ICU Care Guidelines for Patients With COVID-19 · 5/15/2020 · ICU Care Guidelines for Patients...

LastModified:January22,2021 1

ICUCareGuidelinesforPatientsWithCOVID-19PurposeThisdocumentwascreatedbythefellowsandfacultyofNorthwesternUniversityFeinbergSchoolofMedicineDivisionofPulmonaryandCriticalCareMedicine,andtheNorthwesternMemorialHospitalMedicalIntensiveCareUnit(MICU)interprofessionalteamtoprovidegeneralguidelinesanddescribecurrentpracticesforthecareofcriticallyillpatientswithCOVID-19.

EditorsJacquelineKruser,MDJames(Mac)Walter,MD(contactforupdates/questions:james.walter@northwestern.edu)BenSinger,MD(contactforupdates/questions:benjamin-singer@northwestern.edu)CatherineGao,MDTheresaLombardo,APRNRichardWunderink,MDScottBudinger,MDImportantnotes

● Thisdocumentwillbecontinuouslyrevisedandupdatedascarepracticesandpolicieschange.● SomeinformationmayonlyapplytoNorthwesternMemorialHospital(NMH)ortoNorthwesternMedicine

(NM)systempractices,andsomelinksmayonlybeaccessiblefromNMInteractive(NMI).● Thisdocumentsetsoutguidelines,butexceptionswillbemadeonanindividualpatientbasis.● Carepracticescanchangequicklyandmaynotbefullyreflectedbelow.

Tableofcontents

1. IntensiveCareUnit(ICU)Triage2. PersonalProtectiveEquipment(PPE)3. Patient/FamilyEngagementandVisitation,PalliativeCareandEnd-of-LifeCare4. MedicallyInappropriateorNon-beneficialTreatment5. CardiopulmonaryResuscitation6. COVID-19TestingandDiagnostics7. OtherBiomarkersandLab/DiagnosticMonitoring8. VTEProphylaxisandTransfusionGuidelines9. TreatmentOptionsandClinicalTrials10. High-FlowNasalCannula,Non-invasiveVentilationandAirwayClearanceTherapies11. Peri-intubationManagement12. GeneralVentilatorManagementandExtracorporealSupport13. PronePositioning14. RespiratoryECMOServiceStructure15. SedationManagement16. BowelRegimenwhileUsingHigh-doseOpioidsorPhenobarbital17. NeurocriticalCareConsultation18. OBConsultation

19. Lines,TubesandProcedures20. EchocardiographyandPoint-of-CareUltrasound21. OptimizingtheElectronicHealthRecord(Epic)22. TheLogisticsofRounding23. ClearingpatientsofCOVIDstatus

Chronologyofupdatestoguidelines

● March30,2020o New:CPRpolicy,HFNC/NIV/Airwayclearance,logisticsofroundingo Updated:Ultrasoundcleaningrecommendations

● April5,2020o New:VTEprophylaxisandtransfusionguidelineso Updated:ICUprocedures,includingpulmonaryandcentralvenousaccessprocedureservices

● April8,2020o New:LinktoNMHformalpronepositioningprotocolo Updated:RevisedrecommendationsforuseofHFNCinconfirmedorhighpre-testprobabilityCOVID

infections● April16,2020

o New:RespiratoryECMOservicestructure,neurocriticalcareconsultguidelines,bowelregimenwhileonopioidsorphenobarbital

o Revised:CPRpolicy,VTEprophylaxisdosing,extensiveexpansiontosedationguidelines● April21,2020

o New:OBprotocol● April29,2020

o New:Medicallyinappropriateornon-beneficialtreatmento Revised:CPRguidelines

● May12,2020o Revised:Palliativecareconsultation,PPE

● November,2020o Majorupdatestomedicationsandtrialso DecommissioningofpreviousCOVIDCPRpolicyo ClearingpatientsofCOVIDstatuso Minorupdatestoallsections

● January,2021o Updatetosteroidandothertherapeuticsrecommendationso Smalladministrativeupdateso UpdatestoSection4byDr.Neely

Section1:ICUTriageAllCOVIDMICUtriageiscurrentlygoingthroughtheCOVIDICUadmittingpager19075(search‘MICUCOVID’)

Werecommendclear,earlycommunicationwiththepatientorsurrogateaboutpatientpreferencesforlife-sustainingtreatment.Communicationsshouldincludetherangeofexpectedoutcomes(includingthepotentialfordeath)forallpatientswithhigh-riskfeatures(seebelow)ordecompensatingrespiratorystatusrequiringICUtriage.

PageMICUforallpatientswithconfirmedCOVID-19infectionorpersonsunderinvestigation(PUI)and:

● Impendingrespiratoryfailurerequiringintubationo Note:Intubationisahighlyaerosolizingprocedure.Giventherisktoproviders,attemptsshouldbe

madetoenacttransfertoanegativepressureroompriortointubation.● Persistenthypoxemia(SpO2<90%,PaO2<65orP/F<300)despiteFiO20.50or4-6LNC

o Note:Non-symptomatichypoxemiahasbeenreportedasafeatureofCOVID-19,especiallyintheelderly.

● RapidincreaseinsupplementalO2requirement● Acidosis

o ABGwithpH<7.3orPCO2>50orabovepatient’sbaselineo Lactate>2

● Persistenthypotensionafterappropriatevolumechallenge● OtherstandardindicationsforICUadmission/triagealsoapplyinthepatientpopulationwithCOVID-19andPUI

ConsiderpagingMICUforpatientswhoareCOVID-19positiveorPUIpatientswith>1high-riskfeatures(oranyotherconcernforclinicaldeterioration):

● Clinicalo Age>60o HxofDM,CKD,CAD,Cardiomyopathy,ChronicLungDzo Immunosuppression/transplanto HIV+regardlessofCD4counto Alteredmentalstatus

● Vitalso RR>24o HR>125o Escalatingoxygenrequirementso Persistent/highfeversassociatedwithalteredmentalstatus

● Labso D-dimer>1000ng/mLo CRP>20o CPK>twiceupperlimitofnormalo Ferritin>300ng/mLo ALT>24IU/Lo LDH>245o Lymphocytes<0.7

o HighSensitivityTroponinI>28pg/mL

Section2:PersonalProtectiveEquipmentintheICUPurpose/scopeTooutlinerecommendationsfortheuseofPPEinthecareofpatientswithconfirmedCOVID-19andPUI.TheinformationpresentedinthedocumentisbasedonthecurrentguidelinesfromNorthwesternMedicine,theCentersforDiseaseControlandPrevention,andtheWorldHealthOrganization.PPErecommendationsaresubjecttochange.Forthemostup-to-dateinformation,providersshouldreviewtheNMICOVID-19site.

PersonsaffectedAllhealthcareproviderscaringforpatientswithknownorsuspectedCOVID-19intheICU

Generalprinciples● Allhealthcareprovidersshouldwearmasksatalltimesandmaintainphysicaldistance.● Eatinganddrinkingshouldbelimitedtodesignatedareasthatallowisolationfromco-workers.● EnsureyouareuptodateonN95fittestingorelastomericrespiratorfittesting.● DonotparticipateinthecareofpatientswithCOVID-19withoutfirstfamiliarizingyourselfwithproperPPE

donninganddoffing.GuidelinesareavailableontheNMICOVID-19site.● HaveateammemberobservePPEdonninganddoffingtoensureyouarefollowingcorrecttechnique.● Minimizethenumberofpersonnelinpatientrooms,limittime,andtrytoavoidrepeatedlyenteringtheroom.● Ensureyouhaveallsuppliesneededpriortoenteringapatientroomforanyprocedure.● ConservePPE.● FollowguidelinesonreuseofN95respirators:

o AnN95respiratormaybeusedcontinuouslybeyondonepatientaslongasitisnotsoiled,wetortorn,anditisdonnedanddoffedproperlytoavoidcontamination.

o Followthesignonthedoortodeterminewhichmask/respiratortouse.Ifyouperformanaerosol-generatingprocedure,discardtherespirator.Otherwise,youmayextenduseuntiltherespiratorissoiled,wetordamaged.Themaskshouldbediscardedattheendoftheshift.

o YoumaywishtowearafaceshieldovertheN95respiratortoavoidcontaminationoftherespiratorandtoprovideeyeprotection.

o N95respiratorsmaybeworncontinuouslybythesamehealthcareworkerthroughoneshiftandstoredinabrownpaperbag,plasticbiohazardbag,orothercleanlocation.

o Proceduremasksmaybeworncontinuouslytoseemultiplepatientsifnotremovedbetweenencounters.

o Ifthemaskisremovedfromtheface,itcanbere-appliedwithcareperguidelines.o EachtimeanN95respiratorisapplied,performausersealcheck.o AnymaskmayNOTbepulleddownandwornbelowthenoseandmouth.o Replacerespiratorifitbecomescontaminated,soiled,damaged/torn,wetand/orhardtobreathe

through.o PerformhandhygienebeforeandaftertouchingN95respirators. o ReplaceN95respiratorsafteranyaerosol-generatingprocedureincludingbronchoscopy;ifN95is

coveredbyasurgicalmaskduringAGP,thesurgicalmaskmayinsteadbediscarded ● Poweredair-purifyingrespirators(PAPRs):

o PAPRsarelimitedthroughouttheorganizationandrestrictedtoproviderswhoareperforminghigh-riskaerosolizingproceduresandwhoareunabletowearanN95respiratorduetofacialreconstruction,extremeweightloss/gain,bracesordentures.

o FacialhairshouldbeshavedtofitanN95respirator.OnlythosewhoobtainareligiousexemptiontoshavingwillbeconsideredforaPAPR.

o PAPRhoodsmaybeworncontinuouslybythesamehealthcareworkerformultiplepatientsandmultipleshifts,andmustbestoredinalargeplasticbagoranothercleanlocation.

▪ Individualsshouldidentifytheirhoodbywritingtheirnameonitwithamarker.▪ Hoodsshouldbereplacedifanydamageisdetected.▪ Hoodsshouldbewipeddownaftereachusewithhospital-approveddisinfectingwipes.▪ HandhygieneshouldbeperformedbeforeandaftertouchingPAPRhoods.

● Everyeffortshouldbemadetobundleprocedures(e.g.,centralline,arterialline)topreventrepeatedlyenteringthepatient’sroom.

PPEuseintheICUforsuspectedorconfirmedpatientswithCOVID-19● Followairborneprecautions:UseanN95orelastomericrespiratoratalltimes.● Followcontactprecautions:Gownandglovesmustbeworn.● Weareyeprotection:gogglesorfaceshield.

o Performhandhygienebeforeandaftertouchingeyeprotection.o Eyeprotectionmaybeworncontinuously.o Cleangoggles/faceshieldperinstructions(hospital-gradewipes).Allowsurfaceofeyeprotectiontodry.o Disposeofeyeprotectionifitisnolongerclear,orifitiscrackedordamaged.

● AllpeopleenteringtheroommustweartheappropriatePPE.● Additionalconsiderationstopreventthespreadofinfection:

o Designateaworkstationforeachprovider.Trytoworkinaphysicallydistantspacefromotherteammembers(i.e.acallroomorseparateoffice).

o Cleanhigh-touchsurfaces(keyboard,mouse,doorhandles,phone,pager,telephone)frequently.o Donotsharefood.o Considercoveringyourhairtoavoidcontamination.o Forphysicianswhoprefertowearhospital-launderedscrubs,changeintoscrubsforshiftandchange

outofscrubsbeforegoinghome.▪ ThescrubmachineandlockerroomareonthesixthfloorofFeinbergPavilionatNMH.▪ Ifyoudonotalreadyhavescrubaccess,gothroughyourdepartment/divisionadministrators.

Personalcellphonedevicesornursingphones● RestrictuseofanypersonalornursingphoneswheninaroomwithapatientwithCOVID-19.● Ifamemberoftheteamneedssomethingwheninapatientroom,knockonthedoortogettheattentionof

anotherclinicianorusetheroomphonetocallthenursingstation.● Ifitisabsolutelynecessarytouseyourphoneinapatientroom,itmustbecleanedwithapurplewipeupon

exitingtheroom(whencleaninggoggles).

SpecialPPEcircumstances● Endotrachealintubation:PPErecommendationsduringairwaymanagementcanbefoundintheAirway

ManagementGuidelineforKnownorSuspectedCOVID-19Patients.● Tracheostomy:Guidelinesasbelow● Cardiacarrest:

o IntheeventofanarrestwhereCPRwillbeprovided,undernocircumstancesshouldCPRbeperformeduntilfullPPEisdonned(includingN95orelastomericrespirator).

o ThenumberofCPRprovidersintheroomshouldbekeptataminimum.Section3:Patient/FamilyEngagementandVisitation,PalliativeCareandEnd-of-LifeCareInpatientVisitorPolicyissubjecttochange;themostup-to-datevisitorpoliciesforeachhospitalcanbefoundhere.

CheckwithunitmanagementformostrecentvisitorguidelinestotheCOVIDpatients,especiallyregardingendoflifecare.

Surrogatedecision-makersandfamilycommunication● Identify(perstandardpractice)HCPOAagentorsurrogatedecision-maker,andreviewexistingadvance

directivesuponICUadmission.● Alwaysensureasecondaryagentisidentifiedintheeventthattheprimarydecision-makerisillorotherwise

unavailable.● Designateasinglecontactpersonperpatientthatwillbeupdateddailybytheteam.Thisindividualshouldbe

defaulttotheHCPOAagentorlegallyappointedsurrogatedecision-makerunlessthereareexceptionalcircumstances.

o Contactperson(s)shouldbeinformedthattheywillbecontactedonceperdayintheafternoonbyamemberofthemedicalteamforanupdate.

● Inthiscontext,attheclinician’sdiscretion,FaceTimeorothervideochatplatformsonapersonaldevicemaybeusedtofacilitatecommunicationbetweenthefamilyandthecareteam.

o Hospital-suppliediPadsareavailabletosupportvideochat.● EstablishpatientpreferencesforCPR(“codestatus”)onICUadmissionandasnecessaryduringICUstay● Asummativefamilymeetingviavideoconference(ortelephoneifnecessary)shouldbeconductedforall

criticallyillpatientswithCOVID-19bythethirddayoftheirICUstayandatleastweeklythereafter.● AllmeetingsshouldbedocumentedinEpicusingtheFamilyMeetingNotesmarttext.Search‘FamilyMeeting

Note’forthetemplate.● RefertothisresourcefromVitalTalkwithCOVID-19-specificcommunicationtips(exactlywhattosayandwhen).

● ForpatientsorfamilieswhodonotspeakEnglish,useofthelanguagelinetranslationservicesandvideotranslationforallcommunicationisrequired.

