|Year : 2021 | Volume
| Issue : 1 | Page : 53-57
Pediatric intensivists' perspective on managing adult critically ill patients during coronavirus disease-19 pandemic
H Michael Ushay1, Shivanand S Medar1, Pooja Nawathe2, Pavanasam Ramesh3, Giovanna Chidini4, Manu Sundaram5, Utpal S Bhalala6
1 Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
2 Cedar Sinai Medical Center, Los Angeles, California, USA
3 Department of Pediatrics, Pediatric Intensive Care Unit, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
4 Terapia Intensiva Pediatrica, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Via Della Commenda, Milano, Italy
5 Department of Pediatrics, Sidra Medicine, Weill Cornell Medicine Qatar, Doha, Qatar
6 Department of Pediatrics, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio, Texas, USA
|Date of Submission||27-Oct-2020|
|Date of Decision||07-Nov-2020|
|Date of Acceptance||18-Nov-2020|
|Date of Web Publication||08-Jan-2021|
Dr. Utpal S Bhalala
Department of Pediatrics, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio Texas
Source of Support: None, Conflict of Interest: None
The novel corona virus pandemic has stretched health-care systems globally. In parts of countries such as USA, Italy, UK, and Spain, the adult health-care system has been overwhelmed by the sheer volume of patients requiring hospital admissions. Learning from other countries that have earlier peaks, various health-care organizations came up with plans providing guidance on preserving the functioning of health-care system in anticipation of a public health crisis. Coronavirus disease (COVID-19) has been less severe in children, and fewer children have required pediatric intensive care unit (PICU). For this reason, the surge plan to care for high number of critically ill adult patients with COVID-19 was to use PICU. There are various models on how to care for these patients in the surge capacities in the PICUs. We, hereby, reflect on our experience of managing the critically ill adult patients in PICUs in USA, UK, and Spain.
Keywords: Adult, COVID-19, critically Ill, pandemic, pediatric intensivist
|How to cite this article:|
Ushay H M, Medar SS, Nawathe P, Ramesh P, Chidini G, Sundaram M, Bhalala US. Pediatric intensivists' perspective on managing adult critically ill patients during coronavirus disease-19 pandemic. J Pediatr Crit Care 2021;8:53-7
|How to cite this URL:|
Ushay H M, Medar SS, Nawathe P, Ramesh P, Chidini G, Sundaram M, Bhalala US. Pediatric intensivists' perspective on managing adult critically ill patients during coronavirus disease-19 pandemic. J Pediatr Crit Care [serial online] 2021 [cited 2021 Jan 26];8:53-7. Available from: http://www.jpcc.org.in/text.asp?2021/8/1/53/306485
| Introduction|| |
Novel human coronavirus (SARS-CoV-2) and its associated disease (COVID-19) was pronounced a pandemic by the World Health Organization in March 2020. Globally, the COVID-19 pandemic has resulted in more than 5.3 million confirmed cases and more than 340,000 deaths. In a very short span of time, an overwhelming number of adult critically ill patients have created an uncontrolled situation within a large number of health-care systems across the globe. A growing need for managing a large number of adult critically ill patients has created an imbalance with demand and supply of health-care resources. A good number of hospitals have been put in a situation, in which they have converted either entire or a part of pediatric intensive care unit (PICU) to an adult intensive care unit with the PICU team managing adult critically ill patients and limited literature to this effect has been reported.,, We, hereby, describe the pediatric intensivists' perspective on managing adult critically ill patients during COVID-19 pandemic with the hope that the lessons we learned will help our colleagues and us during the current and future pandemics and similar situations. We, the pediatric intensivists from either side of the Atlantic Ocean got together, shared our experience of managing adult critically ill COVID-19 patients in our PICUs and learned that surprisingly enough, a lot of our experience was very common. We, hereby, describe and share our experience with managing adult critically ill COVID-19 patients in our PICUs with the rest of the intensive care community. The Institutional Review Board (IRB) of Baylor College of Medicine (primary institution of the senior and the corresponding author, UB) reviewed the IRB application (H-47999) of the proposed perspective and waived the need for approval.
