Dear Editor,
According to the World Health Organization (WHO), with the increasing number of confirmed cases infected with the new SARS-CoV-2 causing, and recognition of its fatality rate, the growing outbreaks outside of China have resulted in significant worldwide anxiety about its pandemic [1]. To share experience and knowledge related to the COVID-19 pandemic and management of critically ill patients, an online panel discussion was organized, inviting experts from China, Australia, South Korea, Europe, and the USA. We hereby summarize the details of this panel discussion along with experts’ concerns and recommendations.
1. Burden of COVID-19 on critical care medicine
The group expressed their concerns that the number of COVID-19 cases without diagnosis is likely higher as the capabilities for systemic testing had not been established in many countries. The actual mortality rate will not be known until the systemic testing for COVID-19 is established globally. Mild cases, which may not have confirmed diagnosis, are potential contributors to the fast spread of the disease among other individuals. As a result of the rapid rise of the novel coronavirus infection that leads to COVID-19, it is expected that healthcare and critical care resources will be substantially burdened and, in many cases, overwhelmed.
2. Strategies for management of critically ill COVID-19 patients
The impact of universal interventions in China have proven effective in northern Italy and South Korea. The strategy for critically ill patients’ management included 1) preparing adequate crtical care resources; 2) concentrating critically ill patients in predesignated hospitals; 3) triaging. Therefore, preparing ICU teams at the global level via networking and information sharing is very important. Developing adequate critical care resources is essential for the management of the patients requiring intensive care. Planning for preparation outside of multidisciplinary engagement requires simulated scenarios based on previous outbreaks of other viral diseases like H1N1 influenza or others [2].
3. Concerns about supportive therapies for respiratory failure
Critically ill patients’ management should be based on protocolized care. For example, a protocol used by the Chinese critical care physicians for the management of acute hypoxemic respiratory failure is provided in Fig. 1 [3]. Using high flow nasal oxygenation or nebulizers could be associated with higher aerosolization, and thus a higher risk of healthcare worker exposure. It may be necessary to escalate respiratory support for refractory hypoxemia early. The use of bedside ultrasonography could be especially helpful for monitoring lung and heart function in patients with severe acute respiratory distress syndrome (ARDS) from COVID-19. Prone positioning and extracorporeal membrane oxygenation (ECMO) may play a role as a form of rescue therapy in patients where mechanical ventilation may not be enough to provide sufficient oxygenation. Notably, careful planning, judicious resource allocation, and training of personnel to provide complex therapeutic interventions while adhering to strict infection control measures are all crucial components of an ECMO action plan [4].
Fig. 1.
Respiratory treatment protocol for critical coronavirus pneumonia.
HFNC, high-flow nasal cannula oxygen therapy; NIV, noninvasive ventilation; P/F, PO2/FiO2; RR, respiratory rate; ROXI, ROX index, defined as the ratio of SpO2/FiO2 (%) to RR (breaths/min); NE, norepinephrine; IBW, ideal body weight; IPAP, inspiratory positive airway pressure; EPAP, expiratory positive airway pressure; Vt, tidal volume; PEEP, positive end expiratory pressure; Pplat, plateau pressure; DP, driving pressure.
4. Concerns about cytokine storm
Panel members raised concerns regarding the management of cytokine storm in COVID-19 patients. However, the experience seemed limited and heterogeneous. Challenges remained in definition, biomarkers, and therapies for cytokine storm, which could be the next steps in research or management of severe patients with COVID-19. Defining cytokine storm and planning for appropriate management among severely ill patients could be the next steps in research or management of patients with COVID-19. Hemopurification techniques, including hemoadsorption, hemoperfusion, or continuous renal replacement therapies (CRRT), may contribute to the mitigation of the cytokine storm [5].
5. Recurrence of RT-PCR positive COVID-19
There have been some reports that individuals who experienced infection with COVID-19 had a recurrence of positive reverse transcriptase–polymerase chain reaction (RT-PCR) test [6]. In China, the criteria for hospital discharge or discontinuation of quarantine include absence of clinical symptoms and radiological abnormalities and 2 negative RT-PCR test results. It was stated that this could be simply due to false-negative, due to the kits used for RT-PCR test were from different companies with different levels of accuracies. On the other hand, some of the individuals were tested in their recovery phase when they may not have had a chance to completely clear their viral load. These findings suggest that at least a proportion of recovered patients still may be virus carriers. At this point, there is no evidence for recurrence of COVID-19.
6. Experience of dealing with COVID-19
It is essential to prepare and protect health care forces. Testing healthcare providers with exposure to COVID-19 patients seems to be necessary. However, healthcare systems should consider the cost and anxiety caused by excessive testing among these providers and the population.
The panel agreed on most statements and recommended past experiences to be used in critical practices to improve outcomes of critically ill COVID-19 patients. They suggested all providers who provide care to COVID-19 should learn from errors and successes and share experiences with others. In other words, "alone, we lose; together, we win."
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Xuan Song: Conceptualization, Project administration, Writing - original draft, Writing - review & editing. Chunting Wang: Conceptualization, Project administration, Writing - review & editing. Penglin Ma: Conceptualization, Project administration, Writing - review & editing.
Declaration of competing interest
None.
Acknowledgements
The authors would like to thank Prof. Eduardo Mireles-Cabodevila (US), Prof. Claudio Ronco (Italy), Prof. Jean-Louis Vincent (Belgium), Prof. Colin Royse (Australia), Prof. Younsuck Koh (South Korea), Prof. Bin Du (China), Prof. Xiangdong Guan (China), Prof. Dechang Chen (China), Prof. Zhiyong Peng (China), Prof. Yan Kang (China), Prof. Xiuming Xi (China), Prof. Yi Yang (China), Prof. Aiqiang Xu (China), and Prof. Kianoush B. Kashani (US) joining the panel discussion and share their experience and knowledge related to COVID-19.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.tacc.2020.06.002.
Abbreviations
- ARDS
Acute Respiratory Distress Syndrome
- CRRT
Continuous renal replacement therapies
- COVID-19
Coronavirus disease 2019
- ECMO
Extracorporeal membrane oxygenation
- HFNC
High flow nasal oxygenation
- WHO
World Health Organization
Appendix A. Supplementary data
The following is the supplementary data to this article:
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