Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine

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Salient Points 

This article focuses on the following:

  • Preparedness of the ICU
    1. Response plan
    2. Infection Prevention and Control Policies and Training for Healthcare Personnel
    3. Preparing Job Cards for New Staff Being Posted in ICUs/HDUs
    4. ICU Admission and Infection Control Plan
  • Staff and Institutional Capacity
    1. Workforce Alignment
    2. Staff Illness and Quarantine
    3. Alternative Strategies During Shortage of Staff
  • Training and Health care Worker Assurance
    1. Basic Care
    2. Ventilation Strategies
  • Critical Care Triage and Allocation
    1. General Triaging
    2. Discharge Criteria to Step-down Unit or Ward 
  • Equipment
    1. Inventory Checklist
    2. Personal Protective Equipment
  • Logistics and Capacity
    1. Airborne Infection Isolation Rooms Desirable
    2. Environmental Cleaning
  • Communication
    1. Chain of Command
    2. Communication components
  • Diagnostics
  • Sterilization
    1. Cleaning and sterilization
    2. Cycling of patients
    3. Special precautions
    4. Reusage
    5. Alternatives for surge
  • Infection Control and Biomedical Waste Management
    1. Biomedical Waste Management COVID-19 in ICU
    2. Reprocessing of Consumables and Devices for COVID-19 in ICUs
  • Treatment Strategies – I
    1. Basic outline
    2. Noninvasive support
    3. Ventilation support
    4. Rescue strategies
    5. Supportive care
    6. Steroids
  • Treatment Strategies–II
    1. Pharmacological treatment of COVID-19
    2. Anticipated complicators and prognosticators
  • Post-ICU Care
    1. Discharge
    2. Rehabilitation
    3. Follow-up

Detailed Summary 

Preparedness of the ICU 

  • Response Plan
    1. To identify and isolate patients with confirmed or suspected COVID-19.
    2. First and second triage areas should be clearly designated and demarcated.
    3. Cough, sneezing, respiratory etiquettes, and hand hygiene protocols should be printed and displayed.
    4. Alcohol-based hand sanitizer for hand hygiene should be available at each entrance and in all common areas.
    5. Facility should have a process to ensure that patients with confirmed or suspected COVID-19 are rapidly moved to either isolation facilities of designated ICUs or high-dependency units (HDUs).
    6. All hospitals should ensure their staff are trained, equipped, and capable of practices needed to contain it 
  • Infection Prevention and Control Policies and Training for Healthcare Personnel (HCP)should be done regarding reporting of COVID-19 cases, triage procedures, hand hygiene procedures, disinfection of hospitals and high touch surfaces in ICUs, signs and symptoms of the disease and infection control practices and use of personal protective equipment (PPE).
  • Job cards should be prepared for the new staff posted in ICUs regarding the shift plan, documentation, infection prevention,critical care procedures,psychological assessment and care,team meetings and inventory management.
  • If admitted, a patient with known or suspected COVID-19 should be kept in a single-person room with the door closed. Preferably the patient should have a dedicated bathroom.
  • Once the patient has been discharged or transferred, the HCPs, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.
  • After the time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use.

Staff and Institutional Capacity 

  • Workforce Alignment
    1. Hospitals should identify an ICU to provide care to COVID-19 suspected/confirmed cases, rather than accepting them in every ICU.
    2. Staff selected for such patient care should not have comorbidities and should be made aware of the risk of infection and infection control practices to be followed on such patients.
    3. Adequate staff strength should be provided in ICU to prevent long working hours and exhaustion.
  • Staff Illness and Quarantine

All staff members who are exposed or having fever or respiratory symptoms should be reported for exposure for checkup and should be taken off ICU duty.

  • Alternative Strategies During Shortage of Staff

The staff who can be mobilized should be identified and their screening should be done in advance. In case of surge of COVID-19 cases, a makeshift ICU should be commissioned. 

Training and Health care Worker Assurance 

  • Basic Care

In the current COVID-19 pandemic,

10 to 20% patients require ICU admission

3 to 10% patients require intubation and mechanical ventilation

-Tiered staffing with critical care staff collaborating with noncritical care staff for care of all ICU patients is a viable option.

-Noncritical care nurses should be assigned primary responsibilities(patient assessment, documentation, administration of medications, and general care).

-Critical care nurses can supervise and advise noncritical care nurses on issues such as vasopressor and sedation titration. 

