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However, patients treated for ten days had increased rates of renal failure more on this study here. Follow liver function tests.
The World Health Organization currently does not recommend the use of Remdesivir. Rochwerg et al. Remdesivir has some known harms and probably additional unknown side-effects it has never been broadly utilized, so rare side-effects may remain unknown.
Practitioners will continue to be pressured to administer remdesivir, especially in the United States. A five-day course may be reasonable in patients with no contraindications.
When possible, shared decision-making may be beneficial. When administered to rhesus macaques prior to infection with COVID, bamlanivimab reduced the viral load.
Publication of this trial is pending currently only a press release is available. The BLAZE-1 trial evaluated the use of bamlanivimab among outpatients.
Chen et al. Bamlanivimab had no consistent effect on viral load the intermediate dosage of bamlanivimab did seem to reduce viral load, but when considering the multiplicity of statistical tests involved, this may have been due to chance.
A secondary endpoint was hospitalization, which was re-defined in a post-hoc fashion as either admission to the hospital or the emergency department.
Bamlanivimab can cause anaphylaxis. The precise incidence of this adverse event remains unclear, but it seems to be rare. The NIH and CDC guidelines currently recommend against the use of bamlanivimab.
Studies are ongoing, including the use of bamlanivimab combined with another monoclonal antibody into a cocktail. Bamlanivimab has received an Emergency Use Authorization EUA in the United States, with some centers administering it.
This is likely an unwise use of healthcare resources. More on bamlanivimab here. Aggressive fluid resuscitation e. The virus doesn't seem to generally cause a septic shock picture but of course, patients may always suffer from superimposed bacterial septic shock.
More discussion on fluid therapy for COVID is here. This is a strong predictor of mortality. Among non-survivors, troponin tends to increase steadily from day 4 of illness through day 22 Zhou et al.
Type-II MI stress MI Stress cardiomyopathy a. Takotsubo cardiomyopathy Viral cardiomyopathy Investigation should focus on integration of EKG and echocardiographic findings as well as clinical context.
In most cases, specific therapies for acute coronary syndrome will not be indicated. This may be a late feature, which can occur even after patients are recovering from respiratory failure.
These studies lack control groups, so it's unclear to what extent COVID may be causing arrhythmias or whether arrhythmias simply occur in sick patients.
Potential causes: Cardiogenic shock i. PEEP or APRV Anaphylactic reaction to medication Evaluation Complete septic workup e.
Treatment Vasopressor support as guided by echocardiography and physical examination. Empiric antibiotic therapy if concern for septic shock.
Corticosteroid therapy may be considered although most patients will be on this allready. Inhaled pulmonary vasodilator could be considered for intubated patients with acute cor pulmonale.
This doesn't appear to be evidence-based. Guidelines say HFNC is safe. Negative pressure rooms are preferable for patients receiving HFNO therapy.
Therefore, it's doubtful that a patient on HFNC is more contagious than a patient on standard nasal cannula who is coughing. HFNC typically requires less maintenance than invasive mechanical ventilation.
For example, a patient who is on HFNC watching television may be less likely to spread the virus compared to an intubated patient whose ventilator is alarming every 15 minutes, requiring active suctioning and multiple providers in the room.
The intubation procedure places healthcare workers at enormous risk of acquiring the virus, so intubation with a goal of reducing transmission is probably counterproductive see figure above from Tran Existing evidence does not support the concept that HFNC increases pathogen dispersal substantially although the evidence is extremely sparse.
This includes a small study of patients with bacterial pneumonia Leung and an abstract regarding particulate dispersal by volunteers Roberts One case series from China suggested that HFNC was associated with higher rates of survival than either noninvasive or invasive ventilation of course, this could reflect its use in less sick patients Yang et al, see table 2.
A management strategy for COVID by a French group used HFNC preferentially, instead of BiPAP Bouadma et al.
Westafer et al. CPAP could have major advantages here: CPAP can provide the greatest amount of mean airway pressure, and thus most effective recruitment.
CPAP doesn't augment tidal volumes, so this could facilitate more lung-protective ventilation. Possible approach to CPAP therapy in COVID Increase the CPAP pressure to cm if tolerated.
