The lastest updated surviving sepsis guidelines for COVID-19 patient recommends a high-peep strategy in the intubated, mechanically ventilated patient. As most of these patients present with moderate to severe ARDS, PEEP is used to keep lung areas open and therefor to improve oxygenation. This seems to be especially true in the classical case of ARDS, where the lung become 'wet' and 'heavy' which results in widespread atelectasis of the dependent parts of the lungs, often further complicated by pleural effusions.
Classical CT appearance in the acute phase of ARDS is an opacification with an antero-posterior density gradient. Dense consolidation in the most dependent regions merges into a background of widespread ground-glass attenuation and the normal or hyperexpanded lung in the non-dependent areas (Howling SJ et al. Clin Radiol 1998;53(2):105-109). The theory behind these changes is that the increased weight of overlying lung causes compression-atelectasis posteriorly. The fact that prone positioning these patients quickly redistributes these gradients supports this theory (Desai SR et al. Anaesthesiology 1991;74(1):15-23).
Chest CT's in patients with COVID-19 often show ground-glass opacification with or without consolidations. These are changes often seen in viral pneumonia. Several case series suggest, that CT abnormalities seem to be mostly bilateral and tend to have a peripheral distribution, often involving the lower lobes. In contrast to the classical ARDS pleural thickening, pleural effusion and lymphadenopathy seem to be a less common finding (Shi H et al. Lancet Infect Dis 2020).
The leading problem in COVID-19 patients with ARDS is hypoxemia, while hypercapnia does not seem to be a significant problem. Sometimes profound hypoxemia does not seem to correlate with patient symptoms at all. In regards to the images above, atelectasis might not be the predominant reason for V/Q mismatches in these patients.
Observations of mechanically ventilated patients in our unit and other hospitals in Switzerland have shown, that higher PEEP levels (15cmH2O and higher) often result in significantly reduced compliance values complicating ventilation and favouring the development of pulmonary over-inflation. This observation might support the theory that patients with COVID do not represent the traditional manner of ARDS with distinctive atelectasis. Another observation that supports this theory is that COVID-19 patients often do not respond as clearly to Prone Positioning as classical ARDS patients do.
More probably, V/Q mismatch seems so happen on a more microscopical level in COVID-Patients. Lung compliance is often normal on these patients and, therefore, applying high PEEP-levels does NOT add any benefit at all.
Maybe the principle of less is more also applies to COVID-19 patients we treat (Gattinoni L et al. Intensive Care Medicine; 46, pages780–782(2020))
The European Society of Intensive Care Medicine ESICM and the Society of Critical Care Medicine SCCM have been very efficient in providing us health care workers with a guideline manuscript giving recommendations on the treatment of COVID-19 patients in a critical care setting. It is imperative to keep in mind that research is moving forward very quickly in these times and changes to these recommendations are likely to occur.
A collection of many reliable OPEN ACCESS platforms on SARS-CoV-2 can be found on www.foam.education.
When performing aerosol-generating procedures on patients with COVID-19 in the ICU, fitted respirator masks (N95 respirators, FFP2) should be used (in combination with full Personal Protective Equipement PPE)
Aerosol-generating procedures on ICU patients with COVID-19 should be performed in a negative pressure room
During usual care for non-ventilated and non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients surgical masks are adequate
For endotracheal intubation video-guided laryngoscopy should be used, if available
In intubated and mechanically ventilated patients, endotracheal aspirates should be used for diagnostic testing
In COVID-19 patients with shock, dynamic parameters like skin temperature, capillary refilling time, and/or serum lactate measurement should be used in order to assess fluid responsiveness
For the acute resuscitation of adults with COVID-19, a conservative over a liberal fluid strategy is recommended
For the acute resuscitation of adults cristalloids should be used - avoid colloids!
Buffered/balanced crystalloids should be used over unbalanced crystalloids
Do NOT use hydroxyethyl starches!
Do NOT use gelatins!
Do NOT use dextrans!
Avoid the routine use of albumin for initial resuscitation!