Cliniciansupportforfamilycommunication● COVID-19communicationfacilitatorswillbeassignedtotheCOVIDICUservicewhenavailabletoserveasa

liaisonbetweentheclinicalteamandfamilymemberstosupporttelephonecommunication.● ChaplainsareavailabletosupporttheICUteams,families,andpatients

o NMHICUteamscancontactchaplainsat312.695.2028(pager);thisnumbercanalsobeprovidedtofamilies.

o Chaplain-familyinteractionswillbedocumentedinEpicprogressnotes● SocialWorkwillsupportfamilies,patientsandclinicians.

o SocialWorkalsohasinstitutedaproactiveprocesstoascertainorcompleteHCPOApaperworkforallPUIandpatientswithCOVID-19onthegeneralfloorsandintheICU,whenpatientsareable.

● ThePsychiatryconsultliaisonteamisavailabletohelpcliniciansmakeaplanforfamiliesexperiencingextremedistress.

Ethicsandallocationofscarceresources● Iftheprimaryteamreachesapointatwhichdecisionsmustbemadeforallocationofresourcesamongtwoor

morepeoplewhocouldbenefit,consulttheNMAllocationDecision-MakingTeamatethics@nm.orgorpager312.921.3343.

● Thisistominimizeconflictsofcommitmentwheneverpossible.Anindependentdecision-makingteamratherthanbedsidecliniciansisanethicallyjustified,establishedpracticeinthecontextofscarceresources,e.g.UNOSandlocaltransplantdecision-makingcommitteesforallocationoforgansfortransplant.

RespiratorysupportinpatientswhoareDNR/DNIandCOVID-19positiveorruleoutCOVID

● Acceptabletousehigh-flownasalcannulawithheatedhumidityifalignedwithpatientpreferencesforlife-sustainingtreatments

Procedureforwithdrawalofmechanicalventilationandatendoflife:

● Seeabovevisitorsectionforexceptionstovisitationpolicy.● Withdrawalofmechanicalventilationnearendoflife(priortodeath):

1. Prepareallnecessarymedicationsforend-of-lifesymptommanagement(typicallyopioidandbenzodiazepineinfusions)andtitrateasnecessaryperstandardpracticeandprotocols.

2. Ifplantoremovefromventilator:▪ Stopallairflow(turnoffmechanicalventilator)priortodisconnectingtheendotrachealtube

fromthecircuit.▪ Disconnecttheendotrachealtubefromthecircuit,butdonotextubatethepatient.▪ Placeafiltercap/holsterovertheendoftheendotrachealtube,whichwillallowthepatientto

breathethroughtheendotrachealtubewhileminimizingaerosolization.▪ Toavoidaerosolization,donotremovetheendotrachealtubefromthepatientuntilafterdeath.

3. Alternateoption(iffamilypresentorifprioritytoreduceaerosolization):▪ setventilatortopresssupportmode,PSof5withPEEPof5;FiO221%▪ Maintainventilatorcircuituntilafterdeath(seebelow)

4. Continuesymptom-directed,end-of-lifecareperstandardpractice,includingdyspneamanagement.

● Afterdeath:1. AtNMcentral,alldeathsinCOVID-19positivepatientsmustbecalledtotheMedicalExaminer(inCook

County:312.666.0200).▪ Recordemployeenameandbadgenumber,anddocumentindeathnote.▪ TheMEwillneedacopyofcertainpartsofthepatient’smedicalrecord.Emailthefollowing

informationtoMedicalRecords(himexpiration@nm.org)andthemedicalrecordswillbesenttotheMEoffice.Thisisavailable24/7.

● Patient:● Floor/Room:● MRN:● DOB:● DOD/TOD:● Autopsyy/n:● MEy/n:● Chartanddocumentstubedto125or908y/n:uponpaperworkreview● DeathCertificatesignedbyphysiciany/n:(nameofphysician)● FuneralHomehasnotbeendesignatedy/n(listnameandcontactphone)

▪ AftertheMEreceivesthepatientmedicalrecordsacasenumberwillbeassigned.2. IfthepatientisanMEcase,followinstructionsperME,whichwilllikelyincludeleavingendotracheal

tubeinplace.3. IfthepatientisNOTanMEcase,removeendotrachealtubewhilewearingappropriatePPE(including

N95respirator)andusethefollowingprecautionstoreduceaerosolization:▪ Ifventilatorisnotalreadydisconnected,turnoffairflow.▪ Clampendotrachealtubebeforedisconnectingitfromtheventilatorcircuit,thencap.▪ Placeaclearplasticbag(e.g.,patientbelongingsbag)overthepatient’sface.

▪ Whenthebagiscoveringthepatient’sface,removetheendotrachealtubeintothebag.▪ Then,removebagfromthepatient’shead,anddisposeofbagandendotrachealtube.

4. FuneralhomeguidelinesareavailablefromtheIllinoisDepartmentofPublicHealth(SocialWorkandHOAcanprovideifneeded).

PalliativeCareconsultation● WhichpatientstoconsiderforPalliativeCareinvolvement

o Expectedpoorprognosis▪ Age>70▪ Significantcomorbidities▪ Poorfunctionalstatuspre-illness▪ Decliningclinicalstatusdespitecontinuedintensivecare

o Familiesstrugglingwithdecisionso Familiesinneedofemotionalsupporto Difficult-to-controlsymptomso Patientswehavefollowedonthefloororasoutpatients

● HowtoConsultPalliativeCareo PagethePalliativeCOVIDteamdirectly(57393)

● IntroducingPalliativeCaretoFamilieso “Havingalovedoneinthehospitalcanbestressfulandanxietyprovoking,especiallywhendiagnosed

withCOVID-19.Ourpalliativecareteamisskillfulathelpingpatientsandfamiliescopewithaseriousmedicalillnesssuchasyouarecurrentlyfacing.Amemberoftheteamwillbereachingouttoyou(and/oryourfamily)togettoknowyouandhowbesttheycansupportyouthroughthishospitalstay.”

● PalliativeCareRoleo Clarifypatientgoalsofcare

▪ Helppatients/familiesidentifygoals/values,weightrade-offsandmaketreatmentdecisions.▪ CollaboratewiththeICUandfamiliestoestablishtime-limitedtrialsofdifferentinterventions.

o Relievephysical,psychological,spiritualandpracticalsufferingusingthePalliativeCareInterdisciplinaryTeam(physician,nurse,chaplain,socialworker)

o Complexsymptommanagemento Spiritualsupporto Emotionalsupporto Practicalsupport(e.g.socialwork)o SupporttheICUTeam

▪ Checkinwiththeteamsasneededinpersonorbyphone.▪ Unburdentheteambyhelpingwithlongerfamilymeetings,defininggoalsandsupporting

families.▪ Providecoachingwheredesiredonhowtodiscussdifficulttopics.▪ JointheICUteamoncallsforfamilymeetingstodiscusshigh-stakesdecisions.▪ DebriefwiththeICUteamafterdifficultconversations/situations.

Section4:MedicallyInappropriateorNon-beneficialTreatmentUnderordinarycircumstances,whenadequateresourcesexisttomeetpatientneed,attendingphysicians,teamsandconsultantsexerciseclinicaljudgmentwithinrecognizedstandardsofcaretorecommendinterventionsalignedthepatient’spreferencesandvalues.Determiningwhichmedicalinterventionswillandwillnotprovidebenefitisintegraltothisprocess.Characteristicsof“non-beneficial”or“medicallyinappropriate”treatment[1]include:

1.Highlyunlikelytoachieveitsstatedgoals;and/or

2.Disproportionatelyburdensomeinhumanandotherresources;and/or

3.Isintendedtoachieveagoalofquestionablerealismorvalue.

Whenuncertaintyarisesregardingpurportednon-beneficialtreatments,localNMhospitalethicsresourcesandpalliativecareteamscanilluminateandclarifymedicaldecision-making.Ontheoccasionsthatthepatient/legalsubstitutedecision-maker(LSDM)doesnotagreewiththecareteamthataninterventionisnon-beneficial,NMhospitalsprovideafairprocesstoallowthepatient/LSDMtobeheardbyathirdparty(suchasanethicsconsultantorcommittee)and/ortorequestatransfertoanotherhealthcareinstitutionforasecondopinion.

UndercircumstancesofimpendingscarcityimposedbytheCOVIDpandemic,patientcareresourcesmustbecarefullystewarded.Healthcareprovidersmustthereforeengageinproactive,shareddecision-makingprocessesthataddressgoalsofcare,especiallyforanypatient(COVID+orotherwise)whoisatriskofdecompensating.Withdrawingandwithholdingoflife-sustainingmedicalinterventions(e.g.,pressors,dialysis,mechanicalventilation,ECMO)areunderstoodasethicallyequivalent.Therefore,suchinterventionsshouldbeofferedwithinawell-plannedandwell-communicatedtime-limitedtrialwithexplicitobjectiveoutcomes.Beginningwithinitialevaluation,thisapproachshouldframeeveryconsiderationofescalatinginterventions.Onlywhentheofferedinterventionachievestheobjectiveoutcomeswillproviderscontinuetreatmentatthislevelofcare.

Shouldapandemicreachastagewhereresourcesareseverelyconstrained,NMleadershipwillinitiateCrisisStandardsofCare(CSC).Then,theethicalframeworkfordecision-makingshiftsfromhonoringpatientautonomytowardaCSCgoalofachievingthemostgoodforthemostpeople.Tonavigatecomplex,uncertaincasesunderCSCorforassistanceinapplyingCSCallocationguidelinestoaspecificpatientorpopulation(e.g.,patientswithadvancedmetastaticcancer),careproviderscancallupontheNMAllocationDecisionMakingTeam(ADMT).TheADMTassistswithdecisionstolimitorwithdrawinterventions,andalsohelpinpreparingforcommunicationwithpatientsandfamiliesimpactedbythesechallengingdecisions.

Decisionsregardingallocationofscarcemedicalresourcesmustbenon-discriminatoryandmaynotbebasedontherace,gender,religion,citizenship,sexualorientation,disabilityunrelatedtomedicaldiagnosis,orsocioeconomicstatusofthepatient,includingthatpatient’sabilitytopay.Suchdecisionsarenottobebasedonjudgmentsaboutapatient'santicipatedqualityoflifeorsocialvalue.

Illustrativeexample

Frailpatientage85presentstoEmergencyDepartmentfromhomewithadvanceddementiaofseveralyears’standing,CHFcomorbidity,withpneumoniaoflikelyCOVID-19etiology.Medicalteamevaluatessuccessasrelativelyunlikely,

resourceuse(ICU)asdisproportionatelyburdensomerelativetobenefit,andsurrogatestatedgoalofreturntoindependentlivingashighlyunrealisticbasedonbothunderlyingdementiaandCHF,andnewonsetpneumonia.PatientismovedtoamedicalunitwithDNRorderandcomfortcare.

[1]BossletGTetal.AnOfficialATS/AACN/ACCP/ESICM/SCCMPolicyStatement:RespondingtoRequestsforPotentiallyInappropriateTreatmentsinIntensiveCareUnits.2015.AmJRespirCritCareMed(191)1318–1330.

IllinoisDepartmentofPublicHealthGuidelinesonEmergencyPreparednessforHospitalsDuringCOVID19,April18,2020

Section5:CardiopulmonaryResuscitationAsperstandardpractice,patientpreferencesandlimitationsonlife-sustainingtreatment(includinglimitationsoncardiopulmonaryresuscitation,“codestatus”)shouldbediscussedwiththepatient/familyonadmissiontotheICUandasnecessarythroughoutICUstay..

CPRshouldbeperformedforcardiacarrestsinCOVID-19infectedindividualsifconsistentwithpatientpreferences/codestatus

● IntheeventofanarrestwhereCPRwillbeprovided,undernocircumstancesshouldCPRbeperformeduntilfullPPEisdonned(includingN95orelastomericrespirator).

● ThenumberofCPRprovidersintheroomshouldbekeptataminimum.● Duringcodestatusdiscussions,patientsandsurrogatesshouldbeinformedthattheseprovidersafetymeasures

(e.g.donningpersonalprotectiveequipment)willcausenecessarydelayintheinitiationofCPRDecisionsregardingwhethertoperformCPRmustbenon-discriminatoryandmaynotbebasedontherace,gender,age,religion,citizenship,sexualorientation,disabilityunrelatedtomedicaldiagnosis,orsocioeconomicstatusofthepatient,includingthatpatient’sabilitytopay.Suchdecisionsarenottobebasedonjudgmentsaboutpatient’santicipatedqualityoflifeorsocialvalue.

Section6:COVID-19Testing/DiagnosticsWhentotest

● ThethresholdtotestnewadmissionstotheICUforSARS-COV-2shouldbeexceptionallylow,eveninpatientswithrecentnegativetests.

● Ingeneral,itisreasonabletotestallnewlycriticallyillpatientswithsignsorsymptomsofsystemicinfectionorrespiratoryfailure(excludingpatientswithknownCOVID-19).

● Apositiverespiratorypathogenpanel(RPP)isNOTadequateforrulingoutthepresenceofaSARS-CoV-2infection(seebelowinthesectionregardingco-infection).

● Alowerrespiratorysample(usuallyBAL)shouldbeconsideredinahigh-suspicionintubatedpatientwithanegativenasopharyngealswab.

Howtotest● OrderinEpic:Searchfor“COVID-19orderpanel”

● Nasopharyngealswabo Propersamplecollectiontechniqueiscriticalforensuringaccurateresults.o Innon-intubatedpatients,anNPswabshouldcausediscomfort.Ifthepatientdoesnotdescribethis,

suspectincorrecttechnique.

● SeeafullNEJMvideohere:youtube.com/watch?v=DVJNWefmHjE● Bronchoalveolarlavage(BAL)

o Thistestrequiresbronchoscopicsamplingoffluidfromthelowerrespiratorytract/lungs.o Considerperformingimmediatelyafterintubationtotakeadvantageofneuromuscularparalysis,or

earlyafterintubationtorulein/outbacterialsuper-infection

Section7:OtherBiomarkersandLab/DiagnosticMonitoring

Note:pleasedouble-bagallspecimens.ICUAdmissionDiagnostics(seesection6forCOVIDtesting):

● Inflammatoryandotherbiomarkers○ CRP○ D-dimer○ ferritin○ troponin○ procalcitonin○ CK○ LDH

● Evaluationoforgandysfunction(andfortherapeuticscandidacy):○ CMPwithmagnesium○ UA○ CBCwithdifferential○ ABG○ Lactate○ DIClabs○ Centralvenousoxygensaturation(ifhemodynamicallyunstableandhascentralaccess)○ Type&Screen

● Co-Infectionevaluation(considereachtestindividuallyifclinicallyindicatedbasedonpre-testprobability):○ Respiratorypathogenpanel○ Urinelegionellaandstrepantigens○ Bloodcultures○ Sputumculture○ If/whenintubated:

■ Respiratoryculture■ Cellcountanddifferential■ Amylase–aspirationinCOVIDpatientmayhavedifferentprognosisthanviralpneumonia■ Lowerrespiratorytractpanel(NAT)(thisisthenameforanewlyavailableBioFirePneumonia

Panel,nowavailablebyEpicorder)-(doesNOTincludeSARS-CoV-2;doesincludeMecAforMRSA)

■ SARS-CoV-2Coronavirus(Covid2019)PCRtest(evenifNPswabispositivetodefinealternatecauseofrespiratoryfailure;particularlyimportantonsubsequentBALsinordertotakepatientoutofisolation)

■ Galactomannan○ Forimmunocompromisedpatientsorotherspecificriskfactors,consider:

▪ Blastomycosis/histoplasmaurinaryantigen▪ SerumB-Dglucanandaspergillusgalactomannan▪ Ifintubated,BALPJPDFA,galactomannan,AFBculture(noteAFBculturerequiresentireresidual

Recommendedseriallabsandfrequencies(considerdecreasingfrequencyifstableorsevereanemia) ● Inflammatory/otherbiomarkers(nomorethanQ48scheduledlabs;canorderasneededbasedonclinical

indications)● CRP● D-dimer● Consider(case-by-case):ferritin,troponin,procalcitonin,CK,LDH

● Evaluationoforgandysfunction(dailyscheduledlabs;canorderasneededbasedonclinicalindications)● ABG● BMPwithmagnesium● CBCwithdifferential● Consider(case-by-case):transaminases,lactate,centralvenousoxygensaturation,DICevaluation

Imaging/cardiology(considerrisksandbenefitsforeachpatient)Uponadmission(orafterintubationandcentrallineplacement),obtainCXR;minimizetheuseofroutinerepeatedchestfilmsasperusualICUguidelines.● LimitedTTE(limitedprotocolforLV/RVfunction,andvalvulardiseasescreening)shouldbeperformedinsteadof

standardTTEorder.● Patientswithseverevalvedisease,prostheticvalvesorothercomprehensivecardiacdiseaserequiringafull

echoshouldbeorderedasa"2DechowithDoppler"inEpic.

