OVERALL STRUCTURE OF ICU DAILY EXAMINATION
- Think Daily -Why patient is in ICU/Whats the need of ICU for this patient ?
- Think Daily -What can kill them today
- Assess, If you find a pathology think differential diagnosis of each pathology
- Detailed examination of the system which is involved like Neurology exam in Stroke patient
- Always Rely on Tends then single value
- Document Relevant Findings
A. IDENTIFICATION + SUMMARY
- Name, age, sex
- ICU day #
- Primary diagnosis
- Major comorbidities
- Current status (e.g., “septic shock on vasopressors and mechanical ventilation”)
B. OVERNIGHT EVENTS
- Hemodynamic instability?
- Desaturation?
- Arrhythmias?
- Procedures?
- New fever?
C. SYSTEM-WISE APPROACH
General Survey
- Consciousness: Awake / drowsy / sedated / agitated
- Body posture: Comfortable / distressed / decorticate / decerebrate
- Color:
- Pallor → anemia
- Cyanosis → hypoxia
- Jaundice → liver dysfunction
- Mottling → shock
- Nutritional status, muscle wasting
- Edema / anasarca
- Signs of distress (air hunger, accessory muscle use)
2. MONITOR ASSESSMENT (REAL-TIME PHYSIOLOGY)
Vital Parameters
- HR (rate, rhythm)
- BP (IBP preferred)
- MAP (target ≥65 mmHg unless special)
- RR
- SpO₂
- Temperature
Advanced Monitoring
- CVP / ScvO₂
- Cardiac output (if available)
- ICP (neuro ICU)
- Urine output (most important perfusion marker)
Always correlate:
- Hypotension + tachycardia → shock
- Bradycardia + hypotension → neuro / drug cause
3. AIRWAY ASSESSMENT
If Intubated:
- ETT position (cm mark at teeth)
- Tube fixation
- Air leak?
- Cuff pressure (20–30 cm H₂O)
If Not Intubated:
- Airway patency
- Gurgling / stridor
- Risk of aspiration
4. BREATHING (RESPIRATORY SYSTEM)
Inspection
- Chest rise symmetry
- Use of accessory muscles
- Ventilator synchrony
Ventilator Check
- Mode (VC/PC/PS/CPAP)
- TV, PEEP, FiO₂
- Peak & plateau pressures
- Patient-ventilator asynchrony
Auscultation
- Air entry ↓ / absent
- Crackles → ARDS/pulmonary edema
- Wheeze → bronchospasm
Correlate with:
- ABG
- Chest X-ray
5. CIRCULATION (CARDIOVASCULAR)
Inspection
- Peripheral perfusion (warm vs cold)
- Mottling
- Capillary refill time (CRT >3 sec = poor perfusion)
Pulse
- Rate, rhythm, volume
- Radio-femoral delay
Blood Pressure
- IBP waveform analysis:
- Dampened → hypovolemia
- Wide pulse pressure → sepsis
JVP (if visible)-Volume status estimation
Auscultation
- Heart sounds
- Murmurs (acute MR in sepsis/endocarditis)
6. DISABILITY (NEUROLOGICAL EXAM)
Level of Consciousness
- Glasgow Coma Scale (GCS)
- RASS score (sedation)
Pupils-Size, symmetry, reaction
Motor Response-Localizing / withdrawing / posturing
Sedation & Analgesia-Drug review (midazolam, propofol, fentanyl)
Delirium-CAM-ICU assessment
7. EXPOSURE (FULL BODY EXAM)
Skin
- Pressure sores/Rashes (drug reaction, sepsis)/Line site infection
- Temperature-Fever pattern
- Edema-Pitting vs non-pitting
8. ABDOMEN
Inspection-Distension/Surgical scars
Palpation-Tenderness/Guarding/Hepatosplenomegaly
Auscultation-Bowel sounds (ileus vs obstruction)
Check:-Intra-abdominal pressure (if indicated)
9. RENAL & FLUID STATUS
Urine Output-Target ≥0.5 ml/kg/hr
Fluid Balance Chart-Input vs output
Signs of Overload-Edema/Crackles/Raised JVP
RRT-Dialysis ongoing? Indication?
