🏥 This is a prototype/blueprint for RegionsMICU.com — use it as your Wix guide

Regions Hospital · Medical ICU

Your MICU Rotation, Navigated.

Everything residents and students need to hit the ground running — staff, protocols, orientation materials, and key resources, all in one place.

Start Orientation → View Protocols

⚡ Quick Access

Getting Started

Orientation Overview

New to the MICU? Here's what to know on Day 1 — expectations, logistics, and how the unit works.

Logistics
Expectations
Schedule
How to Present
Rounding
🏢

Unit Location

The MICU is located on the 6th floor of the South Building. Resident workrooms are in the 6600 hallway — CC3 for Internal Medicine residents, CC2 for Emergency Medicine residents.

Day 1 Essential
🖥️

Epic & Systems Access

Ensure Epic access is active before your first day. Contact IT at 952-967-7000 if credentials are missing.

Setup
👕

Dress Code & Supplies

Scrubs are available in the resident locker room on the 2nd floor. Bring your own stethoscope. PPE is stocked at each bedside.

Logistics
🅿️

Parking

Use the East Ramp for parking. Resident parking permits issued through the GME office.

Logistics
📝

Documentation

Prioritize accuracy in ventilator settings, drip rates, and daily goals. Avoid cutting and pasting forward inaccurate or irrelevant information.

Clinical
🔄

Sign-Out Culture

Use structured I-PASS handoff. Never leave without a verbal + written sign-out to the oncoming team.

Safety
🎓

Teaching & Learning

Bedside teaching occurs during rounds. Fellows are a primary resource. Don't hesitate to ask questions. Ultrasound machines are stored in the 6600 and 7500 med rooms.

Education

Documentation General Guidelines

  • ◇ All patients brought to the MICU team need an H&P and if discharged directly from the MICU, or deceased, require a discharge summary.
  • ◇ All MICU patients require a daily progress note.
  • ◇ Any change to the plan during night shift requires a significant event note.
    • ○ These are brief notes that merely outline the quick update, assessment made and plan carried out.
  • ◇ Any acute event or decompensation requires a significant event note regardless of time of day.
  • ◇ All code blue activations in or outside the MICU require a code blue note by the fellow or attending who ran the code.
  • ◇ All procedures, even failed ones, require a procedure note.
  • ◇ Initiating neuromuscular blockade requires a note by the fellow, APP or resident.

Note Examples

Example: H&P

HISTORY & PHYSICAL — MICU ADMISSION CHIEF COMPLAINT: Acute hypoxic respiratory failure HPI: 67M with PMH of COPD (on 2L home O2), HFrEF (EF 30%), DM2, and CKD3 presenting with 3 days of worsening dyspnea and productive cough. Per EMS, found at home with O2 sat 74% on RA. In ED: T 38.4, HR 118, BP 94/62, RR 28, SpO2 88% on 15L NRB. CXR showed bilateral infiltrates with pulmonary vascular congestion. ABG: 7.28/58/54/26. Started on BiPAP 10/5, given IV furosemide 80mg, and broad-spectrum antibiotics (vanc/pip-tazo). No improvement after 1 hour — intubated for hypoxic/hypercapnic respiratory failure. Admitted to MICU for further management. PMH: COPD, HFrEF (EF 30%), DM2, CKD3, HTN, HLD MEDICATIONS: Carvedilol 25mg BID, Lisinopril 10mg daily, Furosemide 40mg daily, Tiotropium inhaler, Albuterol PRN, Insulin glargine 20u QHS, Atorvastatin 40mg QHS ALLERGIES: Penicillin (rash) SOCIAL: 30-pack-year smoking history, quit 5 years ago. Lives alone. No EtOH or illicit drugs. REVIEW OF SYSTEMS: Positive: dyspnea, productive cough, bilateral leg swelling, reduced urine output. Negative: chest pain, hemoptysis, fevers prior to today, abdominal pain. PHYSICAL EXAM: Gen: Intubated, sedated, not in acute distress on ventilator Vitals: T 38.4 | HR 110 | BP 98/64 | RR (vent) 18 | SpO2 94% (FiO2 0.6, PEEP 8) CV: Tachycardic, regular; JVD present at 45 degrees Resp: Diffuse crackles bilaterally, decreased BS at bases Ext: 2+ pitting edema bilateral lower extremities to knees Neuro: Sedated on propofol, pupils 3mm bilaterally reactive LABS: WBC 14.2 | Hgb 10.1 | Plt 198 | Na 134 | K 4.8 | Cr 2.1 (baseline 1.6) | BUN 44 | Lactate 2.8 | proBNP 8,400 | Trop 0.08 IMAGING: CXR — bilateral airspace opacities, cardiomegaly, cephalization. Echo: EF 25-30%, elevated filling pressures. ASSESSMENT & PLAN: 1. Hypoxic/hypercapnic respiratory failure — AC/VC TV 420mL, RR 18, FiO2 0.6, PEEP 8; vanc/pip-tazo; bronchodilators 2. Acute-on-chronic decompensated HFrEF — IV furosemide 80mg BID, target -1 to -1.5L/day; hold home carvedilol/lisinopril; cardiology consult 3. AKI (Cr 2.1, baseline 1.6) — likely prerenal vs. cardiorenal; trend Cr; hold nephrotoxins 4. Sepsis/HCAP — cultures sent; de-escalate antibiotics at 48-72h per results 5. DM2 — insulin drip per protocol, goal glucose 140-180 6. DVT prophylaxis — heparin 5000u SQ TID 7. Goals of care discussion with family given severity

