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Acute COVID, What We're Seeing

Posted

Specializes in Critical Care. Has 10 years experience.

COVID-19 has been in my area long enough that we're getting an idea of how it plays out, curious what others are seeing.

The most surprising thing has been the duration of acute illness, I sort of figured it would be like other respiratory viruses just more severe, but with acute symptoms lasting up to 7 days or so.

We've seen timelines similar to what China was reporting; about 10 days from symptom onset to needing ICU care, then critically ill for weeks, the shortest recovery we've seen is 3 weeks of aggressive life support. Time from symptoms onset to death has ranged from 2 to 8 weeks in China. So it's not just the number of patients that will require vents and other equipment, it's the length of time they will need them for.

The first week or so on the vent is similar to a bad influenza; lots of vent support, maybe proning, maybe flolan, not typically requiring inotropes or vasopressors, then they seem to have turned the corner and are out of the woods.

Then they crump, big time. From nothing to max pressors and inotropes and an EF that drops from normal to 10-15% in as little as 12 hours. Sudden onset renal and liver failure, with impressively severe liver failure in such a short amount of time.

Deaths appear more cardiogenic than respiratory, lethal rhythms have varied the full gamut; VT, VF, PEA, and asystole.

We've had enough ventilators so far, but what likely lies ahead will be the need to figure out a process for taking ventilators and other life support equipment away from patients less likely to survive to make them available to patients more likely to survive. Things seem dicey now, but that's a whole 'nuther level of dicey.

This is exceptional information. Please send it pronto to leaders in the field,both medical and governmental.

skydancer7, BSN, RN

Specializes in Operating Room, CNOR. Has 12 years experience.

Thank you. Wondering how hospitals are staffing up for this. It's about to blow up in my area, I am just waiting for the ads for crisis nurses needed but haven't seen anything yet. I guess I will start contacting hospitals. Don't want to get back into nursing long-term but feel the need to come out of grad school land to help out for a few months...

the myocarditis / EF aspect of the virus has been making the rounds of the medicine board on reddit for (what seems like) a week now.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

A couple things we've found that might be helpful:

  • Leave the bathroom door in the patient's room open. With the exception of negative airflow rooms, which make up only a small fraction of the rooms needed, hospitals tend to circulate air by introducing conditioned air into the patient rooms, which then flows into the central area where the outflow vents are. Hospital bathrooms typically also have continuously flowing outflow vents, leaving the bathroom door open may reduce the amount of airflow out into the core. Even though the droplet particles can't remain suspended in the air for all that long, with the right airflow it can travel pretty far.
  • Some hospital rooms utilize a pass-through closet for linen, one that can be stocked from the hallway but accessed from the room. Putting the 'walkie-talkie' COVID patients in nursing units that have these closets can save a huge amount of PPE. We took out the linen and use it pass food, supplies, even medications that would otherwise have required a full set of PPE to be used. Put whatever you need to give the patient in the closet from the hallway, shut the door, then the patient opens the door on their side, so there's also no open airflow out of the room as well.

HandsOffMySteth

Has 3 years experience.

I'm not familiar with treatment options, would putting less severe patients on O2 be a gap fill? Short of bagging, I don't see an option for the lack of ventilators.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

45 minutes ago, juniper222 said:

I'm not familiar with treatment options, would putting less severe patients on O2 be a gap fill? Short of bagging, I don't see an option for the lack of ventilators.

About 12% of those with COVID require hospitalization but not critical care, most commonly it's because of the need for supplemental oxygen and I would say we're already maximizing that as a way of avoiding the need for a ventilator.

We basically took over an ambulatory surgery center and are using their space and their anesthesia machines as vents. Bagging is actually an option, it's how we've been dealing the non-COVID patients that require short term ventilation for procedures, anesthesia recovery, etc.

How are you doing in terms of having enough trained personnel to manage the influx of critical patients? I anticipate that even more than limited rooms, medications, ppe, and ventilators, it's the lack of hospital staff trained in critical care that might wind up being the worst bottleneck as the number of cases surge and doctors and nurses themselves get sick.

nursel56

Specializes in Peds/outpatient FP,derm,allergy/private duty. Has 45 years experience.

Really appreciate your input @MunoRN. So much crazytown out there. Thanks to all of you in critical care, and related higher-risk units.

