ICU pulmonary medicine

1. Covid-19
pandemic
Islam M. Ibrahim, M.D., FACP, FCCP.
Pulmonary and critical care department,
University of California San Diego, USA.

2. • United StatesUnited States
• Confirmed 587,337
• Recovered 44,207
• Deaths
23,649
• WorldwideWorldwide
• Confirmed 1,920,918
• Recovered 453,289
• Deaths
119,686

5. PPE.

8. Healthcare
burden .

9. 9
COVID-19 Surge Capacity Plan
April 1, 2020
Dr. Jess Mandel | Chief, Division of Pulmonary, Critical Care and Sleep Medicine
Mobe Montesa | Nursing Director, Cardiovascular Services
Leah Adrid | Asst. Director of Operations, Capacity Management & Pt. Flow
Jarrod McDonald | Assoc. Director, Health System Innovation & Transformation

10. Anticipated Critical Care Bed Need (Worst Case)
- 1 2 2 4 6 8 12 18 27
39
58
84
121
171
236
316
405
492
561
596 588
542
473
393
317
250
194
149
114
87
66
51
38 29 22 17 13 10 8 6- 1 1 1 2 3 4 6 9 13 20 29
42
60
85
118
158
203
246
281
298 294
271
236
197
159
125
97
75
57
44
33 25 19 15 11 9 7 5 4 3
-
100
200
300
400
500
600
700
3/23/2020 4/23/2020 5/23/2020 6/23/2020 7/23/2020 8/23/2020 9/23/2020 10/23/2020 11/23/2020 12/23/2020
Predicted UCSD Critical Care Census at 50% Social Distancing & 6 day* ICU LOS
icu vent UCSD ICU Capacity
Physically capable
of increasing by
115 to 285 CC beds
Portion At Risk
▪ Send out if possible
▪ LST Rationing / Ethics Protocol
Current COVID Census
Shifts entire model timeline up ~1 ¾ months
Source: U Penn COVID Model
*Improvements in care aim to reduce LOS

11. Key Deliverables:
• Validate outstanding non-traditional areas for overflow
• Determine if non-traditional areas meet structural and regulatory
requirements (O2, Gas, Electric, etc.)
Key Deliverables:
• Determine potential pool and number of staff from non-inpatient areas (e.g.
JMC PACU, Hillcrest PACU, GI, Cath lab, EP)
• Determine total number of nursing, physician & RT staff by level of care
• Create RN staffing model when ratios can no longer be maintained.
Key Deliverables:
• Create an educational plan for educational needs and structured format (e.g.
Social Distancing, Online format, Hands on, Shadowing/floating options)
• Create a content List of Gaps for each unit, level of care, and floating needs
• Work with the staffing plan to take determine staff that need education
Key Deliverables:
• Supply & equipment gap analysis, prioritized by surge phase
• Process for getting the units necessary supplies/equipment
• Implement appropriate Modifications/EPIC/Pyxis access real time
Non
Traditional
Overflow
Unit
Readiness
Education
Staffing
Physician & RN/RT
Taskforce Deliverables in Progress

12. COVID Physician Staffing (Non-Critical Care)
Medical Staff Physician Surge Staffing Request
⮚ Identifies providers with board certifications and/or ability to provide Critical Care,
Emergency Medicine & Hospital Medicine care
⮚ Highlights potential risk factors (>65, existing comorbidities, etc.)
⮚ Captures contact information

13. 6 IMU RNs
Bedside RN ICU Model #1
< 250 ventilators (Utilizes IMU RNs in ICU)
Each Pod
1 ICU RN
2 IMU RN
.7 RT
5 patients
All 1:1 patients in ICU will
be screened for acuity
and paired based off
need (IABP, Impellas,
Tandems, CRRT,
CABG/VALVE, PTE). True
1:1 patients will remain
1:1, and additional ICU
RNs will be added.
Based of 330 ICU patients:
Core group:
66 ICU RNs needed per shift + 1:1
132 IMU RNs
33 RTs
Patient ratio will reduce once we exceed 250
ventilators (see model #2)
This model will be adjusted to each unit’s physical space
**If available
COVID Coordinator- stocks and
monitors PPE. RN/ >
1 PCCM team
.3 Pharmacy
1 Charge RN (ICU
preferred)**
1 COVID Coordinator**
3 ICU RNs
2 RTs*
6 IMU RNs
15 patients
22 additional ICU RN
22 additional non ICU RNs
22 CCP, MA or LVN
**If additional staff are available
deploy based on acuity
Pyramid
1 CCP, MA or LVN**

14. 6 IMU RNs
Each Pod
1 ICU RN
2 IMU RN
.5 RT
5 patients
All 1:1 patients in ICU will
be screened for acuity
and paired based off
need (IABP, Impellas,
Tandems, CRRT,
CABG/VALVE, PTE). True
1:1 patients will remain
1:1, and additional ICU
RNs will be added.
Based of 330 ICU patients:
Core group:
66 ICU RNs needed + 1:1
99 IMU RNs
33 RTs
RT ratio will reduce once we exceed 250
ventilators (see model #2)
This model will be adjusted to each unit’s physical space
**If available
COVID Coordinator- stocks and
monitors PPE. RN or >
1 PCCM team
1 Charge RN (ICU
preferred)**
1 COVID Coordinator**
2 ICU RNs
1 RTs*
3 IMU RNs
10 patients
Bedside RN ICU Model #2
> 250 ventilators
33 additional ICU RN
33 additional non ICU RNs
33 CCP, MA or LVNs
**Extra available staff (including
students) deploy based on acuity
Pyramid
1 CCP, MA, or LVN**
Have the capacity to run ~330 – 400
COVID Critical Care beds total

