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Covid

title: COVID-19 tags: notebook: 🌑-FFICM

Surge

"Surge Capacity" - The new capacity when increased patient numbers is greater than the normal baseline capacity 1

"Mutual Aid" - The gift/loan/exchange of resources for mutual benefit 1

Clinical Characteristics

Overall SARS-CoV-2 infection/COVID-19 will have

  • 15% Acute Severe Infections
  • 5% Critical Illness
  • Organ dysfunction:
  • Acute Hypoxaemic Respiratory
  • Cardiovascular
  • Renal
  • Neurological
  • Hepatic
  • Thromboembolism (Arterial, Venous, Pulmonary)
  • Hyper inflammatory Syndrome 1

Risk Factors

  • Increasing Age
  • Male
  • Obese
  • Black and Asian Minority Ethnic
  • Deprivation

  • Comorbidities 1

  • 4C Mortality Score esics-covid

  • 4C Deterioration Score esics-covid
  • isaric4c.net/risk esics-covid

Diagnosis

  • RT-PCR (Reverse Transcriptase PCR)
  • CXR
  • CT
  • Bloods:
  • Low Lymphocyte
  • Normal PCT
  • Increased CK (Think Myositis/Myocarditis)
  • Increased Troponin (Think Myocarditis / Renal) - Also higher = worse mortality
  • Increased BNP - Higher = worse mortality
  • Increased D-Dimers
  • Increased Ferritin
  • Increased CRP (Could be bacterial could be covid) 1

management

  • Don't use remdesivir (evidence of no benefit)
  • Dexamethasone - 6mg/day - 10 days
  • RECOVERY
    • Ventilated mortality went from 40% to 30%
    • Receiving Oxygen Only Mortality went from 26% to 23%
    • Possible Harm/No Benfit for those not needing Oxygen
  • It may be that more steroids for longer may be useful in some cases
  • Don't need routine antibiotics
    • But bacterial and fungal infection risk increases on ICU
    • So consider antibiotics, and consider antifungals if no better on antibiotics
  • Cohort COVID and Flu separately - Your mortality is worse when you have both
  • NSAIDS? - No evidence that acute use makes more likely to get covid or severe covid 1

Respiratory management

  • Target SpO2 92-96%, accept 90-93% in continuously monitored patients
  • HFNO2 can be used
  • CPAP can be used as trials
  • Intubate if fail to respond to CPAP (harder work of breathing, worsening gas exchange)
  • Some may have CPAP as ceiling of care
  • NIV/BiPAP - Not to be used routinely, may have role in COPD covid
  • Have a filter on the expiratory limb 1

Ventilation

  • Make sure filter present, make sure filter not clogged (as can block tube)
  • Humidified circuit will block inline filters rapidly

  • Dry circuits will get secretion build up, saline and mucolytics will loosen sectretions but may block filters thmselves 1

  • If worried that something is obstructed or patient very poor to ventilate, consider filter is saturated!

  • Try to avoid hand bagging from aerosol risk 1

  • Pathophysiology may be:

  • Pulmonary Vasculopathy/Thrombosis
  • Focal Ground Glass Inflammation
  • Loss of Hypoxic Pulmonary Vasoconstriction - Atelectasis
  • Increase in non aerated pulmonary units - Deterioration of pulmonary mechanics with low compliance 1

Ventilator strategy will depend on Pathophysiology

  • Use lung protective ventilation
  • Tidal Volumes 6ml/kg
  • Driving Pressure <15cm H20. Driving Pressure = Plateau Pressure - PEEP
  • High PEEP or Low PEEP?
    • If normal compliance use low PEEP (high PEEP hurts)
    • If poor compliance use higher PEEP (because you need to)
  • Neuromuscular blockade (to avoid high pressures and further lung injury)
  • Recruitment manoevres - Don't improve outcomes but may be more useful in low compliance lungs
  • Pulmonary Vasodilators? May improve V/Q mismatch? No evidence that they do though.

  • Careful fluid balance (avoid hypovolaemia else they'll get AKI and RRT) 1

  • Prone Positioning

  • No study available showing benefit
    • However most seem to improve gas exchange
  • Turn Head Regularly (3hrly)
  • Monitor pressure areas
  • May have CV/Resp Collapse whilst doing it
  • Prone for 16-18hrs per day

  • Prone when it works. Stop after 1-2 days if it doesn't. It works if the P:F ratio gets better. 1

  • Extubation when:

  • Improved Breathing Pattern/Strength
  • Ability to clear sectretions
  • Radiology better
  • Inflammation/Thrombosis better
  • Oxygenation/Mean Airway Pressure/PEEP better 1

Cardiovascular

  • Right sided heart failure is more likely than left sided heart failure
  • Pericarditis can happen. Tamponade is rare.
  • ACS can happen.

  • Arrythmias will happen. 1

  • Cardiac Arrest

  • In hospital survival post arrest
    • Under 45 = 20%
    • Over 80 = 3% 1

Renal

  • 25% patients needed RRT in critical care (average duration 1 week)
  • High airway pressures and PEEP may worsen renal perfusion
  • Anticoagulat to stop the filter clogging (with heparin etc)
  • Use continuous RRT 1

Haematology

  • Prothrombotic patients is common (seen with high fibrinogen and high d-dimer)
  • 30% of ICU patients may have a clot
    • VTE in 25% of all patients
    • Arterial in 4% of all patients
  • Use compression stockings/TEDS
  • Use twice normal prophylactice heparin
  • Use anti-Xa assay rather than APTT for heparin monitoring 1

Gastrointestinal

  • Feed as normal 1

Glycaemia

  • Insulin Resistance is common
  • You may need a more aggressive glucose lowering plan
  • You may need long acting insulin 1

Hepatic

  • 50% will get raised LFTs without need for intervention 1

Skin

  • Rash/Urticaria/Chilblains/Vesicular Lesions common
  • Fungal infections should be DDx 1

Neurological

  • 1:200 hospitalised patients may seize
  • 1% may stroke
  • 15% reduced consciousness
  • Delirium common
  • Use standard practice sedatives/analgesics/nonpharmacological
  • V Rare Neuro:
  • Meningoencephalitis
  • Guillain-Barre Style neuropathy
  • Transverse Myelitis 1

MSK

  • ICU acquired weakness is common
  • Perform daily Chelsea Critical Care Physical Assessment (CPAX) score
  • Use MRC Sum Score to diagnose ICU-AW 1

  1. COVID-19 Guidance - Updated October 2020 ↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