Dr. Amir Amiri MD
ICU, Acute Care Surgery & Trauma
General concerns for PUI and COVID-19-positive patients
Healthcare Worker safety concerns:
- Droplet precautions for all general contact.
- Airborne precautions for any aerosolized procedures (nasal swab, nebulized treatment, bipap, bronchoscopy, intubation). Recognize the high risk of infection in any of these procedures.
- Full airborne precautions are required for all intubations, including properly fitting N95 and face shield or PAPR, and should be continued for 3 hours following.
- All patients with respiratory symptoms and/or fever will be masked upon arrival to ED and should remain masked when healthcare providers are in the room with the patient. Hospital will limit, if not eliminate, any non-essential visitors to the hospital.
- As the number of admitted COVID patients rises in Sacramento, we will ultimately run low PPE supplies for the hospital and region.
- Make every attempt to discharge PUI or COVID positive patients to home quarantine as quickly as possible when patient is clinically stable. Save hospital beds, limit exposure to healthcare staff, and save PPE.
- Limit the number of staff and number of various exams done throughout the day.
- The number of healthcare workers entering the patient room should be limited to those essential to direct patient care and should be batched.
- Consider a once-a-day physical exam by the primary attending (with proper equipment). All other assessments can be done via cell phone with patient
- Consultants need not directly examine the patient, unless necessary to provide recommendations or interventions, but should confer directly with the primary attending physician managing the patient regarding assessments and recommendations.
- APPs, students, and trainees should not enter COVID-19 confirmed/PUI rooms.
Close respiratory monitoring of PUI and COVID-19-positive patients
The MICU team should be notified EARLY if there is a COVID or PUI patient with worsening respiratory status and will keep a list of all COVID patients in the hospital for monitoring purposes. Avoiding crash intubations is essential. When the intubation of a COVID-19 patient or PUI is needed (outside of the ED), intubation will be conducted by a designated COVID/PUI airway team consisting of a specified attending and fellow.
Notify intensivist EARLY if there is a COVID or PUI patient with worsening respiratory status. Avoiding crash intubations is essential. Intubation (outside of the ED) will be conducted by the intensivist, who will be caring for the patient (or anesthesiologist, if intensivist is unavailable).
The intensivist should be aware of PUI within this hospital and kept aware of any PUI/COVID-19 patient whose status is worsening.
Patient safety concerns:
- COVID-19 patients may deteriorate rapidly.
- Success in reducing mortality has been achieved through early intubation for respiratory failure.
- Every effort should be made to ensure early recognition of PUI and COVID-19 infected patients with worsening respiratory failure and allow time for safe intubation practices.
What to do:
- Maintain a list of all PUI/COVID-19 patients available to the intensivists on duty.
- Have discussions early with the patient/family about patient’s wishes regarding intubation and code status.
- Notify the intensivist and RT early if the patient is worsening or if you think intubation will be required.
- Avoid all aerosolizing procedures on PUI/COVID-19 positive patients, when possible.
- PUI or COVID-19-positive patients requiring oxygen should receive, in order:
- 1. Nasal cannula, then
- 2. Non-rebreather (NRB) mask if > 6 LPM of oxygen is required, then
- 3. Intubation
- Note: A non-rebreather mask is the ONLY option for escalation prior to intubation.
- AVOID any nebulizers, HFO2, BIPAP, bag-mask ventilation, or bronchoscopy. Nebulizer treatments can generate viral aerosol, thus bronchodilator treatments via MDI’s (which patients can self-administer) should be used instead if needed.
- Consider transfer to ICU in preparation for controlled intubation if requiring escalation from 6L NC to NRB.
Need for supplemental oxygen in PUI or COVID-19-positive patients
- PUI or COVID-19-positive patients receiving oxygen via nasal prongs should have a surgical mask that covers their nose placed over their face.
- Switch to a non-rebreather (NRB) mask if > 6 LPM of oxygen is required.
- Note: A non-rebreather mask is the ONLY option for escalation prior to intubation.
- AVOID any HFO2, BIPAP, bag-mask ventilation.
Intubation of PUI and COVID-19-positive patients
Intubation should be conducted by the intensivist caring for the patient if available.
- Protective Gear:
- Full airborne precautions are required for all intubations, including properly fitting N95 and face shield or PAPR.
