Covid 19 has brought unprecedented challenges regarding the ability to generate timely evidence
all while this pandemic overwhelms hospitals and health care workers about 5% of patients
with Covid 19 require admission to the intensive care unit in mechanical ventilation based on the
recent epidemiological models Covid 19 is going to hit all the areas in this country so the surge is
coming and not just to the hotspots like New York City with every ICU in this country preparing for
the surge there are a number of changes that intensive care units are making including ours
we're preparing anesthesiologists who are not critical care medicine trained and also nurse
anesthetists to help us manage patients with covid 19 even though they're not critical care
medicine trained we have a lot of overlap of knowledge especially when it comes to managing
ventilators and we have a lot of overlap with certain procedures by allowing anesthesiologist
and nurse anesthetists to help in this manner it will help other intensivists like myself handle
the surge of patients coming our way and because they're helping us that's the main reason for me
making this video so that they can watch this and be better equipped to handle the surge with
us and this video is intended for any healthcare provider out there who has the potential to care
for critically ill patients with covid 19 and if you're not a healthcare worker most of the
info in this video will probably be too technical for you to understand but feel free to watch it
anyway so in this video I'm gonna cover the most important aspects of caring for a critically ill
patient with Covid 19 and how to manage different scenarios the info in this video is based on
several things one what we know so far about covid 19 patients mainly from studies that were done in
China to standard care for critical care patients in general and 3 my experience and the experience
of many my colleagues of caring for critically ill patients knowing in implementing all the info in
this video does not guarantee you save a covid 19 patient's life in the ICU but it will give you
the best chance of doing so so let's get to if a patient with covid 19 is coming to your ICU they
most certainly have pneumonia and they probably have acute respiratory distress syndrome aired
yes that may or may not be in shock which often happens in patients with ARDS and in patients
with sepsis in general patients with severe disease who require ICU admission are likely to
have high oxygen requirements although both high flow oxygen and non-invasive positive pressure
ventilation have been used for Covid the safety of these is uncertain and they're considered
aerosol generating procedures that warrant specific isolation precautions the same goes
for nebulizer treatments such as duo naps most patients who require ICU admission have ARDS and
they'll likely have a better outcome if intubated sooner rather than later that's another reason why
it's likely better to skip high flow oxygen and non-invasive positive pressure ventilation and
jump straight to intubation Covid 19 patients often have rapid clinical deterioration and
there needs to be a low threshold to intubate once their oxygen requirements start to climb
ARDS is a clinical diagnosis based on non cardiogenic pulmonary edema with bilateral
patchy infiltrates on chest imaging and a po2 to fio2 ratio of less than 300 an ARDS there's a
crazy chaotic inflammatory response within the lungs with damage to the alveoli and Serrano
capillaries which leads to excess protein and fluid accumulation in interstitial and alveolar
spaces that means decreased lung compliance increased VQ mismatch and increases in shunt
and dead space ventilation patients with ARDS are at a higher risk of mortality which increases
with ARDS severity with that said mortality is usually the result of the underlying disease that
triggered ARDS in the first place rather than refractory hypoxemia the severity of ARDS is
important because it's going to determine how we manage patients with ARDS and severity is
determined by the po2 fio2 ratio mile day ARDS is a po2 fio2 ratio between 200 and 300 moderate is
100 to 200 and severe is less than 100 with ARDS the alveoli fill up with protein and fluid this
leads to at least partial alveolar collapse and decreased lung compliance with shunt physiology
this is why having a high peep is crucial meaning a high positive end expiratory pressure increasing
the peep minimizes repeated opening and closing of the distal Airways in alveoli it also improves
homogeneity of the lung parenchyma by reducing drastic differences in regional lung compliance it
also improves VQ mismatch and shunt physiology by maintaining alveoli recruitment you're essentially
popping open as many collapsed alveoli as possible so what is the ideal level of peep no one knows
for sure typically 3 ARDS we set the peep between 10 to 15 when we first intubate someone sometimes
all the way to 20 if they have severe disease you don't want to go too high though because the
higher you go the more likelihood of pneumothorax so here's a table from the ARDS net trial that
gives us a suggested peep and fio2 strategy just remember that the more severe the ARDS the more
people are going to want to have generally speaking so increasing the P pop open alveoli
and improves oxygenation and that's great using low tidal volumes is the other key to managing
air yes patients as this has been shown to improve mortality current ard s goals include both a tidal
volume of 6 mils or 6 CCS per king of predicted body weight and maintenance of the lowest possible
plateau pressure specifically you want to maintain that plateau pressure of less than 30 so when it
comes to tidal volumes that's gonna mean typically on average around 300 range for women of average
height and 400 range for men of average height but giving a patient low lung volumes is not typically
comfortable for the patient so it's important to properly sedate patients in order to accomplish
our long protective strategy of low lung volume ventilation and because of this they're going
to develop a respiratory acidosis it's called permissive hypercapnia that's the sacrifice we
make in order to achieve our ultimate goal which is survival now let's talk about some other things
that you can do for patients with ARDS recently the pro seva trial demonstrated improved mortality
and ARDS patients with the po2 fio2 ratio of less than 150 who were treated with early prone
positioning in low tidal volume ventilation so why is prone positioning so beneficial when we lay in
a prone position the weight of the heart no longer compresses the posterior of lung regions and this
allows for improved VQ matching also with positive pressure ventilation the diaphragm moves more
freely in the prone position which means better chest wall compliance and better gas exchange in
the lower lung fields to get the maximum benefit proning should be done for 16 hours a day although
