BOSTON MEDICAL CENTER ICU COVID-19 TOOLKIT

This document was developed for internal use at Boston Medical Center as a practical guide to aid physicians from all disciplines in caring for patients with COVID-19 in the ICU. These are not recommendations nor are they guidance for use outside of BMC. Please check that you have the latest version of this document here. The latest versions of BMC algorithms and policies can be found here. Questions/concerns regarding this document should be directed to Drs. Nicholas Bosch (), Andrew Berical () or Kari Gillmeyer ()

COVID CONTACTS

Below are important contacts and their respective roles.

WORKFLOW

Team Structure

  1. Team structures will likely vary throughout the course of the COVID-19 pandemic
  2. Typical team members will include an attending, fellow, and one or more house officers
  3. Admissions will be assigned to COVID ICU teams by the ICU triage officer based on team census and acuity
  4. All COVID teams will cap at a total of 10 patients (exception is the SICU team)

Admissions

From ED

  1. Receive signout from ED
  2. Place holding orders using EPIC “COVID ICU admission” order set. Special considerations:
    • Fentanyl infusions, propofol, precedex, midazolam, and MDI inhalers are on shortage; discuss alternatives with pharmacy. See SEDATION/ANALGESIA/PARALYSIS section of the MICU COVID-19 Best Practices
    • First choice vasopressor: Norepinephrine (Levophed)
    • MDI inhalers (NOT nebulizers) should be used to treat COVID-19 patients and persons under investigation (PUI) with albuterol or ipratropium
    • First choice DVT prophylaxis: enoxparin (Lovenox)
    • Avoid q1h interventions if possible
    • Avoid ICU electrolyte repletion order set if possible (requires frequent room entry by nursing)
    • Consolidate medication administration times to minimize nurse exposure
  3. Evaluate patient
    • For non-acute patients: consider nurse evaluation first followed by physician to address outstanding issues
    • For acute patients: consider physician evaluation be performed by physician capable of completing all tasks (e.g., procedures, POCUS)
    • For decompensating patients: prepare for ACLS in COVID-19 patient (see MICU COVID-19 Best Practices) and contact anesthesia COVID-19 team (Pager 3688) early if patient not intubated
    • Verify health care proxy (HCP)/next of kin (NOK) and code status with patient. Complete HCP if patient does not have one
  4. Consult subspeciality teams as appropriate: The below listed consult teams do not need to be consulted on every PUI or COVID-19 patient who is admitted to the ICU but are listed for convenience. Additionally, see COVID contacts above.
    • ID/COVID-19 (Pager 5236): Consult ID for newly confirmed COVID-19 or if there is evidence of accelerated decompensation including worsening hypoxemic respiratory failure and/or inflammatory indices
    • Pulmonary (Pager 0500): Consult Pulmonary if persistent PaO2/FiO2 <200 for greater than 24 hours, persistent respiratory acidosis with pH <7.20, and/or persistently elevated plateau pressures of >30 cm H2O
    • Cardiology (Pager 2273): Consult Cardiology if there is concern for late onset acute heart failure
    • Renal (Pager 0266)
  5. Med-reconciliation
  6. Additional Testing
    • Refer to MICU COVID-19 Best Practices: initial ICU evaluation to see the recommended tests for COVID-19 patients and PUI
    • Consolidate lab order timing to minimize room entries by nursing. Do not be judicious (If you think you will want a lab in the next 24 hrs, get the lab upfront and consolidated with other admission labs)
  7. Contact HCP/NOK/other family to alert/update
  8. Complete documentation and written signout for the night team

From Floors

  1. Receive consult page from floor team
  2. Evaluate patient for consideration of transfer to ICU
    • COVID-19 patients may rapidly deteriorate and thus a low threshold of transfer to the ICU should be maintained
  3. If possible, discuss case in-person with resource nurse, patient’s nurse and primary team before entering room to help anticipate what equipment might be needed when entering
  4. If the patient is not on precautions but there is concern for COVID-19, don enhanced precaution PPE prior to entering room (consider chart review with ICU attending prior to entry to discuss risk of COVID-19 if clinical situation permits)
    • Note: Donning enhanced precautions PPE in this situation may increase anxiety of the patient’s care team, but should be done to ensure safety
  5. If patient warrants transfer to the ICU (e.g, increasing oxygen requirements, hemodynamic instability):
    • Notify ICU charge nurse of transfer and to discuss bed availability/location
    • Place transfer order
    • Call bed control (x45795, pager 1111) to get bed assigned
  6. If patient is being admitted to an alternative ICU team, make sure to contact them and discuss
  7. Proceed with ICU admission steps 2-8 above for ED admissions
    Note: If a patient does not warrant ICU transfer, contact the ICU attending of record to discuss. Then inform primary team of ICU recommendations and complete consult note documentation. Re-evaluate patient in timely manner to ensure clinical status has not changed.