  • Ventilation Strategies           

Ventilation Protocol for Patients with Acute Respiratory Distress Syndrome

-Calculate PBW.

-Males = 50 + 2.3 [height (inches)—60]

-Females = 45.5 + 2.3 [height (inches)—60].

-Set ventilator settings to achieve initial tidal volume ( VT ) = 6 mL/kg PBW

– Intubate the patient (while taking utmost aerosol precautions) with an endotracheal tube with subglottic suction.

-Set initial rate to approximate baseline minute ventilation (not > 35 bpm). Aim for a pH over 7.2.

-Oxygenation Goal: PaO2 55–80 mm Hg or Oxygen Saturation (SpO2) 88–95%.

– If ventilation is needed for two adjacent patients and only one oxygen port is available, convert a single oxygen supply to dual by using the “Y” connector at the outlet or using an oxygen cylinder.

-Judicious use of Noninvasive ventilators (NIV )/ high-flow nasal cannula (HFNC) should be done in mild and recovering cases to compensate for shortage of ventilators.

-Isolation precautions should be followed to prevent cross infection to other patients.

Critical Care Triage and Allocation 

  • General Triaging 

 All COVID-19 suspect patients should undergo triaging to segregate the patients who will require admission,evaluation or admission to ICUs or HDUs.

  • Discharge Criteria to Step-down Unit or Ward 

When patient’s physiological status has stabilized and the need for ICU monitoring and care is no longer necessary.

– Vitals are stabilised ( Heart rate < 90/minutes , SBP > 120 mm Hg off vasopressors,RR < 20/minutes and no need for organ support treatment ).

Equipment 

  • Inventory Checklist

-Staff members responsible for the care of COVID-19 patients should be allocated.

-Proper  training, including the use of PPE among staff dedicated to the care of infected patients should be done and recruitment of additional staff should be planned in case of nonavailability of staffs.

-Adequate stock of materials such as PPE, hand hygiene materials, ventilators, pharmacy supplies, oxygen ,etc. should be there.

  • Personal protective equipment : Procurement of enough PPEs as protection of HCWs is of utmost importance in this stressful exercise.

Logistics and Capacity 

  • Airborne Infection Isolation Rooms Desirable 

They are single-patient rooms at negative pressure relative to the surrounding areas and with a minimum of six air changes per hour (12 air changes per hour are recommended for new construction or renovation). Air from these rooms are exhausted directly to the outside or filtered through a high-efficiency particulate air filter directly before recirculation.

  • Environmental Cleaning
  • Proper cleaning and disinfection of environmental surfaces in patient room should be done.
  • Hypochlorite solution (1% for disinfection and 0.5% for surface cleansing) should be used.

Communication 

  • Chain of command
  • Within hospital: The hospital incident command system (HICS) must be developed and used by hospitals to tackle a disaster. It enables structured communication within the ICU, cross-communication between departments and public health agencies, and effective communication and information flow and requests for personnel and equipment.
  • Within ICU : An ICU leadership team including medical, nursing, and other personnel should be created in each ICU in the hospital. 
  • Communication components
  • The components include internal communication, communication with patients, families,media, other hospitals and healthcare professionals and documentation of patient’s medical records.
  • Effective way of communication:

Internal communication: SBAR method ( Situation Background Assessment Response )

Communicating with Patients and Families : SPIKES approach ( Setting Perception Invitation Knowledge Emotions Strategy ).

Diagnostics 

  • Chest radiography:

        – to assess the severity and disease progression in COVID-19 infection.

– not recommended for diagnosis of COVID-19 infection

–     Collection of samples :

Nasal and throat swabs should be collected with Dacron swabs and put inside the primary viral transport media tubes provided. Samples should be collected after donning PPE.

Transportation should be done safely following the Indian Council of Medical Research (ICMR) guidelines

  • Investigations:

           Complete hemogram, liver function test, renal function test, baseline electrocardiogram (ECG), chest radiograph, arterial blood gas (ABG) (if SpO2 < 94%).

The N/L ratio of >1.9 and progressive increase in C-reactive protein level indicate progressive disease.

