Guide to Adult Critical Care and Triage SARS-CoV-2 (COVID-19)

Guide to Adult Critical Care

and Triage

SARS-CoV-2 (COVID-19)

Vitalité Health Network

April 28, 2020

2 Version – April 28, 2020

Table des matières

Preamble .................................................................................................................................................. 3

Definition of a Suspected Case ................................................................................................................ 3

IMPORTANT .............................................................................................................................................. 3

1. Initial Preparation (at all times)........................................................................................................... 5

2. Personal Protective Equipment .......................................................................................................... 6

3. Patient Admission Procedure .............................................................................................................. 7

a. Criteria for admission to ICU ........................................................................................................................... 7

b. Preparation ...................................................................................................................................................... 7

c. Patient admission to ICU ................................................................................................................................. 8

4. Transport Procedure ............................................................................................................................ 8

5. Airway Management Procedure - Suspected Severe COVID-19 Cases ............................................. 9

6. Ventilatory Support and Bronchoscopy Procedure ......................................................................... 10

7. Sterile Procedure and Techniques (central line, arterial cannula, thoracic drain) ......................... 11

8. Managing Cardiac Arrest ................................................................................................................... 12

a. Creating a Resuscitation Cart – COVID-19................................................................................................. 12

9. Extubation ......................................................................................................................................... 15

10. Samples and Labs ............................................................................................................................. 18

11. Pharmacotherapy ............................................................................................................................ 18

12. Ethics ................................................................................................................................................ 18

TRIAGE IN CRITICAL CARE .......................................................................................................... 19


Preamble This document is addressed to regional hospitals in Vitalité Health Network liable to treat critical care patients who are suffering from, or suspected carriers of, a COVID-19 infection. The document is inspired by the technical procedure guide prepared for the Québec Ministry of Health and Social Services. It’s a generic document that is not a substitute for the practices adapted by critical care and infection prevention and control (IPC) teams in each individual centre. The pandemic situation is changing every day, so these guidelines will probably have to be adapted as we go. Please keep abreast of updated information.

Definition of a Suspected Case The definition of a suspected case for an ICU will be the same as that given by New Brunswick Public Health. For now, all cases of severe respiratory infections testing negative for COVID-19 and without etiology will remain in COVID-19 isolation and be retested in 48 h. If the second test is negative, patients shall be treated in droplet contact isolation until identification of the etiology, with aerosol procedural protection for procedures that generate aerosols.

IMPORTANT The procedures described in this document shall be carried out directly by the intensivist, or failing that, by the person the most familiar with these procedures, until further notice. In the absence or unavailability of an intensivist or a physician, they shall be carried out by the most senior resident available.


At all times, the safety of hospital staff is the priority.


1. Initial Preparation (at all times) A negative-pressure room is kept free at all times and ready to receive a critically ill patient suspected or proven to be infected with SARS-CoV-2 (COVID-19) for all procedures with a high risk of aerosolization (intubation, bronchoscopy, stabilization).

• If the negative-pressure room is occupied or unavailable, an alternative should be free and available (alternative room).

• If no negative-pressure room is available, strict airborne isolation is required for any high risk invasive procedure, as described above.

• Staff shall check daily that negative-pressure or designated rooms are ready, including:

o Negative-pressure system functional with the door closed. o Wireless communication system available and functional

(example: baby monitor). o Alcohol-based solution available inside the room, in the

antechamber and at the exit.

• Personal protective equipment (all sizes) is always available quickly near the designated room.

• Dedicated staff shall always be identified to look after the first case on every shift (one member of the nursing staff, RT, attendant if necessary).

• An updated copy of this document shall be distributed to:

o ICU physicians o Nurse manager and nurse clinician o Members of the nursing staff o RTs


2. Personal Protective Equipment Airborne + contact + eye protection is required for all cases in the ICU of suspected or proven SARS-CoV-2 (COVID-19) infection.

• Staff on site shall wear uniforms provided and washed by the hospital centre and shoes worn shall be used only on working units and in the hospital.

• Equipment shall be put on under the supervision of a person competent to wear this type of protection.

