How is severe or critical coronavirus disease 2019 (COVID-19) managed?

Answer

Not all patients with coronavirus disease 2019 (COVID-19) will require medical supportive care. Clinical management for hospitalized patients with COVID-19 is focused on supportive care of complications, including advanced organ support for respiratory failure, septic shock, and multiorgan failure. Empiric testing and treatment for other viral or bacterial etiologies may be warranted.^[10]

Patients with severe or critical COVID-19 are likely to require aerosol-generating procedures, so they should be placed in an airborne infection isolation room (AIIR), if available.

Supplemental oxygen therapy should immediately be administered to patients with severe COVID-19 who have severe acute respiratory infection (SARI) and respiratory distress, hypoxemia, or shock, with the peripheral oxygen saturation target being greater than 94%.^[4]

Patients with severe COVID-19 should be closely monitored for signs of clinical deterioration (eg, rapidly progressive respiratory failure and sepsis), with supportive care interventions administered immediately.^[4]

In a case of severe COVID-19, the patient’s comorbid condition(s) should be understood in order to tailor the management of critical illness.^[4]

Fluid management: When shock is not evident, conservative fluid management should be used in patients with SARI.^[4]

Empiric antimicrobial therapy should be administered as soon as possible to treat all likely pathogens causing SARI and sepsis, with such treatment provided within 1 hour of initial evaluation for patients with sepsis.^[4]

Severe hypoxemic respiratory failure must be recognized when standard oxygen therapy is failing in a patient with respiratory distress; prepare for administration of advanced oxygen/ventilatory support.^[4]

Remdesivir treatment should be administered to hospitalized patients with severe disease.

Corticosteroids are not routinely recommended for viral pneumonia or acute respiratory distress syndrome (ARDS) and should be avoided unless indicated for another reason (eg, COPD exacerbation, refractory septic shock). Nonetheless, The UK RECOVERY trial showed that low-dose dexamethasone (6 mg PO or IV daily for 10 days) randomized to 2104 patients reduced deaths by 35% in ventilated patients (P = 0.0003) and by 20% in other patients receiving oxygen only (P = 0.0021) compared with patients who received standard of care (n = 4321). No benefit was seen in patients who did not require respiratory intervention (P = 0.14).^[11]

Acute respiratory distress syndrome (ARDS)

Prone ventilation for 12-16 hours per day is recommended in adult mechanically ventilated patients with refractory hypoxemia despite optimized ventilation. ^[4]
Oxygenation for severe ARDS:
- Adults: PaO₂/FiO₂≤100 mm Hg with PEEP ≥5cmH₂0 or nonventilated (When PaO₂ is not available, SpO₂/FiO₂ ≤315 suggests ARDS);
- Children: OI ≥16 or OSI ≥12.3
Cardiologists should prepare to aid other specialists in managing cardiac complications in patients with severe COVID-19. ^[12]

Cardiovascular

Cardiology and critical-care teams should coordinate management of patients requiring extracorporeal circulatory support with veno-venous (V-V) versus veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). ^[12]
Obtain echocardiography in the setting of heart failure, arrhythmia, electrocardiographic (ECG) changes, or cardiomegaly. ^[12]
It is reasonable to triage patients with COVID-19 according to the presence of underlying cardiovascular, diabetic, respiratory, renal, oncologic, and other chronic diseases for prioritized treatment. ^[12]
Providers are cautioned that classic symptoms and presentation of acute myocardial infarction may be overshadowed in the context of COVID-19, resulting in underdiagnosis. ^[12]

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