Daily Rounds

  1. Pre-rounds
    • Do not enter COVID-19 patients’ rooms prior to rounds unless there is an urgent indication
    • Ensure all team members are signed into appropriate pagers
    • Review all vitals, labs, rates of continuous infusions, overnight events, etc in Epic. Use the COVID-19 report accessible through Chart Review to review relevant information including: vitals, medications, labs, ventilator settings, results, radiology, etc.
    • Complete “ventilator rounds.” This is traditionally led by a MICU fellow though the structure may change depending on personnel available. Briefly walk by all intubated patient rooms with RT, review current settings and morning ABG/VBG, discuss anticipated plan for when RT next enters room (ie vent changes, extubation, etc)
    • Huddle with nursing management, care managers, social work
  2. Rounds
    • Perform team rounds in a work room/space that allows sufficient distancing between providers
    • Inform RN prior to rounding on each patient. Ideally conduct rounds in a physical location that allows RN to attend while remaining near the patient
    • Unless an urgent indication arises, table round on all patients, formulate the daily plan, and examine patients after rounds are completed (details below)
    • If team structure allows, designate one provider to enter orders in real-time
  3. ICU Checklist
    • Obtain ICU checklist before starting rounds from unit coordinator
    • Should be completed for every patient. Meant to be a brief (< 1 minute) reminder of critical ICU topics that may get missed on rounds
    • Resident reads through each section aloud and places a simple check mark if it was already discussed. Any topics not previously addressed should be clarified prior to moving on to the next patient
    • Attending/fellow and RN both sign checklist, and RN returns to unit coordinator
  4. Post-rounds
    • Review orders with pharmacy and nursing as necessary to consolidate room entry
    • Examine patient
      • Discuss among fellow/attending/resident who will enter each room. In general, it is okay to have fellow and/or attending see all patients. Routine entry by housestaff on rounds is often unnecessary
      • Touch base with nurses before entering to see if they need anything done by the physician in the room- If examining multiple COVID-19 patients in a row within a cohorted area, keep N95 on between patients (remove all other PPE per protocol)
    • Complete any necessary procedures (utilize the COVID procedure team whenever possible, p5303)
    • Call HCP/NOK to update
    • Ensure daily monitoring labs and imaging are ordered (use daily lab order set): Refer to MICU COVID-19 Best Practices: initial ICU evaluation: Laboratory Testing of Patients with Severe COVID-19 and Imaging
    • Complete documentation and written sign-out for the night team
      • Consider using COVID-19 specific note template dotphrase: “.MICUCOVID19” (or type “MICU COVID 19” into the smart text box when opening a blank note)
    • Reassess patient for clinical changes and re-connect with RN for any additional needs/updates

Night Teams

  1. 10PM – Huddle in MICU A with night staff, anesthesia COVID-19 team, and SCUNC attending coverage to confirm/clarify team assignments, attending coverage, code coverage, sequence of admissions, and patients at high risk of intubation
  2. Identify key clinical contacts for emergency

Transfers Out

  1. Ensure ICU team and nurse in agreement that patient appropriate for transfer out of ICU
  2. Place transfer order (location determined by infection status)
    • PUI with pending test or COVID-19 patient: transfer to COVID-19 floor team
    • Patients in which COVID-19 has been definitively ruled out and are no longer on enhanced or droplet precautions may be transferred to a general medicine/subspeciality team as appropriate
  3. Complete transfer summary
    • Include “.COVIDBUNDLE” dot-phrase
  4. Contact bed control (x45795, pager 1111) to determine which floor team is accepting patient
    • Page floor team to give sign-out once bed is assigned
  5. Ensure HCP/NOK are aware of transfer status

Discharges

  1. Inform case management, social work and nursing leadership early in the day of potential discharges from the ICU (ideally no later than morning huddle)
  2. For positive or pending tests, contact Dr. Carol Sulis () via email and include the following information: MRN, name, discharge location and phone, and whether patient reported a COVID-19 contact so that she can report to DPH as appropriate
  3. For undomiciled patients:
    • Contact Deanna Faretra (Pager 0735) to facilitate discharge
    • For PUI, there is a tent available at 112 Southhampton St. Shelter (call 617-645-9680)
    • For COVID-19 patients, consider Barbara McInnis House COVID Ward
  4. Verify and document patient and NOK/HCP contact information
  5. Complete med reconciliation – ensure adequate supply of all medications (14 day minimum). Consider Meds to Bed Program (Pager 2364)
  6. Schedule additional appointments as necessary
    • Option 1: Call directly GIM PCP: 617-414-5951; FM 617-414-2080
    • Option 2: Place EPIC order “GIM d/c appt” and include if an in-person visit or telephone call is needed
    • Option 3: Patients with high risk for readmission should be discussed with Rachel Weitzner, MPH (Pager 3607)
    • Confirm correct phone number with patient and update in d/c summary and AVS as necessary
  7. AVS document should include the educational document: “BMC AVS COVID” in the correct language
  8. Finalize d/c summary

Other

Consents

Avoid use of pens in the room by patients
1) Verbally consent patient and ask if they agree to have a clinician sign for them
2) If patient agrees, clinician signs consent form for patient and documents “Signed at patient’s direction in his/her presence” on the form, followed by the clinician’s printed name
3) If patient disagrees, obtain a new pen, have patient sign form and leave pen with patient 4) Questions/concerns can be directed to the Legal Department (x87901, Pager 1523)

