These are some of the many guiding tenets I have developed over the years of my clinical practice. They are by no means the absolute recommendations of ICU practice, but a personal compass I have relied on to gain clarity time and time again in the midst of clinical chaos.

Use them or not, it reminds us all that part of the clinical journey is to reflect and develop our own inner barometer, which is a combination of our hard work, clinical experience and maturity, with our personal philosophies and daily reflections.

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✅ Top ICU Secrets

1. Use short-acting titratable drugs during the critical care phase.
2. Procedural working space organised in order of required interventions improves movement economy and translates to improved success, day or night.
3. Successful procedures = 80% position and 20% skill.
4. Beta-lactam infusions are a pharmacokinetically sound strategy in the treatment of sepsis.
5. Minimize paralysis to mitigate ICU-acquired weakness.
6. Early transesophageal (TOE) in undifferentiated post-cardiothoracic surgical patients is critical to rule out loculated tamponade.
7. For massive transfusions = aim for balanced ratio of transfusions (1:1:1 RBC:FFP:Platelets)
8. Brain death is a clinical diagnosis.
9. Two therapies proven to reduce mortality in ARDS patients
   • Protective lung ventilation (6ml/kg of ideal body weight)
   • Prone positioning
10. Right heart failure requires multimodal optimization of:
    • pCO₂
    • pO₂
    • pH
    • volume status (volume overload)
    • pressure overload (reduce PVR)

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1. Delirium is a strong risk factor for increased length of hospital and ICU stay, as well as mortality.
2. The passive leg raise is the most sensitive bedside test for fluid responsiveness. Assess for dynamic response, such as a change in LVOT-Vti, rather than MAP.
3. The validity of pulse pressure variation as a surrogate of intravascular volume status is preconditioned by the following:
   • Sinus rhythm
   • Paralysed patient
   • Vt 8ml/kg
   • Normal lung compliance
4. Regional citrate anticoagulation is considered the standard dialysis modality in the modern era.
5. Blood flow rate of > 120ml/min in citrate HD may increase risk of citrate toxicity.
6. In profoundly shocked patients, Hemosol dialysis may be better suited in lieu of the lagging biochemical evidence of liver injury.
7. Identifying medical staff by name significantly improves communication in resuscitation.
8. Balanced crystalloid resuscitation is preferred in DKA resuscitation.
9. Effective and succinct clinical handovers are a vital communication skill that must be continuously honed through deliberate practice.
10. Clinical handover is not a clinical round.

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1. Protective lung ventilation is not exclusive to patients with ARDS.
2. HSV encephalitis can present with a false-negative CSF PCR. always consider repeating LP before ceasing Acyclovir if risk factors are high.
3. Listeria meningitis typically presents with lymphocytosis with an aseptic meningitis CSF picture.
4. All forms of ICU palliation require clinical consensus, regardless of the time of day.
5. Pressure support ventilation (PSV) and pressure control ventilation (PCV) are not synonymous.
6. PSV = pressure delivered to support a spontaneously triggered breath. PCV = a targeted pressure set that will generate a Vt depending on lung compliance.
7. Augmented BP targets in post-aSAH for management of cerebral vasospasm should be a joint clinical decision between neurosurgical and ICU teams.
8. The team leader of a resuscitation must be clear and succinct, practising situational awareness and closed-loop communication.
9. Mental health challenges amongst ICU medical professionals are common and should be supported by peers empathetically to seek medical help.
10. Pressure-controlled ventilation during bronchoscopy can help mitigate loss of tidal volume.

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1. Early mobilization in critically ill patients can improve short-term ICU outcomes.
2. Multimodal neuroprognostication after 72 hours of cardiac arrest without clinical confounders is an established standard clinical practice worldwide.
3. Fluid therapy should be equally viewed as administering medication therapy. Its role should be sought, and responsiveness assessed.
4. Offering decompressive craniectomy should be a multidisciplinary decision involving the Neurosurgical and ICU teams.
5. Excellent ICU ward round notes are concise, succinct, and reflect recent synthesized information, with categorized and prioritized plans. Copying and pasting, or blindly transcribing results, is robotic and has minimal impact.
6. High intelligence is no excuse for a low emotional quotient. Both are equally important in the people’s business of ICU.
7. Identify an area of interest during the ICU training pathway. The post-ICU exam sphere is vague and heavily influenced by the pursuit of your interests, which should be a combination of in-demand value-added skills and specializations.
8. In cases of influenza pneumonia, avoid steroid therapy to mitigate mortality risk, and consider early empirical antibiotics (such as ceftriaxone and vancomycin) to treat secondary, superadded bacterial pneumonia.
9. N-acetylcysteine infusions are harmless, and should be considered early in acute liver injuries concurrently during diagnostic workup.
10. Understanding the small radiation risk during pregnancy, life-saving radiological investigations should never be delayed in pregnant patients.

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1. All critically ill pregnant patients have a difficult airway.
2. Extreme caution is required with early beta-blockers in tachycardic acute heart failure patients. It may be the only compensatory mechanism maintaining an adequate cardiac output and can lead to complete cardiovascular collapse if reduced disproportionately.
3. CVVHDF is expensive. Always evaluate if IHD is an option.
4. Pain management in the ICU is complex; a multimodal approach can minimize opioid side effects. Non-pharmacologic modalities should not be underestimated and may have a role in a comprehensive pain management strategy.
5. A trial of NIV in hypoxaemic respiratory failure = reassessing clinical response in 60 minutes. Failure to appreciate this nuance can delay intubation with serious adverse respiratory complications.
6. Post-intubation hypotension in severe exacerbations of acute asthma is multifactorial: tension pneumothorax, dynamic hyperairway inflation, and hypovolemia.
7. The pathophysiological process of a large central pulmonary embolism involves an increase in dead space, resulting in a V/Q mismatch. The resultant effect increases minute ventilation, which subsequently causes hypocapnia and secondary bronchoconstriction, leading to alveolar hypoxia.
8. For acute liver failure patients with high-grade encephalopathy, the initiation of CRRT is neuroprotective and should not be delayed until overt renal failure is apparent.
9. In severe acute pancreatitis, early enteral feeding and avoidance of empirical antibiotics are established evidence based therapies.
10. Use the VALUE tool to enhance communication in the ICU: Value family statements, Acknowledge family emotions, Listen to the family, Understand the patient as a person and Elicit family questions.

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