MANAGING

COVID-19 IN ICU
Dr. ENG KAR SENG
Intensivist
Hospital Sungai Buloh

19th January 2021

 ICU SET UP

STAFFING EQUIPMENT - CRITICAL CARE AREA

- NEGATIVE PRESSURE
ROOM FOR AGP
GENERAL ICU CARE O2, HFNC,
NIV
(-pressure
room) Lung
protective
DVT
Prophylaxis
strategy :
L-type &
H-type

PRONE,
Fluid
iNO,
strategy
ECMO

Sedation
COVID SPECIFIC THERAPY
◦ METHYLPREDNISOLONE
◦ Initiation of therapy
Steroid :
Dexamethasone, ◦ Dose : 2mg/kg, 4mg/kg, 8mg/kg
Higher dose of Methyprednisolone (Pulse)
anticoagulant
◦ Duration : 7- 10 days (* longer if
organizing pneumonia)

Metabolic
Tocilizumab
resuscitation

Antiviral
CASE DISCUSSION 1
History of presenting Illness
Mr A, 51 years old male
Underlying :
Hypertension
- On single anti hypertensive, unsure name , non compliant
- Presented on day 5 of illness with cough and SOB, initially admitted to
ILKKM, sent to ED HSgB on day 6 of illness for worsening respiratory
distress
- Vitals on admission
- BP 138/89
- RR 18
- SPO2 97% under room air
- Temp 36.8 degrees
ED PRESENTATION
- Upon presentation to ED :
- Tachypneic, lethargic looking

- Vitals in ED :
- BP 100/63
- PR 104
- SPO2 88% under HFMO2 15L/min
- Temp : 38.5 degree