Procedures

  1. Obtain early consent for potentially necessary procedures early (ie before intubation)
  2. Utilize the designated COVID procedure team (pager 5303, available 24/7) to facilitate placement of triple lumen catheters, arterial lines, hemodialysis catheters, or chest tubes
    • Whenever possible, anticipate pre- or peri-procedure needs (ie pausing heparin drips, transfusion of blood products for coagulopathy, etc)
  3. Attempt to conduct the procedure at a time when the nurse is already planning to enter the room (e.g., to administer medication) so that assistance is available during the procedure without unnecessarily exposing nurses
  4. If using the ultrasound, fully decontaminate with wipes from purple-topped container both inside and outside room, including wheels and screen (protocol forthcoming)
  5. Wear appropriate sterile attire in addition to PPE using the following strategy:
    • While in enhanced precautions PPE, set up patient and room as normal
    • Remove outer pair of nitrile gloves
    • Put sterile surgical gown on over yellow precautions gown
    • Put on sterile gloves (1/2 size larger than normal) over nitrile gloves
    • Complete procedure and dispose of all sharps/other used material
    • Remove sterile gown and gloves and sanitize inner nitrile gloves
      • If there is nothing else for you to do in the patient room, continue with doffing as per protocol
      • If there are additional needs at that time within the room, don a new pair of outer nitrile gloves to complete necessary tasks, then doff per protocol

CLINICAL COVID MANAGEMENT

Refer to MICU COVID-19 Best Practices for BMC-specific recommendations regarding clinical management of COVID-19 in the ICU, including acute respiratory failure, ARDS, pulmonary comorbidities, and experimental COVID-19 treatments (e.g., hydroxychloroquine). The topics below are complementary to the Best Practices guide and cover general ICU care.

GENERAL ICU MANAGEMENT

General ventilator management

  1. The goal of mechanical ventilation is to provide adequate oxygenation and ventilation without causing further injury to the lung (barotrauma, volutrauma).
  2. Oxygenation (indicated by PaO2 and/or SpO2): is affected by the mean airway pressure, which is predominantly determined by:
    • FiO2 – can be set between 21% (room air) and 100%
    • PEEP (positive end-expiratory pressure) – the pressure maintained in the airway at end of exhalation (prevents collapse of alveoli at end-expiration)
  3. Ventilation (indicated by arterial pH and CO2): is determined by respiratory rate (RR) and tidal volume (Vt) (Minute ventilation = RR x Vt)
    • A normal minute ventilation at rest is 5-6 L/min. For critically ill patients this may be as high as 12-16 L/min.
  4. Lung compliance is the lung’s ability to stretch and expand and will worsen/decrease if anything (fluid, blood, pus) fills the alveoli. It is related to both volume and pressure as below:
    • Compliance = ∆ volume / ∆ pressure
    • You will set either volume or pressure on the ventilator, the other variable will be measured and will depend on the lung’s compliance.

Initiating mechanical ventilation

  1. Initial settings:
    • Choose a mode: for nearly all patients this will be AC/VC (see below)
    • Tidal volume: goal 4-8mL/kg ideal body weight (based on height) (ARDSnet Ideal Body Weight Tables)
    • FiO2: start at 100% with goal to quickly wean down to <60% if able (FiO2 > 60% associated with oxygen toxicity)
    • RR: 12-16 breaths/min (adjust based on blood gas)
    • PEEP: minimum 5 cm H2O, will likely need higher (see ARDS section)
  2. Post-intubation check list:
    •  Order CXR to assess ETT placement (below the clavicles and 2-3 cm above the carina)
    •  Check an ABG 20-30 minutes after intubation. Adjust ventilation to achieve pH > 7.3 if possible. This can be done by either increasing the RR or the Vt (but always aim to keep Vt < 8mL/kg).
    •  Order “initiate mechanical ventilation” order set (includes vent settings and pneumonia prophylaxis [chlorhexidine, HOB elevation])
    •  Order sedation (see SEDATION/ANALGESIA/PARALYSIS section of MICU COVID-19 Best Practices)

Modes of mechanical ventilation

  1. Assist control: the mode of ventilation that allows you to control a patient’s minute ventilation and also assist the patient if they take a spontaneous breath. Most commonly used with volume control but can be pressure controlled as well.
    • Volume control (AC/VC)
      • Most commonly used as it easily allows for lung protective ventilation (see ARDS section of MICU COVID-19 Best Practices)
      • You set the tidal volume, pressure will vary based on lung compliance
      • RR, PEEP, FiO2 also set
      • If the patient breathes above the rate that you set, the patient will receive the full set tidal volume on the extra breaths (with assistance from the ventilator)
      • At BMC we use a hybrid volume mode called PRVC (Pressure Regulated Volume Control) (also called VC+) which targets a set tidal volume while minimizing high inspiratory pressures.
    • Pressure control (PCV)
      • You set the inspiratory pressure, lung volumes will vary based on compliance
      • RR, PEEP, FiO2 also set
      • Can be more uncomfortable for patients, so may require higher amounts of sedation
      • Sometimes used in ARDS to control the airway pressures and minimize risk of barotrauma
  2. Pressure support (PS)
    • Used primarily as a weaning mode
    • You set the inspiratory pressure (amount of support the patient will receive) and the PEEP
      • Standard Spontaneous Breathing Trial (SBT) settings are 5/5 (Inspiratory pressure/PEEP).
    • All breaths are spontaneous (initiated by the patient) with a backup respiratory rate in case of apnea
    • The volume received by the patient is determined by their inspiratory effort and will vary from breath to breath
  3. Airway pressure release ventilation (APRV)
    • Used as a rescue therapy for refractory hypoxia in ARDS. Can only be used in spontaneously breathing patients (don’t use if patient is paralyzed).
    • You set a high pressure (Phigh), a low pressure(Plow) as well as the time spent at those pressures (Thigh, Tlow).
    • Ventilation primarily occurs at the Plow, though the patient can also breathe spontaneously throughout
    • Contraindications include high intracranial pressure, severe obstructive lung disease, bronchopleural fistula
    • If considering using this mode, please consult the MICU