15. Diagnosis.

16. PCR.

17. Serology.
immunoassay kit helps to
identify total
immunoglobulin, including
IgG, IgM, and IgA,

18. Laboratory diagnosis
Indications for testing ICU patients for SARS CoV-2
• every critically ill patient arriving with respiratory infection should be
considered potentially infected with SARS-CoV-2.
• (RT-PCR) is the gold standard for similar viral infections,
• extended incubation period poses diagnostic challenges
• viral shedding prior to the onset of symptoms.
European Society of Intensive Care Medicine and the Society of Critical Care Medicine 2020

19. Symptoms.
FEVER (TEMPERATURE >
99 DEGREES FAHRENHEIT)
■ NEW COUGH ■ NEW SHORTNESS OF
BREATH

20. Radiology.

25. Risk stratification.

27. High Flow Nasal Cannula
chest.2020.03.043
HVNI therapy can be substantially slowed
using a surgical facemask in place
increasing flow rate if the patient is
displaying increased work of breathing.
precautions must considered while
managing patients on HVNI

28. Intensive care admission.

30. Intubation/mechanical
ventilation

31. Ventilation
strategies.

32. Joint Statement on Multiple
Patients Per Ventilator
March 26, 2020 12:00 p.m.
The Society of Critical Care Medicine
(SCCM),
American Association for Respiratory
Care (AARC),
American Society of Anesthesiologists
(ASA),
Anesthesia Patient Safety Foundation
(ASPF),
American Association of Critical-Care
Nurses (AACN),
American College of Chest Physicians
(CHEST)

33. Reasons include:
Volumes would go to the most compliant lung
segments.
• PEEP would be impossible to manage.
• measuring pulmonary mechanics would be
challenging, if not impossible.
• Alarm monitoring and management would
not be feasible.
• Individualized management for clinical
improvement or deterioration would be
impossible.
• In the case of a cardiac arrest, ventilation to
all patients would need to be
• Additional external monitoring would be
required.
• patients deteriorate and recover at different
rates,
• The greatest risks occur with sudden
deterioration of a single patient (e.g.,
pneumothorax, kinked endotracheal tube),
with the balance of ventilation distributed to
the other patients.

34. Nonsedation or
light sedation in
critically ill vented
patients.
•Daily sedation breaks
•fewer ICU days
•fewer days on the vent.

35. ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure

36. ECMO
• should be offered to patients with a good prognosis
• advanced age, multiple co-morbidities, or multiple
organ failure
• observing no lung or cardiac recovery after
approximately 21 days* on ECMO can be considered
futile

37. Society guidelines.

38. Surviving Sepsis Campaign:
Guidelines on
the Management of Critically
Ill Adults with
Coronavirus Disease 2019
(COVID-19)

40. PPE.

41. Management of shock.

49. American Thoracic Society‐led International Task Force

55. Management of bronchial asthma with COVID-
19
• continue all inhaled medication, including inhaled corticosteroids,
• acute asthma attacks / short course of oral corticosteroids to prevent serious consequences.
• long-term treatment with (OCS) should be continued in the lowest possible dose
• Biologic therapies should be used in severe asthma patients who qualify
• Nebulisers should,be avoided / increased risk of disseminating COVID-19
• (pMDI) via a spacer is the preferred treatment
• allergic rhinitis should continue to take their nasal corticosteroids,
• Routine spirometry testing should be suspended

56. • Prognosis.

57. Antibiotics.

58. Hydroxychloroquine sulfate for COVID-19.
studies are all small
randomized 30 patients to
hydroxychloroquine plus usual care, or
usual care alone,
hydroxychloroquine group did not do
better,
with a primary outcome of negative viral
testing at 7 days.
more study is needed.

62. Anticoagulations.
Heparin treatment has
been recommended
for COVID-19,
however, its efficacy
remains to be
validated.
• 28-day mortality of heparin users were lower than
nonusers In patients with D-dimer > 3.0 ug/mL.
• Heparin treatment appears to be associated with
better prognosis in severe COVID-19 patients with
coagulopathy.

63. Angiotensin
II for the
treatment
of COVID-
19-related
vasodilatory
shock.
This is a perspective.
exogenous AngII might
be very helpful in treating
COVID-19 patients shock.

64. Clinical trials.

65. Treatment of 5 critically ill pts with COVID-19 with convalescent plasma.
JAMA
• 5 Donors
• lab-confirmed SARS-CoV-2 positive
• turned negative
• asymptomatic for at least 10 days
• high levels of SARS-CoV-2-specific
antibodies.
• Recipients
• lab-confirmed COVID-19,
• severe PNA with rapid progression
• and P:F <300,
• on vent.
The authors say that three patients had no detectable virus by day 3

69. Convalescent sera.
SMALL, UNCONTROLLED
STUDY
MAY AT LEAST BE
SAFE/REASONABLE
MORE STUDIES ARE
NEEDED

79. Coronavirus
polymerase
inhibition with
remdesivir