COVID 19 pandemic - icu management ( for undergraduate level)

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1. ICU management in pandemic Dr FAMNA FAISAL CH Guru Gobind Singh Medical College Faridkot Punjab

2. A pandemic is an outbreak of a disease that occurs on a global scale, affecting a large number of people across multiple countries or continents. It involves a new pathogen or strain of a virus that spreads easily from person to person because humans typically have little to no pre-existing immunity. Pandemics are different from epidemics, which are more localized outbreaks of disease. In addition to widespread illness, pandemics can cause significant social, economic, and healthcare system disruptions, as seen with COVID-19. Historically, pandemics have included diseases like the Spanish flu (1918), H1N1 (2009), and COVID-19 (2020).

3. Factors contributing to pandemics include global travel, industrialization, urbanization, deforestation, and environmental misuse. These activities can lead to emerging zoonotic diseases—pathogens that originate in animals but evolve to infect humans, as seen with diseases like HIV, influenza, and coronaviruses. The world’s interconnectedness makes the rapid spread of these new infections more likely

4. During any pandemic, infected persons can be divided into three categories based on the severity of their symptoms: Asymptomatic persons : They do not show symptoms but are often still infectious . Most infected individuals tend to fall into this category, posing a risk of transmission . Without substantial active surveillance mechanisms, these cases can go unnoticed . To detect asymptomatic carriers, all contacts of confirmed cases should be observed or quarantined and regularly screened, enabling identification in large numbers.

5. 2. Symptomatic persons : Patients in this group show symptoms and often seek medical care. Symptom severity varies: • Mild : Patients are symptomatic but can often be managed outside the hospital. • Moderate : Patients may require hospital care but not intensive care. • Severe : These patients are critically ill and may need intensive care unit (ICU) support. The progression from mild to moderate and severe depends on several factors, including underlying health conditions and immune response. 3. Advanced disease : These are the most critically ill patients, typically requiring intensive medical intervention. I

6. In terms of epidemiological classification, symptomatic individuals can also be categorized as: • Suspected : Based on symptoms and potential exposure. • Probable : Likely infected but not yet confirmed by lab tests. • Confirmed : Positive test results confirming infection.

7. Institutional Approach When an infected person enters the health system, proper triaging is essential. The goals are: • Preventing transmission : Reducing the risk of infecting others through isolation and infection control measures. • Identifying prognostic signs : Recognizing early signs that may predict the disease’s progression. • Providing appropriate care : Implementing care protocols based on the patient’s condition. All healthcare workers involved in triaging should be familiar with the necessary information to be collected (e.g., travel history) and be able to identify bad prognostic indicators, such as worsening symptoms. In cases involving diseases with high transmission potential, contact or airborne precautions should be implemented at the triage point itself, and unnecessary movement of patients and their close contacts should be restricted.

8. Emergency procedures during pandemics

9. Competencies for Managing Complication In such critical situations, the healthcare provider (e.g., the IMG—Internship Medical Graduate) must have the necessary competencies to perform life-saving procedures, such as: • Endotracheal intubation • Mechanical ventilation • Cardiopulmonary resuscitation (CPR) • Tracheostomy Each of these interventions requires precision and extreme care to ensure the safety of both the patient and the healthcare worker performing the procedure. Beyond the technical or psychomotor skills needed to execute these procedures, the healthcare provider must also demonstrate strong knowledge, an appropriate attitude, and effective communication skills to manage these high-stress situations effectively. 9

10. The pandemic diseases had a profound impact on healthcare systems worldwide, particularly in Intensive Care Units (ICUs). Intensive Care is specialized medical care provided in dedicated settings with continuous monitoring and timely corrective measures carried out by a team of trained healthcare professionals. Modern Intensive Care Units (ICUs) are equipped with advanced technology and operate based on standardized protocols. 10

11. Besides technical knowledge related to diagnosis , prognosis, and patient management, the concept of team-based care is essential. Healthcare providers must also be adept at managing emotional and communication issues that arise during ICU care, both with patients and their families. ICU care is often very expensive, adding to the financial burden on families. Maintaining a high-quality ICU requires substantial investment in technology, as well as changes in behavior and attitudes among healthcare workers to ensure optimal care delivery ICUs played a critical role in treating severe cases of pandemic diseases, as patients with serious symptoms often developed acute respiratory distress syndrome (ARDS), requiring advanced respiratory support, including mechanical ventilation. 11

12. WH O’s Response to Health Emergencies • Rapid Response within 48 hours: • Grades the severity of the event • Deploys field teams • Activates stockpiles of supplies (PPE, medicines, vaccines) • Communicates risks through International Health Regulations (IHR) • Coordinates with global partners and systems WHO’s Critical Role in Pandemics: • Rapid detection, communication, and response • Coordination with international partners • Supporting countries with resources and capacity-building

