PRACTICAL CONSIDERATION AND STRATEGIES TO FIGHT

AGAINST COVID-19 IN PICU

YOGI PRAWIRA
KONSULTAN EMERGENSI DAN RAWAT INTENSIF ANAK
 dr. Yogi Prawira, Sp.A (K)

Academic Staff/ Clinical Lecturer in Pediatric Emergency and Critical Care

Division, Cipto Mangunkusumo Hospital/Faculty of Medicine University of
Indonesia, Jakarta

Education
2017 Pediatric Intensivist Consultant, CMH/FMUI, Jakarta
2015 Fellowship Trainee, Pediatric and Congenital ICU, Pediatric and Congenital
Heart Center, National Heart Institute (IJN), Kuala Lumpur, Malaysia
2010 Pediatrician, Faculty of Medicine, University of Indonesia, Jakarta
2005 Doctor of Medicine, Faculty of Medicine, Diponegoro University,
Semarang, Indonesia

Current Position
PIC Intensive Care Unit (Borderless) RSCM Kiara Ultimate
Head of Covid-19 Task Force Indonesian Pediatric Society
KEY PRINCIPLES AND STRATEGIES FOR ICU
PREPAREDNESS
¡ The coronavirus disease 2019 (COVID-19) has rapidly evolved into a worldwide
pandemic
¡ Preparing intensive care units (ICU) is an integral part of any pandemic response

¡ To achieve sustainable ICU services, we propose the need to

¡ (1) prepare and implement rapid identification and isolation protocols, and a surge in
ICU bed capacity
¡ (2) provide a sustainable workforce with a focus on infection control
¡ (3) ensure adequate supplies to equip ICUs and protect healthcare workers
¡ (4) maintain quality clinical management, as well as effective communication
KEY STRATEGIES AT DIFFERENT PHASES OF A PANDEMIC

¡ Maximising containment to reduce community impact and buy time for preparations is
the key priority

¡ Rapid identification and isolation of suspect or confirmed COVID-19 cases

¡ Strict infection control measures to minimise intrahospital transmission and prevent

incapacitation of essential services

¡ A study from Wuhan, China, reported 41% of COVID-19 cases attributable to hospital-
related transmissions, with the majority (70%) being HCWs
KEY STRATEGIES AT DIFFERENT PHASES OF A PANDEMIC
¡ In Italy, up to 20% of responding HCWs were also reported to be infected, emphasising
the need for strict containment measures

¡ If national and regional containment measures fail, healthcare systems are at risk of
being rapidly overwhelmed
¡ In the event of sustained widespread community transmission, emphasis then shifts
towards supporting essential hospital services, such as critical care and emergency
care, to maximise mitigation whilst maintaining containment efforts
¡ Strategies employed with regard to ICU “SPACE”, “STAFF”, “SUPPLIES”, and
“STANDARDS”
SPACE: CRITICAL CARE BEYOND THE ICU
¡ Designating an isolation ICU

¡ Designation of an isolation ICU ward, geographically separated from other clinical areas, allows
for con-centration and segregation of equipment and staff, contributing to more effective
containment
¡ Isolation ICUs should ideally consist of negative pressure airborne infectious isolation rooms
(AIIRs)
¡ AIIRs are kept at negative pressure relative to surroundings and ventilated with at least 6–12 air
changes per hour, with any recycled air filtered before recirculation
¡ For hospitals without AIIRs, containment may also be maximised with a dedicated ICU and strict
infection control measures
¡ If single rooms are unavailable, cohorted patients should ideally be nursed at least 2 m apart with
engineering controls (separation with physical barriers)
 Containment or alert phase*
Scenario Limited community spread
isolated to individuals or
clusters
Key strategy Containment and preparedness
SPACE • Designate an isolation ICU,
with negative pressure AIIR
• Rapid identification and
isolation of suspected/known
COVID-19 cases
• Ensure access to rapid
diagnostic testing (e.g.
laboratory facilities)
• Initiate planning for surge
ICU bed capacity
Pandemic or crisis phase*
Sustained widespread
community transmission
Mitigation and containment
• Utilise normal pressure ICU
beds or existing monitored
beds (e.g. OT, PACU, high
dependency, endoscopy
suites, emergency
department)
• Alternative: cohort beds with
physical barriers (e.g.
curtains) in between patients
• Ensure timely step-down of
stable patients with
deisolation protocol
• Mass critical care: triaging
protocol for patients with
consideration for available
resources, ethical principles,
 Containment or alert phase* Pandemic or crisis phase*

