Assessment of critically

ill patient at the time of

COVID-19 outbreak
 • Staff-Nursing station with central monitor

• Hall/chambers with limited separations and high

ICU set up visibility.

• Beds station- air, O2, suction port, electrical ports,

pt monitor.
 • Reviews and response to therapy.
• General hygiene.
• Postural changes.
General care for patient • Drains and catheters.
• I/O monitoring & documentation.
• Infection prevention and control 
• DVT-VTE prophylaxis, as per the protocol.
• Venous thromboembolism
 • Epidemiological factors:
Factors • co-morbid., CKD, severity of S&S, body
affecting pt indices.

response to • V/S: RR < 24 B/M, HR <120 BPM, SpaO2

COVID-19 >92%, FaO2/FiO2 > 300.

• Lab.s: D-dimer, CK, LDH, troponin.

 • Proof of COVID-19 positive

• PPE

• General appearance:
Assessment restless, looks hypoxic, RR, HR, Fever, Looks pale

• Start by assessing:
Airway - Breathing - Circulation - Disability
 To start with ………

• COVID-19 with hypoxia…… indication for intubation.

COVID-19 • If no, then perform assessment.

• You need quick assessment tools for unstable pts.

 Quick reference to patient assessment:
Acute Physiology and Chronic Health Evaluation

(APACHE II)

“usually done for septic cases”

 APACHE II
1. Age
2. A-aDO2 or PaO2 (depending on FiO2)
3. Body temperature (rectal)
4. MAP
5. PH
6. HR
7. RR
8. Na
9. K
10. Creatinine
11. Hct (PCV)
12. WBC
13. GCS
Organ failure assessment

“SOFA”
 • Hypotension (?sys. > 100 mmHg)
• Altered mental status
ICU scoring systems
SOFA • Tachypnea

• Score more than 2 indicate poor quality outcome.

 • The Sequential Organ Failure Assessment
(SOFA) Score 
• is a mortality prediction score 
ICU scoring systems • that is based on the degree of dysfunction of six
SOFA organ systems.
• The score is calculated on admission and every
24 hours until discharge
 Vital organs affected by
COVID-19
• CVS
• Lungs
• Kidneys
• Brain
• Intestines
Cardiovascular system
What does COVID-19 do to our CVS?
• Vasoconstriction: hypoperfusion
• Pro-inflammatory cytokines.
• Increase Venous thromboembolism
• Fibrosis: cardiopulmonary fibrosis
• ARDS

General assessment
Heart-lung sounds, valve assessment.
• BP, HR, SpaO2
• ECG
• Hemodynamic stability
 • NIBP
Hemodynamic • HR- pulses
monitoring • Mental status
• Mottling (absent)
• Skin temperature
• Capillary refill
• Urine output
 • Massive, abrupt fluid loss:

Indications for Dehydration, Hemorrhage - GI Bleed, Burns

Hemodynamic
• Surgery
Monitoring
• Acute MI & CHF

• Cardiomyopathy

• Shock: all types

 An invasive technique for monitoring ABP.
Preferred in unstable pt - it is accurate & continuous.

Arterial BP Monitoring Indications include:

Pts requiring frequent ABG’s or lab work.
Pts with hypotension/Unable to obtain NIBP/Unstable BP.
Pts with severe hypertension.
Pts with severe vasoconstriction or vasodilation.
Frequent titration of vasoactive drips.
 Placed in an artery, usually the radial, but can use
femoral, or brachial.

Common sites and care Connected to a pressurized source

Complications include VTE, infection

Tubing & transducer: replaced q96 hrs. 4days

 • Phlebostatic Axis: 4th ICS, MAL- level of the atria.

• Invasive monitoring is more accurate.

Trouble shooting:
• Invasive BP should by higher than cuff BP
pt monitor
• If NIBP is higher look for equipment malfunction

• A dampened wave form:?? a move toward hypotension …

an immediate NIBP should be obtained

Dicrotic notch:
• The small notch on the downstroke of the wave.
• It represents the closure of the aortic valve.
• This is the reference point between the sys. and diast.
phases of the cardiac cycle.
 • A direct measure of the right atrium pressure.
Central venous

pressure • CVP reflects:

Intravascular volume status
Right atrium pressure RV function
Pt response to drugs & fluids
Monitoring
• Normal values = 2 – 8 mm Hg.

