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🏥 MICU Student Survival Guide

Medical Student Edition

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1. ORIENTATION - What the MICU Is

• 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

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2. THE BIG 5 MICU CONDITIONS

A. Sepsis & Septic Shock

• Sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score increase ≥2)
• Septic shock = sepsis + vasopressor requirement to maintain MAP ≥65 mmHg + lactate >2 mmol/L despite adequate fluid resuscitation

1. Measure lactate - re-measure if initial lactate >2 mmol/L
2. Blood cultures x2 before antibiotics
3. Broad-spectrum antibiotics within 1 hour
4. 30 mL/kg IV crystalloid (balanced - e.g., Lactated Ringer's) if hypotensive or lactate ≥4
5. Start vasopressors (norepinephrine) if MAP <65 mmHg despite fluids

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B. Respiratory Failure & ARDS

• 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 ≥5)
• Not fully explained by cardiac failure

• Tidal Volume: 4-6 mL/kg predicted body weight (not actual!)
• Plateau pressure ≤30 cmH2O
• PEEP: higher PEEP for worse hypoxemia (use PEEP-FiO2 table)
• Allow permissive hypercapnia (pH ≥7.20)
• Prone positioning ≥16 hours/day for severe ARDS (PaO2/FiO2 <150) - reduces mortality

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C. Shock (All 4 Types)

• Passive leg raise (PLR): Raise legs 45° → if SBP increases >10%, patient is fluid-responsive
• Pulse pressure variation (PPV): PPV >13% on controlled ventilation = fluid-responsive

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D. Acute Kidney Injury (AKI)

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E. Altered Mental Status / Delirium

• T - Toxic (medications, especially benzos, opioids, anticholinergics)
• H - Hypoxia / Hypoglycemia
• I - Infection / Inflammation
• N - Non-convulsive seizures / Neurologic
• K - K (electrolytes), other metabolic

• 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

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3. KEY MICU MEDICATIONS

Vasopressors / Inotropes

Sedation Ladder

1. Propofol - first-line for intubated patients; monitor for propofol infusion syndrome (rare, with prolonged high doses - watch for metabolic acidosis, elevated triglycerides)
2. Dexmedetomidine (Precedex) - alpha-2 agonist; less delirium, allows wake-up, no respiratory depression; causes bradycardia
3. Midazolam/lorazepam - avoid benzodiazepines when possible (↑ delirium)
4. Ketamine - third-line for infusion, 1-5 mg/kg/hr

Analgesia

• Start with scheduled acetaminophen ± 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

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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 → dicrotic notch (aortic valve closure) → 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!)

ABG Interpretation (Systematic Approach)

1. pH: acidosis (<7.35) or alkalosis (>7.45)?
2. PaCO2: respiratory component (↑CO2 = respiratory acidosis)
3. HCO3-: metabolic component (↓HCO3- = metabolic acidosis)
4. Compensation: is it appropriate? (Winter's formula for metabolic acidosis: expected PaCO2 = 1.5×HCO3- + 8 ± 2)
5. PaO2: is oxygenation adequate?
6. AG = Na - (Cl + HCO3-); normal 8-12 mEq/L

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5. COMMON PROCEDURES (Student Role = Observe & Assist)

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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)

• 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

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7. RAPID FIRE MNEMONICS

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8. MUST-KNOW TARGETS IN MICU

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9. STUDENT SURVIVAL TIPS

1. Show up early. Pre-round independently - gather all data before attendings arrive.
2. Know your patient's trajectory. "Compared to yesterday" is the key phrase in ICU.
3. Learn the vent. Ask the respiratory therapist to walk you through the ventilator - they are your best resource.
4. 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.
5. Ask about the goals of care. ICU patients often have complex family dynamics and code status discussions - observe and learn.
6. Use FAST HUG BID daily to make sure nothing is missed for every patient.
7. Procedures: Ask to observe and scrub in - it's expected and welcomed in MICU.
8. Bedside ultrasound (POCUS): Learn the basics - cardiac (LV function, effusion), lung (B-lines for pulmonary edema, pneumothorax), IVC (fluid responsiveness), vascular (access assessment).

