---|---|
| MAP | β₯65 mmHg (higher in chronic hypertension) |
| SpO2 | 92-96% (avoid hyperoxia) |
| PaO2 | 55-80 mmHg |
| Blood glucose | 140-180 mg/dL (avoid hypoglycemia!) |
| Head of bed | β₯30Β° (VAP prevention) |
| Tidal volume | 4-6 mL/kg IBW |
| Temperature | Target normothermia; treat fever (infection source!) |
| Lactate | <2 mmol/L; clear within 2-4 hours in sepsis |
| Hemoglobin | Transfuse if Hgb <7 g/dL in stable patients (higher threshold in ACS/cardiac) |
9. STUDENT SURVIVAL TIPS
- Show up early. Pre-round independently - gather all data before attendings arrive.
- Know your patient's trajectory. "Compared to yesterday" is the key phrase in ICU.
- Learn the vent. Ask the respiratory therapist to walk you through the ventilator - they are your best resource.
- Don't just present numbers - interpret them. "Lactate decreased from 6 to 2.1 - patient is responding to resuscitation" is better than just listing the value.
- Ask about the goals of care. ICU patients often have complex family dynamics and code status discussions - observe and learn.
- Use FAST HUG BID daily to make sure nothing is missed for every patient.
- Procedures: Ask to observe and scrub in - it's expected and welcomed in MICU.
- Bedside ultrasound (POCUS): Learn the basics - cardiac (LV function, effusion), lung (B-lines for pulmonary edema, pneumothorax), IVC (fluid responsiveness), vascular (access assessment).
Key references:
- Washington Manual of Medical Therapeutics - Hemodynamic shock chapter
- Miller's Anesthesia 10e - Hemodynamic resuscitation in shock
- SCCM Medical Student's Guide to the ICU (sccm.org)
- UBC Critical Care Survivor Manual (free PDF - excellent for students)
- Surviving Sepsis Campaign 2021 Guidelines
This guide covers the core of what you'll encounter in the MICU. Let me know if you want a deeper dive into any specific section - ventilator management, sepsis bundles, specific medications, or ECG/monitoring interpretation.
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