- Subsequently was intubated in ED

- ABG post intubation : ph 7.25 / pco2 57 / po2 75 / hco3 25 / be -3.2
(SIMV fio2 1.0, PEEP 8, TV 420, RR 15)\
- PFR 75
- Blood ix :
- Hb 13.5 / plt 174 / wcc 9.7 / ALC 0.6
- Urea 4.2 / creat 97 / NA 136 / K 3.4
- CRP 27.1
CXR 28/12/2020 – DAY 1 ICU
ICU ADMISSION
◦ Given stat dose IV Methylprednisolone 500mg in ED
◦ Admitted to ICU :
◦ Highest ventilator setting : SIMV fio2 0.6 PS 12 PEEP 12 RR 24
◦ ABG : 7.28/47/89/22.1/-4.8
◦ PFR 148
◦ No renal impairment with good urine output
◦ Started on :
◦ IV methylprednisolone 500mg OD (28/12/2020)
◦ IV Augmentin 1.2g TDS
◦ IV Azithromycin 500mg OD
◦ T. Favipiravir 800mg BD
ICU ADMISSION
◦ Blood investigation
- Hb 14 / plt 191 / wcc 9.4 / ALC 0.3
- Urea 4.9 / creat 78 / NA 135 / K 4.2
- CRP 29.6
- D dimer 2502
- Fibrinogen 921
- Trop I 1125
DAY 2 ICU
◦ Able to wean down ventilator settings
◦ CTPA
◦ Ferritin level : 1239
◦ given IV Tocilizumab 480mg STAT in view of persistent
high CRP
CTPA
CTPA report
Impression:
◦ Case of Covid-19 pneumonia
◦ 1. Left subsegmental pulmonary artery embolism as desrcribed.
◦ Scattered ground glass opacities in both lung fields, interlobular
septal thickening, crazy paving appearance.
◦ Patchy consolidation with air bronchograms
◦ 2. Features of the lungs are suggestive of Covid-19 infection
with organising pneumonia changes.
CXR 29/12/2020 – DAY 2 ICU
EXTUBATION
DAY 5 ICU
◦ ON CPAP fio2 0.4, PEEP 8 PS 8
◦ ABG : ph 7.47 / pco2 32 / po2 85 / hco3 24.3 / be 0.3
◦ SPO2 91-95%
◦ PFR 212
VITALS :
BP 175/90
PR 64
◦ CXR : Overall CXR findings are improving.
◦ Therefore was extubated to HFNC Fio2 0.6 , 60L
◦ ABG : ph 7.48/ pco2 30/ po2 82/ hco2 22.3/ be -0.2
◦ Blood investigations :
- Hb 13.9 / plt 246 / wcc 14.7 / ALC 0.5
- Urea 9.9 / creat 66 / NA 135 / K 4.2
- CRP 2.4
TRANSFER OUT
DAY 7 ICU
◦ Subsequently , managed to further wean down o2 requirement
to NPO2 5L/min
◦ And plan for transfer out to ward
◦ Vitals prior to transfer out :
◦ BP170/93
◦ HR 61
◦ SPO2 98%
◦Blood investigations :
- Hb 13.4 / plt 283 / wcc 12.9 / ALC 0.7
- Urea 10.4 / creat 67 / NA 137 / K 3.9
- CRP 0.6
CXR 1/1/2021 – D5 ICU
CXR 3/1/2020 – D7 ICU
PROGRESS IN WARD AND DISCHARGE
