LIVE REFERENCE
ICU Clinical Protocols
Evidence-Based Critical Care — From Bedside to Best Practice
6ml/kg
Lung Protective Vt
⚡ Core ICU Principles — From Clinical Experience
1. ABC Always First
Airway → Breathing → Circulation. No matter how complex the case, always reassess ABCs. A patent airway is life; a compromised one is death in minutes.
2. "Eyes on the Patient, Not the Monitor"
Clinical assessment supersedes numbers. Treat the patient, not the screen. A warm, well-perfused patient with lactate 2.5 may not need aggressive intervention.
3. FAST HUGS BID
Feeding, Analgesia, Sedation, Thrombo-prophylaxis, Head-up 30°, Ulcer prophylaxis, Glucose control, Spontaneous breathing trial, Bowel care, Indwelling catheter review, De-escalation.
4. Least Invasive, Maximum Yield
Every line, catheter, and tube is a potential source of infection. Daily review: "Does this patient still need this device?" Remove early.
Daily ICU Checklist — FAST HUGS BID
F
Feeding
Enteral preferred within 24–48h. Target 25–30 kcal/kg/day. Check gastric residuals q6h.
A
Analgesia
Assess pain using CPOT/BPS for intubated patients. Fentanyl preferred. Morphine if hemodynamically stable.
S
Sedation
Target RASS 0 to -2. Daily sedation vacation. Dexmedetomidine preferred for light sedation.
T
Thromboprophylaxis
LMWH (Enoxaparin 40mg SC OD) or UFH 5000 IU SC BD. Mechanical compression if contraindicated.
H
Head of Bed Elevation
30–45° at all times. Reduces VAP risk by 25–30%. Non-negotiable in ventilated patients.
U
Ulcer Prophylaxis
Pantoprazole 40mg IV OD for high-risk (coagulopathy, MV >48h, head injury). Stop when feeds established.
G
Glucose Control
Target 140–180 mg/dL. Insulin infusion for persistent >180. Avoid hypoglycemia <70 mg/dL aggressively.
S
SBT — Spontaneous Breathing Trial
Daily at 6 AM. PS 5/5 or T-piece for 30–120 min. Pass → extubate. Fail → rest and retry tomorrow.
B
Bowel Care
Monitor bowel movements daily. Lactulose/bisacodyl if >3 days. Rule out ileus and Ogilvie's syndrome.
I
Indwelling Catheter Review
Daily review all catheters: Foley, CVC, arterial line. Remove ASAP. CAUTI risk ↑ by 5% per day.
D
De-escalation of Antibiotics
Culture-guided narrowing at 48–72h. Procalcitonin-guided stop. "Start broad, narrow fast."
ADMISSION PROTOCOL
ICU Admission Protocol
Structured approach to every new ICU admission — the golden first 60 minutes.
First 60 Minutes — Admission Checklist
1
Primary Survey (0–5 min)
ABC assessment. Secure airway if needed. Two large-bore IV access. Continuous monitoring: ECG, SpO2, EtCO2, IBP.
2
Focused History (5–15 min)
SAMPLE: Signs/Symptoms, Allergies, Medications, Past medical hx, Last meal, Events leading up. Get old records.
3
Investigations (15–30 min)
ABG, CBC, RFT, LFT, Coagulation, Lactate, Procalcitonin, Blood cultures ×2 (before antibiotics!), CXR, ECG, POCUS.
4
Resuscitation Plan (15–30 min)
Fluid challenge (if indicated): 250–500ml crystalloid over 15 min. Vasopressors if MAP <65 despite fluids. Target: MAP ≥65, UO >0.5 ml/kg/h, lactate clearance >10%/2h.
5
Orders & Documentation (30–60 min)
Ventilator settings, sedation/analgesia, DVT prophylaxis, stress ulcer prophylaxis, feeds plan, GCS/APACHE scoring, communicate with family.
📊 Severity Scoring on Admission
APACHE II
Worst values in first 24h. Score >25: mortality >50%. Use for prognosis and benchmarking.
SOFA Score
Daily organ dysfunction tracking. ≥2 increase = sepsis. Track PaO2/FiO2, platelets, bilirubin, MAP, GCS, creatinine.
qSOFA (Bedside)
RR ≥22, altered mentation, SBP ≤100. ≥2/3 = high risk. Quick screening, not diagnostic.
MECHANICAL VENTILATION
Ventilator Management Protocol
Lung Protective Strategy (ARDSNet)
Initial Mode: Volume AC or Pressure AC
Start Vt 6-8 ml/kg IBW. RR 14-22. FiO2 100% → titrate to SpO2 92-96%. PEEP per ARDSNet table. Check ABG at 30 min.