Section8:VTEProphylaxisandTransfusionGuidelines

VTEprophylaxis● COVID-19maybeassociatedwithahypercoagulablestate,especiallyinpatientswithmoreseveredisease.As

such,thefollowingVTEprophylaxisrecommendationsproposeamoreaggressiveVTEprophylacticregimen.● Thetreatingteammaydecidetofollowlessaggressivedosingstrategiesbasedonindividualpatientfactors

(hemoglobintrend,bleedingrisk,etc.).● Ingeneral,prophylaxisisrecommendedunlessactivebleedingoraplateletcount<25x109/L.● ForpatientsondirectoralanticoagulantsorwarfarinforAfiborVTE,transitiontofulldoseanticoagulationwith

LMWHorunfractionatedheparinisadvised,basedonrenalfunctionand/orclinicalscenario.

● RenalFunction>30mL/minBMI<40 Enox30mgQ12H*BMI>40 40mgQ12HBMI>50 60mgQ12H

RenalFunction<30mL/min

CrCl15-30mL/min,BMI<40,Age<75 ConsiderEnox30QDorSQH5000TIDbasedoffbleedingrisk

CrCl<30,BMI>40 SQH7500TIDCrCl<15,BMI<40 SQH5000BID/TIDCrCl<15,BMI>40 SQH7500TID**

*PharmDtoconsiderofAXAmonitoringforgoal0.2-0.5w/adjustmentsby10mgBIDasappropriate(lowlevelrec)**PharmDtoconsideraPTTmonitoringtopossiblyupto10,000TIDforLargeBMIs>50-60(lowlevelrec)Transfusionguidelines

● Criticallyillpatientwithoutbleedingo Plateletcount<10x109/Lo Fibrinogen<100mg/dlo Hgb<7

● Ifbleedingispresento Plateletcount<50x109/Lo Fibrinogen<200mg/dlo INR<1.5

● Intheeventofcryoprecipitateshortage,useoffibrinogenconcentratesmaybeadvisedbyhematology/transfusionmedicine

Section9:TreatmentOptionsandClinicalTrials

Drug Recommendation Evidence Monitoring/AdverseEffectsDexamethasone Give(strong

recommendation)RECOVERYtrial:https://www.nejm.org/doi/full/10.1056/NEJMoa2021436-improvesmortalityforthoseneedingoxygenAmongstothers:meta-analysis:https://jamanetwork.com/journals/jama/fullarticle/2770279

HyperglycemiaInfectionDelirium

DetailedRecommendationsontheuseofDexamethasoneforPatientswithCOVID-19Thefollowingarerecommendationsfromamultidisciplinaryworkinggroupwhichmeton6/25/2020withrevisions1/13/21

1. RecommendFORtheuseofdexamethasonewhenthefollowingcriteriaaremeta. PatientswhorequireadmissiontotheintensivecareunitANDb. >7daysfromsymptomonsetANDc. Needforeitherhigh-flownasalcannula,non-invasiveventilation,orinvasivemechanicalventilationforworseninghypoxemiaANDd. Afterprioritizingenrollmentinaclinicaltrial

2. RecommendFORtheuseofcorticosteroidsforpatientswithotherindications(e.g.acuteexacerbationsofobstructivelungdisease).

3. RecommendAGAINSTtheuseofdexamethasoneforpatientswhodonotrequiresupplementaloxygengiventhereportedincreasedmortalitywithsteroidsinthispopulation.4. Recommendthatthedecisiontogivesteroidsforhospitalizedpatientswhorequiresupplementaloxygenoutsideoftheintensivecareunitshouldbeanindividualizedpatient-centereddecision.5. Recommendthatthedecisiontogivesteroidsforhospitalizedpatientsearlyinthecourseoftheirillness(<7daysfromsymptomonset)shouldbeanindividualizedpatient-centereddecision.6. RecommendAGAINSTtheroutineuseofdexamethasone(orothersteroids)forpatientswithARDSof>14daysduration.Steroidscanbeconsideredforpost-infectiousorcryptogenicorganizingpneumoniaorfibroproliferativeARDSinpatientswithworseninglungcompliancethatisnotresponsivetorecruitment

maneuvers.Theseentitiesusuallyhavemeasurableresponsestohigh-dosecorticosteroidswithin72hours.Ifnoresponsetoatherapeutictrialoccursafterthattime,steroidsshouldberapidlytapered.

RecommendedsteroiddosingforCOVID-19-specifictreatment:

- Dexamethasone6mgdailyforupto10days(donotcontinueondischarge)- ForpatientswhorequiresteroidsforbothCOVID-19andanotherindication(e.g.exacerbationsofobstructivelungdisease),recommenddiscussingoptimalagentanddosewithpharmacy.- SteroiddosinganddurationforCOP/fibroproliferationisbeyondthescopeoftheserecommendationsandshouldbedeterminedbythetreatingclinician.

OthertherapeuticconsiderationsforCOVID-19

Drug Evidence Recommendation AdverseEffectsRemdesivir

NEJMACTTtrial(https://www.nejm.org/doi/full/10.1056/NEJMoa2007764)-fasterimprovementofsymptomson8ptscaleWHOSOLIDARITYtrial(https://www.medrxiv.org/content/10.1101/2020.10.15.20209817v1.supplementary-material)-nomortality,ventilation,orLOSbenefitinhospitalizedpatients;trendtowardsharminintubatedpatients

Nostrongevidenceofbenefitincriticallyillpatients;considernotgivingtointubatedpatients(weakrecommendation)

AbnormalLFTsAbnormalINR,PT/PTTReversiblekidneyinjuryNausea,vomiting,diarrheaHeadache

Convalescentplasma Numeroustrials,nicesummarybyFarkas:https://emcrit.org/pulmcrit/convalescent-plasma/PLACIDtrialinBMJ-mayimprovesymptomresolutionPLASMARinNEJM-nodifferenceinoutcomesINFANT-COVIDinNEJM-given<72hrsuponsymptomonsettoolderadults,lessdeteriorationRECOVERY-stoppedearlyforfutility,awaitingfulldata

Dataarestillunclear;norecommendationtogiveinthosealreadycriticallyill.Mayconsiderforthoseearlyincourse<3dofsymptomonset

Bloodproductioninfectionreactions,complications

Tocilizumab Numeroustrials,nicelysummarizedbyJoshFarkashere:https://emcrit.org/pulmcrit/tocilizumab/BACCinNEJM-nosignificantdifferenceCOVACTAtrial-nodifferenceinclinicalstatusby28daysCORIMUNOinJAMA-trendtowardslessrespiratorysupportEMPACTAinNEJM-trendtowardslessintubationREMAP-CAP(preprint)-withhighdose8mg/kg,decreasedmortality,moredaysfreeoforgansupportwhengivenearlytocriticallyillpatients

Conflictingdata;noclearrecommendationtogive(ifgiving,wouldgiveearly<24hrsofinitiatingorgansupportandonlyinthosewithhighlyelevatedCRP)

GIperforation*Contrarytoearlyconcerns,datahavereassuringlyshownthattocilizumabarmshavefewerinfections,althoughbluntedinflammationmaydecreasethelikelihoodthatclinicianstestedforinfection

Baricitinib(JAKinhibitor) ACTT-2trialinNEJM-https://www.nejm.org/doi/10.1056/NE

Noclearrecommendationtogive

JMoa2031994-mayimprovesymptomsonordinalscorewhengivenwithremdesivirtothoseonHFNC/NIPPV,butnobenefittothosealreadyintubated;alsouncleargivenmostpatientsintrialdidnotreceivedexamethasone

(ifgiving,wouldonlyuseinHFNC/NIPPVpatients)

Non-targetedtherapy:EmpiricAntibiotics Empirictherapywith

ceftriaxone/azithromycin(CAPcoverage)Considerdiscontinuationofantibioticsifthereisnoevidenceofbacterialsuperinfectiononbronchoscopy.Considernarrowingofantibioticsinpatientswithanidentifiedco-infectionfromanalysisofBALfluid.ClinicaldecisionsaboutantibioticsshouldnotbebasedontheresultsofendotrachealaspiratesConsiderHAPcoverageonlyifpatientotherwisemeetsHAPcriteria

Standardguidelinesfortreatmentofcommunity-acquiredorhospital-acquiredpneumoniaapply.OurlocalexperiencesuggestsantibioticscanbesafelydiscontinuedormodifiedbasedontheresultsoftheBioFirePneumoniaPanel(‘Lowerrespiratorytractpanel’inEpic)andquantitativecultureofBALfluid.

IncreasedresistanceC.diff

ACEInhibitorsandARBs ACEiinvitromayupregulateexpressionofACE2receptorNoclinicalorexperimentaldatasuggestinguseofACEi/ARBaffectsoutcomesinCOVID-19

WedonotrecommendinitiationorcessationofACEinhibitorsorARBstotreatCOVID-19.Mayadjustuseforotherindication,i.e.AKI,hypotension

Notrecommended:

Drug EvidencetoDate RecommendationBamlanivimab ACTIV-3inNEJM-nobenefitin

hospitalizedpatientshttps://www.nejm.org/doi/full/10.1056/NEJMoa2033130

DonotrecommendinpatientshospitalizedwithCOVID-19

Hydroxychloroquine

Numerousstudiesshowingnobenefit-RECOVERYhttps://www.nejm.org/doi/full/10.1056/NEJMoa2022926

Donotrecommend

Lopinavir-ritonavir NobenefitinRECOVERYtrial-https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32013-4/fulltext

Donotrecommend

ActiveCOVID-19clinicaltrialsatNMH

Seehttps://www.feinberg.northwestern.edu/sites/covid-19/covid-19-clinical-trials.html

Toaddatrialtothewebsite,contactAbbyCosentino-Boehm<a-cosentino-boehm@northwestern.edu>.

CanreachouttotheMICUResearchteampager59285(orsearch‘Study’intheWebPagingSite)

Section10:High-FlowNasalCannula,Non-invasiveVentilationandAirwayClearanceTherapies

Generalrecommendations

● Bronchodilatorso Bronchodilatorsmaybeadministeredwhenclinicallyindicatedviaeithermetereddoseinhaler(MDI)

withaspacerornebulizer.▪ UseofnebulizedtherapyrequiresprovidersintheroomtowearanN95maskorelastomeric

respirator.

● High-flownasalcannula(HFNC)andNon-invasiveventilation(NIV)o BothHFNCandNIVareacceptableforuseinpatientswithCOVID-19althoughN95maskorelastomeric

respiratoryarerequiredforanystaffenteringaroomwithapatientusingthesedevices(COVIDconfirmedornot).

o HFNCistypicallypreferredforoxygenationsupportinacutehypoxemicrespiratoryfailureo NIV(withfilteredexhalationporttominimizeaerosolgeneration)shouldbeconsideredparticularlyin

patientsinwhomNIVisknowntohavebenefit(e.g.,exacerbationsofchronicobstructivepulmonarydiseaseorcongestiveheartfailure).

● IndicationsforInvasiveMechanicalVentilation(IMV)o StandardindicationsforIMVapplytopatientswithCOVID-19o ForpatientswithpotentialorimpendingneedforIMV,contactanesthesia/clinicianperforming

intubationearlytoallowforadditionaltimeforpreparation(PPE,etc.)

● Airwayclearanceformechanicallyventilatedpatientso Patientsfrequentlydevelopthicksecretionsafter5daysofinvasivemechanicalventilation.o Airwayclearancewithavest,sportbedorhandheldpercussivedeviceisrecommendedtoaidsecretion

clearance.Useofmetanebforairwayclearanceiscurrentlybeingstudiedandisreservedforresearchpurposesonlyatthistime.

● Post-extubationo FavorHFNCwithheatedhumidityforimmediatepost-extubationoxygensupplementation.o Acceptabletotrialnoninvasiveventilation(NIV)withafullfacemaskandafilteredexhalationportin

selectcaseswhereNIVmaybeparticularlyefficacious(e.g.,chronicobstructivepulmonarydisease).

● Forpatientswithatracheostomy:o Trachcollarwithin-linesuctionorfilteredheatmoistureexchangercanbeused.o Avoidopensuctioningifpossibleuntilthepatienthasdocumentedclearanceofdetectablevirusunless

emergentlyrequired.ApproachtopatientswhorequirechronicNIV

● Scopeanduniquepatientcharacteristics:

o ChronicNIVreferstothelong-termuseofdevicesthatusemodesincluding,butnotlimitedto,CPAP,BiPAP,BPAP,AVAPSandPC.

o UnlikepatientswhouseCPAPforobstructivesleepapnea(OSA),patientswhorequirechronicNIVuseNIVasalifesupportdevice.ItisNOTsafetowithholdNIVinthesepatients.

o ExamplesofpatientsusingNIVforchroniclifesupportincludethosewithneuromusculardisorders,kyphoscoliosisandchronichypercapnicrespiratoryfailure.

o Thesepatientsareathighriskofclinicaldeteriorationwithinfection,regardlessoftheirbaselinepulmonaryfunction.

o TherehavebeendocumenteddeathswhenthesepatientsaregivensupplementaloxygenvianasalcannularatherthanNIV,asthisapproachmaskstheriskofCO2retentioninthisvulnerablepopulation.