| Anticipation and Preparation|| |
The world watched a local epidemic and banked on the illness being contained. With the spread of the pandemic, some countries learned from countries that had earlier peaks. Various health-care organizations came up with surge plans, provided guidance on preserving the functioning of health-care system in anticipation of a public health crisis. The surge plans during this pandemic were highly dynamic and required frequent updates and clear communication of changes. In anticipation, adult guidelines and practices were shared with the pediatric colleagues. Simulation on donning, doffing, proning the patients, and managing cardiac arrests were carried out in the PICUs accepting adult patients. The large amount of teaching resources from the various intensive care society and sharing of experiences from medical teams all over the world has been very helpful.
| Applying Principles of Pediatric Critical Care to Adult Critically Ill Patients|| |
This has been an opportunity to combine our knowledge of pediatric critical care with principles of adult critical care. In many ways, we are very similar, but this historic event has given us an opportunity to reflect on what we may do differently. For example, we have become extremely consistent at comparing PaO2/FiO2 ratios (from adult critical care medicine) and have also been using oxygenation indices much more consistently than we did previously (more a part of pediatric critical care medicine). We are making decisions on these values rather than just reporting them as part of rounds.
We have become more checklist-based and consistent one patient to the next since the adult patients with COVID-19 disease are similar. Blood gases and labs are drawn every 6 h, collected and run in batches. Patients are rotated from supine to prone at 4 PM and from prone to supine at 10 AM to have both nursing shifts participate in the workload of position rotation. We created proning teams consisting of nurses, respiratory therapists, and physical/occupational therapists that round and perform the rotations at scheduled times. The decision of which patients to prone is decided at the morning and evening preshift briefs. The aggressive use of prone positioning brings us more in line with the acute respiratory distress syndrome (ARDS) practices of our adult colleagues. We have observed that our adult intensivist colleagues are very evidence based in their practice and adhere closely to ARDS net guidelines.
Fluid management and medication dosing are challenging since many, if not most, COVID-19 adult patients are obese. Our pharmacists and/or adult intensive care unit (ICU) pharmacists have been an enormous help in working out medication dosing. Every patient gets an arterial catheter and a central venous catheter. Unlike in pediatric patients where we give these procedures a lot of discussion, it just gets done for these patients. Patient size makes procedures simpler than in children, but obesity adds challenges. Central line-associated bloodstream infection and catheter-associated urinary tract infection rates, which had been excellent, both increased for reasons that are not yet completely clear. Obesity with deep skin folds, accessing lines from outside of rooms, long duration of both central venous lines and urinary catheters, as well as immune suppression from the SARS-CoV-2 infection itself as well as our selected therapies are all potential contributors.
| Being the “Pediatric Critical Care” Member of a Multiprofessional COVID-19 Team for the Adult Patients|| |
Certain hospitals established COVID teams at the time of the pandemic. Some of us from PICU became a part of the team and assisted with vascular accesses in adult critically ill patients. We conducted simulation sessions, team huddles outside the patient room, ensured adequate sedation and/or paralysis of the patients, and room layout before attempting vascular access to minimize viral exposure. The establishment and execution of this team had an immense impact on offloading the primary teams from procedures and facilitated expansion of the team size as per the Society of Critical Care Medicine guidelines. Several quality improvement initiatives were initiated, such as heparin infusion in arterial catheters, a usual practice in the PICU was implemented in the adult ICUs by the line team due to several arterial line malfunction likely related to the hypercoagulability seen in COVID-19 population.
