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    COVID-19 (ICU)

    coronavirus, COVID19, SARS-CoV-2

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    Assessment & Plan (short)

    #Acute Hypoxic Respiratory Failure secondary to COVID-19, confirmed
    Onset of symptoms on 8/18, including fever, cough, SOB, GI sx. Admitted to *med floor *ICU* on 8/25 with hypoexmic/hypercarbic respiratory failure. CXR notable for ***. COVID test positive on ****. Received therapies include *** proning, convalescent plasma, remdesivir, flolan, and/or ECMO.
    Goal SpO2 92-96, PaO2>75
    Labs/dx
    - Admission: CBC w diff, CMP, CRP, procal, CPK, PTT, INR, BNP, ferritin, EKG, CXR
    - Daily: CBC w diff, BMP, Mag, CPK, BNP
    - Strict isolation = Contact (gown+ gloves) + Droplet (N95)
    - AVOID aerosolizing procedures when possible (Non-invasive, high flow, nebs, bronchoscopy)
    Tx:
    - Duoneb q6h
    - Budesonide 0.5mg bid
    - Remdesivir
    - Baricitinib
    - Methyprednisolone (Solumedrol)
    - Zinc 220mg qd, Vitamin D 4,000u qd, Vitamin C 500mg q6h, Thiamine 100mg, Famotidine 20mg bid, Melatonin 9mg qhs
    - Lovenox 55mg q12

    Assessment & Plan (long)

    # COVID-19, suspected or confirmed
    Onset of symptoms on ***, including fever, cough, SOB, GI sx. Admitted to ICU on *** for ***. Initial SOFA ***. GOC ***.
    ## Hypoxemic respiratory failure
    - Goal SpO2 92-96& PaO2>75
    - Avoid CPAP or BiPAP for ARDS, can consider in reversible cases (e.g. flash pulmonary edema, mild COPD exac)
    - @NC 6L/min call anesthesiology to discuss intubation, start venturi mask or non-rebreather
    - Lung Protective Ventilation: Vt 6cc/kg ideal body weight, initial PEEP 10 (for BMI<35) 12 (for BMI 35-50) and 15 (for BMI >50)
    - Titrate PEEP w ARDSnet table (low PEEP table if BMI<35, high PEEP table if BMI>35)
    - for refractory hypoxemia try in this order: 1)PEEP titration 2)increased sedation 3)PRONING (for P:F<150 of FiO2 >0.75) 4)continuous paralysis  5)inhaled epoprostenol 6)inhaled NO 7)ECMO, if candidate
    - Sedation for ARDS: fentanyl / hydromorphone + propofol +/- midazolam (adjunct)
    - Airway clearance should be used only in selected ventilated patients (closed-circuit) with extremely thick secretions to avoid mucus plugging that would require bronchoscopy
    ## Fluids
    - Conservative fluids
    - Assess fluid responsiveness, +/- bedside ultrasound, only small boluses (250-500cc)
    - Target CVP 4-8mmHg and EVEN fluid balance
    ## Labs/dx
    - Admission: CBC w diff, CMP, CRP, procal, CPK, trop, d-dimer, PTT, INR, (NTpro)BNP, ferritin, EKG, CXR
    - Daily: CBC w diff, BMP, Mag, troponin, CPK, BNP, (avoid daily CXR)
    - Every other day: LFTs, LDH, CRP, d-dimer, ferritin (if on propofol also triglyceride)
    - If clinical worsening: ABG, LFT, CPK, troponin, CRP, procal, LDH, ferritin, d-dimer, fibrinogen, PTT, INR, EKG, CXR
    ## Isolation
    - Strict isolation = Contact (gown+ gloves) + Droplet (surgical mask; N95 if in ICU or if w/aerosolizing procedure)
    - AVOID aerosolizing procedures when possible (Non-invasive, high flow, nebs, bronchoscopy)
    ## Consults
    - ID
    - +/- anesthesiology, palliative, cardiology
    ## Tx
    - dexamethasone
    - abx for possible bacterial superinfection (10-20%): vanc/cefepime +/- azithromycin
    -- d/c at 48h if 1) Clinical status is not deteriorating and 2) Cultures do not reveal pathogens at 48h and/or Procalcitonin and WBC are relatively stable from 0 to 48h
    - Discuss therapy options with ID
    -- moderate sx: dexamethasone, remdesivir
    -- critically ill: as above, consider tocilizumab
    ## Prognosis
    - Risk factors at admission for mortality: age, SOFA, Ddimer >1 : calculate http://bit.ly/covidmortcalc
    - More severe illness with elevated/worsening IL-6, high-sensitivity cardiac troponin I, and lactate dehydrogenase; lymphopenia

    # Shock
    DDx Cardiogenic, Secondary bacterial infection, Cytokine storm
    Dx:
    - end organ damage: UOP,  mental status, lactate, BUN/creatinine, electrolytes, LFTs
    - infectious w/u: CBC with differential. BCx x2, LFTs (for cholangitis/acalculous cholecystitis), UA with reflex Cx, sputum culture (if safely obtained via inline suctioning, do not perform bronchoscopy or sputum induction), procalcitonin at 0 and 48h, urine Strep and legionella antigens
    - cardiogenic w/u: SCV02 or MV02 if the patient has central access, troponin x2, NT proBNP, A1c, lipid profile, TSH, EKG (and telemetry)
    - Portable CXR (avoid CT unless absolutely necessary)
    - Full skin exam, extremity perfusion, JVP, CVP, pulse pressure (<25% SBP -> CI < 2.2)
    - consider other causes: vasoplegia (look at med list); adrenal insuff (if high pretest probability, no routine cort stim), obstruction (PE, tamponade, PEEP), allergic rxns, hypovolemia (esp insens losses, diar/vomit)
    Tx:
    - early abx
    - start NE for MAP>65
    - no 30cc/kg, trial 250-500cc boluses then reassess 30m for incr CO, incr MAP, improved PPV (>12% suggests fluid responsiveness)
    - if cardiogenic component:
    -- Goals: MAPs 65-75, CVP 6-14, PCWP 12-18, PAD 20-25, SVR 800-1000, SCvO2 > 60%, CI > 2.2
    -- norepinephrine gtt for goal MAP 65-75
    -- diuretics for CVP > 14, PCWP >18, PAD > 25
    -- Dobutamine gtt for SCvO2 < 60%, CI < 2.2 and MAP > 65.  Start at 2mcg/kg/min. Up-titrate by 1-2mcg/kg/min every 30-60 minutes for goal parameters. Consider mechanical support at 5mcg/kg/min.  Maximum dose is 10mcg/kg/min.

    Description

    Management of COVID-19 patients admitted to ICU; based on covidprotocols.org

    Organ systems
    • Cardiovascular
    • Pulmonology/Critical Care
    • Infectious Disease
    Medical field
    • Internal medicine
    Setting
    • Inpatient
    Author
    Patrick Sanger
    Page info

    Originally created: March 31, 2020 by Patrick Sanger

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    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
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