COVID ICU Bundle

Last update: March 27, 2020

Feeding

• Review nutrition, consult nutrition if not already done
• While awaiting nutrition input, start enteral nutrition:
• In most patients: Peptamen AF @10 mL/hr, advance by 20 mL q6hr to goal 50 mL/hr
• In renal failure and high K or phos: Novasource renal @ 10 mL/hr, advance by 10 mL q6hr to goal 40 mL/hr
• MVI with minerals PO daily
• Thiamine 100mg PO daily x 3 days
• Folate 1mg PO daily x 3 days

Analgesia

• Ask: Is patient's pain controlled?
• Define CPOT goal (e.g., < 3)

Sedation and delirium

• Ask: Is patient delirious (CAM+)?
• Review med list for any deliriogenic medications and discontinue/change where possible
• Define SAS goal (e.g., >2)
• Record QTc daily, consider changing medications if QTc >500

Thromboembolic prophylaxis

• Review patient's current DVT prophylaxis and adjust if needed
• Prefer LMWH due to daily dosing - enoxaparin 40mg SQ daily; if CrCl <30, enoxaparin 30mg SQ daily
• Contraindications to LMWH DVT PPx include ESRD (switch to UFH BID), clinically significant bleeding (hold pharmacologic), platelet count <30K (hold pharmacologic)
• Add SCDs if holding pharmacologic options

Respiratory

• Head of bed elevation >30 degrees
• Chlorhexidine ordered in all intubated patients

Ulcer prophylaxis

• Esomeprazole 40mg PO daily (per OG tube or oral), pantoprazole 40mg IV daily if unable to take PO or no OGT

Glycemic control

• Review glucose range over past 48h and insulin regimen; adjust regimen if needed
• Goal glucose range is 70-180

Spontaneous breathing and awakening trial

• Spontaneous awakening trial (SAT) = turn off sedation
• Spontaneous breathing trial (SBT) = place patient on pressure support 5/5

• Perform SAT and SBT concurrently if able
• Contraindications to SAT/ABT include:
• FiO2 >50%, PEEP >8, O2 saturation <90%, pH < 7.30

• SBP <90 or MAP <60

• Paralysis
• Increased ICP > 15
• Concern for significant bleeding
• If ARDS: goal Vt 6-8 cc/kg of IBW, plateau pressure <30

Bowel regimen

• Ask: Is bowel regimen adequate?
• Make changes if necessary

Indwelling devices removal

• List all tubes/lines/drains and discuss if any can be removed or should be changed

De-escalation of antibiotics

• 48hour timeout to review culture results, clinical course, and de-escalate antibiotics as able

Skin

• Ask: Are pressure ulcers present? Is a wound care consult needed?
• Discuss whether any changes are needed to ulcer management plan

Restraints/mobility

• Ask: Are restraints needed?
• Sign necessary restraint orders
• Discuss barriers to removing restraint ordres
• Consult PT for early mobilization; contraindications include deep sedation and paralysis

Patient/family cmmunication

• Discuss if patient has healthcare decision making capacity
• Update families by phone daily ideally
• If load becomes burdensome, RN update family daily and MD update every 3 days

Code status

• Review current code status, discuss if goals of care are realistic with prognosis - if not, discuss with patient/family

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.