Ohio State University - RIT (Rapid ICU Training)

Overview: This is an overview designed to identify resources and support practicing clinicians  at The Ohio State University to care for critically ill patients with COVID-19. Much of the content is geared toward practicing Anesthesiologists, but more detailed training and handout documents will be added. Additionally, these are distilled guidelines, they are not intended to impart clinical nuance nor dogma. Please email david.stahl@osumc.edu with suggested edits or additions.

The links below are all short tip sheets, graphics, or audio designed to be used in the moment. If you are looking for something longer to read, The SOCCA ICU Guide is detailed but not hard to read.

• Intensivists generally think of complex patients by organ system. This ensures complete care of the patient and avoids missing smaller issues. The educational material here is organized by organ system:
• SARS-CoV-2 is the virus, COVID-19 is the disease

Jump to: Neuro, CV, Pulm, Renal, GI, ID, Endo, Heme, Best Practices, Checklists, Ethics,

Or Jump to: OSU-Specific Handouts

Neuro: 

• ICU Goal → ↓ sedation. Some patients may only need opioids (no sedatives)
• COVID-19 pts likely require significant ventilator support → need sedation +/- paralysis.
• Orders for sedation in the ICU are titrated to the RASS scale our goal is -1 to 0 for most patients, but -4 to -5 for paralyzed patients (Tip: check the goal in your propofol infusion order).

• Most common infusion for sedation: propofol, avoid benzos as they worsen ICU delirium
• Most common opioid infusion: dilaudid (favorable context sensitive half life)

• ICU Delirium is common, review the CAM-ICU test used to identify delirium vs. not

• Remember: delirium involves alteration in thinking (confused) and inattention (cannot stay focused)
• There is no treatment for delirium
• If pt agitated/risk of harm discuss with intensivist: immediately consider
  1) restraints 2) haldol 5-10mg IV q15min to temporize

One page reference on sedation/delirium

Brief overview of neurologic management in the ICU or Listen

ABCDEF is one mnemonic to think about the neurologic management in the ICU

Cardiovascular: 

• In COVID-19 you will likely see three types of hypotension, start here to assess
• It is very important to treat the right type of shock AND to watch for what appears to be a high incidence of delayed cardiogenic shock

• Tachycardia in the setting of shock is usually a symptom NOT a cause (unless arrhythmia), DO NOT GIVE BETA BLOCKERS without significant thought/consultation

• Hypovolemia: may be intentional/permissive → prevent extravascular lung water → worse ARDS outcomes

• Treatment: support with vasopressors and small doses of fluid (250mL plasmalyte or LR) if evidence of malperfusion (e.g. lactate rising)

• Distributive shock: this can be sepsis or cytokine storm syndrome → these are part of the same spectrum of inflammation leading to low SVR.

• Treatment: norepinephrine, add or replace with vasopressin if any concern about RV dysfunction → r/o cardiogenic component particularly if not responding to low dose vasopressors
• Limit fluids while preserving organ function

• Cardiogenic shock: direct viral injury or myocardial ischemia from critical illness

If you are worried consider a STAT TTE (order) or bedside ultrasound to narrow ddx

Check ECG, Troponins q6h

• Preload / Function + Rhythm / Afterload
• Preload: limit volume, particularly in RV failure, consider early diuretics (see renal)
• Function: r/o ischemia, quick audio review here,

If ↓BP → epinephrine (start 0.04mcg/kg/min)

If nl BP → dobutamine (start 5mcg/kg/min)

• Rhythm: If unstable and tachycardic → synchronized cardioversion 200J+

• If afib w/RVR and not hypotensive enough to cardiovert consider amiodarone 150mg IV bolus (10min) + gtt at 1mg/min
• VERY small doses of beta blocker of BP allows, avoid CCB

• Afterload: Target MAP 60-70 in cardiogenic shock, avoid hypertension

If you want more detail, read about myocardial injury from SARS-CoV-2.

• Obstructive shock (e.g. pulmonary embolism) should also be on ddx; early reports of hypercoagulability associated with COVID

COVID Code Blue

Pulmonary: 

• Noninvasive Ventilation (CPAP, BIPAP) should be avoided in COVD-19: here’s why

• Where possible use MDI NOT nebulizers in these patients
• HHFNC should only be used if discussed with attending intensivist and proper PPE and possible negative pressure room

• Considerations for intubation in COVID-19 (graphic), or quick audio

• OSU COVID Airway Management

• Ok, COVID-19 pt intubated → now what → set your initial ventilator settings, then listen to this about how to adjust your settings while you wait 30 min to send an ABG

• More detailed ARDSNet protocols can be found here

• Recommend the Low PEEP Table (copied below)

• Refresh yourself on ventilator tracings to help you optimize the ventilator settings

• What if you need to use an anesthesia machine as a ventilator?

