Biel, 17.03.2020 COVID-19 script

department of intensive care

Guideline COVID-19 Patients

ContentIntroduction.............................................................................................................................................2

COVID-19: what is special? What do you have to think of?...................................................................2Laboratory...........................................................................................................................................2

Imaging...............................................................................................................................................2Forecasting / Risk factors....................................................................................................................3

COVID-19 Handling and management...................................................................................................4Basic information.................................................................................................................................4

Ventilation...........................................................................................................................................4Course parameters laboratory............................................................................................................4

Hemodynamics & Fluid Management.................................................................................................4Haematology.......................................................................................................................................4

Drug therapy...........................................................................................................................................5Antiviral therapy..................................................................................................................................5

Immunomodulatory therapy................................................................................................................5Antibiotics............................................................................................................................................6

Airway/intubation COVID-19...................................................................................................................7Weaning and extubation COVID-19.......................................................................................................7

Extubation criteria............................................................................................................................7Material / qualification......................................................................................................................8

Performing extubation.....................................................................................................................8Special instructions: Monitoring after extubation.............................................................................9

Positioning...........................................................................................................................................9Respiratory therapy...........................................................................................................................10

Nutrition.............................................................................................................................................10

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Biel, 17.03.2020 COVID-19 script

department of intensive care

IntroductionCOVID-19 is a new clinical picture and we have to learn and try to understand the disease better with every patient. In the literature longer courses (intubations up to 2 weeks) are described. In the foreground is the supportive treatment with "best medical practice"!

The most important point is with everything that is done: Avoid contact with the respiratory secretion ("virus transport medium") !

Do not forget to report to the authorities: In case of positive lab results and in case of death link

COVID-19: What is special? What do you have to think of?Incubation period: up to 14 days, clinical manifestation usually 4-5 days after exposure.Course of disease: mild ca. 80%; severe (dyspnoea, hypoxia >50%; Rx changes pulmonary <24-48h) ca.15%; critically ill ca. 5%. The deterioration of critically ill patients usually occurs on day 8-10.

LaboratoryLymphopenia, Troponin↑ (cardiac involvement), LDH↑, Ferritin↑, CRP↑, PCT (initially often negative. Exception ICU patients: PCT often ↑); D-dimer. ImagingRx: Ground glass changes, spotty consolidations, often bilateral and peripheral; temporal course (see graph above). CT: avoid if possible due to aerosol distribution (no diagnostic added value if situation is clear). Only indicated in case of specific questions such as abscess or superinfection or unclear situation.

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Biel, 17.03.2020 COVID-19 script

department of intensive care

Sono: Initial B-Lines without consolidation, increasing consolidation in heavy progressions (See Table 1). Do not bring any material to the patient's bed except for the sonograph and gel; clean both thoroughly. If necessary, leave gel in the room.

Forecasting / Risk factorsRisk factors: Age, ♂, concomitant diseases (CHD, aHT, DM, chronic pulmonary diseases), hypoxia, respiratory rate Laboratory chemical progonosis factors with increased mortality : lymphopenia, D-dimer (cutoff > 1000ug/L). Additional laboratory chemical information for MOF (Multi Organ Failure)

Score to calculate whether a COVID-19 patient becomes critically ill: http://118.126.104.170/

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Biel, 17.03.2020 COVID-19 script

department of intensive care

COVID-19 Handling and managementBasic informationThe treatment of COVID-19 patients is basically no different from the treatment of other ARDS patients / viral pneumonia: it is mainly a supportive treatment. There are, however, individual aspects that are different in COVID-19.

VentilationLung-protective ventilation Controlled ventilation (volume or pressure controlled ventilation) for at least 72h

o Target: Vt 6ml/kg Ideal Bodyweight (14-8ml/kg Ideal Bodyweight).

Patients usually need high PEEP 8-12 (possibly > 15cmH2O) and show a surprisingly good compliance (aim for low driving pressure (i.e. PDriving=Pplat - PEEP))

PEEP above 12mmHg only after consultation with the responsible medical director

Target SpO2 92% - 96% (paO2 independent) (according to SSC GL 2020)o If oxygenation is acceptable, reduce the FiO2 and not the PEEPo With persistent FiO2 > 60-70% or poor compliance, consider prone position and

relaxationo prone position 16-18 hours if paO2/FiO2 ratio <150 and/or FiO2>60% at least 3 x

times

If necessary long I to E ratio (e.g. 1:1) o Goal: Extension of the high mean airway pressure without much driving pressure (<