Titrate FiO2 against oxygen saturation. Falling FiO2 requirements indicate effective recruitment, whereas rising FiO2 requirements suggest CPAP failure.
Further discussion of CPAP in COVID BiPAP could provide benefit beyond CPAP by providing some mechanical support for the work of breathing.
However, this does carry a theoretical risk of possibly encouraging the patient to take excessively large breaths thereby inducing lung damage.
The ideal BiPAP settings probably involve using a high level of end-expiratory pressure with a low driving pressure e.
This will closely resemble CPAP, with a little added support. BiPAP could be particularly useful in patients with combined syndromes e. COPD plus COVID There is a decreased risk of aspiration if emesis occurs.
In one RCT investigating ARDS, the helmet reduced intubation rates and possibly mortality Patel The helmet can be set up without requiring a ventilator, thereby potentially sparing ventilators for other patients.
Helmets have previously not been used in the United States, but they have become available currently. The low compliance of the helmet interface may make it difficult to synchronize with the patient when performing BiPAP.
Thus, these devices might work a bit better with CPAP. A discussion of how to configure this is located here.
This is possible with either a two-limb system involving a full featured mechanical ventilator, or a one-limb system involving a dedicated BiPAP machine e.
Respironics V Improved mask seal may improve safety. Helmet masks might theoretically have an advantage here. For patients with difficult lying in a prone position, alternating between lying on different sides might also be beneficial.
Can be combined with simultaneous use of any other noninvasive support device e. Requires cooperative patient with intact mentation. Could be useful especially in situations where access to invasive ventilation is limited.
Same physiology as proning a patient who is intubated proning is proning. For example: May improve secretion clearance. May recruit atelectatic lung tissue in the dependent lung basis this seems to be a major issue in COVID patients.
Proning intubated patients with COVID is widely reported to be successful in improving oxygenation. It stands to reason that similar success could be obtained by proning a patient who isn't intubated.
Awake proning was recommended by Sun et al. For patients with difficulty maintaining this position, other positions may be used e.
The most important aspect might be to avoid spending considerable time in a supine position which promotes atelectasis. Make sure support devices are well secured to the patient e.
Follow oxygenation and FiO2 requirement. Ideally an improvement in oxygenation should be seen within a few hours. If no change in oxygenation is observed, ongoing pronation may have less merit.
These don't appear to be evidence-based or guideline-supported. Patients vary widely, so use common sense. Patients who can avoid intubation have a substantially better prognosis than patients who are intubated.
Although this obviously doesn't prove causality, it does suggest that intubation should be avoided whenever possible. Ultimately, the decision to intubate is based on the clinical judgement of the bedside practitioner.
Key factors to consider in this decision may include: 1 Oxygenation There is no well-defined oxygen saturation trigger for intubation.
Tachypnea without increased work of breathing is less concerning. Increased work of breathing e. Ongoing decline over time may favor intubation.
However, since this definition is extremely broad, meeting it doesn't have any specific clinical implication. COVID patients may respond favorably to positive airway pressure e.
PseudoARDS is clinically relevant because these patients are less likely to benefit from proning. Prone ventilation does appear to work well for patients with COVID, but it may increase requirements for sedation and paralytics thereby potentially extending time on the ventilator.
Benefits of APRV include: 1 A primary physiologic problem in COVID appears to be de-recruitment, which is well managed by APRV.
This may avoid iatrogenic complications from these interventions e. This may allow us to render patients comfortable and awake on the ventilator more easily, while using fewer medications an especially important challenge as we run out of many sedatives.
APRV initiation can cause hemodynamic shifts, so pay careful attention to blood pressure during initiation. True failure to respond to APRV within hours e.
However, when started early APRV may be more likely to succeed — thereby avoiding the need for proning. The main limitation to APRV is that many centers aren't familiar with it or don't have ventilators which can provide APRV.
There is no consensus regarding exactly how to titrate PEEP. ARDSnet PEEP tables may represent a reasonable starting point.
Titration to clinical effect may be useful if there is sufficient time and experience to do this. Steht es in einem K.
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