Example: Daily Progress Note

MICU PROGRESS NOTE — Day 3 EVENTS OVERNIGHT: No acute events. Urine output 2.1L/24h (net -1.2L). One hypotensive episode at 0300 (MAP 62) — responsive to 500mL NS bolus. SUBJECTIVE: Intubated and sedated on propofol. Nods to simple commands. Family at bedside overnight. VITALS (24h): Tmax 37.8 | HR 88-104 | BP 96-118/58-72 | SpO2 94-97% Vent: AC/VC | TV 420 | RR 16 | FiO2 0.45 | PEEP 6 I/O: In 2,340mL | Out 2,100mL | Net -240mL | Cumulative 3-day net: -2.1L PHYSICAL EXAM: Gen: Intubated, sedated, opens eyes to voice CV: HR 92, regular; JVD decreased; 1+ pitting edema bilateral LE Resp: Reduced crackles bilaterally; improving breath sounds at bases Lines: R IJ triple-lumen (day 3), Foley, R radial arterial line LABS: WBC 10.4 (↓) | Cr 1.9 (↓) | K 3.9 | Lactate 1.2 (cleared) | Vanc trough 18.2 (therapeutic) Cultures: no growth to date. Sputum: GNR — awaiting speciation. ASSESSMENT & PLAN: 1. Respiratory failure — improving; FiO2 0.45, PEEP 6; SAT this AM — CPAP trial planned this afternoon; if passes, extubation tomorrow 2. Decompensated HFrEF — net negative; continue IV furosemide BID; cardiology following; restart carvedilol post-extubation 3. HCAP/GNR sputum — continue vanc/pip-tazo; ID consult placed; procalcitonin trending down 4. AKI — improving (Cr 1.9); continue gentle diuresis 5. DM2 — glucose 128-164 on insulin drip; within goal; continue 6. Nutrition — tube feeds via OGT at goal 50mL/hr; tolerating well 7. Disposition: MICU; plan extubation tomorrow AM if SBT successful

Daily Schedule

6:30 AM
Arrive in MICU and receive sign-out from night float.
6:30–8:00 AM
Pre-round, see patients, start notes.
8:00–8:30 AM
Begin rounds — start time depends on attending preference.
Until 11:00 AM
Attending rounds continue.
11:00 AM
Multidisciplinary rounds in the South 6 Conference Room. Charge nurse calls the team phone to notify interns and residents when ready.
12:30 PM
Internal Medicine lecture and lunch for residents and interns in 2nd floor conference room.
1:00 PM
Earliest allowed sign-out for the non-admitting team.
Afternoon
Residents perform family meetings, procedures, and note-writing. Residents call and update family members who were not present at bedside during rounds.
Until 7:00 PM
Residents admit new patients on their call day.
7:00 PM
Sign out to night float.

Critical Care Google Calendar

📅 Critical Care Google Calendar (link coming soon)

This calendar will display:

  • ◇ Resident schedule
  • ◇ APC trainees
  • ◇ Hospitalist and ED PA fellows rotating through the MICU
  • ◇ Neuro internal medicine rotation (every other month)
  • ◇ iMed teaching days at University of Minnesota — residents and interns
  • ◇ Emergency Medicine Resident Conference — every Thursday 7:00 AM – 1:00 PM
★ Residents should select their days off on the first day or within the first week of their rotation.

Presenting on MICU rounds is concise and problem-focused. Attendings want to understand the patient's trajectory, overnight events, and your plan — not a recitation of every detail in the chart.

Structure of a Presentation

1
One-liner — Name, age, sex, relevant PMH, and reason for admission.
Ex: "Mr. S is a 67-year-old male with COPD and HFrEF admitted for hypoxic respiratory failure, now intubated, on day 3."
2
Overnight events — What happened? Any acute changes, interventions, or notable nursing events.
3
Vitals & vent settings — Tmax, HR range, BP range, SpO2. If intubated: FiO2, PEEP, mode, tidal volume.
4
I/Os & drips — 24h fluid balance, current vasopressors/drips and doses.
5
Exam — Focused and relevant. Highlight changes from prior day.
6
Labs & studies — Overnight and morning results. Trending values (↑/↓). Flag anything critical.
7
Assessment & Plan — Present by problem. Lead with your assessment, then plan. Own the plan — don't just list facts.

Tips

  • ◇ Know your patient's trajectory — is the patient better, worse, or the same as yesterday?
  • ◇ Lead with the most critical problem first.
  • ◇ Don't read the chart — synthesize it. Attendings want your interpretation, not a data dump.
  • ◇ Always know the vent settings, vasopressor doses, and fluid balance cold — these will be asked every time.
  • ◇ End with a clear plan and disposition goal for the day.

Team Structure

  • CC2 and CC3 teams round with the attending starting at 8:00 or 8:30 AM depending on attending preference.
  • On-call teams round with the attending and fellow.
  • A clinical pharmacist rounds with each team.
  • Workstations on Wheels (WOWs) are available in the alcove on the 6600 wing — typically 3–4 computers available per team.

Rounding Presentation Formats

The format depends on attending preference. Be prepared for either.

Systems-Based

Present organ system by organ system (neuro, pulm, CV, ID, renal, GI, heme/endo, lines). Covers every body system in a fixed order. Comprehensive and structured — good for complex patients with multiple active issues.

Problem-Based

Present by active problem in order of priority. Lead with the most critical issue. More efficient for focused patients — requires knowing which problems are active and how they relate to each other.

Example Patient

58M, intubated and sedated, with Streptococcus pneumoniae pneumonia complicated by ARDS (severe), septic shock on vasopressors, and acute kidney injury. Hospital day 3, ICU day 3.

