HJAR May/Jun 2020

HEALTHCARE JOURNAL OF ARKANSAS I  MAY / JUN 2020 15 The current pandemic with SARS CoV-2 represents the realization of imagined scenarios with serious consequences. The current viral interstitial pneumonia has resulted in severe hypoxemic respiratory failure, overcrowded ICUs, equipment and personnel shortages, and significant mortality. Projections for patient volumes are expected to overrun critical care capabilities, with shortages of PPE, staff, and ventilators dominating discussions in local hospitals and the news media. We provide a synthesis of the current experience coming from China, Italy and the US (Seattle & New York) and some common sense approaches from past lessons learned. These discussions are prompted by the frequent questions we receive by email and phone. Whenever possible, the statements here are supported by the most recent findings. At the time of this writing, the statement fromtheSocietyof Critical CareMedicine (SCCM) has beenpublishedaddressing many issues related to treatment of ventilated patients. 1. Maintain strict infectious disease precautions. 2. In severe respiratory distress, do NOT delay intubation. 3. In patients with early hypoxemia, consider high flow nasal oxygen. This is controversial, with some concerns regarding environmental contamination. If used, there should be a low threshold for failure and urgent intubation. Some clinicians will elect to avoid high flow nasal cannula.* Environmental controls should be considered with an emphasis on caregiver protection. 4. The use of NIV is associated with a high rate of failure. Because of high failure rate and the possibility of environmental contamination, we suggest avoiding NIV. (If NIV is used a low threshold for failure; e.g., no improvement in 1-2 hours should prompt intubation).* 5. Mechanical ventilation should follow the ARDSnet recommendations: a. Tidal volumes of 4-8 ml/kg of predicted body weight (volume or pressure control). b. CMV-assist control is recommended due to often heavy sedation requirements. c. Plateau pressure less than 30 cm H2O. d. PEEP/FIO2 Table fromARDSnet (high PEEP). 6. In the face of refractory hypoxemia (PaO2/ FIO2 < 150) – prone positioning is the first recommended therapy. We acknowledge the manpower needs and increased need for PPE associated with manual proning. *These are one area where we are not in complete agreement with the SCCM document. We reiterate these major recommendations: