Intern’s Guide to the MICU

Updated 7/2/2021- originally written by MICU Attendings

Due to the complexity of your patients in the MICU, you will have an incredible amount of data on each patient, and it can be challenging to organize and present all that information in a way that is easy to follow for everyone on rounds. Here are our suggestions to help.

PRESENT BY ORGAN SYSTEM -What we mean by this is to abandon your typical SOAP note format for presentations. Lump together hemodynamic data with CV and volume assessment; pulmonary data with vent settings and blood gas results; neurologic data with wake-up assessment, etc. For a typical follow-up patient on rounds, this means stating the patient’s major events overnight (if any) and then launching in to assessment as below. Except in rare instances, the 1st systems addressed should be cardiovascular, pulmonary or neuro. Both an outline format and sample narratives are below.

  1. Cardiovascular- BP has remained X/Y on the following vasoactive drugs and doses. She appears to be volume-responsive based on X (physical exam findings, straight leg raise, bedside ultrasound, Pulse Pressure Variation, etc). Central venous sat (SVO2) is X. UOP has remained (adequate vs oliguric) and the patient feels (warm with good cap refill vs cold with thread pulses). Tips: ok to give vitals as either a representative sample or as ranges, but if giving ranges, report blood pressure as X/Y – A/B – not as a systolic range and diastolic range – to allow us to hear the pulse pressure. Assessment of cardiac function, myocardial ischemia, dysrhythmia etc. would go here.
    1. Blood pressure
    2. Vasoactive meds and doses
    3. Volume status (with data – CVP, SVO2, I/Os, UOP, PPV)
    4. Heart rate/rhythm
    5. Ischemia or heart function
  1. Pulmonary: Pt remains intubated on the following vent settings: XXXX. By convention, we report vent settings as Mode (AC vs PC vs PS) / Rate/ Tidal Volume/ PEEP/FiO2 – and on these settings the ABG is (report as pH/ CO2/ paO2/ sat –ok to round up to the nearest whole number). Patient’s oxygenation is (improving vs worsening) and the CXR is (better vs worse). We plan a SBT today but are concerned that pt’s (oxygenation/ventilation/neuro status/airway) may prevent extubation. Patient’s acid-base status is …. and the respiratory alkalosis we are observing might be explained by ……
    1. Vent or oxygen status and effort
    2. ABG
    3. CXR
    4. Plan for SBT/extubation
  1. Neurologic: Pt remains sedated on the ventilator. Awoke when sedation held yesterday, followed all commands. Still requires sedation because…
    1. Exam
    2. Sedation
    3. Radiographic studies
  2. ID: Pt is febrile with a rising WBC despite antibiotics (X,Y, and Z). We think the source of infection is …. because….
    1. Temp, WBC, Culture data
    2. Antibiotics
    3. Source of infection
  3. Heme/Onc: Hb dropped from X to Z with 400cc of coffee grounds from OGT. Plan for an EGD today. She required X units PRBCs, Y platelets, and Z FFP overnight
    1. CBC
    2. Onc issues
  1. Renal: Only necessary if this pertinent information is not already addressed in hemodynamics. UOP, Creatinine trends probably belong under hemodynamic data. Patient tolerated intermittent dialysis yesterday and needs more volume off today.


Listen to nurses – They are extremely experienced and have very important information to tell you. If they are paging you, it is because they REALLY need you to come evaluate the patient.

Use your pharmacist – Great resource for information about meds (dosing, interactions, etc)

Ask your residents, fellows, attending and APNs for help – You will learn a lot on this rotation. This will be enhanced if you ask when you don’t completely understand something. If you are ever in a situation where you are writing an order without knowing why you are doing so, ask your residents, fellows, attending or APN .


When pre-rounding – Come before 6am. Look at the orders written overnight and ask your cross cover why they made a change. What prompted them to change the vent/start pressors/extubate etc. The expectation is that you have seen all of your patients and reviewed their information PRIOR to morning rounds.

Sign outs and cross-cover are critical– The MICU is an around the clock endeavor. Thus, our mentality is that each MICU patient is a communal patient. Your sign out and presentations on rounds are ways you communicate your plan and anticipated problems to the cross-covering team. High quality sign out and presentations are the only way to deliver quality around the clock critical care.

  • Everyone should know each patient in the MICU
  • For the post call team, the APN/ED dayfloat are designated “helpers”, especially for procedures, roadtrips, etc
  • Call consults early – you know your patients the best
  • Complete bedside procedures EARLY, which means OBTAIN CONSENT and OPTIMIZE COAGS for procedures early
  • Maintain active type and screens and put blood consents in the CHART for patients who require blood products
  • Have family contact information and any limits of care (code status) on sign out
  • X-cover patients going to the floor should be given to appropriate service (GENS, HONC, etc)
  • ASK whether X-cover spoke to floor team about your patients who went out overnight

Transfers out of the MICU:

  • Remember to complete the order reconciliation prior to transfer
  • All MICU patients need a VERBAL signout given to the receiving floor team and a WRITTEN transfer note (signed before transfer is placed)

Update family qD! – So much can happen in a MICU day and the ICU patients are relatively more likely to have major condition changes compared to floor patients. You will find the family is more prepared for adverse events / need for procedures / status changes, if you keep them in the loop all along. To do this, have the family identify the one person who will be the point person and you can update him/her daily, then he/she will update the family. Also please remember to ask for the PRIVACY CODE (last 4 # of MRN) before giving info via phone or in person.

