Thinking critical care | a blog for thinking docs ...
Notes after conversations with Giacomo Bellani (Milano-Bicocca), Paolo Pelosi (Genoa), Youzhong Ahn (Peking Univeristy), Alberto Goffi (Toronto)LogisticsThe key message is that this challenge requires a deep reorganization of our work and staffing models. Do not let you administrators think they can run business as usual. In few days, we will be all dealing COVID. This is not a MICU problem. STOP OR activity as soon as you see the first inflow of patients. Toronto (St. Michaels) has run simulations and came up with a surge plan. They will shut down the ORs and empty the MICU once 4/5 of their negative pressure rooms are occupied. Then, reassess after 48 expanding to other ICUs or to non ICU environments, including the ORs. Consider training non ICU clinicians (anesthetists and nurses) to take care of ICU patients. You may have to consider involving ethics in case triaging patients is a necessity.The Northern Italy disaster may be a result of a stronger strain but also of the initial mismanagement and confusion. We could be luckier. But some of their delays (delay in testing, restricted screening to China contacts) are eerily familiar. There has been a free flow of Italian tourists to this country as of last week.In normal circumstances, younger patients should do well without advanced measures. Patients come in sick after 7-9 days of milder symptoms. There is a surge of younger patients right now. Alarmingly, the average age of ICU patients is decreasing, partly because of a second wave of sick younger patients. Partly because they are withholding and withdrawing care to older patients with comorbidities. They are also not escalating care (e.g. CRRT). The standard of care is decreasing and patients are being increasingly triaged. The SIAARTI has just issued an ethics guideline.This is the current situation in my old hospital (March 9): University of Milan-Bicocca, Monza (a large academic center of similar size to HUP): As of now, there are 2/3 ICUs dedicate to COVID, plus the former NICU (which had to be reopen), + 4 ORs, plus 4 ORs, plus an area in the recovery room (not clear if Covid or other patients). ICUs are smaller (12-15 beds each). 60 pts in non ICU environment followed with ICU consultation rounding Q day and phone directions to providers (can be other specialties). As of this morning (3/10) they have 25 patients receiving non invasive CPAP. Their biggest regret was not to separate patients since the beginning. The second biggest regret was not to stop elective surgical activities earlier. It would have been better not to have postoperative patients in the units. Their advice is: dedicate units and floors to COVID (a whole wing would be ideal). Create teams of dedicated staff. Separate equipment. Some Clinical pearls (Bellani, Pelosi, An)The good news is that patients to seem to behave predictably. They have severe hypoxemia but easy to ventilate with standard tools and limited need for ECMO. There seems to be a palpable difference with influenza-related ARDS.1) Non invasive support. DO not overdo NIV as patients evolver and crash quickly– if SpO2 is less than 95% or paO2/FiO2 less 200 irrespective of RR at fiO2 60 per cent intubate immediately; if non-invasive CPAP, they use Helmet CPAP: very popular in Europe and extremely handy in this situation, as it can be managed by non ICU people and helps to avoid dissemination. It is not FDA approved. In alternative, it is unclear whether or not NIV vs. High flow NCO2 is better in terms of droplet spreading. The Italians prefer not to use High flow. 2) Invasive ventilation. Standard low stretch ventilation, nothing fancy. Use moderate to high peep 13-18 cmH2O; minimal use of RM; compliance is good so pplat is usually below 25-27 cmH2O (lungs are easy to ventilate) - with driving P below 13 cm H2O; increase FiO2 if needed; they start with usual very low paO2/FiO2 when intubated - than can slightly improve – don’t worry it is normal, most patients do well with conventional settings. Very good response to prone position, use aggressively, but be very well organized and consider time to dress before entering the rooms in case of emergency. Have a solid proning protocol.Use of ECMO seems to be rare. Most patients do well on conventional ventilator management. ECMO is NOT your problem. Having enough ventilators and staff is.They also respond to inhaled vasodilators, but eopprostenol is problematic if you use antimicrobial HME (recommended vs. humidifiers).3) Hemodynamics. Most patients need low medium use of Norepi - since pts are sedated almost for 4-7 days, initially this maintains pressure and reduce the need for entrance in the room); minimize fluids and use pressors early. Myocardial dysfunction seems to be a big deal in China, myocarditis seems to be frequent and suggested by frequent effusions.4) Delayed weaning, have recurrent hypoxemia after weaning airway pressure too fast and then take time to recover. Per Pelosi: keep them deeply sedated for 4-7 days, then try to wean. But be very very careful due to recurrent hypoxemia. Expect a duration of ventilation of 10-14 days. 5) Use of BAL after intubation is controversial: IN Italy they perform post extyubation BAL because of many cases where swab was negative while BAL was positive. This is still subject of discussion.6) antiviral cocktail (Darunavir o lopinavir) + ritonavir + oseltamivir + idrossiclorochina 200x2 + ceftarolina – (ID consult mandatory);7) no corticosteroids - in case of NA higher than 0.7 use only hydrocortisone 50 x4 (very few days). This is also controversial.Open questions: what intubation criteria in absence of CPAP?What do patients die of? It is hard to say and still early as patient remain ventilated for extended time. 6 patients successfully extubated in Monza. Most deaths were from withdrawal of care. The bar is low. Older patients + multiorgan failure = withdrawal (physician decided, no family involvement). The age of ICU patients is decreasing. First 18 yo patient admitted on 3/10. These are notes from an ID conference in California?kindly shared by Dr. Martha Blum MD PhD, from Monterey..3/8/2020?Notes from the front lines:I attended the Infectious Disease Association of California (IDAC) Northern California Winter Symposium on Saturday 3/7. In attendance were physicians from Santa Clara, San Francisco and Orange Counties who had all seen and cared for COVID-19 patients, both returning travelers and community-acquired cases. Also present was the Chief of ID for Providence hospitals, who has 2 affected Seattle hospitals under his jurisdiction. Erin Epson, CDPH director of Hospital Acquired Infections, was also there to give updates on how CDPH and CDC are handling exposed health care workers, among other things. Below are some of the key take-aways from their experiences.?1. The most common presentation was one week prodrome of myaglias, malaise, cough, low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of dyspnea and average 9 days to onset of pneumonia/pneumonitis. It is not like Influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (with either leukocytosis or leukopenia). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates. Aside from that, the other markers (CRP, PCT) were not as consistent.?2. Co-infection rate with other respiratory viruses like Influenza or RSV is <=2%, interpret that to mean if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China.?3. So far, there have been very few concurrent or subsequent bacterial infections, unlike Influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.?4. Patients with underlying cardiopulmonary disease seem to progress with variable rates to ARDS and acute respiratory failure requiring BiPAP then intubation. There may be a component of cardiomyopathy from direct viral infection as well. Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear PAPRs.?5. To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s RCT (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. Placebo). Others have tried Kaletra, but didn’t seem to be much benefit.?6. If our local MCHD lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we (CHOMP) have decided not to collect specimens ordered by outpatient physicians.?7. At facilities that had significant numbers of exposed healthcare workers they did allow those with low and moderate risk exposures to return to work well before 14 days. Only HCW with highest risk exposures were excluded for almost the full 14 days (I think 9 days). After return to work, all wore surgical masks while at work until the 14 days period expired. All had temperature check and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.?8. Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort.?9. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected> 24 hours apart.?10. All suggested ramping up alternatives to face-to-face visits, tetemedicine, “car visits”, telephone consultation hotlines.?11. Sutter and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments.?12. Health Departments (CDPH and OCHD) state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in San Jose area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results. ................
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