In shock use norepinephrine/ noradrenaline as the first-line vasoactive agent
The use of dopamine is NOT recommended
Add vasopressin, if target MAP cannot be reached
Titrate vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets
For patients in shock and with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, adding dobutamine should be used
For persistent shock despite all these measures, low-dose corticosteroids should be tried
Keep peripheral saturation SpO2 above 90% with supplemental oxygen
There is NO need for supplemental oxygen with SpO2 above 96%
In acute hypoxemic respiratory failure despite conventional oxygen therapy, high-flow nasal cannulas (HFNC or High-Flow) should be used next
High-Flow should be used over non-invasive ventilation (NIV)
If High-Flow is not available and there is no urgent need for endotracheal intubation, NIV with close monitoring can be tried
In the event of worsening respiratory status, early endotracheal intubation should be performed
In mechanically ventilated patients, low-tidal volume ventilation should be used: 4 to 8 ml/kg
In mechanically ventilated patients with ARDS targeting plateau pressures (Pplat) of < 30 cm H2O should be aimed for
In patients with moderate to severe ARDS, a high-PEEP strategy should be used (PEEP >10cmH2O). Patients have to be monitored for potential barotrauma
NOTE by Crit.Cloud:
The strategy for high PEEP levels in general is currently discussed controversially. Observations in our own unit showed, that high PEEP levels tend to impaire compliance and therefor the quality of ventilation. Read also: "Less is More" in mechanical ventilatio, Gattinoni L. et al. Intensive Care Med (2020) 46:780-782
Patients with ARDS should receive a conservative/restrictive fluid strategy
In moderate to severe ARDS, prone positioning for 12-16 hours is recommended
To facilitate lung protective ventilation in moderate to severe ARDS, intermittent boluses of neuromuscular blocking agents (NMBA) should be used first
In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, a continuous NMBA infusion for up to 48 hours should be used next
Do NOT use inhaled nitric oxide in COVID-19 patients with ARDS routinely
In severe ARDS and hypoxemia despite optimising ventilation and other rescue strategies, a trial of inhaled pulmonary vasodilator as a rescue therapy can be considered; if no rapid improvement in oxygenation is observed, the treatment should be tapered off
If hypoxemia persists despite optimising ventilation, recruitment manoeuvres should be applied
If recruitment manoeuvres are used, DO NOT use staircase (incremental PEEP) recruitment manoeuvres
If all these measures fail, the patient should be considered for venovenous ECMO
In mechanically ventilated patients WITHOUT ARDS, systemic corticosteroids should NOT be used routinely
In contrast, mechanically ventilated patients WITH ARDS, the use of systemic corticosteroids is recommended
Mechanically ventilated patients with respiratory failure should be treated with empiric antimicrobials/antibacterial agents
Critically ill patients with fever should be treated with paracetamol (acetominophen) for temperature control
In critically ill patients standard intravenous immunoglobulins (IVIG) should NOT be used routinely
Also, the routine use of convalescent plasma is NOT recommended
The routine use of lopinavir/ritonavir (Kaletra®) is NOT recommended
Currently, there is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19
Currently, there is insufficient evidence to issue a recommendation on the use of recombinant interferons (rIFNs); chloroquine or hydroxychloroquine; tocilizumab (humanised immunoglobulin)
The Aerosol-Danger of SARS-Cov-2
The outbreak of the SARS Coronavirus-2 (SARS-CoV-2) in China 2019 has within a short time spread around the globe and is just about to hit central Europe. Although about 80% of all confirmed cases develop a mild febrile illness, around 17% develop severe Corona viral disease (COVID-19) with findings of acute respiratory distress syndrome (ARDS), of which about 4% will require mechanical ventilation.
Since this virus, which was previously unknown to humans, spread rapidly around the globe, a large number of patients requiring intensive medical care now arise within a very short time.
The lungs are the organs most affected by COVID-19 because the virus accesses host cells via the enzyme ACE2, which is most abundant in type II alveolar cells of the lungs. This results in mainly type 1 respiratory failure, which often requires urgent tracheal intubation and mechanical ventilation.
Due to viral shedding in the patient's lungs, COVID-19 spread mainly via droplets. Events like coughing, high flow nasal oxygen (High-Flow), intubation and more can cause aerosol generation, allowing these airborne particles to travel even further distances.
Performing endotracheal intubation in these patients is, therefore, a high-risk procedure, and it is required to adhere to certain principles to avoid infection of health care providers.
The Safe Airway Societies of Australia and New Zealand have published a consensus statement that describes the problem very well and provides practical tips based on the currently available evidence.
1. Non Invasive Ventilation (NIV) and High Flow Nasal Oxygen (High-Flow)
Current evidence suggests that the failure rate of NIV in COVID-19 patients seems to be similarly high as observed among Influenza A patients. Failure in these patients resulted in higher mortality.
In general, NIV is recommended to be avoided or at least used very cautiously!
The utility of High-Flow in viral pandemics in unknown. There is some evidence suggesting a decreased need for tracheal intubation compared to conventional oxygen therapy.
High Flow Nasal Oxygen is worth a try, although it has to be assumed, that this is aerosol-generating.
High-Flow should only be used in (negative pressure) airborne isolation rooms, and staff should wear full personal protective equipment (PPE) including N95/P2 masks.
NIV and High-Flow are NOT recommended for patients with severe respiratory failure or when it seems clear that invasive ventilation is inevitable!
|Acute Exacerbations in Patients with IPF,Kim Respiratory Research 2013, 14:86|
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The authors look at this topic point for point and review current literature in an easy to understand sort of manor. They define major blood loss when it leads to a heart rte of >110/Min or a systolic blood pressure of less than 90mmHg, or simply said: when bleeding becomes haemodynamic relevant. In general it is recommended to have a major haemorrhage protocol at hand (1D) and all staff should be trained to recognise major blood loss early (1D).
