covid-19 medical staff guidelines...many of the slides included in this presentation are derived...
TRANSCRIPT
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COVID-19 Medical Staff GuidelinesMeeting 3
April 1, 2020
Physician or provider Clinical Judgement overrides this guideline when necessary
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Contributors
Tim Dougherty, MD, Medical Director Disaster Preparedness, Emergency Medicine
Sunil Pammi, MD, Gulf Coast Medical Center Department of Medicine Chair
Shyam Kapadia, MD, Critical Care/Pulmonary Medicine
Javaad Khan, MD, Critical Care/Pulmonary Medicine
Dolan Abu Aouf, PA-C, Director of Advanced Providers, Dept. of Academics & Medical Education
Doug Brust, MD, Infectious Disease
Parmeet Saini, MD, Critical Care/Pulmonary Medicine
Ken Tolep, MD, Critical Care/Pulmonary Medicine
Rich Macchiaroli, MD, Emergency Medicine
Ragai Meena, MD, Critical Care/Pulmonary Medicine
Keith Lafferty, MD, Emergency Medicine
Charles Bisbee, MD, Gulf Coast Medical Center Department Chair Anesthesiology
Kurt Markgraf, MD, Anesthesiology
Marilyn Kole, MD, VP Clinical Performance and Medical Director Innovatus Health
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Guiding Premise
“The one thing we know is - we have no idea what is the ideal management of these patients”
We will learn, modify and adapt our guidelines as more information and literature is known.
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Agenda
Pre-oxygenation guide-Dr Lafferty
RT update-Diane Sobel
SCCM-High flow nasal cannula –Dr Pammi
Early Intubation discussion-Dr Pammi
Medication shortages -John Armitstead
Hydroxychloroquine and Azithromycin (QT-Monitoring)-Pete Duggan
SCCM-Vent management and guidelines-Dr Kapadia
NEJM-Prone positioning-Dr Kapadia
SCCM-Fluid recommendations-Dr Pammi
Code blue update- Intubation/code team-Dr Pammi
Summary slide-Dr Dougherty
Appendix
SCCM-Ventilator recommendations
SCCM-Hemodynamics
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SCCM reference
Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”:
Hyperlink: https://journals.lww.com/ccmjournal/Abstract/onlinefirst/Surviving_Sepsis_Campaign__Guidelines_on_the.95707.aspx
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Pre-oxygenation Guide
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Use nasal Cannula
Use BVM with PEEP valve but do not bag the patient unless absolutely
necessary
RSI and intubate
*Need a physician to give the RSI
S. Weingart device-Will not have enough supplies to use this method
Pre-Oxygenation Guidelines
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Respiratory Therapy Update
Diane Sobel, RT
Director Respiratory Therapy, Cape Coral Hospital
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Respiratory Therapy Update
1. Availability of supplies
Ventilators
HFNC
CPAP-Bipap
Vent filters-limited supply
2. HFNC requirements
ICU versus floor
Need for Air availability
special transport requirements
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SCCM – High flow nasal cannula
https://journals.lww.com/ccmjournal/Abstract/onlinefirst/Surviving_Sepsis_Campaign__Guidelines_on_the.95707.aspx
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HFNC-Vapotherm with facemask
• Use with facemask
• Need for Air availability
• Flows higher than 30L= Add headboard
Emcrit –Dr. Weinberg et al
Vapotherm
IS
Self proning
headboard
https://emcrit.org/emcrit/stop-kneejerk-intubation/ [emcrit.org]
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Early Intubation discussion
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Early intubation-Too early to tell?
1. Early intubation
2. Use HFNC?
3. Use CPAP?
4. Preserve ventilators
5. Let patients remain off ventilator for as long as tolerated?
6. Accept lower O2 sats
7. Will require close monitoring
https://emcrit.org/emcrit/stop-kneejerk-intubation/ [emcrit.org]
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Pharmacy Shortages
John Armitstead, R.Ph
System Director Pharmacy
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Medication shortages and monitoring QT Interval
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Q-T interval monitoring
Peter Duggan, R.Ph
Director Pharmacy, Gulf Coast Medical Center
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Hydroxychloroquine and Azithromycin
Q-T interval monitoring added to order per pharmacy
Labs: Magnesium level?
