COVID-19 critical care training case study

Model questions and answers

Day two (first day in ICU)

Joanna is in single organ failure and prior to COVID-19 exposure was fit and healthy, with no comorbidities.

The team has transcribed the drug chart from admission on her arrival this morning at 8am.

You are on your preliminary ward round and are reviewing the drug chart.

Question one

Is Joanna being correctly treated? Would you add any additional therapy?

Answer:

Using FASTHUG-MAIDENS:

Feeding – consideration of feeding.

Early enteral feeding has been associated with better outcomes, with evidence-based guidance recommending feeding within 48 hours.

Some centres might not feed if the patient is paralysed and prone, but this is not a contraindication.

Consider parenteral nutrition if the patient has gone more than five days without nutrition or is malnourished on admission to critical care (National Institute for Health and Care Excellence (NICE) guidance). This can be stretched to eight days as per some evidence.

Analgesia – monitor fentanyl infusion. Depending on supply issues, a change to morphine could be considered.

Sedation – pain and analgesia can be monitored together.

If the Richmond Agitation Sedation Scale score is -2/-3 , this means that the patient is rousable with either a shake or voice. If paralysed then this equals score of -4/-5  (unrousable).

Thromboprophylaxis – needs venous thromboembolism (VTE) risk assessment score:

• Add enoxaparin for VTE prophylaxis (local practice may differ, consult your local guideline and discuss with your tutor if necessary)
• Consider enhanced dosing based on weight and renal function – consult your local guideline

Hypo/hyperactive delirium – nil noted

Ulcer prophylaxis –

• Not being fed so may need prophylaxis with either a H2 antagonist or a proton pump inhibitor (refer to local protocol), for example, lansoprazole 30mg daily

Glycaemic control – none noted

• Aim for blood glucose control 4 -10 mmol/L (NICE-SUGAR study) – fluctuations out of this range may be acceptable but sustained deviations can worsen outcomes. For this, maintain blood glucose control until the patient becomes unwell. As blood glucose rises from sepsis, you may need to start insulin.

Medication reconciliation – completed on admission (no medicines)

Antibiotics – none

Indications for medications – all reasonable

Dosing – all reasonable – renal and hepatic function stable

No drug interactions, allergies, duplication, or side effects – nil noted

Stop dates – none noted

Day three (second day in ICU)

It is Joanna’s second day in the ICU and additions to the drug chart have been made as per your intervention yesterday. In addition, she has been started on Osmolite 1.5, commenced at 10ml/hour, increasing by 10ml/hour every four hours – to a target of 40ml/hour.

The nurse looking after the patient is worried that Joanna’s BP is dropping, despite her having adequate fluids on-board. The nurse thinks Joanna needs a vasopressor.

Question two

What would your recommendation be? And what starting dose and rate would you suggest?

Answer:

Consider what is causing the BP to drop, could the patient be becoming more unstable? Think about whether the low BP is causing perfusion issues, including involvement of the kidneys. In terms of fluid balance, COVID-19 patients are managed in a similar way to acute respiratory distress syndrome,  which involves a fluid balance that is more on the ‘dry’ side.

In this case, the fluid balance was negative. This is appropriate for the initial management for a COVID-19  patient, but in this case the patient will now require fluid resuscitation alongside noradrenaline (NICE guidelines – Hartmann’s 500ml bolus over 15 minutes). Fluid resuscitation may need to be repeated, if they are fluid responsive. The maintenance rate may also need to be increased.

Add noradrenaline – 4mg noradrenaline to 46ml 5% dextrose to make 50ml, in a syringe driver. The starting dose is 0.1mcg/kg/min, then increased to max 1mcg/kg/min. Titrate to target MAP – normally around 65mmHg (Surviving Sepsis guidance).

Day four (third day in ICU)

Joanna’s BP has stabilised and she remains on an infusion of noradrenaline, which is being titrated by nursing staff to her blood pressure. She has however had worsening of her inflammatory markers and blood glucose. This is suggestive of a potential secondary bacterial infection.

Question three

Which antibiotic would you recommend to commence?

Answer:

Follow your local antibiotic prescribing guideline based on the most likely infectious syndrome – (e.g. ventilator-associated pneumonia). Take into account any risk factors for multidrug resistance such as previous microbiology results, antimicrobial therapy or hospitalisation. For ventilator-associated pneumonia, piperacillin-tazobactam is an example of a common treatment regimen as it covers staphylococcus aureus and pseudomonas aeruginosa. Ensure that drug allergies and renal function are taken into account.

Monitor blood glucose levels as these may be less controlled due to sepsis.

Day six (fifth day in ICU)

Joanna has responded to the antibiotics and is no longer requiring noradrenaline. However, she is becoming more agitated and attempting to pull the tube out­.

Question four

What would you recommend?

Answer:

• Exclude other causes such as hyponatraemia/hypoglycaemia/comfort levels (in the context of the ITU), bladder output.
• Has the patient opened their bowels? Consider an aperient as per local bowel management protocol.
• Could the patient be improving and need extubation?
• Could patient be in pain? If so, consider paracetamol via NG or IV. Be cautious if increasing the fentanyl dose as this may increase sedation, which may compromise efforts to wean the patient off sedation for extubation.

Question five

Joanna’s potassium is low. What would you recommend as replacement and how fast would you advise to give?

Answer:

A small potassium bag can be given: 40mmol in 100ml sodium chloride 0.9%. Give via a central line at a maximum rate of 20mmol/hr.