Managing ICU surge during the COVID-19 crisis: rapid guidelines

Aziz, Shadman; Arabi, Yaseen M.; Alhazzani, Waleed; Evans, Laura; Citerio, Giuseppe; Fischkoff, Katherine; Salluh, Jorge I.; Meyfroidt, Geert; Alshamsi, Fayez; Oczkowski, Simon; Azoulay, Élie; Price, Amy; Burry, Lisa; Dzierba, Amy; Benintende, Andrew J.; Morgan, Jill S.; Grasselli, Giacomo; Rhodes, Andrew; Møller, Morten Hylander; Chu, Larry F.; Schwedhelm, Shelly; Lowe, John J.; Du, Bin; Christian, Michael D.

doi:10.1007/s00134-020-06092-5

Cited by 336 publications

(395 citation statements)

References 139 publications

(184 reference statements)

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“…The introduction of protocols, especially for pain and sedation management, could provide an ICU with a systematic and resource-conserving approach that would facilitate delivery of evidence-based ICU care [5,8,11]. However, these results show that a protocol for mobilization did not facilitate implementation of element E possibly because of the several complicated mechanisms of lung injury and different ventilation strategy in the various phases of the illness [33][34][35][36].…”

Section: Discussionmentioning

confidence: 99%

“…However, the novel coronavirus pandemic (SARS-CoV-2) rapidly changed ICU practice internationally [9]. Challenges include an inadequate number of beds to meet the staggering increase in the number of patients with COVID-19 infections [10] and unbalanced interprofessional staff resources to meet the demand [11]. These challenges may lead to patients not receiving the same quality of clinical care, resulting in poorer outcomes including increased mortality [12].…”

Section: Introductionmentioning

confidence: 99%

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ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~

Liu

Nakamura²,

Katsukawa³

et al. 2020

Preprint

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BackgroundAlthough the number of patients with COVID-19 infection is increasing and concerns for their long-term disabilities are increasing, there is a lack of data about the delivery of the ABCDEF-bundle and supportive care in Intensive Care Units (ICUs). The aim of this study is to investigate the implementation of the ABCDEF-bundle and supportive care provided to patients with COVID-19 infections in ICUs. MethodsThis was a world-wide two-day point prevalence study, on June 3 and July 1, 2020. A total of 212 ICUs in 38 countries (166 ICUs on Day 1 and 212 on Day 2) participated. Clinicians in each participating ICU completed web-based online surveys. The implementation rate for elements of the ABCDEF-bundle, other supportive ICU care measures and implementation associated structures were investigated.RESULTSData for 262 patients was collected during the two-day study. Of patients included, 124 (47.3%) underwent mechanical ventilation (MV) and 12 (4.6%) patients were treated with extracorporeal membrane oxygenation (ECMO). The proportion of patients with implementation of each element was: Element A (regular pain assessment) 45%; B (both spontaneous awakening and breathing trials) 28%; C (regular sedation assessment) 52%; D (regular delirium assessment) 38%; E (early mobility and exercise) 47%; and F (family engagement and empowerment) 16%. The implementation of element E for patients on MV was 16% and ECMO was 17%. Supportive care, such as providing protein throughout the ICU stay (under 1.2g/kg for more than 50% of the patients) and introduction of an ICU diary (25%) was inadequate. A higher implementation rate of elements A and D were recognized in ICUs with specific protocols for ICU care and lower numbers of ICU beds exclusively for patients with COVID-19 infection. Element E was implemented at a higher rate in ICUs with more ICU beds for patients with COVID-19 infection.CONCLUSIONSThis worldwide two-day point prevalence study found low implementation of the ABCDEF-bundle. Specific protocols and the number of ICU beds reserved for patients with COVID-19 infections might be key factors to deliver appropriate supportive care.Trial registration: UMIN, UMIN000040405. Registered 14 May 2020, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000046103

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~

Liu

Nakamura²,

Katsukawa³

et al. 2020

Preprint

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“…ICU access for ICP was therefore immediately on the agenda, although no formal deliberation was started between intensivists and referral-specialists to de ne restricted ICU admission for ICP. Early in 2020 national medical and administrative recommendations were issued by legal authorities as well as scienti c societies (9)(10)(11)(12)(13)(14) to guide medical decisions on patient transfer to ICUs. We decided, in consultation with the institutional administrative crisis unit (IACU, see below), that for ICP patients as for every other patient admission to the ICU had to be conditioned by a constant concern to provide equal consideration regarding critical care.…”

Section: Icu Admission Policymentioning

confidence: 99%

Equal critical care consideration for both immunocompromised and immunocompetent patients during the COVID-19 surge

