Intensive care has been raised to the 2020 challenge. Here is what has changed.
This story is part of Six months inside, a special week essential series that reflect where we have been, what we have learned, and what the future holds for the Covid-19 pandemic.
Mthat Morgan, MD, an intensive care physician at University Hospital Wales, UK, vividly remembers his first patient Covid-19. It was a busy day at his hospital and the patient was so ill that he arrived at the intensive care unit (ICU) that he needed life support almost immediately.
Then, late In March, Morgan knew Covid-19 had already caused havoc in Italy and had begun spreading to the UK Morgan, who is also Wales’ leader in critical care research, had expected the disease to reach his hospital, but it was only when he and his team began treating SARS-CoV-2-infected patients that they realized how serious Covid-19 could be.
It’s fair to say in those early days we thought Covid was a lung disease, he says. The virus is now known to cause problems in other organs, including the heart, kidneys and brain. In some cases, surviving patients are left with long-term symptoms.
That first Morgan Morgan patient spent a long time in intensive care, but the attention they received there meant they survived.
All over the world, ICU doctors like Morgan have been battling Covid-19 from day one, although some ICUs have been extended up to capacity. Responding to the pandemic has meant adopting new procedures, such as isolating patients from their families and adapting to change of instructions regarding the use of personal protective equipment (PPE). The hospital staff worked uninterrupted hours. Some have died from Covid-19 people. And many have seen patients slip away while others have retreated.
Now, six months after the pandemic, there is growing evidence that the Herculean effort made by ICU staff has made a real difference in Covid-19 survival levels, which have improved significantly for intensive care patients since the onset of the pandemic. A journal study anesthesia found that Covid-19 death rates in ICU worldwide had dropped from more than 50% in March to about 40% in late May. This is still roughly double the mortality that could be expected from cases of viral pneumonia in intensive care, which again shows how dangerous a Covid-19 disease is. But the improvement is clear and has happened relatively quickly. Si lindi?
For one thing, some intensive care staff have been involved in trials to find out if certain medications can help severe Covid-19 patients penetrate. Three medicines in particular have received attention: remdesivir, dexamethasone and hydrocortisone. The last two, corticosteroids, have been shown to reduce the risk of death in critically ill patients by one-third.
ICU doctors who spoke to him essential all mentioned the importance of these pharmaceutical treatments. And yet none of these medicines is a miracle cure. Doctors working in the ICU think other factors have also been important, including the other treatments they provide to patients and when.
Take ventilation, for example. When someone whose lungs have been destroyed by Covid-19 is struggling to get enough oxygen in their blood, ICU staff can choose from a variety of interventions to try to help them. One technique is high-flow oxygen therapy, which involves blowing oxygen into the patient’s nose through tubes. Another option is to use a CPAP machine, which provides oxygen through a narrow face mask. These are relatively non-invasive methods, but at the beginning of the pandemic, many ICU doctors avoided using them because they feared can help spread the virus through hospital rooms, potentially infecting staff.
Nuala Meyer, MD, professor of medicine at the University of Pennsylvania Hospital, recalls that in the early weeks of the pandemic, she and her colleagues decided more often on ventilation systems. Although airflow can be carefully controlled with these devices, fans are more invasive. They require placing patients in chemically induced comas and inserting tubes deep into their airways. This can cause complications and may be more difficult for patients to recover after being removed from such systems.
As the pandemic unfolded, it became clear that appropriate PPE actually did enough work to protect healthcare workers from the aerosolizing effects of less invasive therapies. It was one reason why fans were used less over time.
One of the most dramatic changes is being less concerned about that spread, Meyer says. This had benefits for patients as well: If you can avoid the ventilator, avoid sedatives and maybe there is a benefit out there, she adds.
However, it is a balancing act, Morgan says, because it can also be detrimental to keeping a patient on less invasive methods if they prove ineffective. The patient just gets exhausted, and switching to the ventilator at that point can be even more of a temptation for them.