Systems-Based Presentation

"Mr. S is a 58-year-old male, ICU day 3, admitted with Strep pneumo pneumonia complicated by ARDS, septic shock, and AKI. Here is his systems review: NEURO / SEDATION: On propofol at 20 mcg/kg/min. RASS target -1 to -2, currently -2. CAM-ICU negative this morning. SAT performed — passed, tolerating lightened sedation. SBT planned this afternoon pending vent wean. PULMONARY / VENTILATOR: Intubated day 3. Mode: AC/VC. Tidal volume 360 mL (6 cc/kg IBW 60 kg). RR 22. FiO2 0.55. PEEP 10. Plateau pressure 26 cmH2O. Driving pressure 16. P/F ratio 136 — moderately severe by Berlin criteria. Last ABG: 7.38 / 42 / 73 / 26. Permissive hypercapnia acceptable. CXR this morning: bilateral diffuse airspace opacities, no new pneumothorax. Plan: Maintain lung-protective ventilation. Continue proning x16 hours. CARDIOVASCULAR: On norepinephrine 0.12 mcg/kg/min. MAP 68–74 over past 12 hours — within goal >65. HR 92–108, sinus tach. Echo on admission: EF 55%, no wall motion abnormalities, no effusion. CVP 8. No arrhythmias overnight. Plan: Continue vasopressor. Wean norepi if MAP remains >65 on lower doses. INFECTIOUS DISEASE: Streptococcus pneumoniae — blood cultures positive from day 1, sputum with GPC in pairs and clusters. Sensitivities: pan-sensitive. On ceftriaxone 2g IV q24h — day 3 of planned 5–7 day course. Azithromycin discontinued after 3 days per CAP guidelines. WBC trending: 18.4 → 14.2 → 11.8. Tmax 38.1 (down from 39.0 on admission). Procalcitonin 24 → 11. Plan: Continue ceftriaxone. Continue surveillance cultures. ID following. RENAL / FLUIDS / ELECTROLYTES: AKI — Cr 2.8 today, up from 2.4 yesterday (baseline 1.0). Urine output 0.45 mL/kg/hr over past 8 hours — oliguria. FeNa 0.8% — consistent with prerenal vs. early ATN from sepsis/hypoperfusion. Cumulative fluid balance: +3.8L since admission. Currently on vasopressor — holding aggressive diuresis. Na 138, K 4.2, Bicarb 22. Nephrology aware — no indication for RRT at this time. Plan: Optimize MAP with vasopressor; reassess diuresis when off pressors. Trend Cr, urine output. GI / NUTRITION: Tube feeds via OGT at 45 mL/hr (goal 50). Tolerating well — residuals <100 mL. Bowel sounds present. No stress ulcer prophylaxis — on continuous tube feeds. Bowel regimen: senna/miralax BID, last BM this AM. Plan: Advance to goal rate today. HEMATOLOGY / ENDOCRINE: Hgb 9.4 — stable. Platelets 142 (↓ from 210 on admission) — monitor, no active bleeding. INR 1.4. DVT prophylaxis: heparin 5,000u SQ TID — no contraindication. Glucose 148–172 on insulin drip — within goal 140–180. Continue. LINES / ACCESS / TUBES: L SC triple-lumen central line — day 3, no erythema or discharge. R radial arterial line — functioning, good waveform. Foley catheter — day 3, indication documented (hemodynamic monitoring/AKI). OGT confirmed on CXR. Plan: Reassess line necessity daily."

Problem-Based Presentation

"Mr. S is a 58-year-old male, ICU day 3, with Strep pneumo pneumonia complicated by ARDS, septic shock, and AKI. He had no acute events overnight. Vitals: Tmax 38.1, HR 92–108, MAP 68–74 on norepi 0.12, SpO2 94% on FiO2 0.55/PEEP 10. Today's problems: #1 — SEPTIC SHOCK (Streptococcus pneumoniae pneumonia): Source is pneumonia — blood cultures positive, sputum with GPC in pairs. On ceftriaxone 2g IV q24h, day 3 of 5–7. WBC 11.8, down from 18.4 on admission. Procalcitonin trending down (24 → 11). Tmax 38.1, improved from 39.0. Hemodynamically: on norepi 0.12 mcg/kg/min, MAP 68–74. Plan: continue ceftriaxone, wean vasopressor as tolerated, ID following. #2 — SEVERE ARDS (P/F 136): Intubated day 3. AC/VC: TV 360 (6 cc/kg IBW), RR 22, FiO2 0.55, PEEP 10. Plateau 26, driving pressure 16. Last ABG 7.38/42/73/26 — permissive hypercapnia acceptable. CXR: bilateral opacities, no pneumothorax. SAT performed this AM — passed. Plan: SBT after P/F >150 and no longer requiring proning. Continue proning x16 hours. #3 — ACUTE KIDNEY INJURY: Cr 2.8 today, up from 2.4 (baseline 1.0). Urine output 0.45 mL/kg/hr — oliguric. FeNa 0.8% — prerenal vs. sepsis-related ATN. Cumulative fluid balance +3.8L. On vasopressor — deferring diuresis until MAP improves off pressors. Nephrology aware; no RRT indication. Plan: optimize perfusion pressure, trend Cr and UO. #4 — SEDATION / NEUROLOGIC STATUS: On propofol 20 mcg/kg/min, RASS -2. CAM-ICU negative. SAT passed this AM. Plan: maintain light sedation, proceed with SBT. #5 — NUTRITION / LINES / PROPHYLAXIS: Tube feeds at 45 mL/hr, tolerating — advance to goal today. Lines: L SC triple-lumen day 3, R radial art line, Foley day 3 — all indications documented, no signs of infection. DVT ppx: heparin SQ TID. Bowel regimen: senna/miralax BID, last BM this AM. Glucose 148–172 on insulin drip — within goal. Platelets 142, trending down from 210 — monitor."

Heroes for Zeroes Rounding Checklist

ICU checklist — Medicare Hospital-Acquired Conditions (HACs). Check off items as you round.

0 / 21 complete
💬 1. Hospital-Acquired Pneumonia (HAP) / VAP
Spontaneous awakening and breathing trials
Early mobility protocol followed
Daily sedation assessment and goal documentation
Incentive spirometry used (non-ventilated patients)
🚿 2. Catheter-Associated Urinary Tract Infection (CAUTI)
Document catheter indication and insertion date
Daily review of catheter necessity
💉 3. Central Line-Associated Bloodstream Infection (CLABSI)
Central line insertion site evaluated daily
Daily necessity review and prompt removal if not needed
🩹 4. Pressure Injuries (HAP-I)
Daily skin assessment (emphasis on skin pressure points and around devices)
⚠️ 5. Falls with Injury
Fall risk assessment performed and documented
Bed alarm in place if high risk
🩹 6. Surgical Site Infections (SSI)* (if applicable)
Signs of infection monitored and reported
🦰 7. DVT/PE (Deep Vein Thrombosis / Pulmonary Embolism)
VTE prophylaxis ordered and administered
Mechanical prophylaxis in place if pharmacologic contraindicated
Mobility encouraged as tolerated
Daily DVT risk assessment documented
🦠 8. Sepsis
Fever above 100.4°F? (review cultures, reassess antibiotics)
🦠 9. C. diff
Number of eligible stools in first 48 hours of admission documented
💊 10. Stress Ulcer Prophylaxis
Consider PPI or H2RA

Clinical Reference

Protocols & Guidelines

Unit-specific clinical protocols and commonly referenced pathways. Always verify with your attending for patient-specific decisions.