- Intubating location proposal:
- Intubations should occur in designated ICU beds within the SICU, with the limited essential personnel in PPE, and with the door closed.
- Patients should be in a negative pressure room for intubation if available.
- Patients should be closely monitored for worsening respiratory function to facilitate early transfer as needed and avoid crash intubation situations.
- Intubation personnel (limit number of people in the room during procedure) should include only:
- Intubating physician (ED, PCCM, or anesthesia).
- Single RT.
- Single RN.
- Intubation personnel:
- Intubations for PUI or COVID-19 patients will be performed ONLY by Anesthesia CCM attending, or ED providers ONLY.
- When a patient is to be intubated, entry to the room will be limited to the following persons:
- Intubation criteria guidelines:
- PO2 < 65 or SaO2 < 92% on NRB mask OR
- Labored breathing with RR > 35-40, or PCO2 > 50 (in patient w/o hx of chronic CO2 retention) with pH < 7.30.
- Please do not wait for these criteria to be present before notifying the ICU team if your patient is worsening; there may be cases in which we choose to intubate before all these criteria are met.
- DO NOT INTUBATE without proper PPE (Aerosol generating procedure).
- Pre-procedure checklist should be performed prior to entering the room
- Intubation with Rapid Sequence Intubation (RSI) recommended.
- Preoxygenate and avoid bagging both before and after intubation.
- Minimize bagging once patient has been pre-oxygenated.
- Glidescope or Video Laryngoscopy with disposable blades should be used to minimize operator exposure to droplets.
- Once intubated, avoid breaking the circuit for any reason including bagging. Use in-line suction.
- Glidescope or C-MAC preferred to minimize operator exposure to droplets.
- Other considerations:
- ARDSnet protective lung ventilation.
- DO NOT routinely give corticosteroids or NSAIDs (potential harm with COVID-19).
- Prone Position and Nero-muscular blockers, as per ARDS considerations.
- Conservative fluid management if patient is not in shock.
- Once intubated, contact ID pharmacy to discuss current medication recommendations and options specific to COVID-19 at the time.
- Limitations for participation in the care of critically ill PUI and COVID-19 patients:
- Avoid having pregnant women or those currently taking immunosuppressive agents or immune compromised by illness care for COVID-19 patients
Extubation of PUI and COVID-19-positive patients
Extubation is also an aerosolizing procedure and RT should don appropriate PPE and perform in a closed room. To avoid airway emergencies of PUI and COVID-19 patients who are being extubated, extubation should only proceed when attending physicians are present but need not be in the room at the time.
- Equipment Considerations
- Intubation should be performed with glidescope/video laryngoscopy with disposable blades to minimize risk to intubating physician.
- Hospital ICU equipment (Glicescope or Ultrasound) on a COVID-19 PUI or confirmed case, the standard hospital disinfection methods for cleaning medical equipment are adequate. Virus is killed by our disinfectants. Disposable parts (glidescope cover) need safe permanent disposal.
ICU Procedures and Interventions
- Try to consolidate procedures into one trip with minimal personnel.
- For Central line access in those with acute renal failure, consider early placement of a trialysis catheter to avoid additional future procedures.
- Run a thorough checklist prior to entering room and anticipate need for all supplies.
- Limit lab draws to those necessary for clinical decision making and try to consolidate/batch timing of blood drawn.
- Like all procedures, non-essential EGDs can be delayed for suspected/confirmed cases.
- Procedure is relatively lower risk compared to Intubation and bronchoscopy.
- Strict Droplet isolation practice with Physician/Surgeon using surgical mask + face shield is adequate. N95/PAPR masks are not mandatory for this procedure.
- Several patients develop acute cardiomyopathy. The University of Washington reports indicate these patients have all had CKs in the 1000s and is therefore a recommended lab for suspicion. The utility of echocardiogram is not yet known. Due to the need for additional personnel and equipment, this study should only be performed if it will likely change management of the patient.
All patients should have early and documented code status discussion focused on goals of care around intubation and resuscitation. Admitting physician or ED physician should place palliative care consult upon admission. Goal is Palliative Care consult with family and patient within 24hr of admission with prognosis and goals of care discussed specific to COVID experience.