15 mBar)o Cave: for obstructive pneumopathy (autopeep)

Possible permissive hypercapnia (pH arterial > 7.2, as long as haemodynamically stable)o Permissive hypercapnia : correct only if pH < 7.20 / PaCO2 > 60 mmHg=> VT

to 7-8 ml/kg PBW as long as Pplat < 30 cmH2O & ΔP < 14 cmH2O

In the course of switching to assisted spontaneous breathing mode o Aim: PEEP, and little DU (e.g. PEEP 15-18, DU 5-10 with tube compensation). Vt at

least 5ml/kg IBW. o Objective: subjective patient condition. Possibly again controlled ventilation for

tachypnea and indisposition; high Vt (>8ml/kg KG Ideal Bodyweight) or AF >30/m. Experience from the Ticino shows that it is important not to switch to spontaneous breathing mode too quickly.

In the course of decreasing compliance described (fibrotic remodeling, superinfection), then if necessary PEEP reduction and classic ARDS ventilation (Low Vt (6ml/kg Ideal Bodyweight (4-8ml/kg Ideal Bodyweight))

1 Calculate with a calculator ( e.g. App MedcalX or Calculate )2 Brower RG et al for National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. N Engl J Med. 2004 Jul 22;351(4):327-36. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.

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Biel, 17.03.2020 COVID-19 script

department of intensive care

No deconnectionso Tracheobronchial secretion collection plan to be successful in the 1st attempto Closed suction system (even with deep PEEP)

Bronchoscopies should be avoided (poor benefit-risk ratio for personnel).

Course parameters laboratoryDaily Electrolytes, creatinine, urea CRP + procalcitonin daily (no longer daily if PCT is decreasing) Blood count ABGA always in pair with VBGA and lactate, at least every 12h (correlate with monitor etCO2

and respiratory minute volume)

Every 2nd day PT/INR Liver values Troponin (search of myocarditis, not ACS)

Every 3rd day Coagulation status incl. D-dimer Ferritin, LDH Machine differential blood count for lymphocytes

Hemodynamics & Fluid Management Fluid-saving strategy for lung damage

o After the resuscitation phase, aim for a cumulative balance of 0 or negative. Avoid a positive balance.

o Noradrenaline is often necessary to support MAP (target > 65mmHg). If increased norepinephrine requirement (> 10 ug/min) Evaluation Cause (Cardiac Output? Right heart strain? Vasodilatation? Volume status?)

o "not every lactate needs volume" Echocardiography in case of elevated troponin or suspected low output (myocarditis in the

context of COVID-19? right heart strain in case of high PEEP?)

Haematology DIC possible (fibrinogen, D-dimer, thrombocytopenia) Prothrombotic situation: correct thrombosis prophylaxis

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Biel, 17.03.2020 COVID-19 script

department of intensive care

Drug therapyThe drug therapy is based on the hospital's internal standards. There are currently two basic therapeutic approaches. First, reduction of the viral load and second, attenuation of the immune response. As of March 2020, there are no human studies that show evidence for a specific therapy. All therapies are therefore experimental in nature and cannot be recommended by most guidelines.

Antiviral therapy Remdesivir: In vitro and animal studies show effect against MERS. Not commercially

available, but can be ordered from the company with a special application form. Kaletra (Lopinavir/Ritonavir): HIV drug that potentially blocks viral replication and was effective

against MERS-CoV in animal studies. Human data on SARS and MERS are mixed and without clear effect. Young et al. show no effect in 16 patients with a dose of Kaletra 200/100mg. First randomized study on 199 patients confirms this (NEJM 2020). Kaletra has a broad side effect profile including Stevens-Johnson syndrome, malignant arrhythmia, blood count disorders, pancreatitis, liver failure, kidney failure.

Chloroquine: antimalarial drug with an acceptable toxicity profile. The mechanism of action is probably based on the effect of ACE2 interaction and inhibition of endosome formation. To date there are no clinical studies.

Oseltamivir (Tamiflu): No effect

Immunomodulatory therapy

The course of the disease is divided into a replication phase (high virus load) and an immune phase with a prolonged course (INT patients). Whether an immune modulation of this prolonged phase is useful remains unclear at present.

Steroids: should not be given in the current data situation. Wu et al. retrospectively showed a benefit. There may be a benefit in the critically ill patients with corresponding comorbidities (persistent cytokine storm (high CRP), vasodilatory shock, COPD exacerbation)

Tocilizumab (IL-6 inhibitor): Experimentally, Xu et al describe successful treatment of 21 patients with deep side effect profile. Currently no therapeutic option in everyday life.

