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title: 2022-20-01 Covid 5 Min Teaching tags: #FFICM notebook: 🌑-FFICM type: inprogress

Source: GRI COVID-19 ARDS Protocol

Covid respiratory failure is just ARDS

Lung Protective Ventilation

Markers Of Failure of Current Management:

  1. FiO2 >0.6 AND
  2. PF Ratio < 20kPa, resulting in SpO2 <92%

Stage One

  • Tidal Volumes <6ml/kg/PBW
  • Peak Airway Pressures <30cmH20
  • PEEP 10-15 cm H20

  • SpO2 target 88-92%

  • RR can increase up to 35 to bring down CO2

  • If 35 and still CO2 > 10, then TVs can increase to 8ml/kg

Stage Two

  • Neuromuscular blockade (Atracurium infusion)
  • Diurese +++ (unless CV support worsened or creatinine 2x baseline)

  • Try higher PEEP still, go up in 2cmH2O

  • This can be tried for 12 hours

Stage Three

  • Prone For 16hours/day

Three B

  • Transpulmonary Pressure Monitoring
  • PV Tool To Ensure PEEP
  • ECMO Referral

NICE

https://www.nice.org.uk/guidance/ng191

Oxygen Therapy

  • Respiratory Therapy trial arm of recovery did not show any benefits of HFNO2 over conventional

  • So if you would intubate someone, don't give them HFNO2 as their escalation plan

  • Respiratory Therapy trial arm of recovery did show benefit from CPAP, it reduces numbers needing ventilated/numbers admitted to ICU

  • So you can give CPAP to people you might intubate later

  • There is not clear evidence if it helps with mortality though

  • I haven't put any numbers in this as NICE report there's a low level of certainty for much of it

Corticosteroids

  • Dexamethasone - 6mg oral or IV once a day for 10 days
  • Or equivalent doses of pred or HC

  • If septic shock may continue for a month

  • Giving adults with covid who need oxygen steroids, brings deaths down from just over 300 per 1000 to just over 250 per 1000

  • The evidence is much less clear in patients who don't need oxygen, with a signal towards steroids worsening chances of death

  • Risk of steroids, maybe slight increase in risk of GI bleeding and bacterial infections, weaknesss, maybe not

  • Certainly increased risk of hyperglycaemia

Casirivimab/Imdevimab

  • If you are seronegative and hospitalised from covid, you should get these (RECOVERY trial) - The brand name being REGEN-COV - 9000 patients
  • Only looked at the over 12s
  • No benefit if you are seropositive
  • However, if you are seronegative, the number needed to treat to prevent one death was about 20

Remdesivir - recovery

  • Consider fiving for 5 days if you are in hospital and needing low-flow supplemental O2
  • If you give it to sicker folk, they're more likely to die
  • If you give it for 10 days, you're more likely to die
  • So should you give it in ICU - no probably no
  • It might increase the risk of death in those who are already ventilated, by just as much as steroids reduced it

Tociluzimab - remap/cap

  • il6
  • single dpse iv 8mg/kg
  • Give this to folk if they are in their first 48hrs of needing either HF O2 or mechanical ventilation
  • And as long as they aren't already on a different IL-6 blocker
  • and as long as they dont have evidence of other bacterial infetion

  • There's evidence of benefit between the 21 day and 90 day mark

  • If cant give toci consider sarilumab

Don't give:

  • Azithromycin (No benefit) - Recovery
  • Budesonide (No Benefit)
  • Colchicine
  • Doxycycline
  • Ivermectin

RCPCH

  • Corticosteroids - Dex 150micro/kg/day - 10 days - Definitely if over 5, probably if younger too
  • Remdesivir - Yes for Kids > 12yrs and 40kgs
  • Casirivimab/Imdevimab - Commissioned for kids > 12 yrs - seronegative
  • other paeds guidance says gives sarilumab (birmingham guidance)

Newer Still

  • Baricitinib - JAK 2 inhibitor - can give w steroids instead of il6 according to who