Ventilatory crises

  1. High airway pressures (peak inspiratory pressure [PIP] > 35 cm H20)
    • In a volume mode, this signifies an increase in airway resistance or a decrease in lung compliance
    • To determine the cause, ask RT to check a plateau pressure (Pplat) by performing an end inspiratory pause. Pplat represents the pressure in the alveoli.
    • A wide difference (> 10 cm H20) between the PIP and the Pplat signifies increased airway resistance (problem is in the airways)
      • Differential for this includes bronchospasm, mucous plugging, kinking of the ETT, patient biting the ETT
    • A narrow difference (< 10 cm H20) between PIP and Pplat signifies decreased lung compliance (problem is in the alveoli)
      • Differential for this includes worsening ARDS or other airspace disease (pneumonia, pulmonary edema), pleural effusions, pneumothorax, right mainstem intubation, auto-PEEP (see below)
  2. Low airway pressures
    • Causes: disconnected, malpositioned, or ruptured ETT, bronchopleural fistula, leak in the vent circuit, vigorous patient effort
  3. Dynamic hyperinflation (aka air-trapping or auto-PEEP)
    • Patients who have high respiratory rates often cannot empty their lungs fully before the next breath is delivered. This happens particularly in patients with asthma/COPD though can happen to any patient.
    • Can lead to ineffective breath triggering, increased work of breathing, and hemodynamic instability (increased intrathoracic pressures that decreases central venous return to the heart)
    • Clues: high plateau pressures, distressed patient, flow on the ventilator does not return to baseline before next breath is delivered (see Flow v Time curve below).

 

      • Can quantify the amount of auto-PEEP by doing an expiratory hold (RT will do)
      • Management: provide more time for expiration by decreasing the RR (most effective) or the tidal volume or by increasing the inspiratory flow rate (breath is delivered faster giving more time for expiration). Treat bronchospasm with inhalers.
    1. Patient-ventilator asynchrony
      • Issues with breath triggering, inspiratory flow rates, and breath duration can lead to asynchrony between patient effort and the ventilator. This can result in patient distress and difficulties with both oxygenation and ventilation.

    Weaning from mechanical ventilation

    1. Assess daily whether patient is appropriate for a spontaneous breathing trial (SBT)
      •  Improved oxygenation (SpO2 > 90%) on PEEP ≤ 5, FiO2 ≤ 40%
      •  pH > 7.25
      •  Minute ventilation < 12 L/min
      •  Hemodynamic stability on minimal or no vasopressors
      •  Reliable respiratory efforts when sedation weaned
    2. If appropriate, perform SBT using pressure support (PS) mode with an inspiratory pressure of 5 cm H20 and a PEEP of 5 cm H20 (5/5)
    3. If patient appears comfortable on PS after 30 minutes (taking slow deep breaths), assess for appropriateness for extubation including:
      •  Adequate mental status (able to follow simple commands when sedation is weaned)
      •  Minimal secretions (suctioning frequency < q2h)
    4. If patient develops respiratory distress after extubation, can consider presence of laryngeal edema (if stridor present, give racemic epinephrine, IV methylprednisolone 40mg) or cardiogenic pulmonary edema (give Lasix) though have a LOW threshold for immediate re-intubation
    5. See Extubation procedure recommendation on the MICU COVID-19 Best Practices guide for further recommendations for extubation.

    Noninvasive mechanical ventilation

    1. We are currently avoiding non-invasive positive pressure ventilation (NIPPV) in PUI or confirmed COVID patients due to aerosolization risk
    2. NIPPV can be considered in non-COVID patients. The strongest evidence for its use is in heart failure exacerbations and COPD exacerbations not requiring invasive mechanical ventilation
    3. Patients on NIPPV must be alert and able to protect their airway. Additional contraindications for NIPPV include facial trauma, hemodynamic instability, or profound acid-base disturbances (if pH < 7.2 patient should probably be intubated)
    4. Initial settings:
      • Inspiratory airway pressure (IPAP) (helps ventilation by providing pressure support): typical starting pressure 10-12 cm H2O
      • Expiratory airway pressure (EPAP) (stents open the airway): typical starting pressure 5-6 cm H2O
      • FiO2: typically starting at 40-100%, wean to lowest FiO2 needed to maintain adequate oxygenation

    Other oxygen delivery devices

    1. Nasal cannula: for most patients, each additional 1L/min flow increases the FiO2 by 3% (1L: 24%, 2L: 27%…) up to 6L/min
    2. Nasal pendant: due to the larger reservoir, can provide roughly twice the oxygen content per liter of flow compared to nasal cannula. Can go up to 10L/min.
    3. Face mask: can provide oxygen flow rates between 6-10 L/min, delivering an FiO2 of 35-50% depending on the patient’s RR and mask fit
    4. Non-rebreather mask: with a flow rate of 10-15 L/min, can theoretically deliver 100% FiO2. In reality FiO2 is probably closer to 70-80%.

