Summary covid

As coronavirus disease 2019 (COVID-19) spreads across the world, the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic. Streamlining of workflows for rapid diagnosis and isolation, clinical management, and infection prevention will matter not only to patients with COVID-19, but also to health-care workers and other patients who are at risk from nosocomial transmission. Management of acute respiratory failure and haemodynamics is key. ICU practitioners, hospital administrators, governments, and policy makers must prepare for a substantial increase in critical care bed capacity, with a focus not just on infrastructure and supplies, but also on staff management. Critical care triage to allow the rationing of scarce ICU resources might be needed. Researchers must address unanswered questions, including the role of repurposed and experimental therapies. Collaboration at the local, regional, national, and international level offers the best chance of survival for the critically ill.

Introduction

Coronavirus disease 2019 (COVID-19) is the third coronavirus infection in two decades that was originally described in Asia, after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).1 As the COVID-19 pandemic spreads worldwide, intensive care unit (ICU) practitioners, hospital administrators, governments, policy makers, and researchers must prepare for a surge in critically ill patients. Many lessons can be learnt from the cumulative experience of Asian ICUs dealing with the COVID-19, SARS, and MERS outbreaks. In this Review, we draw on the experience of Asian ICU practitioners from a variety of settings—and available literature on the management of critically ill patients with COVID-19 and related conditions—to provide an overview of the challenges the ICU community faces and recommendations for navigating these complexities. These challenges and recommendations are summarised in Table 1, Table 2.

Table 1Challenges in clinical management

Recommendations

Epidemiology and clinical features

Prediction of disease trajectory from the time of symptom onset is difficult

Support research to develop and validate prognostic tools and biomarkers

Diagnosis

Clinical features are non-specific; risk of missing a case early in a local outbreak is substantial

Adopt a low threshold for diagnostic testing, where available

Sensitivity of RT-PCR assays for critically ill patients is unknown

Repeat the sampling if necessary, preferably from lower respiratory tract

RT-PCR assays might not be available in many ICUs; if available, assays will take time to complete

Maintain a high index of suspicion for COVID-19

Management of acute respiratory failure

Benefits of NIV and HFNC, and associated risks of viral transmission through aerosolisation, are unclear

Reserve for mild ARDS, with airborne precautions, preferably in single rooms, and a low threshold for intubation

Intubation poses a risk of viral transmission to health-care workers

Perform intubation drills; the most skilled operator should intubate with full PPE and limited bag-mask ventilation

ECMO is extremely resource-intensive, even if centralised at designated centres

Balance the needs of a larger number of patients with less severe disease against the (unproven) benefit to a few

Other intensive care management

Patients often develop myocardial dysfunction in addition to acute respiratory failure

Administer fluids cautiously for hypovolaemia, preferably with assessments for pre-load responsiveness; detect myocardial involvement early with troponin and beta-natriuretic peptide measurements and echocardiography

Bacterial and influenza pneumonia or co-infection are difficult to distinguish from COVID-19 alone

Consider empirical broad-spectrum antibiotics and neuraminidase inhibitors at presentation and subsequent rapid de-escalation

Benefits and risks of systemic corticosteroids are unclear

Avoid routine use until more evidence is available

Transfer out of the ICU for investigations such as CT scans poses risk of viral transmission

Minimise transfers by using alternatives such as point-of-care ultrasound

Viral shedding in the upper respiratory tract continues beyond 10 days after symptom onset in severe COVID-19

De-isolate patients only after clinical recovery and two negative RT-PCR assays performed 24 h apart

Repurposed and experimental therapies that are not supported by strong evidence are being used

Seek expert guidance from local or international societies and enrol patients in clinical studies where possible

ARDS=acute respiratory distress syndrome. COVID-19=coronavirus disease 2019. ECMO=extracorporeal membrane oxygenation. HFNC=high-flow nasal cannula. ICU=intensive care unit. NIV=non-invasive ventilation. PPE=personal protective equipment.

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