Intensive Care Unit Setup for COVID-19

Training of Residents

It is also important to ensure adequate communication with the team that provides training and the COVID-19 task force which is responsible for the deployment of residents. Residents should not be posted to any COVID-19 facility without undergoing an essential training module conducted by the hospital infection control team. Additional training must be provided at the facility where the resident is allocated, based on the levels of the facility. For instance, if there are two locations where screening takes place, the content of the facility level training must be the same, although delivered by different team leaders at different locations. This will ensure training all key aspects, irrespective of the site of delivery and trainer. This requires that the coordination by the faculties who supervise these facilities will need to coordinate to ensure a uniform level of training. Training on COVID-19 and clinical evaluation of patients should also be provided for residents, especially those from departments with no regular patient-care activity (pre- and paraclinical departments). Optional training must be offered to residents from departments that have limited engagement with sick patients. These modules are developed by the COVID-19 task force. The inclusion of psychologists may be considered part of the training, to enhance the motivation of participating residents.

Faculty Deployment

The same general principles, according to the department involved (based on clinical exposure and participation in the management of critically ill patients) and the level of the facility, should be used for deployment of faculty for this purpose. Private hospitals and medical colleges may also follow identical guidelines.

Nursing student allocation to handle workforce shortage for COVID-19: India is facing an unprecedented public health emergency with the COVID-19 pandemic affecting several parts of the nation. The number of COVID 19 patients are increasing with the requirement for adequate workforce to handle the surge of cases. If the need arises, nursing students may be recruited to handle the crisis, based on their level of skills and training (Fig. 1).

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Fig. 1

Management protocol for walk-in patients with flu-like illness.

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Case Definition of COVID-19

Mild disease: Symptoms of upper respiratory tract infection and fever with no breathlessness/no hypoxia, and hemodynamically stable.

Moderate disease: if any one of the following is present: respiratory rate (RR) >24/min or SpO2 ≤ 93% on room air. Bilateral opacities on chest radiograph or CT scan.

Severe disease: features of moderate disease plus any one of the following: SpO2 < 90%, PaO2/FiO2 < 300 mm Hg; confusion/drowsiness; systolic blood pressure < 90 mm Hg or diastolic blood pressure < 60 mm Hg, chest radiograph or CT scan showing bilateral opacities not fully explained by effusion/lung collapse/nodules. Worsening of underlying illness in the past 1 week despite adequate management.

Classification of Disease

Group 0: Mild disease/no risk for COVID-19/throat/nasopharyngeal swab not performed.

Group 1: (a) Group 1x–mild disease/report awaited; (b) Group 1a–mild disease/report negative; and (c) Group 1b–mild disease/report positive

Group 2: (a) Group 2x–moderate disease/report awaited; (b) Group 2a–moderate disease/report negative; and (c) Group 2b–moderate disease/report positive

Group 3: (a) Group 3x–severe disease/report awaited; (b) Group 3a–severe disease/report negative; and (c) Group 3b–Severe disease/ report positive

Management Protocol for COVID-19

Group 0

Investigations: No investigations are performed unless recommended by the COVID-19 physician treatment–desloratidine 5 mg once daily orally or levocetrizine 5 mg once daily orally, paracetamol 650 mg (15 mg/kg/dose) in case of fever > 100°F/body pain. Salt water gargle thrice a day. Consultation by physician or pulmonologist in case of clinical deterioration.

Group 1

Investigations: No investigations to be performed unless recommended by COVID-19 physician treatment–oseltamivir 75 mg twice daily orally for 5 days; azithromycin 500 mg once daily, orally for 3 days, desloratidine 5 mg or levocetrizine 5 mg once daily, orally and paracetamol 650 mg (15 mg/kg/dose) orally if fever > 100°F/ body pain/ headache; salt water gargle four times a day.

Group 2

Routine investigations: complete blood count, C-reactive protein, renal and liver function tests, procalcitonin level, blood culture, serum ferritin level, arterial blood gas analysis, chest radiograph, ECG, 2D echocardiography, urine routine and culture. Optional: creatine kinase (CK), CK-MB, troponin-I, and brain natriuretic peptide (BNP), as recommended by the COVID physician or cardiologist.

Treatment: supportive–oxygen therapy via nasal prongs/mask, titrated to achieve SpO_{2 > 93}%; IV antibiotics if bacterial infection is suspected. Ceftriaxone 1 g IV 12 hourly or co-amoxiclav 1.2 g IV 8 hourly (may be modified based on culture reports); desloratidine 5 mg orally or levocetrizine 5 mg orally, once daily. Metered dose inhalers: ipratropium 20 mcg + levosalbutamol 100 mcg) two puffs 8 hourly and budesonide (200 mcg, one puff 12 hourly through spacer)

COVID-19 specific therapy: hydroxychloroquine (HCQ) 400 mg orally, twice daily on day 1, followed by 200 mg twice daily for 5 days; oseltamivir 75 mg twice daily, orally, for 5 days. HCQ may be withdrawn once the COVID-19 test report is negative.