◦ In ward, able to further wean down oxygen requirement
◦ He is comfortable under room air
◦ Vitals sign prior to discharge :
◦ BP 140/70
◦ PR 70
◦ SPO2 98% on room air
◦ Discharge home with tapering dose of prednisolone, TCA to rehab , TCA IPR
◦ Blood investigations :
- Hb 13.4 / plt 292 / wcc 8.5 / ALC 1.2
- Urea 10.4 / creat 74 / NA 140 / K 3.7
- CRP <0.4
SUMMARY
◦ Completed :
◦ T Favipavir x 5/7
◦ IV Augmentin 1.2 g x 5/7
◦ IV Azithromycin 500mg OD X 5/7
◦ IV Tocilizumab 480mg
◦ IV Methylprednisolone total 4.5g
◦ Blood cultures no growth
CASE PRESENTATION 2
Mr S, 58 years old,Indonesian
Male
NKMI
PRESENTATION
Presented to HSgB on Day 5 of illness (referred from Private center) :
- Cough since 24/12/2020
- Day 4 of illness, develop SOB , vital signs :
SpO2 under RA : 63%
Spo2 under FMO2 5L : 88%
SpO2 under HFMO2 15L/min : 96-98%
ABG : ph 7.42 / pco2 37.6 / po2 111 / hco3 23.9 / be 25 / 98
RR 28 breath/min
- Given IV methylprednisolone 150mg OD on 28/12/2020
- Subsequently was referred to HSgB
WARD
◦ Upon arrival to ward (28/12/2020), noted patient tachypneic RR
28, was put under HFM 15L/min
◦ BP 158/86
◦ PR85
◦ SPO2 96%
◦ ABG : ph 7. 49 / pco2 42 / po2 65 / hco3 32 / be 7.8 on HFMO2
15L/min
◦ CRP > 12
◦ Case was referrred to anaesth team in view of Type 1 respiratory
failure.
◦ another 150mg IV Methylprednisolone given in ward
◦ Blood investigations :
◦ Hb 14.4 / plt 205 / wcc 5.2 / ALC 0.4
◦ Urea 9.0 / creat 81 / NA 142 / K 3.6
◦ CRP 24.3
CXR on 28/12/2020
ICU REVIEW IN WARD
◦ GCS full, but speaking in phrases, with RR ~40bpm
◦ Vitals :
◦ BP 148/78
◦ PR 87
◦ SPO2 94%
◦ Planned for ICU admission
ICU ADMISSION
◦ Upon arrival to ICU , GCS Full
◦ Put on HFNC Fio2 0.6 flow 60l
◦ Spo2 ~92%
◦ ABG : ph 7. 48 / 37/ 71/ k 3.2 / lact 1.9 / 27.6 / 4,pfR 118
◦ Vitals
◦ BP:170/80
◦ PR : 80
◦ Afebrile
◦ Blood ix upon admission :
◦ Hb 14.4 / plt 208 / wcc 4.8 / ALC 0.6
◦ Urea 9.7 / creat 83 / NA 142 / K 3.5
◦ CRP 21.6
◦ AST 51 / ALT 49 / ALP 71
◦ INR 1.04
◦Started :
◦ IV methylprednisolone 250mg OD → Increased to 500mg OD on day 2 of ICU
◦ T Favipavir 800mg BD
◦ S/C Clexane 60 mg BD
◦ Covering for CAP, atypical pneumonia
◦ IV Rocephine 1.5g BD
◦ IV Azithromycin 500mg OD
PROGRESS IN ICU