Sterilization

  • The minimum requirement of cleaning and disinfection is at least once a day and more frequently if surfaces like benchtops or workbenches are soiled.
  • The decontamination procedure for cleaning a cubical or room housing suspected cases is adopted from the guidelines of environmental disinfection NCDC, Delhi
  • The concentration of sodium hypochlorite :

1000 ppm (0.1%) for general surface disinfection

10,000 ppm (1%) for disinfection of large clinical samples

Infection Control and Bio medical Waste Management

  • Biomedical Waste Management COVID-19 in ICU
  • Suction tubing, catheter, ET tubes, ventilator tubings, urobag, intercostal drain (ICD) drain, central line, syringe,gloves,goggles: red bag
  • ECG electrodes, glucose strip, cotton, gauze, mask,apron, shoe cover and cap,: yellow bag.
  • Needles and sharp ampoules: puncture proof container.
  • Syringe cover, catheter cover, medicine cover and stationary: black bag.
  • ICD bottle, ampoules: blue bag
  • Reprocessing of Consumables and Devices for COVID-19 in ICUs
  • Reuse of single-use medical devices (SUDs) is not allowed
  • In case of pandemic, reprocessing of SUDs include disassembling, decontamination, cleaning, inspection, testing, packing, relabeling and sterilization. 

Treatment Strategies – I

  • Basic Outline
  • Patients requiring critical care : management in accordance with the management of acute hypoxemic respiratory failure.
  • Patients with suspected COVID-19 : keep in isolation rooms
  • Patients with mild hypoxemic respiratory failure : supplemental oxygen.
  • Patients with ARDS : fluid conservative strategies after initial fluid resuscitation, lung protective ventilation, empirical antibiotics to cover for suspected common bacterial pathogens, sedation with sedation-free intervals, thromboprophylaxis to prevent venous thromboembolism, and emphasis on nutrition.
  • Patients with refractory hypoxemia: prone positioning or ECMO.
  • Invasive Mechanical Ventilation
  • A lung protective strategy (4 to 8 mL/kg PBW) should be followed
  • Plateau pressure goal: ≤30 cm H2O.
  • Check Pplat (0.5 second inspiratory pause), at least every 4 hours and after each change in PEEP or VT. If Pplat >30 cm H2O: decrease VT by 1 mL/kg steps (minimum = 4 mL/kg).
  • Consider the use of incremental FiO2/PEEP combinations such as shown below to achieve goal.
  • Rescue Strategies
  • Venovenous ECMO (VV-ECMO) to be used in ARDS with refractory hypoxemia.
  • Steroids
  • Systemic corticosteroids not to be routinely prescribed for critically ill patients with COVID-19.
  • Inhaled steroids can be continued if indicated, in patients with COVID-19-related acute respiratory failure. 
  • Supportive Care

  All patients should receive standard supportive care  recommended for other critically ill patients with ARDS.

Treatment Strategies–II 

  • Pharmacological treatment of COVID-19.
  • Flu of unknown etiology : Oseltamivir 75 μg twice daily in all adult patients with normal renal function [stop if H1N1/H3N2 reverse transcription polymerase chain reaction (RT-PCR) is negative].
  • Empirical antibiotics for the treatment of bacterial pneumonia, per guidelines, should also be added (β lactams along with macrolides).
  • Pruning should be done in cases of difficult oxygenations.
  • Drug Management of COVID-19– Currently no effective drug.
  • Some drugs on trial basis are remdesivir, lopinavir/ritonavir alone or with ribavirin, chloroquine/hydroxychloroquine, its active metabolite.
  • Chemoprophylaxis
  • Hydroxychloroquine 400 μg twice daily for day 1 followed by a weekly dose of 400 μg for 7 weeks in case of HCWs and for 3 weeks for close contacts.
  • Monitoring

      Patients should be monitored daily for any clinical worsening and discharged after obtaining two consecutive negative RT-PCR results at least 24 hours apart from the oropharyngeal swabs.

  • Anticipated Complications of COVID-19 infections
  • Acute cardiac injury: 7 to 12% of cases.
  • Fulminant myocarditis.
  • Acute kidney injury: less than 10% of cases.
  • Disseminated intravascular coagulation
  • Thrombocytopenia
  • Coagulopathy

 Post-ICU Care

  • Discharge Criteria for COVID-19 Infected Patients
  • Afebrile for 3 days
  • Improved respiratory symptoms
  • Nucleic acid tests (rRT-PCR) negative for SARS COV2 from two consecutive samples of nasopharyngeal or throat swabs at 24 hours’ interval
  • There should be an interval of 7 days between the first and final tests before discharge (even if the patient clinically recovers earlier than 7 days).

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