Additional considerations below
Baseline EKG recommended
https://www.dicardiology.com/article/covid-19-hydroxychloroquine-treatment-brings-prolonged-qt-arrhythmia-issues
QTc additional information
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SCCM – Vent Management
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ED Initial vent settings - Quick guideDr. Dougherty
TV- 6cc/kg IBW
Plateau airways pressure <30cmH20
PEEP- start 10-12 and titrate with ARDSNET peep guide
FiO2 –Drop as quickly as possible to keep O2 sats “ideally” >=92%
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SCCM COVID-19 Algorithm
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Strategies for ARDS Management
Low tidal volume strategies (Vt: 6 ml/kg; Pplat<30)
Permissive hypercapnia; pH > 7.15, PaO2 > 55 is acceptable practice
Based on SARS-1 and MERS-COV, high PEEP table should be used for ARDS
Fluid restrictive strategies with goal net negative fluid balance
For P/F ratio less than 150 consider early neuromuscular blockade (early use decreases mortality in ARDS)
For P/F ratio less than 150 consider prone positioning (early use decreases mortality in ARDS)
NEJM Prone Positioning Video without roto-prone bed for nursing/RT staff review:
https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
Vasodilator therapy - Flolan at HP vs Veletri at Lee. Soon to have Veletri at GCMC and Cape. Prolonged use can lead to renal failure*
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http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
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NEJM – Prone Positioning
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Prone Positioning
NEJM Prone Positioning Video without roto-prone bed for nursing/RT staff review:
https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
Self Proning for non intubated patients?
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SCCM – Fluid Recommendations
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Fluid Resuscitation
Fluid restrictive strategies with goal: net negative fluid balance
Add pressors earlier
With inadequate evidence to support a specific IVF strategy for the management of early septic shock, two alternative approaches have emerged:
(1) a liberal fluids approach that relies on a larger volume of initial IVF administration [often 50 – 75 ml/kg (4–6 liters in an 80 kg adult)];
(2) a restrictive fluids approach consisting of a smaller volume of initial IVF [often ≤30 ml/kg (≤2–3 liters)] and earlier use of vasopressors.
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SCCM -Fluids: LR versus NS when available
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Code Blue UpdateIntubation/code team
When to activate Anesthesia teams for campuses with 24 hour coverage?
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Code Blue Guide to enter the room
N95 and eyewear are brought with
provider, RT etc.
Donn the PPE
Draw up meds from RSI kit outside
room, label, and give doc
Respiratory brings their equipment and
respiratory bag
Pharmacy gives bag of meds to Doc
Nurse brings tubing and IV’s (2)
1 person CPR brings defibrillator
Who will Attend Code:(gatekeeper to limit number of people entering room-
and ensure appropriate PPE)
4-5 people on code team in room
Provider – ED/ICU/Anesthesia
1 Respiratory therapist
2 Registered Nurses (compressions and
medications) will switch out on compressions
Code Recorder will remain outside the door
Pharmacists will be available but will not go in room.
Recorder (outside of room)
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Intubation/Procedure Box-Optional
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Code Blue meds to bring in room
3 EPI
2 Atropine
2 Sodium Bicarb
2 Calcium
1 Amiodarone (2x 150 mg vials)
5 Saline flushes
1L bag of crystalloid (NS)
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Intubation Plan
INTUBATION PACK (large bag):
1. Adult BVM
2. Nasal Cannula
5. ET Tube Securement
7. PEEP Valve
8. ET Tube 7.0 and 7.5
9. CO2 detector
10. 10mL syringe
11. Yankauer suction
12. Surgi-lube (2)
13. OG Tube
14. ACLS Sheet
Intubation medications- RSI drawn up outside room
Video laryngoscope + appropriate blade + Stylet
Insert OGT by Provider
RSI Kit example
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Rescue Airway Bag
LMA (size 3,4,5)
Flexible Tip Bougie
Bag Valve mask (with internal viral filter)
PEEP valve
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Make ACLS Protocol available
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Coding a Mechanically Ventilated PUI or Confirmed COVID-19
When coding a mechanically ventilated PUI or patient with confirmed Covid-19 the following steps should be
followed.
1) Do not remove patient from ventilator to manually ventilate. Patient should remain on the ventilator as to
keep a closed system. Effective compressions are of utmost importance here and supersedes ventilation.
2) Titrate FiO2 to 100%.
3) Set volume control ventilation. Adjust RR to 10. Adjust Pt. trigger to Maximum pressure trigger in an attempt
to avoid triggering of the ventilator from compressions.
4) Vt should already be appropriate based off of Patient’s calculated IBW. (Consider a higher upper pressure
limit in an attempt to avoid compressions from short-cycling each breath)
5) PEEP should not exceed 10 cm H2O
Changes per clinical judgement
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Coding a non vented PUI or Confirmed COVID-19
When coding a non ventilated PUI or patient with confirmed COVID-19 the following steps should be:
• Consider LMA placement with filter
• Do not intubate emergently or intubate first?
• Place patient on N/C O2 with face mask?
• Do not bag patients unless absolutely necessary
• Compressions, meds, and defibrillation as needed
• Physician/provider decision for duration of code
Changes per clinical judgement
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Thank You
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APPENDIX
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SCCM – Ventilator
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SCCM Recommendations: Ventilation
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Ventilation continued SCCM Recommendations
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Ventilation continued SCCM Recommendations
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SCCM – Hemodynamics
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SCCM Recommendations
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Hemodynamics continued SCCM Recommendations