The SARS-COV-2 pandemic started in January 2020 and has decimated the majority of U.S. hospitals for the past 18 months. The impact of COVID-19 has not only affected available hospital beds, but has limited the ability of hospitals to perform elective surgeries and procedures and to care for patients who are acutely ill from non-COVID illnesses. The new delta variant of COVID-19 is more contagious and deadlier than the native virus and has perpetuated the pandemic almost exclusively among people who have chosen to decline COVID vaccination.
As an ICU physician and procedural expert, I wanted to share some tips that I have learned at our hospital caring for critically ill patients with severe COVID pneumonia. The first tip is an acknowledgement that CPR for patients mechanically ventilated secondary to severe COVID-19 pneumonia is essentially futile. Several studies have noted a 100% in-house mortality for patients who have had cardiac arrest from severe COVID-19 pneumonia. One study from a health system in Georgia evaluated 63 patients who developed severe COVID-19 pneumonia and suffered a cardiac arrest. 80% of these patients were mechanically ventilated and 60% of them were on vasopressors. 90% of the patients had a non-shockable rhythm (PEA vs asystole) and there was a 100% mortality.[i] Another study analyzed 54 patients with severe COVID pneumonia who suffered in-hospital cardiac arrest and also found a 100% in-hospital mortality.[ii] Given this fact, I recommend an early discussion with these patients that you will do everything possible to help them including intubation, mechanical ventilation and even hemodialysis up to the point of CPR. Consider an early goals of care discussion and an early DNR code status.
Regarding airway management, try to minimize the providers in the room at the time of intubation. A bedside nurse, RT and yourself are all that is needed. Everyone should have full PPE and, if time allows, try to have all IV pumps and the ventilator monitor in an ante-room outside the patient’s room. A separate nurse can remain in the ante-room to adjust drips and ventilator settings.
Bring everything you might possibly need into the patient’s room at the time of intubation and in preparation of central line placement and arterial line placement including the following:
- Point-of-care ultrasound
- Two sterile probe sheaths
- Multi-lumen central venous catheter kit
- Sterile saline flushes if not in the kit
- Two biopatch if not in the kits
- Three needleless caps if not in the kit
- Two sterile occlusive dressing if not in the kits
- Sterile gown
- Sterile gloves
- Arterial line kit
- Wide sterile drape
- Suture on a Keith needle
- Chlorhexidine swabs
- Arterial line pressure transducer tubing (nurse setup)
- Video laryngoscope with appropriate blades
- 0, 7.5 and 8.0 endotracheal tubes
- Intubating stylet
- Bougie
- BVM
- EtCO2 detector
- 10 mL syringe to inflate endotracheal tube cuff
- High-flow nasal cannula for apneic oxygenation
- Induction agent (etomidate or ketamine)
- Neuromuscular blocker (succinylcholine vs rocuronium)
- Push dose pressors (e.g., phenylephrine 1 mg in 10 mL syringe)
- Have sedating meds ordered and ready for administration (e.g., fentanyl and propofol if BP allows or ketamine if BP marginal)
- Have norepinephrine available should the patient develop post-intubation hypotension
Assure that the patient has good vascular access that all flush well.
Transition the patient to high-flow nasal cannula with a non-rebreather mask to attempt preoxygenation as best as possible. Consider intubating the patient in a semi-upright position since they may become profoundly hypoxic in supine position. Perform rapid sequence intubation using an induction agent and a neuromuscular blocker using a video laryngoscope (e.g., a Glidescope) as quickly as possible. Avoid bagging patient prior to intubation if possible to minimize excessive viral aerosolization in the room. Utiize phenylephrine 100 mcg q30 seconds for any peri-intubation hypotension. Once the tube is in place, initiate ventilator sedation and analgesisa +/- norepinephrine (if the patient remains hypotensive).
Most of these ventilated COVID patients will benefit from prone positioning and will need stable vascular access. Therefore, I recommend the immediate placement of a central line and arterial line. I have found that once the endotracheal tube is secure and the hemodynamics are stabilized, attempt to place the patient in mild Trendelenberg position (if oxygenation allows) and place an ultrasound-guided internal jugular central line. Can prep and drape and anesthetize the site, prepare your line and place your sterile sheath over the ultrasound probe all with the patient in an upright position. Then, place patient in mild Trendelenberg to cannulate the vein and insert the catheter. Once the catheter is in place, the patient can be placed back into an upright position while the central line is secured. An arterial line is best placed in the radial artery using ultrasound guidance.
These are the most common ICU procedures that you will perform in a critically ill patient with severe COVID-19 pneumonia with some tips on how to accomplish them. If you need a refresher on how to perform any of these procedures, Hospital Procedures Consultants can teach you how to perform all of these procedures using simulation-based procedural training and many more at any of our Hospitalist and Emergency Procedure courses. Hope this helps!
REFERENCES:
[i] Shah P et al. Is Cardiopulmonary Resuscitation Futile in Coronavirus Disease 2019 Patients Experiencing In-Hospital Cardiac Arrest. Crit Care Med. 2021; 49: 201-8
[ii] Thapa SB, Kakar TS, Mayer C, Khanal D. Clinical outcomes of in-hospital cardiac arrest in COVID-19. JAMA Intern Med. 2020 Sept 28;e204796. Accessed November 10, 2020.