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COVID-19 Intelligence Report: Critical Care

June 15, 2020

Updates on obstetric, pediatric, inflammatory, and severe disease complications: 

  • A study of pulmonary function tests in adult survivors of severe COVID-19 performed at hospital discharge and 2 weeks later found persistent deficits in VC, FVC, FEV1, and FEV1/FVC.  
  • PRE-PRINT: In a study of outcomes in 17 million adult COVID-19 patients in the UK NHS, mortality was higher among Asian and Black patients, and this was not fully explained by pre-existing clinical factors.

June 1, 2020

Title: COVID-19 Infection: Implications for Perioperative and Critical Care Physicians Publisher: Anesthesiology/ASA Publications

Publication Date: June 2020

URL: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763458

Key Takeaway: This review provides a comprehensive summary of the evidence currently available to guide management of critically ill patients with COVID-19.Authors review COVID-19 pathogenesis, presentation, diagnosis, and potential therapeutics, with a focus on management of COVID-19–associated respiratory failure. The authors draw on literature from other viral epidemics, treatment of acute respiratory distress syndrome, and recent publications on COVID-19, as well as guidelines from major health organizations.

 

Title: Routine Venous Thromboembolism Prophylaxis May Be Inadequate in the Hypercoagulable State of Severe Coronavirus Disease 2019

Publisher: Critical Care Medicine Publication Date: May 27, 2020 URL:

https://journals.lww.com/ccmjournal/Abstract/9000/Routine_Venous_Thromboembolism_Pr ophylaxis_May_Be.95638.aspx

Key Takeaway: This is an observational study of 109 critically ill Covid-19 patients admitted to the ICU to determine the frequency of venous thromboembolism and the degree of inflammatory and coagulation marker elevation associated with venous thromboembolism. VTE was diagnosed in 31 patients (28%) 8 ± 7 days after hospital admission. Twelve patients (11%) had thromboelastography performed and 58% of these patients had a hypercoagulable study. The calculated coagulation index was hypercoagulable in 50% of patients with thromboelastography. This study confirms that Covid-19 results in a hypercoagulable state and that routine chemical venous thromboembolism prophylaxis may be inadequate in preventing venous thromboembolism in severe Covid-19.

 

Title: Management of Venous Thromboembolism During the COVID-19 Pandemic Publisher: Journal of Vascular Surgery: Venous and Lymphatic Disorders Publication Date: May 23, 2020

URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245280/.

Key Takeaway: The authors propose detailed management algorithms treatment and prevention of venous thromboembolism for patients with and without Covid-19 infection.

 

Title: Venous Thrombosis Among Critically Ill Patients With Coronavirus Disease 2019 Publisher: Critical Care Medicine

Publication Date: March 29, 2020

URL: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766543

Key Takeaway: This study from French critical care physicians prospectively performed a venous ultrasonogram of the inferior limbs for 34 consecutive patients admitted to their ICU for Covid-19 disease and found deep vein thrombosis in 22 patients (65%) at admission and in 27 patients (79%) when the venous ultrasonograms performed 48 hours after ICU admission with 26% proximal, 68% distal and 53% bilateral. In view of the high rate (ie, 79%) of deep vein thrombosis reported in this study, prognosis might be improved with early detection and a prompt start of anticoagulant therapy. Despite anticoagulant prophylaxis, 15% of patients in this study developed deep vein thrombosis only 2 days after ICU admission.

Title: Pulmonary and cardiac pathology in African American patients with COVID-19: an autopsy series from New Orleans

Publisher: The Lancet Publication Date: May 27, 2020

URL: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30243-5/fulltext Key Takeaway: This is a report on the cardiopulmonary findings of the first autopsy series of ten African Americans with recorded cause of death of COVID-19. The distinctive pathological findings are likely to have important implications for treatment of severe disease in this patient population. The authors state, “We believe that effective therapy for this patient demographic—and probably patients with severe infection across demographics— should target not only the viral pathogen, but also the thrombotic and microangiopathic effects of the virus, and possibly a maladaptive immune response to viral infection.”

