COVID-19 (ICU)

# 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.