Chengda Zhang, MD

My COVID-19 reading

5/27/2020

  1. Infection Control
    1. Fitted N-95 respiratory along with other PPEs and negative pressure room for aerosol-generating procedures

      Aerosol-generating procedures in the ICU include: endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, physical proning of the patient, disconnecting the patient from the ventilator, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation.

    2. Surgical/medical masks along with other PPEs for non-aerosol-generating procedures.
    3. Video-guided laryngoscopy for endotracheal intubation by experienced provider.
  2. Resuscitation in patients with COVID-19 and shock
    1. There are very low-quality evidence regarding restricted vs. liberal use of fluid resuscitation. Clinician should constantly assess fluid responsiveness and status of ARDS when administering fluid resuscitation.
    2. Norepinephrine should be used as the first-line vasoactive agent. If not available, vasopressin or epinephrine can be used.
    3. Vasopressin is the recommended second-line agent.
    4. MAP goal for vasoactive agents should be 60-65mmHg.
    5. When cardiac dysfunction is present and hypoperfusion not responding to norepinephrine alone, dobutamine is suggested over increasing norepinephrine dose.
    6. Corticosteroid for shock is recommended, typical dosing hydrocortisone 200mg qd.
  3. Managing respiratory failure
    1. Supplemental O2 is recommended when SpO2 is below 92%. Goal of SpO2 should be no higher than 96%.
    2. HFNC not NIPPV should be attempted if failed conventional nasal oxygen Summary of recommendations on the initial management of hypoxic COVID-19 patients
    3. For vented patients with ARDS, low tidal volume ventilation is recommended. Summary of recommendations on the management of patients with COVID-19 and ARDS
    4. Target plateu pressure should be < 30mmH2O.
    5. Higher PEEP strategy is recommended.
    6. Prone ventilation is recommended in those with moderate to severe ARDS for 12-16 hours
    7. As needed intermittent boluses of neuromuscular blocking agents can be used for moderate to severe ARDS
    8. In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, we suggest using a continuous NMBA infusion for up to 48 hours
    9. Pulmonary vasodilator may be used as a rescue therapy
    10. Inhaled nitric oxide has potential harm and no clear mortality benefit, therefore it is not recommended. It could cause rebound pulmonary vasoconstriction.
    11. Traditional recruitment maneuvers can be used for persistent hypoxia.
    12. VV-ECMO if nothing works
  4. COVID-19 treatment
    1. Cytokine Storm Syndrome: In vented patients, the presence of ARDS could justify systemic corticosteroids use.
    2. Empiric antibiotics should be given for patients with COVID-19 and respiratory failure
    3. Routine use of IVIG is not recommended
    4. Routine use of convalescent plasma is not recommended. Efficacy and safety is unclear.
    5. Routine use of lopinavir/ritonavir is not recommended. In a recent trial from China, the drug did not significantly reduce 28-day mortality. The drug has generally good safety profile, but may have interactions with many drugs
    6. In ICU patients, there is insufficient evidence to issue a recommendation regarding antiviral agents for COVID-19. More evidence is needed for remdisivir, rIFNs, and chloroquine or hydroxychloroquine, and tocilizumab.