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LastModified:January22,2021 1
ICUCareGuidelinesforPatientsWithCOVID-19PurposeThisdocumentwascreatedbythefellowsandfacultyofNorthwesternUniversityFeinbergSchoolofMedicineDivisionofPulmonaryandCriticalCareMedicine,andtheNorthwesternMemorialHospitalMedicalIntensiveCareUnit(MICU)interprofessionalteamtoprovidegeneralguidelinesanddescribecurrentpracticesforthecareofcriticallyillpatientswithCOVID-19.
EditorsJacquelineKruser,MDJames(Mac)Walter,MD(contactforupdates/questions:[email protected])BenSinger,MD(contactforupdates/questions:[email protected])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
LastModified:January22,2021 2
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
LastModified:January22,2021 3
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
LastModified:January22,2021 4
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):
LastModified:January22,2021 5
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:
LastModified:January22,2021 6
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).
LastModified:January22,2021 7
● 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
LastModified:January22,2021 8
● 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([email protected])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.
LastModified:January22,2021 9
▪ 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.
LastModified:January22,2021 10
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,
LastModified:January22,2021 11
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..
LastModified:January22,2021 12
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.
LastModified:January22,2021 13
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.
LastModified:January22,2021 14
● SeeafullNEJMvideohere:youtube.com/watch?v=DVJNWefmHjE● Bronchoalveolarlavage(BAL)
o Thistestrequiresbronchoscopicsamplingoffluidfromthelowerrespiratorytract/lungs.o Considerperformingimmediatelyafterintubationtotakeadvantageofneuromuscularparalysis,or
earlyafterintubationtorulein/outbacterialsuper-infection
LastModified:January22,2021 15
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
BAL)
LastModified:January22,2021 16
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.
LastModified:January22,2021 17
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
LastModified:January22,2021 18
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
LastModified:January22,2021 19
maneuvers.Theseentitiesusuallyhavemeasurableresponsestohigh-dosecorticosteroidswithin72hours.Ifnoresponsetoatherapeutictrialoccursafterthattime,steroidsshouldberapidlytapered.
RecommendedsteroiddosingforCOVID-19-specifictreatment:
- Dexamethasone6mgdailyforupto10days(donotcontinueondischarge)- ForpatientswhorequiresteroidsforbothCOVID-19andanotherindication(e.g.exacerbationsofobstructivelungdisease),recommenddiscussingoptimalagentanddosewithpharmacy.- SteroiddosinganddurationforCOP/fibroproliferationisbeyondthescopeoftheserecommendationsandshouldbedeterminedbythetreatingclinician.
LastModified:January22,2021 20
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
LastModified:January22,2021 21
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
LastModified:January22,2021 22
ActiveCOVID-19clinicaltrialsatNMH
Seehttps://www.feinberg.northwestern.edu/sites/covid-19/covid-19-clinical-trials.html
Toaddatrialtothewebsite,contactAbbyCosentino-Boehm<[email protected]>.
CanreachouttotheMICUResearchteampager59285(orsearch‘Study’intheWebPagingSite)
LastModified:January22,2021 23
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:
LastModified:January22,2021 24
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.
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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.
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LastModified:January22,2021 27
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
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LastModified:January22,2021 29
LastModified:January22,2021 30
Section13:PronePositioning
NorthwesternMemorialHospital’sapprovedprotocolfortheuseofpronepositioninginacuterespiratorydistresssyndromecanbefoundhere.
Highlights:
● ProningisoneofthefewtechniquesinARDSthatimprovesoutcomes● ConsiderproningwhenPaO2:FiO2<150● Considerproningasearlyaspossibleindiseasecourse● SedatepatienttoRASS-5(noresponsetoverbalorphysicalstimuli);thepatientmaystillexhibitreflexessuchas
cough/gag,theydoNOTneedtobeparalyzedpriortoproning(unlessotherwiseindicated)● Mobilizeteam(detailsinprotocol)● Generalgoalis16hoursinpronepositionoutofevery24hourperiod
LastModified:January22,2021 31
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.
LastModified:January22,2021 32
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
LastModified:January22,2021 33
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
LastModified:January22,2021 34
● 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
LastModified:January22,2021 35
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.
LastModified:January22,2021 36
▪ 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
LastModified:January22,2021 37
● 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
LastModified:January22,2021 38
▪ 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
LastModified:January22,2021 39
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
LastModified:January22,2021 40
extubatingwhiledexmedetomidineisinfusing.Theinfusionmaybecontinuedforashortperiodoftimeafterextubationtofacilitatetheperi-extubationperiod.
6. Ketaminereintroduction(optional)forextubation▪ Ifanagentisrequiredtofacilitateextubationthenre-introductionoflowdoseketaminecould
beconsidered7. Weaningadjunctiveagents
▪ Remainingadjunctiveagentscanlikelybeweanedonageneralmedicineunitoverthecourseofdays.Phenobarbitalcanbeweanedbyreducingmaintenancedoseq48H.
LastModified:January22,2021 41
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
LastModified:January22,2021 42
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
LastModified:January22,2021 43
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
LastModified:January22,2021 44
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.
LastModified:January22,2021 45
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
LastModified:January22,2021 46
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.
LastModified:January22,2021 47
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
LastModified:January22,2021 48
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
LastModified:January22,2021 49
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.
LastModified:January22,2021 50
● 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.
LastModified:January22,2021 51
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.
LastModified:January22,2021 52
▪ 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.
LastModified:January22,2021 53
● 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.
LastModified:January22,2021 54
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.
LastModified:January22,2021 55
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
LastModified:January22,2021 56
Pointofcarelungultrasound
● Indicationso Peakpressurealarm(ruleoutpneumothorax)o Progressivehypoxemia
● Probeo Phasedarrayo Linearprobemaybeusedifsolelyrulingoutpneumothorax
● Preseto Abdominal(forphasedarray)
● Viewso Anteriorchest–Ultrasound4lungzonesoneachside(seepicture)o Posteriorchest–Ultrasound1lungzoneoneachside
● Notablediseasepatternso B-linepatternindicatinginterstitialedema
o Consolidationwithairbronchograms
LastModified:January22,2021 57
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
LastModified:January22,2021 58
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
LastModified:January22,2021 59
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.
LastModified:January22,2021 60
Section23:ClearingpatientofCOVIDstatushttps://nmi.nmh.org/wcs/blob/1390909567123/clinical-clearance-guidelines.pdfKeypointsforintubatedortrachedpatients:
● After20daysfromfirstpositivetest,patientmusthavetwonegativetests>24hoursapart;● ifstillintubated,thesemustbothbeBALspecimens;● iftrached,oneofthetwotestsmustbelowerrespiratorytract(endotrachealaspirateorBAL);● ifnowextubated,anytwospecimentypeswillsuffice.