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COVID-19 Medical Staff GuidelinesMeeting 3

April 1, 2020

Physician or provider Clinical Judgement overrides this guideline when necessary

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

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

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

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

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

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

Medication shortages and monitoring QT Interval

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Q-T interval monitoring

Peter Duggan, R.Ph

Director Pharmacy, Gulf Coast Medical Center

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

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%

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*

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

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NEJM – Prone Positioning

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

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.

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)

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

Rescue Airway Bag

LMA (size 3,4,5)

Flexible Tip Bougie

Bag Valve mask (with internal viral filter)

PEEP valve

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

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