Title: Angiopoietin-2 as a Marker of Endothelial Activation Is a Good Predictor Factor for Intensive Care Unit Admission of COVID-19 Patients

Publisher: Angiogenesis Publication Date: May 27, 2020

URL: https://link.springer.com/article/10.1007/s10456-020-09730-0

Key Takeaway: The authors propose angiopoietin-2 is a relevant predictive factor for ICU direct admission in COVID-19 patients. This is a prospective cohort study that enrolled 40 consecutive COVID-19 patients admitted to the emergency department that fulfilled criteria for hospitalization; 20 were admitted in conventional wards without any ICU transfer during hospitalization and 20 others were directly transferred to ICU. Angiopoietin-2 cut-off of 5000 pg/mL was the best predictor for ICU outcome further confirmed in multivariate analysis after adjustment for creatinine, CRP or D-dimers. This result showing an endothelial activation reinforces the hypothesis of a COVID-19-associated microvascular dysfunction.

May 25, 2020

Title: Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?

Publisher: JAMA

Publication Date: May 15, 2020

URL: https://jamanetwork.com/journals/jama/fullarticle/2766290

Key Takeaway: Two studies are discussed in this editorial comment:

Study 1: 24 patients with acute hypoxemic respiratory failure and infiltrates on chest CT scans, 6 of 15 patients who tolerated prone position showed a mean (SD) increase in Pao2 of more than 20% from baseline (74 [16] to 95 [28] mm Hg; P = .006) but 3 patients returned to baseline Pao2 after supination.

Study 2: Awake patients with mild and moderate ARDS.  Proned in 3 hour sessions, median of 2 NIV sessions. 12 of 15 had improved oxygenation (Pa O 2 :FiO 2 100 to 122) and respiratory rate (28 /min to 24 /min) during and for 1 hour after NIV session. At 14 days, 1 patient was intubated and 1 other died.

Conclusion: many but not all patients with hypoxemic respiratory failure tolerate the prone position while awake, breathing spontaneously or while receiving NIV. Among patients who tolerated a session of prone positioning, improvement in oxygenation and decrease in respiratory rate occurred. The effects were transient, and respiratory rates and oxygenation often returned to baseline after supination.

May 18, 2020

Title: Development and Validation of a Clinical Risk Score to Predict the Occurrence of Critical Illness in Hospitalized Patients With COVID-19

Publisher: JAMA Internal Medicine

Publication Date: May 12, 2020

URL: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2766086

Key Takeaway:  Study in China, using 1590 patients and a validation cohort of 710 patients, developed and validated a risk score (COVID-GRAM, http://118.126.104.170/) to predict the development of critical illness (ICU admission, mechanical ventilation, or death). The 10 risk score predictors included: chest radiography abnormality, age, hemoptysis, dyspnea, unconsciousness, number of comorbidities, cancer history, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, and direct bilirubin. Limitations include need for further validation, especially in other populations.

May 11, 2020

Title: Impact of Corticosteroid Therapy on Outcomes of Persons With SARS-CoV-2, SARS-CoV, or MERS-CoV Infection: A Systematic Review and Meta-Analysis

Publisher: Leukemia / Nature

Publication Date: May 5, 2020

URL: https://www.nature.com/articles/s41375-020-0848-3

Key Takeaways: Corticosteroid use in subjects with SARS-CoV-2, SARS-CoV, and MERS-CoV infections delayed virus clearing and did not convincingly improve survival, reduce hospitalization duration or ICU admission rate and/or use of mechanical ventilation. There were several adverse effects.  Because of a preponderance of observational studies in the dataset and selection and publication biases the conclusions, especially regarding [steroid use in] SARS-CoV-2, confirmation is needed in a randomized clinical trial. The authors suggest caution using corticosteroids in persons with COVID-19. 

 

Editor’s Note: This remains a debated topic, and a non-peer reviewed article recently demonstrated conflicting information.