💨
Mechanical Ventilation Protocol
Lung-protective (ARDS), standard airway protection, chronic CO₂ retainer & auto-PEEP
→
❤️
Vasopressor & Hemodynamic Support
Norepinephrine first-line, vasopressin, stress-dose steroids, phenylephrine in AF/RVR
→
🧠
Sedation & Analgesia (ABCDEF Bundle)
Analgesia-first, RASS targets, propofol vs dex, SAT/SBT, delirium
→
🩸
Glycemic Management
Target 140–180, NICE-SUGAR evidence, insulin infusion, hypoglycemia protocol
→
🦠
Sepsis & Septic Shock
Hour-1 bundle, fluid choice, empiric antibiotics by source, resuscitation endpoints
→
🫀
AKI & Renal Replacement Therapy
KDIGO staging, AEIOU indications, CRRT vs IHD, citrate anticoagulation
→
🍽️
Nutrition in the ICU
Early EN within 24–48h, caloric & protein targets, TPN indications, special populations
→

Clinical Reference

Common MICU Diagnoses

Detailed workup, management, and medication dosing for the diagnoses you'll encounter most. Always verify with your attending for patient-specific decisions.

🔍 Diagnosis (Berlin Criteria)

  • Acute onset within 1 week of known insult
  • Bilateral opacities on CXR/CT not fully explained by effusions, collapse, or nodules
  • Respiratory failure not fully explained by cardiac failure or fluid overload
  • Mild: PaO₂/FiO₂ 200–300 on PEEP ≥5
  • Moderate: PaO₂/FiO₂ 100–200 on PEEP ≥5
  • Severe: PaO₂/FiO₂ <100 on PEEP ≥5

💨 Lung-Protective Ventilation

  • Tidal volume: 6 mL/kg IBW (start at 8, wean to 6)
  • Plateau pressure: <30 cmH₂O
  • Driving pressure: target <15 cmH₂O
    Defined as plateau pressure − PEEP; reflects the stress applied to the lung with each breath.
  • PEEP: titrate per ARDSnet table to FiO₂
  • SpO₂ target: 88–95%, PaO₂ 55–80
  • pH target: permissive hypercapnia acceptable if pH >7.20

🔄 Adjunct Therapies

  • Proning: indicated if P/F <150 on FiO₂ ≥0.6, PEEP ≥5 — prone 16+ hrs/day
  • Neuromuscular blockade: consider cisatracurium infusion in severe ARDS first 48 hrs
  • Conservative fluid strategy: target even to negative once hemodynamically stable
  • Steroids: dexamethasone 6 mg IV daily x10 days (COVID-ARDS); methylprednisolone in unresolving ARDS
  • iNO / prostacyclins: rescue therapy only, no mortality benefit
  • ECMO: consider VV-ECMO if P/F <80 despite optimal management — consult Dr. Bruen's team

⚠️ Common Pitfalls

  • Overshooting tidal volumes — always calculate IBW, not actual body weight
  • Under-treating PEEP in severe ARDS
  • Delaying proning — earlier is better
  • Aggressive fluid resuscitation once the acute phase has passed

🔍 Diagnosis

  • Sepsis = life-threatening organ dysfunction from infection (SOFA ≥2)
  • Septic shock = sepsis + vasopressor requirement + lactate >2 mmol/L despite adequate resuscitation
  • Workup: 2x blood cultures (before antibiotics if possible), UA/Ucx, CXR, lactate, BMP, LFTs, CBC, coags, procalcitonin
  • Identify source: pneumonia, UTI, abdominal, line, skin/soft tissue

💊 Hour-1 Bundle

  • Measure lactate — repeat if initial >2
  • Blood cultures x2 before antibiotics
  • Broad-spectrum antibiotics within 1 hour of recognition
  • 30 mL/kg IV crystalloid for hypotension or lactate ≥4
  • Vasopressors if MAP <65 during/after resuscitation

💉 Vasopressors & Dosing

  • Norepinephrine (first-line): 0.01–3 mcg/kg/min — titrate to MAP ≥65
  • Vasopressin (add-on): 0.04 units/min fixed dose — add when NE >0.25
  • Epinephrine: 0.01–0.5 mcg/kg/min — for refractory shock
  • Phenylephrine: avoid in septic shock (reduces cardiac output)
  • Hydrocortisone: 50 mg IV q6h if refractory to 2 vasopressors

🦠 Empiric Antibiotics by Source

  • Unknown source: Vancomycin + Piperacillin-tazobactam
  • Pneumonia (CAP): Ceftriaxone + Azithromycin ± Vancomycin
  • HAP/VAP: Vancomycin + Cefepime or Pip-tazo
  • UTI: Ceftriaxone (adjust per sensitivities)
  • Abdominal: Piperacillin-tazobactam ± Fluconazole
  • Always deescalate once cultures return

🔍 Diagnosis & Risk Stratification

  • Onset: minor symptoms 6–12h, seizures 12–24h, DTs 24–72h after last drink
  • CIWA-Ar score: nausea, tremor, diaphoresis, anxiety, agitation, perceptual disturbances, headache, orientation (max 67)
  • Mild: CIWA <8 | Moderate: 8–15 | Severe: >15
  • High risk: prior seizures or DTs, heavy/prolonged use, concurrent illness
  • Wernicke's risk: give thiamine BEFORE any glucose

💊 Benzodiazepine Protocol

  • Symptom-triggered (preferred): Lorazepam 2–4 mg IV/PO q1h PRN for CIWA ≥8
  • Fixed-schedule (severe/high risk): Diazepam 10 mg PO q6h x4 doses, then 5 mg q6h x8 doses
  • Refractory / DTs: Diazepam 5–10 mg IV q5–10 min until calm
  • Liver failure / elderly: prefer Lorazepam (no active metabolites)

🧪 Adjunct Therapies

  • Thiamine: 500 mg IV TID x3 days — always before dextrose
  • Phenobarbital: 130–260 mg IV q15–30 min for benzo-refractory DTs
  • Propofol / Dexmedetomidine: for intubated patients or ICU-level agitation
  • Ketamine: emerging adjunct for refractory cases
  • Electrolytes: aggressively replete Mg, K, Phos, glucose
  • Folate: 1 mg PO daily

⚠️ Common Pitfalls

  • Undertreating early — DTs are preventable with aggressive early management
  • Giving glucose before thiamine → can precipitate Wernicke's encephalopathy
  • Using symptom-triggered protocol in patients who can't self-report
  • Forgetting concurrent illness (infection, GI bleed, pancreatitis)

