Publication - Advice and guidance

Coronavirus (COVID-19): guidance on critical care management of adult patients

Guidance for healthcare practitioners working in critical care environments and staff involved in the planning and delivery of critical care services.

Coronavirus (COVID-19): guidance on critical care management of adult patients
Clinical context

Clinical context

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is the pathogenic organism leading to COVID-19 disease1. Transmission predominantly occurs through respiratory droplet spread between individuals or direct contact with fomites on contaminated surfaces [1].

The clinical spectrum of COVID-19 disease is wide, from asymptomatic infection to severe pneumonia and the development of multiple organ failure leading to death. Approximately 5% of patients with confirmed SARS-CoV-2 infection requiring hospital admission become critically ill [2]. Several risk factors for progression to critical illness have been identified, including increasing age [3], obesity [4], male gender [5], Black and Asian ethnicity [6], low socio-economic status[7] and the presence of chronic co-morbidity [4].

COVID-19 disease may lead to the development of severe hypoxaemic respiratory failure, with most patients fulfilling the Berlin Criteria8 for diagnosis of Acute Respiratory Distress Syndrome (ARDS). As a new disease, the pathophysiology of COVID-19 is not yet fully understood. Although controversial, two distinct clinical phenotypes of respiratory failure in COVID have been proposed, which may occur in sequence [9]. Early in the disease course, it is proposed that some patients have an atypical viral pneumonitis with severe hypoxaemia with relative preservation of compliance and a low ventilation - perfusion (V: Q) ratio. This subsequently progresses into a more classic "ARDS" phenotype, as defined by the Berlin Criteria [8], with poor compliance, high lung weight, and the potential for recruitment.

In addition to respiratory failure, multi-system involvement is common in COVID-19 disease, with over 25% of patients developing cardiovascular failure, and over 30 % suffering an acute kidney injury necessitating renal replacement therapy [10]. Patients with COVID-19 disease are also recognised to be at increased risk of arterial, venous and pulmonary thromboembolism, the mechanisms of which are not fully understood [11]. SARS-CoV-2 infection has also been associated with the development of a potentially severe inflammatory syndrome in children called paediatric multisystem inflammatory disorder (PIMS) [12].

Initial outcome data for the critically ill Scottish Population with confirmed COVID-19 disease indicates a 30-day mortality of 39%, which is increased in those receiving advanced respiratory support, older patients, and those requiring multiple organ support [13]. The long-term sequelae of COVID-19 survivors are currently unknown. Guidance for the longer term recovery needs of COVID-19 survivors is currently being developed and when published will be signposted within this document.