Here's a summary of the recommendations made by the British Committee for Standards in Haematology (BCSH):
In Major Haemorrhage....
Red Blood Cells RBC
- Hospitals must be prepared to provide emergency Group 0 red cells and group specific red cells (1C)
- Patients must have correctly labelled samples taken before administration of emergency Group 0 blood (1C)
- There is NO indication to request 'fresh' or 'young' red cells (under 7d of storage, 2B)
- Note: The optimum target haemoglobin concentration (Hb) in this clinical setting in general is NOT established. Current literature shows a tendency towards restriction towards 70-90g/L, but the BCSH makes no recommendations therefore (see blow)
Cell Salvage (e.g. cell saver)
- 24h access to cell salvage should be available in cardiac, obstetric, trauma and vascular centres (2b)
- Use haemostatic tests regularly during haemorrhage, every 30-60min, depending on severity of blood loss (1C)
- Measure platelet count, PT, aPTT (1C)
- Note: The BCSG does not recommend TEG and ROTEM at this stage
Fresh Frozen Plasma FFP
- Use FFP in a 1:2 ratio with RBC initially (2C)
- Once bleeding is under control administer FFP when PT and/or aPTT is >1.5 times normal (recommended dose 15-20ml/kg, 2C)
- The use of FFP should not delay fibrinogen supplementation if necessary (2C)
- Supplement fibrinogen when levels fall below 1.5g/L
Prothrombin Complex Concentrates PCC
- Do not use PCC
- Keep the platelet count >50 x 10^9/L (1B)
- If bleeding persists give platelets if count falls below 100 x 10^9/L (2C)
Tranexamic Acid TA
- Give tranexamic acid as soon as possible to patients with, or at risk of major haemorrhage (Recommended dose: 1g IV over 10min, followed by 1g IV over 8h, 1A)
- Note: TA has no known adverse effects
- Note: Aprotinin is not recommended
Recombinant Activated Factor VIIa (Novo Seven)
- Do not use
Specific Clinical Situations
- Fibrinogen levels increase during pregnancy to 4-6g/L
- In major obstetric haemorrhage fibrinogen should be given when levels are <2.0g/L (1B)
- Use restrictive strategy for RBC transfusion is recommended in most patients (1A)
- Transfuse adult trauma patients empirically with a 1:1 ratio of FFP : RBC (1B)
- Consider early use of platelets (1B)
- Give tranexamic acid as soon as possible (Dose 1g over 10min and then 1g over 8h, 1A)
Prevention of Bleeding in High-Risk Surgery
- Use tranexamic acid (Dose 1g over 10min and then 1g over 8h, 1B)
Hunt B et al. British J Haemat, July 6 2015
Read more HERE:
Great Review on Transfusion, Thrombosis and Bleeding Management
Restricitve Transfusion Threshold in Sepsis, the TRISS Trial
Transfusion: Harmful for Patients Undergoing PCI?
These guidelines outline the nature and properties of biofilms and and their implications on mostly chronic infections caused. As biofilms are very common in critically ill patients it is important to know what specific problems you might encounter, how to proceed and perform a proper diagnosis and what are the essential bits and pieces in the prevention and treatment of biofilm infections.
The article is OPEN ACCESS: Clin Microbiol Infect. 2015 Jan 14. pii: S1198-743X(14)00090-1.
ARISE and ProCESS had been published before (read here) and both of them showed no difference between EGDT and 'usual care'.
ProMISe included 1251 patients with severe sepsis or septic shock that were admitted to a total 56 hospitals in the UK. Again classical EGDT with measurement of continuous central venous oxygenation was compared to so called 'usual treatment'. It's remarkable to notice that in the 'usual treatment' group about half of the patient didn't get a central line and central venous oxygenation wasn't even measured in the ones who got one. And here's the result:
There was no difference in 90-day mortality and no differences in secondary outcomes. In contrast EGDT actually increased costs.
It has become difficult to ignore these three trials!
Our conclusion: The classical EGDT therapy has ended here and now... but EGDT will keep its central role in the treatment of septic patients!
- Identify septic patient quickly, start screening for patients if indicated
- Administer antibiotics within the first our of recognition of sepsis
- Start IV-fluid therapy immediately
- Take (blood) cultures as quick as possible, but do not delay antibiotic treatment
- Aim for a reasonable mean arterial pressure (e.g. 65mmHg)
- Aim for a sufficient urinary output (0.5ml/h)
- Central venous pressure (CVP) certainly and most probably central venous oxygenation (ScvO2) are not parameters to measure fluid responsiveness
- Lactate remains an issue of debate
- Simple: Whatever the physician feels is best!
ProMISe Trial, Mouncey et al. N Engl J Med. 2015 Mar 17.
BIJC Review on ARISE and ProCESS
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