● RecommendationsforwhenapatientwhorequireschronicNIVpresentstotheEDorhospital:

o ConfirmifapatientisonCPAPforOSAorinfactuseNIVforchronicrespiratoryfailure.o PatientsonchronicNIVshouldbeplacedinanegativepressureroomandcontinuedontheirhomeNIV

machinependingclinicalassessment.o PatientswithchronicrespiratoryfailureonNIVshouldbetestedforCOVID-19rapidlyifanycompatible

symptomsarepresentandiftheyareexpectedtostayinthehospital.o ThePulmonaryConsultserviceshouldbeconsultedformanagement,inparticulartoevaluateifNIV

shouldbecontinuedpendingCOVIDtesting.

Section11:Peri-intubationManagement

Endotrachealintubation

● ReviewtheIntubationandAirwayManagementGuidelinesforknownorsuspectedpatientswithCOVID-19.● Anabbreviatedsummaryofthisguidelineisprovidedbelow:

o LimitthenumberofHCPsintheroomwherethepatientistobeintubated.▪ Recommendation:Twoanesthesiaprovidersintheroomwithanadditionalprovider(runner)

outsidetheroom.Theventilatorcanbesetupbytherespiratorytherapistpriortointubation(ifnotanemergency)orafterintubation.

o Themostexperiencedanesthetistavailableshouldperformintubation,ifpossible.o Standardmonitoring,IVaccess,instruments,drugs,ventilatorandsuctionshouldbecheckedpriorto

theprocedure.Donotbringtheanesthesiologyairwayemergencysupplybagorrespiratorytherapyairwayemergencysupplybagintothepatient’sroom.

o Avoidallawakeintubationsunlessspecificallyindicated.o Rapidsequenceintubation(RSI)shouldbeperformedinallcasesandventilationafterinductionof

anesthesiaavoided.o Give5minutesofpreoxygenationwithoxygen100%andperformRSIinordertoavoidmanual

ventilationofpatient'slungsandpotentialaerosolizationofvirusfromtheairways.o Ensurethatahigh-efficiencyhydrophobicfilter(i.e.,viralfilter)isinterposedbetweenthefacemaskand

thebreathingcircuit,orbetweenfacemaskandmanualresuscitationbag.Theviralfiltershouldbeplacedasclosetothepatientaspossible(i.e.,immediatelydistaltotheETT).

o Ifapatientwasbeingpre-oxygenatedwithBIPAPorHFNC,flowsshouldbeturnedoffimmediatelyafterthepatientisasleepandparalyzedandbeforelaryngoscopy.

o Intubateandconfirmthecorrectpositionofthetrachealtube.Useofvideolaryngoscopeprovidesdistancebetweenproviderandpatient’smouthaswellasminimizationofintubationattempts.ThecolorimetriccapnometerusedtoconfirmETTpositionshouldbeplacedbetweentheviralfilterandthemanualresuscitationbag.Usethepatient’sin-roomdisposablestethoscopetoauscultatebilaterallungfields.

o Institutemechanicalventilationandstabilizethepatient.EnsureoxygenflowstoambubagarediscontinuedandETTclampedpriortodisconnectingAmbagandattachingpatienttoventilatorcircuit.

o Anydisconnectionofthepatientfromtheventilatorcircuit(i.e.,placementofin-linesuctiondevice)mustbeprecededbyclampingtheETTpriortocircuitdisconnection.AviralfiltershouldalwaysbeplacedbetweentheETTandthemanualresuscitationbagwhenthemanualresuscitationbagisused.

o Allreusableairwayequipmentmustbedecontaminatedanddisinfectedaccordingtoappropriatehospitalpolicies.

Section12:GeneralVentilatorManagementandExtracorporealSupport

PresentationonmanagementofCOVID-19patients:ZoomConference:https://northwestern.zoom.us/rec/share/wG-eRoxJF2AWkbMPp_zPcBhzhlDSuTTK6Xw6XqCqyzWJcaQIZ09IAE1Z1tLDxYkj.UT0jeKbfrnTQDLVR+slides:https://northwestern.box.com/s/4dqzbvhbofq5696lk6mp7jlw0jxv1guz

BasicPrinciples:

● PatientswithCOVID-19whorequireinvasivemechanicalventilationshouldreceiveevidence-basedstrategiesforARDS.

● TheARDSnetPocketcard(http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf)canbeprintedoutandusedasareminderforventilatortitrationandphysiologictargets.

● Lung-protectiveventilation○ Low-tidal-volumeventilation

■ StartingVtof8mL/kgPREDICTEDBODYWEIGHTwithagoalof6mL/kgPBW■ TheVtisloweredstep-wisein1mL/kgintervalsuntil6mL/kgisreached.Therespiratoryrateis

typicallyraisedconcurrentwiththisstep-wiseloweringofVttoavoidsevereacidemia○ Lowdistendingpressures

■ Goalplateaupressure(Pplt)<30cmH2O(Ppltismeasuredduringaninspiratoryholdmaneuver)■ APplt>30cmH2OshouldpromptloweringofVtin1mL/kgintervalsuntilaPplt<30cmH2Ois

achieved.● AdequatePEEP

○ Ingeneral,patientswithCOVID-19-associatedARDSrequiresignificantlevelsofPEEPtomaintainalveolarrecruitment

○ ThePEEPtablefromthePROSEVAtrial(below)isareasonablestartingpointforsettingPEEP.○ UseofanesophagealballoontoguidePEEPtitrationshouldbeconsideredforpatientswithrefractory

hypoxemiaorclinicalsuspicionofelevatedintrapleuralpressure(obesity,ascites,pleuralspacedisease,etc.

● Earlyuseofpronepositioning

○ Seebelowfordetails● Neuromuscularblockade

○ NMBagentsshouldbeconsideredfor:■ refractoryhypoxemiadespitetheaboveinterventionsand/or■ significantpatientventilatordyssynchronydespitedeepsedation

(https://link.springer.com/article/10.1007/s00134-020-06227-8).○ IntermittentNMBshouldbeconsideredpriortocontinuousinfusion○ NMBisNOTarequirementforpronepositioning

Section13:PronePositioning

NorthwesternMemorialHospital’sapprovedprotocolfortheuseofpronepositioninginacuterespiratorydistresssyndromecanbefoundhere.

Highlights:

● ProningisoneofthefewtechniquesinARDSthatimprovesoutcomes● ConsiderproningwhenPaO2:FiO2<150● Considerproningasearlyaspossibleindiseasecourse● SedatepatienttoRASS-5(noresponsetoverbalorphysicalstimuli);thepatientmaystillexhibitreflexessuchas

cough/gag,theydoNOTneedtobeparalyzedpriortoproning(unlessotherwiseindicated)● Mobilizeteam(detailsinprotocol)● Generalgoalis16hoursinpronepositionoutofevery24hourperiod

Section14:RespiratoryECMOServiceStructurePurpose

● AswemovetoestablishVVECMOasaproceduretosupportpatientswithCOVID-19inducedrespiratoryfailureinourMedicalIntensiveCareUnits,itisimportantthatweestablishclearguidelinesforservicelineresponsibilities.ThisisanalogoustoothersupportivecareservicesintheMedicalICUthatrequireservice-specificexpertiseformanagement(e.g.,hemodialysisandplasmapheresis).

Multidisciplinaryrounds

● TeammembersfromPulmonaryandCriticalCareMedicine(PCCM)includingPCCMattendingandThoracicSurgeryalongwiththebedsideECMOspecialistshouldideallyroundtogetherdailyintheCOVID-ICUat7:30AMonallcannulatedpatients.

● ThegoaloftheseroundsshouldbetocollaborativelydiscussspecificcomponentsofICUmanagementincludingbutnotlimitedto

o ECMOsupporto Mechanicalventilationo Needforandtimingoftracheostomyo Analgesia/sedationo Anticoagulationo Mobilization

Service-specificresponsibilities

● PulmonaryCriticalCareServiceo Managementofallorders

● ThoracicSurgeryo Timingandneedforoxygenatorexchangeso ECMOcannulamanagementincludingcannularepositioningandmanagementofaccesssitebleedingo Collaborativeinteractionstomanageanticoagulationo TheThoracicSurgeryServicenotewilldocumentplansforthesecomponentsofcareonadailybasiso TheThoracicSurgeryServicewillprovide24-hourcallcoveragetotroubleshootissueswithECMOorto

makeurgentchangestoECMOsettings.

Section15:SedationManagementActiveandTransitionalPhaseCOVID-19SedationGuidanceFigure

ProtocolIntroduction

● ThisguidanceappliestotheuniquescenarioofsedationincriticallyillCOVID-19patients.Thisguidanceshouldnotbeextrapolatedtootherpopulationswherestandardsedationprotocolsandordersetsshouldbeused.

● COVID-19ICUillnessisdividedintothreephasestoguidesedationmanagement:active,transition,andconvalescent.Featuresofthesephasesareprovidedbelow

● Agentsarelistedinthepreferredorderofescalationduringtheactivephase.● Activephaseadditionsareintendedtobestepwiseandsynergistic.Earlieragentsshouldbecontinued,ordose

adjusted,iftheirtoxicitiesarenotadequatelytolerated.● DuringthetransitionphaseofCOVID-19ICUillness,adjunctiveagentsareaddedinpreparationforweaningof

anestheticagentsduringtheconvalescentphaseofCOVID-19ICUillness.● ThesedationgoalforearlycriticalcaretherapyisRASS0to-2.RASS-2to-4mayberequiredinselectpatients

atincreasedriskforself-extubationorventilatordyssynchrony.Deepersedationgoals(RASS-4to-5)are

requiredforneuromuscularblockadeandmayberequiredduringselectprocedurestoreducetheextentofaerosolizationofsecretions(suchasbronchoscopy,proning,lineplacements,tracheostomy,transitiontotransportventilators).

● GuidanceforneurocriticalcareconsultationisprovidedinSection16ofthisguidelines● Considerpsychiatryconsultationforthosewithunderlyingsubstanceabusedisorder,psychiatrichistoryon

homemedications,orpersistentdeliriumduringthetransitionandconvalescentphases.

COVIDICUDiseasePhases

● Phase1–ActiveICUphaseo Characterizedby

▪ Fever,oftenhighandpersistent▪ RisinginflammatorymarkersincludingD-dimer,CRP,ferritin,CK▪ Acuteagitation▪ Worseningoxygenation-highlevelsofPEEPareneeded▪ Developmentofotherorgansysteminvolvementincludingshock,acutekidneyinjury,

transaminitis,cardiomyopathyandhypercoagulablestateso Duringthisphase,sedationrequirementsmaybehightocombatagitationandtoallowforpatient

ventilatorsynchronywhichmayrequireparalysis,proneventilation,andbronchoscopy.

● Phase2–TransitionICUphaseo Characterizedby

▪ Improvingfevers▪ Resolvingshock▪ Inflammatorymarkersstabilizeandmaytrenddown▪ ImprovingCPKlevels▪ ImprovingLFTs▪ Mayseeimprovementinothernon-pulmonaryorganfunctionaswellalthoughestablished

organfailureswilltakelongertoresolve.o Duringthisphase,starttopreparetobackdownonhighdosesedationbyconsideringadditionof

adjunctiveagentstofacilitateweaningofanestheticsedatives.Theclinicianmustmakepreparationsforaggressiveweansduringtheconvalescentphase

● Phase3–ConvalescentICUphaseo Characterizedby

▪ Ventilatorsettingsthathavebeen/arebeingweanedbackandpatientsarereadytostartspontaneousbreathingtrialsonceotherICUissueshavebeenaddressed

▪ Inflammatorymarkersdeclining▪ Fevershaveresolved

o DeliriumandagitationarelikelytobeduetodrugsandICUinterventionsthoughselectgroupsmayhaveCOVID-19CNSinvolvementorinflammatoryCNSconditionscontributingtoagitationandencephalopathy.Agitationmaybemultifactorial.

o Ifsedationhasnotbeensuccessfullyweanedbynow,otherstrategies,includingpsychiatryandneurocriticalcareconsultation,areneeded.

AgentInitiationandTitrationRecommendations

● ActivePhase-PhaseI1. Propofol

▪ Propofolinfusion:initiateatarateof10mcg/kg/minandincreaseq2minprnby5-10mcg/kg/mintogoalRASS.

● Maximuminfusionrateof65mcg/kg/min.Notifyproviderifthepatientisnotatgoaldespitemaximuminfusionrate.

● Underphysiciansupervision,higherinfusionratesmaybeusedtemporarilyduringbedsideprocedures.

● Withinfusionsof40-65mcg/kg/min,propofolinfusionsyndromemonitoringlabsshouldbeinitiatedandmonitoredq24hours.Monitoringlabsinclude:ABG/VBG,lactate,CK,creatinine,LFTs,triglycerides,serumpotassium.

● Increasingvasopressorrequirementsshouldtriggerthecliniciantoconsiderthepossibilityofpropofolinfusionsyndromeorpossiblesepsisandnotbeattributedtosedation-mediatedhypotensionalone.

● Vasopressorsupportmayberequiredwithhigherdosesofpropofol.Analternativesedationstrategyshouldbeconsideredifmorethanonevasopressorneedstobeaddedinordertotoleratepropofoldosing.

▪ Considerstartingfentanylinfusion(25-50mcg/hr)concurrentwithpropofolwhenpropofoldoseexceeds20mcg/kg/min.

● Hourlybolusdosesoffentanyl(25-50mcg)asneededmaybeusedratherthaninfusionsfortheelderly(≥70yearsold),thoselethargicatthetimeofintubation,orthoseinwhompropofol20mcg/kg/minorlessprovidessufficientsedationbutintermittentpaincontrolisneeded.

● Needforfrequenthourlybolusesshouldtriggerconversiontoinfusioninordertominimizenurseentrytotheroom.

▪ Plantotransitionoffof(ordosereduce)propofoltoanalternativeagentwhenserumtriglyceridesexceed500mg/dL

▪ Iftheclinicianbelievespainisthepredominantcauseofagitation,thenastrategyofopioidinitiationbeforepropofolmaybeconsidered.

2. Fentanylandhydromorphone(morphineifsupplyshortagesoccur)▪ Fentanylinfusionshouldbeattemptedpriortohydromorphoneinfusion▪ AbowelregimenshouldbeinitiatedwhenIVopioidsareinitiatedforanalgesiaandsedation.

SeeSection15▪ Fentanylinfusion:infusionraterangesfrom25-150mcg/hr.Titratefentanylinfusionby25-

50mcg/hrq15minutes.Eachinfusionrateincreaseshouldbeaccompaniedbyabolusdoseof25-50mcg.

● Fortheelderly(≥70yearsold),fentanylbolusesmaybetrialedpriortoinfusionfentanyl.Provide25-100mcgIVpushq15minPRNCPOT≥3.Increaseeachpushby25mcgifrepeatedpushesareneededforbreakthroughpainorsedationcontrol.

● Ifthepatientrequireshourlyboluses,thenconverttoinfusioninordertominimizenursingentryintotheroom.

● Forpatientswithpre-morbidopiateexposure,fentanylupto300mcg/hr(orhydromorphoneover5mg/hr)mayberequired.