10. GASTROINTESTINAL & NUTRITION
- Feeding:Enteral vs parenteral
- Tolerance (residuals, vomiting)
- LFTs
11. INFECTION / SEPSIS
- Fever trend
- TLC / Procalcitonin
- Cultures
Antibiotics:
- Drug
- Day #
- Spectrum
12. HEMATOLOGY
- Hb, Platelets
- Coagulation (INR, aPTT)
13. MEDICATION REVIEW
- Sedation
- Analgesia
- Antibiotics
- Vasopressors
- Anticoagulants
STOP unnecessary drugs (deprescribing is key ICU skill)
14. LINES, TUBES, DRAINS
Vascular Access
- Central line (site, infection, duration)
- Arterial line waveform
Tubes
- ETT / tracheostomy
- Ryle’s tube
Drains
- Chest drain (air leak?)
- Surgical drains (amount, color)
Foley catheter
- Indication & infection risk
Remove unnecessary lines = infection prevention
15. LABS & INVESTIGATIONS CORRELATION
- ABG
- CBC
- Lactate (shock marker)
- Renal function
- LFT
- Cultures
DAILY ICU CHECKLIST FAST HUGS BID
- Feeding
- Analgesia
- Sedation
- Thromboprophylaxis
- Head elevation
- Ulcer prophylaxis
- Glycemic control
- Spontaneous breathing trial
- Bowel care
- Indwelling catheter removal
- De-escalation of antibiotics
FULL ICU ROUND DOCUMENTATION
CASE: Septic Shock due to Pneumonia
Patient Details
- Mr. X, 65/M
- ICU Day 3, Hospital Day 5
- Diagnosis: Septic shock secondary to community-acquired pneumonia
- Comorbidities: Type 2 Diabetes Mellitus, Hypertension
Overnight Events
- Required escalation of norepinephrine from 0.08 → 0.15 µg/kg/min
- Fever spike 101°F
- Urine output dropped to 0.4 ml/kg/hr
- No desaturation episodes
Vitals & Monitoring
- HR: 112/min
- BP: 90/60 (MAP 65 on vasopressors)
- SpO₂: 94% (FiO₂ 0.5)
- Temp: 38.3°C
- Lactate: 4.2 → 3.5 mmol/L
SYSTEM-WISE DOCUMENTATION
1. CVS
- Septic shock, on norepinephrine 0.15 µg/kg/min/MAP borderline (65 mmHg)/Lactate improving
Plan
- Assess fluid responsiveness (passive leg raise)/Consider vasopressin if NE >0.2
- Bedside echo to assess cardiac function
2.Respiratory
- On volume control ventilation/TV: 6 ml/kg, PEEP: 8, FiO₂: 0.5
- ABG: PaO₂ 70, mild ARDS
Plan
- Maintain lung-protective ventilation/Target SpO₂ 92–96%
- Consider proning if P/F <150
3. CNS
- Sedated, RASS -3
Plan
- Daily sedation interruption/Assess for delirium once awake
4. Renal
- Creatinine rising: 1.2 → 2.0 mg/dL/Oliguria present
Plan
- Optimize perfusion/Avoid nephrotoxins/Consider RRT if worsening
5. Infection
- Likely pneumonia/Blood cultures pending
- On Piperacillin-Tazobactam + Azithromycin (Day 3)
Plan
- Review culture results/De-escalate as per sensitivity
- Repeat procalcitonin
6. GI/Nutrition
- Enteral feeding started/Tolerating well
Plan
- Target 25 kcal/kg/day/Continue PPI prophylaxis
7.Hematology
- Hb: 9.5 g/dL/Platelets: 120k
Plan
- No transfusion needed/Continue LMWH for DVT prophylaxis
8. Metabolic–Blood glucose: 220 mg/dL
Plan-Start insulin infusion (target 140–180 mg/dL)
9. Lines & Devices
- Central line Day 3/Foley Day 3/ETT Day 3
Plan
- Maintain asepsis/Remove when not needed