🔍 Diagnosis & Workup

  • Worsening dyspnea, cough, sputum in known COPD patient
  • ABG: hypercapnia (PaCO₂ >45), respiratory acidosis — compare to baseline
  • CXR: rule out pneumonia, pneumothorax, CHF
  • Triggers: infection (most common), non-compliance, PE, cardiac
  • Severity: mild (responds to bronchodilators) → severe (AMS, paradoxical breathing, accessory muscle use)

💊 Medical Management

  • SABA: Albuterol 2.5 mg nebulized q20 min x3, then q1–4h
  • SAMA: Ipratropium 0.5 mg nebulized q6h
  • Steroids: Methylprednisolone 125 mg IV x1, then Prednisone 40 mg PO daily x5 days
  • Antibiotics: if increased sputum purulence — Azithromycin or Doxycycline x5 days
  • O₂ target: SpO₂ 88–92% — avoid over-oxygenation

😷 Non-Invasive Ventilation (BiPAP)

  • Indications: pH <7.35 + PaCO₂ >45, moderate-severe dyspnea, RR >25
  • Starting settings: IPAP 10–15, EPAP 4–5, FiO₂ to target SpO₂ 88–92%
  • Reassess ABG in 1–2 hrs — expect improvement in pH and PaCO₂
  • Failure → intubate: worsening AMS, unable to protect airway, hemodynamic instability, no improvement after 1–2 hrs

⚠️ Common Pitfalls

  • Over-oxygenating — SpO₂ >95% can worsen hypercapnia
  • Delaying BiPAP — earlier initiation reduces intubation rates
  • Missing alternative diagnosis (PE, ACS, pneumothorax)
  • Not checking baseline ABG from prior admissions

🔍 Diagnosis

  • MAP <65 or SBP <90 + signs of hypoperfusion (cold/clammy, AMS, oliguria, elevated lactate)
  • Evidence of cardiac dysfunction: elevated BNP, pulmonary edema, reduced EF on echo
  • SCAI stages A–E — Stage C (classic): hypotension + hypoperfusion
  • Workup: EKG, troponin, BNP, echo (STAT), right heart cath if needed
  • Etiologies: ACS (most common), acute decompensated HF, myocarditis, valvular emergency, stress cardiomyopathy

💉 Vasopressors & Inotropes

  • Norepinephrine (first-line): 0.01–3 mcg/kg/min
  • Dobutamine (inotrope): 2–20 mcg/kg/min — improves CO; may cause hypotension
  • Milrinone: 0.125–0.75 mcg/kg/min — preferred in RV failure; avoid if hypotensive
  • Dopamine: avoid — higher arrhythmia risk
  • Epinephrine: 0.01–0.5 mcg/kg/min — last resort

🫀 Mechanical Circulatory Support

  • IABP: reduces afterload, augments diastolic pressure — easiest to place
  • Impella: LV unloading — more powerful; requires cath lab
  • VA-ECMO: full cardiopulmonary support — contact ECMO team early if deteriorating
  • Involve cardiology and ECMO team early — do not delay escalation

⚠️ Common Pitfalls

  • Giving fluids reflexively — cardiogenic shock patients are often volume overloaded
  • Delaying echo — essential to differentiate from distributive shock
  • Missing RV failure — requires different management (avoid high PEEP, milrinone preferred)
  • Late MCS escalation — earlier support improves outcomes

🔍 Diagnosis

  • Seizure lasting >5 min OR ≥2 seizures without return to baseline
  • Refractory SE: failure of 2 adequate AED trials
  • Super-refractory SE: ongoing after 24h of anesthetic therapy
  • Workup: glucose (STAT), BMP, CBC, AED levels, tox screen, LP, continuous EEG, MRI brain
  • Causes: AED non-compliance, stroke, CNS infection, metabolic, anoxic injury, autoimmune encephalitis

💊 Treatment Algorithm (Time-Based)

  • 0–5 min: ABCs, glucose check, IV access, O₂
  • 5–20 min (1st line): Lorazepam 0.1 mg/kg IV (max 4 mg) x1; IM Midazolam 10 mg if no IV
  • 20–40 min (2nd line): Levetiracetam 60 mg/kg IV (max 4500 mg) OR Valproate 40 mg/kg IV OR Fosphenytoin 20 mg PE/kg
  • 40–60 min (refractory): intubate + Propofol or Midazolam or Phenobarbital infusion
  • Involve neurology early — continuous EEG for refractory cases

🧠 Anesthetic Infusions (Refractory SE)

  • Propofol: 1–2 mg/kg IV load, then 20–200 mcg/kg/min — monitor for PRIS (triglycerides, CK, acidosis)
  • Midazolam: 0.2 mg/kg IV load, then 0.05–2 mg/kg/hr
  • Phenobarbital: 20 mg/kg IV at 50–75 mg/min
  • Ketamine: 1–4.5 mg/kg/hr — NMDA antagonist, emerging option
  • Target burst suppression on EEG

⚠️ Common Pitfalls

  • Underdosing benzodiazepines — give full weight-based dose
  • Delaying 2nd-line AEDs — move quickly through the algorithm
  • Missing non-convulsive SE in persistent AMS after convulsive seizure → get EEG
  • Not checking AED levels in known epilepsy patients

🔍 Diagnosis

  • DKA: glucose >250, pH <7.3, bicarb <18, anion gap >12, ketonemia/ketonuria
  • HHS: glucose >600, serum osm >320, pH >7.3, minimal ketones, profound dehydration
  • DKA severity: Mild pH 7.25–7.30 | Moderate 7.00–7.24 | Severe <7.00
  • Triggers: infection (most common), insulin non-compliance, new diagnosis, ACS, pancreatitis
  • Workup: BMP q2–4h, phosphate, Mg, CBC, UA, blood cx, EKG, lipase

💧 Fluid Resuscitation

  • 1st hour: 1L NS bolus (repeat if hemodynamically unstable)
  • Ongoing: 250–500 mL/hr NS x4–6h, then adjust based on corrected Na
  • When glucose 200–250: switch to D5 0.45% NS to prevent hypoglycemia while continuing insulin
  • HHS patients are more severely depleted — may need 8–10L over 24h

💉 Insulin & Electrolytes

  • Insulin infusion: 0.1 units/kg/hr (no bolus); hold if K <3.5
  • Potassium: replace aggressively — target K 4–5 before starting insulin
  • Phosphate: replace if <1.0 or symptomatic
  • Bicarb: only if pH <6.9 — 100 mEq NaHCO₃ over 2h
  • Transition to SQ: anion gap closed + patient eating; overlap IV/SQ by 2h
  • Do NOT stop insulin just because glucose normalizes — gap must close first