Group 3

Investigations: routine investigations–complete blood count, C-reactive protein, renal and liver function tests, procalcitonin level, blood culture, serum ferritin level, arterial blood gas analysis, chest radiograph, ECG, 2D echocardiography, urine routine and culture.

Treatment: supportive–oxygen therapy and ventilatory management according to the ICU team; oseltamivir 75 mg twice daily for 5 days; IV antibiotics if bacterial infection is suspected; ceftriaxone 1 g IV 12 hourly or co-amoxiclav 1.2 g IV 8 hourly (may be modified based on culture reports); desloratidine 5 mg or levocetrizine 5 mg orally, once daily. Metered dose inhalers: ipratropium 20 mcg + levosalbutamol 100 mcg 2 puffs 8 hourly and budesonide 200 mcg, one puff 12 hourly through spacer

COVID-19 specific: HCQ 400 mg orally, twice daily on day 1, followed by 200 mg twice daily for 5 days; oseltamivir 75 mg twice daily, orally, for 5 days.

Critical Care Management of COVID-19 Patient

Moderate disease (mild tyachypnea rate around 24–26/min, Sp02 <94% on room air, P/F ratio 200–300 mm Hg): start oxygen with face mask at 6 to 10 l/min. Observe over 1h if tachypnea worsens/SpO2 not maintained/falls considering high-flow nasal cannula (HFNC) after ruling out underlying (a) altered mental status (b) hypercarbia on arterial blood gases (ABG), (c) hypotension (SBp < 90 mm Hg, DBp < 60 mm Hg), and (d) multiorgan failure

HFNC: modifications to HFNC use; specific to COVID-19: (i) flow should be limited to 30 L/min to prevent aerosol generation, (ii) patient’s airway should be covered with N95 mask. Keep a close watch on clinical scenario and repeat ABG after 1h on HFNC.

Endotracheal intubation and mechanical ventilation must be considered in case of (i) worsening tachypnea/paradoxical breathing, (ii) increasing FiO2 requirements, (iii) altered sensorium, (iv) hypotension, and (v) hypercarbia on ABG at 1 h from initiation of HFNC.

Ventilatory Management of COVID-19 Patient

Patients with severe disease should be intubated and mechanically ventilated.

• Endotracheal intubation should be performed by a trained and experienced provider using aerosol precautions. Patients with ARDS, especially young children or those who are obese or pregnant, may desaturate quickly during intubation. Preoxygenate with 100% FiO2 for 5 minutes via a face mask with reservoir bag, bag-valve mask, and HFNO. Rapid sequence intubation is appropriate after an airway assessment that identifies no signs of difficult intubation. In patients with severe acute respiratory distress syndrome (ARDS), prone ventilation for > 16 hours per day is recommended. All patients after intubation should be connected to appropriate bacterial and viral filter (one attached to endotracheal tube and second at end of expiratory circuit connecting to ventilator) to prevent dissemination of virus into the atmosphere.

  Procedure for initial ventilator settings: (i) adjust the tidal volume (Vt) to a maximum of 4 to 8 mL/kg ideal body weight. For volume modes, simply adjust the set or target Vt, and for pressure modes, adjust the peak pressure to achieve initial Vt; (ii) adjust the set RR based on PaCO2 levels; (iii) permissive hypercapnia can be allowed with target pH of 7.2; (iv) set the initial positive end expiratory pressure (PEEP) to maintain the SpO2 within 88 to 92%; (v) after changes have been completed, check the plateau pressure (Pplat). If the Pplat is > 30 cm H2O and driving pressure (Pplat minus PEEP) is >15 cm H2O, decrease the Vt by 1 mL/kg increments until the Pplat is less than or equal to 30 cm H2O or driving pressure < 15 cm H2O (minimum Vt = 4 ml/kg); (vi) recruitment maneuvers (RMs) may be used if necessary, delivered as episodic periods of high continuous positive airway pressure (CPAP) (30–40 cm H₂O); and (vii) in patients with moderate-to-severe ARDS (PaO2/FiO2 <150), neuromuscular blockade by continuous infusion can be used to prevent ventilator desynchrony.

Cardiac Arrest

Chest compressions and intubation subjects HCWs to a high-risk of aerosol exposure. Proper use of PPE should be adhered to while minimizing the number of personnel to three to four during code management. Use of an automated compression device should be considered to minimize exposure.¹¹ Code responders should don full PPE prior to entering the patient area. The team includes a code leader, code registered nurse, anesthesiologist, and an extra person for performing chest compressions.

Circulation: Until a definitive airway is obtained, compression-only CPR should be performed. Multiple studies have shown that compression-only CPR is noninferior to standard CPR.¹² If the patient has a shockable rhythm (VF/VT), defibrillate as soon as possible.

Airway: Prior to securing a definitive airway, oxygen should be applied via a nonrebreather mask at 15 L/min without humidification. Avoid bag mask ventilation (BMV) ventilation, high-flow nasal cannula, and noninvasive ventilation (CPAP, BiPAP) to minimize aerosolized virus.¹³ If passive oxygen is not available, place a surgical face-mask and a blanket over the patient’s face prior to chest compressions. If the patient does not have a shockable rhythm, proceed with rapid sequence intubation as early as possible to limit aerosolization.

Endotracheal intubation: Endotracheal intubation is the procedure that subjects the rescuer to the highest risk of infection during resuscitation. To maximize the success rate of intubation, airway interventions should be performed by experienced individuals, and chest compressions should be stopped. This may deviate from usual cardiac arrest care, leading to a pause in chest compressions; however, this is acceptable to maintain the safety of code responders.¹³

Chest compressions should resume once the endotracheal tube (ETT) cuff is inflated, and it is connected to the ventilator. If the pause in chest compressions is excessive and endotracheal intubation does not seem likely, consider laryngeal mask airway or other supraglottic airway device.³ Code responders other than the one who is intubating should distance themselves from the head of the bed during the intubation procedure (6 ft distance).⁴ Continuous capnography should be used to monitor ventilation.

Etiologies to Consider

Data from a retrospective study in Wuhan revealed the cause of death to be as follows¹⁴:

1. Respiratory failure (53%).

2. Heart failure with respiratory failure (33%).

3. Myocardial damage (7%).

4. Unknown cause (7%).

It is important to attempt to identify and treat reversible causes (5H’s, 5T’s) before stopping the code.

Terminating Resuscitative Efforts

1. Avoid prolonged resuscitation if there is no easily reversible etiology identified.

2. No one factor alone, or in combination, is predictive of outcome during cardiac arrest; however, it is reasonable to stop resuscitation efforts if return of spontaneous circulation (ROSC) has not been achieved within 30 minutes.

3. In intubated patients, failure to achieve an ETCO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR should be considered as one component of a multimodal approach to decide when to end resuscitative efforts.¹⁵

Postresuscitation Care

1. Dispose of, or clean, all equipment used during CPR. Any work surfaces used for airway/resuscitation equipment will also need to be cleaned.

2. After the resuscitation has ended, adhere to strict doffing procedure to limit exposure.

3. If ROSC is achieved, provide usual postresuscitation care consistent with current recommended guidelines, including targeted temperature management.¹⁶

In summary, when setting up an ICU specific to the needs of the COVID-19, the following must be considered:

1. Personal protective equipment: In view of shortage of PPE, consideration is given to usage of PPE beyond the manufacturer’s designated shelf life. Training of medical personnel must include junior physicians, nurses, physiotherapists, other technical and housekeeping staff. Correct methods of donning and doffing of the PPE must be inculcated for all these medical personnel (please see above). Contact surface decontamination of medical equipment is necessary. Cell phones may be banned inside the COVID-19 ICU, and if cell phones are permitted, disposable polythene bags should cover the cell phones, and this disposable polythene bag must be discarded at the end of the shift. Restrict and limit the number of visitors and visiting time of the family members: it is preferable to use video conferencing methods for the patient family to react with the patient if the patient is conscious in the ICU

2. ICU infrastructure capacity building: If there is a surging number of critically ill patients, increasing the ICU capacity is needed. The ICU care may be provided in HDUs outside the ICU, and special ward beds may be converted into a semi-ICU for moderately sick patients. This also calls for attention to logistics and supply chains to maintain all essential components of care. Elective surgery must be postponed.

3. ICU staffing: Increase in the ICU bed numbers should proportionately increase the number of staff working in the ICU. The hospital staff may be augmented from the noncritical areas with appropriate short-term training programs. Staff need to be educated about critical care in a short time and such personnel should receive clear communication about the limitation of shift hours, provision of rest areas and psychological support. A scheme of utilization of medical personnel as proposed by the Government of Karnataka is highlighted above.

4. ICU triage is an essential component of prioritizing patients for intensive care. Patients who are young with prognostically good outcome must be given priority over patients who are elderly with multiple comorbidities

5. ICU research: Prompt conduct and sharing of information through communication and publications is necessary but when analyzing and interpreting the published literature, caution must be needed because some of these literature may be published in haste and the applicability must be tailored to the needs of the particular institution.