May 4, 2020

Title: Treating ARDS in the Era of COVID: A Refined Approach 

Publisher: John Hopkins Center for Health Security

Publication Date: April 30, 2020

URL: https://www.centerforhealthsecurity.org/cbn/2020/cbnreport-04302020.html     

Key Takeaway: Two phenotypes of Corona-ARDS (CARDS) are described - L & H

  • In L-CARDS, lungs are still compliant, and endothelial damage causes improper shunting resulting in VQ mismatches. Use high flow. Don’t intubate unless tachypneic. Low PEEP, normal tidal.
  • In H-CARDS, lungs are full of infiltrates and debris, similar to classic ARDS. High PEEP, low tidal, permissive hypercapnia. Prone.

 

Title: Rationale for Prolonged Corticosteroid Treatment in the Acute Respiratory Distress Syndrome Caused by Coronavirus Disease 2019 

Publisher: Society for Critical Care Medicine

Publication Date: April 2020

URL: https://journals.lww.com/ccejournal/fulltext/2020/04000/rationale_for_prolonged_corticosteroid_treatment.18.aspx     

Key Takeaway: International critical care group disagrees with WHO recommendations to save steroids for clinical trials. Authors propose 1mg/kg/day for early mod-severe Corona-ARDS.

April 27, 2020

Title:  Respiratory Support in Novel Coronavirus Disease (COVID-19) Patients 

Publisher: American Journal of Tropical Medicine and Hygiene 

Publication: April 21, 2020

URL: https://doi.org/10.4269/ajtmh.20-0283

Key Takeaway: 

  • Supplemental oxygen is the first essential step in the treatment of severe COVID-19 patients with hypoxemia. It can be delivered using a non-rebreathing mask and prone positioning. This can help extend vent availability in low-resource settings. 
  • For patients requiring invasive ventilation due to exhaustion or other cause, lung protective strategies may reduce the currently very high CFR of >50%. 

 

Title:  Management of COVID-19 Respiratory Distress

Publisher: JAMA Network

Publication: April 24, 2020

URL: https://jamanetwork.com/journals/jama/fullarticle/2765302 

Key Takeaway: 

  • With the understanding that COVID-19 is not purely a respiratory pathogen but a systemic disease that injures the vascular endothelium, the management of ARDS in patients with COVID-19 may need to differ from the usual approach. 

COVID-19 patients initially tend to retain relatively good compliance despite very poor oxygenation (“Type L” lung disease). This may progress in some patients, either because of disease severity, host response, or suboptimal management, to “Type H” disease characterized by low compliance, higher lung weight, and higher PEEP response.  

  • Lung-protective ventilation strategies must be adjusted to the stage and type of disease.  ● This follows a previous report.

April 20, 2020

Title: Covid-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome

Publication: Journal of American Thoracic Society, March 30, 2020

URL: https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE

Key Takeaway:

  • Continuous Positive Airway Pressure or Non Invasive Ventilation,
    presenting with clinical signs of excessive inspiratory efforts, intubation should be prioritized to avoid excessive intrathoracic negative pressures and self-inflicted lung injury.
  • High PEEP in a poorly recruitable lung tends to result in severe hemodynamic impairment and fluid retention.
  • Prone positioning of patients with relatively high compliance results in a modest benefit at the price of a high demand for stressed human resources.

 

Title: Fast Literature Assessment and Reviews (FLARE) from Massachusetts General Hospital

URL: https://www.massgeneral.org/news/coronavirus/treatment-guidance/fast-literature-updates

Key Takeaway: A collaborative effort within the Pulmonary and Critical Care Division to review:

  • Antibodies in Severe Covid-19 patients
  • Update on Remdesivir
  • Pots-Extubation Stridor in Covid-19 patients
  • Fluid Management in Covid-19 patients
  • Viral Load in Covid-19 patients
  • Procalcitonin in Covid-19 patients
  • Managing PEEP and Recuritment
  • Myocarditis in Covid-19 patients
  • Coagulatin in Covid-19 patients
  • And more topics

 

Title: Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations

Publication: Lancet, April 6, 2020

URL: https://go.openathens.net/redirector/gwu.edu?url=https%3A%2F%2Fwww.clinicalkey.com%2F%23!%2Fcontent%2FplayContent%2F1-s2.0-S2213260020301612%3Freturnurl%3Dnull%26amp%3Breferrer%3Dnull

Key Takeaway: Comprehensive intensive care practice guidelines developed by the Asian Critical Care Clinical Trials Group

 

Title: COVID-19 pneumonia: different respiratory treatment for different phenotypes?