DAY 3 OF ICU
◦ Subsequently managed to wean down fio2 to HFNC fio2 0.55 flow 60L
◦ ABG : ph 7.53 / pco2 34 / po2 86 / hco3 28.4 / BE 5.8 / lac1.1
◦ Vitals :
◦ BP 148/74
◦ PR 68
◦ SPO2 94%
◦ Blood cultures no growth , Mycoplasma pneumoniae Ab (29/12/2020): Positive
(Titre 1:160)
◦ MTB Gene expert : negative
◦ Blood investigations :
◦ Hb 14.2 / plt 275 / wcc 13.4 / ALC 0.9
◦ Urea 10.1 / creat 82 / NA 146 / K 3.2
◦ CRP 6.4
◦ AST 34 / ALT 40 / ALP 66
◦ INR 0.98
CXR 31/12/2020
PROGRESS IN ICU
DAY 4 ICU
◦ Subsequently able to further wean down oxygen
requirements to FMO2 8L/min
◦ ABG ph 7.54 / pCO2 33 / pO2 85 / HCO3 28.2 / BE 5.9
◦ Spo2 94%
◦ Vitals :
◦ BP 151/73
◦ PR 67
◦ Planned for transfer out to ward
WARD PROGRESS AND DISCHARGE
◦ In ward , manage to further wean down oxygen requirements
and wean off oxygen
◦ Spo2 remains >95%
◦ Vitals in ward :
◦ BP 129/78
◦ PR 78
◦ CTPA done
◦ Impression:
◦ 1. Subsegmental pulmonary arteries embolism at the lower lobes.
◦ 2. Covid -19 lung changes with features of organising pneumonia.
◦ Therefore was started on S/C clexane 60mg BD
◦ Blood investigation on discharge to ward :
◦ Hb 13.8 / plt 322 / wcc 12.9 / ALC 1.9
◦ Urea 9.4 / creat 82 / NA 136 / K 3.7
◦ CRP <0.4
◦ AST 42 / ALT 87 / ALP 63
◦ INR 1.04
CXR on 4/1/2021
CTPA
CTPA Report
◦ Diffuse ground glass opacities with septal thickening and arch like perilobular
densities in bilateral lungs
◦ Band like opacities at the periphery of both lungs
◦ Filling defect in subsegmental branches of descending PA
◦ He was allowed discharge after 13 days in hospital
◦ Vitals prior to discharge :
◦ BP 131/73
◦ PR 86
◦ SPO2 94%
◦ Follow up :
◦ TCA to IPR
◦ Tapering dose of prednisolone
SUMMARY
◦ Completed :
◦ IV Rocephine 1.5g BD x2/7
◦ IV Azithromycin 500mg OD x1/52
◦ IV methylprednisolone total 3.8g
◦ T Favipavir 800mg BD x5/7
CASE PRESENTATION 3
◦ Mr S, 40 years old malay male
◦ Non smoker
◦ Underlying:
◦ HPT - On T Twynsta OD (Telmisartan 80mg +
Amlodipine 5mg)
◦ Morbid obesity - BMI: 39 (BW 120kg, Ht 174cm)
HISTORY OF PRESENTING ILLNESS
1. Fever on 24/12/2020
2. Cough
- Non productive cough
-> went for swab on 27/12/2020, came back positive , subsequently was planned for
admission to ILKKM

