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Novel Coronavirus Disease 2019 (COVID-19)UPHS Critical Care Clinical OperationsBedside respiratory care and respiratory failure managementGuiding principlesBalance staff safety and standard of care for acute respiratory failureMany respiratory interventions may cause aerosolization and pose a risk to healthcare workers and bystanders including High Flow Nasal Cannula (HFNC), Non-invasive ventilation, oxygen by face-mask, nebulizers, open-circuit suctioning, and intubation/extubation. These should only be performed with airborne (PAPR or N-95 with face shield or goggles) and contact PPE in an isolation room with negative pressure, if available. IntubationConsiderations:This poses the greatest risk to providers, particularly when done emergently. Thus, strong consideration should be given to intubate earlier than usual, to allow for controlled intubation to reduce risk of exposure to intubation team.No specific threshold is specified to allow for clinical judgment, however, clinical experience suggests that patients requiring greater than 6L NC often progress rapidly to intubation and mechanical ventilation. Thus, when 6 L NC is required move the patient to a negative pressure room, if available, to either prepare for intubation or to trial HiFLow NC or CPAP/NIV. 2. If HFNC, CPAP/or NIV is attempted avoid prolonged trials (> 1 hour) or switching between modalities, as this increases risk of emergent intubation which greatly increases risk of healthcare worker transmission. Anesthesia to intubate using UPHS Critical Care Committee guidelinesWhen possible, intubate in negative pressure roomFor ward patients in a negative pressure room: Preferable to intubate in ward negative pressure room and then transfer to ICU to avoid transfer of non-intubated patientIf ward patient is not in a negative pressure room: Preferable to transfer to ICU first (w/ mask on patient) and then intubate (since intubating in non-negative pressure room has greater risk than transferring a non-intubated patient)Important Notes Risk for healthcare worker transmission is greatest during intubation and decreases once intubated with a secure airway. Extubation also carries a greater risk for healthcare worker transmission and requires same caution as the intubation processes.Optimal Mechanical ventilation strategy: Since these patients usually have ARDS, select - the Low Stretch Protocol in the mechanical ventilation order (use embedded link to Penn Pathways for protocol details). Non-invasive oxygen delivery beyond 6L NC- only consider for milder cases as experience in Europe and China was that patients placed on non-invasive ventilation, CPAP, or high flow nasal cannula rapidly progress to require intubation. High Flow Nasal Cannula (HFNC) vs (Non-invasive Ventilation) NIV or CPAPEither of these modalities may be attempted to avert intubationSafety data from SARS era is equivocal and does not take into account modern risk-reducing NIV technologiesUsing clinical judgment, either approach can be attempted to avert intubation if used with risk-reducing strategies and for a short trialHFNC:This modality has the advantage of preserving the ability to take PO medications (COVID-19 experimental treatments are mostly PO route)Utilize lowest effective flow rates (begin at 15-20 L/min)Ideally patient wears a surgical mask over HFNC, especially when clinicians are in the room and always during travelThis may be difficult logistically but a priority when clinicians are in the room and during travel to or from the ICUCPAP or NIVReduces ability to take PO medications (COVID-19 treatments are mostly PO route)Must be used with a filter on the exhalation limb (either through ventilator or V60 NIV machine with a mask that has an expiratory filter)Begin with CPAP (most patients only require oxygenation support, not ventilation) using the lowest effective pressure. This can be escalated to BiPAP but may be safer to proceed with intubation. Strive for best mask fit with lowest possible leak; monitor leak on ventilator or V60NebulizersAvoidConsider MDIs as alternativesPulmonary vasodilatorsConsider avoiding inhaled epoprostenol to avoid aerosolization and clogging of vent filterBronchoscopyNo role in COVID-19 diagnosisNP swab superior to BAL for testing logisticsBronchoscopy risk: aerosolizing secretionsNative airway: high risk; to be avoidedProtected airway: lower riskIf a high likelihood of impacting care, then may meet risk-benefit assessment, examples:Scenario 1: ARDS; unclear cause; awaiting COVID-19 testingBronchoscopy for ARDS work-upScenario 2: COVID-19 confirmed; c/f secondary/separate respiratory insult without a confirmed etiology or requiring bronchoscopic interventionBronchoscopy for secondary/separate insult work-upDefer elective proceduresRisk reductionOnly through established airwayBronchoscopy in negative pressure roomMinimal necessary personnelPersonnel in standard/contact/airborne PPEIn-hospital travel for patient in acute respiratory failureGoal is to minimize