⚠️ Common Pitfalls

  • Starting insulin before repleting K — can cause fatal hypokalemia
  • Stopping insulin infusion before anion gap closes
  • Missing the trigger — always look for infection, ACS, non-compliance
  • Forgetting to check phosphate — drops severely with treatment

🔍 Diagnosis & Staging (KDIGO)

  • Cr increase ≥0.3 mg/dL within 48h OR ≥1.5x baseline within 7 days OR UO <0.5 mL/kg/hr x6h
  • Stage 1: Cr 1.5–1.9x | Stage 2: 2–2.9x | Stage 3: ≥3x or Cr ≥4 or RRT
  • Etiology: Pre-renal (most common in ICU), intrinsic (ATN, GN, AIN), post-renal
  • Workup: BMP, UA + microscopy, urine Na/Cr (FENa, FEUrea), renal US, review nephrotoxins
  • FENa <1% suggests pre-renal (unreliable if diuretics — use FEUrea)

💊 Management

  • Pre-renal: volume resuscitation with crystalloid; avoid over-resuscitation
  • ATN: supportive care, remove nephrotoxins, optimize hemodynamics
  • Nephrotoxins to stop: NSAIDs, aminoglycosides, vancomycin (monitor levels), ACE/ARBs in acute illness
  • Adjust all medication doses for GFR
  • Avoid hyperkalemia — dietary restriction, kayexalate/patiromer

🧪 Emergent RRT Indications (AEIOU)

  • A — Acidosis: pH <7.1 refractory to treatment
  • E — Electrolytes: hyperkalemia >6.5 or refractory to medical management
  • I — Intoxication: dialyzable toxins (methanol, ethylene glycol, lithium, salicylates)
  • O — Overload: volume overload refractory to diuretics
  • U — Uremia: uremic pericarditis, encephalopathy, bleeding
  • CRRT preferred in hemodynamically unstable patients

⚠️ Common Pitfalls

  • Delayed nephrology consult — call early if trending toward RRT
  • Over-resuscitating — fluid overload worsens AKI outcomes
  • Forgetting to renally dose medications
  • Missing obstruction — always check renal US if cause unclear

🔍 Diagnosis

  • SBP >180 and/or DBP >120 + acute end-organ damage
  • Distinguish from urgency: urgency = no end-organ damage → outpatient oral management
  • End-organ manifestations: hypertensive encephalopathy, ICH, aortic dissection, acute pulmonary edema, ACS, eclampsia, AKI
  • Workup: EKG, CXR, BMP, UA, troponin, CT head (neuro symptoms), CT chest (dissection concern)

🎯 BP Targets by Emergency Type

  • Most emergencies: reduce MAP by 10–20% in first hour, then 15–25% over next 23h — do NOT normalize acutely
  • Ischemic stroke: only treat if >220/120 — target 15% reduction
  • Hemorrhagic stroke: SBP <140 target
  • Aortic dissection: SBP 100–120 and HR <60 ASAP — most aggressive target
  • Acute pulmonary edema: rapid reduction with vasodilators

💉 IV Medications & Dosing

  • Nicardipine: 5–15 mg/hr — first-line for most; smooth titration
  • Labetalol: 20 mg IV q10 min (max 300 mg) or 0.5–2 mg/min infusion — avoid in acute HF, asthma
  • Clevidipine: 1–32 mg/hr — ultra-short acting; excellent perioperative
  • Esmolol: 500 mcg/kg load, then 50–200 mcg/kg/min — ideal for dissection
  • Hydralazine: 10–20 mg IV q4–6h — unpredictable; OK in pregnancy
  • Nitroprusside: 0.3–10 mcg/kg/min — caution with prolonged use (cyanide toxicity)

⚠️ Common Pitfalls

  • Dropping BP too rapidly — cerebral autoregulation is reset; too-fast reduction causes ischemia
  • Treating hypertensive urgency with IV drips — oral agents are appropriate
  • Missing aortic dissection — always consider if tearing chest/back pain; get CT chest immediately
  • Using nicardipine in acute HF with pulmonary edema — use nitrates instead

🔍 Diagnosis & Risk Stratification

  • Upper GI bleed (UGIB): source proximal to ligament of Treitz — hematemesis, coffee-ground emesis, melena
  • Lower GI bleed (LGIB): source distal to ligament of Treitz — hematochezia, bright red blood per rectum
  • Common UGIB causes: peptic ulcer disease (most common), esophageal varices, Mallory-Weiss tear, gastritis, Dieulafoy lesion, malignancy
  • Common LGIB causes: diverticulosis (most common), AVM, ischemic colitis, IBD, malignancy, hemorrhoids
  • Glasgow-Blatchford Score (GBS): use for UGIB risk stratification — score ≥1 requires inpatient management; higher score = higher risk
  • Rockall Score: post-endoscopy rebleed and mortality risk

💧 Initial Resuscitation

  • 2 large-bore IVs (16g or larger) or central access if needed
  • Type & crossmatch, CBC, BMP, coags, LFTs, lactate
  • pRBC transfusion: restrictive strategy — transfuse for Hgb <7 (or <8 if ACS/hemodynamically unstable); target Hgb 7–9
  • FFP/platelets: for active bleeding with INR >1.5 or plt <50k; avoid over-correction in cirrhosis
  • Avoid aggressive crystalloid — worsens coagulopathy and portal hypertension
  • NPO for anticipated endoscopy; secure airway early if hematemesis + altered mental status
  • Massive transfusion protocol if hemorrhagic shock: 1:1:1 ratio pRBC:FFP:platelets

💊 Medical Management

  • UGIB — PPI: Pantoprazole 80 mg IV bolus then 8 mg/hr infusion (pre-endoscopy); transition to 40 mg IV/PO BID post-endoscopy
  • Variceal UGIB: Octreotide 50 mcg IV bolus then 50 mcg/hr infusion x3–5 days; Ceftriaxone 1g IV daily x7 days (SBP prophylaxis)
  • Non-variceal UGIB: hold anticoagulants; reverse if life-threatening bleed
  • LGIB: most self-limited; aggressive resuscitation; colonoscopy after prep when stable
  • Anticoagulation reversal: Warfarin → Vitamin K + 4-factor PCC; DOACs → specific reversal agents (andexanet alfa, idarucizumab)
  • Avoid NSAIDs, aspirin unless critical cardiac indication (discuss with team)

