Last Updated: July 30, 2020
The vast majority of patients who are critically ill with COVID-19 have attributes and comorbidities, such as older age, hypertension, cardiovascular disease, diabetes, chronic respiratory disease, cancer, renal disease, and obesity, that place them at higher risk for serious disease.1
As is the case for 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 comorbidities 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 procedures that require disruption of a closed airway circuit. Thus, while some clinicians do not routinely start empiric broad-spectrum antimicrobial therapy for patients with severe COVID-19 disease, other experienced clinicians routinely use such therapy. For the treatment of shock, however, empiric broad-spectrum antimicrobial therapy is the 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 pulmonary or extrapulmonary sources, 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.
Thromboembolic Events and COVID-19
Critically ill patients with COVID-19 have been observed to have a prothrombotic state, which is characterized by the elevation of certain biomarkers and an apparent increase in the incidence of venous thromboembolic disease. In some studies, thromboemboli have been diagnosed in patients who received chemical prophylaxis with heparinoids.12-14 Autopsy studies provide additional evidence of both thromboembolic disease and microvascular thrombosis in patients with COVID-19.15 Some authors have called for routine surveillance of ICU patients for venous thromboembolism.16 Please refer to Antithrombotic Therapy in Patients with COVID-19 for a more detailed discussion.
Renal and Hepatic Dysfunction Due to COVID-19
Although severe acute respiratory syndrome coronavirus 2 (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 case series.5 See Acute Kidney Injury and Renal Replacement Therapy for a more detailed discussion.
Special Considerations in Children
Several large, epidemiologic studies suggest that rates of ICU admission are substantially lower for children with COVID-19 than for adults. However, severe disease does occur in children.17-22 The risk factors for severe COVID-19 disease in children have not yet been established. Based on data from studies of adults and extrapolation from data on other pediatric respiratory viruses, severely immunocompromised children and those with underlying cardiopulmonary disease may be at higher risk for severe disease.
A new syndrome, multisystem inflammatory syndrome in children (MIS-C), which appears to be a postinfectious complication, has been described.23,24 Certain symptoms of MIS-C often require ICU-level care, including blood pressure and inotropic support. These symptoms include severe abdominal pain, multisystem inflammation, shock, cardiac dysfunction, and, rarely, coronary artery aneurysm. A minority of children with MIS-C meet criteria for typical or atypical Kawasaki disease. For details on MIS-C clinical features and the treatments that are being investigated, see Special Considerations in Children.
Drug-Drug Interactions Between Drugs Used to Treat COVID-19 and Drugs Used to Treat Comorbidities
All ICU patients should be routinely monitored for drug-drug interactions. The potential for drug-drug interactions between investigational medications or medications used off-label 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. When treating patients with COVID-19, clinicians also need to minimize the risk of conventional ICU complications in order to optimize the likelihood of a successful ICU outcome.
Advance Care Planning and Goals of Care
The advance care plans and the goals of care for all critically ill patients must be assessed at admission and regularly thereafter. This is an essential element of care for all patients. Information on palliative care for patients with COVID-19 can be found at the National Coalition for Hospice and Palliative Care website.
To guide shared decision-making in cases of serious illness, advance care planning should include identifying existing advance directives that outline a patient’s preferences and values. Values and care preferences should be discussed, documented, and revisited regularly for patients with or without prior directives. Specialty palliative care teams can facilitate communication between clinicians and surrogate decision makers, support front-line clinicians, and provide direct patient-care services when needed.
Surrogate decision makers should be identified for all critically ill patients with COVID-19 at admission. Infection-control policies for COVID-19 often limit direct communication with the surrogate decision makers, and most surrogates will not be physically present when discussing treatment options with clinicians. Many decision-making discussions will occur via telecommunication.
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 2020.27 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.
- 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.
- 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;180(7):1-11. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32167524.
- Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 2020;323(16):1612-1614. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32191259.
- 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;382(21):2012-2022. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32227758.
- 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;8(5):475-481. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105632.
- 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.
- 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;201(11):1372-1379. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32242738.
- 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;5(7):802-810. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32211816.
- 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.
- 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.
- 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;323(11):1061-1069. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32031570.
- Llitjos JF, Leclerc M, Chochois C, et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients. J Thromb Haemost. 2020;18(7):1743-1746. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32320517.
- Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089-1098. Available at: https://pubmed.ncbi.nlm.nih.gov/32367170.
- Klok FA, Kruip M, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020;191:145-147. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32291094.
- Menter T, Haslbauer JD, Nienhold R, et al. Postmortem examination of COVID-19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction. Histopathology. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32364264.
- Tavazzi G, Civardi L, Caneva L, Mongodi S, Mojoli F. Thrombotic events in SARS-CoV-2 patients: an urgent call for ultrasound screening. Intensive Care Med. 2020;46(6):1121-1123. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32322918.
- Sun D, Li H, Lu XX, et al. Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center's observational study. World J Pediatr. 2020;16(3):251-259. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32193831.
- Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020;145(6):e20200702. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32179660.
- CDC COVID-19 Response Team. Coronavirus disease 2019 in children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:422-426. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm.
- Chao JY, Derespina KR, Herold BC, et al. Clinical characteristics and outcomes of hospitalized and critically ill children and adolescents with coronavirus disease 2019 at a tertiary care medical center in New York City. J Pediatr. 2020;223:14-19. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32407719.
- Zachariah P, Johnson CL, Halabi KC, et al. Epidemiology, clinical features, and disease severity in patients with coronavirus disease 2019 (COVID-19) in a children's hospital in New York City, New York. JAMA Pediatr. 2020:e202430. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32492092.
- DeBiasi RL, Song X, Delaney M, et al. Severe coronavirus disease-2019 in children and young adults in the Washington, DC, metropolitan region. J Pediatr. 2020;222:199-203. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32405091.
- Whittaker E, Bamford A, Kenny J, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32511692.
- Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet. 2020;395(10239):1771-1778. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32410760.
- 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.
- 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.
- 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;48(6):e440-e469. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32224769