How to Treat COVID Patients in the ICU?

COVID 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 require admission to the intensive care unit and mechanical ventilation.
Based on the recent epidemiological models, COVID will hit all the areas in the USA.

Every ICU is preparing for the surge. There are several changes that intensive care units are making, including ours.

We prepare anesthesiologists (who are not CCM trained) and nurse anesthetists to manage patients with COVID. Even though they are not CCM 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.

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Allowing anesthesiologists and nurse anesthetists to help in this manner will help other intensivists like myself handle patients' surges coming our way.

And because they are helping us, that is the main reason for me making this video, so that they can watch this and be better equipped to handle the surge with us.

“Knowing and implementing all of the info in this video does not guarantee you save a COVID patient living in the ICU, but it will give you the best chance of doing so.”

If a patient with COVID is coming to your ICU, they most certainly have pneumonia, and they probably have acute respiratory distress syndrome (ARDS) as well.

Patients with severe disease who require ICU admission are likely to have high oxygen requirements.
Although high flow oxygen and noninvasive positive pressure ventilation have been used for COVID, their safety is uncertain. They are considered aerosol-generating procedures that warrant specific isolation precautions.

Most patients who require ICU admission have ARDS, and they will likely have a better outcome if intubated sooner rather than later. That is another reason why it is likely better to skip Hi-Flow oxygen and NIPPV and jump straight to intubation.

Acute Respiratory Distress Syndrome (ARDS)
ARDS is a clinical diagnosis based on non-cardiogenic pulmonary edema, with bilateral patchy infiltrates on chest imaging and a PaO2/FiO2 ratio of less than 300.

In ARDS, this crazy, chaotic inflammatory response within the lungs, with damage to the alveoli and surrounding capillaries, leads to excess protein and fluid accumulation in interstitial and alveolar spaces.

That means decreased lung compliance, increased V̇/Q̇ mismatch, and increases in shunt and dead-space ventilation.

Patients with ARDS are at high risk of mortality, which increases with ARDS severity. With that said, mortality is usually the result of the underlying disease that triggered ARDS rather than refractory hypoxemia.

The severity of ARDS is important because it’s going to determine how we manage patients with ARDS.

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.

Increasing the PEEP minimizes the repeated opening and closing of distal airways and alveoli. It also improves the homogeneity of the lung parenchyma by reducing drastic differences in regional lung compliance.

What is the ideal level of PEEP?
No one knows for sure. Typically for ARDS, we set the initial PEEP between 10 to 15. Sometimes all the way to 20 if they have severe disease. You don’t want to go too high, though, because this increases the risk of pneumothorax.
The recommendation is to give COVID patients steroids only if they have ARDS.

Critically ill patients with COVID often develop septic shock. And for shock, we give IVF and vasopressors. But ARDS patients generally do better when you keep them in a negative fluid balance state.

COVID patient, who is in shock and ARDS, what should you do?
Based on my experience treating ARDS patients in shock, my recommendation would be to use minimal fluid and start vasopressors early. In my experience, patients tend to respond better to albumin than 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, just stick with the vasopressors.

Note: To get the proper details, please watch the video from first to last without skipping.

Doctor Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine
Website: https://doctormikehansen.com/
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