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CARE OF CRITICALLY ILL PATIENTS WITH COVID-19

Webinar Series on COVID-19: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH
Speaker: Dr Lee Chew Kiok, Consultant Intensivist, Hospital Sungai Buloh, MOH Malaysia.
More info about the speaker and this webinar available here: https://clinupcovid.mailerpage.com/resources/g8q7y5-critical-care-of-covid-19

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CARE OF CRITICALLY ILL PATIENTS WITH COVID-19

  1. 1. CARE OF CRITICALLY ILL PATIENTS WITH COVID-19 By Dr. Lee Chew Kiok MBBS (UM), Mmed ANAES (UM). Consultant Intensivist For healthcare professionals use only. The organizer of this CME will share the slides after the session. Participants should not take or reproduce this slide in any form without permission. Webinar Series On COVID-19
  2. 2. Disclaimers ● This slide was prepared for the Webinar Series on COVID-19 session on 17th Feb 2021, by Dr. Lee Chew Kiok, Consultant Intensivist from Hospital Sungai Buloh, Malaysia. ● This is intended to share within healthcare professionals, not for public. ● Kindly acknowledge “Clinical Updates in COVID-19 http://www.nih.gov.my/covid-19/” should you plan to share the information obtained from this slide with your colleagues. For healthcare professionals use only.
  3. 3. Let’s start with a case – one that unfortunately we have seen way too frequently over the past 1 year…. For healthcare professionals use only.
  4. 4. Mr. HN……. •44 year old Malay man •Hypertension on T. amlodipine •Diagnose to have positive Covid-19 on screening. •Presented with fever for 4/7, Shortness of breath on exertion, poor oral intake. •On referral to ICU, he was D9 of illness, tachypnea on HFM 10L/min, RR 40-45 breath per minutes, SPO2 94 to 95%, T 39 degree celcius. For healthcare professionals use only.
  5. 5. ■ He was intubated and ventilated with BILEVEL ventilation, on muscle relaxant infusion and sedation. ■ ABG post intubation: pH 7.28, pCO2 48, PO2 93, HCO3 22.6, BE -4.5. on FiO2 1.0, PEEP 12. P peak 22, P plateau 16. (PaO2/FiO2 ratio: 93) ■ He was prone subsequently for 16 hours, also started on IV methylprednisolone 150mg dly, IV tazocin 4.5gm qid ■ His ventilation improved markedly after proning and we able to cut down the FiO2 to 0.5. For healthcare professionals use only.
  6. 6. •CXR post intubation showed bilateral middle and lower zone opacity. For healthcare professionals use only.
  7. 7. ■ He was supine after 16 hours of prone position. ■ Subsequently extubated after 5 days of mechanical ventilation. ■ He was on IV methylprednisolone 150mg dly till extubation, and the methylprednisone was wean off after extubation. ■ And discharge to Ward after 13 days stay in ICU , and subsequently discharge home well after 21 days of hospitalization. For healthcare professionals use only.
  8. 8. Chest X rays after 7 days in ICU For healthcare professionals use only.
  9. 9. Full article: https://zenodo.org/record/4278413 For healthcare professionals use only.
  10. 10. Malaysian Data ■ 1st Feb to 30th May: 5889 covid-19 cases. STAGES Number of Patients Percentage (%) I : asymtomatic 2956 50.2 II : Symptomatic without Pneumonia 1859 31.6 III : Pneumonia without hypoxia 801 13.6 IV: Pneumonia with hypoxia 210 3.6 V: Multiorgan involvement 63 1.1 For healthcare professionals use only.
  11. 11. Characteristics of Severe COVID-19 in ICU For healthcare professionals use only.
  12. 12. Risk Factor associated with Severe COVID-19 Disease For healthcare professionals use only.
  13. 13. Manifestation of Severe COVID-19 Disease For healthcare professionals use only.
  14. 14. VS Classical ARDS COVID-19 ARDS For healthcare professionals use only.
  15. 15. Different Phenotypes of COVID 19 For healthcare professionals use only.
  16. 16. Thrombosis ■ Bilaloglu et al ■ Out of 3334 hospitalized patient, 16% having thrombotic event. ( 6.2% venous Vs 11.1% arterial). ■ Among 829 ICU patients, the rate was 29.4% ( 13.6% venous vs 18.6% Arterial). The occurrence of thrombosis is independent risk factor for mortality. For healthcare professionals use only.
  17. 17. Extrapulmonary Manifestation For healthcare professionals use only.
  18. 18. Cytokines Storm For healthcare professionals use only.
  19. 19. For healthcare professionals use only.
  20. 20. IL 6 level in Covid-19 VS ARDS Plasma Levels of Interleukin-6 Reported in COVID-19 Compared With Levels Previously Reported in ARDSa JAMA Intern Med. Published online June 30, 2020. For healthcare professionals use only.
  21. 21. Manifestation of Severe COVID-19 Disease For healthcare professionals use only.
