COVID-19 ICU Admission Order Set
"COVID-19" refers to clinical illnesses caused by the novel coronavirus SARS-CoV-2. The terms "COVID", "COVID-19", "coronavirus" and "SARS-CoV-2" are used interchangeably in current clinical practice. COVID-19 related illness can be acute (initial infection and inflammatory response during the first month), subacute (complications and co-morbidity effects 1-3 months post-infection) or long-term (post-COVID syndromes persisting beyond 3 months). This Order Set applies to adults with a suspected or swab-confirmed acute COVID-19 illness who are admitted to a critical care setting.
The median incubation period to acute illness is about 5 days from exposure (range of 2-10 days). The acute COVID-19 disease spectrum ranges from mild to severe clinical impact. Severe illness can include viral pneumonia, Adult Respiratory Distress Syndrome (ARDS) and septic shock. While most cases of acute illness (~80%) are mild, imminent or impending severe disease is a common reason for inpatient admission.
In contrast to influenza, severe disease progresses over several days. Dyspnea typically starts about 6 days post-exposure followed by deterioration 10-14 days post-exposure, often in the form of respiratory failure, ARDS and/or sepsis. Mild disease usually resolves within 2 weeks, but severe disease may take 4-6 weeks before improvement is secure.
Indications for Admission
Age is the most important predictor for hospitalization. Other important risk-modifiers include history of hypertension, cardiovascular disease and diabetes.
Indications for admission include:
Hypoxemia - Oxygen saturation <= 94% on room air); partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300 mmHg
Pneumonitis - Lung infiltrates on imaging > 50% within 24-48 hours
Respiratory distress - Tachypnea > 30 breaths per minute or other signs of increased work of breathing
Frailty and/or comorbidity burden requiring admission for anticipated COVID-19-related deterioration
Signs and symptoms of mild disease are similar to those of influenza-like Illness. Illness requiring admission usually presents as a lower-respiratory tract infection with dyspnea and cough, with pharyngitis and rhinorrhea uncommon. Fever, although common at some point during illness, may not be seen at presentation. Absence of fever does not exclude the diagnosis. Similarly, the timing or technique of a prior diagnostic swab may give false negatives.
There are no specific physical exam findings. Hypoxemia may be the only abnormality. Crackles, wheezes or other abnormal breath sounds could be due to a concomitant or complicating disorder, such as heart failure.
Investigation results are non-specific, of more value to prognostication than differential diagnosis. Possible prognostic markers include elevated d-Dimer, troponin, C-reactive protein, LDH, and ferritin, and depressed lymphocyte count. A high Sequential Organ Failure Assessment (SOFA) score is predictive of worse outcomes.
Chest x-rays typically show bilateral peripheral infiltrates, but these may be subtle early in the disease. CT chest most commonly shows bilateral infiltrates with a ground-glass pattern and sometimes "crazy paving". Dense consolidation can also be seen. Progression to ARDS-like patterns is more common with severe disease.
Strict isolation precautions in keeping with AHS IPC guidelines are to be maintained.
Treatment is generally supportive. Conservative intravenous fluid management strategies are recommended. Patients currently stabilized on ACEIs/ARBs are recommended to be continued on that therapy unless a contraindication is present (e.g., acute kidney injury).
Antibiotics are recommended for critically ill patients or those at risk of early deterioration, or for suspicion of secondary bacterial pneumonia. The role of antiviral therapy such as lopinavir/ritonavir is an important unanswered question; there are multiple trials currently investigating this question.
Immunosuppressives, Immunomodulators and Neutralizing Antibodies
Infectious Diseases consultation is suggested prior to the initiation of antiviral, hydroxychloroquine, biologic or other immunosuppressive therapy.
Glucocorticoids (dexamethasone) are recommended in patients who have hypoxemia requiring supplemental oxygen. For use outside of this, expert consultation advised.
Dexamethasone at 6 mg/day is sufficient to treat most patients hospitalized for severe COVID-19 who require supplemental oxygen (e.g. for COVID pneumonia or ARDS).
For patients that tolerate dexamethasone treatment, ten days of therapy is recommended, as this primary duration that has been studied to date
In the absence of evidence, doctors should use their clinical judgement to determine the dose of dexamethasone or other steroids to be administered to COVID-19 patients who are immunocompromised or are recipients of solid organ transplants
Immunocompromised patients receiving dexamethasone for COVID-19 should be monitored for bacterial or fungal infections that may arise due to immune suppression.
The efficacy and safety of awake prone positioning of non-intubated COVID-19 patients with hypoxemic respiratory failure is not established and hence this practice is not recommended for routine application.
Antithrombotics (COVID-19 VTE Prophylaxis)
Pharmacological prophylaxis (low molecular-weight heparin, tinzaparin, preferred) should be used in all hospitalized COVID-19 adults (including immuno-compromised and hospital-acquired COVID-19 but excluding patients with contraindications to anticoagulation), continuing through to discharge. COVID-19 is a major risk factor for venous thromboembolism (VTE), increasing the likelihood of oxygen requirement progression, organ failure, mechanical ventilation or death.
Admitted patients with COVID-19 who are not critically ill (oxygen requirements up to 15L/min and not on HHHFO), pregnant or at high bleeding risk should be considered for weight-based therapeutic-dose anticoagulation.
High bleeding risk can be determined by a HAS-BLED score of 3 or more.
Admitted patients with COVID-19 selected for prophylactic dosing should receive tinzaparin as close as possible to 75 units/kg. Additional dose bands (6,000 units of tinzaparin per day for persons weighing 80-90 kg and 7,000 units for persons weighing 90-100 kg) have been added to facilitate this.
At this time, there is insufficient evidence to recommend higher doses of tinzaparin for COVID-19 patients admitted directly to critical care, given an increased risk of bleeding and lack of improvement in the associated primary outcomes. COVID-19 patients admitted to critical care should continue to receive weight-based low molecular weight (tinzaparin) prophylactic dosing.