Indications of icu admission and guidelines for treating covid 19

1. Indications of ICU admission and
ICU management of critically ill
COVID 19 patients
DR AVINASH AGRAWAL
Prof & HOD
Dept. Of critical Care Medicine,
King George’s Medical University, UP, Lucknow

2. Brief Overview
 There are 7 different strains of corona virus-
 (229E- alpha, NL63- alpha, OC43- beta, HKU1- beta, mers-cov-
beta, sars-cov-beta & sars-cov-2- novel)
 Sars-cov-2 previously referred as 2019-ncov
 It is a SS RNA virus, with size 120 nm
 In feb 2020 who designated the disease covid-19 (corona virus
disease 2019).

3. Transmission
 Mainly by droplet- cough, sneeze or talk.
 Droplets direct contact with mucus membrane
 Droplets don’t travel more than 6 feet
 Virus persist for longer time in faeces and urine.

4. Clinical features
Incubation period : 2- 14 days, most cases within 5 days
Spectrum of illness: Most- self limiting
Mild illness 80- 82%
Severe illness 14- 15%
(Dyspnea- RR≥ 30/min, Hypoxemia- spo2≤ 93%/pao2/fio2< 300,
>50%lung involvement on imaging within 24- 48 hours)
Critical disease- 4- 5% (Resp failure, Septic shock, MODS)
Overall case fatality- 2.3- 5%

5. Brief Overview
CATEGORIES:
A Fever/ mild sore throat/ dry cough/ rhinitis/ diarrhoea
B Fever and severe sore throat/ cough/ diarrhoea
OR
Category A plus two or more of the following
• Lung/Heart/Liver/kidney/neurological disease/HTN/haematological
disorder/uncontrolled DM/Cancer/HIV-AIDS
• On long term steroids/immunosupressive drugs.
•Pregnant lady.
•Age > 60 years.
OR
Category A plus Cardiovascular disease
C • Breathlessness, chest pain, drowsiness, Hypotension, haemoptysis, cyanosis
(red flag sign).
• Worsening underlying chronic conditions.
Categorization should be reassessed ever 24- 48 hours for category A & B

6. Indications for ICU admission
•Criteria for selection and admission in ICU
•on the basis of diagnosis, objective or on priority basis.
In covid 19 cases criteria are:
1. Need for mechanical ventilation
2. Need for vasopressors
3. Respiratory rate > 30 breaths per minute
4. Pao2 < 50 mm hg on room air/spo2 <90% on supplemental oxygen of 6lpm
5. Confusion
6. LeukopeniaThrombocytopenia
7. Uraemia
8. Multi-lobar infiltrates
9. Hypotension requiring fluid resuscitation
10. Hypothermia
11. qSOFA >2

7. Indications for ICU admission
•CRITERIA FOR SELECTION AND ADMISSION IN ICU CAN
BE ON THE BASIS OF DIAGNOSIS, OBJECTIVE OR ON
PRIORITY BASIS.
In COVID 19 cases criteria are:
Other indications are CURB 65

8. Indications for ICU admission
Validated definition includes either one major criterion or three or more minor
criteria
Minor criteria:
i. Respiratory rate > 30 breaths/min
ii. Pao2/FIO2 ratio < 250
iii. Multilobar infiltrates
iv. Confusion/disorientation
v. Uraemia (blood urea nitrogen level > 20 mg/dl)
vi. Leukopenia* (white blood cell count , 4,000 cells/ml) thrombocytopenia
(platelet count , 100,000/ml)
vii. Hypothermia (core temperature , 368C)
viii. Hypotension requiring aggressive fluid resuscitation
Major criteria:
i. Septic shock with need for vasopressors
ii. Respiratory failure requiring mechanical ventilation

9. ICU Management
 Initial resuscitation
 Screening for sepsis and
performance improvement
 Diagnosis
 Antimicrobial/antiviral/ other
therapy
 Source control
 Fluid therapy
 Vasoactive medications
 Corticosteroids
 Blood products
 Immunoglobulins
 Blood purification
 Anticoagulants
 Mechanical ventilation
 Sedation and analgesia
 Glucose control
 Renal replacement therapy
 Bicarbonate therapy
 Venous
thromboembolism
prophylaxis
 Stress ulcer prophylaxis
 Nutrition

