COVID-19: Considerations in the ICU

The Basics

Firstly, it is vitally important to keep yourself safe. Ensure that you are well versed in “donning and doffing PPE”. If you have a “buddy” available, then make sure they watch you throughout these processes. Also familiarize yourself with your site’s airway management protocols and how risk is mitigated in any aerosol generating procedures (intubation, ventilator disconnections, ALS / Code Blue responses) that you may be involved in.

The National COVID-19 Clinical Evidence Taskforce has excellent up to date guidelines for all relevant therapies.

As the pandemic progresses, the evidence base for management strategies and treatments will evolve. For example, the use of steroids following the RECOVERY and REMAP-CAP trials. Not only this, but with the emergence of variants, treatments that were effective for one variant may not be effective for another

Recent COVID trials are summarised on The Bottom Line.

Current COVID-19 specific treatments to consider

• Respiratory Strategies
  • Awake Proning
  • CPAP:
    • The use of CPAP has been a contentious topic
    • In hypoxic patients (needing FiO2 > 0.4) then CPAP was shown to reduce the need for intubation or death compared to HFNC or conventional oxygen therapy. This was predominantly due to a reduction in intubation (RECOVERY-RS).
    • Careful monitoring of patients using NIV is needed by experienced clinicians, and endotracheal intubation shouldn’t be delayed in deteriorating patients.
• Medications
  • If O2 requirement: Steroids (usually Dexamethasone 6mg) (RECOVERY trial, REMAP-CAP)
    • 10 day course
  • If O2 requirement and no need for NIV or invasive ventilation: Remdesivir (ACTT1 trial)
    • 5 day course
  • If O2 requirements and evidence of systemic inflammation (e.g. raised CRP without signs of secondary bacterial infection): Tocluzimab (RECOVERY trial) or Baricitinib (ACTT2, COV-BARRIER)
    • Tocluzimab – single dose, with consideration for second dose
    • Baricitinib – up to 14 day course
  • Molnupiravir and Paxlovid can be used early following symptom onset in unvaccinated patients who do not require O2.
• LMWH
  • In critically ill COVID normal dosing of LMWH (i.e. 40mg daily in patients with normal renal function and weight)

References and Further Reading

ANZICS COVID-19 Guidelines

ICS / RCOA Guidance and Resources for COVID – 19

SCCM SSC COVID – 19 Guidelines

LITFL: COVID-19

BJA: COVID-19-related organ dysfunction and management strategies on the intensive care unit: a narrative review

Author: George Walker