STAFF • Staff segregation

• Implement strict infection
prevention and control
measures
• Education of HCWs on
infection control measures
with just-in-time N95 fit
testing
• In situ, just-in-time
simulation training with
before-and-after
multidisciplinary peer-review
processes
• Periodic retraining of HCW
on infection control
measures
• Staff surveillance (e.g.
temperature monitoring) and
access to designated staff
clinics
 Containment or alert phase*
STAFF • Ensure dissemination of
timely and factual
information and establish
two-way communication
• Provide helplines and
psychological support,
temporary staff quarters,
gratitude messages from
hospitals and public
• Initiate ICU hands-on training
for non-critical care nurses
and ICU refresher courses for
HCW using online materials
and instructional videos
Pandemic or crisis phase*
• Minimise unnecessary
procedures and transport
• Increase manpower capacity
by changing work structure
(e.g. extra shifts or work
hours) and restricting leave
• Suspend elective procedures
and non-essential services
• Redeployment of HCW with
critical care experience from
other departments into ICUs
• Consider reducing nurse- and
doctor-to-patient ratios
• Mass critical care: reassign
non-intensive care HCW from
other departments to support
essential services, with ICU
nurses providing a
supervisory role
 Containment or alert phase*
SUPPLIES • Ensure adequate supply and
stockpiles of PPE, essential
consumables, medication, and
equipment
• Source for alternative supply
channels for supplies and
equipment; consider extended
use of supplies/consumables
where safe to do so and
rationalise use of essential
medications
• Switch to single-use items (e.g.
disposable bronchoscopes)
• Segregate equipment (e.g.
designated ultrasound
machines)
• Harmonise item purchase
within hospital and clusters
• Ensure adequate cleaning
services and waste
management capacity
Pandemic or crisis phase*
• Consider extended or limited
re-use of N95 respirators
Consider alternatives to N95
respirators, e.g. PAPR
• Rationalise the use of N95
respirators (e.g. risk stratify
by activity type)
• Obtain alternative sources of
mechanical ventilators
• Utilise stockpiled transport
ventilators if available
• Mass critical care: use
alternative forms of
respiratory support (e.g. NIV,
HFNC) to replace invasive
mechanical ventilation
 Containment or alert phase* Pandemic or crisis phase*

STANDARDS • Maintain clinical standards and principles of ARDS (e.g. lung

protective ventilation, prone ventilation when appropriate)
• Consider early intubation; avoid NIV in the absence of
evidence-based indications
• Adapt resuscitation and emergency procedural workflows to
optimise patient safety and minimise risk of transmission
• Identify ECMO referral centre, establish referral and transport
workflows
• Establish a hospital outbreak response command centre for
effective communication and coordination Inter- and
intrahospital teleconferencing to share experience and
knowledge
• Coordinate hospital ICU efforts with regional and national plans
Continue to engage patients’ relatives
• Utilise public relations and communications resources to build
public trust
MODIFIED ICU MONITORING
TINGKAT KEPARAHAN PENYAKIT
ü Asimtomatik (tidak bergejala dan gambaran rontgen normal): 4%

ü Ringan (gejala ringan meliputi demam, Lelah, nyeri otot, batuk): 51%

ü Sedang (pneumonia dengan gejala klinis atau gejala subklinis dengan kelainan rontgen

toraks): 39%

ü Berat (sesak, sianosis sentral, hipoksia): 5%

ü Kritis (ARDS, gagal napas, syok or MODS): 0.6%

https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html
 E GE DALIA
E (C PANDUAN DIAGNOSIS & TATA LAKSANA
ID-19)

Panduan Pelayanan Kesehatan Balita

Pada Masa Tanggap Darurat COVID-19

KEMENTERIAN KESEHATAN
2020 1
 Bagan Alur Pelayanan Balita Sakit Masa Pandemi COVID-19