Brought in to ED from quarantine center, ILKKM, on day 11 of illness, 3/1/2021

as noted to be tachypnoiec :
RR 28
SPO2 87% under RA,
89% on NPO2
97% on HFM

Upon arrival to ED ,
Tachypneic, RR 37
BP 154/117 mmHg
PR 126 bpm
spo2 98% on HFM15L/min

ABG on HFMO2 15L/min : pH 7.48/pco2 32/po2 100/ lac 1/ hco3 23.8

Subsequently was referred to ID and ICU team for ICU admission

◦ In ED , given stat dose of IV methylprednisolone 300mg
◦ CXR : ground glass opacities
◦ Planned for admission to ICU
◦ Investigations in ED:
◦ urea 3.1 / creat 68 / k 4.0 / na 131 / alt 86 / ast 105
◦ CRP 7.9
◦ Hb 14.1 / plt 248 / wcc 5.7 / ALC 0.8
CXR on presentation
Admission to ICU
◦ Upon arrival to ICU , alert but tachypneic RR ~ 30bpm ,
on HFMO2 15L/min
◦ Vital signs :
- BP 170/101mmHg
- PR 87
- SPO2 97%
- T afebrile
◦ Bedside ECHO : no right heart dilatation, valve and
chambers normal
◦ ABG under HFMO2 15L/min :
◦ pH 7.46 pCO2 29 pO2 117 Lac 0.7 HCO3 20.6
◦ Wean down to FMO2 8L/min
◦ Started on :
◦ T. Favipiravir 1800mg BD x 1/7
◦ T. Favipiravir 800mg BD
◦ IV Pantoprazole 40mg OD
◦ T. Vitamin C 2g OD
◦ T. Multivitamin 2/2 OD
◦ T. Thiamine 100mg OD
◦ T. Folic Acid 5mg OD
◦ Syrup Lactulose 20mls TDS
◦ IV Methylprednisolone 300mg OD
◦ S/C clexane 80mg OD

◦ Encourage on self prone and for CTPA

Investigation Upon Icu Admission
◦ Hb 14.5 / Plt 225 / WCC 4.7 / ALC 0.4
◦ Urea 3.2 / creat 61 / NA 132 / K 3.7
◦ CRP 7.7
◦ Ferritin 1347
HFNC
◦ However, patient is not compliant to self prone , only able to self
prone for 2 hours
◦ Spo2 during prone 95-97%
◦ ABG post prone : ph 7.48 / pco2 28 / po2 62 / hco3 20 / sao2 93%
/ lac 2.1
◦ Thus was started on High Flow Nasal Canula fio2 60% flow 60L
◦ SPO2 ~95%
◦ ABG : pH 7.48 pco2 28 po2 54 hco3 20.9 be -1.4 lac 2.7
◦ PFR : 90
◦ MEDS : IV methylprednisolone increased to 500mg OD
INTUBATION
◦ Despite regular self proning (~2hours each time), there is
worsening hypoxemic failure, thus decided for intubation on day
3 of ICU admission
◦ ABG prior to intubation on HFNC 60% 60L/min : pH 7.49/ pCO2 28
/ pO2 61 / HCO3 21 / BE -0.8 / lactate 2.3
◦ PFR : 101
◦ Post intubation , still requires high oxygen requirement : SIMV FiO2
90%, peep 12, PS 10, RR 16
◦ ABG : pH 7.39/pCo2 37/pO2 107/HCO3 22.4/BE -2.3/lac 1.7
◦ PFR : 119
◦ Therefore, decided for prone positioning
◦ Investigations :
◦ Urea 7.5 / creat 69 / NA 136 / K 4.3 / AST 27
◦ CRP 1.03
◦ Hb 12.5 / plt 343 / wcc 9.3 / ALC 0.5
◦ Ferritin 1347 / D dimer 1687
CXR post intubation
PRONE
◦ Post prone able to wean down fio2 to 0.5
◦ ABG : pH 7.48/pCo2 34/pO2 75/HCO 25.3/BE 2.3/Lac 2.0
◦ PFR : 150
◦ Turn back supine the next day (~24hours prone)
◦ Able to maintained spo2 >95% on fio2 0.5 post supine
◦ Planned for CTPA
CXR post prone
CTPA
CTPA Report
Impression:
◦ 1. Pulmonary embolism involving subsegmental branches of right and
left descending pulmonary arteries
◦ Patchy consolidation in peribronchovascular distribution , lower lobes.
Minimal groundglass opacities at both upper lobes,
◦ Perilobular densities with arch like pattern in both lungs.
◦ 2. Findings are in keeping with Covid- 19 lung infection with some
features of organizing pneumonia.
→ Started on S/C Clexane 80mg BD
NEW BOUT OF SEPSIS
◦ In view of increasing secretion load with increasing CRP, started
on IV Unasyn 3g TDS to cover new bouts of sepsis
◦ Investigation :
◦ CRP 3.2 > 8.9
◦ Hb 12.4 / Plt 279 / WCC 15.2 / ALC 1.0
◦ Urea 7.2 / creat 55 / NA 136 / K 4.3
CXR
EXTUBATION
DAY 8 OF ICU
◦ Subsequently able to extubate, after 3 days of antibiotics, to
HFNC FIO2 0.5 Flow 50L
◦ And able wean down further to NPO2 3L/min, PO2 69,
maintaining spo2 > 92% in 48 hr