  22. 22. Criteria for ICU Referral ■ Facemask 5L/min. ■ Haemodynamic instability. ■ When the patient require close monitoring on fluids and vital signs. ■ Prognosis, potential benefit from interventions ■ Bed availability For healthcare professionals use only.
  23. 23. Intubation Criteria 1. SPO2<90% on HFM 2. Respiratory muscle fatigue (increase CO2, tachycardia, sweating, and patient subjective feeling) Intubation has to be timely, but not premature… For healthcare professionals use only.
  24. 24. Revised Intubation Criteria • Rate of deterioration • Anticipated trajectory: excessive work of breathing, worsening fatigue. • Altered mental state and agitation. • Anticipated difficulty in intubation. For healthcare professionals use only.
  25. 25. Ventilatory support in Patient with ARDS secondary to COVID-19. For healthcare professionals use only.
  26. 26. Ferrando et al… ■ Average PF ratio on intubation: 120 ■ Compliance 35mls/cmH20 ■ Plateau pressure 25cmH2O ■ PEEP 12 ■ Duration of ventilation: prolonged ( 4 ventilator free day at D30) ■ Mortality at 28 days: 32% ■ Thus with severe ARDS: 39% For healthcare professionals use only.
  27. 27. • doi: 10.21037/jeccm-20-82 • https://jeccm.amegroups.com/article/view/6490/html For healthcare professionals use only.
  28. 28. For healthcare professionals use only.
  29. 29. Protective Lung Ventilation Strategy •Tidal volumes (Vt) of 4-6 mL/kg Predicted Body Weight •Aim for plateau pressures (Pplat) < 30 cmH20 •Driving Pressure ≤ 15 cmH2O Menk et al. Int Care Med. 2020 For healthcare professionals use only.
  30. 30. MV >10 Target for Mechanical Ventilation 01 02 03 04 SPO2 88 -95% PaO2 55-80 mmHg MV >10 pH > 7.15 For healthcare professionals use only.
  31. 31. Positive End Expiratory Pressure. •A trial of high PEEP is suggested. •PEEP should be individualized and titrated to patients response. For healthcare professionals use only.
  32. 32. Rescue Strategies for Refractory Hypoxaemia Neuromuscular blockage ECMO Recruitment maneuvers Inhaled Nitric Oxide Prone position For healthcare professionals use only.
  33. 33. Evidence for Prone Position in ARDS For healthcare professionals use only.
  34. 34. For healthcare professionals use only. https://cutt.ly/ProneICUHSgB
  35. 35. Our Sg Buloh Data (n=49) For healthcare professionals use only.
  36. 36. Neuromuscular Blockade Critical illness Related Weakness . Positive Effect Adverse Effect Controlled Ventilation For healthcare professionals use only.
  37. 37. Neuromuscular Blockade WHO 2021: In patient with moderate-severe ARDS ( PF ratio <150), Neuromuscular blockade by continuous infusion should not be routinely used. May be consider in patients with ARDS eg: Ventilatory dyssynchrony despite sedation, refractory hypoxaemia/hypercapnia. For healthcare professionals use only.
  38. 38. Extracorporeal Membrane Oxygenation ( ECMO) WHO 2021: Its use be “considered” in centres with appropriate expertise. The utility of ECMO for COVID19 is uncertain and there are concerns about the resource implications of ECMO in the context of a global pandemic Consider when PF ratio <50mmHg for 3 hours, a PF ratio < 80mmHg for 6 hours despite lung protective ventilation. For healthcare professionals use only.
  39. 39. Awake Prone For healthcare professionals use only.
  40. 40. For healthcare professionals use only.
  41. 41. WHO recommendation Conditional recommendation: We suggest Awake prone positioning of severely ill patients hospitalized with COVID-19 requiring supplemental oxygen. For healthcare professionals use only.
  42. 42. High-flow Nasal Cannula (HFNC) NHF use results in 1. Reduced mortality both in the ICU and up to 90 days. 2. Lower 28 days intubation rate ( PF ratio < 200mmHg) 3. An increased in degree of comfort, reduction in severity of dyspnea, and decreased RR For healthcare professionals use only.
  43. 43. High-flow Nasal Oxygen (HFNO) N=62, 63% required intubation, 34% succeeded on HFNO, 3% died on HFNO after a decision not to intubate. For healthcare professionals use only.
  44. 44. High-flow Nasal Oxygen (HFNO) For healthcare professionals use only.
  45. 45. Non Invasive Ventilation ■ NIV is not proven for Hypoxaemic Failure, in certain patient eg Acute Exacerbation of obstructive lung disease, cardiogenic pulmonary oedema or obstructive sleep apnea, it may be useful ■ In situation where mechanical ventilation is not available, bubble CPAP may be useful. For healthcare professionals use only.
  46. 46. Other Supportive Management •Fluids Management •Analgesia and Sedation •Thromboprophylaxis For healthcare professionals use only.