TRIAGE &
PISAHKAN RUANG PEMERIKSAAN

PASIEN GEJALA DEMAM, PASIEN TANPA GEJALA DEMAM, BA-

BATUK, PILEK, SESAK NAPAS
Atur jarak pelayanan antara petugas dan pasien
Petugas menggunakan APD masker bedah, gaun,
sarung tangan, pelindung mata, penutup kepala,
alas kaki
Pasien anak dan pengantar pasien menggunakan
masker (penutup mulut dan hidung)
TUK, PILEK, SESAK NAPAS
Petugas berpedoman pada standar pencegahan
dan melakukan penilaian risiko, APD sedikitnya
masker, sarung tangan, penutup kepala, baju
kerja, alas kaki
Pasien anak dan pengantar pasien menggunakan
masker (penutup mulut dan hidung)

TENTUKAN STATUS BALITA SAKIT

PERNAH KONTAK DENGAN PASIEN COVID-19 ATAU PERNAH
BERKUNJUNG KE DAERAH TERJANGKIT DALAM 14 HARI

YA TIDAK

ADA GEJALA: TIDAK ADA GEJALA: PELAYANAN MTBS

Demam/ riwayat demam Demam/ riwayat demam,
dan/atau dan/atau Anak yang tidak termasuk
kategori OTG/ODP/PDP
Batuk/pilek/nyeri Batuk/pilek/nyeri diberikan pelayanan MTBS
tenggorokan/ sesak napas tenggorokan/ sesak napas

Jika timbul Pneumonia

Tatalaksana:
ODP/PDP Gejala Ringan:
isolasi diri di rumah
PDP Gejala Sedang: Rujuk
ke RS darurat
PDP Gejala Berat: Rujuk ke
RS rujukan
Lapor ke Dinas Kesehatan/
hotline COVID-19
Tatalaksana OTG:
Karantina di rumah 14 hari Tatalaksana sesuai
Lapor ke Dinas Kesehatan/ alur PDP
hotline COVID-19
Pemeriksaan RT PCR atau
Rapid Test
Jika selama karantina MENGALAMI GEJALA
sesuai kriteria, maka tatalaksana sebagai berikut:
ODP/PDP Gejala Ringan: isolasi diri di rumah
PDP Gejala Sedang: Rujuk ke RS darurat
PDP Gejala Berat: Rujuk ke RS rujukan

DAN:
Lapor ke Dinas Kesehatan/hotline COVID-19

Panduan Pelayanan Kesehatan Balita Pada Masa Tanggap Darurat COVID-19 Bagi Tenaga Kesehatan
16
TANDA BAHAYA PADA ANAK
ü Peningkatan frekuensi pernapasan

ü Tidak berespons atau gelisah

ü Gambaran rontgen toraks mengalami progresifitas dalam waktu singkat

ü Gambaran rontgen toraks infiltrasi bilateral atau multilobus dan efusi pleura

ü Usia dibawah 3 tahun, anak dengan penyakit penyerta seperti PJB, NPD, deformitas

saluran napas, abnormalitas Hb, gizi buruk, imunodefisiensi atau dalam terapi
imunosupresi

http://kjfy.meetingchina.org/msite/news/show/cn/3337.html
ILUSTRASI KASUS
¡ Anda bekerja sebagai dokter jaga IGD. Anda dikonsulkan oleh perawat triage
pasien anak yang tampak letargis dan takipnea:

¡ Apa yang akan anda lakukan?

KEGAWATDARURATAN ANAK DI ERA PANDEMI:
APA YANG MEMBEDAKAN?

¡ PEDIATRIC ASSESSMENT TRIANGLE ¡ PRIMARY SURVEY

Airway

Exposure Breathing
Appearence Circulation

Breathing Disability Circulation

KEGAWATDARURATAN ANAK DI ERA PANDEMI:
APAYANG MEMBEDAKAN?

¡ Pandemi global di era COVID-19 à Precaution terhadap risiko infeksi

¡ Setiap pasien yang masuk IGD à status infeksi SARS-CoV-2 tidak diketahui

¡ Anak pun dapat terinfeksi virus yang menyebabkan COVID-19

¡ Ringan, Sedang >> Berat

¡ Transmisi droplet à aerosol’s generating procedure (AGD) à transmisi aerosol

¡ Semua ujung tombak layanan harus memiliki pemahaman yang lebih baik mengenai layanan
kegawatdaruratan anak di era pandemi COVID-19
PRINSIP KEGAWATDARURATAN ANAK DI ERA
PANDEMI COVID-19
 TRIASE
¡ Penapisan dan klasifikasi pasien untuk menentukan prioritas kebutuhan dan
lokasi terapi yang sesuai

