Acute Crit Care.  2021 Feb;36(1):1-14. 10.4266/acc.2020.00864.

Evolution of COVID-19 management in critical care: review and perspective from a hospital in the United Kingdom

• Jha AK
• Kulkarni SG

• KMID: 2513248
• DOI: http://doi.org/10.4266/acc.2020.00864

Abstract

The unexpected emergence and spread of coronavirus disease 2019 (COVID-19) has been pandemic, with long-lasting effects, and unfortunately, it does not seem to have ended. Integrating advanced planning, strong teamwork, and clinical management have been both essential and rewarding during this time. Understanding the new concepts of this novel disease and accommodating them into clinical practice is an ongoing process, ultimately leading to advanced and highly specific treatment modalities. We conducted a literature review through PubMed, Europe PMC, Scopus, and Google Scholar to incorporate the most updated therapeutic principles. This article provides a concise and panoramic view of the cohort of critically ill patients admitted to the intensive care unit. We conclude that COVID-19 management includes low tidal volume ventilation, early proning, steroids, and a high suspicion for secondary bacterial/fungal infections. Lung ultrasound is emerging as a promising tool in assessing the clinical response. Managing non-clinical factors such as staff burnout, communication/consent issues, and socio-emotional well-being is equally important.

Keyword

burnout; COVID-19; critical care; delirium; hydroxychloroquine

Figure

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  Figure 1. Royal Preston Hospital critical care admission protocol. ADL: activities of daily living.

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  Figure 2. Coronavirus disease 2019 (COVID-19) emergency intubation checklist. PPE: personal protective equipment; HME: heat and moisture exchanger; ET: endotracheal tube; LMA: laryngeal mask airway; RSI: rapid sequence intubation; BMV: bag mask ventilation; SGA: supraglottic airway device; FONA: front of neck access; BP: blood pressure; ECG: electrocardiogram; MACOCHA: MACOCHA intubation score; NG: nasogastric tube; NIV: noninvasive ventilation; HFNC: high-flow nasal cannula; IV: intravenous. Adapted with permission from Difficult Airway Society, UK [8].

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  Figure 3. COVID-19 intubation pathway. PPE: personal protective equipment; HME: heat and moisture exchanger; NMBA: neuromuscular blocking agents; SGA: supraglottic airway; FONA: front of neck access. Adapted with permission from Difficult Airway Society, UK [8].

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  Figure 4. (A) High-resolution computed tomography of chest showing L and H phenotypes in coronavirus disease 2019 (COVID-19). (B) Lung ultrasound in COVID-19—decision-making flowchart. PEEP: positive end-expiratory pressure.

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  Figure 5. Approach to ventilatory management in coronavirus disease 2019 (COVID-19). ICU: intensive care unit; CPAP: continuous positive airway pressure; CT: computed tomography; PEEP: positive end-expiratory pressure; ARDS: acute respiratory distress syndrome; PBW: predicted body weight; P/F: PaO2/FiO2; APRV: airway pressure release ventilation; ECMO: extracorporeal membrane oxygenation.

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  Figure 6. (A) Thromboprophylaxis pathway in coronavirus disease 2019 (COVID-19). (B) Low molecular weight heparin dosing in COVID-19. VTE: venous thromboembolism; LMWH: low molecular weight heparin; ICU: intensive care unit; PE: pulmonary embolism; CTPA: computed tomography pulmonary angiography; NEWS: National Early Warning Score; ESRF: end stage renal failure; CrCl: creatinine clearance; SC: subcutaneous; OD: once a day; BD: twice a day; FBC: full blood count; U+E: urea/creatinine and electrolytes; IBW: ideal body weight. aClinical improvement/deterioration refers to changes in NEWS, blood test results, and/or radiology.

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  Figure 7. Factors contributing to delirium in coronavirus disease 2019 (COVID-19).

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