IBW Calculation (Clinical Pearl)
Male: 50 + 2.3 × (height in inches – 60). Female: 45.5 + 2.3 × (height in inches – 60). USE IBW, never actual weight. Obesity kills if you use actual weight for Vt.
Permissive Hypercapnia
pH ≥7.20 is acceptable. Don't chase PaCO2 at the cost of lung injury. Maintain Pplat ≤30 as priority. Buffer with NaHCO3 only if pH <7.15.
🫁 ARDS Classification & PEEP Strategy
Mild200–3005–10 cmH₂O~27%
Moderate100–20010–16 cmH₂O~32%
Severe<10016–24 cmH₂O~45%
🔄 Weaning & Extubation Protocol
Daily Screen for SBT Readiness
FiO2 ≤40%, PEEP ≤8, hemodynamically stable, no active sedation, adequate cough, GCS ≥8T. All criteria must be met.
SBT Method
PS 5/5 cmH₂O for 30–120 minutes. Monitor: RR, HR, SpO2, accessory muscle use, diaphoresis. RSBI <105 = favorable.
Cuff Leak Test (Before Extubation)
Deflate cuff → audible leak should be present. Absent leak: risk of post-extubation stridor. Consider IV methylprednisolone 40mg q6h × 4 doses pre-extubation.
SURVIVING SEPSIS
Sepsis & Septic Shock Bundle
⏰ Hour-1 Bundle (SSC 2021) — "Time Zero = Recognition"
1
Measure Lactate
If lactate >2 mmol/L → re-measure in 2–4h. Target: lactate clearance ≥10% every 2 hours. Lactate >4 = severe tissue hypoperfusion.
2
Blood Cultures BEFORE Antibiotics
At least 2 sets (aerobic + anaerobic) from 2 different sites. Do NOT delay antibiotics >45 min for cultures.
3
Broad-Spectrum Antibiotics
Within 1 hour of recognition. Each hour delay = 7.6% increase in mortality. Piperacillin-Tazobactam + Vancomycin as empirical cover. Add antifungal if risk factors present.
4
Rapid Fluid Resuscitation
30 ml/kg crystalloid (RL or NS) within 3 hours for hypotension or lactate ≥4. Use fluid responsiveness assessment (PLR, IVC variability, stroke volume variation).
5
Vasopressors if MAP <65 Despite Fluids
Norepinephrine FIRST line (start 0.1 mcg/kg/min, titrate to MAP ≥65). Add Vasopressin 0.03 U/min as 2nd agent. Epinephrine as 3rd line. Dopamine only if bradycardia risk.
🩸 Vasopressor Titration Table
Norepinephrine0.05–0.1 mcg/kg/min1–2 mcg/kg/min1st Line
Vasopressin0.03 U/min (fixed)0.04 U/min2nd Line
Epinephrine0.05 mcg/kg/min0.5 mcg/kg/min3rd Line
Dobutamine2.5 mcg/kg/min20 mcg/kg/minCardiac ↓
SEDATION & ANALGESIA
Sedation, Analgesia & Delirium
📏 RASS Scale (Richmond Agitation-Sedation)
+4CombativeViolent, danger to staff
+1RestlessAnxious, non-aggressive movements
0Alert & Calm ✓ TARGETSpontaneously attentive
-2Light Sedation ✓Brief eye contact to voice
-5UnarousableNo response to voice or physical stim
💊 Sedation & Analgesia Agents
Dexmedetomidine0.2–1.4 mcg/kg/h15 minNo resp depression. Best for light sedation & delirium prevention.
Propofol5–80 mcg/kg/min30 secCheck triglycerides q48h. PRIS risk if >80 mcg/kg/min >48h.
Fentanyl25–200 mcg/h1–2 minFirst-line analgesic in ICU. No histamine release. Chest wall rigidity at high bolus doses.
Midazolam1–5 mg/h2–3 minAvoid if possible. ↑ delirium, prolonged sedation with renal failure.
🧠 CAM-ICU: Delirium Screening
Step 1: Acute onset/fluctuating course?
Change from baseline mental status? Fluctuation in past 24h?
Step 2: Inattention
Squeeze hand on letter "A": S-A-V-E-A-H-A-A-R-T. Errors ≥3 = positive.
Step 3: Disorganized thinking
4 yes/no questions + "Hold up this many fingers" command.
Step 4: Altered LOC
RASS ≠ 0. CAM-ICU positive = Step 1 + 2 + (Step 3 OR 4). Start ABCDEF bundle.
