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COVID-19 – Ten Things I Wish We Had Known

August 21, 2020

Written by Aaron Lacy

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While we are learning more about COVID-19 each day, it would have been nice to know these clinical and logistical points of interest when it all started. There are many publications about COVID-19, but this paper sought to present 10 lessons learned that were relatively underrepresented.

Why does this matter?
As we move forward in this pandemic and eventually take away lessons to store away for the next one, we must reflect on what we can do better now and in the future.

Hindsight is the year 2020

  1. Crisis management in the ICU: Planning for surge capacity and the necessary resources (equipment and personnel) needs to occur as soon as possible.  This planning is psychologically demanding and takes time.

  2. Personnel management: Start training residents and non-ICU nurses in advance. Part of this training and planning must allow for peer support and moral deliberation for our healthcare workers.

  3. The value of conventional biomarkers: In general, patients come in with a high CRP and a low PCT. Decreasing temperature kinetics and CRP tend to point toward ability to tolerate early extubation. Elevated D-dimers helped lead us to the next problem found with COVID-19…

  4. The hidden problem of hypercoagulation and thrombosis: There is a high incidence of thrombosis and PE. The threshold to scan for PE needs to be low, and rapid changes in dead-space ventilation or D-dimer need to be taken seriously. Some patients will present with acute-circulatory arrest as a first presentation of COVID. Universal precautions during resuscitation are a must.

  5. Cardiac Involvement: Patients with preexistent cardiovascular disease are prone to hemodynamic decompensation. If you see an elevated troponin, be worried.

  6. Pharmacological treatment: So far, no specific treatment has shown clinical benefit. Starting any medication needs to be a risk/benefit discussion with patients and their families, not a reflexive “just do it” policy. Steroids during refractory shock are currently advocated. Bear in mind, this editorial was written before RECOVERY.

  7. Mechanical ventilation: Ventilation strategy should be applied to each patient’s mechanical lung properties. Either L-type (low elastance, low driving pressure) or H-type (high elastance, high driving pressure) needs to be treated differently. Use non-invasive ventilation to try to stave off intubation, and only prone when intubated.

  8. Be prepared to make the hard decisions: It is important to come up with a triage decision system before an overwhelming number of critically ill patients flood ICU capacity and resources. It won’t make it emotionally easier but is fairer for patients.

  9. Managing info overload: The tsunami of research, emails, and info-overload has plagued and muddied the waters. Everyone had good intent, but it made navigating the pandemic early on difficult. National societies can play a larger role in providing cyclic updates and establishing committees that select clinically relevant information to distribute to their members.

  10. Post-intensive care follow-up: Post-ICU follow up needs to be organized early, and a large step-down ICU facility is just as important as escalating ICU equipment and personnel. I learned from a great MICU attending that the patient’s time in the ICU follows them out of the hospital, as they need a community of resources to continue to help them regain health.

COVID-19: 10 things I wished I’d known some months ago. Intensive Care Med. 2020 Jul;46(7):1449-1452. doi: 10.1007/s00134-020-06098-z. Epub 2020 Jun 3. 

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3 thoughts on “COVID-19 – Ten Things I Wish We Had Known

  • L type and H type phenotypes of lung physiology have no evidence to support their existence as distinct clinical entities, and absolutely no evidence to support that they require different therapeutic approaches.

    The recurring theme of the best literature to date is that patients should be intubated based not he same criteria applied to non-COVID respiratory failure, and should be managed the same as other patients when ventilated; ie, lung protective ventilation with low tidal volumes, carefully titrated PEEP, prone ventilation for PF <150, etc.

What are your thoughts?