Cricoid pressure prevents aspirations, preoperative antibiotics avoid infections, and compression stockings protect against deep vein thrombosis. Many medical measures aim to reduce morbidity and mortality among patients, but unfortunately, the benefit of these measures is often not, or insufficiently, proven. Under certain circumstances, they may lead to additional problems or even cause harm (e.g. cricoid pressure Read Here).
Time has definitely come to take a closer look at compression stockings for surgical patients. Apart from the fact that they look terrible, they are just as uncomfortable to wear and even carry certain risks in patients with peripheral vascular disease, for example. The effectiveness of compression stockings in modern practice has been questioned, but robust evidence has been lacking.
This seems to change, as the long-awaited GAPS-Trial has been published and now provides further evidence on what concern patients undergoing elective surgery.
Among this population, adding compression stockings to pharmaco-thromboprophylaxis was non-superior compared to pharmaco-thromboprophylaxis alone (primary outcome). There was also no difference in the quality of life outcomes found (secondary outcome).
There is now some robust evidence to omit compression stockings in surgical patients that receive pharmacological thromboprophylaxis.
Shalhou J. et al. BMJ 2020;369:m1309
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)
Teaching in medical school and opinions in literature are in agreement: The application of vasopressors requires central venous access. The reason for this are concerns that vasopressors given over a peripheral venous catheter (PCV) may cause phlebitis or even worse necrosis or ischemia through extravasation.
While irritation of a peripheral vein is often observed with the administration of drugs like potassium or amiodarone, this usually is not the case with the application of, e.g. norepinephrine. Besides, it is essential to keep in mind that the insertion of a central venous catheter (CVC) is technically demanding and takes a certain amount of time when performed correctly. The procedure is also associated with potentially dangerous complications that might be hazardous to the patient.
Therefore a fundamental question arises:
Do all patients that require vasopressors need a central venous catheter?
What about the peripheral access (PVC) - Any dangers there?