● Serotonintoxicityshouldberoutinelyassessedforbytheclinicalteamwhenfentanylinfusionsexceed150mcg/hr,particularlyinthoseexposedtomultipleserotonergic

agents(suchasSSRIs,SNRI,Triptans,MAOIs,anti-emetics,linezolid).Nursingstaffshouldinformthephysicianteamwhenfentanyldoseexceeds150mcg/hr.Developmentofmyoclonus,stereotypedmovements,orrigidityshouldtriggerconsiderationforholdingfentanylwhileseekingneurocriticalcareconsultation.Serotonintoxicitycanmanifestasworseningagitationdespiteescalatingfentanyldoses.

● Patientsdevelopingsignsofserotonintoxicityshouldbeconvertedfromfentanyltohydromorphoneifcontinuedopioidtherapyisneeded.Ifopioidtherapyinexcessoffentanyl300mcg/hrisindicated,thenconversiontohydromorphonecanbediscussedinconsultationwithpharmacy.Fentanyltohydromorphoneis100mcgfentanylIV=1mghydromorphoneIV.

▪ Hydromorphoneinfusion:Standardinfusionrangesfrom0.5-5mg/hr.Titratehydromorphoneinfusionby0.5mgq15minutes.Eachinfusionrateincreaseshouldbeaccompaniedbyabolusdoseof0.5mg.

▪ Morphineinfusion:Morphineinfusionmaybeusedinthecaseofsupplychainshortagesaffectingfentanylandhydromorphone.Infusionrangesfrom1-10mg/hr.TitrateIVinfusionby1mg/hrq30minuteswithabolusof2-4mgIVpush.Additionalintermittentbolusesofmorphinemaybegivenas2-4mgIVpushq1Hasneeded.

3. Haloperidol,quetiapineorolanzapine(listedinpreferentialorder)▪ Notethatantipsychoticswillbemosteffectiveforagitationratherthanprovidingsedation.If

theprimaryneedissedation,thenmovetoitem4.▪ Scheduleddosingispreferredoverasneededdosingtoavoidadditionalneedfornursingto

entertheroom.▪ Haloperidol:2-5mgPO/IM/IVq6-8hscheduledwithadditional2-5mgprnonceforamaximum

dailydoseof20mg.▪ Quetiapine:100mgPO/PertubeBID.Titratedailyby25-50mg/daytoamaximumof400mg

PO/pertubedividedBID▪ Olanzapine:5-10mgPO/IM/SLdaily-BID.Titratetoamaximumdailydoseof20mgdaily

(alternativetoquetiapine).▪ AvoidtheseagentsifthepatienthasevidenceofCOVID-19associatedcardiomyopathy,

arrhythmia,orQTcprolongation.Rhythmstripassessmentisrecommendedafterinitiationanddoseescalation.

▪ DivideddosingislesslikelytoprolongQTc.QTcshouldbecheckedbyrhythmstripafterinitiationandtitration.

4. Low-dosemidazolam▪ Midazolaminfusion:Raterangesfrom5-25mg/hr,shouldbetitratedevery30minutesby

incrementsof5mg/hrwitha5mgbolus.● Vasopressorsupportmayberequiredwithhigherdosesofmidazolam.Analternative

sedationstrategyshouldbeconsideredifmorethanonevasopressorneedstobeaddedinordertotoleratemidazolamdosing.Additionalwork-upofhypotensionshouldbepursuedwhenevervasopressorrequirementschangesignificantlyafterremainingonstabledoseofmidazolaminfusionfor24hrs.

5. Lorazepam(asanalternativetomidazolamifmidazolamsuppliesaredepleted)▪ Duetotheriskoftoxicityfromthepropyleneglycoldiluent,midazolamisthepreferred

benzodiazepinesedativewhenavailable.

▪ Lorazepaminfusion:infusionraterangesfrom2-10mg.Lorazepamshouldbetitratedevery30minutesbyincrementsof2mg/hrwitha2mgbolus.

● Lorazepamdoseshouldnotexceed10mg/hrandtheclinicianshouldbeginmonitoringforpropyleneglycoltoxicity(aniongapmetabolicacidosis)atdosesexceeding6mg/hr,particularlywhenpatientsarereceivingotherIVformulationswithpropyleneglycol(phenobarbitalandphenytoinIV).

● Bioequivalentdosesofdiazepammaybeusedasanalternativetolorazepamwhenmidazolamorlorazepamsuppliesaredepleted.5mgdiazepam=1mglorazepamIV

6. Low-dose(benzo-opioidsynergistic)ketamine▪ Ketamineinfusion:raterangesfrom2.5-5mcg/kg/min,titrateafter30minutesifneededby

providinga0.2-0.5mg/kgbolusandincreasingtherateby2.5mcg/kg/min.● Agitationcanoccurwithemergencefromketamine,particularlyathigherandmore

prolongeddoses.Thereportedincidencevariesfrom0-30%withmostcasesbeingmild.Pre-medicationwithbenzodiazepinesreducestheincidenceofemergencereactionsandbenzodiazepinescanbeusedtotreatemergencereactions.

7. High-dosemidazolam▪ Midazolamtitration:1mg/kg/hridealbodyweight,titrateevery15-30minutesbyprovidinga

10mgbolusandincreasingtheinfusionby10mg.● Intheelderly(≥70yearsold),slowertitration(5mgbolusevery15-30minutesand

increaseinfusionby5mg)to0.75-1.0mg/kg/hridealbodyweightmaybeusedinanattempttominimizebenzodiazepineexposure.

● Anticipatetheneedforvasopressorsupportatdosesapproaching80mg/hr.Analternativesedationstrategyshouldbeconsideredifmorethanonevasopressorneedstobeaddedinordertotoleratemidazolamdosing.

● Dosesofversedupto3mg/kg/hridealbodyweighthavebeenreportedforsustainedusebutshouldonlybepursuedafterconsultationwithpharmacologyandneurocriticalcare.

8. High-doseketamine▪ Ketamineinfusion:Raterangesfrom5-30mcg/kg/min,titrateevery30minutesbyprovidinga

0.2-0.5mg/kgbolusandincreasingtherateby2.5-5mcg/kg/min● Consultneurocriticalcareifinfusiondoseexceeds30mcg/kg/min● Sustaineddosesupto160mcg/kg/minhavebeentoleratedintheliterature● Agitationcanoccurwithemergencefromketamine,particularlyathigherandmore

prolongeddoses.Thereportedincidencevarieswidelyfrom0-30%withmostcasesbeingmild.Pre-medicationwithbenzodiazepinesreducestheincidenceofemergencereactionsandbenzodiazepinescanbeusedtotreatemergencereactions.

9. Phenobarbital▪ Duetosignificantmorbiditywhenusedincriticallyillpatientsatriskformulti-systemorgan

failure,phenobarbitalforsedationshouldbelastlineintheactivephaseofCOVIDillnessafterotherapproacheshavebeenexhausted.

▪ Phenobarbitalloading:Initiatewithaloadof10mg/kggivennofasterthan60mg/mintoavoidhypotension

▪ Phenobarbitalmaintenance:doseof1-2mg/kg/daydividedtwicedailybyIVorenterally▪ Phenobarbitalbreakthroughagitationdosing:65-130mgIVpushq1-2hoursprn

● Routine,serialdruglevelmonitoringmaynotbenecessarybutmaybeclinicallyusefulincasesofincreasedmetabolism.Considerinitiallytargetingtroughlevelsof10-15mcg/mLforagitationcontrolifotheragentsarealsobeingused.Troughlevelsofphenobarbitalshouldonlyexceed25mcg/mLwithcautionashigh-dosephenobarbitalmayproduceprolongedover-sedation,ileus,andcardiogenic/vasodilatoryshock,contributingtoprolongedICUstay.

● UsecautionandtargetlowerdosesifthepatienthasevidenceofCOVID-19associatedcardiomyopathy

● TransitionPhase-PhaseIIAdjunctiveagentsshouldbeaddedinthisphasetofacilitatesedativewean.Initially,startwithoneadjunctiveagentwhilebeginningaslowsedativewean.Addadditionalagentsasneededtofurtherfacilitatesedativewean.Ofnote,COVID-19patientsmaynottolerateacutespontaneousawakeningtrials.Adjunctsarelistedinorderofpreference.

1. Haloperidol,quetiapine,orolanzapine▪ Theseagentsarerecommendedifnotalreadyutilizedinphase1▪ Scheduledquetiapine,olanzapine,orhaloperidolmaybeinitiated.Scheduleddosingis

preferredtoavoidadditionalneedfornursingtoentertheroom.▪ Haloperidol:2-5mgPO/IM/IVq6-8hscheduledwithadditional2-5mgprnonceforamaximum

dailydoseof20mg.▪ Quetiapine:100mgPO/PertubeBID.Titratedailyby25-50mg/daytoamaximumof400mg

PO/pertubedividedBID▪ Olanzapine:5-10mgPO/IM/SLdaily-BID.Titratetoamaximumdailydoseof20mgdaily

(alternativetoquetiapine).▪ AvoidtheseagentsifthepatienthasevidenceofCOVID-19associatedcardiomyopathy,

arrhythmia,orQTcprolongation.Rhythmstripassessmentisrecommendedafterinitiationanddoseescalation.

▪ DivideddosingislesslikelytoprolongQTc.QTcshouldbecheckedbyrhythmstripafterinitiationandtitration

2. Dexmedetomidine,clonidine,orguanfacine▪ Dexmedetomidinecanbeinitiatedifthepatientisnotbradycardicorhypotensive.Clonidinecan

beinitiatedifthepatientisnothypotensive(bradycardiacanoccurwithclonidinebuttendstobemilderthanwithdexmedetomidine)

▪ Dexmedetomidineinfusion:Raterangesfrom0.2-1.5mcg/kg/hr,titrateby0.1mcg/kg/hrq30mintomaintainRASS0to-2whileweaningothersedativeagents.

▪ Clonidine:Initiatedas0.1mgTIDpertubeandtitratedq8Hupto0.3mgTID.Clonidinepatchesshouldbeavoidedwhilethepatientiscriticallyillandintheobese,wherepharmacokineticsmaybeunpredictable.

▪ Guanfacine:Asimmediaterelease1mgtwicedaily.Maytitratetomaximum4mgperday.● Considerguanfacineifthepatienthasbeenunabletotolerateclonidineor

dexmedetomidine.Guanfacinehascentralalpha-2agonistpropertieswithpotentiallylesstendencytowardsbradycardiaorhypotension.

▪ Useofbothdexmedetomidineandclonidine/guanfacineisnotrecommendedunlessclonidine/guanfacineisbeingusedtoweanthepatientoffdexmedetomidine.

3. Propofol

▪ Iftriglycerideshaveimproved(<400mg/dL)thenpropofolmaybere-introducedtofacilitatesedativeweaning.Propofolmayhaveparticularbenefitsinfacilitatingweanfrombenzodiazepinesandbarbituratesandmaybepreferredoverdexmedetomidineorclonidineifhighdosesofbenzodiazepinesorbarbiturateshavebeenused.

▪ Propofolinfusion:Initiateatarateof10mcg/kg/minandincreaseq2minprnby5-10mcg/kg/mintogoalRASS.

● Maximuminfusionrateof65mcg/kg/min.4. Valproicacid

▪ Avoidthisagentifthepatientisknowntobehyperammonemic,significantlythrombocytopenic,hassevereliverinjuryorpancreatitis,orhassignificanthypertriglyceridemia.Valproicacidcanbeinitiatedifthepatientisonpropofolprovidedtheyhavenotdemonstratedsignificanthypertriglyceridemiafrompropofol.

▪ ValproicAcidLoadingdose:20-30mg/kgtotalbodyweightover1hourforagitation▪ ValproicAcidMaintenancedose:500-750mgevery6hours.Highermaintenancedosesmaybe

neededforpatientswithincreasedmetabolism.▪ Concurrentlywithvalproicacidinitiation,loadlevocarnitine50mg/kgIVonceandstart

maintenancelevocarnitine990mgPOevery8hours.Inaddition,startthiamine500mgIVPBevery8hoursforthreedaysandthencontinue100mgPOorIVdailywhilecriticallyill.Monitordailyammonialevels.Ammonialevelsupto100aretolerableinmostpatients.

▪ DrugLevels:Routinemonitoringmaynotbenecessary.Considertitratingtoclinicaleffectandmaintainingtroughlevelsbelow100mcg/mL.Freedruglevelsmaybeelevateddisproportionatelyifserumalbumenislow,whichmaycontributetodrugtoxicity.

▪ Valproicacidshouldbeusedasashort-termtherapytofacilitatesedativewean.ConsiderdiscontinuationifINRincreasesabove1.7orAST/ALTexceed5timestheupperlimitofnormal.

5. Trazadone▪ Trazodonemaybeinitiatedifpatientsappeartohave“sundowning.”Dosesshouldstartat

50mgqHSandcanbeincreasedto150mgqHS.Trazodonemayfacilitateentrainmentofthecircadianrhythmbutcanalsobeusedas50mgq8Hprnforagitation.Trazodoneshouldbeavoidedinpatientsonmultipleserotonergicagentsduetotheriskofserotoninsyndrome.

6. Gabapentin▪ Gabapentin:600mgevery8hourstitratedtomaximumof900mgevery6hours.Dose

adjustmentisneededforrenalinsufficiency(consultwithpharmacy).Itmayhaveparticularbenefitifpatientshaveahistoryofneuropathicpain,autonomicdysregulation,orconcernforalcoholorbenzodiazepinewithdrawal.Slowlytaperforthoseonhighorprolongeddosing.

7. Phenobarbital(consultneurocriticalcareandpsychiatrypriortoinitiation)▪ Ifthepatienthasbeenonbenzodiazepinesforgreaterthan72hoursandhasrequired3or

moresedativeinfusions,thentheadditionoflowdosephenobarbitalshouldbeconsideredifnotalreadyinitiated,otherwisealternativeadjunctiveagentsshouldbepursued.

▪ Phenobarbitalloading:Initiatewithaloadof5-10mg/kggivennofasterthan60mg/mintoavoidhypotension

▪ Phenobarbitalmaintenance:Doseof1-2mg/kg/daydividedtwicedailybyIVorenterally▪ Phenobarbitalbreakthroughagitationdosing:65-130mgIVpushq1-2hoursprn▪ Routinedruglevelmonitoringmaynotbenecessary,andthedrugcanbetitratedtoclinical

effectasanadjunctforweaning.Ifdrugleveltargetsareused,considerinitiallytargetingtrough

levelsof10-15mcg/mLandavoidlevelsexceeding20mcg/mLgivenriskofmorbidityincriticallyillpatients.

● Convalescentphase-PhaseIII

Agentsarelistedinsuggestedorderofwean

1. Weaninghigh-doseketamine▪ Duetotheriskofemergencereactionswithhighdosesandprolongeduseofketamine,

adjunctiveagentsorbenzodiazepinesshouldbeinplacewithaplanforsedationifemergencereactionsoccur.Trialreducingketaminedoseby20%every6hoursandmonitorfortolerance.Concurrentbenzodiazepineshavebeenshowntoreducetheriskofemergencereactions.

