Nursing Care & Monitoring

#### Nursing Care Considerations

- Rapid decompensation may occur 5-7 days out from onset of symptoms, and ARDS onset within 12 to 48hrs following initial signs of clinical deterioration. Close monitoring during this period is critically important to allow for early intervention.
- Always keep clamp at head of bed for clamping ET tube if ventilator disconnected.
- Periodic prone positioning and percussive chest physiotherapy, if tolerated, may improve secretion clearance.
- Ventilator patients placed in reverse Trendelenberg positioning (head of bed up, spine straight) improve breathing. Avoid semi-recumbent position (bent at the waist) which impedes breathing
- Strongly recommend IV pump over dial-a-flow over drip-chamber titration due requirement to continually monitor/adjust titration.
- Establish invasive procedures & pressure monitoring early, especially if considering advanced ARDS management techniques and/or evidence of impending distributive shock.

#### Arrythmias

- Development of arrhythmias & dilated cardiomyopathy with cardiogenic shock may develop in severely ill COVID-19 patients due to systemic inflammation, stress, or a direct viral myocarditis and may require vasopressors. Manage arrhythmias as per ACLS guidelines.
- Measures of volume responsiveness (urine output, pulse pressure variation, and blood pressure response to passive straight leg raise) guides need for further fluid resuscitation. Note: An increase of EtCO2 of >5% OR 3mmHg after passively raising a patient’s legs up 45 degrees from a fully supine position suggests volume responsiveness.

Note: Hypotension out of proportion to sedation and PEEP indicates further need of evaluation into causes of shock. Development of jugular venous distension and cool mottled extremities may indicate cardiogenic shock. Limited transthoracic echocardiography may be useful in discriminating between hypovolemic, cardiogenic, & distributive shock (in personnel trained to perform the assessment).

#### Pneumothorax

- Anticipate ventilator patient complications such as pneumothorax. Sudden increases in PIP and/or hemodynamic instability suggest pneumothorax.
- Pneumomediastinum with subcutaneous emphysema may develop with high PEEP. Look for crepitus across the chest, neck, and/or upper extremities. Tension physiology from pneumomediastinum is rare.

#### Low Urine Output (less than 0.5 mL/kg/hour)

- If oliguria does not improve with resuscitation, consider acute tubular necrosis (ATN), especially if UOP remains low for more than 6 hours.
- If iStat creatinine testing for acute kidney injury (AKI) not available, use urine dipstick testing for specific gravity, proteinuria, and hematuria.
- Abnormally low (dilute) specific gravity in the setting of oliguria suggests tubular damage and the inability to concentrate urine.
- Significant proteinuria can be seen in acute tubal necrosis (ATN), but may not be specific.
- Hematuria may suggest the presence of myoglobinuria – consider rhabdomyolysis as cause of acute kidney injury (AKI).
- If urinary output (UOP) suddenly declines or stops, flush Foley/perform a bladder ultrasound to determine mechanical (Foley blockage) vs. organic (true kidney disease) cause.
- If ATN suspected, DO NOT AGGRESSIVELY FLUID RESUSCITATE OR DIURESE to meet UOP goals. Use alternate markers of fluid responsiveness (blood pressure response to passive straight leg raise) to help determine the need for further fluids and vasopressors.
- Monitor electrolyte closely for disturbances, specifically metabolic acidosis and hyperkalemia. Diuresis for management of hyperkalemia may be appropriate but should be done after teleconsultation.

#### Hypercoagulation

- Deep vein thrombosis (DVT) often begin in the vessels of legs or arms, leading to fatal outcomes by traveling to the heart (myocardial infarction), brain (stroke), and/or lungs (pulmonary embolism).
- Monitor for signs or symptoms of DVT including pain or tenderness, swelling, increased warmth in the affected area, and redness or discoloration of the overlying skin.
- Monitor for the most common signs or symptoms of pulmonary embolism including unexplained shortness of breath, pleuritic chest pain, cough or hemoptysis, and syncope.
- Provide thromboembolism prevention measures including calf muscle exercises, range-of-motion, properly fitted compression stockings if available.

#### Sedation/Ventilation Synchronization

- Absence of muscle movement and no evidence of spontaneous breathing on the ventilator. If possible, titrate to 2/4 train-of-four (TOF) score (likely only available for surgical teams).
- Increased HR and BP may suggest undersedation and should be empirically treated with an increased dose of sedation.
- Recommend checking TOF every 2-4 hours until stable, then consider extending to every 6-8 hours.
- Once the patient is stabilized, consider holding the paralytic at least once every 24 hours to provide for assessment of sedation depth.
- DO NOT hold sedation until 4/4 TOF twitches, unless absolutely necessary (e.g. sudden hypotension). Alternatively, spontaneous respiratory efforts (respiratory rates higher than the set rate) can be used as evidence of adequate paralytic medication reversal.

#### Nutrition

- NG/OGT should be placed early for gastric decompression. If medical evacuation is significantly delayed (greater than 24 hours), consider starting enteral nutrition.
- Enteral nutrition is contraindicated in hemodynamically unstable patients (i.e. those on high or increasing doses of vasopressors). Low volume enteral feeding on patients with stable low doses of vasopressors is generally safe.
- At a minimum, confirm presence of gastric placement with auscultation over both lung fields and the abdomen along with aspiration of gastric contents. Urinalysis test strips for pH may provide an addition method for field expedient NG/OGT placement confirmation in patients not on acid suppressive therapy.
- Ensure presence of normal bowel sounds prior to initiating any enteral feeding. Enteral feeding contraindicated in the presence of signs of acute abdomen and/or gastro-intestinal bleeding.
- Goal 25-30kcal/kg/day + 1-1.2gm/kg protein; however, this might be difficult, especially in the absence of formal concentrated tube feeds.
- Hypocaloric feeding is acceptable if accompanied by adequate protein supplementation.
- Meal supplement drinks are not sufficient. For example, 1x Muscle Milk Light bottle contains only 150kcal and 28gm protein in 500mL, more diluted than most tube feeding formulations. This may cause increased extra-vascular lung water and minimal benefit for those critically ill.
- Use commercially available protein powder (with similar caloric/protein content per scoop) at 1/4 the recommended concentration and mix in a blender until no clumps are visible. Administer in small volume boluses (e.g. 60mL via Toomey syringe) as tolerated every 2 to 4 hours to a goal of 1gm/kg/day protein content.