• Here are supplementary videos, if needed, that show how to dress and undress safely:

o En français : https://www.youtube.com/playlist?list=PL7ApdZUkX0i0rAuVFOVc2UCeTaPANNFTd

o English: https://www.youtube.com/watch?v=0o6ZvKg0Q

Sw&feature=youtu.be

• See Vitalité Health Network’s documents

• If possible, a staff member should be present to monitor the procedure by which staff involved in the procedure dress and undress.

• Minimum personal protective equipment includes:

o Disposable gown o Surgical mask, except N95 for aerosol-generating medical procedures

(AGMP)* o Long gloves (covering the gown sleeves) o Eye protection (visor)

• AGMP (non-exhaustive list): Intubation, bronchoscopy, resuscitation including cardiac massage alone, tracheostomy care, non-invasive ventilation, high-flow oxygen via nasal cannula (OptiFlow, Airvo), use of CoughAssist, nasogastric tube insertion).

https://www.youtube.com/playlist?list=PL7ApdZUkX0i0rAuVFOVc2UCeTaPANNFTd

https://www.youtube.com/playlist?list=PL7ApdZUkX0i0rAuVFOVc2UCeTaPANNFTd

http://www.youtube.com/watch?v=0o6ZvKg0Q


• For patients with a trach, the balloon has to be kept inflated, unless the COVID-19 test is negative twice at least 24 hours apart (at least one test from the lower airway).

•

• No cough assist, no open suction or recruitment unless in a negative-pressure room.

• N95 mask for staff caring for intubated patients with COVID-19: o personnel caring for intubated patients with COVID-19

should wear N95 masks in the rooms of intubated patients, as well as during patient transportation.

3. Patient Admission Procedure

a. Criteria for admission to ICU The proposed criteria for admission to the ICU generally include:

• FIO2 40% for saturation > 90%

• Significant respiratory distress or RR > 24

• Persistent hemodynamic instability despite adequate volemic resuscitation

• Altered state of consciousness

• Any intubated patient

b. Preparation • The physician responsible for the critically ill patient who is suspected

or proven to be infected with SARS-CoV- 2 (COVID-19) shall call the intensivist on call to request admission to the ICU.

• Initial transfer to a regional hospital (Edmunston, Campbellton, Bathurst and Dumont UHC) should be considered for proven cases if the patient’s clinical condition requires.


c. Patient admission to ICU • The physician responsible for the ICU shall authorize admission of the

patient and pass on the necessary pertinent information, in particular the equipment needed and the individual medication required when receiving the patient. The physician responsible for the ICU is responsible for the decision to admit the patient to the ICU or to transfer the patient to another centre or to the floor.

• The patient is transferred from the ER by the dedicated staff (ER team vs ICU team, depending on the centre), with personal protective equipment, including a nurse, RT, attendant if necessary.

• Non-essential staff shall not be present in order to avoid any unnecessary exposure. Transport shall be facilitated to avoid as much as possible any contact with the rest of the hospital community.

4. Transport Procedure • Since it constitutes a risk for transmission, patient transport should

be reduced to a minimum. • In consequence, the decision to call for examinations must be taken

after due reflection: o Is it highly probable that the examination will answer a clinical

question that will change treatment? o Before starting, consider all the imaging that may potentially

be needed to treat the patient. o Daily lung x-rays are not recommended. Instead, they should

be taken at admission and then as needed based on the patient’s clinical condition.

• A transport procedure for COVID-19 patients shall be put in place in each centre to reduce exposure to the staff and the hospital community.

• Determine the staff needed to accompany the patient from the unit: Nurse, RT, attendant if needed (all with PPE).


5. Airway Management Procedure - Suspected Severe COVID-19 Cases

Non-invasive ventilation (NIV) and high-flow nasal cannula ventilation (Optiflow, Airvo) are not encouraged as a treatment. This does not apply to pediatrics so long as a negative-pressure room is available.

• Consider early intubation: Emergency intubation increases the risks of transmission by exposing care staff and other patients to aerosols.

• A dedicated intubation cart for SARS-CoV-2 infections shall be set up in each place where intubation may take place (ER, ICU, operating theatre and COVID-19 unit if a room in the ICU isn’t available immediately).

• All the material shall be available nearby, including the material required to manage a difficult level of intubation.

• Refer to the checklist before entering the room.