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Biel, 17.03.2020 COVID-19 script

department of intensive care

AntibioticsCOVID-19 is not an indication for antibiotics. Secondary infections occur in up to 16% of patients (Ruan 3/3/20) and should be actively sought. In critically ill patients, generous use of broad-spectrum antibiotics (primarily ceftriaxone / co- amoxicillin) with antibiotic stewardship.

The current SZB guidelines (March 2020) recommend therapy with Remdesivir and Chloroquine for intubated patients.

Airway/intubation COVID-19IntroductionIn the respiratory tract, the focus is on minimizing "viral load" and personal exposure.

There is currently no clear evidence against high flow oxygen therapy. It can delay intubation and according to the guidelines of the Sepsis surviving campaign there is no increased risk of environmental contamination compared to conventional oxygen therapy. Nevertheless, some papers recommend aerosol isolation with FFP2 masks.

The guidelines generally advise against NIV (failure rate 92%, aerosol formation. Indication of comorbidities (COPD) if applicable.

In case of severe hypoxaemia (paO2/FiO2 < 200mmHg), intubate promptly: High flow oxygen therapy must not lead to waiting too long before intubation Due to the severe hypoxaemia and to minimize the "viral load" (secretion contamination of

the environment).

The most experienced doctor present always intubates!

Procedure: Optimal preparation (medication, intubation material, positioning aids, video laryngoscope

ready) Supervising staff must be kept small and experienced Appropriate protective measures (aerosol and contact insulation): hood, FFP 3 mask, face

shield, 2 pairs of gloves if necessary. Coat. HME (Hydroguard Mini) filter yellow between mask and disposable ambu-bag, and between

tube and ambu-bag during trial ventilation on tube. Preoxgenation: Ambu-bag with PEEP valve (set to 5) and enough O2 flow. Install Philipps CO2 monitoring for intubation (tube position verification). Primary rapid RSI (High Dose Rocuronium 1.2mg/kgKG) without intermediate ventilation. The "most experienced" intubates, if possible with a video laryngoscope (4 blade). Cuffen directly. Application Stethoscope restrained (Hygiene!) 1 person ready in front of the isolation for bringing necessary material and medicine.

Weaning and extubation COVID-19Introduction

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Biel, 17.03.2020 COVID-19 script

department of intensive care

Pulmonary weaning and preparation for extubation are central aspects in the treatment of the critically ill patient, as is COVID-19, where the primary weaning parameter is FiO2 before PEEP and DU are weaned. On each visit the patient has to be evaluated if a reduction of sedation up to sedation stop and a reduction of respiratory support up to electronic extubation is possible.

Targets: Wake-up attempt and spontaneous respiration attempt / electronic extubation daily Extubation according to COVID-19 guideline (deviations allowed, but must be ordered by the

plant manager)

Weaning

If the ventilation parameters improve after 72h: paO2/FiO2 ratio > 200 / T < 38°C / ↓ CRP, ↓D-Dimers CAVE - Because NIV and High Flow are limited for reasons of hospital hygiene, not too rapid

extubation

Procedure:• PEEP Stepwise back by 1 (-2) mbar as long as PaO2/FIO2 > 200.• YOU if PEEP < 10 mbar and PaO2/FIO2 > 200 during > 6 hours

! if VT > 8ml/KG or AF > 30/min => Return to protective ventilation

Think about extubation: if PEEP ≤ 8 mbar and FIO2 ≤ 50% and AF < 30/min, DU 5 cmH2O and PEEP 5 cmH2O

during 30 min.

Extubation criteria

Respiration: No use of the respiratory muscles, no rocking breathing No reversible thoracic/lung pathology (effusion, atelectasis) Sufficient spontaneous breathing Satisfactory gas exchange (ABGA, pulse oximetry) Existing protective reflexes (cough reflex, gag reflexes) and good saliva management Consciousness: Wakeable, contact is possible Stable cardiovascular situation Normothermal energy Sufficiency coughing during endotracheal suctioning Rapid Show Breathing Index (RSBI) (Rathgeber, 2010)

o Describes the ratio of tidal volume to breathso An RSBI of >/= 105/m indicates unsuccessful extubation. o The individual needs of the patient are always taken into account.

