Handling Critical CoVid-19 Patients: a Guide from Italian Anesthesiologists

Update 3/19/2019: we received a clarification from GiViTi doctors. Considering the historical moment and the uncertainty around treatment of CoVid-19, the advice that was extracted from the video-conference should not be referred to as “guidelines”. In addition to removing the use of the term “guidelines” from the article, we report this statement that we received from GiViTi (English translation follows):

“Il Centro di Coordinamento e il Comitato Tecnico Scientifico GiViTI sottolineano che l’obiettivo di questa videoconferenza è quello di condividere esperienze. Il GiViTI non ha fra le sue finalità quella di fornire raccomandazioni diagnostiche e terapeutiche, in particolare in una situazione di incertezza in cui la conoscenza è in divenire giorno per giorno.”

“The Coordination Center and the GiViTI Technical-Scientific Committee clarify that the goal of this video-conference is to share experiences. GiViTI does not have providing diagnostic and therapeutic recommendations among its purposes. This applies particularly in a situation of uncertainty in which knowledge is evolving on a daily basis.”
End of update.

As everyone knows, Italy has experienced Europe’s largest coronavirus outbreak. Because of this, Italian hospitals have been the front line in fighting the effects of the infection for patients in critical conditions.

While much is known by doctors worldwide, they have been operating in uncharted territories with regard to what specific actions and methodologies are most effective in handling those patients, and, effectively, maximizing their chances to save their lives.

GiViTi is a group of Italian professionals operating in the intensive care departments  of Italian hospitals. Last week GiViTi doctors had a video conference in which they shared their respective experiences and practical advice for best handling critical CoVid patients. The salient points were captured by Dott. Dario Pietrantozzi, Anesthesiologist, University of Pisa, into practical advice directed at anesthesiologists and intensive care workers  in Italian hospitals.

VNY has asked Italian-speaking US doctors to translate that summary into English. The translation is the work of  Dr. Emiliano Mugnaini, MD/PhD, hematologist, and Dr. Italo Ibi, MD/PhD, anesthesiologist, both from the George Washington University in Washington DC.

Important note: while every effort has been made in translating the document to the best of the knowledge of everyone involved, this article does not constitute medical advice. In addition to this, further research and experience in this field may make some of the recommendations in this document obsolete in the weeks and months to come. La Voce di New York does not accept responsibility for use of the information contained in this article. Any action taken by professionals who may have read this article is entirely at their own risk.

GiViTI COVID19 MEETING 10 March 2020 – ICU PATIENTS

Patient Characteristics

• The average age of patients is about 70 years old.
• The most frequent co-morbidity is OBESITY.
• A clear majority of patients are males.
• On admission PaO₂/FiO₂ < 100.
• CXR on presentation usually bilateral interstitial pneumonitis (can be asymmetric if co-infections).
• Beware of swab results as they may be negative initially. Clinical impression is more reliable. Confirmation often comes only later via BAL, as pulmonary involvement is lower.

Hematochemistry

• Pro-calcitonin (PCT) = 0 (in the absence of co-infections).
• High CRP.
• High LDH.
• Elevated liver enzymes (from virus +/- medications).
• High CK especially in younger patients (who usually have high fever, chills etc.).
• Extreme elevation of, and difficult to control blood glucose levels, often causes ketoacidosis.
• Low albumin (collected in the lungs??).
• Lymphopenia (low CD4).
• BNP normal.

Pharmacologic Therapy

• Lopinavir/ritonavir (KALETRA) 200/50 mg po BID.
• Chloroquine 500 mg po BID or hydroxychloroquine 200 mg po BID.
• Prophylactic antibiotics (variable according to local practice: piperacillin/tazobactam, ceftriaxone, TMP/SMX, antifungals (the use of azithromycin has been abandoned).
• Acetylcysteine 300 mg po TID (secretions not abundant, but dense when present).
• Steroids? Only in cases with fibrosis (do not use prematurely).
• Tocilizumab? IL-6 receptor inhibitor. Rationale is vast inflammation BUT use must be evaluated in setting of lymphopenia. At the moment NO indication for routine use and NO precocious use.

Intensive Therapy

• Profound sedation.
• Paralysis
• Fluid balance net NEGATIVE: the lungs act like sponges due to inflammation.
• Protective ventilation (require high PEEP, even > 15 cm H₂0, monitor carefully for possible complications such as subcutaneous emphysema, PNX – tolerate pH up to 7.3 – in contrast to classical ARDS, patients usually have good compliance and can be ventilated without high driving pressure).
• PRONE POSITION (18-24 hour duration – fundamental principle of management = extremely effective – require up to 7 rotations – do not trust initial improvement and continue this therapy at least until clear signs of progress with therapy).
• Tracheostomy often within 7 days allows for earlier and safer weaning attempts (high risk of relapse).
• CRRT? Reserve for patients with greatest chance of favorable outcome for the following reasons: increases labor burden on nursing staff, greater difficulties with prone position, creates problem of disposal of infected bags/waste.
• Nitric Oxide: have not seen significant beneficial effects, but can be useful in gaining time for the most critical patients (extreme therapy).
• ECMO: rarely necessary, because patients are very responsive to adequate ventilation. Indicated in cases of patients not responsive to therapy and extreme hypoxia.

Monitoring

• CXR to define clinical presentation. May be repeated but imaging does not correlate strictly with clinical condition.
• CT Chest NOT indicated because great difficulty of transport, great risk of spreading contagion
• U/S Chest highly indicated for daily assessment of pulmonary condition (PATTERN 1: diffuse B lines, PEEP responder – PATTERN 2: anterior zone clear, posterior zone consolidation, responsive to prone position) – useful in evaluating complications from high PEEP and recruiting maneuvers.
• Echocardiography: look out for dyskinesia (myocarditis?).

Weaninig

• Afebrile.
• Decrease in inflammatory parameters (CRP, LDH).
• Euvolemia.
• PEEP < 12 cm H₂
• PaO₂/FiO₂ > 150.
• FiO₂ ≤ 50%.
• Do not trust initial improvement, because patients may experience early relapse.

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