Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID‑19)

Recommendations issued from a panel of 36 experts from 12 countries to help support healthcare workers caring for critically ill ICU patients with COVID-19.

References

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID‑19) ncbi.nlm.nih.gov/pubmed/32222812

Acute Respiratory Infection

An Acute Respiratory Infection (ARI) is diagnosed when certain findings are present. It is considered severe (SARI) if the patient requires hospitalization.

References

World Health Organization. Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) is suspected. Interim guidance. 2020. WHO/bCoV/Clinical/2020.2

ARDS Berlin Definition

The ARDS Definition Task Force developed a definition for Adult Respiratory Distress Syndrome (ARDS) in Berlin in 2011. This involved the European Society of Intensive Care Medicine, the American Thoracic Society and the Society of Critical Care Medicine.

References

The ARDS Definition Task Force. Acute Respiratory Distress Syndrome. The Berlin Definition. JAMA. 2012; 307: 2526-2533.

Arterial pH Target Brigham Womens

The target for the arterial pH is to maintain a range from 7.30 to 7.45. Changes in the respiratory rate is often the first step to change the pH when needed.

References

Brigham and Woman’s Hospital

Close Contact to a Respiratory Infection

The risk of acquiring a communicable respiratory infection increases if a person comes into close contact with an infected patient.

References

Centers for Disease Control and Prevention. Interim guidance for healthcare professionals. 2019 Novel Coronavirus.

Centers for Disease Control and Prevention. Interim guidance for risk assessment and public health management of persons with potential 2019 novel coronavirus (2019-nCoV) exposure in travel-associated or community settings.

COVID19 Adult Mortality Model Zhou

Zhou et al developed a simple model for predicting in-patient mortality of a patient with COVID-19. This can help to identify a patient who may benefit from more aggressive management. The authors are from multiple institutions in China.

References

Zhou F, Yu T, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. doi: 10.1016/S0140-6736(20)30566-3.

COVID19 Clinical Findings

Infection with the 2019 Novel Coronavirus (2019-nCoV) shows a number of clinical findings shared with SARS and MERS.

References

Chen N, Zhou M, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020. doi: 10.1016/S0140-6736(20)30211-7.

Holshue ML, DeBolt C, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020. doi: 10.1056/NEJMoa2001191.

Huang C, Wang Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020. doi: 10.1016/S0140-6736(20)30183-5.

Li Q, Guan X, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020. doi: 10.1056/NEJMoa2001316

World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected. WHO/nCoV/Clinical/2020.2

COVID19 Clinical Stages of Siddiqi

Siddiqi and Mehra reported clinical stages for the progression of a COVID19 Infection.

References

Siddiqi HK, Mehra MR. COVID-19 illness in native and immunosuppressed states: A clinical-therapeutic staging proposal. J Heart Lung Transplantation. 2020.

COVID19 Critical Illness Model Petrilli

Petrilli et al evaluated patients with COVID-19 who required critical care. They identified risk factors that can help to identify a patient who may require more aggressive management. The authors are from New York University in New York City.

References

Petrilli CM, Jones SA, et al. Factors associated with hospitalization and critical illness among 4.103 patients with Covid-19 disease in New York City. 2020 medRxiv preprint. doi.org: 10.1101/2020.04.08.20057794.

COVID19 Exposure Risk

The risk of being exposed to COVID-19 depends on a number of factors.

References

Centers for Disease Control and Prevention. Interim US Guidance for risk assessment and public health management of persons with potential 2019 novel coronavirus (2019-nCoV) exposure in travel-associated or community settings. 2020.

COVID19 Lab Findings Poor Prognosis Brigham Womens

A number of laboratory findings are associated with a poor prognosis for a patient with COVID19. These reflect high risk complications (ARDS, multi-organ failure, DIC, myocarditis, cytokine release, etc).

References

Yan L, Zhang H-T, et al. Prediction of criticality in patients with severe Covid-19 infection using three clinical features: a machine learning-based prognostic model with clinical data in Wuhan. 2020. doi: 10.1101/2020.02.27.20028027. medRxiv.org

Zhou F, Yu T, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. doi: 10.1016/S0140-6736(20)30566-3.

COVID19 Model of Yan for Mortality

Yan et al reported a prognostic model for a patient with COVID19 in Wuhan, China, based on laboratory testing.

References

Yan L, Zhang H-T, et al. Prediction of criticality in patients with severe Covid-19 infection using three clinical features: a machine learning-based prognostic model with clinical data in Wuhan. 2020. doi: 10.1101/2020.02.27.20028027. medRxiv.org

COVID19 Patient Risk for Fatal Disease simplified

The risk for mortality associated with a COVID-19 infection increases with age and comorbid conditions.

References

Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from WRuan Q, Yang K, et al. uhan, China. Intensive Care Medicine. doi: 10.1007/s00134-020-05991-x

COVID19 Patient Risk for Fatal Disease

The risk for mortality associated with a COVID-19 infection increases with age and comorbid conditions.

