|Year : 2020 | Volume
| Issue : 7 | Page : 36-41
Pediatric intensive care management in coronavirus infection-19
Namita Ravikumar1, Manu Sundaram2, Utpal Bhalala3, Dhiren Gupta4, Arun Bansal1
1 Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Division of Critical Care Medicine, Sidra Medicine; Department of Pediatrics, Weill Cornell Medicine, Doha, Qatar
3 Department of Pediatrics, The Children's Hospital of San Antonio; Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas, USA
4 Department of Pediatric Critical Care, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||01-May-2020|
|Date of Decision||06-May-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||29-May-2020|
Dr. Arun Bansal
Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Coronovirus-19 disease (CVOID-19) caused by severe acute respiratory syndrome-CoV2 has more than affected 3 million people worldwide, accounting for one of the largest pandemics known to humankind. Originating in China and traveling all across the globe, it spreads by droplets and fomites. Cohort intensive care units have been set up to manage critically ill CVOID-19 patients requiring organ support. Respiratory support, including low and high-flow oxygen devices, noninvasive and invasive ventilatory support have been used in the management of patients with severe acute respiratory illness. Aerosol generating procedures pose a high risk of transmission to health-care workers and need strict infection control practices and the use of personal protective equipment. Various anti-viral drugs have been tried, but there is inadequate evidence to recommend their routine use.
Keywords: 2019-novel coronavirus, acute respiratory distress syndrome, coronovirus-19 disease, pediatric intensive care unit management, severe acute respiratory illness
|How to cite this article:|
Ravikumar N, Sundaram M, Bhalala U, Gupta D, Bansal A. Pediatric intensive care management in coronavirus infection-19. J Pediatr Crit Care 2020;7, Suppl S1:36-41
|How to cite this URL:|
Ravikumar N, Sundaram M, Bhalala U, Gupta D, Bansal A. Pediatric intensive care management in coronavirus infection-19. J Pediatr Crit Care [serial online] 2020 [cited 2020 Sep 25];7, Suppl S1:36-41. Available from: http://www.jpcc.org.in/text.asp?2020/7/7/36/285383
| Introduction|| |
Coronovirus-19 disease (COVID-19) is one of the largest global pandemics affecting over 3 million people in 213 countries worldwide. It has led to a death toll of >200 thousand patients in a short span of 4 months as per the World Health Organization (WHO) on May 1, 2020. India has reported over 33,000 cases with >1000 deaths.
| Epidemiology|| |
COVID-19 is caused by the 2019-novel coronavirus, later named the severe acute respiratory syndrome-CoV2. It was first detected in Wuhan, China, in patients with “pneumonia of unknown etiology.” It is believed to have originated from bats and transmitted to humans. The transmission is mainly through droplets, fomites and to a lesser extent through airborne mode.
| Pediatric Coronovirus-19 Disease|| |
Children account for 1%–2% of the total population affected with COVID-19, with about 2%–6% of them requiring management in the intensive care unit (ICU).,, The disease appears to be less severe in children and various theories have been proposed for the same. Children have lesser opportunities to get exposed, and they are found to have immature angiotensin-converting enzyme 2 receptors, which have been proposed as the binding sites for coronaviruses.
| Intensive Care Unit Needs in Coronovirus-19 Disease|| |
Severe acute respiratory illness (SARI), including severe pneumonia and acute respiratory distress syndrome (ARDS), septic shock, myocardial dysfunction, acute kidney injury, and other organ dysfunction, require admission to the pediatric ICU. Intensive care needs such as mechanical ventilation, renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO) and cardiopulmonary resuscitation (CPR) pose a significant risk of transmission to health-care workers, and other patients. Strict infection control practices are essential to prevent the spread through fomites, contact, droplets, and aerosol.
| Cohort Intensive Care Unit|| |
Children with SARI are preferably managed in a separate area different from the ICU where other children are being taken care. In addition, suspect and confirmed cases should have separate designated areas. Negative pressure isolation rooms equipped with intensive monitoring tools are recommended. If unavailable, single rooms with exhaust fans are preferred.
| Management of Severe Acute Respiratory Illness|| |
Child presenting with cough and difficulty in breathing or tachypnea with one of the following:
- Hypoxemia (oxygen saturation [SpO2] <90% or central cyanosis)
- Severe chest indrawing or grunting
- Danger signs such as altered sensorium, poor feeding, convulsions as per WHO definition of severe pneumonia. Monitoring: Clinical monitoring, including heart rate, respiratory rate, invasive/noninvasive blood pressure, and continuous pulse oximetry at least every two hourly.
Complete blood count, neutrophil
Lymphocyte ratio calculation, renal function, liver function test, triglyceride, ferritin, C-reactive protein, procalcitonin, coagulogram with D-Dimer, X-ray chest, and other investigations as per organ dysfunction.
