JAMA: Management of Critically Ill Adults With COVID-19

[NRSKarenRN, BSN, RN]

JAMA Clinical Guidelines Synopsis

March 26, 2020

Management of Critically Ill Adults With COVID-19

https://jamanetwork.com/journals/jama/fullarticle/2763879

Quote

Infection Control and Testing

1. For health care workers performing aerosol-generating procedures (eg, endotracheal intubation, nebulized treatments, open suctioning) use of fitted respirator masks is recommended (N95 respirators, FFP2), instead of surgical masks, in addition to other personal protective equipment (PPE) (best practice statement).
2. For usual care of nonventilated patients, or for performing non–aerosol-generating procedures on patients receiving mechanical ventilation, use of medical masks is recommended, instead of respirator masks, in addition to other PPE (weak recommendation, low-quality evidence [LQE]).
3. Diagnostic lower respiratory tract samples (endotracheal aspirates) are preferred over bronchial washings, bronchoalveolar lavage, and upper respiratory tract (nasopharyngeal or oropharyngeal) samples (weak recommendation, LQE).

Hemodynamic Support

1. For acute resuscitation of adults with shock, the following are suggested: measuring dynamic parameters to assess fluid responsiveness (weak recommendation, LQE), using a conservative fluid administration strategy (weak recommendation, very LQE), and using crystalloids over colloids (strong recommendation; moderate QE). Balanced crystalloids are preferred over unbalanced crystalloids (weak recommendation, moderate QE).
2. For adults with shock, the following are suggested: using norepinephrine as the first-line vasoactive (weak recommendation, LQE), use of either vasopressin or epinephrine as the first line if norepinephrine is not available (weak recommendation, LQE). Dopamine is not recommended if norepinephrine is not available (strong recommendation, high QE). Adding vasopressin as a second-line agent is suggested if the target (60-65 mm Hg) mean arterial pressure cannot be achieved by norepinephrine alone (weak recommendation, moderate QE).

Ventilatory Support

1. Starting supplemental oxygen is recommended if the Spo2 is less than 90% (strong recommendation, moderate QE). Spo2 should be maintained no higher than 96% (strong recommendation, moderate QE).
2. For acute hypoxemic respiratory failure despite conventional oxygen therapy, use of high-flow nasal cannula (HFNC) is suggested relative to conventional oxygen therapy and noninvasive positive pressure ventilation (NIPPV) (weak recommendation, LQE). If HFNC is not available, a trial of NIPPV is suggested (weak recommendation, very LQE). Close monitoring for worsening of respiratory status and early intubation if worsening occurs is recommended (best practice statement).
3. For adults receiving mechanical ventilation who have acute respiratory distress syndrome (ARDS), use of low tidal volume ventilation (4-8 mL/kg of predicted body weight) is recommended and preferred over higher tidal volumes (>8 mL/kg) (strong recommendation, moderate QE). Targeting plateau pressures of <30 cm H2O (strong recommendation, moderate QE) is recommended. Using a higher positive end-expiratory pressure (PEEP) strategy over lower PEEP strategy is suggested (weak recommendation, LQE).
4. For adults receiving mechanical ventilation who have moderate to severe ARDS, prone ventilation for 12 to 16 hours is suggested over no prone ventilation (weak recommendation, LQE). Using as-needed neuromuscular blocking agents (NMBAs) instead of continuous NMBA infusion to facilitate protective lung ventilation is suggested (weak recommendation, LQE).
5. For adults receiving mechanical ventilation who have severe ARDS and hypoxemia despite optimizing ventilation, a trial of inhaled pulmonary vasodilator is suggested. If no rapid improvement in oxygenation is observed, the treatment should be tapered (weak recommendation, very LQE). The use of lung recruitment maneuvers (intended to open otherwise closed lung segments, such as 40 cm H2O inspiratory hold for 40 seconds) is suggested, over not using recruitment maneuvers (weak recommendation, LQE), but using staircase (incremental PEEP) recruitment maneuvers is not recommended (strong recommendation, moderate QE). Use of veno-venous circulation for extracorporeal membrane oxygenation (ECMO) or referral to an ECMO center is suggested, if available, for selected patients (weak recommendation, LQE).