• Intubation shall: o Be carried out in a negative-pressure room or in strict

airborne isolation if a room is not available. o Be carried out with personal protective equipment for all, as

described above. o Be carried out by the designated person in the hospital

centre. o Pre-oxygenation FiO2 100% (Ventimask with reservoir) x 5

minutes if the situation allows. o Ventilation via mask (bag mask) shall be avoided as much as

possible before intubation. If ventilation via mask is administered, place a HEPA filter between the mask and the ambu, two-person ventilation and use an oropharyngeal cannula (Guedel cannula) and ventilate with small volumes.

o Staff in the room reduced to a minimum: ▪ Nurse responsible for the patient ▪ RT ▪ Professional intubating


• A video laryngoscope (Glidescope/King vision) shall be used and dedicated to COVID-19 cases.

• Rapid sequence intubation shall be preferred (limits the risk of cough and aerosols).

• Avoid using topical Xylocaine – could produce aerosols. • As soon as the tube is in the trachea:

o Inflate the balloon o Clamp the tube immediately after the mandrel is removed o Attach the ventilator + HEPA OR ventilate with the ambu +

HEPA depending on the clinical situation o Unclamp the tube and confirm IET with ETCO2 o Don’t auscultate! o Start sedation post-intubation and stabilize hemodynamics o Protective ventilation 4-6 cc/kg adjust to pre-intubation

ventilation/minute o Install an NG tube +/- central line, urinary catheter, etc. o Restrain the patient o Remove PPE following the protocol under surveillance o Exit the room

• Post-intubation, the patient is transferred to another room in the ICU.

• You have to wait the set length of time before going back into the negative-pressure room while the aerosol load decreases, unless you are wearing an N95 mask. This varies by zone depending on air exchange.

6. Ventilatory Support and Bronchoscopy Procedure

a. Apply the highest standards of protective ventilation for SARS (e.g. “ARDSNet”).

b. Back-up therapies: i. Ventilation in a ventral position may be used and shall be

applied following the guidelines ii. Cases of severe refractory hypoxemia have to be

discussed quickly with centres having expertise in severe SARS.


c. A closed-circuit suction system shall be used. d. Avoid as much as possible disconnecting the respirator.

i. If the respirator has to be disconnected, first clamp the endotracheal tube and put the respirator on standby.

e. If possible, all staff shall leave the room for the designated period for air exchanges to occur depending on the room – enough time for the aerosol load to decrease.

f. Accidental extubation requiring reintubation shall be treated as a situation at high risk for aerosols where the safety of staff and the premises is the priority.

g. Bronchoscopies generate a lot of aerosols and must be

avoided as much as possible: i. The decision to do a bronchoscopy must be made

taking into account the anticipated benefits for the patient (alternative diagnosis that cannot be obtained any other way).

ii. It must be done in a negative-pressure environment.

iii. Curarization is encouraged for the procedure.

7. Sterile Procedure and Techniques (central line, arterial cannula, thoracic drain)

a. The procedures are carried out by the intensivist or the most experienced person available.

b. Ideally, dressing in sterile PPE outside the room and movement toward the procedure room involve two persons, one who is not sterile and facilitates maintaining asepsis for the main operator.

c. The nursing staff assists the physician.

d. Prepare and review all material in advance to reduce entrances and exits.

e. Minimize material in the room.

f. The use of an ultrasound is encouraged.

g. Ultrasound machines shall be cleaned following the manufacturer’s recommendations and the policy and procedure after each procedure.


8. Managing Cardiac Arrest Resuscitation procedures are considered to hold a high risk of propagation of aerosols and the potential risk for care staff has to be balanced with the intended benefits to the patient.

Except in rare circumstances, in-hospital cardiac arrest has a poor prognosis. In rare targeted circumstances (example: arrhythmia that may lead to defibrillation or cardioversion), efforts may be justifiable. In all other circumstances, the decision to resuscitate and the intensity of efforts must be modulated based on the risk to staff and the rest of the clientele.

The intensity of care must be reassessed regularly and rediscussed with patients and/or their loved ones.

a. Creating a Resuscitation Cart – COVID-19

Underlying principles: • The major principle within the context of resuscitating a suspected

or confirmed COVID-19 patient is to do the resuscitation in the STANDARD manner, along with protective measures for the care staff.

