The intensive care unit (ICU) community needs to prepare for the challenges associated with the coronavirus disease 2019 (COVID-19) pandemic, according to a review published in The Lancet Respiratory Medicine. This includes streamlining workflows for rapid diagnosis and isolation, clinical management, and infection prevention. It will also require that ICU practitioners, hospital administrators, governments, and policy makers prepare for substantial increases in critical care bed capacity, with a focus on infrastructure and supplies and staff management.
For this review, the investigators identified references via searches in PubMed for articles published between January 1, 1950 and March 22, 2020 using combinations of search terms such as “coronavirus”, “COVID-19”, “SARS-CoV-2”, “nCoV”, “severe acute respiratory syndrome”, “SARS”, “pandemic”, “MERS”, “intensive care” and other several other related terms. The World Health Organization and Centers for Disease Control and Prevention guidelines for COVID-19 management and articles from searches of the author’s personal files were also reviewed.
The review offered several recommendations including that as the pandemic progresses ICU practitioners should increasingly have a high index of suspicion and a low threshold for diagnostic testing for COVID-19 because clinical features of COVID-19 are nonspecific and can be difficult to distinguish from other causes of severe community-acquired pneumonia. Due to uncertainty of the sensitivity of reverse transcriptase polymerase chain reaction diagnostic tests for critically ill patients, repeat sampling should be done as necessary, preferably from the lower respiratory tract. Moreover, as a result of shortage of personal protective equipment, ICU practitioners should consider reuse between patients and use beyond the manufacturer-designated shelf life. The review also recommended minimization of risks for infection via segregation of ICU teams and physical distancing to limit unprotected exposure of multiple team members, and travel restrictions to limit exposure to COVID-19.
Management of acute respiratory failure and hemodynamics was also highlighted as a key for COVID-19 treatment. The investigators suggested that noninvasive ventilation and high-flow nasal cannula were used in between one-third and two-thirds of critically ill patients with COVID-19 in China; however, weak evidence suggests that high-flow nasal cannula might reduce intubation rates without affecting mortality in unselected patients with acute hypoxemic respiratory failure, delayed intubation as a consequence of its use might increase mortality. Therefore, these methods should be reserved for patients with mild acute respiratory distress syndrome. Because of the risk for myocardial dysfunction the review authors also suggested that fluids should be administered cautiously, and preferably with assessments for pre-load responsiveness.
To prepare for surges in capacity the review authors recommended, “the addition of beds to a pre-existing ICU, provision of intensive care outside ICUs, and centralization of intensive care in designated ICUs, while considering critical care triage and rationing of resources should surge efforts be insufficient.” Recommendations were also made for infection prevention practices, and ICU staffing and infrastructure, such as the use of well-ventilated rooms with closed doors or dedicated staff for cohabitated rooms—both of which are secondary options to airborne infection isolation rooms.
The review authors also pointed out that, “many questions on clinical management remain unanswered, including the significance of myocardial dysfunction, and the role of noninvasive ventilation, high-flow nasal cannula, corticosteroids, and various repurposed and experimental therapies.” Researchers will need to address key questions regarding this poorly understood disease. Furthermore, “collaboration at the local, regional, national, and international level—with a focus on high quality research, evidence-based practice, sharing of data and resources, and ethical integrity in the face of unprecedented challenges—will be key to the success of these efforts.”
Phua J, Weng L, Ling L, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020; 8: 506-517.