    Shock

    Key Concepts

    1. Shock is a state of circulatory failure that leads to insufficient tissue perfusion and tissue hypoxia resulting in end organ damage (cerebral ischemia, cardiac ischemia, acute kidney injury, and acute liver injury, etc)
    2. Most commonly manifests as hypotension but hypotension alone does NOT always mean shock. In the ICU, the goal blood pressure is typically a mean arterial pressure (MAP) greater than 60-65 mmHg.
      • Keep in mind the patients baseline blood pressure. A cirrhotic patient may have a baseline MAP of 50 mmHg in which case the MAP goal can be lowered. In a normally hypertensive patient, MAP goal may need to be increased if they continue to have signs of end organ damage at a MAP of 60 mmHg.

    Shock Classification

    ** the red circle highlights the primary hemodynamic problem; the other boxes show the compensatory responses

    ** patients can have different types of shock at the same time

    Common causes of shock/evaluation

    1. General evaluation: in addition to the findings listed in the table above, consider the following metrics to help identify the most likely scenario and to follow the clinical course:
      • Check central venous saturation (ScvO2) from central line. In states of decreasing oxygen delivery, the body will attempt to maintain the same O2 consumption by extracting a higher percentage of the delivered oxygen, leading to decreased oxygen content in the venous circulation
        • Low ScvO2 (<65%) is consistent with low CO (eg: cardiogenic shock)
        • High ScvO2 consistent with high CO (eg: distributive shock)
        • Normal ScvO2 may indicate a mixed shock picture
      • Lactate, but keep in mind a few caveats.
        • There are 2 forms of lactate and our lab does not routinely differentiate between the two. Type A is associated with hypoperfusion. Type B can be seen with medication overdose/toxicity, malignancy, alcoholism, albuterol, and epinephrine use.
        • Lactate is cleared by the kidney and liver and so clearance will be decreased in patients with renal or liver dysfunction.
        • Lactate > 2 in the setting of hypotension can be a useful marker of hypoperfusion. It can be trended to judge the efficacy of an intervention. It does not need to be continually trended until normalization and an isolated elevation of lactate without other evidence of hypoperfusion requires additional consideration.
      • BUN & creatinine to trend any renal injury.
      • BNP can be checked intermittently during a course of diuresis in the setting of heart failure.
    2. Assessing fluid responsiveness: there is no one well-validated measure. Consider the following:
      • Passive straight leg raise: lay patient completely flat and raise both legs 45 degrees. An increase in CO or stroke volume (SV) by 10% indicates fluid responsiveness (pulse pressure on an arterial line can be used as a surrogate for SV).
      • Ultrasound: check for IVC collapsibility with respiration. May be fluid responsive if:
        • >50% collapse in a spontaneously breathing patient
        • <15% collapse in an intubated, paralyzed patient at a TV > 8 cc/kg
        • Note: unreliable based on user and patient (esp if mechanically ventilated)
      • Check central venous pressure (CVP) if central access. May be fluid responsive if:
        • CVP is < 8 in a patient on mechanical ventilation
        • CVP is low, ie < 5, in a spontaneously breathing patient

    General management

    1. In general, unless your top differential is heart failure or PE, you can try a fluid bolus (500 cc – 1L). Note that for COVID patients, we are recommending earlier initiation of vasopressors over large volume resuscitation (30cc/kg fluids).
    2. If you’re at all thinking sepsis – the most important intervention is timely administration of antibiotics!
    3. If you’re concerned about cardiogenic shock, consider diuresis. Would start with IV push dosing though they may progress to require a drip diuretic and/or inotropic support until we are able to improve their volume status.
    4. If you’re concerned about pulmonary embolism, please activate the PERT team and prepare for possible vasopressors and TPA.

    Vasoactive medications

    1. Vasopressors are used in shock to reduce perfusion to less important regions (i.e. limbs) in order to increase perfusion to vital organs (i.e. brain). Again, they don’t work well and can worsen situation in setting of hypovolemic or obstructive shock.
    2. Inotropes modulate the contractility of the heart and chronotrope modulates the heart rate.
    3. Vasopressors and inotropes target the following receptors:
      • α1 – peripheral vasoconstriction
      • β1 – inotrope and chronotrope
      • β2 – peripheral vasodilation
      • D1 – renal and splanchnic vasodilation
      • V1 – peripheral vasoconstriction

