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#3400.159 Rev. 10/16 COVID-19 Medical Staff Guidelines Meeting 3 April 1, 2020 Physician or provider Clinical Judgement overrides this guideline when necessary

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Page 1: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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COVID-19 Medical Staff GuidelinesMeeting 3

April 1, 2020

Physician or provider Clinical Judgement overrides this guideline when necessary

Page 2: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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

Page 3: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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.

Page 4: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:
Page 5: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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

Page 6: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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

Page 7: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Pre-oxygenation Guide

Page 8: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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

Page 9: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Respiratory Therapy Update

Diane Sobel, RT

Director Respiratory Therapy, Cape Coral Hospital

Page 10: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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

Page 11: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM – High flow nasal cannula

https://journals.lww.com/ccmjournal/Abstract/onlinefirst/Surviving_Sepsis_Campaign__Guidelines_on_the.95707.aspx

Page 12: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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]

Page 13: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Early Intubation discussion

Page 14: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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]

Page 15: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Pharmacy Shortages

John Armitstead, R.Ph

System Director Pharmacy

Page 16: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

Medication shortages and monitoring QT Interval

Page 17: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Q-T interval monitoring

Peter Duggan, R.Ph

Director Pharmacy, Gulf Coast Medical Center

Page 18: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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

Page 19: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM – Vent Management

Page 20: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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%

Page 21: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

SCCM COVID-19 Algorithm

Page 22: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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*

Page 23: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

Page 24: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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NEJM – Prone Positioning

Page 25: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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?

Page 26: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM – Fluid Recommendations

Page 27: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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.

Page 28: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

SCCM -Fluids: LR versus NS when available

Page 29: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Code Blue UpdateIntubation/code team

When to activate Anesthesia teams for campuses with 24 hour coverage?

Page 30: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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)

Page 31: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

Intubation/Procedure Box-Optional

Page 32: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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)

Page 33: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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

Page 34: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

Rescue Airway Bag

LMA (size 3,4,5)

Flexible Tip Bougie

Bag Valve mask (with internal viral filter)

PEEP valve

Page 35: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

Make ACLS Protocol available

Page 36: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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

Page 37: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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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

Page 38: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:
Page 39: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

Thank You

Page 40: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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APPENDIX

Page 41: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM – Ventilator

Page 42: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM Recommendations: Ventilation

Page 43: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Ventilation continued SCCM Recommendations

Page 44: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Ventilation continued SCCM Recommendations

Page 45: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM – Hemodynamics

Page 46: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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SCCM Recommendations

Page 47: COVID-19 Medical Staff Guidelines...Many of the slides included in this presentation are derived from the SCCM Covid-19 recommendations and are listed with “SCCM”: Hyperlink:

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Hemodynamics continued SCCM Recommendations