Indications of ICU admission and ICU

management of critically ill COVID 19

patients

DR AVINASH AGRAWAL
Prof & HOD

Dept. Of critical Care Medicine,

King George’s Medical University, UP, Lucknow

Brief Overview
 There are 7 different strains of corona virus-
 (229E- alpha, NL63- alpha, OC43- beta, HKU1- beta, mers-cov-beta,
sars-cov-beta & sars-cov-2- novel)

 Sars-cov-2 previously referred as 2019-ncov

 It is a SS RNA virus, with size 120 nm

 In feb 2020 who designated the disease covid-19 (corona virus disease
2019).
Transmission

 Mainly by droplet- cough, sneeze or talk.

 Droplets direct contact with mucus membrane

 Droplets don’t travel more than 6 feet

 Virus persist for longer time in faeces and urine.

Clinical features
Incubation period : 2- 14 days, most cases within 5 days

Spectrum of illness: Most- self limiting

Mild illness 80- 82%

Severe illness 14- 15%
(Dyspnea- RR≥ 30/min, Hypoxemia- spo2≤ 93%/pao2/fio2< 300,
>50%lung involvement on imaging within 24- 48 hours)
Critical disease- 4- 5% (Resp failure, Septic shock, MODS)
Overall case fatality- 2.3- 5%
 Brief Overview
CATEGORIES:
A Fever/ mild sore throat/ dry cough/ rhinitis/ diarrhoea

B Fever and severe sore throat/ cough/ diarrhoea

OR
Category A plus two or more of the following
• Lung/Heart/Liver/kidney/neurological disease/HTN/haematological
disorder/uncontrolled DM/Cancer/HIV-AIDS
• On long term steroids/immunosupressive drugs.
•Pregnant lady.
•Age > 60 years.
OR
Category A plus Cardiovascular disease

C • Breathlessness, chest pain, drowsiness, Hypotension, haemoptysis, cyanosis (red flag

sign).
• Worsening underlying chronic conditions.

Categorization should be reassessed ever 24- 48 hours for category A & B

 Indications for ICU admission
•Criteria for selection and admission in ICU
•on the basis of diagnosis, objective or on priority basis.
In covid 19 cases criteria are:
1. Need for mechanical ventilation
2. Need for vasopressors
3. Respiratory rate > 30 breaths per minute
4. Pao2 < 50 mm hg on room air/spo2 <90% on supplemental oxygen of 6lpm
5. Confusion
6. LeukopeniaThrombocytopenia
7. Uraemia
8. Multi-lobar infiltrates
9. Hypotension requiring fluid resuscitation
10. Hypothermia
11. qSOFA >2
 Indications for ICU admission
•CRITERIA FORSELECTION AND ADMISSION IN ICU CAN BE
ON THE BASIS OF DIAGNOSIS, OBJECTIVE OR ON PRIORITY
BASIS.
In COVID 19 cases criteria are:

Other indications are CURB 65

 Indications for ICU admission
Validated definition includes either one major criterion or three or more minor criteria

Minor criteria:
i. Respiratory rate > 30 breaths/min
ii. Pao2/FIO2 ratio < 250
iii. Multilobar infiltrates
iv. Confusion/disorientation
v. Uraemia (blood urea nitrogen level > 20 mg/dl)
vi. Leukopenia* (white blood cell count , 4,000 cells/ml) thrombocytopenia (platelet count ,
100,000/ml)
vii. Hypothermia (core temperature , 368C)
viii. Hypotension requiring aggressive fluid resuscitation

Major criteria:
ix. Septic shock with need for vasopressors
x. Respiratory failure requiring mechanical ventilation
 ICU Management
 Initial resuscitation
 Mechanical ventilation
 Screening for sepsis and
performance improvement  Sedation and analgesia
 Diagnosis  Glucose control
 Antimicrobial/antiviral/ other  Renal replacement therapy
therapy
 Source control  Bicarbonate therapy
 Fluid therapy  Venous
 Vasoactive medications thromboembolism
 Corticosteroids prophylaxis
 Blood products  Stress ulcer prophylaxis
 Immunoglobulins
 Nutrition
 Blood purification
 Anticoagulants
 ICU Management
i. INITIAL RESUSCITATION:

a. Sepsis and septic shock are medical emergencies, and treatment and
resuscitation begin Immediately.

