COVID 19 for critical care – Critical Care Update

Updated 7/22/2020

Since the discovery of Covid 19(Coronavirus SARS COV 2) in December 2019, flow of information and circumstances are changing everyday. It is hard to keep up with so much information and sort out real from myths.

In general, following points are important to remember which are referenced from reputable sources

Tolicizumab is the latest drug shown to improve mortality and shorten duration of mechanical ventilation in COVID 19.
Dexamethasone showed improved survival in mechanically ventilated patients.
Colchicine improved the time to deterioration in a small study.
Therapuetic plasma exchange may improve outcome in severe COVID.
Remdesivir has been shown to shorten duration of illness in a trial conducted by NIH, and there is a trend towards improved mortality, but not statistically significant. However, another trial published in Lancet showed no benefit.
A comparative study from New York shows that full dose anticoagulation may improve survival in COVID patients.
Hydroxychloroquine did not work for post exposure prophylaxis. Observational study from Newyork did not show any benefit in hospitalized patients.
A retrospective case-controlled study showed benefit of convalescent plasma. However, a randomized controlled trial from China showed no benefit in terms of clinical duration. The trial was stopped prematurely, therefore, it was not powered to detect mortality.
Early intubation is being discouraged, and use of HFNC and NIV is allowed(earlier it was discouraged for fear of aerosolization).
Mechanical ventilation remains same as ARDS due to any other illness.
Social distancing can reduce the rate of spread, thereby preventing over burdening the hospitals, thereby reducing the mortality.
Virus can survive up to 17 days on fomites.
Ideal personal protective equipment is the one shown by Chinese, covering head to toe, howeever, recommendations by CDC wrok pretty well.
Basic infection control measures still work, such as handwashing.
There are up to 30% false negative test results. New antibody tests have come in to the market but several experts warn about their validity. FDA has recently taken half of the tests off market.
Significant number of infected patients are asymptomatic. Interestingly, one study from Germany, other from Iceland showed 15% population was infected, mostly had no symptoms.
Mortality rates are much lower than 3.4% as reported by WHO. A rough estimate shows about 7-9 per thousand.

Vaccine and immunity

mRNA based vaccine produced by moderna healthcare proved its safety profile, and pending phase 3 trials.
Adenovirus based vaccine by Oxford University also showed the same.

Antibody fades away in people who had COVID-19 and recovered in few weeks, but it does not mean they do not have immunity from coronavirus.

An update on sedation requirements in COVID 19 patients.

Summary

Unusually high sedation requirements in large proportion of COVID-19 patients.
Need to administer combinations of multiple agents (e.g., propofol, ketamine, hydromorphone, dexmedetomidine, midazolam), increasing potential risks of side effects (e.g. QT prolongation, hypertriglyceridemia, hypotension, delirium)
Deeper sedation levels may be required to facilitate ventilator synchrony
Intermittent administration of certain drugs (e.g. narcotics) may not be feasible for protection of healthcare workers.
A subset of patients with severe ARDS is likely to require prolonged sedation (oftentimes >2
weeks)
Increased precision in monitoring the depth of sedation (e.g. processed EEG) is required
High doses of opioids may trigger large tidal volumes, paradoxically.
Drug shortages have been reported, which leads to use of less commonly used agents (barbiturates, methadone, clonidine,
chlorpromazine, propranolol) . The use of inhalational anesthetics (e.g. isoflurane), at least in locations with appropriately designed scavenging systems
Potential interaction between sedative drugs and other agents

Here is a short and sweet summary from Massachusetts General Hospital to take care of Covid 19 patient. Mortality for those who required mechanical ventilation was 35.7% reported in one study.