Denis

Baldacini

Schenck

et al. 2020

Preprint

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Background: SARS-CoV-2 disease (COVID) affects all sections of the community, but some people contract the disease in a form requiring ICU admission. Immunocompromised patients (ICP) figure among the fragile patients whose access to critical care may be denied in the event of ICU bed-shortage. Our aims were: 1) to describe our management experience in seeking to assure equal critical-care consideration for both ICP and immuno-competent patients during the COVID surge, 2) to assess how successful this would be in terms of outcome for all patients, 3) to compare ICU stays of ICP, whether they survived or not, so as to detect possible prognostic factors.Methods: We conducted a cohort study in medical ICUs of a university-affiliated hospital hit by an uncontrolled cluster of COVID. We compared the levels of activity before and during COVID: number of patients (whether COVID+ or COVID-, whether ICP or not); bed-occupancy and bed-availability; mortality rates and the need for sanitary evacuations analyzed to avoid triage decisions.Results: During the pre-COVID period, 396 patients, including 9.3% ICP, were admitted. During the COVID period, 547 patients, including 243 COVID+ (of whom 24 ICP), were admitted: this required an 8 ICU bed-extension (+14.5% beds), a transfer of 69 immuno-competent COVID- patients to surgical ICU step-down beds, and the transfer of 22 immuno-competent COVID patients to distant hospitals. Despite sanitary evacuations, there was a daily average of 2 ICU-access refusals, the patients being taken in charge by step-down units. Health evacuations were decided on when the weekly number of COVID admissions doubled. No ICP was denied access to the ICU; no COVID- ICP was hospitalized during the first 9 weeks of the surge. 28-day mortality was 41.6% in ICP versus 27.3% in immuno-competent patients (p=0.021, log-rank test). With the exception of SAPSII and SOFA, no factor was different between clinical and ICU-stay characteristics among ICP, whether surviving or not.Conclusion and Relevance: Equal critical-care consideration for both immuno-compromised and immunocompetent patients during the COVID-19 surge was possible with acceptable outcome. Sanitary doctrine and fine-tuned hospital logistics were mandatory both at local and national level to reach this goal.

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“…Inclusion criteria: Patients older than 18 years, who were diagnosed with COVID-19 and were administered LMWH, and agreed to participate in the study were included Exclusion criteria: Patients with previous coagulopathy, continuous indication of anticoagulant therapy (atrial brillation (AF), valve disease), glomerular ltration rate (GFR) <30 mL/min or undergoing dialysis, or with known liver dysfunction were excluded from the study. Diagnosis COVID-19 was diagnosed according to the WHO interim guidelines and con rmed in our laboratory by SARS-CoV-2 RNA detection with reverse-transcriptase polymerase-chain-reaction (RT-PCR) using nasal and pharyngeal swab samples [13].…”

Section: Study Patientsmentioning

confidence: 99%

Eosinophil and Anticoagulation in COVID-19 Patients

Arı

Can

Demir

et al. 2020

Preprint

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Introduction: Despite prophylactic anticoagulant treatments, thrombotic complications may develop in patients with Coronavirus disease 2019 (COVID-19). This study aimed to evaluate anti-Factor Xa levels to determine the anticoagulant activity of low molecular weight heparin (LMWH) in COVID-19 patients.Materials and methods: We prospectively evaluated 80 COVID-19 patients, diagnosed using polymerase-chain-reaction test, who were admitted to our clinic and administered LMWH; enoxaparin was applied according to the weight, D-dimer levels, and clinical condition of patients. Anti-Factor Xa levels in blood, drawn 4h after the 3rd dose of LMWH, were measured and a level of <0.2IU/ml was considered subprophylactic. Patients were followed up clinically and anti-Factor Xa levels were re-examined before discharge.Results: Groups 1 and 2 included 13 and 67 patients with subprophylactic (0.18±0.06) and prophylactic (0.43±0.23) anti-Factor Xa levels, respectively. The proportion of eosinophils in patients was significantly higher in group 1 than in group 2 (2.96±2.55 vs 0.90±1.28;p=0.001). At the time of discharge the eosinophilic proportion of patients was significantly higher (3.06±1.49 vs 2.07±1.92;p=0.001) but the activated partial thromboplastin time was significantly lower (22.34±1.38 vs 24.38±3.58; p=0.01) in group 1 than in group 2. Of 14 patients with eosinophil content >4%, 6 were in group 1 ((6/13) 46.2%) while 8 were in group 2 ((8/63) 11.9%); (p=0.009), and all had a D-dimer level <1µg/mL (p=0.03). ROC analysis for the presence of anticoagulation at subprophylactic level revealed an area under curve of 0.79 (95% CI:0.64-0.93); p=0.001).Conclusions: In COVID-19 patients, eosinophil levels could be considered for determining effective prophylactic anticoagulant administration. (NCT04507282)

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Managing ICU surge during the COVID-19 crisis: rapid guidelines

Cited by 336 publications

References 139 publications

ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~

ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~

Equal critical care consideration for both immunocompromised and immunocompetent patients during the COVID-19 surge

Eosinophil and Anticoagulation in COVID-19 Patients

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