Keep the work rooms clean –We share these spaces that are almost continually in use 24/7. Please be cognizant of your belongings. Hang up coats. Store bags in/on top of cabinets. Return medical records to the patient’s chart. DO NOT bring supplies into workroom. Unlocked needles are in violation of Illinois Department of Public Health requirements.



7:00am – MICU Teaching Case, followed by MICU Rounds

  • One post-call patient will be presented to both MegaTeams as a teaching case
  • Bedside patient care rounds are performed outside of the patient’s room. If you do not see the patient’s RN participating in rounds, please notify them that rounds are taking place.
  • Resident presents patient within 7 minutes. All members of the team are expected to listen and learn from these presentations.
  • RN presents COMPLEXCARE.
  • Pharmacy needs are addressed.

10:00 am – Pulmonary Morning Report

  • If your attending and fellow go to pulmonary morning report, so should you. This is not an opportunity to break from rounds to get other work done.

2:00pm – Afternoon Lecture

  • Great lecture series. Must attend every day unless a patient is actively crashing. By the end of the month, you should understand the 4 types of respiratory failure, mechanisms of hypoxemia, types of shock, familiarity with vasoactive meds, modes of mechanical ventilation, and sepsis


MICU Procedure Guidance


  • Start planning and preparing for procedures immediately after rounds. Goal to complete procedures prior to lunch/lectures.
  • Obtain consent.
  • Gather supplies prior to start of procedure. Return all extra supplies to supply room (not the work room!)
  • Notify RN of procedure. Perform procedure timeout as a team. Request RN to complete time out documentation. Request RN to set up transduction supplies for arterial lines.
  • Perform procedure with attending +/- fellow.


  • Order lidocaine 1% injection (WITHOUT epinephrine) 20ml bottle
  • Utilize order sets to order diagnostics
    • IP Lumbar Punctions(#1947)
    • IP Thoracentesis/Paracentesis (#1101)
  • Verify specimens have been labeled. Request RN to release the labs in the system. Hand deliver specimens to Mitchell lab
  • Proceduralist should collect and dispose of all sharps.
  • Clean up all procedure supplies and garbage.
  • Order and follow up CXR following central line placement and thoracentesis.
  • Document central line placement
    • Click on left sided “Procedure” tab. Document under CL Insert 1 section. Request RN to complete observer documentation.
    • Place ok to use order after CXR verification

NEJM Procedure Resources


Consult procedure service for midline/ PICC placement.

  • Midline: Standard line used for long term (>5days) medication administration of non-vesicants. Considered a “short PICC” that does not cross the midline. No CXR is needed to confirm placement. Ordered as “PICC” in Epic.
  • PICC: Catheter tip ends in distal third of superior vena cava. Indicated for chemotherapy, TPN and vasoactives. CXR must confirm placement. RN requires “ok to use” order.
  • Renal Clearance: Obtain approval from nephrology prior to consulting procedure service for GFR <45.
  • Tip: Order the least number of lumens possible to minimize the risk of infection and intra-lumen clot.
  • Troubleshooting:
    • Bleeding: Apply manual pressure at insertion site for at least 5 minutes. Do not apply external pressure dressing or leave bedside until hemostasis is achieved.
    • Sluggish/No Blood Return: Order alteplase 2mg for each non-functioning lumen. Let drug dwell up to 2 hours. If no blood return, repeat another 2mg dose and dwell x2hr.
    • Leaking: Order Doppler to rule out clot.



Central line

  • Chux
  • Sterile Gloves
  • Additional PPE (masks, gloves, bouffants, gowns) for additional proceduralists
  • Central line supply bundle
  • Central line (e.g. triple lumen, trialysis, cordis)
  • 2inch 16g angiocath/IV (for trialysis lines)
  • Scalpel (for trialysis lines)

Lumbar Puncture

  • Sterile gloves
  • Mask
  • 1 Chux
  • Betadine
  • Gauze pack
  • LP kit
  • Specimen bag
  • Consider ordering additional lidocaine

Arterial Line

  • Sterile gloves
  • Mask
  • Chux
  • Chlorhexidine
  • Sterile towel pack
  • Sterile ultrasound probe cover
  • Gauze pack
  • Arterial line arrow
  • Tegaderm
  • Tape


