Emergency Preparedness Considerations for COVID-19

Sepsis and septic shock are life-threatening conditions that can complicate respiratory illnesses caused by viruses such as COVID-19 and influenza. As your hospital revisits its emergency preparedness plan, it is important to consider readiness for addressing septic shock.

Recent reports of critically ill COVID-19 patients show that many may present with or develop hypotension and shock.1-4 The first U.S.case series published in New England Journal of Medicine indicated that a majority of patients presented with shock and hypotension requiring vasopressors.4 Patients in this series evaluated by ECHO did not have myocardial dysfunction,4 though elevated troponin levels consistent with myocardial injury have been noted in other COVID-19 case series.5 Newly updated Surviving Sepsis Campaign COVID-19 guidelines advise careful bedside assessment of fluid responsiveness to avoid fluid overload in the ICU.3 The SSC, WHO, and other COVID guidelines recommend a careful and controlled fluid resuscitation strategy for acute shock and hypotension using crystalloid fluid boluses of 250-500 mL, with frequent bedside monitoring of patient response following each bolus, followed by a conservative fluid management strategy.3, 6-9

Early and targeted fluid resuscitation for septic shock reduces risk of endotracheal intubation, shortens duration of mechanical ventilation, decreases organ injury and hospital length of stay, and saves lives.10-12  In fact, patients who receive their fluid bolus early in their course of treatment have shown the lowest likelihood of requiring endotracheal intubation.13 In hospitals experiencing a sudden influx of critically ill patients, immediate response to those with hypovolemic shock or suspected sepsis may be a key factor in stabilizing patients and reducing subsequent complications, including death.

LifeFlow is a single-patient-use, portable device that can deliver a 250ml fluid bolus in <1 minute.

  • Ideally suited for the anticipated large numbers of patients in contact and droplet isolation rooms
  • Offers user-titrated fluid administration, which facilitates rapid reversal of shock while preventing fluid overload for patients with severe respiratory illness
WHO recommendations for suspected COVID-19 patients with septic shock:8
  • Adults: 250–500 mL crystalloid fluid and reassess after each bolus
  • Children: 10–20 mL/kg crystalloid fluid and reassess after each bolus

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References

  1.  Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 9 March 2020. DOI: 10.1016/S0140-6736(20)30566-3.
  2. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. February 2020. DOI: 10.1001/jama.2020.1585. https://jamanetwork.com/journals/jama/fullarticle/2761044.
  3. Alhazzani W, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020. https://www.sccm.org/getattachment/Disaster/SSC-COVID19-Critical-Care-Guidelines.pdf?lang=en-US.
  4. Bhatraju PK, et al. Covid-19 in Critically Ill Patients in the Seattle Region — Case Series. NEJM. 30 Mar 2020. DOI: 10.1056/NEJMoa2004500.
  5. Arentz M, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. Research Letter. Published online March 19, 2020. DOI:10.1001/jama.2020.4326.
  6. Treatment Guide for Critically Ill Patients with COVID-19. Massachusetts General Hospital. 5 April 2020.
  7. Bohula E, et al. Shock: Septic, Cardiogenic, and Cytokine. Brigham and Women’s Hospital COVID-19 Guidelines. 30 March 2020. covidprotocols.org/protocols/07-shock-septic-cardiogenic-and-cytokine.
  8. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim Guidance. World Health Organization. 13 March 2020. Pg. 9. WHO/2019-nCoV/clinical/2020.4. who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.
  9.   COVID-19 Treatment Guidelines. NIH. Site update 21 April 2020. https://www.covid19treatmentguidelines.nih.gov/critical-care/hemodynamics/.
  10. Lee SJ, et al. (2014). Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest. 2014 Oct;146(4): 908-915. DOI: 10.1378/chest.13-2702. https://www.ncbi.nlm.nih.gov/pubmed/24853382.
  11. Leisman D, et al. Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Ann Emerg Med. 2016 Sep;68(3):298-311. DOI: 10.1016/j.annemergmed.2016.02.044. https://www.ncbi.nlm.nih.gov/pubmed/27085369.
  12. Williams JM, et al. “Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study.” Eur J Emerg Med. 2018 Apr; 25(2): 97-104. DOI: 10.1097/MEJ.0000000000000419. https://www.ncbi.nlm.nih.gov/pubmed/27547885.
  13. Kuttab H, et al. Evaluation and Predictors of Fluid Resuscitation in Patients with Severe Sepsis and Septic Shock. Crit Care Med. 2019 Nov;47(11):1582-1590. DOI: 10.1097/CCM.0000000000003960. https://www.ncbi.nlm.nih.gov/pubmed/31393324.