Emory ECMO CenterEmory Critical Care Center

Clinical and team management in the COVID-ICU:

Updates from week 4

COVID-19 CLINICAL ROUNDS

Mark Caridi-Scheible, MD

Emory Critical Care Center, Atlanta, GA

Emory ECMO CenterEmory Critical Care Center

Introduction• Critical care attending, Emory University Hospital

• Focusing on 1 hospital experience

• Recommendations are now by committee consensus on best practices informed by local experience and available literature (scant)

• Outcomes likely to vary based on patient mix, location and resources available (a rapidly moving target)• Especially would like to acknowledge the plight of New York City

• Quick recap, then few new clinical highlights

Emory ECMO CenterEmory Critical Care Center

The Disease• COVID waits for no one

• Slow, extended plateaus with rapid, unpredictable transitions over hours• Prodrome• Silent hypoxia (O2 2-8L, comfortable, floor phase)

• Tachypnea may be early warning

• Struggling (O2 10-15L, increasingly tachypneic +/- anxiety&SOB, worse CXR)• Increasing presentation, some recover from this phase but fewer, must be in ICU

• Respiratory Failure (O2 > 15L)• HFNC or Intubation

• Recovery or MOSF/sudden death

• Encephalopathy, atypical hypoxic failure (normal compliance, not really ARDS), mild AHI, variable but common AKI, hypercoagulability, difficult & occult secretions)

• Sudden death (hyperinflammatory/myocarditis picture) still appears uncommon• Seen a few, investigating currently

Emory ECMO CenterEmory Critical Care Center

Patients & Statistics• At EUH, approx 50 known positive patients that were critically ill

• Wide age range but few < 40 yo• Variety of co-morbidities including HTN, asthma, sarcoid, transplant, myxedema, CAD, morbid

obesity, HF

• Approx 45 (90%) required intubation• Relatively few proning, paralysis, flolan• Many high PEEP (14-18), unclear optimal strategy• 2 VV-ECMO, 1 now decannulated and extubated, 1 close to decannulation• 50% extubated, half of those now on floor

• About half sent to floor on 0-4L O2

• Majority are still improving, albeit slowly

• 5-10% mortality for ICU admits• Phenotypes consistent with deaths from flu – esp immunosuppressed, advanced age• 2 deaths that seem to have been associated with cardiac decline (etiology remains unclear)

• Increasing number presenting sicker and requiring intubation immediately• Accordingly increased number of vent days per patient• expect increased mortality as well, although seems plateaued at moment

Emory ECMO CenterEmory Critical Care Center

Our approach1. Strong and rapid supportive care

appears best tx, no strong signal yet for pharmacological therapy

2. Ongoing committee providing review and best practice recommendations

3. Protocol development, adapted for facility variances

4. Good communication and team support

Emory ECMO CenterEmory Critical Care Center

Pulmonary• Tachypnea may lead hypoxic decompensation

• Growing deadspace and shunt

• Not ARDS: normal compliance• High versus low peep?

• Continue to favor early intubation• Airvo may be okay upto 60% *OR* 60L *OR* tachypnea sustained > 25

• Dysynchrony function of vent mode and encephalopathy• Want to breath variably and high flow rate• Consider PCV or APRV where can vary flow rate and tidal volumes

• Microvascular thrombus and increased deadspace

Emory ECMO CenterEmory Critical Care Center

Pulmonary• Pulm hygiene – pre-intubation, post-intubation, post-extubation

• Secretions can be deep, thick and occult

• Avoid anticholinergics (ipratropium, Duoneb)

• Extubated patient (pre-intubation or post-extubation): • minimum of oscillatory tx (Aerobika, Acapella, etc) and humidified NC• HTS nebs as increasing tachypnea or hypoxia• IPV/vest/metaneb PRN

• Intubated patient: • scheduled HTS, frequent suctioning• IPV/metaneb if increasing drive pressure, O2 or minute vent requirements

Emory ECMO CenterEmory Critical Care Center

Hypercoagulability• Increasingly evident part of fundamental pathology of COVID

• Evidence: clotting lines, pulmonary deadspace, DVT, few PE

• Microvascular damage and thrombi• May be source cardiomyopathy and sudden death

• May account for increased deadspace and MV requirements

• New protocol to address aggressively

Emory ECMO CenterEmory Critical Care Center

Hypercoagulability

Emory ECMO CenterEmory Critical Care Center

Final thoughts• Supportive care #1 tx

• Prepare now

• It continues to be worth it

Photos by Christina Creel-Bulos, MD, Critical Care Fellow