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

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.
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Let’s start with a case – one
that unfortunately we have
seen way too frequently
over the past 1 year….
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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.
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■ 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.
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•CXR post intubation
showed bilateral middle
and lower zone opacity.
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■ 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.
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Chest X rays after 7 days in ICU
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Full article: https://zenodo.org/record/4278413
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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
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Characteristics of Severe COVID-19 in ICU
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Risk Factor
associated with
Severe COVID-19
Disease
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Manifestation of Severe COVID-19
Disease
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VS
Classical
ARDS
COVID-19
ARDS
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Different Phenotypes of COVID 19
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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.
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Extrapulmonary
Manifestation
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Cytokines
Storm
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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.
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Manifestation of Severe COVID-19
Disease
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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
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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…
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Revised Intubation Criteria
• Rate of deterioration
• Anticipated trajectory: excessive work of breathing,
worsening fatigue.
• Altered mental state and agitation.
• Anticipated difficulty in intubation.
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Ventilatory support in Patient with
ARDS secondary to COVID-19.
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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%
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• doi: 10.21037/jeccm-20-82
• https://jeccm.amegroups.com/article/view/6490/html
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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
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MV >10
Target for Mechanical Ventilation
01
02
03
04
SPO2 88 -95%
PaO2 55-80 mmHg
MV >10
pH > 7.15
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Positive End Expiratory
Pressure.
•A trial of high PEEP is suggested.
•PEEP should be individualized and
titrated to patients response.
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Rescue Strategies for Refractory
Hypoxaemia
Neuromuscular
blockage
ECMO
Recruitment
maneuvers
Inhaled Nitric
Oxide
Prone
position
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Evidence for Prone Position in ARDS
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For healthcare professionals use only.
https://cutt.ly/ProneICUHSgB

Our Sg Buloh Data (n=49)
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Neuromuscular Blockade
Critical illness
Related
Weakness
.
Positive
Effect
Adverse
Effect
Controlled
Ventilation
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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.
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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.
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Awake Prone
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WHO recommendation
Conditional recommendation:
We suggest Awake prone positioning of
severely ill patients hospitalized with
COVID-19 requiring supplemental oxygen.
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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
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High-flow Nasal Oxygen (HFNO)
N=62, 63% required intubation, 34% succeeded on HFNO,
3% died on HFNO after a decision not to intubate.
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High-flow Nasal Oxygen (HFNO)
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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.
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Other Supportive Management
•Fluids Management
•Analgesia and Sedation
•Thromboprophylaxis
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Fluids Management
•Use a conservative fluid management strategy
•Avoid positive fluid balance/ hypervolaemia
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• 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
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• 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
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Pharmacological Therapy for Covid-19
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The RECOVERY Trial
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The RECOVERY Trial
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Why dexamethasone? Is anything
special about Dexamethasone?
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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.
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Tolicizumab
■ Interleukin - 6 ( IL-6) plays a key role in cytokines storm.
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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.
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Preprint Article
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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.
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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.
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■ He was started on Kalestra, hydroxychloroquine,
S/C interferon.
■ No steroids was given
■ He was extubated on D15 of illness.
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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.
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■ 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.
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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.
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CXR after reintubation and now
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To be continue….
■
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Take Home Message
Early identification and early intubation
of critically ill patient is the key to better
outcome.

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