10. ICU Management
i. INITIAL RESUSCITATION:
a. Sepsis and septic shock are medical emergencies, and treatment
and resuscitation begin Immediately.
b. Resuscitation from sepsis-induced hypo perfusion, at least 30
ml/kg of iv crystalloid fluid be given within the first 3 hours.
a. Following initial fluid resuscitation, additional fluids be guided by
frequent reassessment of hemodynamic status.

11. a. Further hemodynamic assessment (such as assessing cardiac
function) to determine the type of shock if the clinical examination
does not lead to a clear diagnosis.
a. Dynamic over static variables be used to predict fluid
responsiveness, where available.
a. Initial target mean arterial pressure of 65 mm hg in patients with
septic shock requiring vasopressors.
a. Guiding resuscitation to normalize lactate in patients with elevated
lactate levels as a marker of tissue hypo perfusion.

12. ICU Management
VII. VASOACTIVE MEDICATIONS:
1. Nor epinephrine as the first-choice vasopressor
2. Vasopressin or Epinephrine to Nor epinephrine with the intent of
raising mean arterial pressure to target or decraese dose of
noradrenaline
3. dopamine as an alternative vasopressor agent to nor epinephrine
only in highly selected patients
(e.g. Patients with low risk of tachyarrhythmia and absolute or relative
bradycardia).
4. Against using low-dose dopamine for renal protection.
.

13.  5. Using dobutamine in patients who show evidence of persistent hypo
perfusion despite adequate fluid loading and the use of vasopressor
agents
 6. All patients requiring vasopressors have an arterial catheter placed as
soon as practical if resources are available

14. ICU Management
IX. BLOOD PRODUCTS:
1. RBC transfusion when Hb decreases to < 7.0 g/dl
in adults except in myocardial ischemia, severe
hypoxemia, or acute hemorrhage.
2. Against the use of erythropoietin for treatment of
anaemia associated with sepsis.
3. Against the use of fresh frozen plasma to correct
clotting abnormalities in the absence of bleeding or
planned invasive procedures.

15.  Prophylactic platelet transfusion when counts are < 10,000/mm3 (10 ×
109/L) in the absence of apparent bleeding
 When counts are < 20,000/mm3 (20 × 109/L) if the patient has a
significant risk of bleeding.
 Higher platelet counts (≥ 50,000/mm3 [50 × 109/L]) are advised for active
bleeding, surgery, or invasive procedures.

16. ICU Management
XIII. MECHANICAL VENTILATION:
 Patients on HFNC and NIV should be thoroughly monitored
 If worsening of respiratory conditions and need of intubation, intubation should
not be delayed in such cases
Invasive mechanical ventilation
 Initaite Mechanical ventilationuse using lung protective strategy (tidal volume 4-
8ml/kg predicted body weight).
 Plateau pressure goal: ≤ 30 cm h2o
 Check pplat (0.5 second inspiratory pause), at least every 4h and after each
change in PEEP or VT.
 If pplat > 30 cm h2o: decrease vt by 1ml/kg steps (minimum = 4 ml/kg).
 Consider use of incremental fio2/peep combinations such as shown below to
achieve goal

17. ICU Management
XV. GLUCOSE CONTROL:
A protocolized approach to blood glucose management in ICU patients with
sepsis,commencing insulin dosing when two consecutive blood glucose levels are >
180 mg/ dl
Target an upper blood glucose level ≤180 mg/dl rather than an upper target blood
glucose level ≤ 110 mg/dl.
Blood glucose values be monitored every 1 to 2 hours until glucose values and insulin
infusion rates are stable, then every 4 hours thereafter in patients receiving insulin
infusions.
That glucose levels obtained with point-of-care testing of capillary blood be
interpreted with caution because such measurements may not accurately estimate
arterial blood or plasma glucose values.
Use of arterial blood rather than capillary blood for point-of-care testing using glucose
meters if patients have arterial catheters.