Extubation

Atemfrequenz /min /Tidalvolumen l=RSBI

12/0.4 l=30 Yes

30/0.4 l=75 Yes

30/0.2 l=150 No

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Biel, 17.03.2020 COVID-19 script

department of intensive care

According to prescription, electronic extubation for 30 minutes, (no pressure support, no PEEP, only tube compensation), followed by ABGA, tidal volume, respiratory frequency.

After removal of the ABGA, set PEEP and pressure support again as before electronic extubation and wait for values.

In COVID-19 patients, derecruitment after extubation with consecutive hypoxaemia can

be a problem with high re-tubation rate

These guidelines are indicative of successful extubation and do not allow extubation without the approval of the medical director.

Material / qualification / preparation

Stop Novorapid (if possible) two hours, but at least 1 hour, before stopping the diet. Stopping enteral feeding Appropriate protective measures (same as for intubation), FFP 3 mask, safety glasses, gloves Cuff syringe Suction device functional and complete, suction catheter Ch 14 (green) Mask with reservoir lies next to the patient and connected to oxygen Ambu-bag with HME filter, PEEP valve and disposable mask is ready to hand FGD car ready before isolation, 1 person in front of the isolation bunk Experienced "extubation team" and as small as possible (1 doctor + 1 nurse) Patient is positioned with raised upper body,

o Support any arms with cushions. o Possibly place two small cushions under the buttocks as "slide stop

Suction of stomach contents, (from Freka probe stomach contents can be sucked off badly) Time: ideal at the beginning of the day shift

Performing extubation

Implementation Justification

get material ready

Control: Respiratory rate on the monitor on?

Discuss procedure in the extubation team allocation of responsibilities

Upper body elevation, 30

Suction of mouth and throat, if necessary oral hygiene with chlorhexidine

Germ-contaminated secretion that could be aspirated is removedSubglottic suction if possible:

With 20 ml syringe or installed secretion suction system

Preoxygenate for 3 minutes with 100% oxygen Patient has oxygen reserve, if re-tubation is necessary

Endotracheal suction (closed) Germ-contaminated secretion is removed

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Biel, 17.03.2020 COVID-19 script

department of intensive care

Switch off alarms Noise reduction

Release tube fixation

Blow on the ventilator with PEEP increase (15 - 20 cmH2O) for 15-20 seconds - do not blow with the Ambu bag

Atelectasis Prophylaxis

Stop the respirator when finished and simultaneously unblock cuff and extubate

Atelectasis Prophylaxis

If necessary directly with Respirator High flow oxygen therapy

PEEP, Reduction Work of Breathing.

If necessary, aspirate the patient orally again

Ask patient to "cough", Cough sufficiency? Because of coughing up secretions do not ask for a strong coughing impulse

Check whether sufficient protective reflexes are present.

Switch the machine to standby, Switch off hose heating

Noise reduction

Special instructions for the time after extubation :

Monitoring Cough sufficiency? Respiratory movements: Use of the respiratory muscles, rocking breathing? depth of breath + breathing frequency = breathing pattern Breath sounds Blood pressure, monitoring heart rate, sudden sweating? Oxygen saturation - observe positioning and oxygen saturation. Patients can deoxygenate

relatively asymptomatically. ABGA 30 minutes after extubation, if required or prescribed by a doctor Pain Can you swallow? (CASTING!) Voice?

Positioning Cardiac chair/sitting bearing stable positioning

o Extremities can be easily movedo The poor are supportedo body is bent in the hips, back is straight

Respiratory therapy Repositioning Mobilization

Physio about extubation at an early stage, so that they can perform a can schedule pulmonary ventilation therapy

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Biel, 17.03.2020 COVID-19 script

department of intensive care

NutritionAfter extubation: at least 2 hours food leave First swallow test in a sitting position, with thickened water Score: Gugging Swallowing Screen (GUSS) in case of the slightest suspicion of swallowing

disorders Consultation with speech therapy if necessary

For dying ill / deathRelatives are allowed to join their family member under the same hygiene conditions according to the isolation.

In the event of death: handle the body in the same way as other contact insulations.

Message to the FOPH: enter keywords in Google or click on the link: BAG notifiable Corona : fill in the form "Notification form for clinical findings after death send to the cantonal medical office epi@be.ch and to the FOPH covid-19@hin.ch

Forms are available from 23.03.2020 in KISIM

Version N° Created From Validated Valid from1 K.Bachmann/ ETR 17.03.2020 LRC / C.Beguelin / GEB

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