• Read a lot OR Quick Reference OR OSU Guide

Brief overview of mechanical ventilation in the ICU

Brief overview of other pulmonary management in the ICU

If the patient continues to be hypoxemic, follow the OSU Guideline (recently updated)

ECMO may be considered, listen about it here

Renal: 

• Dry lungs are happy lungs → limit fluids, ask pharmacists to concentrate IV infusions

• If not hypotensive: furosemide (20-40mg IV q6h as needed) to maintain a negative total body balance (TBB) to help the lungs

• TBB = everything into the pt minus everything out
• If persistently fluid positive call Intensivist; if also oliguric consider nephrology consult for possible RRT

• Watch for acute kidney injury (AKI), manage the kidneys
• If the Cr doubles in less than 24h, your EGFR is <30 (kidneys are not working at all)

Gastrointestinal: 

• NGT/Dobhoff (nasoenteric tube) placement is an aerosolizing procedure → consider placement at time of intubation
• Start early enteral (tube feeding) nutrition (ASAP).

• Preferred for critically ill patients, even on moderate dose vasopressors
• Quick estimate: 30kcal/kg/day / 24 hrs / 1.2 kcal/mL = hourly goal rate (Vital AF)

Brief overview of GI management in the ICU or listen here

Infectious Disease: 

• The syndrome of COVID and a diagnostic algorithm can be found here
• There is limited data for any treatment of COVID-19.

• OSU Inpatient Treatment Guideline
• If you start a COVID-specific therapy, check for drug interactions (there are many!).

• Remember to order Droplet + Contact precautions for confirmed or suspected COVID-19.
• Conflicting data about rates of co-infection:

• If you are worried about co-infection →

• Blood Cx (2 peripheral or 1 peripheral + all central access)
• Lower respiratory cultures (tracheal aspirate or bronchoalveolar lavage)
• Urine Culture
• Consider: Respiratory viral panel (labeled immunocompromised in the OSU orders) + Rapid influenza

• Infectious Disease consult will be helpful.

• Vancomycin (MRSA and gram+ coverage) + Cefepime (gram- and Pseudomonas) are our standard broad spectrum antibiotics at OSU.

Brief refresher on infectious disease in the ICU

You will see the surviving sepsis guidelines for COVID-19 posted, use extreme caution with these recommendations as they are based on limited evidence and early data from centers experienced in COVID conflicts many recommendations

Endocrine: 

• Steroids are NOT recommended in ARDS or COVID-19
• Hyperglycemia should be managed with goal 80-180 mg/dL

• Insulin gtt preferred but may be challenging for hourly glucose and nursing staff exposure → hyperglycemia better than hypoglycemia

Brief overview of endocrine management in the ICU or listen

Hematologic: 

• Anemia is common in the ICU, we generally do not transfuse for hgb>7 unless actively hemorrhaging. Multiple studies have shown no benefit to maintaining higher hgb.
• Thrombocytopenia is common in critical illness, often due to sepsis
• DVT prophylaxis discussed in checklists

Best Practices: 

• Remember to consult physical therapy and occupational therapy early → mobilization will be limited in COVID due to risk of staff exposure

Checklists: Rounds in the ICU end with a checklist to ensure completeness and prophylaxis (ppx) are met.

• Ventilator Associated Pneumonia ppx: elevate the head of the bed to 30 degrees, chlorhexidine mouthwash is no longer supported
• Stress Ulcer ppx: H2RA (famotidine) for patients who are intubated, PPI (omeprazole) in situations of
• Bowel regimen: particularly for patients on opioids, docusate + miralax as default
• DVT ppx: critically ill patients are at high risk for DVT and should be on prophylaxis (if kidneys OK consider lovenox in COVID to decrease nursing doses)
• Restraints: evaluate the need at least every 24h
• Lines: what do they have, what can be removed
• Dispo: issues keeping the patient in the ICU, and where will they go next

Ethics in the setting of limited resources:

Reminder: Goals of Care should be assessed early to inform code status

DNR-CCA (do not resuscitate from cardiac arrest) vs. DNR-CC (comfort care)

Read or Listen