Lisinopril?

Did he day that the aerosolized virus was 5 microns? Isn't that small?

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 40 years experience.

On 3/19/2020 at 1:25 AM, toomuchbaloney said:

Lisinopril?

Did he day that the aerosolized virus was 5 microns? Isn't that small?

He said the definition of aerosol means that the droplet that suspends the virus has to be about 5 microns.

These are my notes (see below). I have tried to be accurate, but these are not exact quotes.

Coronavirus update with Anthony Fauci, MD

6.45: Sensitivity of the testing? Time from initial exposure to when the test will turn positive? We don't know, but we can surmise it. Time from initial exposure to symptoms; the medium is 5 days, range 2 to 14 days. Maybe 2 days from initial exposure, you might see a positive test. By the time a person is symptomatic, you will almost always have a positive test. This is an extrapolation; we don't have solid data to say this.

9: NSAIDS? No firm data

10.5: ACE inhibitors? We need data. Use of ACE inhibitors can result in an increased expression of the receptor of ACE. It's possible that people who are on ACE inhibitors may be increasing receptors for the virus itself. This is not based on known data, but it is a possibility that we need to address.

12.18: In Italy, 75% of those who died had hypertension. Is it because of one of their drugs? We must look at this.

15.20: Viability droplet onto hard surfaces, 36 to 48 hours.

16: Aerosol form; Aerosol means that the droplet that suspends the virus has to be about 5 microns, so it can stay in the air for several minutes before dropping to the floor.

16.40: Viability droplet onto hard surfaces, probably detectable but so low that it may not have clinical impact by 36 to 48 hours.

17.30: Something contaminated with the virus that comes from a place with a high degree of infection, like China, by the time it gets here, that virus is dead. This is much different from a doorknob that was touched 5 minutes ago

18: Hydroxychloroquin ? Active discussion about this. We don't know yet.

19: Supply problems PPE: do we have enough to do the testing that we need to do, or should those supplies go to protect the healthcare workers who are taking care of people on the front lines.

21.20: When can healthcare workers come back to work? Perfect would be after end of symptoms, and 2 negative tests, 24 hours apart. But we are getting to the place where we can't do that. We don't have the ability to do the tests. We are going to have to make a best judgment recommendation about how many days after end of symptoms for people to go back to work. Evolving situation.

22.30: Antivirals? Don't know yet. China has 2 studies going. We desperately need the data. We need to know efficacity, and side effects.

25.15: Incubation is about 2 weeks; What do you think this next 2-3 week period is going to tell us? By then we will have a sense of whether we have enough of the supplies that it's going to take to give the care that we want to give.

27: Health equity? We have to talk with the healthcare workers, the people on the streets, the ethicists: we have to hash this out. Deciding who gets something and who does not get something creates ethical stress, ethical dilemma. No one organization can decide this.

28.30: What should local, state, and federal government do? Try to stick to the CDC guidelines.

pixierose, BSN, RN

Specializes in ED, psych. Has 4 years experience.

Kitiger - thank you for the notes, so much appreciated. Lisinopril and hypertension ... 5 microns ... this is a scary virus.

MunoRN - thanks for documenting your experiences. We’ve gotten them ready to go to the floors, so it’s fascinating to see what you guys do when these pts get there. We’ve been sending them to both ICUs and med surg floors - the teamwork between everyone in the hospital has been amazing.

So is it just ACE or ARBs too?

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

16 hours ago, Cowboyardee said:

How are you doing in terms of having enough trained personnel to manage the influx of critical patients? I anticipate that even more than limited rooms, medications, ppe, and ventilators, it's the lack of hospital staff trained in critical care that might wind up being the worst bottleneck as the number of cases surge and doctors and nurses themselves get sick.

There's been plenty to delegate to non-critical care staff, who take to even the ICU-specific care pretty quickly. One thing about all nurses is that they can often just figure things out even without the official training.

Some we use as runners, we've ripped the white boards off the walls and use them as shopping lists when we're in the room, we write what we need on the board and face it towards the window into the hallway, as the runners (spare non-ICU nurses) come around they get what's on the lists and leave it in a bin outside the door.

