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As the COVID-19 pandemic evolves, we gradually are accumulating knowledge to guide patient care. Although most disease is mild, an estimated 5% of patients require intensive care for issues such as acute respiratory distress syndrome (ARDS), shock, and multiorgan failure.
Synthesizing our current understanding of this patient population, these authors report on diagnosis, treatment, and unique features of critically ill COVID-19 patients. Diagnosis usually is accomplished by polymerase chain reaction testing of nasal swabs, although endotracheal aspirates or sputum also can be used. Treatment is the same as it would be for any patient with ARDS caused by viral pneumonia: lung protective ventilation, conservative fluid management, and prone positioning. The authors also support consideration of extracorporeal membrane oxygenation, a topic of debate nationally. Concern is raised about noninvasive ventilation and high-flow nasal cannula because aerosolization of virus is possible. They note that data are insufficient on adjunctive therapies and place an emphasis on randomized trials moving forward.
The update includes discussions of protecting the healthcare workforce with appropriate personal protective equipment, strategies to minimize nosocomial spread, local and regional preparedness for surge capacity, and need for policies on resource allocation.
Murthy S et al. Care for critically ill patients with COVID-19. JAMA 2020 Mar 11; [e-pub]. (https://doi.org/10.1001/jama.2020.3633)
Comment
As the authors appropriately note, our emphasis should be on slowing the rate of infection across the U.S. Sharing knowledge on how to care for the minority of patients who become critically ill is important. For the most part, we are using standard principles to treat patients with ARDS and multiorgan failure, with a greater emphasis on protecting healthcare providers.