2. Weaningbenzodiazepines▪ Withprolongeduseofmidazolam,activebenzodiazepinemetabolitesaccumulateandcan

facilitateweaning(“self-weans”).Lorazepamalsoleadstometaboliteaccumulationwithprolongedusebutlikelyrepresentsahigherriskofwithdrawalsymptomsthanmidazolam.Asaprecaution,benzodiazepineinfusionsshouldbereducedby25%every4to6hourswhilemonitoringforsymptomsofwithdrawal.Ifwithdrawalissuspectedthanlorazepam2mgorclonazepam1mgcanbegivenasneededinresponsetowithdrawalsymptoms.

▪ Benzodiazepineandopiatewithdrawalmayhavesimilarfeaturesthoughfeverandtremoraremorelikelytooccurwithbenzodiazepinewithdrawalwhilediarrhea,lacrimation,andrhinorrheaaresuggestiveofopiatewithdrawal.

3. Weaningopioids▪ Considerinitiationofascheduledopioidtoreducewithdrawalsymptomsasinfusionsare

reduced.Approachessuchasfentanylpushes(25-50q4-6H)orscheduledIV/enteraloxycodoneorhydromorphone(forexample,2-10mgq6Hdependingonpeakinfusiondose)asmaintenanceopioidcanbeconsideredtoreducewithdrawalsymptoms.Trialreducingopioidcontinuousinfusionsby20%every6-12hoursandmonitorfortolerancetorefinetherateofwean.

▪ Benzodiazepineandopiatewithdrawalmayhavesimilarfeaturesthoughfeverandtremoraremorelikelytooccurwithbenzodiazepinewithdrawalwhilediarrhea,lacrimation,andrhinorrheaaresuggestiveofopiatewithdrawal.

▪ Duetothepossibilityofopioidsupplychainshortages,opioidsshouldbetransitionedtoPOorpertubedosingassoonasfeasible.Dosingoptionsinclude

● Oxycodone5-20mgPOq4-6hoursscheduledwithadditionalq4-6hourbolusesasneeded

● Hydromorphone2-4mgPOq4-6hoursscheduledwithadditionalq4-6hourbolusesasneeded

● Morphine5-30mgPOq4hourscheduledwithadditionalq4hourbolusesasneeded.4. Weaningpropofol

▪ Propofolinfusionmaybereducedby10mcg/kg/minevery1-2hourswhilemonitoringfortolerance.

5. Dexmedetomidinetofacilitateventilatorweanandextubation▪ Dexmedetomidinecanbeusedtofacilitateextubationinagitatedpatientswhoareotherwise

appropriateforextubation.Considerweaningdexmedetomidinedoseto1mcg/kg/hrand

extubatingwhiledexmedetomidineisinfusing.Theinfusionmaybecontinuedforashortperiodoftimeafterextubationtofacilitatetheperi-extubationperiod.

6. Ketaminereintroduction(optional)forextubation▪ Ifanagentisrequiredtofacilitateextubationthenre-introductionoflowdoseketaminecould

beconsidered7. Weaningadjunctiveagents

▪ Remainingadjunctiveagentscanlikelybeweanedonageneralmedicineunitoverthecourseofdays.Phenobarbitalcanbeweanedbyreducingmaintenancedoseq48H.

Section16:BowelRegimenWhileUsingHigh-doseOpioidsorPhenobarbitalRoutinebowelregimens

● Shouldbestarteduponinitiationofanalgesia/sedation● Docusate/senna2tabletsPO/pertubeBID● PolyethyleneglycolPO/pertubeBID

Adjunctiveregimens

● Magnesiumcitrate300mlPO/pertubex1● BisacodylPO/RectaldailyordailyPRN● FleetEnema/tapwaterenemaPRx1● Lactulose20g(30ml)PO/pertubedaily-BID● Naloxone3-12mgPOTID(48-hourtrialrecommended)

Refractory

● Methylnaltrexone(weightbased,renallyadjusted):8-12mgSQeveryotherday

Section17:NeurocriticalCareConsultationIndicationsforNeurocriticalCareConsultation

● Encephalopathywithoutfocalmotororcranialnervefeatures*o Non-intubatedpatientwithoxygensaturation>92%,serum(venousorarterial)pH>7.3,MAP>65mmHg

▪ ConsultifGCS12orlesso IntubatedpatientwithPaO2>60mmHg,serumpH>7.25,MAP>65mmHg

▪ ConsultifGCSis8Torlessandpatientisoffsedativesbesidesmoderate-dosedexmedetomidine● Propofolheld1hour,fentanylorbenzodiazepinesheld6hoursifsedativesused<72

hoursor8hoursifsedativesusedmorethan72hours)▪ ConsultifagitationorventilatorsynchronypreventcompletecessationofsedativesbutGCSis

8Tandnoneurologicimprovementisappreciatedwithatrialofsedativedosereduction(consider25-50%reduction)

o Ifoxygensaturation,serumpH,orMAParebelowthenotedcutoffsthenattempttoaddressthesederangementspriortoconsultation.

● Focalmotororcranialnervefeatures*notknowntobepresentpriortoacuteCOVID-19infectionorexplainedbypastmedicalhistory

● Sustainedorintermittentstereotypedmotormovementor“spells”duringwhichthepatientwouldnotrespondpurposefullytotheexaminerbyverbalortactilestimuliorthepatientwouldnotdemonstratebilateralpurposefulmovements(suchaspurposefullypullingagainstrestraintsorreachingforlines/tubes).

● Severeagitation(RAAS3-4)disproportionatetolevelofstimulationorinsettingofextensivesedativeuse(i.e.useofgreaterthanthreeseparatesedativeagents,midazolamgreaterthan1mg/kg/hr,orketaminegreaterthan30mcg/kg/min)

● Patientswith“recovered”COVID-19infectionsshouldreceiveneurologicalconsultationaccordingtostandardclinicalpractice

*excludesanisocoria(unequalpupils),whichhasahighprevalenceinthenormalpopulation,withoutothermotororcranialnervefindings

Section18:OBConsultationGuidelines

Communication/Operations

● MICUtonotifyOB-Cattending(2.2804)ofanyadmissionsofpregnantwomeno Allpregnantwomen>16weeksshouldhaveasetupforresuscitativehysterotomyintheirMICUroom

(includingabedsidecesareantrayandatimeoutblade)▪ Roomsofpregnantwomeninwhomfetalinterventionorneonatalresuscitationwouldbe

consideredshouldalsohaveNICUequipmentavailable▪ CoordinatesetupbynotifyingL&DChargeNurse(2.0807)

o OB-CattendingshouldnotifytheL&Dunitattending(2.2032),OBanesthesiology(2.2016),andL&DChargeNurse(2.0807)ofanynewMICUadmissions.Inaddition,theyshouldcommunicatedaily(morningshift,~8-10am)abouttheMICUOBcensus

▪ TheMICUOBcensusshouldbeontheL&Dbackboardtopromoteawareness▪ TheOBAnesthesiologyfellowordesigneeshouldcompleteananesthesiaconsultation

● AteachL&Dsignout,theL&DteamshouldidentifywhowouldberesponsibleforrespondingtoaMICUOBemergencyalongsidetheOB-Cunitattending

o ThisteammemberandtheirAscomphonenumbershouldbedesignatedonthegreaseboardandrelayedtotheOB-CattendingandOB-Cnursingstaff

OBClinicalCare

● TheOB-CattendingshouldroundintheMICUdaily(ideallywithMFMfellow,ifavailable,topromotecommunication/awarenessbetweenteams).

o IftheOB-CisnotanMFMandafellowcannotjoinrounds,MFMshouldbeupdateddailytoassistwithanyclinicalquestionsand/orcontributetomanagement

● Allwomen>22w0dshouldhaveanMFM/NICUconsultationtoinformfetalmonitoringandneonatalresuscitativedesires

● Fetalmonitoringo Forwomeninwhomfetalinterventionwouldbeconsidered,NSTsshouldoccurdailyo Forwomeninwhomfetalinterventionisnotbeingconsidered,FHTshouldoccurweeklyforwomen

whoarenotintubated;dailyforthosewhoareintubated● Ifmaternalrespiratorydeteriorationoccursdespitemaximumsupportiveefforts,consideracontrolledcesarean

intheFeinbergORasresuscitativemeasureo MICUphysiciantonotifyOB-Cattendingifrespiratorystatusisworseningtodiscusswhetherdelivery

shouldbeconsidered● IntheeventofamaternalcodeinFeinbergorintheMICU,theFeinberg/MICUteamwillimmediatelynotifythe

OB-Cattending(2.2804)whowilldeploytothepatient’slocation.TheOB-Cnursingstaffwillnotifya)thedesignatedco-responder,b)theL&Dunitattending,andc)theNICUteamifapplicableviaanOBEmergencypage.

o IfthereareanyactiveclinicalissuesonOB-C,theL&DunitattendingwillcoverwhiletheOB-CisintheMICU

Section19:Lines,TubesandProcedures

GeneralguidelinesforallproceduresperformedonCOVID-19positiveorsuspectedpatients● Alleffortsshouldbemadetominimizeexposuretohealthcareworkers.Safetyprocedures,includingdonning

anddoffingofPPE,shallnotbealterednomatterhowemergentthesituation.● PPE,includingN95orelastomericrespirator,gloves,gogglesorfaceshield,andgown,aremandatoryforall

providerspresentforanyprocedure.● Limitthenumberofhealthcareprovidersintheroomduringtheprocedure.● Proceduresshouldbeperformedbythemostexperiencedprovideravailable.● Ifmultipleproceduresarerequired,providersshouldmakeeveryefforttocoordinateandbatchthese

procedurestominimizetripsinandoutofthepatient’sroomanduseofPPE.● Carefulpreparationoutsidetheroomisstronglyrecommended.Allnecessarysuppliesshouldbegatheredand

checkedpriortoenteringtheroom.SuggestedsupplylistsforcommonICUproceduresarelistedinthefollowingsections.

● Anoutsidetheroomtimeout,includingareviewofnecessarysupplies,shouldbeperformed.● Clearlinesofcommunication,possiblyviawhiteboard,shouldbemaintainedthroughthewindowtoarunner

outsidetheroom.

Pulmonaryprocedureservice● DuringtheCOVID-19pandemic,therewillbeaneedforincreasedpulmonaryprocedures,especiallyforpatients

intheCOVIDICUs.ThePCCMteamswillperformoridentifyphysicianstoperformnecessarypulmonaryprocedures(bronchoscopyandpleuralprocedures).TheinterventionalpulmonaryteamwillperformpercutaneoustracheostomiesandtheThoracicSurgeryServicewillperformsurgicaltracheostomieswhenneeded.

● AllservicesshouldidentifypatientsrequiringbronchoscopyorpleuralproceduresonroundswhenpossibleandcommunicatethesetoaPCCMteamimmediatelyafterrounds.TheCOVIDICUteamsmayalsopagetheIPserviceasneededtodiscusspatients.Bronchoscopyandpleuralprocedurescanbearrangedforthesamedaywithimmediatenotice,buttracheostomyprocedureswillrequirenotificationatleast24hoursinadvance.Tracheostomyproceduresrequirecoordinationwithancillaryservices,includingRTandAnesthesia,andwillthereforebedonewithinbusinesshoursMondaythroughFriday.PleaseseeseparateTracheostomyProtocolProcedurefordetails.

CentralvenousaccessserviceAcentralvenousaccessserviceisavailabletoassistwithcentrallineplacement.Thisservicecanbecontactedatpager57557(COVIDLineTeam),whenserviceisactive.

SpecificprocedureguidelinesCentralvenousaccess

● Recommendedstaff:physician,registerednurse● MostCOVID-19positivepatientsinourcenterhaverequiredvasopressorsintheimmediateperi-intubation

period.ThisshouldbeanticipatedandpreparedforbythecareteamwithaplanforimmediateplacementofIJcatheteronceairwayissecured.

● TolimitexposureofPICCplacementproviders,triplelumencathetersarepreferredasafirstlineforvasopressoradministration.PICCsshouldbeconsideredifvasopressorrequirementisexpectedtolastforlongerthan10daysorlong-termcentralIVaccessisneededforotherindications.PleaseindicateinIRordersthatplacementisonaCOVID-19positivepatient.

● Unlesstherearecontraindications,theinternaljugularispreferredforcentralvenousaccess.o ConsidertrialysislineifunderlyingCKDorsevereAKIwithanticipatedrenalreplacementtherapy.

● I/Olinesarealsoanoptionforemergentneeds.IfI/Oisplaced,planimmediatelytogainmorelong-termcentralaccess;donotwaitthe24hoursuntilI/Oisexpired.

● Aswithotherprocedures,bolusNMBcanbeconsideredtofacilitateCVCplacement.● Remindershoppinglisttohelpminimizeenteringandexitingrooms:

o Ultrasoundo Chloraprepsx3o Multi-LumenCentralVenousCatheterizationKito TripleLumenInsertionwithThyroidKit(containsthyroiddrapeandsteriledressing)o IfplacingalineotherthanTLC,gettheappropriatekit(e.g.,cordis,trialysis,duallumendialysiscatheter,

etc).Notewhatisinthesekitsverycarefullybeforeenteringtheroom:Manydonothavesutureorgauze;ifangiocathisdesired,bringseparately.

o BluecapsforTLCo Sterileultrasoundprobecovero Sterilesalineo Sterilebowlo Sterilegloves,gown,bouffanto Additionalsterilegauze

Arteriallines

● Recommendedstaff:physician,registerednurse● MostCOVID-19positivepatientswhorequireintubationcanbeexpectedtorequireserialarterialbloodgas

assessmenttoguidemanagementoftheirrespiratoryfailure.Therefore,arteriallineplacementisrecommendedinpatientswithrespiratoryfailuretoavoidrepeatedproviderexposuredrawingbloodgases.

● Remindershoppinglisttohelpminimizeenteringandexitingrooms:o Ultrasoundo Chloraprepsx3o Arrowkitx3o Sterileultrasoundprobecovero Steriletowelso Thyroiddrapeo Sterilegloveso Bouffantcaps

Extubation● Recommendedstaff:registerednurse,respiratorytherapist(RT)● Evaluationforextubationshouldbedonewithpressuresupporttrialsontheventilator.T-pieceis

contraindicatedgivenaerosolizationrisks.● Secretionmanagementshouldbeamajorconsiderationwhenassessingpatientforextubation,astraditional

airwayclearancetechnologymaynotbereadilyavailableforCOVID-19positivepatients.● Duringtheextubationprocedure,theRTshouldleavetheETtubeconnectedtotheventilatorcircuitforaslong

aspossible.● Beforeextubation,crossclamptheETtubeandapplyaviralfiltertotheendoftheETtube.● Deeporopharyngealsuctioningisrequiredduringmostextubationprocedures,butcreatesasignificantriskfor

aerosolgeneration.Healthcareteamshouldplanforthisandlimitmembersofthehealthcareteampresentduringsuctioning.