Overall, however, the consensus among ICU staff seems to be that being able to opt for CPAP or high-flow oxygen therapy is a good thing. Over time, clinical studies may prove that this has affected mortality.
Strangely enough, yes, of course it was a disease and a new burden to learn, but that’s kind of what we do every day.
It has also become more common for ICU physicians to place patients in what is called a prone position, where they lie on their front rather than on their back. In this position, patients’ lungs are slightly cheaper to expand and absorb more oxygen, which is essential for those with Covid-19 pneumonia.
Usually we kept it for the heaviest patients, says Meyer, who explains that over time it became customary for patients in the ICU to ask for self-inclination, as long as they were not in shock or under pressure. low blood pressure, for example. In many of these cases, oxygen levels improved. I think that allowed us not to escalate into the fan, she adds.
Yet another example of altered treatments is the practice of reducing blood thinners for patients in ECMO life support systems, which continuously draw blood from patients’ bodies, remove carbon dioxide, inject oxygen, and then pump it back. Anecdotal evidence divided into Magnification discussions has supported the hypothesis that lowering blood thinners in such patients could stop fatal bleeding in the brain.
Things have evolved so quickly during the pandemic that there has been no time to review ICU practices through medical conferences or studies supported by long-term clinical trials. Doctors have had to move much faster, all while trying to maintain high standards of safety for patients.
One way they have managed to do this is by talking to each other. Across the globe. The emergence of Covid-19 was followed by a boom in electronic communications among ICU physicians. Doctors and nurses found themselves regularly attending Zoom conference calls, cheating on Twitter discussions, scrolling through email chains, and joining WhatsApp groups with their counterparts in other hospitals around the world. Through these points, they have shared valuable knowledge about what ways they seem to work.
It has been great to have a whole host of other units at our fingertips, says Liz Thomas, MD, a consultant in intensive care medicine and anesthesia at the Stockport NHS Foundation Trust in Stockport, UK and chair of Women in Intensive Care Medicine. Thomas refers to a WhatsApp group used by around 250 ICU staff from across the UK that emerged during the pandemic as a knowledge-sharing portal.
The group allows staff to check medical instructions, share treatment approaches, and exchange notes regarding the distribution of medical equipment across the country, so a separate ICU can detect when to expect a new shipment of fans, for example.
Technology has helped address other problems, perhaps even more significant, the issue of separation created when patients with severe Covid-19 are transferred to isolation rooms. Catherine Bonham, MD, an intensive care physician at UVA Health in Virginia, says that at her hospital, staff have tried to reduce the number of visits patients need to make within these rooms. They have repositioned some ventilation controls outside the door, for example. Staff initially found it difficult to read information on observers from patient beds when looking through the window into the room. One even brought a pair of binoculars so they could spot small numbers on the device.
We had to get extra screens that made the numbers literally bigger, so you can see them just by looking through the glass, Bonham says.
Not being able to allow family members on Covid-19 units to visit has been the biggest upheaval, something Morgan describes as alien to ICU staff. Bonham agrees: Part of being a doctor or intensive care provider is that you are always caring for your patients and considering their family, she says.
Over time, ICUs have begun offering tablet computers to patients that are good enough to use so that they can make video calls with their families. Thomas notes that a charity donated 16 such tablets to its ICU for this purpose.
Other times, doctors and nurses have had to step on their own. They held the hands of dying patients and tried to make them as comfortable as possible. Morgan recalls a patient whose condition had deteriorated so much that they would not recover. He phoned their family over the phone to tell the news.
They asked, Please, can you play their favorite song? he says. So he did.
They are the kind of things we have with us in the future.
Many stories like this have unfolded in intensive care units in recent months. And yet the data show that things continue to improve for patients who find themselves seeking that level of critical care. All of the above efforts have played some role. Meyer also points out that at some hospitals, including hers in Pennsylvania, fewer patients appear to be seeking treatment at the ICU at the moment, reducing staff overload, which has also helped.
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