• Consider the resuscitation algorithms for COVID-19: https://cpr.heartandstroke.ca/s/article/COVID-19-Interim-CPR-Algorithms?language=en

• Other patients as well as staff not essential to the resuscitation must leave the room where the patient undergoing the cardiac arrest is located.

• If the patient is not intubated, by default, the resuscitation is performed in the patient’s room (even if it is not a negative pressure room), with staff wearing the appropriate PPE, including N95 masks. The door to the room is closed and, as needed, the patient is intubated in their room. Based on local practices and the various scenarios, a transfer to a negative pressure room can take place while minimizing the interruptions in the resuscitation and limiting the exposure that material and staff not considered contaminated undergo. To achieve this, it shall be clearly communicated to the

https://cpr.heartandstroke.ca/s/article/COVID-19-Interim-CPR-Algorithms?language=en

https://cpr.heartandstroke.ca/s/article/COVID-19-Interim-CPR-Algorithms?language=en


staff if this measure is envisaged.

• If the patient is intubated, they are kept in their room and staff proceed with the resuscitation in the standard manner, wearing PPE that includes N95 masks.

• For an intubated patient for whom cardiac massage will be initiated, it is necessary to clamp the endotracheal tube, shut off the ventilator, disconnect the ventilator, and connect the resuscitation balloon to the antiviral filter, then unclamp the endotracheal tube before initiating ventilation with the resuscitation balloon. Then block the ventilator circuit if possible.

• The staff members who respond to code blue events, such as ECG technologists, phlebotomists or others, should make themselves available outside the contaminated zone in which the patient is located.

• While waiting for the resuscitation team, the care staff may initiate cardiac massage. The care staff initiating cardiac massage must wear the appropriate PPE, including N95 masks. Care must be taken to properly position the mask of the person performing the cardiac massage and to prevent it from shifting during the massage. Cardiac massage must not be initiated until everyone in the room is wearing appropriate PPE, including N95 masks.

• In the case of a non-intubated patient, we recommend placing any type of oxygen mask (passive oxygenation), if available or already in place, on the face of the patient in cardiac arrest, rather than ventilating them with a mask and ambu. For a patient who does not have an oxygen mask on their face and for whom the latter is not immediately available, the patient’s mouth must be covered with a surgical mask or any other physical barrier to reduce the dispersion of droplets or eventual aerosols during cardiac massage, prior to intubation.

• It is recommended to prioritize intubation if required as soon the resuscitation team is present; do not ventilate other than with an endotracheal tube with an inflated cuff and an antiviral filter in place with a resuscitation balloon, during a resuscitation.

• Divide up the tasks between an internal team (responsible for the interventions and for administering treatments to the patient) and an external team (responsible for preparing medications and


documentation). • The code blue resuscitation team should be limited to the following

individuals: • Inside the room where the patient is located:

• Physician responsible for the resuscitation (intensivist from intensive care, if present);

• 2 nurses; • 1 respiratory therapist; • 1 attendant for CPR.

• In the anteroom or outside the room: • Runner nurse; • Second respiratory therapist; • Second physician, if one is available.

• Manage airways using the principles already stated: • Manual ventilation is to be avoided in most cases. If

ventilation is imperative, use two-person ventilation and an oropharyngeal cannula (Guedel) to reduce the presence of leaks around the mask. Place a high efficiency filter between the mask and balloon.

• After confirmation of intubation, continue usual resuscitation.

• Wait the designated amount of time for air exchanges to occur after the intubation before performing any non-urgent procedures in the room and have non-essential staff leave, unless they are wearing N95 masks.


9. Extubation

When extubation criteria have been met:

*Do not use a T tube for ventilation weaning.

• For any ventilated patient who is not a suspected/confirmed COVID-19 patient or who has two negative COVID-19 test results 24 hours apart: Extubate according to normal standards.

• For any ventilated patient who is a suspected COVID-19 or Covid-

19 (+) patient (and/or in COVID-19 isolation – droplets/contact): The professional should follow the extubation protocol for COVID patients.

Plan and Preparation:

1. Ensure the patient meets the extubation criteria. 2. Avoid performing extubation with non-invasive ventilation or

with a high flow O2 nasal cannula. 3. Ensure a physician is available on the unit in case re-intubation

is needed.