What's probably been a bigger issue is the lack of intensivists, so all of our anesthesiologists have been emergently credentialed as intensivists.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

On 3/19/2020 at 1:25 AM, toomuchbaloney said:

Lisinopril?

Did he day that the aerosolized virus was 5 microns? Isn't that small?

That's actually a bit bigger than typical influenza droplet particles have been reported to be, although the virus itself probably doesn't really determine the droplet nuclei size.

PAPR and N95 / M95 effectively filter down to about 0.3 microns, where they start to allow penetration of about 5% of particles.

There is no specific micron size that a surgical or procedure mask will effectively stop penetration since they aren't tested for that purpose, but generally they're only considered effective for particles of 100 microns or larger.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

On 3/19/2020 at 6:57 AM, Kitiger said:

He said the definition of aerosol means that the droplet that suspends the virus has to be about 5 microns.

These are my notes (see below). I have tried to be accurate, but these are not exact quotes.

Coronavirus update with Anthony Fauci, MD

6.45: Sensitivity of the testing? Time from initial exposure to when the test will turn positive? We don't know, but we can surmise it. Time from initial exposure to symptoms; the medium is 5 days, range 2 to 14 days. Maybe 2 days from initial exposure, you might see a positive test. By the time a person is symptomatic, you will almost always have a positive test. This is an extrapolation; we don't have solid data to say this.

9: NSAIDS? No firm data

10.5: ACE inhibitors? We need data. Use of ACE inhibitors can result in an increased expression of the receptor of ACE. It's possible that people who are on ACE inhibitors may be increasing receptors for the virus itself. This is not based on known data, but it is a possibility that we need to address.

12.18: In Italy, 75% of those who died had hypertension. Is it because of one of their drugs? We must look at this.

15.20: Viability droplet onto hard surfaces, 36 to 48 hours.

16: Aerosol form; Aerosol means that the droplet that suspends the virus has to be about 5 microns, so it can stay in the air for several minutes before dropping to the floor.

16.40: Viability droplet onto hard surfaces, probably detectable but so low that it may not have clinical impact by 36 to 48 hours.

17.30: Something contaminated with the virus that comes from a place with a high degree of infection, like China, by the time it gets here, that virus is dead. This is much different from a doorknob that was touched 5 minutes ago

18: Hydroxychloroquin ? Active discussion about this. We don't know yet.

19: Supply problems PPE: do we have enough to do the testing that we need to do, or should those supplies go to protect the healthcare workers who are taking care of people on the front lines.

21.20: When can healthcare workers come back to work? Perfect would be after end of symptoms, and 2 negative tests, 24 hours apart. But we are getting to the place where we can't do that. We don't have the ability to do the tests. We are going to have to make a best judgment recommendation about how many days after end of symptoms for people to go back to work. Evolving situation.

22.30: Antivirals? Don't know yet. China has 2 studies going. We desperately need the data. We need to know efficacity, and side effects.

25.15: Incubation is about 2 weeks; What do you think this next 2-3 week period is going to tell us? By then we will have a sense of whether we have enough of the supplies that it's going to take to give the care that we want to give.

27: Health equity? We have to talk with the healthcare workers, the people on the streets, the ethicists: we have to hash this out. Deciding who gets something and who does not get something creates ethical stress, ethical dilemma. No one organization can decide this.

28.30: What should local, state, and federal government do? Try to stick to the CDC guidelines.

We typically take people off their ACE inhibitors anyway given the likelihood of sudden onset hypotension as well as renal impairment in COVID patients, we typically use shorter acting pushes (hydralazine or b blocker), and drips if necessary (nicardipine, NTG, or nipride). But at some point they often need pressors / inotropes.

At least in the ICU setting there hasn't been a big push yet to using hydroxychloroquine, but we have been using Remdesivir in patients who qualify under the compassionate use exemption and it at least seems effective, there are two trials currently underway. There are liver function requirements for the compassionate use exemption that exclude many or most COVID patients since there is usually some amount of LFT bump in these patients, although we haven't seen Remdesivir significantly increase those bumps.

DannyBoy8, RN

Has 4 years experience.

Is there a need or use for non-ICU nurses who come from perinatal nursing to assist with covid-19 care?

Mas Catoer

Specializes in General. Has 30 years experience.

Very valuable information. Thank you. We need to provide more support to our staff faving the situation. Will help them with more valuable information.