  47. 47. Fluids Management •Use a conservative fluid management strategy •Avoid positive fluid balance/ hypervolaemia For healthcare professionals use only.
  48. 48. • COVID-19 patients may be at greater risk of venous-thromboembolism (VTE), DIC, and clotting of extracorporeal circuits (e.g. CRRT). • 184 ICU patients with COVID pneumonia, 57% developed symptomatic venous thromboembolism despite prophylactic anticoagulation. Klok,F. et al,2020 Thromboprophylaxis For healthcare professionals use only.
  49. 49. • Due to the high incidence of thromboembolic events, some groups suggest the use of therapeutic doses of heparin/low molecular weight heparin Lin, L et al.2020 • prospective evidence is lacking and caution is essential given the risk of bleeding complications. Thromboprophylaxis For healthcare professionals use only.
  50. 50. Pharmacological Therapy for Covid-19 For healthcare professionals use only.
  51. 51. The RECOVERY Trial For healthcare professionals use only.
  52. 52. The RECOVERY Trial For healthcare professionals use only.
  53. 53. For healthcare professionals use only.
  54. 54. Why dexamethasone?  Is anything special about Dexamethasone? For healthcare professionals use only.
  55. 55. Why Methyprednisolone? ■ Based on pharmacokinetic data (better lung penetration) ■ Genomic data specific for SARS-CoV-2 ■ A long track record of successful use in inflammatory lung diseases. For healthcare professionals use only.
  56. 56. Tolicizumab ■ Interleukin - 6 ( IL-6) plays a key role in cytokines storm. For healthcare professionals use only.
  57. 57. For healthcare professionals use only.
  58. 58. Stone et al. N Eng J med 2020 ■ Tocilizumab did not show benefit among 243 patients with covid-19 and lower respiratory tract involvement. The hazard ratio for intubation and death in the treatment group was 0.83 ( CI 0.38-1.81) ■ There was increase in the percentage of patient with worsening of disease at 14 days. ■ Further data on tocilizumab in needed. For healthcare professionals use only.
  59. 59. Preprint Article For healthcare professionals use only.
  60. 60. Convalescent Plasma ■ Simonovich et at 2020 : No mortality difference was observed between the convalescent plasma group and placebo group. ■ Additional convalescent plasma study are underway. For healthcare professionals use only.
  61. 61. Case No.2: Mr RA ■ 64 year-old man, Ex Army, Known case of Diabetes Mellitus, presented with fever and cough for 7 days ■ COVID-19 RT PCR positive. ■ Developed shortness of breath on D10 of illness, subsequently intubated for hypoxaemic respiratory failure. ■ Post intubation, he was ventilated with SIMV pressure control mode with PEEP of 10. Generating good tidal volume with peak airway pressure of 20. For healthcare professionals use only.
  62. 62. ■ He was started on Kalestra, hydroxychloroquine, S/C interferon. ■ No steroids was given ■ He was extubated on D15 of illness. For healthcare professionals use only.
  63. 63. D 18 of illness ■ Reintubated for hypoxaemic failure ■ Post Intubation ABG: pH7.20, PCO2: 99, Po2: 80, BE -10 Spo2: 88. ■ He was subsequently turned to prone position. ■ His ventilatory setting was SIMV Vt 350 , Peep 12, FiO2: 0.5, RR30, IE 1:1.5. pPeak 46, P plateau 42, driving pressure of 30. ■ ABG: ph 7.3, pCO2: 72, PO2: 120, HCO3: 35.4 ■ He has worsening non oligulic AKI. ■ He was started on meropenem and Micafungin and HRCT was planned. For healthcare professionals use only.
  64. 64. For healthcare professionals use only.
  65. 65. ■ He was treated with IV methylprednisolone 500mg OD for 5 days and subsequently wean to T prednisolone 60mg dly. (total methylprednisone 3gm) ■ Of course, he was infected with MRO due to prolonged stay, tracheostomy was done and subsequently weaned off. ■ He was discharge after 71 days in ICU with NP oxygen with rehab follow up. For healthcare professionals use only.
  66. 66. Latest CT on 4th Feb 2021 Previously seen diffuse ground glass densities had generally resolved. Multiple subpleural blebs predominantly at right upper lobe. Currently there are bilateral volume loss, more on the right. The interlobular septal thickening, traction bronchiectasis are predominetly at posterior segment of right upper lobe Correlating with previous covid 19 positive case, current CT findings depict Chronic lung changes with slight progression of lung fibrosis. For healthcare professionals use only.
  67. 67. CXR after reintubation and now For healthcare professionals use only.
  68. 68. For healthcare professionals use only.
  69. 69. To be continue…. ■ For healthcare professionals use only.
  70. 70. Take Home Message Early identification and early intubation of critically ill patient is the key to better outcome.
  71. 71. For healthcare professionals use only.
  72. 72. For healthcare professionals use only.

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