Materiel to be prepared in the negative pressure room where the extubation will take place:

1. Disposable blue pad 2. Scissors PRN 3. Yankauer suction 4. Standard O2 mask 5. 10mL syringe


• Transfer the ventilated patient into the negative pressure room.

• Extubate in a negative pressure room with an N95 mask, gloves,

gown and visor.

1. Ideally only have two people present during the extubation. 2. Pre-oxygenate the patient with 100% FiO2. 3. Put the patient in a minimum 30° position. 4. Do gentle oral aspiration. 5. Do ONE closed aspiration with the cuff INFLATED. 6. Do a leak test corner depending on the physician** based on the

risk of post-extubation stridor. 7. Remove the endotracheal tube attachments (Anchor fast) and

hold the tube in place. 8. Shut off the ventilator. 9. Disconnect the tubing from the ventilator / ambu bag. 10. Deflate the endotracheal tube cuff with the 10mL syringe. 11. Remove the endotracheal tube WITHOUT additional suction

and DO NOT ask the patient to cough voluntarily when the endotracheal tube is removed.

12. Immediately put an O2 mask on (to minimize droplet dispersion if the patient coughs) and open the O2 flow as needed.

13. Discard the endotracheal tube and blue pad. 14. Put a surgical mask over the O2 mask when the patient is ready to be transferred back to their room (ideally, wait 20 minutes in the negative pressure room for the aerosolized particles to disperse).

Post-extubation:

Consider reintubation of:

• Stridor; • Obstructive/difficult respiratory pattern, or if respiratory rate

exceeds 30/minute; • Need for over 50 percent O2 in order to reach 92% oxygen

saturation; • Excessive agitation by non-cooperative patient.

Updated: April 28, 2020 17

Proceed with extubation:

1. Ideally only have two people present during the extubation. 2. Pre-oxygenate the patient with 100% FiO2.

3. Put the patient in a minimum 30° position.

4. Do gentle oral aspiration.

5. Do ONE closed aspiration with the cuff INFLATED.

6. Do a leak test depending on the physician** based on the risk of post-extubation stridor.

7. Remove the endotracheal tube attachments (Anchor fast) and hold the tube in place.

8. Shut off the ventilator.

9. Disconnect the tubing from the ventilator / ambu bag.

10. Deflate the endotracheal tube cuff with the 10mL syringe.

11. Remove the endotracheal tube WITHOUT additional suction and DO NOT ask the patient to cough voluntarily

when the endotracheal tube is removed.

12. Immediately put an O2 mask on (to minimize droplet dispersion if the patient coughs) and open the O2 flow as

needed.

13. Discard the endotracheal tube and blue pad.

14. Put a surgical mask over the O2 mask when the patient is ready to be transferred back to their room (ideally, wait

20 minutes in the negative pressure room for the aerosolized particles to disperse).

Post extubation: Consider re-intubation if:

• Stridor

• Obstructive/difficult respiratory pattern, or if respiratory

rate exceeds 30/min

• Need for over 50% O2 in order to reach 92% oxygen

saturation

• Excessive agitation by non-cooperative patient

**Risk factors for stridor post extubation: 1. Extended intubation (over 48-72h)

2. Large endotracheal tube (>8 in ♂, > 7 in ♀)

3. Over age 80

4. GCS < 8

5. Traumatic intubation

6. History of asthma

7. Excessive mobility of endotracheal tube

8. Aspiration

Suspected COVID-19 or COVID-19 (+) or in isolation

No (or two negative COVID -19 tests results 24h apart)

Yes

Extubate according to normal standards

Materiel to be prepared in the negative pressure room where the extubation will take place:

1. Disposable blue pad

2. Scissors PRN

3. Yankauer suction

4. Standard O2 mask

5. 10mL syringe

Plan and Preparation: 1. Ensure patient meets extubation

criteria.

2. Avoid extubation with non-

invasive ventilation or high flow

O2 nasal cannula.

3. Ensure a physician is available on

the unit in case re-intubation is

needed.

Follow extubation protocol for COVID-19 patients

Transfer ventilated patient into a negative pressure room with the following protection: N95 mask, gloves, gown and visor.

Ventilated patient who meets extubation criteria: Avoid using a T tube for ventilation weaning.


10. Samples and Labs • Limit samples to those that are urgent and will change treatment.

• Handle samples according to the institutional procedures in effect.