travelAvoid travel if on NIV/CPAP except from ward to MICU (e.g., in order to intubate in negative pressure room)Avoid travel on HFNC except from ward to MICU (e.g., in order to intubate in negative pressure room)If traveling with HFNC, keep surgical mask over HFNCTravel with intubated patient (closed system) is lower risk than non-invasively delivered oxygenHemodynamic management There is limited to no data on circulatory management of COVID patients. This guideline is based on communication with experienced physicians. Overall, the circulatory management of COVID patients is similar to other patients with pneumonia. Most patients become hypotensive after intubation and during sedation, but respond to mild-moderate doses of vasopressors. Start Norepinephrine immediately after intubation at a dose of 0.05-0.1 mcg/kg/min and titrate accordingly.A small fraction of patients require more higher doses of vasoactive agents. This could result from having more severe vasodilation or from cardiac dysfunction, likely myocarditis. Echo findings typically show hypokinesis, dyskinesis, and pericardial effusions. Pulmonary hypertension has also been observed. Most patients have elevated BNP at presentation either due to cardiac dysfunction or fluid overload.Consider diuretics if IVC is not collapsed. Consider careful fluid boluses in patients requiring higher PEEP (e.g. > 15 cmH2). Escalate hemodynamic support according to response and consider f/u bedside TTE. Maintain negative fluid balance if possible, without causing signs of organ hypoperfusion. Consider VA ECMO in appropriate patients with severe myocarditis.Chest X-rayPerform CXR and KUB after initial intubation and nasogastric tube insertion to confirm position of tubes and assess lung fieldsLimit further CXR’s unless significant clinical deterioration, i.e. no daily routine CXR EKG12 lead EKG is a risk for provider transmission due to close patient contact, leaning over the patient, so limit to clinical situations where it will change management. Initially, attempt to obtain a 12 lead EKG using the central monitor. QTc can be calculated using the monitor.?Myocarditis is present in many patients so cardiac Troponins should be measured and trended.Key Pharmacological considerations in critically ill patients - See Table I Goal is to optimize supportive care for these patients while minimizing risk to healthcare workers (limiting entries into the room)Antiviral therapies should preferentially be delivered to the stomach (vs small bowel)Drug-drug interactions should be reviewed for all of these patients, especially in the setting of antiviral therapy Try to time medications together to cluster care for nurse In patients who require therapeutic anticoagulation, consider use of low molecular weight heparin to avoid frequent PTT draws, unless contraindicated (CrCl <30ml/min, AKI, anticipated procedure, or risk of bleeding)Try to time medication administration to standardized lab times (i.e. AM labs)Any medication that’s brought into the room, should NOT be taken out, regardless of whether it was used. Waste the product. Do not bring medication drawers into the room.Aspect of CareConsiderations Feeding Patients receiving Kaletra (lopinavir/ritonavir) – avoid small bore/dobhoff tubes as they are polyurethane-based and drug may be incompatible. Larger bore clear OG/NG tubes are polyvinyl chloride based and are compatible with Kaletra. Has decreased absorption when delivered to the small bowel, gastric administration preferred. Hydroxychloroquine tablets cannot be crushed; suspension should be ordered for all patients with enteral tubes. Sedation/Analgesia Patients receiving Kaletra (lopinavir/ritonavir) – ritonavir is a potent CYP3A4 inhibitor and can increase the concentrations of fentanyl and midazolam (5-28 fold). Consider hydromorphone, propofol, or lower dose fentanyl. Lorazepam is an alternative benzodiazepine, but at doses >1mg/kg/day propylene glycol toxicity should be considered. Midazolam can be used for intubations since it is bolus dosing. ThromboprophylaxisPreference for once daily sq enoxaparin or every 12h heparin (where appropriate) over every 8-hour heparin (when renal function permits and no other contraindications). Please adjust enoxaparin administration to 9am for all patients. Ulcer Prophylaxis Preference for once daily medications. Consider lansoprazole 30 mg daily over twice daily famotidine. Glycemic Control When able, manage with subcutaneous insulin. Consider every 6 hour administrations vs every 4 hour. Insulin infusions require every 1 hour fingersticks. Leave insulin pen in room and dispose when patient leaves ICU.Bowel Regimen Preference for once daily when appropriate. Drug De-escalation/ Antibiotics Preference for antimicrobials with less frequent dosing intervals (i.e. cefepime every 8 hours > piperacillin/tazobactam every 6 hours)Table 1. Pharmacological ConsiderationsContact: Anesi, George L George.Anesi@uphs.upenn.edu Updated: 3/13/20 ................
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