Berks County Medical Society Medical Record Winter 2021 - 29

M e d i c a l R ec o r d F e a t u r e

COVID-19 ICU Management
Introduction
The COVID-19 pandemic has brought worldwide attention
to the practice of critical care medicine and the intensive care unit
(ICU). Day in and day out, media outlets broadcast scenes of
busy ICUs caring for COVID-19 patients. The most feared clinical
course of COVID-19 is life-threatening pneumonia leading to
respiratory failure and death.
Early on during the pandemic, physicians were aware of the
virulence of COVID-19. There appears to be 2 main processes
involved in the pathogenesis of COVID-19 infection. Initially,
the disease is driven by replication of the severe acute respiratory
syndrome corona virus 2 (SARS-CoV-2). Later in the course, a
severe immune-inflammatory response to the virus develops. This
exaggerated immune response leads lung tissue damage.
Medical management of symptomatic COVID-19 patients is
based on severity of presentation. When patients are hospitalized,
attention is given to impending respiratory failure. Obviously, the
goal is to keep the patients from requiring intubation and ICU
level of care. Close monitoring of oxygen saturation and trending
acute phase reactants (ferritin and D-dimer to name a few) has been
helpful in managing hospitalized patients for disease severity.
COVID-19 infection is classified as mild, moderate, or severe.
Patients with mild disease may present with malaise and cold
symptoms without respiratory complaints. In moderate disease,
patients begin to experience dyspnea and hypoxemia. In Severe
COVID-19 infection, individuals experience acute respiratory failure
as a result of the pneumonia and require ICU management.
ICU-Basic COVID-19 Management Concepts
Treatment and therapy
COVID-19 patients who require mechanical ventilation and
ICU care have a higher mortality rate. Intensivists try to avoid
the need for mechanical ventilation in this patient population.
Supplemental oxygen and noninvasive techniques are employed first
to address the hypoxemia. Unfortunately, in severe cases, intubation
is inevitable. Along with supporting a patient's oxygenation,
individuals with moderate to severe disease may be considered for
COVID-19 designated therapies.
COVID-19 Medication
Remdesivir, an FDA approved antiviral medication, often
improves clinical outcomes for patients with COVID-19. The
therapeutic effect is thought to result from reducing viral load
in human airway epithelial (HAE) cells. This medication is
made available to individuals with moderate to severe disease.
Additionally, dexamethasone a corticosteroid, also improved
survival rates in patients suffering from COVID-19 pneumonia.
Dexamethasone is thought to help alleviate the severity of the intense
inflammatory response associated with COVID-19 pneumonia.

Another therapy offered to ill COVID-19 patients is convalescent
plasma. This therapy is available under emergency use authorization
by the FDA. Convalescent plasma is obtained from individuals
who were positive for COVID-19 infection and generated serum
antibodies to the virus. This donor plasma is administered to
critically ill COVID-19 patients. Generally, there is an emphasis to
provide these therapies or a combination of these therapies earlier on
in the clinical course of the infection rather than later.
COVID-19 Ventilation-Basic Concepts
Patients suffering from severe
COVID-19 pneumonia may
require mechanical ventilation.
Patients are managed with
ventilator strategies directed
at addressing acute respiratory
distress syndrome (ARDS). In the
ICU, the ventilatory support is
geared towards higher positive end
expiratory
pressure (PEEP) and low tidal volume (TV) ventilation. Another
strategy that has been utilized to care for the COVID-19 population
is the practice of prone ventilation. Individuals are placed in the
prone position to allow for better surface area oxygenation and gas
exchange.
Critical care workflow and logistics
The COVID-19 pandemic
has led to the development of
novel workflows in the ICU to
better care for the patients as well
as to protect the ICU staff while
administering care. COVID-19
patients are clustered together
within the ICU. This arrangement
allows for localization of resources
as well as minimizing unnecessary
exposure of through traffic to
the unit. Prior to the pandemic, most ICUs had a few designated
negative pressure rooms to care for airborne isolation patients
(i.e. Tuberculosis). Facilities management at Reading Hospital
has equipped all ICU beds with negative pressure capabilities.
Innovative workflows have been created to help minimize clinician
staff exposure. ICU monitoring equipment and IV pumps are now
stationed outside the rooms to minimize provider exposure.
The COVID-19 pandemic is challenging our ICU resources.
The critical care community at Tower Health continues to meet that
challenge through its commitment to patient care. As the world
awaits the delivery of the COVID-19 vaccine, the dedicated men
and women who practice critical care medicine and work in our ICU
use will be on the ready to care for those who need them.
WINTER 2021

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Berks County Medical Society Medical Record Winter 2021

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