- Low flow oxygen delivery devices: Such as nasal prongs oxygen are the initial choice with a target SpO2 of ≥95%. A surgical mask can be placed over the nasal prongs to minimize droplet transmission of infection in older children. In infants, an oxygen hood may be placed over the head along with nasal prongs to decrease spread of aerosols due to leaks around the cannula, especially if higher flows are used. Nebulization should be avoided. If necessary, in children with airway obstruction like asthma, metered-dose inhalers are preferred
- Heated high-flow nasal cannula which is a commonly used modality of respiratory support in bronchiolitis and pneumonia is avoided in COVID-19 as it is found to be associated with aerosol generation due to use of higher flows and leaks
- Noninvasive ventilation: (NIV) using various interfaces such as nasal mask, oronasal mask, full face mask, and helmets have been tried in adults with COVID-19. However, they are associated with aerosol generation, especially if adequate seal cannot be maintained. In children, finding the appropriate fit as well as maintaining adequate seal without sedation is difficult. NIV use has also shown high failure rates and delay in intubation. The use of NIV is discouraged unless full aerosol precautions with negative pressure rooms are available
- Invasive mechanical ventilation: In case of nonimprovement or worsening of respiratory failure on nasal prongs, early elective intubation is preferred to avoid the risks involved in emergency intubation. The decision to intubate may include a combination of clinical, radiological, and pulse oximetry or blood gas parameters, as per the availability. The procedure of intubation is high risk in view of aerosol generation and has to be performed by the most experienced team member using the technique of rapid sequence intubation with a few modifications from the routine [Figure 1] and [Table 1]. If available and trained, video-laryngoscope guided intubation is preferred. The use of a transparent plastic hood enclosure (Aerosol box) with two openings for the incubator's hands has been tried in some units to contain the aerosol within the hood. Invasive mechanical ventilation strategies for children with COVID-19 are along the lines of management of pediatric ARDS (PARDS) [Figure 2]. ARDS is stratified using the Pediatric Acute Lung Injury Consensus Conference criteria for PARDS and Saturation targets of 92%–95% for moderate and 88%–92% for severe ARDS is followed. Closed suction catheters are preferred to avoid disconnection, aerosol production, and de-recruitment. A subset of critically ill adults have shown atypical features of ARDS having lungs with low elastance, low ventilation/perfusion, low lung weight, low recruitability (Type L phenotype) versus the typical ARDS (Type H). Silent hypoxemia with minimal distress has also been reported. Patients not behaving like typical ARDS respond well to higher FiO2 rather than invasive mechanical ventilation. Extubation is also associated with the high aerosol generation and should be done in a controlled setting directly to nasal prongs, avoiding NIV. It should be planned once the team is sure that the child will tolerate extubation. The use of plastic bags or sealed enclosures around the face after disconnection from the ventilator and ensuring minimal coughing during extubation can minimise aerosol generation
- Shock: Restricted crystalloid fluid bolus (10–20 ml/kg of 0.9% saline or balanced salt solution) has been recommended by surviving sepsis guidelines followed by adrenaline infusion as the first vasoactive drug in pediatric septic shock,
- Myocarditis: There have been unpublished reports of children from the UK presenting with abdominal pain and gastrointestinal symptoms and having cardiac involvement with overlapping features of toxic shock syndrome and atypical Kawasaki disease. Diuretics, inodilator, and ECMO have been recommended for myocarditis. Immunomodulators like intravenous immunoglobulin (IVIG) may be considered
- Acute kidney injury: Failure of conservative management like anuric fluid regime and trial of diuretics requires the initiation of RRT like peritoneal dialysis, hemodialysis, or continuous RRT
- Acute liver failure, coagulopathy, and disseminated intravascular coagulation (DIC): These are managed conservatively with blood component therapy as necessary
- Cytokine release syndrome: It is characterised by severe inflammation with hyperferritinemia, high C-reactive protein, and high Interleukin-6 levels which is likely to respond to tocilizumab
- Supportive care:
- Early enteral nutrition: Enteral nutrition should be started within 24 h and full feeds established by 48 h if there are no contraindications
- Blood transfusion: If stable hemodynamics and oxygenation, a hemoglobin (Hb) of >7 g/dL is targeted. In the case of refractory hypoxemia or unstable hemodynamics, the trigger to transfuse would be Hb <10 g/dL
- Antibiotics: Co-infection with other viruses and bacteria have been observed within 72 h of ICU admission. Oseltamivir, azithromycin, third-generation cephalosporin such as Ceftriaxone and anti-staphylococcal cover with cloxacillin is necessary, especially in mechanically ventilated patients. If clinical and radiological worsening appears after 48 h, active screening and treatment for ventilator-associated pneumonia as per the local culture and sensitivity patterns should be considered
