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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 7  |  Page : 36-41

Pediatric intensive care management in coronavirus infection-19


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 Submission01-May-2020
Date of Decision06-May-2020
Date of Acceptance13-May-2020
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Arun Bansal
Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_77_20

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  Abstract 

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 Jul 9];7, Suppl S1:36-41. Available from: http://www.jpcc.org.in/text.asp?2020/7/7/36/285383




  Introduction Top


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.[1]


  Epidemiology Top


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.[2] The transmission is mainly through droplets, fomites and to a lesser extent through airborne mode.


  Pediatric Coronovirus-19 Disease Top


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).[3],[4],[5] 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.[6]


  Intensive Care Unit Needs in Coronovirus-19 Disease Top


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.[7] 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 Top


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 Top


Definition

Child presenting with cough and difficulty in breathing or tachypnea with one of the following:

  1. Hypoxemia (oxygen saturation [SpO2] <90% or central cyanosis)
  2. Severe chest indrawing or grunting
  3. Danger signs such as altered sensorium, poor feeding, convulsions as per WHO definition of severe pneumonia.[8] Monitoring: Clinical monitoring, including heart rate, respiratory rate, invasive/noninvasive blood pressure, and continuous pulse oximetry at least every two hourly.


Investigations

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.

Respiratory support[9],[10],[11],[12]

  1. 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
  2. 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
  3. 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
  4. 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.[13] Invasive mechanical ventilation strategies for children with COVID-19 are along the lines of management of pediatric ARDS (PARDS) [Figure 2].[14] 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).[15] 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
  5. 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[10],[16]
  6. 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[7]
  7. 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[7]
  8. Acute liver failure, coagulopathy, and disseminated intravascular coagulation (DIC): These are managed conservatively with blood component therapy as necessary
  9. 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[17]
  10. Supportive care:
  11. Table 1: Contents of Intubation tray, drug tray, and intubation trolley

    Click here to view


    1. Early enteral nutrition: Enteral nutrition should be started within 24 h and full feeds established by 48 h if there are no contraindications
    2. 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
    3. Antibiotics: Co-infection with other viruses and bacteria have been observed within 72 h of ICU admission.[18] 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
    4. 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.[19],[20]
    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

    Click here to view
    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

    Click here to view


  12. 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[21]
  13. 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.[22] The mortality is as high as 60% in critically ill adults.[7]


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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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.  Back to cited text no. 12
    
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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].  Back to cited text no. 13
    
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Gattinoni L. COVID-19 pneumonia: Different respiratory treatment for different phenotypes? Intensive Care Med 2020. doi.org/10.1007/s00134-020-06033-2.  Back to cited text no. 15
    
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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.  Back to cited text no. 16
    
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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.  Back to cited text no. 20
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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].  Back to cited text no. 22
    


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