Therapy

1. In adults receiving mechanical ventilation who do not have ARDS, routine use of systematic corticosteroids is suggested against (weak recommendation, LQE). In those with ARDS, use of corticosteroids is suggested (weak recommendation, LQE).
2. In COVID-19 patients receiving mechanical ventilation who have respiratory failure, use of empiric antimicrobial/antibacterial agents is suggested (no evidence rating); assess for deescalation.
3. In critically ill adults with fever, use of pharmacologic agents for temperature control is suggested over nonpharmacologic agents or no treatment. Routine use of standard IV immunoglobulins is not suggested. Convalescent plasma is not suggested. There is insufficient evidence to issue a recommendation on use of any of the following: antiviral agents, recombinant interferons, chloroquine/hydroxychloroquine, or tocilizumab

[herring_RN, ASN, BSN]

On 4/19/2020 at 12:22 PM, NRSKarenRN said:

JAMA Clinical Guidelines Synopsis

March 26, 2020

Management of Critically Ill Adults With COVID-19

https://jamanetwork.com/journals/jama/fullarticle/2763879

Thank you Karen!

I read this yesterday and bought a pulse oximeter today after reading this. It is well worth reading.

Quote

The Infection That’s Silently Killing Coronavirus Patients

... There is a way we could identify more patients who have Covid pneumonia sooner and treat them more effectively — and it would not require waiting for a coronavirus test at a hospital or doctor’s office. It requires detecting silent hypoxia early through a common medical device that can be purchased without a prescription at most pharmacies: a pulse oximeter...

https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html

[NRSKarenRN, BSN, RN]

Herring:

Thanks for posting this excellent opinion article by Dr. Levitan about what he learned during 10 days of treating Covid pneumonia at New York's Bellevue Hospital.

Quote

...We are just beginning to recognize that Covid pneumonia initially causes a form of oxygen deprivation we call “silent hypoxia” — “silent” because of its insidious, hard-to-detect nature.

...Pneumonia is an infection of the lungs in which the air sacs fill with fluid or pus. Normally, patients develop chest discomfort, pain with breathing and other breathing problems. But when Covid pneumonia first strikes, patients don’t feel short of breath, even as their oxygen levels fall. And by the time they do, they have alarmingly low oxygen levels and moderate-to-severe pneumonia (as seen on chest X-rays). Normal oxygen saturation for most persons at sea level is 94 percent to 100 percent; Covid pneumonia patients I saw had oxygen saturations as low as 50 percent....

...We are only just beginning to understand why this is so. The coronavirus attacks lung cells that make surfactant. This substance helps the air sacs in the lungs stay open between breaths and is critical to normal lung function. As the inflammation from Covid pneumonia starts, it causes the air sacs to collapse, and oxygen levels fall. Yet the lungs initially remain “compliant,” not yet stiff or heavy with fluid. This means patients can still expel carbon dioxide — and without a buildup of carbon dioxide, patients do not feel short of breath....

Patients compensate for the low oxygen in their blood by breathing faster and deeper — and this happens without their realizing it. This silent hypoxia, and the patient’s physiological response to it, causes even more inflammation and more air sacs to collapse, and the pneumonia worsens until oxygen levels plummet. In effect, patients are injuring their own lungs by breathing harder and harder. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure.

By the time patients have noticeable trouble breathing and present to the hospital with dangerously low oxygen levels, many will ultimately require a ventilator...

Quote

https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html

[HiddenAngels]

So true, and this happens fast. I do keep my eye on the 02 sats and also am starting to hear more about the correlation with D-dimer, RBCs and such. Even tho I may get a pt that is r/o Covid I still wear protective PPE when doing suctioning as if they tested positive... Don't wanna chance it..