  • Lidocaine: Order in epic. Request RN to get out of omincell prior to procedure
  • Sterile gloves
  • Mask
  • Skin marking pen
  • 1 Chux
  • Chlorhexidine
  • Thoracentesis kit
  • 60 cc syringe
  • 19g needle or pink vacutainer to transfer fluid for diagnostic specimens
  • ABG syringe
  • Anaerobic culture bottle
  • Aerobic culture bottle
  • Lavender top tube
  • Gold top tube
  • Sterile specimen cup
  • Specimen bag


  • Lidocaine: Order in epic. Request RN to get out of omincell prior to procedure
  • Sterile gloves
  • Mask
  • Skin marking pen
  • 2 Chux: 1 for patient’s lap, 1 for floor
  • Chlorhexidine
  • OR towel pack
  • 14 g angiocath
  • 10 ml syringe
  • 5ml syringe
  • 19g needle
  • 25g needle
  • 19g needle or pink vacutainer to transfer fluid for diagnostic specimens
  • 60cc syringe
  • Suction tubing
  • Orange containers
  • Gauze pack
  • Tegaderm
  • Anaerobic culture bottle
  • Aerobic culture bottle
  • Lavender top tube
  • Gold top tube
  • Sterile specimen cup
  • Specimen bag
  • Gold top tube
  • Sterile specimen cup
  • Specimen bag



Advanced Practice Nurses (APNs)

  • Contact:
    • Stefanie Blummer
    • Kelly Coudron
    • Ana Huaringa
    • Kalina Gorczyca
    • Meaghan Maroney
    • Ann Nelson
  • Role: Assist with post-call team. Rotate through procedure service. Provide procedural oversights. Provide pulmonary consults for CCU patients on mechanical ventilation.


  • Bedside Nurse
    • Tips:
      • Please do not adjust IV pumps and/or ventilators without nurse in room.
      • If you enter a STAT order, please speak with the bedside RN.
      • Restraint orders must be entered in EPIC within an hour of application and every 24 hours. DO NOT LET YOUR RESTRAINTS EXPIRE!! Check/renew during rounds.
      • When medications are OG/ NG please enter in EPIC “Per Tube “.
      • Try to cluster labs together. If labs were just sent, please place order as “add on”.
    • Charge Nurse, x61504


  • Consult: Epic is preferred. Also available verbally, by page and during MICU Multidisciplinary Huddle
  • Role: Assess patients (lab data, medical/surgical history, nutrition focused physical exam, anthropometric data, diet history, medical plan of care), diagnose malnutrition (where applicable), and provide recommendations regarding: tube feeding for patients with enteral tubes (OG, NG, DHT, PEG/PEJ), standard peripheral or standard central parenteral nutrition (PPN/TPN), oral nutrition supplements, oral diet, vitamin/mineral repletion, nutrition related medications (bowel meds, appetite stimulants), etc., monitor progress toward goals and re-evaluate as appropriate.
  • Tips: I do not follow transplant surgery service patients or GI nutrition patients.  ASPEN/SCCM guideline “highlights” regarding feeding critically ill patients are: 1. Early enteral feeding (within first 24-48 hours) reduces infectious morbidity, mortality, and length of stay. 2. We DO NOT routinely check gastric residual volumes as they are poorly correlated with aspiration events. 3. Serum protein markers (albumin, transferrin, pre-albumin, retinol binding protein) are NOT a good representation of the nutritional status of critically ill patients. 4. PLEASE do not change a tube feeding formula without talking with a dietitian (changing a formula may increase/decrease calories/protein or certain vitamins/minerals, significantly).

Physical Therapy

  • Role: Facilitate early mobility on any hemodynamically stable patient regardless of their level of alertness.
  • Consult: When consulting PT and OT, place two consult orders (one to evaluate and another to treat).
  • Tips: Consult as soon as possible and consider upon MICU admission. PT also provides wound care, specifically negative pressure therapy and debridement.

Occupational Therapy

  • Consult: Please make sure to place two consult orders (one to evaluate and one to treat).
  • Role: Assist with early mobilization with PT as well as assess/treat cognitive impairments; prolonged periods of immobility lead to increased rates of delirium and skeletal muscle breakdown resulting in ICU acquired weakness. Occupational Therapists also perform splint fabrication to prevent joint immobility.
  • Tips: Address the CAM ICU sooner than later. Occupational therapy can assist with helping family members understand delirium and provide interventions to prevent this while in the ICU.


Respiratory Therapy

  • Contact: 9N RT x 61889, 9S RT x61898
  • Tips: Verify all of your intubated patients have a “Mechanical Ventilation” order that includes vent settings. Notify RT of all vent changes.

Social Work

  • Consult: Epic consult, page, conversation, interdisciplinary daily rounds with fellows
  • Role: Placement (LTACH, rehab, hospice, etc.), Healthcare Power of Attorney, psychosocial pt/family needs, participate in family meetings and goals of care discussions, assist pt/families with financial needs such as UCM financial aid/SSDI/etc., substance abuse treatment resources, identification of unidentified pts and/or location of families, and a varying assortment of other interesting pt needs (I might not know the answer, but I’m happy to work as a team to figure it out!).