COVID-19 Curbside Consults

Management of patients with COVID-19 in the medical ICU

Chao Ping Wu, MD, Mani Latifi, MD and Eduardo Mireles-Cabodevila, MD
Cleveland Clinic Journal of Medicine June 2020, DOI: https://doi.org/10.3949/ccjm.87a.ccc017
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  • TABLE 1

    Recommendation for personal protective equipment for COVID-19

    Face Mask (surgical or ear-loop mask)N95 (fit-tested respirator)Protective Eyewear (goggles or faceshield)Gown & Gloves
    If you are a Patient or Visitor who is asymptomatic, no risk factorsNo personal protective equipment precautions required. Follow CDC guidelines, limit social interactions, practice hand hygiene. Follow visitation guidelines to limit exposure.
    If you are a Patient with respiratory symptoms OR confirmed or pending test results for respiratory virus or COVID-19Wear Face Mask while being transported (Not required while in hospital room)
    If you are a Visitor seeing a patient who is undergoing respiratory viral testing with pending results or who is COVID-19 positive
    • VISITATION by EXCEPTION ONLY as per policy    		Wear Face Mask (in room w/patient only)Wear Gown & Gloves
    Caregivers Performing Screening at Hospital or Department at Point of EntryWear Face Mask*Wear Protective Eyewear**
    Clinical Caregivers Actively Seeing Patients
    • Contact/Droplet + Eyewear & Specified Precautions
    • For transportation guidance olease click here    		Wear Face MaskWear Protective E yewearWear Gown & Gloves
    Collection of all Respiratory Viral Specimens for Testing (Including COVID)
    • caregivers obtaining nasopharyngeal/oropharyngeal swab    		Wear Face MaskWear Protective EyewearWear Gown & Gloves
    Performing Procedures and Surgeries
    • aerosolized risk: Bronchoscopy, nebulization.
    NIPPV. open tracheal suctioning, intubation/extubation. endoscopies, naso-enteric tube placement. TEE. high flow 02; ear-nose throat surgery, oropharyngeal/tracheal surgeries, lung laparoscopic surgery    		WearN95Wear Protective EyewearWear Gown & Gloves

    • ↵* Face mask usage: Extended use for face masks: One mask per shift. Change face mask with contamination with respiratory secretions or obvious soilage or damage. Masks should always be worn covering nose and mouth. Used mask handled by ear loops ONLY. Never touch the front of the mask. Perform hand hygiene after handling used mask. Do not reapply a used mask.

    • ↵** Protective eyewear: Reusable goggles or facemask preferable. Can be worn for extended period. Must be cleaned with disinfectant wipes with contamination/soilage and after each use.

  • TABLE 2

    Failure criteria for noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC)

    NIV Failure Criteria
    • Tidal volume > 9.5 mL/kg/IBW consistently over the first 4 hours
    • FiO2 > 60% to maintain target SpO2
    HFNC Failure Criteria
    • ROX scorea ≥ 4.88 at 2, 6 and 12 hrs is a good predictor of no need for intubation and < 3.85 is high risk for need for intubation

    • ↵a ROX score = (SpO2/FiO2)/RR.

  • TABLE 3

    Cleveland Clinic MICU COVID-19 workup checklist (updated 4/15/2020)

    1. Upon admission:
    • Complete blood count with differential, basic metabolic panel (BMP), liver function tests (LFTs), lactate dehydrogenase (LDH), C-reactive protein (CRP), fibrinogen, D-dimer, high-sensitivity troponin, NT-proBNP, creatine kinase (CK), CK-MB, procalcitonin, ferritin, aPTT, INR, IL-6, electrocardiography
    2. Follow-up:
    • Troponin: If troponin upon admission is elevated, then check troponin daily for 3 days or clinical deterioration
    • CRP: Check CRP daily, if it is elevated, consider checking triglyceride (TG), ferritin, fibrinogen, LFTs
    • TG: Check TG every 48 hrs while on propofol
    • D-Dimer, ferritin, PT/INR, aPTT: Monitor every 48 hrs for 3 times
     • If patient has evidence of diffuse vascular coagulation (DIC), then check fibrinogen, PT/INR and aPTT
     • Stop monitoring ferritin if patient is on Tocilizumab
     • Stop monitoring D-dimer and PT/aPTT if patient is on therapeutic anticoagulation
    3. Chest x-ray (CXR):
    • Perform CXR upon admission after all lines and tubes, then further CXR should perform only if it will change clinical management
    4. Electrocardiography:
    • Perform upon admission, and check QTc interval from bedside monitor
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