◦ Post extubation complicated with thrombophlebitis over left arm ,

antibiotics changed to IV Cloxacilin 2g 6 hourly, which resolves
without complication.
TRANSFER OUT OF ICU
DAY 10 ICU
◦ Able to transfer him out of ICU
◦ Vital signs prior to transfer out of ICU :
◦ BP 144/82
◦ PR 56
◦ SPO2 94%
◦ Meds :
◦ Total methylprednisolone : 2550mg
◦ T Favipiravir X4/7
◦ IV unasyn 3g TDS x 4/7
◦ IV Cloxacillin 2g QID X 2/7
◦ Cultures : no growth
WARD PROGRESS AND DISCHARGE
◦ In ward , he is comfortable on NPO2 1l/min, subsequently able to
wean off oxygen , able to maintain spo2 >90%
◦ Vitals prior to discharge :
◦ BP : 131/67
◦ PR : 99
◦ Temp : 36.7C
◦ RR : 20Breath/min
◦ SPO2 : 95%

◦ Was discharged on day 2 post transfer out ICU, with tapering

dose of T prednisolone , UITM respi follow up on 16/2/2021 , and T.
Dabigatran 150mg BD for PE treatment.
CASE DISCUSSION 4
Mr A , 46 years old , Male
Underlying :
DM / Obesity BMI 51
PRESENTATION
◦ Presented on day 9 of illness to ED HSGB with
◦ Fever and Cough
◦ SOB
◦ Covid RT-PCR positive 7/1/2021
◦ Vitals :
◦ BP 136/89
◦ PR 104
◦ RR 40
◦ Spo2 97%
◦ Temp 38.1
◦ Started on HFMO2 5L/min :
◦ ABG pH 7.48, PCO2 36, pO2 85, HCO3 26.8, BE 3.4, Lactate 1.2
◦ Escalated to HFMO2 15L/min :
◦ ABG pH 7.46 / pCO2 37 / pO2 127 / HCO3 26.3 / BE 2.6 / Lac 1.0
◦ Referred to ID team and ICU team
◦ Given stat dose of IV Methylprednisolone 500mg , T PCM 1g, S/C Clexane 60mg OD
◦ Blood investigation
◦ Hb 14.3 / plt 223 / wcc 6.1 / ALC 0.6
◦ Urea 4.1 / creat 84 / NA 130 / K 4.2
◦ CRP 7.5
CXR
ICU ADMISSION
◦ GCS Full, on HFMO2 12L/min
◦ Vitals :
◦ BP 130/70
◦ PR 92
◦ SPO2 97%
◦ RR 30 bpm
◦ ABG on HFMO2 12L/min : pH 7.51 / Pco2 33 / pO2 65 / Hco3 26.3 / BE 3.7
◦ Bedside ECHO : good contractility
◦ Started on :
◦ T. Favipiravir 800mg BD
◦ IV Methylprednisolone 500mg OD
◦ S/C Clexane 80mg OD
◦ Covering for HAI
◦ IV Augmentin 1.2g TDS
◦ IV Azithromycin 500mg OD
◦ Advised on lateral/prone positioning as tolerated
Blood investigation
◦ Hb 14.3 / plt 223 / wcc 6.1 / ALC 0.6
◦ Urea 5.5 / creat 74 / NA 132 / K 4.1
◦ CRP 7.8
◦ Trop I <2.51
◦ D Dimer 476
◦ Fibrinogen 798
◦ INR 1.1
HFNC
day 2 ICU
◦ Started on HFNC fio2 0.6 flow 60l/min , self proning
◦ More comfortable , RR 16-18
◦ SPO2 ~ 98-100%
◦ ABG : ph 7.49/ pco2 34/ po2 82/ hco3 25.9/ be 2.9 , pfr 136
HFNC
day 3-5 ICU
◦ Able to further wean down HFNC to fio2 0.5, flow 50l/min,
subsequently to HFNC 30% / 30L/min
◦ More comfortable , compliant to self proning
◦ SPO2 ~ 88-94%
◦ ABG HFNC 50%/50L/min :
◦ pH 7.48, pCO2 39, pO2 76, HCO3 29, BE 5.2, lact 1.4
◦ ABG HFNC 30% Flow 30L/min :
◦ pH 7.52 / pCO2 34 / pO2 68 / HCO3 27.8 / BE 5.1
CXR day 5 ICU
FMO2
day 6 ICU
◦ Weaned down to FMO2 8L/min, subsequently to NPO2
3L/min
◦ Spo2 > 95%
◦ RR 23-25
◦ Vitals :
◦ BP 110/81
◦ PR 67
◦ ABG on NPO2 3L/min :
◦ Ph 7.46 / pco2 37 / po2 88/ hco3 26.3 / BE 2.5/lact 1.1
◦ reduce IV Methylprednisolone to 250mg OD
Transfer out
day 6 ICU
◦ Comfortable on NPO2 3L/min
◦ Spo2 98%
◦ Vitals stable prior to transfer out
◦ Blood investigation :

- Hb 14.3 / plt 333 / wcc 10.9 / ALC 1.5

- Urea 5.8 / creat 73 / NA 132 / K 4.1
- CRP 1.2
SUMMARY
◦ IV Methyprednisolone 500mg x4/7, 250mg OD x2/7
◦ Total dose : 2.5g
◦ Currently on IV MTP 150mg OD
◦ IV Augmentin 1.2g TDS x5/7
◦ T Azithromycin 500mg OD x5/7
◦ T Favipiravir 800mg BD x5/7
◦ Blood and urine cultures : no growth
Progress in ward
20/1/2021
◦ Comfortable on NPO2 3l/min
◦ Vitals
◦ BP 108/60,
◦ HR 64bpm
◦ RR 18/min
◦ SPO2 : 95%
◦ Tolerating orally well
Conclusion

◦ TIMING OF INITIATION OF STEROID IS CRITICAL

◦ TOTAL REQUIREMENT OF STEROID IS NOT WELL STUDIED, NEED FURTHER TRIALS TO

VALIDATE

◦ DURATION OF MV : 3-7 DAYS

◦ TO BE VIGILANT ON NEW BOUT OF SEPSIS