Background
At the end of December 2019, public health authorities in China noted a cluster of cases of acute respiratory disease in Wuhan City, Hubei province. The cause was found to be a new coronavirus. The disease is now referred to as ‘coronavirus disease 2019’ or ‘COVID-19’. The name given to the virus is ‘severe acute respiratory syndrome coronavirus 2’ or ‘SARS-CoV-2’.
Symptoms
COVID-19 is a respiratory condition affecting a patient’s lungs and airways. Most people with the infection will develop a mild illness and recover without hospital treatment. The commonest symptoms are fever, dry cough and lethargy. Other symptoms include: sore throat, muscle aches, shortness of breath and diarrhoea.
In more severe cases, COVID-19 leads to pneumonia – infection of the lungs that is visible on a chest X-ray or CT scan. The lungs become inflamed, the airways become narrowed and the lung air spaces fill with inflammatory fluid. This can lead to parts of the lung becoming stiff and some segments closing down on themselves. These changes in the lungs make it harder for the patient to breathe and for oxygen to pass into the blood stream. Breathing difficulty and/or low blood oxygen levels may trigger the involvement of the intensive care team.
Intensive care support
Treatment consists of giving a combination of drugs that have been shown through clinical trials over the last year to be effective, supporting the body’s organ systems and giving time for the patient to recover. Patients admitted to intensive care with COVID-19 primarily require breathing support. Some patients can continue to breathe for themselves on oxygen or being supported with a flow of pressurised oxygen called CPAP. CPAP (pronounced see-pap) can be delivered via tight fitting face mask or transparent helmet/hood over the patient’s head. Patients receiving this type of support are awake and able to communicate with staff. We frequently ask patients to lie prone on their front, as we know adopting this position can help boost blood oxygen levels.
Sadly some patients deteriorate despite CPAP and need to go onto a ventilator (sometimes called a breathing machine, respirator or ‘life support’). A ventilator is a machine that breathes for the patient by blowing air/oxygen into their lungs. For this, patients first need a breathing tube to be placed through their mouth and into their windpipe – a procedure called ‘intubation’. Patients are sedated with anaesthetic drugs before being intubated and sedation is continued whilst they are on the ventilator. Patients on the ventilator are also often turned into the prone position to aid oxygenation. The team take great care to minimise contact/pressure on the patient’s face – and specifically their eyes – whilst they are lying on their front. It is common however for prone patients to develop some facial swelling/redness whilst in this position. Patients are usually turned onto their back after 16 to 20hrs and reassessed.
Along with many other types of infection, COVID-19 may lead to ‘sepsis’. Sepsis is the body’s overwhelming and life-threatening response to infection that leads to multi-organ failure. The organs most commonly affected, asides from the lungs, are the heart, circulation and kidneys. Many patients require blood pressure support medication delivered through a central line. Some patients will require a form of dialysis for kidney failure.
Drug Therapy
Dexamathasone – a steroid that can be given as either a tablet or intravenous injection – thought to reduce inflammation caused by the virus.
Remdesivir – an antiviral drugs that aims to reduce the duration of a patient’s viral illness
Tocilizumab – an immunosuppressant, normally used in rheumatoid arthritis, that dampens down the inflammation associate during with CoViD-19.
CoViD complications
Bacterial infection – patients can develop a superadded bacterial pneumonia on top of / after their viral infection. Patients have daily blood tests looking for evidence of bacterial infection and suspected infections are treated with antibiotics.
Blood clots – CoViD-19 is associated with a higher risk of developing blood clots. Patients are routinely given blood thinning medication to try and prevent clots. CT and ultrasound scans can help detect blood clots. Patients found to have developed a clot(s) are treated with higher doses of blood thinning medication. Life threatening clots in the lung (pulmonary embolism) may be treated with ‘clot busting’ medication called thrombolysis. These medicines can cause bleeding.
Pneumothorax – any patient on a ventilator can develop a ‘popped lung’ or pneumothorax where air escapes outside the lung and the lung collapses down inside the chest. Patients with CoViD-19 seem at higher risk of developing a pneumothorax – which can happen even without a ventilator. A small plastic tube is inserted between the ribs to drain away the air and allow the lung to re-expand.
Infection control
SARS-CoV-2 is a virus that is easily passed between people and so intensive care units, along with the wider hospital, are taking the recommended precautions to try and limit the spread of the virus. We have a duty to protect staff, visitors and other patients using the hospital. Staff caring for a patient with possible or confirmed COVID-19 will wear Personal Protective Equipment (PPE). This consists of a combination of an apron/gown, mask, gloves and eye protection. Patients who have tested positive for coronavirus, those awaiting test results and non-COVID-19 patients are all nursed in separate areas to minimise the risk of transmission between patients.
Surge capacity
Due to the number of people that have needed intensive care support during the pandemic, all intensive care units have expanded beyond their normal geographical limits into other parts of the hospital. These so called ‘surge’ plans have existed for many years in anticipation of a flu epidemic. Theatre suites and other ward areas have been adapted to care for critically ill patients. We aim to provide the same high standard of care to every patient in intensive care, wherever they are physically located.
Visiting & family communication
The COVID-19 pandemic has brought with it unprecedented national measures to help control the spread of the virus. It has also radically changed the way we interact with the family & friends of our intensive care patients. Sadly, visiting is now severely restricted in intensive care. This change is necessary to protect patients, visitors, staff and the wider public. We appreciate how worrying and stressful it is to have a loved one admitted to intensive care and our staff will do their utmost to keep the family and friends of our patients updated via the telephone and via video calling e.g. FaceTime.
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