11. Pharmacotherapy In the current state of knowledge, treatment for COVID-19 is supportive. There is no literature supporting a standardized pharmacological approach. Please refer to the Spectrum application found on the Vitalité Health Network website.

12. Ethics • Please consult the ethics policy and guideline section 1G; taken from

the regional pandemic plan - COVID-19 for ethical considerations. • End of life care should represent a shared decision that takes into

account the dignity of the patient, the wishes of the family, risks of contagion and available resources.

• There exists a triage document that may be used according to available resources.


TRIAGE IN CRITICAL CARE

During a pandemic, it is very possible that the demand for critical care and ventilators will be increased. The predictive hypotheses used to model the demand for ventilators and critical care are as follows: The average proportion of patients admitted who have COVID-19 will be 10%. The average proportion of patients admitted who have COVID-19 and require ventilators will be 5%. The average length of a stay in the ICU for a COVID-19-related illness will be 10-14 days.

A fair system of access to critical care must be applied to all hospitalized patients and not just those with COVID-19. When it is activated, this triage shall apply to the whole province of New Brunswick. Activation will be ordered by the provincial EOC (emergency operations centre). Pediatric patients will continue to be transferred to the IWK when possible.

Decision-making process for triage for critical care The critical care working group recommends the following process to apply the triage protocol for critical care:

i. The Emergency Operations Centre shall coordinate the activation or

deactivation of the triage protocol for critical care in the whole province simultaneously. This centralized coordination will provide fair access to critical care in the entire province, to the extent available, until resources are at full capacity and the triage protocol for critical care is activated. In the same way, deactivating the protocol will also require province-wide coordination. A centralized decision-making process will be based on declarations by the former RHAs about the availability of resources for critical care.

ii. After activation, a patient’s attending physician shall apply the triage protocol for critical care.

iii. When faced with difficulties in applying the protocol for critical care, the attending physician may consult with colleagues in the working zone or elsewhere in Vitalité Health Network via the usual means of communication. There won’t be a team on call to provide support with this for all of Authority A. Each zone must predetermine a group of at least three persons to help the attending physician with what are often difficult decisions and monitor cases in the ICU daily.

iv. The physician on call will be responsible for indicating on the patient’s chart the appropriate information about any consultation with a colleague. It is recommended that all other persons involved in the patient’s case maintain their own documents related to their participation, to proposed decisions and to advice given.


Clinical assessment – Triage protocol for critical care

The triage protocol for critical care is described below, accompanied by a flowchart of the process. A tool for noting patients’ results is also available (see Tool 6.1).

1st Step – Assess the patient to determine criteria for inclusion. To meet these criteria, the patient must present with a criterion A or a criterion B. Requirements related to invasive ventilatory assistance:

• Significant hypoxemia – during COVID-19 infection:

o FiO2 ≥ 40% for saturation > 90%. • Significant hypoxemia – no COVID-19 infection: SPO2 < 90% with non-rebreathing mask

/FIO2 on 0.85.

• Respiratory acidosis with a pH < 7.2.

• Clinical signs of imminent respiratory failure. Inability to protect open airway.

• Altered state of consciousness.

Hypotension:

• Hypotension (ABP < 65 or BPs < 90) with clinical signs of shock (altered state of consciousness, decreased elimination of urine or other terminal organ failure) refractory to reestablishment of fluid volume, requiring vasopressor/inotrope treatment that cannot be dealt with on the unit.

If the patient meets the criteria for inclusion, go to the second step.

Otherwise, reassess the patient later in case their clinical state has deteriorated.

2nd step – Assess the patient to determine criteria for exclusion. First and foremost, validate whether there exist any limitations related to the patient’s level of care (cardiac resuscitation, intubation and admission to the ICU). Then, if a criterion for exclusion is found, do not admit the patient to critical care. Continue the current level of care, or commence palliative care based on the indications. A patient’s admissibility to critical care may be reassessed as resources become available and the protocol for critical care is deactivated.

The criteria for exclusion include the following in particular:

• Cardiac arrest: unwitnessed, recurrent (except torsade de pointes and hypothermia), refractory to usual measures; related to trauma.

• Metastatic malignity with vital prognosis < 1 year, unless the patient has recently started immunotherapy treatment and is suffering from immune complications of this treatment.