- Specific therapy: Various antiviral drugs and immunomodulators have been tried in COVID-19 patients. However, there is no strong evidence to recommend the routine use of any therapy. Randomized control trials are on-going for the use of chloroquine, hydroxychloroquine, Azithromycin, interferon-α, ribavirin, remdesivir, and anti-retroviral drugs, namely ritonavir-lopinavir. Corticosteroids, IVIG, and convalescent plasma, are being used in a few cases.,
|Figure 1: RSI algorithm in children with suspected or confirmed COVID-19. RSI: Rapid sequence intubation, COVID-19: Coronavirus infection-19, PPE: Personal protective equipment, ECG: Electrocardiography, SpO2: Oxygen saturation by pulse oximetry, ETT: Endotracheal tube, NRM: Non-rebreathing mask, IV: Intravenous, ETCO2: End tidal carbon dioxide|
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|Figure 2: Strategies for management of PARDS. PARDS: Pediatric acute respiratory distress syndrome, COVID-19: Coronavirus infection-19 TV: Tidal volume, PEEP: Positive end expiratory pressure, Pplat: Plateau pressure, NMB: Neuromuscular blockade|
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- Resuscitation: Cardiac arrest during ICU care of COVID-19 patients requiring CPR poses a high risk of aerosol generation. Two persons for alternately performing chest compressions and handling airway and one nurse for medication should enter the room after wearing complete Personal protection equipment (Hazmat suit, cap/hood, goggles/face shield, fitted N95 respirator, full sleeve water impermeable gown, double gloves and boots) and close the door. It is preferable to leave the patient connected to a ventilator as it forms a closed circuit and increase FiO2-100%, turn off the trigger, set the ventilator rate to 10 breaths/min and limit tidal volume to 6 ml/kg on the pressure control mode of ventilation. If the airway is not in place, to minimize aerosol, complete seal of the face mask is ensured and may require another person to prepare for intubation. A supraglottic device like Laryngeal mask airway may also be used during resuscitation
- Course and prognosis: Respiratory failure occurs around day 7 of onset of symptoms with a peak severity on day 10. Recovery starts by about day 14. The mortality is as high as 60% in critically ill adults.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al
. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N
Engl J Med 2020;382:1199-207.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the chinese center for disease control and prevention. JAMA 2020;323:1239-42.
CDC COVID-19 Response Team. Coronavirus disease 2019 in children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422-6.
Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al
. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics 2020. pii: e20200702. doi: 10.1542/peds.2020-0702. [Epub ahead of print].
Tarentino AL, Maley F. A comparison of the substrate specificities of endo-beta-N-acetylglucosaminidases from Streptomyces griseus
and Diplococcus Pneumoniae. Biochem Biophys Res Commun 1975;67:455-62.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al
. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81. doi:10.1016/S2213-2600(20)30079-5.
The Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines Version 1; 16 March, 2020.
Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al
. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 2020;46:854-87.
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020;75:785-99.
Kneyber MC, Medina A, Alapont VM, Blokpoel R, Brierley J, Chidini G, et al
. Practice recommendations for the management of children with suspected or proven COVID-19 infections from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) and the section Respiratory Failure from the European Society for Paediatric and Neonatal Intensive Care (ESPNIC)-A consensus statement. Intensive Care Med 2017;43:1764-80.
Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N
Engl J Med 2020. doi: 10.1056/NEJMc2007589. [Epub ahead of print].
Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: Consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015;16:428-39.
Gattinoni L. COVID-19 pneumonia: Different respiratory treatment for different phenotypes? Intensive Care Med 2020. doi.org/10.1007/s00134-020-06033-2.
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017;43:304-77.
Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. The cytokine release syndrome (CRS) of severe COVID-19 and Interleukin-6 receptor (IL-6R) antagonist Tocilizumab may be the key to reduce the mortality. Int J Antimicrob Agents 2020:105954. doi: 10.1016/j.ijantimicag.2020.105954. [Epub ahead of print].
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al
. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
Zhang L, Liu Y. Potential interventions for novel coronavirus in China: A systematic review. J Med Virol 2020;92:479-90.
Sarma P, Prajapat M, Avti P, Kaur H, Kumar S, Medhi B. Therapeutic options for the treatment of 2019-novel coronavirus: An evidence-based approach. Indian J Pharmacol 2020;52:1-5. [Full text]
Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al
. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®
-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation 2020. doi: 10.1161/CIRCULATIONAHA.120.047463. [Epub ahead of print].
Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al
. Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia. Radiology 2020:200370. doi: 10.1148/radiol.2020200370. [Epub ahead of print].
[Figure 1], [Figure 2]