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• 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

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🖥️ MICU Machines: How to Read Them + Patient Transfer Guide

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PART 1: MACHINES IN THE MICU - What They Are & How to Read Them

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1. 🫀 Cardiac / Bedside Monitor (Multi-Parameter Monitor)

1. Look at rate - is it fast, slow, or normal?
2. Look at rhythm - regular or irregular?
3. Look at P waves - present before every QRS?
4. Look at QRS width - narrow (<0.12s = normal) or wide?
5. Look at ST segment - elevated or depressed?

• Red alarm = critical (HR <40 or >150, SpO2 <85%, life-threatening arrhythmia)
• Yellow alarm = warning (mild parameter drift)
• Never silence alarms without assessing the patient first

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2. 🫁 Mechanical Ventilator

• Pressure-time curve: Should rise smoothly, not have a "notch" (notch = patient fighting the vent)
• Flow-time curve: Should return to zero before next breath (if doesn't = auto-PEEP / air trapping in COPD/asthma)
• Volume-time curve: Consistent; sudden drop = circuit disconnect

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3. 💉 Infusion Pumps (Syringe Pumps / Volumetric Pumps)

• Norepinephrine / Vasopressin (vasopressors)
• Propofol / Dexmedetomidine (sedation)
• Fentanyl / Morphine / Hydromorphone (analgesia)
• Heparin (anticoagulation)
• Insulin (glucose control)
• Broad-spectrum antibiotics (intermittent, not continuous)

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4. 🩸 Arterial Line Monitor (Invasive Blood Pressure)

       Peak (Systolic BP)
      /\
     /  \
    /    \  Dicrotic Notch (aortic valve closes)
   /      \/\___
             Diastolic BP

• Sharp upstroke = good cardiac contractility
• Dicrotic notch = aortic valve closure (should be visible)
• Slow upstroke + small amplitude = low cardiac output, hypovolemia
• Wide swings with breathing = patient is fluid-responsive (>13% pulse pressure variation = give fluid)
• Dampened/flat waveform = clot in line, kink, or transducer not leveled - check before acting!

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5. 🫀 Central Venous Pressure (CVP) Line

• a wave = atrial contraction
• c wave = tricuspid valve closure
• v wave = venous filling of the atrium

• High CVP (>12) + low BP = cardiogenic or obstructive shock
• Low CVP (<2) + low BP = hypovolemia
• Important: CVP alone is a poor predictor of fluid responsiveness - always interpret with the whole clinical picture

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6. 🩹 Pulse Oximeter (SpO2)

• SpO2 % - oxygen saturation (normal ≥95%)
• Heart rate - derived from the pulse waveform
• Plethysmographic (pleth) waveform - pulse wave; should be strong and regular

• Nail polish, dark skin pigmentation → falsely LOW SpO2
• Hypothermia / poor perfusion → poor waveform, unreliable reading
• Carbon monoxide poisoning → falsely NORMAL SpO2 (CO-oximetry needed)
• Motion artifact → erratic waveform; clamp digit loosely or move to ear probe

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7. 🌡️ Temperature Monitoring

• Bladder catheter temp probe = most continuous and accurate in ICU
• Rectal probe = accurate but uncomfortable
• Axillary = often 0.5-1°C lower than core - unreliable in ICU
• Fever ≥38.3°C in ICU = look for infection source (do blood cultures, CXR, UA)
• Hypothermia <36°C = watch for coagulopathy, arrhythmias, reduced drug clearance

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8. 💧 Foley Catheter + Urine Output Meter

• Hourly urine output is one of the most sensitive markers of perfusion
• Target: ≥0.5 mL/kg/hr
• Oliguria (<0.5 mL/kg/hr for >6 hours) = early AKI alarm
• Fluid balance = total inputs minus total outputs over 24 hours

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9. 🌀 Sequential Compression Devices (SCDs) + Specialty Equipment

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PART 2: HOW A PATIENT IS TRANSFERRED FROM MICU TO THE GENERAL WARD

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Step 1: DETERMINE READINESS (Is the patient safe to go?)