• Low CVP = hypovolemia or ↓ venous return.

• High CVP = over hydration, ↑ venous return, or Rt HF.

Elevated RAP Decreased RAP
• RV failure • Hypovolemia
• Tricuspid regurgitation/stenosis • Increased contractility
• Pulmonary hypertension
• Hypervolemia
• Cardiac tamponade
• Chronic LV failure
• Ventricular Septal Defect
• Constrictive pericarditis
 • Change tubing and fluid bag q 96hrs.

• No mixing of pressors with other fluid through

Trouble shooting
CVP port.

• Antibiotics, NS boluses, blood, & IV pushes are

allowed through the CVP line.

Complications
• Pneumothorax • Arrhythmias

• Hemothorax • Air embolism

• Hemorrhage • PE

• Cardiac tamponade • VTE

• Vessel, RA, or RV perforation • Infection

Respiratory • This will be covered in-full next.
assessment
Neurological
assessment
Neurological
assessment
 Posture response

• Decorticate response (flexion):

corticospinal damage, above brainstem.

• Decerebrate response (extension):

brain stem and midbrain injuries.
 Intake………
Renal assessment I.V route
Fluid and electrolyte Enteral route
balance Fluids (crystalloids, colloids, I.V. drugs)

Output………
- Urine - Drain/dressing
- Skin - Respiration
- GI (feces, aspiration)
Body Fluid Compartments

2/3
ICF:
55%~75%

TBW
3/4
Extravascular
Interstitial
ECF fluid
1/3
1/4
Intravascular
plasma
 Cations Anions
150

100

ECF
Na+
50
Cl-

0 HCO3-

Ca 2+
Mg 2+
Protein
50
PO43-

ICF
Organic
K+ anion

100

150
Osmolarity = Osmoles/solution in L.

Osmolality = osmoles/solvent in Kg (280~310 mOsm/kg)

Anion gap = 8-12 mmol/L = Na – (Cl + HCO3)

Tonicity = effective osmolality

Plasma osmolality = 2 x (Na) + (Glucose/18) + (Urea/2.8)

Plasma tonicity = 2 x (Na) + (Glucose/18)

Na deficit (mEq) = (135 - [Na+] ) x Bodyweight (kg) x 0.6 

 • Isotonic crystalloids
- Lactated Ringer’s - 0.9% NaCl
- only 25% remain intravascularly

Crystalloids • Hypertonic saline solutions

- 3,5,7% NaCl

• Hypotonic solutions
- D/S 0.45%
- <10% remain intra-vascularly, inadequate for fluid
resuscitation
 - Albumin: 5%, 25%
Colloid
Solutions - Haes-sterile 6%, 10%
Solutions Vol. Na K Ca2+ Cl- HCO3- Dextrose mOsm/L

ECF 142 4 5 103 27 280-310

R/L 130 4 3 109 28 273

0.9% NaCl 154 154 308

0.45% NaCl 77 77 154

D/S 0.45% 77 77 50 406

NaCl 3% 513 513 1026

6% Hetastarch 500 154 154 310

5% Albumin 250, 500 130-160 <2.5 130-160 330

25% Albumin 20,50,100 130-160 <2.5 130-160 330

 RIFLE CRITERIA

Risk (50% creatinine)

Acute kidney injury Injury (100% creatinine)

Failure (150% creatinine) or anuria for 24 hrs.

Loss (< 4 weeks)

End-stage (permanent loss)

RIFLE criteria
for AKI
Diagnostics and

Monitoring in

the ICU
 • Serum
RBS, KFT, Ca, CBC-Differential, protein, albumin, ABGs,
Blood cult.

Investigations • Urine: urinalysis, cult.

• Tracheal secretions cult.

• X-rays: Chest, abdomen, as required.

• U/S: Chest-cardiac, abdomen.
• CT scan-MRI: as indicated.