Intensive care for severely ill COVID-19 patients

The COVID-19 patients who fit the following criteria are admitted in the ICU:

• A person who requires mechanical ventilation of either kind, invasive or non-invasive would be admitted in the ICU (both invasive and non-invasive).
• If a person is hemodynamically unstable, that means the blood does not have enough pressure to pump through the veins and capillaries, then they would require intensive care.
• If the mental status of a person deteriorates with time, they would need ICU support.
• A person would be admitted to the ICU if they would show the symptoms of multi-organ dysfunction.

Despite all the intensive care, people who are aged, with lymphopenia (extremely low levels of lymphocytes), increased LDH, high neutrophil-lymphocyte ratio and increased levels of D-dimer (a protein found in the blood after a blood clot is destroyed), tend to have poor outcomes.

The following procedures are done to manage the airway and fluid balance, to improve the status and to check the progression of the disease: 

• The patient is pre-oxygenated for 3-5 minutes in the closed-circuit device before providing them ventilator support. The doctors avoid AMBU bag-mask ventilation as it can produce aerosols which can be harmful to the ICU staff. 
• In order to deliver the required medication, MDI (metered dose inhalers) are preferred over nebulisation to avoid the formation of aerosols.
• The patients who require mechanical ventilation are anaesthetised using either etomidate or propofol depending on the hemodynamic status.
• The patients are given either succinylcholine or rocuronium for muscle relaxation that helps in easy intubation.
• Anaesthesiologists are present in each shift to maintain the vitals while the patients are under anaesthesia.
• The doctors use video laryngoscopy for inserting the endotracheal tube inside the patient. The endotracheal tube is inserted through the mouth till the windpipe. It helps in delivering oxygen from the ventilator to the lungs.   
• The mucus from the throat is suctioned by placing a tracheostomy tube in the throat of the patient. Normal suction is not used to prevent the formation of aerosols.
• The patients are given balanced crystalloids (ringers lactate and ringers acetate) to maintain the fluid balance of the body as normal saline increases the chances of kidney dysfunction.
• To maintain the hemodynamics, vasopressors are given as they constrict the blood vessels, thus improving blood pressure. The first choice of vasopressor used is nor-adrenaline; if it is not available then vasopressin or adrenaline are used. Dopamine is not to be used as it causes an increase in the heart rate and increases the chances of fatality.
• Since patients in the ICU are intubated and hemodynamically unstable, chest X-rays cannot be used, so the doctors use ultrasounds to check the progression of the disease. If the ultrasounds show vertical lines called the B profile starting from the pleura, it would suggest oedema in the lungs. It will also help in determining the presence of pneumonia in the lungs.
• Drug therapy only involves drugs to treat the symptoms of the disease. Research is being done to find the definite cure of this infectious disease.

The following are kept in mind to make sure that no complications arise in a patient who is admitted to the ICU:

• The patient is kept in a semi-recumbent position, that is at 30 to 45 degrees.
• Since most patients admitted in the ICU have the risk of developing deep vein thrombosis and pulmonary embolism, doctors administer Low Molecular Weight Heparin (LMWH) and use mechanical devices like an intermittent pneumatic compression device for prevention.
• Since the patients are under sedation, they are fed through feeding pipes within 24 to 48 hours after ICU admission to meet the requirements of the body.
• Critically ill patients especially those who have been in mechanical ventilation for more than 48 hours or have coagulopathies or Multiple Organ Dysfunction Syndrome (MODS) are at a high risk of developing stress-related gastrointestinal bleeding. In order to prevent that, stress ulcer prophylaxis is done using H2 blockers and proton-pump inhibitors.
• To prevent the formation of pressure sores in the sedated patients, gel pads are placed on every pressure point such as ankle joints and knee joints. If gel pads are not available, the ICU staff changes the position of the patient every two hours.
• Doctors keep an eye on the blood sugar levels of the patient which has to be in a range of 150 to 180 mg/dl.
• Weaning and mobilization of patients is done immediately after they come out of sedation and no longer require mechanical ventilation.

The challenges being faced by the ICU staff appointed for treating the critical patients of COVID-19 are:  

• A global shortage of personal protection equipment (PPE) for the medical staff endangers the efforts to prevent transmission of the disease.
• Isolation rooms with negative pressure ventilation are not available for everyone which makes it difficult to prevent the spread of the disease. 
• At any point, there can be a surge in the numbers of critically ill patients with COVID-19 and there are not enough ICUs to accommodate them.
• There is a lack of ICU equipment such as ventilators and medications across the nation. 
• Even after increasing the number of ICU beds, there is a shortage of work staff. Due to the increasing infection, the staff is being exposed to illnesses and have to be quarantined after unprotected exposure to COVID-19. 
• Due to the increasing workload, the current working staff is going through physical and mental fatigue. They are vulnerable to mental health problems such as depression and anxiety during outbreaks. There should be proper infection prevention measures, limited hours work shifts, availability of rest areas and mental health support.