| Preparing Pediatric Intensive Care Unit Team in Managing Adult Critically Ill Patients in the Pediatric Intensive Care Unit Or Preparing Pediatric Intensive Care Unit Team For Working in Adult Intensive Care Unit Settings|| |
We believe that nurses and physicians adapted extremely quickly to the expanded age range and caring for adult patients. The similarities in managing critically ill adults and children were greater than the differences. We believe that the very critical nature of these patients as well as the overwhelming societal necessity of caring for these patients inspired our nurses, respiratory therapists, physical therapists, unit support staff, and physicians, thus making them very willing to work with this new and challenging patient population. At the same time, we were caring for adult COVID-19 patients we also were admitting pediatric COVID-19 patients, some of whom were extremely ill. On 1 day our youngest patient in the ICU was 2 months and the oldest was 49 years. During our discussion with our colleagues, we learned that in certain hospitals, especially in Europe, all critically ill children were transferred to nearby PICU situated in standalone children's hospital and therefore the PICUs which were converted to adult ICUs looked after ventilated COVID-19 adult patients. In these centers, all the PICU medical and nursing staff received some exposure (2–8 h) in adult intensive care unit before accepting adult patients. This helped alleviate anxiety in managing adults. Nurses also received support and guidelines from their adult counterparts.
In an effort to reduce time in patient rooms to minimize potential infectious exposure as well as reduce the amount of time nurses were in personal protective equipment (PPE), IV pumps were placed outside of rooms with long infusion lines. When possible, ventilator control consoles were also placed outside rooms, thus making ventilator adjustment and monitoring of respiratory parameters easier. This added significant efficiency to care. Concerns about long infusion lines becoming trip hazards and patients becoming trapped in their lines did not become reality.
Rounding when maintaining social distancing presented challenges. Early on, the ICU rounding teams stopped rounding at the bedside and instead rounded away from the bedside, often with only the attending, fellow, and the resident. This rounding technique resulted in our bedside nurses becoming secondary participants in rounds and limiting their input on the patients' conditions as well as being active participants in management planning. In that, the nurses were in full PPE at the bedside of highly infectious patients for prolonged periods of time, some resentment developed. We transitioned back to actual bedside rounds, with appropriate staff spacing and a rounding team that was limited in size. With a bedside nurse often being in a patient's room delivering care in full PPE, flexibility was required on the part of rounding teams who frequently had to come back at a later time when the nurse was free outside of the room. In addition, elective care modifications that required going to a bedside were consolidated to minimize times the nurse or ancillary staff members had to gown up and go to the bedside. These small practice modifications significantly improved staff morale. With the implementation of universal masking and systematized PPE in the PICU, there were no more documented cases of health-care workers becoming infected with SARS-CoV-2 that could be attributed to work in the PICU.
We modified our ICU physician–staffing schedule to accommodate the increased acuity of the ICU and frequent rapid response calls to an adult-filled COVID-19 unit. Our usual schedule of two attending and two fellows during the day and one attending and one fellow on call in house overnight was changed by increasing overnight coverage to two fellows when maintaining one overnight attending. For a 4-week period, our fellows worked 12 h on and 12 h off with 3 days off after 6 days. A backup attending call schedule was created to accommodate for attending that could not work due to sickness. During our discussion with our colleagues, we learned that certain hospitals, especially in Europe, recruited general pediatric consultants who had previous experience in PICU. These general pediatric consultants with some PICU training provided a buffer to the PICU consultants.
| USING Adult Intensive Care Unit Protocols in Pediatric Intensive Care Unit|| |
Since our adult colleagues were dealing with COVID-19 disease for a week or two earlier than us in pediatrics, there were more adult-based standardized treatment and research protocols. We implemented these rather readily, including research protocols for remdesivir and Sarilumab. From an operational standpoint, we used pediatric subspecialty consultants for all patients in the PICU as well as for adult patients with COVID-19 throughout our children's hospital. This placed a significant burden on the subspecialists who were going between pediatric and adult patients and had to adjust research and treatment protocols depending on patient age.
| Working With Multidisciplinary Pediatric Intensive Care Unit Team and Pediatric and/or Adult Consultants and Subspecialists When Managing Critically Ill Adult Patients|| |
As intensivists and knowing that there are a lot of similarities between how we treat critically ill adults and children, it has been fun to work closely with our adult intensive care colleagues. We frequently bounced ideas off of them to make sure we were moving in a direction usual for adult medical practice. There was a lot of collaboration. As noted above, the pediatric subspecialty consultants (renal, infectious disease, rheumatology, and hematology) did much of the interfacing with the adult subspecialists to provide high quality care for patients of all ages in the PICU. A critical care command center was established under the direction of adult critical care medicine. The PICU became a resource for the command center to send patients to as well as a resource for us to review our care plans for adult patients.