NUTRITION PROTOCOL
ICU Nutrition Protocol
🍽️ Early Enteral Nutrition (EEN)
Route: Enteral > Parenteral ALWAYS
Gut is the motor of MODS. "If the gut works, use it." Start trophic feeds (10–20 ml/h) and advance. PN only if enteral fails by Day 7.
Gastric Residual Volume (GRV)
Do NOT routinely check GRV (NUTRIREA-2 trial). Only if clinical signs of intolerance: vomiting, distension. GRV >500ml = hold feeds, add prokinetic.
Prokinetics
Metoclopramide 10mg IV TDS. Erythromycin 250mg IV BD (motilin agonist). Post-pyloric tube if both fail.
⚠️ Refeeding Syndrome — The Silent Killer
High risk: BMI <16, weight loss >15% in 3–6 months, minimal intake >10 days, low K⁺/PO₄/Mg²⁺. Start feeds at 10 kcal/kg/day → advance over 4–7 days. Supplement thiamine 200–300mg IV before feeding. Monitor electrolytes q12h for 72h.
CARDIAC PROTOCOLS
Cardiac ICU Protocols
🫀 Acute MI — STEMI Management
MONA-B (Modified for 2024)
Morphine (only if pain persists), O₂ only if SpO₂ <90%, Nitroglycerine SL/IV (avoid if RV infarct/SBP <90), Aspirin 325mg chewed, Beta-blocker (Metoprolol 25mg PO if no contraindications).
Door-to-Balloon: ≤90 Minutes
PCI is preferred. If PCI not available within 120 min → Fibrinolysis (Tenecteplase weight-based). Dual antiplatelet: Aspirin + Ticagrelor 180mg (or Clopidogrel 600mg loading).
Cardiogenic Shock Protocol
Dobutamine 2.5–20 mcg/kg/min + Norepinephrine for MAP. IABP if refractory. Early cath. Avoid overdiuresis. Monitor mixed venous O₂ sat (SvO₂ >65% target).
⚡ Arrhythmia — Rapid Response
SVT / AFib with RVR
Stable: Diltiazem 0.25 mg/kg IV over 2 min → drip 5–15 mg/h. Or Amiodarone 150mg IV over 10 min. Unstable: Synchronized cardioversion 50–200J.
VT / VF — Pulseless
CPR immediately. Defibrillation 200J biphasic. Epinephrine 1mg q3–5min. Amiodarone 300mg → 150mg. Address H's and T's. Continuous capnography to confirm CPR quality.
Bradycardia
Atropine 0.5mg IV q3–5min (max 3mg). If refractory: dopamine 5–20 mcg/kg/min or transcutaneous pacing. Avoid atropine in transplant hearts.
Torsades de Pointes
Magnesium 2g IV over 2 min. Overdrive pacing. Isoproterenol if pacing unavailable. Correct QTc-prolonging drugs. Target Mg²⁺ >2 mg/dL.
NEURO ICU
Neurological ICU Protocols
🧠 Raised ICP Management
Tier 1 (General Measures)
HOB 30°, midline head position, avoid jugular compression, adequate sedation (Propofol/Fentanyl), normothermia, normoglycemia, seizure prophylaxis (Levetiracetam).
Tier 2 (Osmotherapy)
Mannitol 20% (0.5–1 g/kg IV bolus, keep osmolality <320). Hypertonic saline 3% (250ml bolus) or 23.4% (30ml via CVC). Target Na⁺ 145–155.
Tier 3 (Refractory ICP)
Pentobarbital coma (5 mg/kg loading → 1–3 mg/kg/h, monitor burst suppression on EEG). Decompressive craniectomy. Therapeutic hypothermia 33–35°C.
🩺 Status Epilepticus — Time-Critical Protocol
0–5'
Benzodiazepine
Lorazepam 0.1 mg/kg IV (max 4mg) OR Midazolam 10mg IM. Repeat once at 5 min. Check glucose!
5–20'
2nd Line AED
Levetiracetam 60 mg/kg IV (max 4500mg) over 15 min OR Valproate 40 mg/kg IV OR Fosphenytoin 20 mg PE/kg.
20–40'
Refractory SE → Intubation
Midazolam infusion 0.2 mg/kg/h OR Propofol 1–2 mg/kg bolus → 30–200 mcg/kg/min. Continuous EEG monitoring mandatory.
RENAL & FLUIDS
Renal & Fluid Management
💧 Fluid Therapy — "The 4 D's"
D1: Drug (Resuscitation)
Bolus 250–500ml crystalloid over 15 min. Assess response: ΔBP, ΔHR, ΔUO, ΔIVC. Stop if no response. "Fluid is a drug — titrate, don't flood."
