- 1) An IV pump is recommended over dial-a-flow and drip-chamber titration (if available).
- 2) When outdoors, place the monitor, ventilator, and IV pumps upwind and as far away as possible from the patient to minimize contamination of caregivers.
- 3) Establish arterial line monitoring early when possible for patients with severe COVID-19 disease as they often become hemodynamically unstable.
- 4) If possible, establish central access early in anticipation of the need for continuous vasopressors. Multiple peripheral IVs may also be needed for infusions of sedatives, analgesia, antibiotics, etc.
- 5) A conventional central venous catheter can be placed through an introducer catheter (i.e. Cordis) to expand the number of available infusion ports. This should be done during the initial insertion under sterile technique, if possible.
- 6) Some severely ill COVID-19 patients may develop dilated cardio-myopathy with florid cardiogenic shock. This may be secondary to systemic inflammation, stress, or a direct viral myocarditis. Patients may also develop arrhythmias. Manage arrhythmias following Red Cross advanced life support guidelines.
- 7) An unexpected change in the vital sign trends or hypotension out of proportion to sedation and PEEP should merit evaluation for additional causes of shock. Limited transthoracic echocardiography may be useful in discriminating between hypovolemic, cardiogenic, and distributive shock (in personnel trained to perform the assessment).
- 8) Utilize dynamic parameters (i.e. skin temperature, capillary refilling time, pulse pressure variation, blood pressure response to passive straight leg raise, and/or serum lactate measurement) over static parameters to help guide the need for further fluid resuscitation (Surviving Sepsis Campaign COVID-19 Guidelines).
- 9) Norepinephrine is the first line vasopressor for most causes of shock. Fixed rate vasopressin infusion (0.04 units/min) is useful as an early adjunct in non-cardiogenic shock; start vasopressin when norepinephrine reaches doses above 12mcg/min. Epinephrine is sometimes the only option available in remote locations.
- 10) Vasopressors should be titrated to a MAP goal of 60- 65 mm Hg. (Surviving Sepsis Campaign COVID-19 Guidelines.)