13. The Criteria for ICU Admission •Severe Hypoxia (SpO2 < 90% despite oxygen therapy) •Increased work of breathing •Hemodynamic instability (requiring vasopressors) •Acute organ failure (especially renal or cardiac) •Altered mental status (due to hypoxia or other causes)

14. INITIAL STABILISATION OF PATIENT IN ICU 1. Make sure that the below said equipments are available: Oxygen source Airwaycart Working suction Monitors Emergencydrugs - Defibrillator Attac h monitors

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17. Wall mounted suction Neonates: 60–80 mm Hg
Infants: 80–100 mm Hg
Children: 100–120 mm Hg
Adults: 100–150 mm Hg
Higher pressures can cause trauma, atelectasis, and hypoxemia The catheter size used for suction should be less than 50% of the internal diameter of the endotracheal tube 17

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21. The primary survey should follow A-B-C-D-E A- Airway ● If the patient can speak, the airway is patent ● Airway patency not maintained, triple manoeuvre -head tilt, chin lift and jaw thrust. ● If still not maintained, use oropharyngeal/nasal airways. B- Breathing ● Check for oxygen saturation and respiratory rate ● If SpO2<90% and RR>30 give oxygen supplementation via ) Nasal prongs ) Simple face mask ) Venturie face mask )NRM mask 21

22. C- Circulation ● SBP<90—check distal pulses, confirm IV access and give fluid bolus ● Start on inotropic support D – Determine GCS and assess pupils
E- Examine the patient 4. Inform superior officer 22

23. Respiratory Support IN ICU 1. High-Flow Nasal Oxygen (HFNO) •Used in patients with moderate hypoxia. •Advantages: improved oxygenation, reduced need for intubation 2.Non-Invasive Ventilation (NIV) •Can be used in specific settings but carries a risk of aerosolization 3. Mechanical Ventilation •Indicated in patients with severe ARDS or respiratory failure. •Low tidal volume ventilation (4-6 mL/kg) is recommende •Prone positioning: improves oxygenation in ARDS. 23

24. Hemodynamic Support •Fluid management: Conservative strategy to avoid fluid overload. •Vasopressors: •First-line: Norepinephrine for shock management. •Second-line: Vasopressin or Dobutamine for refractory shock. •Monitoring: Use invasive arterial pressure monitoring when necessary. 24

25. Sedation and Analgesia • Goal: Ensure patient comfort, reduce work of breathing, and synchronize with the ventilator. • Common agents: Propofol, Midazolam , Fentanyl. • Avoid deep sedation if possible, aim for lighter sedation using tools like the Richmond Agitation-Sedation Scale (RASS). 25

26. Renal Support in ICU • COVID-19 patients may develop Acute Kidney Injury (AKI). • Renal replacement therapy (RRT) indications: • Severe AKI with electrolyte imbalances. • Fluid overload. • Uremia. • Continuous renal replacement therapy (CRRT) is preferred in hemodynamically unstable patients. 26

27. Antiviral and Immunomodulatory Therapy • Antiviral treatments: Remdesivir has shown benefit in hospitalized patients. • Immunomodulators : • Dexamethasone: Reduces mortality in severe cases. • Tocilizumab : May be used in patients with evidence of a cytokine storm. 27

28. Thromboprophylaxis and Anticoagulation • COVID-19 is associated with a high risk of thromboembolism. • Use low molecular weight heparin (LMWH) for thromboprophylaxis . • In critically ill patients, therapeutic anticoagulation may be considered. 28

29. Nutritional Support • Initiate early enteral nutrition within 24-48 hours. • Energy requirements: 25-30 kcal/kg/day. • Protein intake: 1.2-2.0 g/kg/day. • Adjust based on tolerance and clinical condition. 29

30. Infection Control in the ICU • Strict isolation protocols for COVID-19 patients. • Use of personal protective equipment (PPE) by healthcare workers • Limit aerosol-generating procedures when possible. 30

31. Ethical Considerations 31 • Resource allocation: Triage and prioritization in resource-limited settings. • End-of-life care: Clear communication with families about prognosis and decision-making. • Palliative care should be integrated where recovery is unlikely

32. Spot the icu equipments from the pictures 32

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37. Conclusion 37 • The ICU management of COVID-19 requires a multidisciplinary approach. • Early identification of deterioration and appropriate interventions improve outcomes. • Ventilation strategies, hemodynamic support, and infection control are key components

38. References World Health Organization (WHO) Guidelines for the clinical management of COVID-19. Surviving Sepsis Campaign (SSC) Guidelines on the management of critically ill adults with COVID-19. National Institutes of Health (NIH) COVID-19 Treatment Guidelines British Medical Journal (BMJ) Best Practice guidelines for critical care management of COVID-19. American Thoracic Society (ATS) recommendations on respiratory support and ARDS management. Clinical research articles published in The Lancet, JAMA, and other peer-reviewed medical journals that provide insights on the management of severe COVID-19 cases. 38