COVID-19 PICU Admission Order Set

Applicability

"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 pediatric patients (age < 18 years) with a suspected or swab-confirmed acute COVID-19 illness who are admitted to a critical care setting.

Anticipating Admission

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

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

  • Comorbidity burden requiring admission for anticipated COVID-19-related deterioration

Clinical Evaluation

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.

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.

Isolation

Strict isolation precautions in keeping with AHS IPC guidelines are to be maintained.

Inpatient Treatment

General

Treatment is generally supportive. Conservative intravenous fluid management strategies are recommended.  

Antimicrobials

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.

Positioning

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.

Resources