🔬 Endoscopy & Interventional

  • Urgent EGD: within 24h for UGIB (within 12h if high-risk or variceal)
  • Colonoscopy: within 24h for LGIB requiring transfusion after bowel prep
  • Balloon tamponade (Blakemore tube): temporizing measure for refractory variceal bleed — bridge to TIPS; max 24h inflation
  • IR angioembolization: for LGIB or UGIB not amenable to endoscopic therapy
  • TIPS: for refractory variceal bleeding — early TIPS (<72h) in Child-Pugh B/C cirrhosis improves survival
  • Surgery: last resort for uncontrolled hemorrhage

⚠️ Common Pitfalls

  • Over-transfusing in cirrhotic variceal bleed — worsens portal hypertension; target Hgb 7–8
  • Delaying intubation in massive hematemesis — secure airway before endoscopy
  • Forgetting antibiotics in cirrhotic GI bleed — SBP prophylaxis reduces mortality
  • Missing aortoenteric fistula in patients with prior aortic surgery — herald bleed precedes massive hemorrhage
  • Stopping octreotide too early — continue 3–5 days for variceal bleed

🔍 Diagnosis & Severity

  • Cirrhosis = irreversible hepatic fibrosis; decompensation = variceal bleed, ascites, hepatic encephalopathy, jaundice, or SBP
  • Child-Pugh score: A (5–6), B (7–9), C (10–15) — estimates surgical mortality and prognosis
  • MELD-Na score: predicts 90-day transplant-free survival; guides transplant listing
  • Workup: CBC, CMP, coags (INR), LFTs, albumin, ammonia, blood/urine/ascites cultures, hepatitis serologies, abdominal US with Doppler
  • Always look for precipitating cause of decompensation: infection, GI bleed, medication non-compliance, hepatotoxins, portal vein thrombosis

🧠 Hepatic Encephalopathy

  • Grades: I (mild confusion) → IV (coma); Grade III–IV may require intubation for airway protection
  • Lactulose: 30–45 mL PO/NG q1–2h until 2–3 soft stools/day, then titrate to 2–3 BM/day maintenance; can use as enema (300 mL in 700 mL water) if unable to take PO
  • Rifaximin: 550 mg PO BID — add for recurrent or refractory HE; reduces rehospitalization
  • Identify & treat precipitants: infection, GI bleed, constipation, electrolyte disturbance, sedatives, dietary protein excess
  • Zinc supplementation: 220 mg PO BID in chronic HE
  • Avoid benzodiazepines if possible — can precipitate/worsen HE

🦠 Spontaneous Bacterial Peritonitis (SBP)

  • Diagnosis: ascitic PMN ≥250 cells/mm³ regardless of culture result
  • Symptoms: fever, abdominal pain, worsening HE — may be subtle or absent
  • Treatment: Cefotaxime 2g IV q8h x5 days (first-line); Ceftriaxone 1g IV q24h acceptable alternative
  • Albumin: 1.5 g/kg IV on day 1 + 1 g/kg IV on day 3 — significantly reduces HRS and mortality
  • Secondary prophylaxis: Norfloxacin 400 mg PO daily (or Ciprofloxacin 500 mg PO daily) indefinitely after first SBP episode
  • Primary prophylaxis: consider in patients with ascites protein <1.5 g/dL + renal/hepatic dysfunction

🧱 Hepatorenal Syndrome (HRS)

  • HRS-AKI (Type 1): rapid deterioration, Cr doubling to >2.5 within 2 weeks — median survival weeks without treatment
  • HRS-CKD (Type 2): slower progression; median survival months
  • Diagnosis: AKI in cirrhosis after excluding other causes, no improvement after 48h of diuretic hold + albumin challenge (1 g/kg/day x2 days)
  • Terlipressin (preferred): 0.5–2 mg IV q4–6h + Albumin 20–40 g/day — FDA approved 2022
  • Alternative: Norepinephrine 0.5–3 mg/hr IV + Albumin (ICU setting); Midodrine 7.5–12.5 mg TID + Octreotide 100–200 mcg SC TID + Albumin (step-down)
  • Liver transplant is definitive treatment — refer early

💧 Variceal Bleed & Ascites

  • Variceal bleed: Octreotide 50 mcg bolus then 50 mcg/hr + Ceftriaxone 1g daily + urgent EGD; early TIPS if Child-Pugh B/C
  • Primary variceal prophylaxis: non-selective beta-blocker (Propranolol, Nadolol, or Carvedilol) OR endoscopic band ligation
  • Refractory ascites: large volume paracentesis (LVP) + Albumin 6–8 g per liter removed >5L; TIPS for recurrent refractory ascites
  • Diuretics for ascites: Spironolactone 100 mg + Furosemide 40 mg PO daily (maintain 100:40 ratio); titrate to weight loss 0.5 kg/day

🧬 Coagulopathy & Common Pitfalls

  • Coagulopathy in cirrhosis is complex: INR elevated but does NOT reflect true bleeding risk — pro- and anticoagulant factors both reduced (rebalanced hemostasis)
  • Do NOT correct INR prophylactically with FFP — ineffective, worsens portal hypertension, causes volume overload
  • For active bleeding: Vitamin K 10 mg IV x3 days; TXA if massive hemorrhage; platelet transfusion if <50k; consider thromboelastography (TEG) to guide therapy
  • Pitfall: over-diuresing — can precipitate HRS; max 500 mL/day fluid removal in absence of edema
  • Pitfall: using nephrotoxic agents (NSAIDs, aminoglycosides, IV contrast) — dramatically increases HRS risk
  • Pitfall: giving lactulose without monitoring bowel movements — over-treatment causes hypernatremia and worsens renal function

The Team

Meet Your MICU Staff

Get to know the attendings and advanced practice clinicians who make this unit run.