18. ICU Management
XVIII. VENOUS THROMBOEMBOLISM PROPHYLAXIS:
Pharmacologic prophylaxis against venous thromboembolism (VTE) in
the
Absence contraindications to the use of these agents
LMWH rather than UFH for VTE prophylaxis In the absence of
contraindications to the use of LMWH
Combination pharmacologic VTE prophylaxis And mechanical
prophylaxis, whenever possible
Mechanical VTE prophylaxis when pharmacologic VTE is
contraindicated.

19. ICU Management
XX. NUTRITION:
Against the administration of early parenteral nutrition alone or parenteral nutrition in
combination with enteral feedings.
2. Early initiation of enteral feeding rather than a complete fast or only IV.
3. We suggest either early trophic/hypocaloric or early full enteral feeding in critically
ill patients with sepsis or septic shock then feeds should be advanced according to
patient tolerance.
4. Against the use of omega-3 fatty acids as an immune supplement.
5. Use of prokinetic agents for feeding intolerance.
6. We recommend against the use of IV selenium, Arginine, Glutamine and
Carnitine.

20. ICU Management: General
GENERAL MANAGEMENT DURING ICU STAY:
F- feeding
A- analgesia
S- sedation
T- thromboembolism prophylaxis
H- head end up
U- ulcer prophylaxis
G- glucose control
S- spontaneous breathing trial
B- bowel regimen
I- indwelling cathater removal
D- de-escalation of antibiotics

21. ICU Management: General
GENERAL MANAGEMENT DURING ICU STAY:
A- Assess, prevent and manage pain
B- Both spontaneous breathing and awakening trials
C- Choice of sedation and analgesia
D- Delirium assessment, prevention and management
E- Early mobility and exercise
F- Family communication and involvement.

22. ICU Management
INVESTIGATIONS:
BASELINE:
Complete hemogram
Liver funtion test
Renal function test ft,
Serum electrolytes
Coagulation profile,
Viral profile, viral markers (hbs ag, anti hcv, hiv1& 2)
Baseline ECG
Chest radiograph, ABG (if spo2 <94%), cxr,
Total cpk, cpkmb and trop t (quantitative) in all patients.
Oher specific investigations pertaining to their co morbid illness as the case may
arise.

23. ICU Management
RISK FACTORS AND PROGNOSTIC DETERMINANTS:
• History of co morbidities (Htn, DM, COPD, Asthma, Hemato-lymphoid cancer,
Solid organ cancer, CLD, CKD, CHF,IHD, Stroke, Dementia etc.).
• Higher body temperatures were associated with more severe disease and
higher fatality.
• In the wuhan cohort, the following laboratory cut offs appeared to indicate a
poor prognosis
• lymphopenia < 2000/cu.mm
• Neutrophil / lymphocyte ratio >2
• LDH > 245 u/l
• hs-cardiac troponin > 28 ng/ml
• Prothrombin time > 16 s
• Serum ferritin > 300 μg/l
• D dimer

24. COVID 19 Management

25. COVID 19 Management

26. Cardiopulmonary resuscitation
in COVID 19
 Causes of cardiac arrest- 5Hs and 5 Ts
 5Hs- Hypoxia, Hypovolemia, Hydrogen ion (Acidosis), Hyper/
Hypokalaemia, hypothermia
 5Ts- Toxins, Tamponade (Cardiac), Tension Pneumothorax,
Thrombosis (Coronary and Pulmonary),
 Rhythms of cardiac arrest
 Shockable rhythm- Pulse less VT and VF
 Non Shockable rhythm- Asystole and PEA
 Shock 200 J Biphasic
 Compression to ventilation ratio 30:2
 Drugs Used during CPR- Adrenaline, Amiodarone, MgSO4 etc.

27. References:
 COVID 19 Guidelines- WHO
 COVID 19 Guidelines- Position statement ISCCM
 COVID 19 Guidelines- International Pulmonologist’s
Concensus
 COVID 19 Guidelines- Government of Kerala
 Surviving Sepsis Campaign 2016 guidelines