BronchoscopyNMHCOVID-19ICUBronchoscopyprotocol:BronchoscopyintheCOVIDICUwillbeperformedfordiagnosticandtherapeuticpurposes,including,butnotlimitedto:

· Diagnosticevaluationofnewlyintubatedpatient,includingCOVIDrule-outtesting· EvaluationofpossibleVAPorsuperimposedbacterialCAP· Airwayclearance

BronchoscopycanbeperformedatthediscretionoftheICUattending,butthegeneralpolicywillbethatoff-hourbronchoscopyperformedbyafellowwithoutanattendingshouldbelimitedtoemergentsituationssuchasmucousplugging.Thefollowingprotocolwillbeusedforbronchoscopyandwillbeperformedby1-2member(s)oftheIPserviceortheICUattending.TheICUfellowwillparticipateifwillingandavailable(perfellow’spreference).GiventhelongercircuitbreakwithNBBAL,thesewillnotbeperformedonCOVID-19patients.

Thenursewillhelpwithprintingorderlabels,pre-proceduralsedationincludingadministrationofneuromuscularblockadebutthenwillleavetheroom.RTmayhelpwithgatheringequipmentbutdoesnotneedtobepresentintheroom.Role1:primarybronchoscopist(fellow,attending,IPattending)–thispersonisresponsibleforassessingtheclinicalsituation,consentingthefamily,ensuringallnecessaryequipmentareready,orderinglabtests,ensuringadequatesedation,performingthebronchoscopy,cleaningtheequipmentafterwards,andensuringsamplesdeliveredtothelab.Role2:secondarybronchoscopist(supervisingIPattendingorICUattendingorfellow)–thispersonwillassisttheprimarybronchoscopist,silenceventilatoralarms,assistincircuitmanipulation,instillsalineforlavage,withdrawBAL,andconnectlukenstrap.Orderchecklist:

· Adequatesedation–goalofRASS-4ifneuromuscularblockadetobeused· Cisatricurium0.2mg/kg(Pharmacistmayoftenhave,otherwisecall9thfloorpharmacy)· Labwork

oBALcellcountanddifferentialoBALamylaseoBALrespiratoryculture(normal,+/-fungal,AFBpercliniciandetermination)oLowerRespiratoryTractPanel(BioFirePneumoniaPanel)oSARS-CoV-2test(repeatevenifstatusalreadyknown,tomonitorforclearance/reinfection)oCytology,Galactomannan,PJPDFApercliniciandeterminationoExtrapatientlabelforresearchspecimen

PPEchecklist:

· N95maskorelastomericrespirator(ensureadequatefit)+coveringsurgicalmask· Gown,gloves(discardafterprocedure)· Faceshieldorgoggles(wipedownafterprocedure)

Equipmentchecklist:

· Ambuscope(large/orangeifconcernformucusplugging,butcheckETTsize;regular/greenotherwise)· Ambutower(ensureadequatelycharged)· Drapeorchucktolaydownsupplieson· ScopeadaptorforETT· ClampforETT· Scopelubricant· Extrasuctiontubing,iffarfromthebed· 4x30ccsyringes(sliptippreferred–ifluerlock,ensuresliptipadaptorsavailable;ofteninthescopebag)· Normalsaline(500ccbottles)· Lukenstrap· Orangespecimencup+labels· ResearchEppendorftube+patientsticker· Extraspecimenbagsoutsideroomfordouble-baggingspecimens

Proceduresteps:

1. Outsidetheroom,PrimaryBronchoscopisttimesoutwithnursingandensuresconsenthasbeensigned,ordersplacedandlabelsprinted.SedationadjustedtogoalRASS-4withcisatraciurium0.2mg/kgadministeredat

provider’sdiscretion(thisissuggestedwhenpatientinearly/acutephasewithlikelyhighviralloadandtenuousstatusbutmaynotbenecessaryforconvalescingpatientslateindiseasestage).FiO2increasedto100%.2. Asable,PrimaryBronchoscopistprepsthebronchequipmentoutsidetheroom

a. Drawingup30ccnormalsalinex4b. ConnectingAmbuScopetoMonitorc. LubricatingAmbuScoped. Pre-loadingAmbuScopeontoscopeadaptore. Applyinglabelstospecimencupsandresearchtube

3. PrimaryBronchoscopistandSecondaryBronchoscopistenterroom;NursingandRTavailablebutareoutsidetheroom.

a. PrimaryBronchoscopistresponsiblefornarratingstepsoutloud,standsatthesideofthepatient;SecondaryBronchoscopiststandsnexttofirst,closertotheventilatorb. PrimaryBronchoscopistensuresequipmentsetup,suctionconnectedandfunctioning,sedationisadequateandvitalsarestabletotoleratetheprocedurec. PrimaryBronchoscopistclampsETTd. SecondaryBronchoscopistdisconnectsinspiratorylimbfromtheventdistaltothefilter(i.e.,thefilterremainsconnectedtotheventilator)e. PrimaryBronchoscopistplacestheadaptor(pre-loadedwiththescope)ontotheETTf. SecondaryBronchoscopistreconnectstheinspiratorylimbg. PrimaryBronchoscopistunclampstheETTh. PrimaryBronchoscopistperformsinspection,toiletingsecretionsasneeded,wedgesintotargetlobei. SecondaryBronchoscopistinstillssalinein30ccaliquots,120ccrecommended,drawsbackanddiscardsfirst5cc,drawsbackmoresampleifable,thenconnectsthelukenstrap(goal>40ccreturn)j. PrimaryBronchoscopistsuctionssampleintolukenstraporAmbusamplerdevicek. SecondaryBronchoscopistdisconnectlukenstrap,hooksbackuptowallsuctionl. PrimaryBronchoscopistcleansupanyremainingsecretions,pullsscopebacktoedgeofadaptor,thenclampsETTm. SecondaryBronchoscopistdisconnectsinspiratorylimbfromtheventdistaltothefilter(i.e.,thefilterremainsconnectedtotheventilator)n. PrimaryBronchoscopistremovesadaptorandscopeinonemotiono. SecondaryBronchoscopistreconnectstheinspiratorylimbp. PrimaryBronchoscopistunclampstheETTq. Sampleplacedintoorangespecimencupfromlukenstrap(havehadseveralbreak),with10-15ccplacedinEppendorftubeforresearchteam

i. Samplesbaggedfirstinroom,thenplacedinanotherbagheldbysomeoneoutsidetheroom ii. Orangespecimencup+labelsdeliveredto7thfloorlab iii. Researchspecimen-TheMICUresearchteamcanbecontactedbyphoneat62752orbypagerat59285.Iftheyarenotreadilyavailabletopickupthespecimen,itcanbeleftinthespecimenfridgeinthedirtyutilityroominthe9thfloorMICU.

r. Disposableequipmentplacedinredbiohazardbagfordisposals. Monitorandpolewipeddownbeforeleavingroom,returnedtoRTroomt. PrimaryBronchoscopistreturnsFiO2topre-procedurelevel(assumingtolerated)andensureshemodynamicsacceptableu. BothproceduralistsdoffPPEandwashhands;surgicalmaskoverN95shouldbediscardedbutN95canbereused;goggles/faceshieldswipeddownandreusedv. PrimaryBronchoscopistdocumentsprocedurenote

SpecialCircumstances:

· Pronepositioning:continuewithstandardprocedure· iNO:continuewithstandardprocedure· Brushings:sometimesrequestedbyresearchteam,whowillprovidebrushes,brushcutter(wirecuttercanalsobefoundinbronchsuite),researchtube/mediumforbrushtobecutinto

PleasedonothesitatetocontacttheInterventionalPulmonaryteamwithquestions.

● Non-ICUbronchoscopy

o ForpatientswhorequireaCOVIDrule-outbronchoscopybutdonotrequireICUlevelcare,theirbronchoscopywillbeperformedbytheprocedureserviceintheFeinberg9thfloorMICUprocedureroom,whichisnegativepressure.Nursingstaffwillbefromthebronchoscopysuite.ThesecasesshouldbescheduledbycontactingRebekahWernerwhocanbepaged.Or,usethedotphrase.covidbronchrequestinEpic,whichwillgenerateaformtocomplete,promptyoutoplaceanorderforthebronchoscopytobescheduled,andallowyoutospecifyanappropriateandrequestedtimeframe.

o PatientsinCOVIDruleoutstatuswillbebroughttotheFeinberg9thfloorMICUprocedureroomusingstandardprecautionsofsuchpatientsduringtransport.Intheprocedureroom,N95maskswillbewornbyallpersonnel,anddisposablebronchoscopeswillbeused.Thepatientwillberecoveredinthisprocedureroombythestaff.Theroomwillbeleftemptyoncethepatientleavesfor70minutesperhospitalprotocol.Sampleswillbedouble-bagged.Alldisposableswillbeplacedindoublebiohazardredbagsfordisposal.

Tracheostomy● Identifyingpatientsandmultidisciplinarydiscussion

o TheCOVIDICUandLungRescueteams,includingtheECMOteam,willmeetroutinelytodiscussCOVIDpatientswithrespiratoryfailure.

o Therewillbemultidisciplinarydiscussionaboutpatientselection,timingandtechniquefortracheostomy.

o Patientselectionandtimingwillbeatthediscretionoftheprimaryteams.o Patients’familieswillbeapproachedearlyintheircourseaboutthepotentialneedfortracheostomy,so

thatgoalsofcarecanbeaddressedearly.o Effortswillbemadetoperformtracheostomyproceduresatthebedsideinordertominimize

transportingpatientsandexposingotherenvironments.o Opentracheostomywillbereservedforpatientsinwhomanatomicconsiderationsaredeemedunsafe

forpercutaneoustracheostomy.

● Percutaneoustracheostomy

o Step1:Pre-proceduralpreparation▪ Thedaypriortoprocedure,contactORschedulingtorequestAnesthesiasupport▪ Thedayoftheplannedprocedure,thefollowingproceduralitemswillbeassembledoutsidethe

roombythenursingstaffandRespiratoryTherapy:● CookMedicalBlueRhino● Shiley6andShiley6XLTtracheostomytubeswithcuffs● Bronchadapter● Sterilebasin● TwopackagesofsterileORtowels● Kerlixtopacknose/mouth● Clampforventilatorcircuit● Bag-maskdevicewithPEEPvalve● Bottleofsalineandsterilebowl● Onemediumsizeduoderm● Ultrasoundmachine● Disposablebronchoscopewithmonitor● Medications,includingcontinuousICUsedatives,phenylephrineandcisatracurium,

providedbyAnesthesia● 2biohazardbags

▪ ThefollowingPPEitemswillalsobeassembledoutsidetheroombynursingstaffandrespiratorytherapy:

● FourPAPRswithhoods● Foursetsofsterilesurgicalgloves,withsizesatthediscretionofoperators● Foursterilegowns● Fournon-sterileregularPPEgowns● Fourfoot/bootcovers● Tworedbiohazardbags

▪ Thetracheostomyteamwillbenotified,andthefollowingteammembersassembled:● COVIDICUattending,nurseandRT● On-call/designatedAnesthesiaattendingorfellow● On-call/designatedInterventionalPulmonologyattending● On-call/designatedsurgeon,ThoracicSurgeryattending

▪ IncaseAnesthesiaisnotrequestedandRTisrequested,sedationandparalyticswillbeadministeredunderthedirectionoftheproviderperformingtheprocedureiftheyhaveprivilegestoadministersedation.Medicationswillbeinitiatedbythenursingstaffwhocanleavetheroompriortothestartofprocedure.However,everyeffortwillbemadetolimitpersonnelintheroom,asthisisahighaerosol-generatingprocedure.Everyeffortwillalsobemadetobeconsistentinhowthisprocedureisperformed,regardlessoftheproceduralteam.

o Step2:Proceduralsetup

▪ Onceallmaterialshavebeenassembledoutsidetheroom,teammemberswillmeetforasign-inandproceduralpauseoutsidetheroom.Thepatient’smedicalhistory,vitalsigns,labs(includingCBC,INR,ABG),imaging,medications,IVinfusions,allergies,ventilatorsettingsandcodestatuswillbereviewed.ConsentwillhavealreadybeenobtainedbytheCOVIDICUteam,andtheconsentformwillbereviewed.Assembledtracheostomyteammemberswilldecideupondesignatedroles:bronchoscopist,anesthesiologistandoperator(s).IdeallyonlythesethreeorfourpeoplewillentertheroomwithstandardPPEprecautionsaswellasPAPRdevicesandmaximalbodycoverage,includingnon-sterilegowns,gloves,eyeprotectionandfootcovering.

▪ Role1:Bronchoscopist.Thispersonwillberesponsibleforairwaymanagement,includingbronchoscopyandpossibleneedforflexibleintubation.Theywillstandattheheadofthebedandhelppositionthehead.Theywillberesponsibleformanagingtheairwayduringtheprocedure,includingpositioningoftheendotrachealtube,packingthenoseandmouth,anddeflatingthecuffattheappropriatetime.

▪ Role2:Anesthesiologist.Thispersonstandsattheleftsideofthepatientandisresponsibleformanagingtheventilatorandmedicationsduringtheprocedure.TheywillmanageIVsedationandgivethedoseofparalytic(traditionally0.1mg/kgcisatracurium)atthedesignatedtime(traditionallyjustbeforeincision).Theywillmonitorhemodynamicsandprovidevasoactivemedicationsattheirdiscretion.TheywillincreasetheFiO2ontheventilatorto100%andconsiderarecruitmaneuver(PEEPorbreath-hold)beforetheprocedure.Theywillberesponsibleforventilatortubemanagement,includingclampingandbaggingasdescribedbelow.

▪ Role3:RespiratoryTherapist.TheywillincreasetheFiO2ontheventilatorto100%andconsiderarecruitmaneuver(PEEPorbreath-hold)beforetheprocedure.Theywillberesponsibleforventilatortubemanagement,includingclampingandbaggingasdescribedbelow.Theywillassistwithventilatorsetupaftertheprocedure.

▪ Role4:Operator(mayneedtwopeopleforthisrole).Thisperson(s)willstandattherightsideofthepatientandperformthetracheostomy.Theywillpositionandexaminethenecktodecideuponthemostappropriatetechnique(i.e.,percutaneousoropen).Theywillopensuppliesandtrays,putonsterilematerialsandpreparethetracheostomytube.

o Step3:Tracheostomyprocedure(percutaneous).Thefollowingstepsdescribeamodifiedpercutaneoustracheostomyapproachthatminimizesexposuretoaerosols.Iftheoperatorsfeelthatthiscannotbeperformedsafelybecauseofanatomy,thenskipthisstepandproceedtoStep5foropen/surgicaltracheostomy.

▪ Theoperatorwillpositionthepatientinthestandardpositionandexaminetheneck(palpation+/-ultrasoundtoidentifyanatomy).Theywillcleanseneckoncewithchlorhexidineandthenputonsterilegownsandgloves.Theywilldrapetheneckandbody.CareshouldbetakensothatventilatorandIVtubingiseasilyaccessibletoanesthesia.

