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General Considerations

Last Updated: April 21, 2020

Co-Morbid Conditions

The vast majority of patients who are critically ill with COVID-19 have attributes and co-morbidities that place them at higher risk for serious disease, such as older age, hypertension, cardiovascular disease, diabetes, chronic respiratory disease, cancer, renal disease, and obesity.1

As with any patient in the intensive care unit (ICU), successful management depends on attention to the primary process leading to ICU admission, as well as to other co-morbidities and nosocomial complications.

Bacterial Superinfection of COVID-19-Associated Pneumonia

Limited information exists about the frequency and microbiology of pulmonary coinfections and superinfections in patients with COVID-19, such as hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Some studies from China emphasize the lack of bacterial coinfections in patients with COVID-19, while other studies suggest that these patients experience frequent bacterial complications.2-7 There is appropriate concern about performing pulmonary diagnostic procedures, such as bronchoscopy or other airway sampling that requires disruption of a closed airway circuit. Thus, while some clinicians do not routinely start empiric broad-spectrum antimicrobial therapy for COVID-19 patients with severe disease, other experienced clinicians routinely use such therapy. For the treatment of shock, however, broad-spectrum empiric antimicrobial therapy is standard of care. Antibiotic stewardship is critical to avoid reflexive or continued courses of antibiotics.

Septic Shock and Cytokine Storm Due to COVID-19

Patients with COVID-19 may express high levels of an array of inflammatory cytokines, often in the setting of deteriorating hemodynamic or respiratory status. This is often referred to as “cytokine release syndrome” or “cytokine storm,” although these are imprecise terms. Intensivists need to consider the full differential diagnosis of shock to exclude other treatable causes of shock (e.g., bacterial sepsis due to pneumonia or an extra-pulmonary source, hypovolemic shock due to a gastrointestinal hemorrhage that is unrelated to COVID-19, cardiac dysfunction related to COVID-19 or comorbid atherosclerotic disease, stress-related adrenal insufficiency).

COVID-19-Induced Cardiac Dysfunction, Including Myocarditis

There is a growing body of literature relating COVID-19 to myocarditis and pericardial dysfunction in approximately 20% of patients.3, 5, 8-11 Acute cardiac injury and arrhythmias have also been described in patients with COVID-19.

Renal and Hepatic Dysfunction Due to COVID-19

Although SARS-CoV-2 is primarily a pulmonary pathogen, renal and hepatic dysfunction are consistently described in patients with severe disease.3 Continuous renal replacement therapy was needed in more than 15% of cases of critical disease in one series.5

Drug-Drug Interactions Between Drugs Used to Treat COVID-19 and Drugs Used to Treat Co-Morbidities

All ICU patients should routinely be monitored for drug-drug interactions. The potential for drug-drug interactions between investigational or off-label medications used to treat COVID-19 and concurrent drugs should be considered. QTc prolongation due to agents such as chloroquine or hydroxychloroquine is a potential problem for patients with underlying heart disease and/or those who concurrently use drugs that prolong the QTc interval (e.g., azithromycin, quinolones).

Other Intensive Care Unit-Related Complications

Patients who are critically ill with COVID-19 are at risk for nosocomial infections and other complications of critical illness care, such as VAP, HAP, catheter-related bloodstream infections, and venous thromboembolism. The focus on COVID-19 should not reduce attention to minimizing conventional ICU complications in order to optimize the likelihood of a successful ICU outcome.

Goals of Care

For any critically ill patient, the goals of care must be assessed when the patient is admitted and regularly thereafter. This is essential regardless of the availability of resources, the age of the patient, or the patient’s co-morbid conditions.12, 13

The Surviving Sepsis Campaign (SSC), an initiative supported by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, issued Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) in March 2020.14 The COVID-19 Treatment Guidelines Panel (the Panel) has based these recommendations on the SSC COVID-19 Guidelines, with permission, and the Panel gratefully acknowledges the work of the SSC COVID-19 Guidelines Panel. The Panel also acknowledges the contributions and expertise of Andrew Rhodes, MBBS, MD, of St. George’s University Hospitals in London, England, and Waleed Alhazzani, MBBS, MSc, of McMaster University in Hamilton, Canada.

References

  1. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14 states, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):458-464. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32298251.
  2. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32167524.
  3. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32191259.
  4. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. COVID-19 in critically ill patients in the Seattle Region—case series. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32227758.
  5. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105632.
  6. Chen T, Wu D, Chen H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020;368:m1091. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32217556.
  7. Du Y, Tu L, Zhu P, et al. Clinical Features of 85 Fatal Cases of COVID-19 from Wuhan: A Retrospective Observational Study. Am J Respir Crit Care Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32242738.
  8. Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32211816.
  9. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31986264.
  10. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32171076.
  11. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32031570.
  12. White DB, Lo B. A Framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32219367.
  13. Curtis JR, Kross EK, Stapleton RD. The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32219360.
  14. Alhazzani W, Moller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32224769.