b. Resuscitation from sepsis-induced hypo perfusion, at least 30 ml/kg of iv

crystalloid fluid be given within the first 3 hours.

c. Following initial fluid resuscitation, additional fluids be guided by

frequent reassessment of hemodynamic status.
a. Further hemodynamic assessment (such as assessing cardiac function) to
determine the type of shock if the clinical examination does not lead to a
clear diagnosis.

b. Dynamic over static variables be used to predict fluid responsiveness,

where available.

c. Initial target mean arterial pressure of 65 mm hg in patients with septic

shock requiring vasopressors.

d. Guiding resuscitation to normalize lactate in patients with elevated lactate

levels as a marker of tissue hypo perfusion.
 ICU Management
VII. VASOACTIVE MEDICATIONS:

1. Nor epinephrine as the first-choice vasopressor

2. Vasopressin or Epinephrine to Nor epinephrine with the intent of raising

mean arterial pressure to target or decraese dose of noradrenaline

3. dopamine as an alternative vasopressor agent to nor epinephrine only in

highly selected patients
(e.g. Patients with low risk of tachyarrhythmia and absolute or relative
bradycardia).

4. Against using low-dose dopamine for renal protection.

.
 5. Using dobutamine in patients who show evidence of persistent hypo perfusion
despite adequate fluid loading and the use of vasopressor agents

 6. All patients requiring vasopressors have an arterial catheter placed as soon as

practical if resources are available
 ICU Management
IX. BLOOD PRODUCTS:
1. RBC transfusion when Hb decreases to < 7.0 g/dl in
adults except in myocardial ischemia, severe
hypoxemia, or acute hemorrhage.

2. Against the use of erythropoietin for treatment of

anaemia associated with sepsis.

3. Against the use of fresh frozen plasma to correct

clotting abnormalities in the absence of bleeding or
planned invasive procedures.
 Prophylactic platelet transfusion when counts are < 10,000/mm3 (10 × 109/L) in
the absence of apparent bleeding

 When counts are < 20,000/mm3 (20 × 109/L) if the patient has a significant risk
of bleeding.

 Higher platelet counts (≥ 50,000/mm3 [50 × 109/L]) are advised for active
bleeding, surgery, or invasive procedures.
 ICU Management
XIII. MECHANICAL VENTILATION:
 Patients on HFNC and NIV should be thoroughly monitored

 If worsening of respiratory conditions and need of intubation, intubation should not be

delayed in such cases

Invasive mechanical ventilation

 Initaite Mechanical ventilationuse using lung protective strategy (tidal volume 4- 8ml/kg
predicted body weight).
 Plateau pressure goal: ≤ 30 cm h2o
 Check pplat (0.5 second inspiratory pause), at least every 4h and after each change in
PEEP or VT.
 If pplat > 30 cm h2o: decrease vt by 1ml/kg steps (minimum = 4 ml/kg).
 Consider use of incremental fio2/peep combinations such as shown below to achieve goal
 ICU Management
XV. GLUCOSE CONTROL:
A protocolized approach to blood glucose management in ICU patients with
sepsis,commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/
dl

Target an upper blood glucose level ≤180 mg/dl rather than an upper target blood glucose
level ≤ 110 mg/dl.

Blood glucose values be monitored every 1 to 2 hours until glucose values and insulin
infusion rates are stable, then every 4 hours thereafter in patients receiving insulin infusions.

That glucose levels obtained with point-of-care testing of capillary blood be interpreted with
caution because such measurements may not accurately estimate arterial blood or plasma
glucose values.

