Clinical Management of Critical COVID-19 Patients: Insights from the Literature and “On the Field” Experience

Abstract

The recent outbreak of the coronavirus disease (COVID-19) is a health emergency all over the world. Several health care professionals are currently putting their best efforts to deal with this situation. The aim of this review is to report insights from the literature and “on the field” experience in clinical management of critical COVID-19 patients. Respiratory support varies from high flow nasal cannula (HFNC) to noninvasive and invasive mechanical ventilation, often associated with nitric oxide, prone position, and extracorporeal membrane oxygenation (ECMO). Experienced specialists have to manage the airways minimizing any contamination and virus spread. The hemodynamic management of critical COVID-19 patients requires not only an accurate fluid strategy, but also an appropriate use of vasopressors and inotropes. Various adjuvant treatments have been proposed: antiviral drugs, immunomodulators, anticoagulants, antibiotics, and nutrition.

Intensive Care Management of Corona Virus Disease

“…Avoiding of hyperoxemia is recommended Starting conventional oxygen therapy is suggested when peripheral oxygen saturation drops <92% and recommended for SpO 2 < 90% The SSC panel suggests to prefer HFNC over NIV when treating acute hypoxemic respiratory failure not responding to oxygen therapy NHS guidelines advise against the use of HFNC in COVID19 patients The SSC panel suggests a trial of NIV if HFNC is not available and there is no urgent indication for endotracheal intubation NHS guidelines: For some patients, CPAP or NIV could represent the "appropriate ceiling of treatment" Invasive mechanical ventilation Endotracheal intubation and invasive mechanical ventilation is mandatory if noninvasive support is not enough and the patient shows symptoms and signs of respiratory fatigue along with impairment of gas exchanges The type L patients can be ventilated with volumes greater than 6 mL/kg (up to 8-9 mL/kg); the PEEP should be reduced to 8 . In these patients, the pathophysiology of shock and organs hypoperfusion is multifactorial: patients often present at hospital admission with severe dehydration and hypovolemia, after several days of hyperthermia and gastrointestinal symptoms, including severe diarrhea [41,42]. Distributive shock is probably the main mechanism for acute circulatory failure, and the magnitude of the "cytokine storm" is directly involved in the severity of the clinical presentation [10].…”

“…Fluid therapy is a key point in restoring perfusion in patients with hypovolemic shock along with fluid resuscitation strategy. In COVID-19 patients, fluid infusion should aim to maintain organ perfusion to avoid fluid overload ("keeping lungs dry") [42]. Recommendations from SSC COVID-19 panel, based on the evidence available for general management of fluid therapy in sepsis and septic shock, suggest initial conservative approach with buffered/balanced crystalloids and advise against the use of colloids (i.e., hydroxyethyl starch, gelatins, dextrans) [27].…”

“…Optimal antimicrobials stewardship in the COVID-19 pandemic is debated; a ratio between the risk of patients' clinical deterioration and the concern about antimicrobial resistance must be considered [52,53]. Several antibiotics showed a synergic effect on virus clearance: teicoplanin was found to effectively prevent the entry of Ebola virus, MERS, and SARS-Cov1 and is a promising agent for the prophylaxis and treatment of SARS-CoV2 infection [42,52,55]. Azithromycin showed in vitro activity against different viruses and has been found useful in preventing severe respiratory tract infections [42].…”

Advancing Neuroanesthesia and Neurocritical Care during the COVID-19 Pandemic and Infodemic: Focus on Education, Innovation, and Collaboration

“…Given the circumstantial limitations, such guidance is usually based on limited data, translation of evidence from other relevant situations, and collective wisdom. 5,6 The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) has developed consensus recommendations for neuroanesthesia practice during COVID-19. 7,8 Nevertheless, it is imperative that efforts be made to conduct research and collect data from larger patient populations to further inform clinical care.…”

“…18 This edition of the Journal of Neuroanaesthesiology and Critical Care (JNACC) includes two narrative reviews and a commentary related to COVID-19. 6,19,20 As new data emerges, we will continue to learn more about COVID-19 and its neurological implications.…”