Attendings

Dr. David Niccum

Dr. David Niccum

Head of Critical Care & MICU

Medical Director
Dr. Charles Bruen

Dr. Charles Bruen

MICU Attending

Head of ECMO Program
Dr. Michael Alter

Dr. Michael Alter

MICU Attending

Dr. William Amundson

Dr. William Amundson

MICU Attending

Dr. Petr Bachan

Dr. Petr Bachan

MICU Attending

Dr. Andrew Caraganis

Dr. Andrew Caraganis

MICU Attending

Dr. Firas Elmufdi

Dr. Firas Elmufdi

MICU Attending

Dr. Sara Erickson

Dr. Sara Erickson

MICU Attending

Dr. Inga Forde

Dr. Inga Forde

MICU Attending

Dr. Kate Gillen

Dr. Kate Gillen

MICU Attending

Dr. Jannica Groom

Dr. Jannica Groom

MICU Attending

Dr. Alexandra Schick

Dr. Alexandra Schick

MICU Attending

Dr. John Selickman

Dr. John Selickman

MICU Attending

Dr. Felix Zamora

Dr. Felix Zamora

MICU Attending

Dr. Alexander Zanotto

Dr. Alexander Zanotto

MICU Attending

Advanced Practice Clinicians

Travis Reddinger

Travis Reddinger

Advance Practice Clinician

Krista Nuessle

Krista Nuessle

Advance Practice Clinician

Kristen Connor

Kristen Connor

Advance Practice Clinician

Stephani Johnson

Stephani Johnson

Advance Practice Clinician

Alicia Dykstra

Alicia Dykstra

Advance Practice Clinician

Danielle Lyons

Danielle Lyons

Advance Practice Clinician

Justin Martinez

Justin Martinez

Advance Practice Clinician

Clinical Pharmacists

Hollie Lawrence

Hollie Lawrence

Clinical Pharmacist

MICU Pharmacist
Yohannes Haile

Yohannes Haile

Clinical Pharmacist

Tools & References

Resources & Links

Curated references, calculators, and educational materials for the MICU rotation.

📖

UpToDate

Available via Regions Hospital library access. Use your employee credentials to log in.

Reference
🧮

MDCalc

APACHE, SOFA, CURB-65, and other critical care scores. Bookmark on your phone.

Calculator
🫁

ARDS Network

ARDSnet tables, tidal volume calculator, and landmark trial summaries.

Clinical
🤖

OpenEvidence

AI-powered clinical decision support trained on medical literature. Fast answers at the bedside.

Clinical
📱

ICU Onepagers

Downloadable one-page summaries of key MICU topics, made by your fellows.

Education
📞

Key Contact Numbers

Rapid response, pharmacy, blood bank, radiology, and subspecialty pager list.

Logistics

Reference Documents

Policies

Hospital policies relevant to the MICU rotation. Click to open.

📋

ICU Triage Guidelines

Criteria and process for ICU admission triage.

Download PDF ↓
🧠

Brain Death Policy

SW Brain Death Policy and Procedure for Adults (11.2024).

Download PDF ↓
🩹

Body Fluid Exposure Policy

Protocol for managing occupational body fluid exposures.

Download PDF ↓

Quick Reference

Hospital Phone Directory

Internal extensions unless otherwise noted. Dial 9 for outside lines.

The prefix for all numbers is 651-254-xxxx.

🚨 Emergency

Code Blue / Stroke / PERT / RRT11111
Anesthesia Lead41687
Trauma / Acute Care Surgery41007
Security STAT44911
Security Non-Emergency43876

🏥 Admitting

Admitting / Patient Placement42337
Bed Hub42337
RPC / Admins RN Supervisor42052

📱 CC Day Team Sat Phones

CC146044
CC246037
CC346038
SICU40774

🧪 Lab / Blood Bank

ABGs / Urinalysis45531
Blood Bank49657
Central Lab952-833-1800
Chemistry49633
Coags49616
Heme49612
Histology45144
Lab Dispatch49657
Micro49685
Pathology44795
Point of Care (POC)43544

💊 Pharmacy

Hollie / SR Pharmacist44699
Inpatient Pharmacy49027
Compounded / PI Specific Meds49027 Opt. 4.1
Unit Dose Products49027 Opt. 4.2
Pyxis Support49027 Opt. 3
Discharge / Home Meds49027 Opt. 2
Pharmacy Tech42445

🏥 ICU Resources

Care Management Office46260
Diabetes Educator629-0181
Dialysis44834
HP Med Transport (HPMT)43160 Opt. 2
Infection Prevention43488
Interpreter Services44767
Language Line67000
Lead Respiratory Therapist42744
Morgue43781
Patient Rep43370
Regions Direct40006
Spiritual Care43417
Transport Lead43270
Volunteer Services43520

🍽️ Dietary

Meal Trays43601
Dietary (1st & floor stock)43678
Dietitian SR43026

🦴 Therapy

PT / OT / Speech42017
Pulm Rehab43047
Cardiac Rehab46043

🏢 Hospital Resources

Copy Center41726
Financial Services42059
Guest Services – South Lobby43481
Guest Services – West Lobby43501
Loading Docks43037
Medical Records952-845-7800

🛏️ Floor Charge Nurses

South 6 Charge Nurse46000
South 7 Charge Nurse46100

How Things Work

Logistics

Key workflows and processes for the MICU rotation.

Patients may be transferred out of the MICU to hospital medicine preferably by 2:00 PM. Very stable patients (e.g. DKA) may be transferred up until 5:00 PM.

ICU Transfer Work-Flow

Step I

ICU Team determines that a patient is medically ready to transfer out of the ICU to progressive or general care.

Step II

*If not the first transfer of the day, SKIP to Step IV

Each day the ICU team creates a new group chat with the following:

  • RH Patient Placement
  • RH Hospital Medicine Triage

**There should only be one thread per day per team**

Step III

At the top of the thread, notify the team who you are:

"This is CC1, call back number today will be *****"

Step IV

Without attaching a patient, enter transfer information with at least TWO patient identifiers (preferably initials and MRN).

Ex: 6630, JR, MRN 55555555

Step V

Triage or patient placement will thumbs up the message to let you know it has been received.

Step VI

Patient will be assigned and hospitalist will call back when ready for sign out.

Multidisciplinary Rounds

  • Held daily in the S6 Conference Room at 11:00 AM.
  • The charge nurse will call the team phone when they are ready for the resident/intern to come to rounds.

Forwarding Calls — Team Phone

Method 1

Menu Navigation

Navigate to Settings > Features > Forward. Select the type of forwarding (Always, No Answer, or Busy), enter the target number, and press the Enable soft key.

Method 2

During a Ring

While the handset is ringing, select the Forward soft key, enter the target number, and press Forward again.

Deactivate

To disable, go to Settings > Features > Forward and press the Disable soft key.