¡ Saat wabah COVID-19, triase sangat penting guna memisahkan pasien yang
kemungkinan terinfeksi virus yang menyebabkan COVID-19

¡ Triase yang efektif dapat mencegah transmisi virus yang menyebabkan

COVID-19 terhadap pasien dan tenaga medis
TRIASE
ALAT PELINDUNG DIRI (APD)
§ Tenaga medis yang kontak dengan PDP atau kasus COVID-19
terkonfirmasi harus mengenakan APD yang sesuai
Tenaga medis yang akan melakukan
pemeriksaan terhadap pasien dengan
gejala respiratorik
APD LEVEL 3

§ Sebelum melakukan aerosol

generating procedure
 Triage of patients with suspected COVID-19 infection
(widespread community transmission)
Identify signs and symptoms of respiratory infection:
• Fever (>38°C) or history of fever*
No Continue with usual
-And- triage, assessment and
• At least 1 sign or symptom of respiratory disease (e.g., care
cough or shortness of breath)
Yes
Place medical mask on patient

Yes
Separate from the rest of the patients:
• Place the patient in a single-person room with the door closed or in other designated area
• Ensure healthcare personnel (HCP) caring for the patient adhere to Standard, Contact, and Droplet Precautions
• Only essential HCP with designated roles should enter the room and wear appropriate personal protective
equipment
Inform
• Notify the hospital infection control program and other appropriate staff
*Elderly people may not develop fever, but new-onset of cough or worsening respiratory symptoms
Appearence
Breathing

≠N N
Circulation N ↑

N
≠N

RESPIRATORY DISTRESS SHOCK

NEUROLOGIC/METABOLIC CARDIOPULMONARY FAILURE

≠N N ≠N ↑/↓

N ≠N

*Kumpulan materi Pelatihan Resusitasi Pediatrik Tahap lanjut 2011-2014

PRINSIP UMUM RESUSITASI SUSPEK DAN KASUS COVID-19
TERKONFIRMASI

¡ Kurangi paparan terhadap COVID-19

¡ Sebelum memasuki area layanan, seluruh penolong sebaiknya mengenakan APD untuk
melindungi terhadap partikel droplet atau pun transmisi airborne
¡ Batasi personil yang berada di dalam ruangan, hanya mereka yang esensial untuk melayani
dan merawat pasien
¡ Protokol dan pakar harus ada sesuai kebutuhan, serta disiapkan tenaga pengganti
¡ Komunikasikan dengan lugas status pasien kepada semua tenaga medis sebelum tiba di area
atau sebelum menerima pasien rujukan
PRINSIP UMUM RESUSITASI PDP DAN KASUS COVID-19
TERKONFIRMASI

¡ Pasang HEPA filter secara aman

¡ Setelah tenaga kesehatan yang menilai irama dan melakukan defibrilasi (sesuai indikasi), pasien
yang mengalami henti jantung harus segera diintubasi dengan menggunakan ETT dengan cuff

¡ Minimalkan risiko gagal intubasi dengan:

a) Tenaga medis yang paling ahli dan kompeten yang melakukan prosedur intubasi
b) Hentikan kompresi dada saat intubasi

¡ Gunakan video laringoskop

RESUSITASI
RESUSITASI
TATA LAKSANA JALAN NAPAS
RESPIRATORY SUPPORT
LAIN-LAIN
TAKE HOME MESSAGES
COVID in Cri ica I Chi dren A Narra i e Re ie of he Li era re

INFANTS YEAR MAY BE AT HIGHEST RISK

FOR SEVERE ILLNESS Ma a a a a :
10% ( = 40 379 ) (O2
<92%),
(7.3% 1-5, 4.2% 6-10, 4.1% 11-15 3% > 16 )*
1. C - a a
a , a a
CHILDREN APPEAR TO BE
RELATIVELY SPARED OF
SEVERE DISEASE
a a ab ; b a a a
94.1%
/ 2. I ba a a

%
94.8
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6%

OF COVID CHILDREN
4.6% 0.

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OF COVID CHILDREN
( =113) 2,143
*
COVID+ ba a
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C a.
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CONCLUSIONS 7. Ca a b a
C CO ID-19 ,
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cc a.
Da a O , J., a : Pedia C i Ca e Med 2020.
#P ICU
TERIMA KASIH