at least 12 hours would be the minimum sometimes with ARDS it's so severe that despite all those
things that we just mentioned they're still hypoxic sometimes in those cases we do inverse
ratio ventilation or we do aprv airway pressure release ventilation a few years ago we looked
at doing high-frequency oscillatory ventilation but that didn't prove to be beneficial in adults
corticosteroids such as methylprednisolone aka solu-medrol if given early for severe ARDS may
improve ICU length of stay in number of days on mechanical ventilation these studies are
based on ARDS patient before over nineteen came about the idea here is that steroid suppress the
inflammation that occurs in the beginning phase of ARDS there was recently a retrospective
non-peer-reviewed report of 46 covid 19 patients who had severe pneumonia and 26 of those patients
were treated with methylprednisolone specifically 1 to 2 milligrams per kilogram per day for 5 to 7
days and that was associated with a reduction in duration of fever and the need for a supplemental
oxygen so right now the recommendation is to give Covid 19 patients steroids only if
they have a yes neuromuscular blockade such as with cysts atracurium or NIM Beck's is sometimes
used for severe refractory or life-threatening hypoxemia especially if there's severe ventilator
dis synchrony there's not enough evidence to definitively say that there's a mortality
benefit of using paralytics and the downside to using them is that patients can develop critical
care illness myopathy or neuropathy so only use neuromuscular blockade if absolutely necessary if
they have vent to synchrony inhaled nitric oxide is a pulmonary vasodilator but it's not routinely
done for adults with ARDS because although it usually improves oxygenation it's not been shown
to reduce morbidity or mortality but if you're maxed out on your vent settings and the patient
is still hypoxemic then give it a try critically ill patients with Covid 19 often develop septic
shock which is a form of distributive shock and for shock we give IV fluids and face oppressors
but ARDS patients generally do better when you keep them in the dry side so in a negative fluid
balance state so if you have a covid 19 patient who's in shock and Aird yes what should you do
based on my experience of treating ARDS patients who are in shock my recommendation would be to use
minimal fluid possible and start based oppressors early and my experienced patients tend to respond
better to albumin compared to crystalloids especially if they have low albumin levels
either way you're going to want to assess fluid resuscitation responsiveness and if they don't
respond well to fluids then just stick with the vasopressors first-line vasopressor is always
going to be norepinephrine aka IVA fed with second line being vasopressin especially if
they're tachycardic what about a central line do you really need to get a central line in not only
does inserting a central line expose more health care workers to the virus but it also entails
using more PPE so hopefully patients don't need a central line sometimes you can run a presser
through a peripheral IV you can get away with doing so if one your peripheral IV is relatively
large gauge to your peripheral is not extremely distal so if you have an anti cubital and three
if you're running only one presser at a low dose so for example if you have Levophed running yet
less than ten Mike's you should be okay if you can't meet these criteria or if you're gonna
require multiple infusions then you're likely to require a central line in critically ill adults
with fever using medications for temperature control is sometimes needed the biggest concern
of having fever in the ICU is the potential to worsen tachycardia and tachy arrhythmias if the
fever is only mild or the tachycardia is not a concern then treatment is less warranted but if
you need to treat it acetaminophen tylenol is the go-to drug unless they're in liver failure just
remember to aim for less than 3 grams per day and even lower if they have liver injury even before
covid 19 came around and said such as ibuprofen are rarely given to ICU patients because these
drugs have a lot of potential for side effects including acute kidney injury gastritis and
peptic ulcer disease and more ICU patients are already at higher risk for getting acute kidney
injury and gastritis and NSAIDs are only going to add to that risk there are some investigational
agents out there that may or may not help covid 19 patients but routine use of standard IVIG for
example is not suggested and the same goes for convalescent plasma and there's also insufficient
evidence right now to recommend using antiviral agents like REM des vir recombinant interferons
chloroquine hydroxychloroquine and tousle is UMass what about ECMO extra corporal membrane
oxygenation it's a type of prolonged mechanical cardiopulmonary support that is usually delivered
in the intensive care unit and it's only to be performed in centers with appropriate equipment
and expertise they're about 250 hospitals in this country that can do ECMO it's reserved for
patients with severe but potentially reversible acute respiratory or cardiac failure that is
unresponsive to conventional management there are two types of ECMO there's veno-venous or V V and
V no arterial VA so VV ECMO is used in patients with respiratory failure all VA ECMO is used in
patients with cardiac failure the most common complication of ECMO is bleeding which occurs
about 35 percent of patients thromboembolism and cannula complications occur in less than 5% I can
tell you right now that if a covid patient needs ECMO it's going to be very difficult
for that patient to get ECMO because very few patients meet the criteria and if they do meet
that criteria they have to be at a hospital that does the ECMO and there are very few hospitals
right now if any that are willing to accept a covid patient from another hospital so maybe
this will change when the pandemic slows down but right now it's highly unlikely anyone's gonna die
normally when the patient comes to the hospital especially when it comes to the
ICU we have a discussion with the patient and our family regarding their code status like
do they want CPR if their heart were to stop do they want a breathing tube if they can't
breathe on their own etc and ultimately the family and/or the patient decide on whether
or not they want to be full code or DNI DNR however with the surge of covid 19 patients
that's changing the decision-making process in some places some places have a team that
decides which patients will be DNR or not this is happening simply because resources
are limited especially with ventilators so if this video was helpful to you please give it a
like and if you know someone who's treating Covid 19 patients or has the potential to do
so please share this video with them as it could save a life thanks for watching