D2: Dosing (Maintenance)
25–30 ml/kg/day as maintenance. Account for insensible losses, drains, GI losses. Daily I/O chart is sacred.
D3: Duration (Optimization)
Target zero or negative fluid balance after 48–72h. Cumulative positive balance = worse outcomes in ARDS, AKI. "Dry lungs are happy lungs."
D4: De-escalation (Removal)
Active deresuscitation with diuretics (Furosemide 20–40mg IV) once hemodynamically stable. Target: net negative 1–2L/day.
🔬 AKI — KDIGO Staging & RRT Indications
11.5–1.9× baseline<0.5 ml/kg/h × 6–12h
22.0–2.9× baseline<0.5 ml/kg/h × ≥12h
33.0× or ≥4.0 mg/dL<0.3 ml/kg/h × 24h or anuria 12h
RRT Indications ("AEIOU")
Acidosis (pH <7.1 refractory), Electrolyte (K⁺ >6.5 refractory), Intoxication (methanol, ethylene glycol, lithium), Overload (pulmonary edema refractory to diuretics), Uremia (encephalopathy, pericarditis). CRRT preferred in hemodynamically unstable patients.
PROCEDURES
Lines, Catheters & Procedures
🩹 Central Venous Catheter — Checklist
Site Selection (Order of Preference)
1. Subclavian (lowest infection rate). 2. Internal Jugular (US-guided). 3. Femoral (last resort, highest infection rate). Avoid subclavian if coagulopathic or on RRT.
Maximal Barrier Precautions
Cap, mask, sterile gown, sterile gloves, large sterile drape. 2% chlorhexidine skin prep. Allow 2 min to dry. ALWAYS ultrasound-guided for IJV and subclavian.
Post-Insertion
CXR to confirm tip position (cavo-atrial junction). Check for pneumothorax. Transparent dressing, change q7d. Daily assessment for removal. CHG-impregnated dressing preferred.
🫁 Chest Tube — Indications & Management
Tension Pneumothorax
EMERGENT needle decompression: 14G in 2nd ICS MCL → definitive chest tube in 5th ICS anterior axillary line. Size: 28–32F for hemothorax, 20–24F for pneumothorax.
Pleural Effusion
US-guided pigtail catheter (12–14F). Drain max 1.5L initially (re-expansion pulmonary edema risk). Send: pH, protein, LDH, glucose, cell count, cultures, cytology.
ANTIBIOTIC STEWARDSHIP
Antibiotic Stewardship in ICU
🦠 Empirical Antibiotic Guide — Common ICU Infections
VAP (Early <5d)Pip-Tazo / Cefepime7 daysDe-escalate by Day 3 per cultures
VAP (Late ≥5d)Meropenem + Vancomycin ± Colistin7–8 daysMDR risk
CLABSIVancomycin + Pip-Tazo7–14 daysRemove line if possible
CAUTINitrofurantoin / Ceftriaxone7 daysRemove catheter first!
Intra-abdominalMeropenem + Metronidazole4–7 daysSource control is #1 priority
📉 De-escalation Principles
Procalcitonin-Guided Cessation
PCT <0.25 ng/mL or >80% drop from peak → consider stopping antibiotics. Reduces antibiotic days by 2–3 days without ↑ mortality.
Culture-Guided Narrowing
At 48–72h: review culture results. Narrow to most targeted agent. "The narrowest effective antibiotic is the best antibiotic."
DISCHARGE CRITERIA
ICU Discharge Readiness
✅ Discharge Checklist
Respiratory
Extubated ≥24h. SpO₂ >92% on ≤4L NC. No respiratory distress. RR 12–24. Adequate cough & secretion clearance.
Cardiovascular
Off vasopressors ≥24h. Stable BP. No active arrhythmias requiring IV drugs. Adequate peripheral perfusion.
Neurological
GCS ≥13 (or at baseline). No active seizures. Delirium resolved or managed. Following commands.
Metabolic
Electrolytes stable. Glucose controlled. Tolerating enteral nutrition. Acid-base normalized.
Lines & Devices
CVC removed or conversion to PICC planned. Arterial line removed. Foley removed if possible. Chest tubes removed.
Communication
Detailed handover to ward team. Clear medication reconciliation. Family briefing. Physiotherapy plan. Follow-up ICU review at 48h post-transfer.
🏥 Clinical Pearl — Post-ICU Syndrome (PICS)
Up to 50% of ICU survivors develop PICS: cognitive impairment, PTSD, depression, physical weakness. Recommend ICU follow-up clinic at 3 and 6 months. Early mobilization in ICU is the best prevention. "The goal is not just survival — it's a life worth living after ICU."