• Hematological neoplasia with probability of mortality ≥80% in 1 year.

• Serious burn – when two of the following three criteria are reached, mortality in the ICU is over 80%: age ≥ 60, TBSA ≥40%, severe inhalation injuries.

• Severe trauma (using the revised trauma score (RTS) or TRISS with predicted mortality above 80%).

• Moderate to severe dementia (unable to name known family and friends even when well, or requiring quasi-total assistance with ADL/DA, or institutionalized patient).

• Frail patient ≥ 70 who it is suspected will not survive admission to the ICU (Clinical Frailty Scale ≥ 7).

• Advanced or untreatable neuromuscular disease (e.g.: ventilator-dependant ALS).

• Serious and irreversible neurological event or condition (e.g.: serious CVA in brain


stem, neurovegetative state) unless organ donation foreseeable.

• Any chronic disease with vital prognosis < 1 year.

• Patient aged 80 or over. • Organ failure that meets the following criteria:

o Cardiac: ▪ Cardiogenic shock in patients ≥ 75. ▪ NYHA functional class ≥3/4 present for 6 months in patients ≥ 75 ans.

o Pulmonary: ▪ COPD with FEV < 25% or O2 dependant ▪ Cystic fibrosis with FEV <30%. ▪ Idiopathic pulmonary fibrosis with FVC < 50% or O2 dependant or diffusion < 30% ▪ Pulmonary arterial hypertension (group 1) requiring IV prostaglandins or with

NYHA functional class 4/4.

o Liver: ▪ Cirrhosis with MELD score ≥25 in a patient who is not a candidate for a liver transplant.

o Kidney: ▪ Dialysis patient ≥ 75.

If a patient does not present with any of the criteria for exclusion, go to the third step.

N.B.: These criteria for exclusion may change during the pandemic based on the availability of information about the disease.

3rd step: Assess SOFA score (sequential organ failure)

Before a patient is admitted to the ICU, their SOFA score has to be assessed (see Table 6.1) and taken into account just as much as the criteria for inclusion and exclusion. Table 6.1: Sequential Organ Failure Assessment Score (SOFA) (Adapted from: F.I. Ferreira, D.P. Bota, A. Bross, C. Melot, J.L. Vincent (2001). “Serial evaluation of the SOFA score to predict outcome in critically ill patients”, JAMA, vol. 286, p. 1754-1758.)

Variable 0 1 2 3 4 PaO2/FiO2, mmHg > 400 ≤ 400 ≤ 300 ≤ 200 ≤ 100

Platelets, x 109/L > 0.150 ≤ 0.150 ≤ 0.100 ≤ 0.050 ≤ 0.020

Bilirubin, μmol/L <20 20-32 33-100 101-203 > 203

Hypotension

None

Average blood pressure (ABP) < 70 mmHg

Dop ≤ 5

Dop > 5 or Epi ≤ 0.1 or Norepi ≤ 0.1

Dop > 15 or Epi > 0.1 or Norepi > 0.1

Glasgow Coma Scale 15 13-14 10-12 6-9 <6

Creatinine, μmol/L <106 106-168 169-300 301-433 >434

Notes for Table 6.1: The doses of dopamine (Dop), epinephrine (Epi) and norepinephrine (Norepi) are expressed in μg/kg/min

Explanation of variables: PaO2/FiO2 indicates the amount of oxygen in the patient’s blood. Platelets play an essential role in blood clotting. Bilirubin is measured with a blood test and indicates liver function. Hypotension indicates low blood pressure; scores of 2, 3 or 4 indicate that blood pressure has to be maintained with powerful medication, in particular dopamine, epinephrine and norepinephrine, requiring monitoring in the ICU. The Glasgow Coma Scale is a standardized scale of neurological functioning; a low score indicates poor functioning. Creatinine is measured with a blood test and indicates kidney function.


Then the patient is assigned to a category of treatment based on these results. The patient is assessed 72 hours after admission to the ICU, then reassigned based on readjustment of the SOFA requirements for each category.

▪ Blue: High probability of mortality; should not be admitted to ICU or

should be discharged from critical care and receive medical treatment and palliative care, if required.

• Initial: Criteria for exclusion or SOFA > 11.

