Critical Care Management of COVID 19...

Vikram Mukherjee, MDAssistant Professor NYU School of Medicine, Director, Bellevue Medical ICU, New York, NY, USA

Critical Care Management of COVID 19 Patients

Clinical aspects: overall impressions so far

▪ Presentation

▪ Clinical Characteristics

▪ Organ dysfunction

▪ Outcomes

Onset of symptoms

Presentation to ER

Admitted to floor

Worsening hypoxia

Admitted to ICU

Severe ARDS Cytokine Storm

Renal failure

Ongoing ventilator and RRT

needs

Death

Onset of symptoms

Presentation to ER

Admitted to floor

Worsening hypoxia

Admitted to ICU

Severe ARDS Cytokine Storm

Renal failure

Ongoing ventilator and RRT

needs

Death

Onset of symptoms

Presentation to ER

Age (y)

21.2%

40.1%38.7%

0

10

20

30

40

50

60

18-49 50-64 >65

Age (y)

21.2%

40.1%38.7%

0

10

20

30

40

50

60

18-49 50-64 >65

M=72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Clear Lobar Consolidation Multifocal infiltrates Interstitial abnormalities

Inflammatory Surge

0%

20%

40%

60%

80%

100%

120%

D-dimer Ferritin Troponin LDH CRP IL-6

Clinical Characteristics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ARDS Shock State Renal Replacement Tracheostomy Death

Organ Dysfunction

▪ ARDS

▪ Cytokine Storm

▪ Renal failure

▪ Hypercoagulable state

Severe ARDS

▪ Conventional management:

▪ Trial of HFNC

▪ Lung Protective Strategy

▪ ARDSNET peep/fio2 ladder, though some patients improve on lower PEEPs

▪ Account for insensible losses and undetected hypovolemia

▪ Recruitment

▪ Attention to fluid balance

▪ Trial of antibiotics

▪ Neuromuscular blockade and RASS-4 sedation

▪ iNO for refractory hypoxia

▪ Manual proning

▪ ECMO

Severe ARDS

▪ Other issues

▪ CVL and A-line in most patients▪ Prefer left IJ CVL

▪ Many have substantial sedation requirements

▪ Many need neuromuscular blockade to achieve ventilator dysynchrony

▪ Tracheostomy team with protocolized bedside PDT

▪ Plaquenil/Azithromycin▪ Watch Qtc

▪ Family updates

Cytokine Release Syndrome

▪ Common to see the following a few days into ICU course▪ Recurring marked fevers in the absence of obvious infectious source

▪ Tachycardia, tachypnea, diaphoresis

▪ Elevated CRP, ferritin, LDH, IL-6▪ Trend daily (except IL-6)

▪ D-Dimer

▪ Progression to renal failure▪ ~30% of our ICU patients are in acute renal failure requiring RRT

▪ Unclear on how to mitigate▪ Steroids

▪ Risks

▪ Anti- IL6

▪ No clear data on efficacy

Renal Replacement Therapy (RRT)

• High incidence of AKI requiring RRT

• Unclear etiology

• Role of Peritoneal Dialysis in crisis situations

Hypercoagulability

• High incidence of arterial and venous thromboembolism

• Inflammatory milieu

• Virus- induced endothelial damage

• D-dimer as a surrogate of clot formation

• Further studies ongoing to define risk & therapies

Other considerations

▪ No evidence based treatment

▪ Critical care support is the mainstay of therapy

▪ Altered standard of care

▪ Role of POCUS

▪ Things move slowly

▪ Has repercussions on management choices▪ Levels of sedation

▪ Timing of invasive interventions

Need for a multidisciplinary approach

▪ Tracheostomy team

▪ Proning team

▪ Palliative care team

▪ Procedure team

▪ Renal Replacement Therapy Team

▪ Site manager team

Vikram Mukherjee, MDAssistant Professor NYU School of Medicine, Director, Bellevue Medical ICU, New York, NY, USA

Critical Care Management of COVID 19 Patients