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Covid 19 (1)
The document summarizes information and recommendations regarding the Covid-19 pandemic from the perspective of intensive care and critical care specialists. It provides worldwide case statistics and projections for hospital bed and ventilator needs in California. Guidelines are presented on testing, diagnosis, treatment strategies including ventilation, use of sedatives, ECMO, and experimental drugs. Risk stratification, PPE guidance, and management of complications like shock are also addressed. Clinical trials and the potential use of convalescent plasma are discussed.
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Covid 19 (1)
- 1. Covid-19 pandemic Islam M. Ibrahim,M.D., FACP, FCCP. Pulmonary and critical care department, University of California San Diego, USA.
- 2. • United StatesUnitedStates • Confirmed 587,337 • Recovered 44,207 • Deaths 23,649 • WorldwideWorldwide • Confirmed 1,920,918 • Recovered 453,289 • Deaths 119,686
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- 8. 8 COVID-19 Surge CapacityPlan 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
- 9. Anticipated Critical CareBed 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
- 10. Key Deliverables: • Validateoutstanding 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
- 11. 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
- 12. 6 IMU RNs BedsideRN 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**
- 13. 6 IMU RNs EachPod 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
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- 16. Serology. immunoassay kit helpsto identify total immunoglobulin, including IgG, IgM, and IgA,
- 17. Laboratory diagnosis Indications fortesting 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
- 18. Symptoms. FEVER (TEMPERATURE > 99DEGREES FAHRENHEIT) ■ NEW COUGH ■ NEW SHORTNESS OF BREATH
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- 26. High Flow NasalCannula 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
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- 31. Joint Statement onMultiple 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)
- 32. Reasons include: Volumes wouldgo 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.
- 33. Nonsedation or light sedationin critically ill vented patients. •Daily sedation breaks •fewer ICU days •fewer days on the vent.
- 34. ECMO for COVID-19Patients with Severe Cardiopulmonary Failure
- 35. ECMO • should beoffered 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
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- 37. Surviving Sepsis Campaign: Guidelineson the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
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- 48. American Thoracic Society‐ledInternational Task Force
- 51. Management of bronchialasthma 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
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- 58. Hydroxychloroquine sulfate forCOVID-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 beenrecommended 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 treatmentof COVID-19- related vasodilatory shock. This is a perspective. exogenous AngII might be very helpful in treating COVID-19 patients shock.
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- 65. Treatment of 5critically 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 MAYAT LEAST BE SAFE/REASONABLE MORE STUDIES ARE NEEDED
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