• 72 hours: Criteria for exclusion or SOFA > 11 or SOFA 8 to 11, unchanged.

▪ Red: Highest priority for critical care.

• Initial: SOFA < 7 or failure of one organ.

• 72 hours: SOFA < 11 and declining.

▪ Yellow: Intermediate priority for critical care.

• Initial: SOFA 8 to 11.

• 72 hours: SOFA < 8 with minimal decline (drop of < 3 points in 72 hours).

▪ Green: Low probability of mortality; put off admission to or discharge from critical care.

• Initial: no major organ failure.

• 72 hours: no longer needs a ventilator.


Does the patient present with any of the following criteria for exclusion?

• Score SOFA > 11

• Cardiac arrest: unwitnessed, recurrent, refractory to usual measures; arrest related to trauma

• Metastatic malignity with poor prognosis

• Serious burns: body surface > 40%, severe inhalation injuries

• Organ failure in terminal stage: cardiac: class 3 or 4, New York Heart Association pulmonary: chronic severe pneumopathology with FEV < 25% liver: MELD score > 20 renal: requiring dialysis neurological: grave and irreversible neurological event/status with high probability of mortality

NO

Blue

Diagram 6.1: CRITICAL CARE TRIAGE PROTOCOL For all patients requiring treatment in the ICU, whether or not they have COVID-19

NO

YES

YES

Refractory hypoxemia (FiO2 ≥ 40% for saturation > 90% for COVID-19 patients or SpO2 < 90% with non-rebreathing mask /FiO2 > 0.85 for non- COVID-19 patients)

• Respiratory acidosis with a pH < 7.2

• Clinical signs of imminent respiratory failure

• Inability to protect airway or to keep it open

• Hypotension with clinical shock refractory to reestablishment of fluid volume, requiring vasopressor/inotrope treatment that cannot be dealt with on the unit

•

Does the patient present with any of the following criteria for inclusion?

Yellow

Red

Do not admit to ICU or discharge from ICU

Discharge from ICU Good prognosis

Green

Administer/continue treatment - Low Priority

Administer/continue treatment - High Priority

What category is the patient in at this time?

• Blue: High probability of mortality; should not be admitted to ICU or should be discharged from critical care and receive medical treatment and palliative care, if required o Initial: Criteria for exclusion or SOFA > 11 o 72 hours: Criteria for exclusion or SOFA > 11 or SOFA 8 to 11,

unchanged

• Red: Highest priority for critical care o Initial: SOFA < 7 or failure of one organ o 72 hours: SOFA < 11 and declining

• Yellow: Intermediate priority for critical care o Initial: SOFA 8 to 11 o 72 hours: SOFA < 8 with minimal decline (drop of < 3 points in

72 hours)

• Green: Low probability of mortality; put off admission to or discharge from critical care o Initial: no major organ failure o 72 hours: no longer needs a ventilator

Do not admit to ICU

Do not admit to ICU


Tool 6.1, 2nd PHASE: Critical Care Triage Tool

What category is the patient in at this time?

YES

NO

YES

Initial 72 hours Priority MEASURE

BLUE

Criteria for exclusion or SOFA > 11

Criteria for exclusion or SOFA > 11 or SOFA < 8, unchanged

High probability of mortality; should not be admitted to ICU or should be discharged from critical care and receive medical treatment and palliative care, if required.

Do not admit to ICU or discharge from ICU

RED

SOFA < 7 or failure of one organ

SOFA < 11 and declining progressively

Highest priority for critical care

Administer/continue treatment HIGH PRIORITY

YELLOW

SOFA 8 to 11

SOFA < 8 with minimal decline (drop of < 3 points in 72 hours)

Intermediate priority for critical care

Administer/continue treatment LOW PRIORITY

GREEN

No major organ failure

No longer needs a ventilator

Low probability of mortality; put off admission to or discharge from critical care

Discharge from ICU GOOD PROGNOSIS

Does the patient present one of the following criteria for exclusion?

MEASURE Do not admit to

ICU

Does the patient present one of the following criteria for inclusion?

MEASURE Do not admit to

ICU

Guide to Adult Critical Care and Triage SARS-CoV-2 (COVID-19)

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Transcript of Guide to Adult Critical Care and Triage SARS-CoV-2 (COVID-19)