    Vasopressors

    1. Norepinephrine (Levophed)
      • predominantly α1 agonist, some β1 agonist (sometimes tachycardia offset by reflex bradycardia from α1)
      • First line agent for nearly all types of shock
    2. Vasopressin
      • V1 agonist
      • less incidence of HD dependence
      • when used alone, nonsignificant increase in mortality, less arrhythmia compared to levophed
      • second line, often used in conjunction with norepinephrine as a catecholamine sparing agent
    3. Epinephrine
      • predominantly β1 agonist, also significant α1 and β2 agonist
      • at low dose, more β1, at higher doses more α1
      • disadvantages include tachyarrhythmias and splanchnic vasoconstriction
      • increases lactate
      • no difference in mortality compared to norepinephrine
      • second line, prefered over vasopressin if there is concern for cardiogenic component to shock and depending on severity of the shock, it is a stronger vasopressor compared to vasopressin
    4. Phenylephrine
      • pure α1 agonist
      • useful for vasodilatory shock in setting of arrhythmia like AF with RVR or VT
      • can cause reflex bradycardia and decreased CO
    5. Dopamine
      • dose dependent response:
        • 1-2 mcg/kg/min –> D1 agonist
        • 5-10 mcg/kg/min –> β1 agonist
        • >10 mcg/kg/min –> α1 agonist
      • increased mortality, tachyarrhythmias compared to levophed. Should be avoided.
      • increases BP through increased CO (HR + SV) mostly

    Inotropes: sometimes indicated in cardiogenic shock

    1. Dobutamine
      • β1 and β2 agonist
      • effect on blood pressure depends on drug’s relative effects on CO and SVR
      • some patients require vasopressor support in conjunction with dobutamine
    2. Milrinone
      • PDE3 inhibitor (decrease breakdown of cAMP), increases contractility, vasodilator (ionodilator)
      • ? less arrhythmia and more hypotension compared to dobutamine
      • some patients require vasopressor support in conjunction with dobutamine

    Shock in COVID-19 Patients

    Two-thirds of ICU patients with COVID-19 may require vasopressors. Shock may be distributive (e.g., septic shock) or cardiogenic. Consider TTE in patients with evidence of cardiac dysfunction (elevated troponin) and hemodynamic instability to evaluate for cardiogenic shock. Note: given the exposure risk during TTE, all potential TTEs should be discussed with the ICU attending of record, and TTE order requisitions should clearly state that the patient has COVID-19 or is a PUI. In most patients, norepinephrine should be the initial vasopressor chosen to manage both distributive and cardiogenic shock. In distributive shock, the first additional vasopressor to add after norepinephrine is vasopressin.

    Cardiology Issues in the ICU

    Arrhythmias

    Cardiac arrhythmias are common in ICU patients due to severity of acute illness, comorbid cardiac conditions, use of vasoactive medications, and large fluid (and electrolyte) shifts. The most common arrhythmia is atrial fibrillation, though ICU patients may develop any tachy- or bradyarrhythmia. These arrhythmias may be brief, self-resolved and asymptomatic or may lead to significant symptoms, cardiogenic shock and ultimately death. All ICU patients are on continuous cardiac monitoring (telemetry). Generally MICU patients, especially those being actively diuresed, should have daily comprehensive metabolic panels (including magnesium). Use ACLS algorithms for stable and unstable tachy- and bradyarrhythmias.

    Decompensated Heart Failure

    Congestive heart failure (both with reduced and preserved ejection fraction) is a common complicating factor in MICU patients and volume status of these patients can be difficult to ascertain. Additionally, CHF exacerbations with cardiogenic pulmonary edema can closely mimic ARDS in COVID-19. There are many causes, and they each should each be considered carefully.

    1. Causes – iatrogenic volume overload, withheld home medications, physiologic stress of critical illness, myocardial ischemia (see ACS above), *Covid-19 related cardiomyopathy/myocarditis
    2. Diagnostics – serum BNP (<100 has good negative predictive value, unless patient obese), markers of end organ perfusion (mental status, lactic acid, creatinine), troponin, 12-lead electrocardiogram, chest x-ray, echocardiogram.
    3. Treatment – dependent on underlying cause.
      • Diuresis if total body overloaded; if Lasix naïve, consider 10-20mg initial dose.
      • Consider restarting home medications if previously withheld (especially if hemodynamically stable).
      • Treat underlying ACS if present.
      • Low threshold to evaluate for new onset cardiomyopathy, given initial reports of viral induced heart failure

    Fever in the ICU

    Patients with COVID-19 often have ongoing fevers, though ICU patients are also at risk for other causes of fever. Additional causes of fever in the ICU to consider:

    Work-up:

    1. A basic work-up starts with a CBC with diff, liver panel, blood cultures, sputum culture, urine culture, procalcitonin, and chest xray.
    2. Additional work-up will depend on your clinical suspicion and may include cultures of other suspected sites (stool, catheters, surgical drains), abdominal imaging (ultrasound or CT), sinus CT, etc).

    Select causes of fevers:

    1. Intravascular catheter-related infections:
      • Should be considered in any patient with a fever and central line placed > 48 hours prior, particularly if any erythema, pain, or purulence near the insertion site.
      • Be sure to draw two blood cultures from a peripheral site as the catheter may be colonized with skin contaminants and growth on cultures drawn from the catheter may not represent true infection.
      • Catheter removal is warranted for tunneled lines and ports; in the presence of sepsis, clot, endocarditis or other metastatic spread; in the presence of persistent bacteremia x 72 hours despite antibiotics; and in infections due to S. aureus, Pseudomonas, drug resistant gram negative rods, and Candida. Catheter removal is not necessary for patients with unexplained fever who are hemodynamically stable in the absence of bacteremia.
      • Empiric antibiotic therapy should be guided by gram stains: vancomycin for gram positive infections, ceftriaxone for gram negative infections (cefepime if neutropenia present). Tailor antibiotics to culture results.
    2. Ventilator-associated pneumonia (VAP):
      • VAP is a clinical diagnosis in a patient who has been intubated for ≥ 48 hours who develops a new or progressive infiltrate on imaging that is thought to be infectious (fever, purulent sputum, leukocytosis)
      • Empiric therapy should include coverage for MRSA (vancomycin) and Pseudomonas (Cefepime, Zosyn, or Meropenem).
    3. UTI (particularly related to urinary catheters):
      • Diagnosis made in the presence of bacteriuria and signs of infection.
      • Urine specimens for culture should ideally be obtained by removing the indwelling catheter and collecting urine from a midstream sample, or by collecting from a newly placed catheter if a midstream sample is not possible.
    4. Acalculous cholecystitis
      • All ICU patients are at risk, particularly those with diabetes, ESRD and those on total parenteral nutrition.
      • Patients will present with fever, RUQ abdominal pain or tenderness, and elevated bilirubin or alkaline phosphatase.
      • Diagnosis can usually be made with abdominal ultrasound in the right clinical context.
      • Treatment includes antibiotics (Zosyn or meropenem) and drainage (percutaneous cholecystostomy)
    5. Drug fever: culprits to consider include antiepileptics (common), beta-lactam and sulfa antibiotics (common), heparin (rare).

    Bacterial superinfection in COVID-19

    Clinical reports indicate that rates of bacterial superinfection are low (10-20%) but are associated with increased mortality. Anecdotal reports suggest less MRSA superinfection than with influenza. Send sputum culture, blood cultures, urine strep and legionella antigens, MRSA nasal swab, procalcitonin (PCT level > 0.5 suggests bacterial process may be present) on admission and when there is increased suspicion of second/alternative diagnosis. Consider trending procalcitonin to identify those with possible superinfection.

    Therapy

    1. Without risk factors for MRSA or Pseudomonas (i.e. living in community, no prior MDR infections) use Ceftriaxone and Azithromycin
    2. With risk factors for MRSA or Pseudomonas (i.e. chronic hospitalization, prior MDR infections) use Vancomycin and Cefepime; consider adding Ciprofloxacin if high concern for Pseudomonas.

    Renal issues in the ICU

    Acute kidney injury (AKI)

    1. AKI is common in the ICU, and patients need BUN, Cr and urine output (UOP) monitored closely
      • UOP 100-400cc/d or < 0.5cc/kg/h = oliguria, UOP < 100 cc/d = anuria
      • Transient decrease in UOP with normal BUN/Cr (ie if RN asks for bolus due to several hours low UOP) likely does not need intervention
      • Similarly, rise in BUN/Cr with normal UOP shows kidney still functioning reasonably well and labs may improve without intervention
      • Combination of sustained decrease in UOP (>8-12 hours) and rising BUN/Cr concerning for worsening kidney injury
    2. Common nephrotoxic medications such as NSAIDs and ACEI/ARBs are typically held on admission to the ICU
    3. Work-up to classify AKI as pre-renal, intrinsic-renal and post-renal includes:
      • Assessment of BUN/Cr ratio
      • Urinalysis with microscopy
      • Can consider urine electrolytes/Urea/Cr to calculate FENa or FEUrea (if patient using Lasix), though this is less useful in critical illness
      • Assessment of urine sediment by renal consult service for casts
      • Renal ultrasound

    1. *For all types of worsening AKI:

      1. Dose-adjust medications metabolized/cleared via kidneys (involve pharmacy)
      2. Temporize hyperkalemia (Calcium, insulin/dextrose)
      3. Consider sodium bicarb infusion for progressive metabolic acidosis
      4. Involve renal consult service early for possible replacement therapy (RRT) if necessary

      Initiation of Renal Replacement Therapy (RRT)

      1. AKI can evolve rapidly in the ICU and especially in the setting of AKI on CKD may lead to the need for RRT
      2. Common indications for dialysis include refractory metabolic acidosis, hyperkalemia, volume overload impacting oxygenation, uremia contributing to severe delirium.
      3. Involve the renal consult service when trajectory of AKI is worsening. It is preferable to have them on-board early to anticipate when RRT may become necessary.
      4. Also reach out early to COVID procedure team (pager 5303, available 24/7), once the decision is made to initiate RRT, in order to facilitate placement of dialysis catheter.

      Acid-base disorders

      Acid-base disorders are common in the ICU and require a step-wise approach to assess the primary disturbance. See the UpToDate article Simple and mixed acid-base disorders for further information.

