Evaluation and Management of Severe Covid-19
• Patients with severe coronavirus disease 2019 (Covid-19) may become critically ill with acute respiratory distress syndrome that typically begins approximately 1 week after the onset of symptoms.
• Deciding when a patient with severe Covid-19 should receive endotracheal intubation is an essential component of care.
• After intubation, patients should receive lung-protective ventilation with plateau pressure less than or equal to 30 cm of water and with tidal volumes based on the patient’s height.
• Prone positioning is a potential treatment strategy for refractory hypoxemia. • Thrombosis and renal failure are well-recognized complications of severe Covid-19. • Data are needed from randomized trials to inform the benefits and risks of antiviral or
immunomodulatory therapies for severe Covid-19; as of mid-May 2020, no agents had been approved by the Food and Drug Administration for treatment of these patients.
• Preliminary data from a randomized, placebo-controlled trial involving patients with severe Covid-19 suggest that the investigational antiviral remdesivir shortens time to recovery.
Discussion The COVID-19 pandemic has brought unprecedented chal- lenges regarding the ability to generate timely evidence, even as the disease overwhelms health care systems and stresses the clinical workforce. This SSC guideline2 will be frequently updated online as global evidence accrues, but it reflects the central tenants of best practices for ARDS: low tidal volume strat- egy, PEEP titration, avoidance of hyperoxia, and a conservative fluid strategy.
Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic - a narrative review.
Personal protective equipment has become an important and emotive subject during the current coronavirus disease 2019 epidemic. Coronavirus disease 2019 is predominantly caused by contact or droplet transmission attributed to relatively large respiratory particles which are subject to gravitational forces and travel only approximately 1 metre from the patient. Airborne transmission may occur if patient respiratory activity or medical procedures generate respiratory aerosols. These aerosols contain particles that may travel much longer distances and remain airborne longer, but their infective potential is uncertain. Contact, droplet and airborne transmission are each relevant during airway manoeuvres in infected patients, particularly during tracheal intubation. Personal protective equipment is an important component, but only one part, of a system protecting staff and other patients from coronavirus disease 2019 cross-infection. Appropriate use significantly reduces risk of viral transmission. Personal protective equipment should logically be matched to the potential mode of viral transmission occurring during patient care - contact, droplet or airborne. Recommendations from international organisations are broadly consistent, but equipment use is not. Only airborne precautions include a fitted high-filtration mask, and this should be reserved for aerosol generating procedures. Uncertainty remains around certain details of personal protective equipment including use of hoods, mask type and the potential for re-use of equipment.
Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID‐19 Pandemic
Caputo N, Strayer R, Levitan R. Academic Emergency Medicine 2020
OBJECTIVE Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19 pandemic. METHODS This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2. SpO2 measurements were recorded at triage and after five minutes of proning. Supplemental oxygenation methods included non-rebreather mask (NRB) and nasal cannula. We also characterized post-proning failure rates of intubation within the first 24 hours of arrival to the ED.RESULTS Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre- to post-median by the Wilcoxon Rank-sum test yielded P=0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. CONCLUSION Awake early self-proning in the emergency department demonstrated improved oxygen saturation in our COVID-19positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.
Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations
Yao W et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth. 2020 Apr 10. doi: 10.1016/j.bja.2020.03.026. [Epub ahead of print] PubMed PMID: 32312571
Tracheal intubation in COVID-19 patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were male (n=136, 67.3%) and aged 65 yr or more (n=128, 63.4%). Most patients (n=152, 75.2%) were hypoxaemic (SaO2<90%) before intubation. Personal protective equipment (PPE) was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (SaO2<90%) was common during intubation (n=148, 73.3%). Hypotension (arterial pressure <90/60 mmHg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in 4 (2.0%). Pneumothorax occurred in 12 (5.9%) and death within 24 h in 21 (10.4%) patients. Up to 14 days post-procedure, there was no evidence of cross-infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy and methods for tracheal intubation in COVID-19 patients.
COVID-19 pneumonia : different respiratory treatment for different phenotypes ?
Gattinoni L et al. Intensive Care Med. 2020 Apr 14.
Based on detailed observation of several cases and discussions with colleagues treating these patients, we hypothesize that the different COVID-19 patterns found at presentation in the emergency department depend on the interaction between three factors: (1) the severity of the infection, the host response, physiological reserve and comorbidities; (2) the ventilatory responsiveness of the patient to hypoxemia; (3) the time elapsed between the onset of the disease and the observation in the hospital. The interaction between these factors leads to the devel- opment of a time-related disease spectrum within two primary “phenotypes”: Type L, characterized by Low elastance (i.e., high compliance), Low ventilation-to-per- fusion ratio, Low lung weight and Low recruitability and Type H, characterized by High elastance, High right-to- left shunt, High lung weight and High recruitability.
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.
We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.
The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy.
The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.
In-hospital cardiac arrest outcomes among patients with COVID-19pneumonia in Wuhan, China
Objective: To describe the characteristics and outcomes of patients with severe COVID-19 and in-hospitalcardiac arrest (IHCA) in Wuhan, China.Methods: The outcomes of patients with severe COVID-19 pneumonia after IHCA over a 40-day periodwere retrospectively evaluated. Between January 15 and February 25, 2020, data for all cardiopulmonaryresuscitation (CPR) attempts for IHCA that occurred in a tertiary teaching hospital in Wuhan, China werecollected according to the Utstein style. The primary outcome was restoration of spontaneous circulation(ROSC), and the secondary outcomes were 30-day survival, and neurological outcome.Results: Data from 136 patients showed 119 (87.5%) patients had a respiratory cause for their cardiacarrest, and 113 (83.1%) were resuscitated in a general ward. The initial rhythm was asystole in 89.7%,pulseless electrical activity (PEA) in 4.4%, and shockable in 5.9%. Most patients with IHCA were monitored(93.4%) and in most resuscitation (89%) was initiated <1 min. The average length of hospital stay was 7days and the time from illness onset to hospital admission was 10 days. The most frequent comorbiditywas hypertension (30.2%), and the most frequent symptom was shortness of breath (75%). Of the patientsreceiving CPR, ROSC was achieved in 18 (13.2%) patients, 4 (2.9%) patients survived for at least 30 days,and one patient achieved a favourable neurological outcome at 30 days. Cardiac arrest location and initialrhythm were associated with better outcomes.Conclusion: Survival of patients with severe COVID-19 pneumonia who had an in-hospital cardiac arrestwas poor in Wuhan.
Am I Part of the Cure or Am I Part of the Disease? Keeping Coronavirus Out When a Doctor Comes Home
Brewster D, Chrimes N, Do T et al. Medical Journal of Australia 2020. This a living document so please monitor the website for updates: