Apr 3, 2020

Wards ready

The story

The ED

• Make COVID testing part of standard fever work-up if there are any cases in your area, even for patients without known exposure
• Some COVID cases present as new or unexplained GI disturbance without respiratory symptoms
• We’ve seen plenty of false negatives, so re-test when clinical suspicion is high
• If it looks like bad ARDS on the CXR, it’s probably COVID

The floor

• Proning while on nasal cannula helps and can in some cases delay intubation. Or put another way: Awake proning! It’s a thing and can relieve hypoxia 
• Use nasal cannula —> non-rebreather—> high-flow nasal cannula (HFNC) for O2 support. Intubate immediately if rapidly progressive respiratory failure. Avoid BiPAP due to viral aerosolization (some centers are avoiding HFNC for the same reason) 
• Patients are tenuous, so even if O2 sats are ok, consider ambulating patients prior to discharge to avoid hypoxic collapse at home

Respiratory distress

• Ferritin and CRP often jump prior to respiratory distress
• Consider intubating patients with sky-high inflammatory markers early. Start off with high PEEP as soon as intubated
• Make sure sedation and paralytics are present at intubation to avoid coughing fits and vent dyssynchrony

The vent

• Patients are very PEEP responsive. Consider higher PEEPs than used for typical ARDS (e.g. > 12 cm H20, particularly for obese patients). We are routinely using PEEPs > 20 cm H20 
• Maximize sedation, paralyze if needed, prone if able (at least 12-16 h / day). You may face limitations due to staffing needs and personal protective equipment (PPE) shortages 
• Patients remain on the vent for a looooooong time. Don't rush to prematurely extubate

The unit

• Dry lungs = happy lungs. Consider diuresis for HD stable patients
• Obese patients (even if young and healthy) appear to be at greater risk for severe disease and respiratory complications
• Some patients see pulmonary improvement, but suddenly enter VT, VF, or even asystolic arrest on telemetry. Myocarditis is the suspected culprit 
• Goals of care. Early and often

Safety first

• To reduce PPE use and avoid exposure, abandon the typical daily CXR and decrease med frequency when able
• Use any available extra tubing to run drips from outside the room. Some vents can be adjusted from outside the room if set up appropriately
• Limit code teams to 3 - 5. Bring PPE with you (MUST have n95) and make sure it is on before you enter the room. Your safety is #1

Nephrons

• Think trialysis if you’re going to place a central line. Many patients develop renal failure, often with significant proteinuria. Keep a close eye on creatinine and urine output
• Inflammatory markers tend to rise a day or two before renal failure develops

Fingersticks

• Watch sugars carefully, many patients present with or develop ketoacidosis. We have been using insulin drips
• Some patients have normal fingersticks with an elevated beta hydroxybutyrate and anion gap acidosis without an alternative explanation

Meds

• Push for early treatment! Many think treatments have less utility once the inflammatory second stage of disease hits, usually around day 10
• There's a national shortage of azithromycin. Use doxycycline for non-COVID patients who need atypical coverage
• Watch QTc for all COVID patients on chloroquine and azithromycin, and replete electrolytes aggressively. Patients have gone into Torsades 
• Check HIV and HBV serology for all COVID patients if your institution has trials for lopinavir - ritonavir or IL-6 inhibitors
• Don't treat COVID with steroids, but don't withhold them if there is another indication 

And more

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