The keypoints in treatment of the critical COVID-19 infected patients:
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Reasonable application of vasoconstriction drugs in critically ill patients with COVID-19:
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It is necessary to closely monitor the circulation status of patients, especially in patients with invasive mechanical ventilation. Hemodynamic instability often occurs during tracheal intubation induction and sedation and analgesia after intubation 90 mmHg (1 mmHg = 0.133 kPa) or 40 mmHg lower than the basal blood pressure.
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Immediately give pumps of vasoconstrictor drugs such as norepinephrine or dopamine to boost blood pressure.
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For volume shock, appropriate fluid resuscitation should be given first [ Refer to the cluster treatment of septic shock]. 30 ml / kg fluid resuscitation should be given within 3 hours, but the oxygenation changes should be closely monitored during rehydration to prevent volume overload from aggravating lung injury.
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Sedative and analgesic drugs can inhibit sympathetic nerve excitement leading to hypotension, and vasoactive drugs should be used with caution while timely adjusting the drug dose.
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In critically ill patients with COVID-19, commonly myocardial enzymes (especially troponin) or (and) B-type natriuretic peptide (BNP) have significantly increased. Thus, heart function needs to be closely monitored, which must be considered Cardiogenic shock is possible.
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Be vigilant against septic shock, measure blood lactate levels during fluid resuscitation, take blood culture samples, give broad-spectrum antibiotics, closely monitor changes in mean arterial pressure, and respond to initial fluid resuscitation with booster medication Maintain an average arterial pressure of ≥65 mmHg (1 mmHg = 0.133 kPa).
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The selection of vasoconstrictor drugs is also very important. Common drugs include norepinephrine, epinephrine, vasopressin, dopamine, and dobutamine. These drugs have their own characteristics and also have adverse reactions that require our special attention. The guidelines recommend that norepinephrine is the preferred vasoactive drug, but it should be noted that some adverse reactions related to catecholamines caused by the drug during use.
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Vasoconstriction drugs should be pumped with a deep venous catheter to prevent complications such as skin necrosis caused by extravasation of the drug; closely monitor renal function and changes in urine output and urine color.
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When conditions permit, non-invasive and convenient methods such as ultrasound Doppler monitoring can be used to correctly handle different types of shocks and help to rationally select vasoconstriction drugs.
Prevention of venous thromboembolism (VTE) in patients with COVID-19
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Patients with severe COVID-19 might have risk of VTE due to prolonged bed rest and often associated with abnormal coagulation function. It has been observed in clinical practice that nearly 20% of patients with COVID-19 will have abnormal coagulation function, and almost all patients with severe and critically ill patients have coagulation disorders.
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Should pay attention to whether there is pulmonary thromboembolism (PTE) after the occurrence of deep vein thrombosis (DVT), and we must be alert to clinical manifestations such as sudden deterioration of oxygenation, respiratory distress, and blood pressure.
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The occurrence of PTE should be treated in a timely manner.
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D-dimer is the most commonly used indicator for VTE monitoring. However, in previous studies of patients with COVID-19, the level of D-dimer in severe patients admitted to ICU was significantly higher than that of patients with milder disease .
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While alerting to VTE, the condition of D-dimer and COVID-19 need to be considered. In various studies, high correlation was reported between increased D-dimer and patient severity.
Supporting Reports :
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Ribelles et al. found that D-dimer was highly correlated with the mortality rate of patients with community-acquired pneumonia (CAP).
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The analysis of 147 CAP patients by Snijders et al. also gave the same result. Patients at levels <500 µg / L have fewer complications. The reason may be that inflammatory mediators have a tendency to promote coagulation after imbalance of coagulation and fibrinolysis in the alveoli, which activates the fibrinolytic system and causes D-dimer to increase.
Contradictory Reports :
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The results of a prospective cohort study of 102 CAP patients by Duarte et al. showed that there was no significant correlation between D-dimer levels and patient disease severity. The dynamic evolution of D-dimer in critically ill patients with COVID-19 late rehabilitation is still lacking.
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The risk assessment and prevention of VTE is particularly important in the comprehensive treatment of COVID-19. The condition of some patients changes rapidly, and there is a dynamic change in the risk of VTE and bleeding during treatment. Dynamic assessment should be made and strategies adjusted in time to reduce the incidence of VTE and prevent the occurrence of fatal PTE.
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Nutritional support for critically ill COVID-19 patients
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Nutritional support is vital for critically ill patients with COVID-19
- At present, most guidelines recommend that patients in the ICU be assessed for nutritional risks early and set nutrition support targets. For example, if there is no contraindication, early enteral nutrition support is started within 24-48 hours
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Commonly used nutritional risk assessment tools include nutritional risk screening (NRS 2002), nutritional risk score for critically ill patients (NUTRIC score), and so on. High risk of aspiration, such as loss of airway protection, age> 70 years, decreased consciousness, poor oral care, prone position, gastroesophageal reflux, and enteral nutrition given in a single load.
Main Goals include energy and protein.
- Energy supply: It is recommended to supply according to the severity of the disease, according to 20 ~ 30 kcal.kg -1 .d -1 .
Fluid Balance: COVID-19 patients should pay attention to maintaining fluid balance. For large areas of pulmonary consolidation and elderly patients, control is recommended. Intravenous fluid volume. However, the author believes that such patients who have just been admitted to the hospital often have insufficient intake due to symptoms such as high fever and decreased appetite in the early stage of onset.
- Protein supply: Most guidelines consider that the protein requirement is suitable in the range of 1.2 to 2.0 g / kg. Severe patients have muscle atrophy due to increased protein catabolism, which affects survival and prognosis.
- Studies have shown that supplementing protein intake in critically ill patients can reduce their mortality, but determining the optimal protein needs of patients remains controversial. But,
In the study of Ferrie et al. (120 cases), compared with 0.8 g / kg when amino acid 1.2 g / kg was administered through parenteral nutrition, there was no difference between patient mortality and ICU monitoring and treatment time, while the TOP-UP study (125 cases) and the EAT-ICU study (203 cases) showed that protein intake had no effect on mortality, length of hospital stay, mechanical ventilation time, nosocomial infection rate, and organ failure.
- Therefore, it is necessary to pay attention to individual differences during nutrition support, closely observe adverse reactions and evaluate treatment effects, and dynamically adjust treatment plans to ensure energy supply while reducing metabolic stress reactions and improving prognosis.
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