Use of arterial blood rather than capillary blood for point-of-care testing using glucose
meters if patients have arterial catheters.
 ICU Management
XVIII. VENOUS THROMBOEMBOLISM
PROPHYLAXIS:
Pharmacologic prophylaxis against venous thromboembolism (VTE) in the
Absence contraindications to the use of these agents

LMWH rather than UFH for VTE prophylaxis In the absence of

contraindications to the use of LMWH

Combination pharmacologic VTE prophylaxis And mechanical prophylaxis,

whenever possible

Mechanical VTE prophylaxis when pharmacologic VTE is contraindicated.

 ICU Management
XX. NUTRITION:
Against the administration of early parenteral nutrition alone or parenteral nutrition in
combination with enteral feedings.

2. Early initiation of enteral feeding rather than a complete fast or only IV.

3. We suggest either early trophic/hypocaloric or early full enteral feeding in critically ill patients
with sepsis or septic shock then feeds should be advanced according to patient tolerance.

4. Against the use of omega-3 fatty acids as an immune supplement.

5. Use of prokinetic agents for feeding intolerance.

6. We recommend against the use of IV selenium, Arginine, Glutamine and Carnitine.

 ICU Management: General
GENERAL MANAGEMENT DURING ICU STAY:
F- feeding
A- analgesia
S- sedation
T- thromboembolism prophylaxis
H- head end up
U- ulcer prophylaxis
G- glucose control
S- spontaneous breathing trial
B- bowel regimen
I- indwelling cathater removal
D- de-escalation of antibiotics
 ICU Management: General
GENERAL MANAGEMENT DURING ICU STAY:
A- Assess, prevent and manage pain

B- Both spontaneous breathing and awakening trials

C- Choice of sedation and analgesia

D- Delirium assessment, prevention and management

E- Early mobility and exercise

F- Family communication and involvement.

 ICU Management
INVESTIGATIONS:
BASELINE:
Complete hemogram
Liver funtion test
Renal function test ft,
Serum electrolytes
Coagulation profile,
Viral profile, viral markers (hbs ag, anti hcv, hiv1& 2)
Baseline ECG
Chest radiograph, ABG (if spo2 <94%), cxr,
Total cpk, cpkmb and trop t (quantitative) in all patients.
Oher specific investigations pertaining to their co morbid illness as the case may arise.
 ICU Management
RISK FACTORS AND PROGNOSTIC DETERMINANTS:

• Historyof co morbidities (Htn, DM, COPD, Asthma, Hemato-lymphoid cancer, Solid organ
cancer, CLD, CKD, CHF,IHD, Stroke, Dementia etc.).

• Higher body temperatures were associated with more severe disease and higher fatality.
• In the wuhan cohort, the following laboratory cut offs appeared to indicate a poor prognosis
• lymphopenia < 2000/cu.mm
• Neutrophil / lymphocyte ratio >2
• LDH > 245 u/l
• hs-cardiac troponin > 28 ng/ml
• Prothrombin time > 16 s
• Serum ferritin > 300 μg/l
•D dimer
COVID 19 Management
COVID 19 Management
Cardiopulmonary resuscitation in
COVID 19
 Causes of cardiac arrest- 5Hs and 5 Ts
 5Hs- Hypoxia, Hypovolemia, Hydrogen ion (Acidosis), Hyper/
Hypokalaemia, hypothermia
 5Ts- Toxins, Tamponade (Cardiac), Tension Pneumothorax, Thrombosis
(Coronary and Pulmonary),
 Rhythms of cardiac arrest
 Shockable rhythm- Pulse less VT and VF
 Non Shockable rhythm- Asystole and PEA
 Shock 200 J Biphasic
 Compression to ventilation ratio 30:2
 Drugs Used during CPR- Adrenaline, Amiodarone, MgSO4 etc.
References:

 COVID 19 Guidelines- WHO

 COVID 19 Guidelines- Position statement ISCCM
 COVID 19 Guidelines- International Pulmonologist’s
Concensus
 COVID 19 Guidelines- Government of Kerala
 Surviving Sepsis Campaign 2016 guidelines