Medication Administration

#### ARDS

Consider systemic corticosteroids in the treatment of COVID-19 related moderate to severe Acute Respiratory Distress Syndrome (ARDS). Discuss with advanced provider via telehealth prior to initiating treatment.

#### Antimicrobial Therapy: (to treat possible bacterial pneumonia co-infection)

- Consider early azithromycin (oral or IV 500mg daily for a minimum of 5 days) for community acquired pneumonia (CAP) for those with lower respiratory tract symptoms and fever. Use azithromycin with caution due to potential arrhythmias, particularly in older patients or those with known cardiac problems. Monitor QTc interval if possible.
- For severe symptoms, add ceftriaxone (IV 2gm q24h is the best option) or ampicillin-sulbactam (IV 3gm q6hr is a better option) or ertapenem (IV 1g q24h is a good option). If critically ill, include levofloxacin (IV 750mg q24h) to treat of bacterial co-infection.
- Due to potential harm, prior to starting chloroquine (CQ) or hydroxychloroquine (HCQ) plus azithromycin, discuss with advanced provider via telehealth.
- If azithromycin not available, may substitute doxycycline (IV or PO 100mg q12h) to treat bacterial pneumonia.

#### Fever Management

IV acetaminophen 1000mg every 6 hours (or PO/PR 975mg every 6 hours) as needed for temperature over 38degC (100.4 degF)

#### Sedation and Analgesia

- Sedation goal is Richmond Agitated Sedation Scale (RASS -1 to -2 comfortable, transiently responsive to verbal stimulation) and synchronous with the ventilator. Increase sedation and/or add narcotics to improve patient-ventilator synchrony. Use of paralytics is likely to be required for very severe cases.
- Ketamine may cause increased secretions requiring more frequent suctioning. If in-line close-circuit suction devices are not available, patients may not tolerate the de-recruitment caused by disconnecting the ventilator for suctioning. This will also increase aerosolization risk. For limited medication availability, consider midazolam administration more frequently to decrease Ketamine dose requirement & secretion burden.
- Combined use of multiple sedatives (i.e. propofol, dexmedetomidine, and/or midazolam) may decrease total sedative requirement, mitigating the hypotensive effects of propofol. Use caution in combining propofol and dexmedetomidine, especially in younger patients, leading to bradycardia & hypotension.
- Intermittent or continuous infusions of fentanyl or intermittent hydromorphone (if available) may be used for analgesia & ventilator synchronization.
- Low dose vasopressors may be necessary to maintain blood pressure with administration of deep sedation & higher PEEP

#### Paralysis for Patient-Ventilator Synchronization

- Adequate depth of sedation is essential prior to starting paralytic; recommend at least RASS -3.
- Recommend intermittent paralytics over continuous infusions if possible.

#### Paralysis with Vecuronium

- Bolus (for push-dose or for loading dose of an infusion): IV 5mg to 10mg every 60-90 minutes as needed.
- Infusion: 0.8 to 1.2mcg/kg/min (approx. 80mcg/min for 80kg).
- Without pump: 40mg vecuronium in 250mL bag of normal saline yields 40mg/290mL = 138mcg/mL. For 80mcg/min = 0.58mL/min ~ 1gtt every 10 seconds in 10gtt tubing.

#### Bronchodilation

- Use metered-dose-inhalers (MDIs) over nebulized bronchodilators to minimize aerosolization.
- If the ventilator tubing does not have a capped inlet for medication administration (aka MDI adapter): clamp the ETT, disconnect the ventilator, and administer the MDI (6 puffs) directly into the INHALATION circuit. Then, reconnect the ventilator and unclamp ETT to insufflate the medication.
- Magnesium Sulfate 2gm IV over 20 minutes (similar to asthma exacerbation treatment) may be safer to treat of bronchospasm due to aerosolization risk from circuit disconnection.

#### Vasopressors

Fixed rate vasopressin infusion (0.04 units/min) is useful as an early adjunct in non-cardiogenic shock; may start vasopressin when norepinephrine reaches doses above 12mcg/min. Epinephrine is the second line titratable pressor.