• Cause of respiratory failure resolved
• pH >7.25, FiO2 ≤50%, PEEP ≤5-8 cmH2O
• Hemodynamically stable (no/minimal vasopressors)
• Awake, cooperative, following commands
• RSBI ≤105 (Respiratory Rate ÷ Tidal Volume in Liters)
• Passes a Spontaneous Breathing Trial (SBT) of 30-120 minutes on PS 5/PEEP 5 or T-piece without: RR >35, SpO2 <90%, HR or BP change >20%, increased work of breathing or distress
• Adequate cough and gag reflex
• Morgan & Mikhail's Clinical Anesthesiology, 7e and Washington Manual of Medical Therapeutics

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Step 2: THE WEANING PROCESS (Gradual removal of support)

Full Ventilator Support
        ↓
Reduce FiO2 + PEEP gradually
        ↓
Daily Spontaneous Awakening Trial (SAT) - stop sedation
        ↓
Daily Spontaneous Breathing Trial (SBT) - PS 5 / PEEP 5
        ↓
Extubation → HFNC or NIV if at risk → Nasal cannula → Room air
        ↓
Vasopressor weaning (reduce by 10-20% every 1-2 hours if MAP stable)
        ↓
IV-to-oral medication conversion
        ↓
Remove arterial line (when no longer needs frequent ABGs or continuous BP)
        ↓
Remove central line (when vasopressors stopped + peripheral access adequate)
        ↓
TRANSFER READY

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Step 3: PRECAUTIONS TAKEN BEFORE TRANSFER

• Confirm receiving ward can manage the patient's remaining needs
• Ensure no pending critical labs or imaging results outstanding
• Convert all IV medications to oral/subcutaneous equivalents
• Ensure all lines dated and assessed for removal
• Check code status and document clearly
• Verify no overnight deterioration risk (do NOT transfer if high overnight risk)
• Confirm VTE prophylaxis, GI prophylaxis, and skin care orders are set

• Transfer during daytime hours only (nighttime transfers have 31% higher in-hospital mortality risk)
• Avoid weekends if possible (less specialist availability on the ward)
• Ensure receiving ward is staffed and prepared before the patient moves

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Step 4: THE HANDOVER (Most Critical Step)

• Reason for ICU admission and course summary
• Key diagnoses and active problems
• Medications - especially new ones started in ICU (and drugs stopped)
• Antibiotic name, start date, intended duration and stop date
• Lines and when to remove (e.g., "PICC line inserted, can be used for IV antibiotics")
• Pending results (cultures, biopsies, labs)
• Goals of care / code status
• Follow-up plans (respiratory therapy, physio, nutrition, wound care)
• Warning signs to watch for (what should trigger calling for help or activating MET/RRT)

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Step 5: ACTIONS ON THE WARD AFTER TRANSFER

• Vital signs every 2-4 hours (vs every 1 hour in ICU)
• Oxygen saturations monitored (step down monitoring, not full cardiac monitoring in most wards)
• Intake and output every 8 hours
• Blood glucose as per insulin protocol
• Morning labs as ordered (CBC, BMP, cultures if still pending)

• Weakness and deconditioning (ICU-acquired weakness)
• Delirium continuing into the ward
• PTSD-like symptoms (nightmares, anxiety about ICU)
• Nutritional deficits
• Pressure ulcers

• Explain why the move is happening ("You are getting better")
• Explain the new monitoring level (fewer alarms is normal, not dangerous)
• Encourage mobilization, oral feeding, and self-care
• Introduce the ward nurse and explain who to call for help

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Step 6: CRITERIA THAT WOULD CANCEL or REVERSE THE TRANSFER

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Quick Summary Visual

MICU Patient
     │
     ├── All machines → Wean gradually (vent, vasopressors, monitoring)
     │
     ├── Meet transfer criteria (airway, breathing, circulation, neuro stable)
     │
     ├── Precautions: daytime transfer, full handover, ward prepared
     │
     ├── ISBAR handover → ICU to ward nurse + doctor
     │
     └── Ward: q4h vitals, watch for deterioration, mobilize, educate

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