      Electrolyte derangements

      1. Electrolyte derangements are common and often co-occur. Remember to check Mg/Phos when abnormalities are noted on BMP (Na disturbance, K disturbance, AKI)
      2. In COVID patients the ICU electrolyte repletion order sets are often impractical, as they may recommend repletion of relatively normal electrolyte levels and prompt unnecessary nursing entry into patient rooms. Review electrolytes at least daily and make individualized plans for any interventions.
      3. Reference the pharmacy medication guidelines document on electrolyte repletion for a review of the exact formulations/dosing of electrolyte repletion available

    Nutrition in the ICU

    ICU patients have increased metabolic demands and thus are at high risk for calorie malnutrition. In general, if a patient is predicted to be NPO for greater than seven days, enteral feeding should be started (this includes most ICU patients). Nearly all ICU patients have oro-gastric tubes, making this process relatively seamless. Considerations for tube feeding are as follows:

    1. Enteral versus parenteral – without contraindication to enteral feeding (#6 below), this is the preferred method due to less infectious complications and improved bowel wall integrity (as compared to total parenteral nutrition)
    2. Location of tube – gastric is generally acceptable for most patients; post-pyloric may be used for patients with severe GERD or anatomical complications such as gastric/duodenal fistulas, etc.
    3. Continuous versus bolus feeds – does not make a difference, but tend to use continuous feeds in the ICU.
    4. Formulation – varies from patient to patient (renal diet, diabetic diet, etc) and is based also on metabolic demands. This is a complex topic, but to simplify it for the purpose of this document, nutritional services (via EPIC consult) is helpful in determining type and rate of tube feeds.
    5. Prior to any attempt at extubation, ensure that tube feeds are discontinued several (at least 2) hours prior.
    6. Contraindications to enteral feeding – hemodynamic instability, ileus, bowel obstruction, severe GI bleeding, abdominal compartment syndrome.

    Communication

    Special thanks to Dan Gavin, Keri McDonough, Suzette Bianchi, Avital Rech and Perla Macip Rodriguez for their help in developing this section. Caring for COVID-19 patients may present communication challenges. There is uncertainty regarding clinical course, outcomes, and COVID-19 information is rapidly changing, leading to increased anxiety and uncertainty. In addition, family members are unable to visit patients during this difficult time. Also, the added steps involved with donning/doffing PPE may lead to reduced clinician efficiency. Thus, early and frequent communication with team members and HCP/NOK/family is imperative for excellent patient care.

    Communication Tips

    1. Patients: Use intercom or in-room telephone to communicate with patient (see appendix for room phone numbers)
    2. Family: Make sure to designate a point of contact. No visitors are allowed. Exceptions can be made in case-by-case situations, such as if a patient is dying, for asymptomatic family members. Family meetings via zoom can be arranged with case managers.
    3. Nurses: Communicate frequently with the nurse to consolidate room entry, verify rounding sequence, introduce personnel-intensive-treatments early (e.g., proning).
    4. Respiratory therapists: Establish with RT on morning ventilator rounds a strategy to perform vent checks and changes throughout the day so that respiratory therapists can minimize room entry. Observe outside the room and communicate with intercom when RTs are making vent changes to minimize RTs having to return to the room with multiple changes.
    5. Care Managers and Social Work: Huddle in the morning with care managers, social work, charge nurse, nurse managers, PT/OT and physicians. Notify care managers of family members who have been allowed exceptions for visiting patients to facilitate family arrival and safety.

    End of Life Care/Considerations

    Please refer to the Palliative Care Toolkit for more specific guidance on management of pain, dyspnea as well as communication skills.

    Heath Care Proxy and Code Status

    As with several other topics, it is best to try to batch tasks with COVID patients to minimize exposure. Recognizing that patients can decompensate quickly, it is important to discuss these during the admission H&P. Floor teams have built this into the workflow and if receiving a transfer, discuss with the team what conversations have been had.

    1. Healthcare proxy
      • “Who is your backup person–who helps us make decisions if you can’t speak? Who else? (having 2 backup people is best)”
      • Ideally nurse would be in the room when you obtain this information to serve as the witness. Once outside the room and doffed, fill out HCP form. If no witness, document in admission note patient’s reported preference.
    2. Code Status
      • Make a recommendation that is tailored to each specific patient that takes into consideration baseline functional status, preferences/values and current patient condition.
        • “Tell me about yourself and what’s important to you in your life”
        • “Based on what you have told me, in the emergency that you were to get worse, I would recommend not performing aggressive interventions like chest compressions and artificial life support that are unlikely to change the outcome and could cause more harm than good. What do you think?”

    Patient and family support

    The COVID pandemic presents unique challenges as patients are often isolated without any visitors and infrequent interactions with people who are all covered in gowns. Families are also suffering not being able to see their loved ones and feeling like they have no control over the situation.

    1. We strongly encourage daily communication updates with the families (HCP to serve as point person) in the afternoon. We recommend dividing the list equally amongst all providers so that this important task doesn’t just depend on one intern as this can be time consuming. Try to maintain continuity in communication when possible.
    2. Try using video chat (ipad available in nursing manager’s office for this reason)
    3. Consider palliative care consults not only for patient symptoms but also in difficult circumstances to help support families as they can talk with them daily.
    4. If a patient and family choose to focus on comfort, please consult Hospice in Hospital not just for the patient but for families, as there are several support resources available to them for several months after the death of a loved one.

    End of life care

    1. Work closely with social work and case management to identify patients who are at high risk of decompensation or cardiac arrest. They will help with bringing families in to see their loved ones.
    2. They can also facilitate family meetings at specific times so that key family members are all present. These can either be done via telephone with multiple family members or via zoom chat such as in a conference room
    3. Verbalize empathic statements and try to capture the emotion (disbelief) that family is having: “I am sorry, I wish it was a different circumstance. He worsened so quickly and we did everything we could to help”
    4. Praise the family for their help and support: “Thank you so much for all your support and allowing us to take care of him in the best way possible”