Coronavirus

Continuous Renal Replacement Therapies (CRRT) are dialysis treatments that are provided as a continuous 24 hour per day therapy.

GiViTI COVID19 MEETING 10 March 2020 – ICU PATIENTS

Patient Characteristics

• The average age of patients is about 70 years old.
• The most frequent co-morbidity is OBESITY.
• A clear majority of patients are males.
• On admission PaO₂/FiO₂ < 100.
• CXR on presentation usually bilateral interstitial pneumonitis (can be asymmetric if co-infections).
• Beware of swab results as they may be negative initially. Clinical impression is more reliable. Confirmation often comes only later via BAL, as pulmonary involvement is lower.

Hematochemistry

• Pro-calcitonin (PCT) = 0 (in the absence of co-infections).
• High CRP.
• High LDH.
• Elevated liver enzymes (from virus +/- medications).
• High CK especially in younger patients (who usually have high fever, chills etc.).
• Extreme elevation of, and difficult to control blood glucose levels, often causes ketoacidosis.
• Low albumin (collected in the lungs??).
• Lymphopenia (low CD4).
• BNP normal.

Pharmacologic Therapy

• Lopinavir/ritonavir (KALETRA) 200/50 mg po BID.
• Chloroquine 500 mg po BID or hydroxychloroquine 200 mg po BID.
• Prophylactic antibiotics (variable according to local practice: piperacillin/tazobactam, ceftriaxone, TMP/SMX, antifungals (the use of azithromycin has been abandoned).
• Acetylcysteine 300 mg po TID (secretions not abundant, but dense when present).
• Steroids? Only in cases with fibrosis (do not use prematurely).
• Tocilizumab? IL-6 receptor inhibitor. Rationale is vast inflammation BUT use must be evaluated in setting of lymphopenia. At the moment NO indication for routine use and NO precocious use.

Intensive Therapy

• Profound sedation.
• Paralysis
• Fluid balance net NEGATIVE: the lungs act like sponges due to inflammation.
• Protective ventilation (require high PEEP, even > 15 cm H₂0, monitor carefully for possible complications such as subcutaneous emphysema, PNX – tolerate pH up to 7.3 – in contrast to classical ARDS, patients usually have good compliance and can be ventilated without high driving pressure).
• PRONE POSITION (18-24 hour duration – fundamental principle of management = extremely effective – require up to 7 rotations – do not trust initial improvement and continue this therapy at least until clear signs of progress with therapy).
• Tracheostomy often within 7 days allows for earlier and safer weaning attempts (high risk of relapse).
• CRRT? Reserve for patients with greatest chance of favorable outcome for the following reasons: increases labor burden on nursing staff, greater difficulties with prone position, creates problem of disposal of infected bags/waste.
• Nitric Oxide: have not seen significant beneficial effects, but can be useful in gaining time for the most critical patients (extreme therapy).
• ECMO: rarely necessary, because patients are very responsive to adequate ventilation. Indicated in cases of patients not responsive to therapy and extreme hypoxia.

Monitoring

• CXR to define clinical presentation. May be repeated but imaging does not correlate strictly with clinical condition.
• CT Chest NOT indicated because great difficulty of transport, great risk of spreading contagion
• U/S Chest highly indicated for daily assessment of pulmonary condition (PATTERN 1: diffuse B lines, PEEP responder – PATTERN 2: anterior zone clear, posterior zone consolidation, responsive to prone position) – useful in evaluating complications from high PEEP and recruiting maneuvers.
• Echocardiography: look out for dyskinesia (myocarditis?).

Weaninig

• Afebrile.
• Decrease in inflammatory parameters (CRP, LDH).
• Euvolemia.
• PEEP < 12 cm H₂
• PaO₂/FiO₂ > 150.
• FiO₂ ≤ 50%.
• Do not trust initial improvement, because patients may experience early relapse.