▪ Thebronchoscopistwillcoverandpacknoseandmouthwithtowels,vaginalpacksorspongestominimizeexposuretosecretionsoraerosols.

▪ TheanesthesiologistorRTwillpausetheventilator,clamptheETT,disconnecttheventilatortubing,andplacethebag-maskdevicewithPEEPvalveand100%oxygenflowing.AbronchoscopeadapterwillalsobeattachedtotheETTatthistime.UnclamptheETTandbeginmanualventilation.

▪ ThebronchoscopistwillplacescopethroughtheETT,toiletsecretions,deflatethecuff,and

drawbackthetubetothelevelofthesubglotticspace.Careshouldbetakensothattheconnectionswiththeadaptoraretight,andthentheadaptorandtubecanbecoveredwithtowels.

▪ Theoperatorwillagaincleansewithchlorhexidineandtheninstilllidocaineintothedermisanddowntothetrachealrings.A10mmdermalincisionwillbemade,andanangiocatheterplacedthroughtheincisionanddowntothetrachea.

▪ Theangiocatheterwillenterthetracheaguidedbydirectvisualizationbythescope.Idealplacementwillbebetweenthe2ndand3rdorbetweenthe3rdand4thrings,andtheneedleshouldenterbetweenthe10:00and2:00positionsofthetracheaasviewedbythescope.

▪ Theneedlewillberemoved,andthecatheteradvanced.Fingerocclusionwillbeperformeduntilaguidewirecanbeplaced,andthenthecatheterisremoved.Awetlapspongewillbeusedaroundtheincisionsitetominimizeaerosol.

▪ Theanesthesiologist/RTwillholdventilation.A14Frdilatorisplacedoverthewireandusedtodilatedowntothetrachea.Dilationisperformedtwice.Oncethedilatorisremoved,wetgauzeshouldbeappliedaroundthewiretominimizeleakofaerosols.Theanesthesiologist/RTcanresumeventilationattheirdiscretion.

▪ Theanesthesiologist/RTwillagainholdventilationoncetheoperatorisreadywiththenextdilator.TheRhinodilatorwillbeplacedoverthewireandintothetracheawithdirectvisualizationoftheappropriate-sizedblacklinesintheairwaybythescope.TheRhinodilatorwillberemoved,andfurtherpackingwillbeappliedaroundthefreshstoma.Theanesthesiologist/RTcanresumeventilationattheirdiscretion.

▪ Theanesthesiologist/RTwillholdventilation.Thetracheostomyintroducerandtubewillbeplacedoverthewireandintotheairway.Thewireisremoved,andthecuffofthetracheostomytubewillbeinflated.

▪ Theanesthesiologist/RTwillholdmanualventilationandattachtheregularventilatortubingtothetracheostomytube.Mechanicalventilationcanberesumedthroughthetracheostomytube.Thebag-maskdevicedoesnotneedtoberemovedfromtheETT.

▪ Thebronchoscopewillbeusedtoensureproperpositioningofthetracheostomytube.ThescopeandETTcanthenberemoved.

▪ Thetracheostomytubecanthenbesecuredintheroutinefashionwithpadding,suturesandtracheostomyties.

▪ Non-reusablematerialswillbeplacedintoredbiohazardbags(doubled).Sharpswillbediscardedperroutine.PAPRdeviceswillbecleansedperroutine.

▪ Doffing:Theglovesandgownswillberemovedintheroomanddiscardedwithinthebiohazardbags.Theoperatorswillthenleavetheroom,withPAPR’sinplace.AnassistantwillwipedownthePAPRusingSANI-WIPESperInfectionPreventionprotocolandwillhelpremovethePAPRhoods.Hand-washinganddisposalofanyotherPPEwillthenbeperformed.

● Tracheostomyprocedure(open/surgical)o Ifthisisdeemednecessary,everyeffortwillbemadetoperformtheprocedureatbedside,butthismay

requiretransportingthepatienttotheORwiththeCOVID-19ORprotocolinplace.EveryeffortwillbemadetodelaytheseproceduresandextubatethepatientratherthantransportingtotheORforanopen/surgicaltracheostomy.

o Timing▪ Sign-outbetweenCOVIDICUanddesignatedpersonnelintheOR(attendinganesthesiologist

designatedfortheprocedureandORnursing)beforetransferisinitiatedfromCOVIDICUtoexpeditetransfertoassignedroom.

▪ Allopen/surgicaltracheostomyprocedureswillbeperformedduringregularworkinghourswhennursingpersonneltrainedinthisprocedureareavailable.

o Personnel▪ Nursing:1scrubnurse,1circulatingnurse.BothmustbeENT/thoracictrainedandexperienced

inperformanceoftracheostomyprocedure.▪ Anesthesia:Personnelmustbeexperiencedwithtracheostomyprocedureandcomfortablewith

COVID-19protocols.▪ Surgery:Attendingotolaryngologistorthoracicsurgeon,1residentPGY4/5.

o Pretransferhuddle▪ Allmembersoftheaboveteamwillhuddletoensurereadiness(ofanesthesiaandsurgical

equipment,andchecklistofnecessaryPPE)beforetheattendinganesthesiologistcanperformasign-outwithCOVIDICUtoinitiatetransfer.

o PPEchecklist▪ PAPRswithhoodsx5▪ N95masksx5▪ Sterilesurgicalgloves▪ Sterileimpermeablegownsx3(for2surgeonsand1scrubnurse)▪ Non-sterileregularPPEgownsx2(foranesthesiologistandcirculatingnurse)▪ Impermeablebootcovers▪ Redbiohazardbags

o Performatimeout:IncludeCOVID-19specificlanguageforpositivepatients;includebuddychecksforPPE;includecheckoftracheostomysurgicalequipmentandchoiceoftracheotomytube/s.

● Surgicalprocedureo Performstandardpreppingofneckanddrapingofpatient.o Injecttrachsitewith1%lidocainewith1:100,000epinephrinesolution(atsurgeon’sdiscretion).o MakeahorizontalincisionusingBoviecautery.Makesurefumeevacuatorispresentanddeployed.o Dissectdowntotracheaquicklyusingverticaldissection,strictlykeepingtothemidlineandretracting.

Dividethyroidisthmusonlyifneededtoexpediteprocedure.o Stopventilationandparalyzethepatient.Communicatewithattendinganesthesiologistabout

anticipatedtimeofstoppingventilation,assomeofthesepatientswillhavepoorreserve.o Makeaverticalorhorizontalincisioninthetrachealwall(surgeon’sdiscretion).MakeaBjorkflapif

needed(asopentracheostomywillonlybeperformedforanatomicallyunfavorablepatients).o Removeendotrachealtubeandinserttracheotomytube.Disposeoftheendotrachealtubesafely(ina

doublebiohazardbag).o Inflatethecuffontracheostomytubeandconnecttoventilator.o FollowNMHprotocolfordoffing.

Section20:EchocardiographyandPoint-of-CareUltrasound

Goals● Obtainthediagnostictestingnecessarytoguidethecareofcriticallyillpatients.● Minimizetheriskofexposuretocliniciansandsonographers.● Guidetheutilizationofapotentiallylimitedresourceduringatimeofunprecedentedstressonthehealthcare

system.

Transthoracicechocardiography(TTE)● Goal-directedqualitativepointofcareultrasound(POCUS)bytrainedcliniciansalreadycaringforCOVID-19

positivepatientsisencouragedtolimitthenumberofTTEsordered.● SuggestedindicationsforTTE:

o Clinicalconcernforacutecardiacpathology(e.g.,risingtroponins,dynamicEKGchanges,unstablearrhythmias,undifferentiatedorsuspectedcardiogenicshock).

o Clinicaldeteriorationinapatientwithpreexistingcomplexcardiacdisease.o Considerationofmechanicalcirculatorysupport.

● OrderingaTTE:o Forpatientswithseverevalvularheartdisease,prostheticvalvesorothercomplexcardiacdiseases,

order“2DEchowithDoppler”inEpic.o AllotherTTEsshouldbeorderedas“LimitedEcho,”whichwillfollowafocusedCOVID-19TTEprotocol.o Thisprotocolprovidesinformationaboutleftandrightventricularfunctionaswellasascreenfor

valvulardisease.o Ifassessmentofdiastolicfunctionorcardiacoutputisrequired,addthisrequestinthecomments

section.● Infectionpreventionwithpointofcareultrasound:

o AttemptsshouldbemadetolimitenteringCOVID-19positivepatientrooms.POCUSshouldonlybeperformedwhenthereisaspecificclinicalquestionforwhichPOCUSislikelytochangemanagement.

o Leaveexcess/additionalprobesoutsideofpatientroomswhennotinuse.

Pointofcarecardiacultrasound

● Indicationso Shocko Suspectednewheartfailureo Risingtroponino RecommendagainstPOCUSforfrequentassessmentofvolumeresponsiveness(favorpulsepressure

variationand/orclinicalresponsetosmallfluidbolusestolimitexposure)● Probe

o Phasedarray● Preset

o Cardiac● Views

o Parasternallongaxiso Parasternalshortaxis(midpapillarylevel)o Subcostalfourchambero Inferiorvenacava

● Notablecardiacdiseasepattern

o Acutecardiacinjury▪ Incidence7%–22%▪ Troponinand/orEKGchanges▪ Acutecoronarysyndrome▪ Incidenceunknown▪ Mayseeregionalwallmotionabnormalities

o Fulminantmyocarditis▪ Casereports▪ GloballyreducedLVfunction+-troponin

o Arrhythmias▪ Incidence~50%inICUpatientsincludingVT/VFlateincourse

Pointofcarelungultrasound

● Indicationso Peakpressurealarm(ruleoutpneumothorax)o Progressivehypoxemia

● Probeo Phasedarrayo Linearprobemaybeusedifsolelyrulingoutpneumothorax

● Preseto Abdominal(forphasedarray)

● Viewso Anteriorchest–Ultrasound4lungzonesoneachside(seepicture)o Posteriorchest–Ultrasound1lungzoneoneachside

● Notablediseasepatternso B-linepatternindicatinginterstitialedema

o Consolidationwithairbronchograms

Section21:OptimizingtheElectronicHealthRecord(Epic)

● COVID-19testresultswillappearunderdifferentnamesdependingonwhichplatformthetestwasrun.ResultscanbefoundunderCOVID-19orSARS-COV-2.PleasenotethecoronavirusresultontheLowerRespiratoryTractPanelisfortheendemichumancoronavirus,notthepandemicCOVID-19virus.

CommonCOVID-19ordersandordersets● COVIDOrderPanelorderset

o usetoorderCOVIDNPandBALtest● COVIDInpatientOrdersorderset

o admissionorderso ICUspecificorders(labs,tests)o treatmentmedications(Remdesivir,dexamethasone)o VTEprophylaxis

● ConvalescentPlasmaorderseto usetoorderconvalescentplasmao PleasenoteconvalescentplasmaconsentformcanbefoundonNMIontheBloodBankorAntimicrobial

StewardshipProgrampage.Youwillneedthisinadditiontostandardbloodconsent.● COVIDICUSedation/Analgesiaorderset

o ordersforDilaudid,Ketamine,Midazolam,andMorphinebasedontheCOVIDSedationGuidelines● RemdesivirOrderPanel

o usetoorderRemdesivir● HelpfulICUordersets

o VentilatorManagemento Sedation/AnalgesiaforICUpatients

▪ ordersforPropofol,fentanyl,andprecedex

Tipsfromclinicaldocumentationspecialists

● Documentingwork-upAspeoplearebeingruledout,considerusingtheterms“suspect,beingruledout,possible.”

● Whencultureresultsarereceived,pleaseclarifythediagnosisusingthefollowingguidelines○ Documentingnegative/ruledoutforCOVID-19(examples):

■ COVID-19ruledout■ ExposuretoCOVID-19;ruledout

○ DocumentingpositiveCOVID-19■ Itwillremainimportanttolinkapatient’spresentingsymptomstoCOVID-19,whenappropriate.■ Examples:

● PneumoniaduetoCOVID-19● COVID-19pneumonia● AcutehypoxicrespiratoryfailureduetoCOVID-19● Sepsis2/2COVID-19● Viralsepsis2/2COVID-19● SeveresepsisduetoCOVID-19(whenappropriate)● Acutebronchitisd/tCOVID-19● ARDSrelatedtoCOVID-19

● DocumentingCOVID-19despiteanegativetest○ IfaCOVID-19testissuspectedtobefalselynegative,pleaseuseoneofthefollowingphrases

■ EvidenceofCOVID-19despitenegativetest■ PatientwithCOVID-19

Section22:TheLogisticsofRounding

● Daytimeroundingteamsaretypicallymadeupofattending,fellow,and2residentsorAPPs.o Interprofessionalteammembersshouldjoinforrelevantpatients.o Interprofessionalteamincludesbedsidenurse,RTandpharmacist(ifavailable).

● Morningroundstypicallystartat730everyday,oratthediscretionoftheattending.● “Bedside”interprofessionalroundsareconductedinfrontofeachpatient’sroom.

o Ifnursingispresent,theyshouldpresentpatient’sup-to-datevitals,drips,lines,ventsettingsandotherobjectivedatausingtheMICUroundingguide.

● Teamdoesnotenterroomafterdiscussion.o IfanyventchangesordripchangesneedtobemadeandthereisanurseorRTintheroom,please

communicatethroughthedoortominimizepersonnelenteringandusingPPE.o Nursingcanmakeanyventchangesyouneediftheyareintheroomorabouttoentertheroom.o Afterdevelopingplan,pleasecommunicateclearlywithnursingaboutanychangesindrips,vent

changesorlabdrawssonursesonlyhavetoentertheroomonce.● Examinationofpatientsoccursafterroundingonallpatients.

o InanefforttoconservePPE,patientsshouldbeexaminedoncedailybytheattendingo Residentsmayneedtoentertheroomatothertimesduringtheday,butarenotexpectedtophysically

seethepatientswhentheypre-roundorjusttoconductaroutine/dailyexam.● Allexaminationsandproceduresarebundledtoreducetrafficinandoutofroom.● Disposablestethoscopesareineveryroom.Ifusingyourpersonalstethoscope,pleaseensureyoucleanitbefore

steppingoutusingthewipesfromthepurplebottle.

Section23:ClearingpatientofCOVIDstatushttps://nmi.nmh.org/wcs/blob/1390909567123/clinical-clearance-guidelines.pdfKeypointsforintubatedortrachedpatients:

● After20daysfromfirstpositivetest,patientmusthavetwonegativetests>24hoursapart;● ifstillintubated,thesemustbothbeBALspecimens;● iftrached,oneofthetwotestsmustbelowerrespiratorytract(endotrachealaspirateorBAL);● ifnowextubated,anytwospecimentypeswillsuffice.

ICU Care Guidelines for Patients With COVID-19 · 5/15/2020 · ICU Care Guidelines for Patients...

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