Publication: Intensive Care Medicine, 2020

URL: https://www.esicm.org/wp-content/uploads/2020/04/684_author-proof.pdf

Key Takeaway: This editorial describes two primary “phenotypes” of Covid-19 related pneumonia:

  • Type L, characterized by Low elastance (i.e., high compliance), Low ventilation to perfusion ratio, Low lung weight and Low recruitability. Treat with low PEEP.
  • Type H, characterized by High elastance, High right-to-left shunt, High lung weight and High recruitability. Type H patients, should be treated as severe ARDS, including higher PEEP, if compatible with hemodynamics, prone positioning and extracorporeal support.

 

Title: Swivel-HEPA-ETT (SHE) Bougie and HEPA-ETT (HE) Methods for Safe Intubation While Managing Patients With COVID-19 

Publication: Journal of Emergency Medicine, April 15, 2020

URL: https://www.ncbi.nlm.nih.gov/pubmed/32295770

Key Takeaway: This article reports on methods to reduce aerosolization during intubation. The authors utilized two methods that incorporated HEPA filters (HEPA-ETT and Swivel-HEPA-ETT) that they believe helped to reduce aerosolization during intubation and allow for confirmation of placement without auscultation.

April 9, 2020

Title: With ventilators running out, doctors say the machines are overused for Covid-19

Web Address:
https://www.statnews.com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/?utm_source=STAT+Newsletters&utm_campaign=9eaf99b9bb-Daily_Recap&utm_medium=email&utm_term=0_8cab1d7961-9eaf99b9bb-149678261

Key Takeaway: This is an interesting article by a science reporter about the growing uncertainty of the pulmonary pathophysiology of severe Covid-19 infection and how to best treat it.

 

Title:  High-Dose Intravenous Immunoglobulin as a Therapeutic Option for Deteriorating Patients With Coronavirus Disease 2019

Website: https://academic.oup.com/ofid/article/7/3/ofaa102/5810740

Key Takeaway: This case series reports 3 patients with severe COVID-19 who received high-dose intravenous immunoglobulin (IVIg) with satisfactory recovery. With no definite effective treatments for this novel pathogen, based on these observations high-dose IVIg may be considered for clinical trials or compassionate use in deteriorating patients infected with COVID-19 respiratory failure.  March 21, 2020

April 4, 2020

Updated CDC Webinar slide deck on Covid-19 clinical management

Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019,United States, Feb 12–March 28, 2020

  • https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e2.htm 
  • This analysis of preliminary US COVID-19 data, indicates that persons with underlying health conditions such as diabetes mellitus, chronic lung disease, and cardiovascular disease, appear to be at higher risk for severe COVID-19–associated disease than persons without these conditions. April 3, 2020

April 2, 2020

Preliminary observations on the ventilatory management of ICU COVID-19 patients

Joint Statement on Multiple Patients Per Ventilator  

March 31, 2020

Care of the Critically Ill and Injured During Pandemics and Disasters 

Primer on care of critically-ill patients with Covid-19                 

Society of Critical Care Medicine Surviving Sepsis Recommendations

 Management of Critically Ill Adults with Covid-19

  • https://jamanetwork.com/journals/jama/fullarticle/2763879
  • Poston JT, Patel BK, Davis AM. Management of Critically Ill Adults With COVID-19. JAMA. Published online March 26, 2020. doi:10.1001/jama.2020.4914
  • Note from submitter: JAMA Clinical Guidelines Synopsis, “Management of Critically Ill Adults With COVID-19.” 

Other Resources

Guidelines