References

Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from WRuan Q, Yang K, et al. uhan, China. Intensive Care Medicine. doi: 10.1007/s00134-020-05991-x

COVID19 Restrictions

The level of risk for exposure to COVID19 determines the level of restrictions placed on the patient.

References

Centers for Disease Control and Prevention. Interim US Guidance for risk assessment and public health management of persons with potential 2019 novel coronavirus (2019-nCoV) exposure in travel-associated or community settings. 2020.

COVID19 Severe Disease

Infection with the 2019 Novel Coronavirus (2019-nCoV, COVID-19) may show a number of complications, some of which can be fatal.

References

Chen N, Zhou M, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020. doi: 10.1016/S0140-6736(20)30211-7.

Holshue ML, DeBolt C, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020. doi: 10.1056/NEJMoa2001191.

Huang C, Wang Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020. doi: 10.1016/S0140-6736(20)30183-5.

Li Q, Guan X, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020. doi: 10.1056/NEJMoa2001316

World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected. WHO/nCoV/Clinical/2020.2

COVID19 Triage to ICU Brigham Womens

A patient with COVID19 should be triaged for ICU admission early if certain findings are present.

References

Brigham and Women’s Hospital COVID-19 Critical Care Clinical Guidelines. covidprotocols.org

Cytokine Release Syndrome Grading System Lee

Lee et al reported a grading system for the Cytokine Release Syndrome (CRS). The authors are from the National Cancer Institute, Seattle Children’s Hospital, University of Pennsylvania, Texas Children’s Hospital and Children’s Hospital of Philadelphia.

References

Lee DW, Gardner R, et al. Current concepts in the diagnosis and management of cytokine release syndrome. Blood. 2014; 124: 188-193.

Riegler LL, Jones GP, Lee DW. Current approaches in the grading and management of cytokine release syndrome after chimeric antigen receptor T-cell therapy. Therapeutics and Risk Management. 2019; 15: 323-335

DIC Criteria ISTH

The Subcommittee on DIC for the Scientific and Standardization Committee (SSC) of the International Society on Thrombosis and Haemostasis (ISTH) has developed a definition and scoring algorithm for disseminated intravascular coagulation (DIC).

References

Ha SO, Park SH, et al. Performance evaluation of five differentiated disseminated intravascular coagulation (DIC) diagnostic criteria for predicting mortality in patients with complicated sepsis. J Korean Med Sci. 2016; 31: 1838-1845.

Levi M. Disseminated Intravascular Coagulation: New diagnostic criteria and supportive treatment strategies. 47th Scientific and Standardization Committee Meeting of the International Society on Thrombosis and Haemostasis. July 6-7, 2001. Paris, France. Medscape Cardiology. 2001. www.medscape.com. Accessed 08/22/2001.

Taylor FB Jr, Toh CH, et al. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001; 86: 1327-1330.

Initial FIO2 and PEEP Brigham and Womens

The initial FIO2 and PEEP for a patient on mechanical ventilation can be based on the ARDS Network recommendations.

References

Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000; 342: 342: 1301-1308.

Tidal volume and Predicted Body Weight

The ratio of tidal volume to predicted body weight is used to adjust mechanical ventilation.

References

ARDSNet

Robinson JD, Lupkiewicz SM, et al. Determination of ideal body weight for drug dosage calculations. Am J Hosp Pharm. 1983; 40: 1016-1019. 6869387

Asymptomatic Suggested Follow Up

A patient who is asymptomatic after a possible exposure to the novel coronavirus should be monitored for signs and symptoms during the possible incubation period (up to 14 days after the exposure).

Asymptomatic Suggested Restriction

A patient who is asymptomatic after a possible exposure to the novel coronavirus should be monitored for signs and symptoms during the possible incubation period (up to 14 days after the exposure).

Coronavirus Asymptomatic

A patient who is asymptomatic after a possible exposure to the novel coronavirus should be monitored for signs and symptoms during the possible incubation period (up to 14 days after the exposure).

Coronavirus Lancet Flow Diagram

Zhang et al reported a flow diagram for managing a patient in a fever clinic faced with 2019 novel coronavirus (COVID-19).

Coronavirus Symptomatic

A symptomatic patient who may have COVID19 needs to be managed according to the severity of the infection.

COVID19 Quarantine Release

A person with COVID-19 can be released from quarantine/isolation if certain conditions are present. The patient should not be released if still infectious to others.

ECMO Respiratory Failure Brigham Womens

Selected patients with severe respiratory failure may benefit from extracorporeal membrane oxygenation (ECMO) therapy.

Refractory Hypoxemia Brigham Womens

Symptomatic Suggested Action

A symptomatic patient who may have COVID19 needs to be managed according to the severity of the infection.