| Dealing With Challenges of Multiple Comorbidities in Adult Patients|| |
Very quickly, the “standard” comorbidities of obesity, hypertension, and diabetes became part of the daily parlance. Often, these chronic issues were a little easier to manage in critically ill patients where oral medications could be transitioned to IV infusions. Furthermore, it was common for PICU medical and nursing staff to struggle initially with interpretation of “normal” adult vital signs such as heart rate and blood pressure (BP). For example, we would be more worried if the BP went up to 150 systolic which may have been completely normal for a 60-year-old adult. However, we learned to “accept” these values as normal very soon.
Additional and unexpected challenging comorbidities were intellectual disabilities such as Down syndrome, profound autism, and psychiatric diagnoses such as bipolar disorder. Many of the younger adults who were triaged to our unit had these comorbidities, which presented several challenges, especially with respect to coming off of high doses of sedatives and working toward extubation and postextubation behavioral management. We found a surprising paucity of published information about this patient population in the intensive care setting. Several of the adult patients we cared for were profoundly intellectually disabled and often group home residents. We worked closely with our psychiatry colleagues in devising pharmacologic strategies for patient management.
| Dealing With Drug Dosing in Adult Critically Ill Patients|| |
This was a challenge that was exacerbated by the severe obesity that many, if not most, of our adult patients manifested. Some drugs were dosed for ideal weight, some for actual weight (for example, enoxaparin), and others at a fixed dose. We also had to move to more of the mcg/min dosing typical in adult patients for norepinephrine, rather than the mcg/kg/min dosing we are more accustomed to in pediatrics. This required adjustment of drug libraries in our smart pumps.
A greater pharmaceutical challenge was the frequent shortages of agents. Fentanyl and morphine were frequently in extremely low supply or nonexistent. We used more hydromorphone than usual, a lot of enteral methadone and fentanyl patches as ways to overcome shortages of opiate analgesic medications. Neuromuscular blockade was necessary for many of our adult patients, and insufficient supplies of rocuronium or vecuronium were common. We transitioned a number of patients to atracurium. Shortages seemed to develop quickly creating a need for rapid medication transitions and a lot of creative pharmacology. When discussing with the colleagues, we learned that the drug shortage was not an issue with most European ICUs.
The infectious nature of stool with SARS-CoV-2 made us very reluctant to use full enteral feeds in an effort to avoid frequent large volume stools. We used minimal caloric intakes and low residual formulas. We did not use Total Parental Nutrition (TPN).
| Dealing With Family-Centered Care in Adults|| |
This was an enormous challenge. Visiting was very restricted, and no visitors were permitted for adult patients. Pediatric ICU attending and fellows had very difficult goals of care discussions at a much higher frequency than usually seen in pediatric critical care practice. It was a challenging experience for us to have a conversation with a patient who was asking not to be intubated when they were in respiratory failure. Our social workers, faculty members deployed to a family communication team, and our palliative care team played an enormous role in reaching out to families on a daily or more frequent basis to update them on their loved one's condition. When discussing with European colleagues, we learned that in their ICUs, they had to deal with such challenges themselves. On reflection, we treated some of the adults and their families like children, which was sometime hilarious, but everyone appreciated it.
| Dealing With End of Life Care in Adults|| |
Dealing with the end of life care in adults was extremely challenging. The pediatric palliative care team was expanded to deal with end of life issues. Patients were very aware of the very high risk of mortality that was occurring in patients that were intubated and made very difficult decisions based on this information. Knowing that there was a very high chance of renal failure with intubation, patients made informed decisions whether or not to receive dialysis or renal replacement therapy. Some patients expressed a desire for a time-limited trial of mechanical ventilation and when not better at the agreed upon time, were extubated in accordance with their wishes. This was very difficult for our staff. Much more than we are used to in pediatrics, the importance of goals of care discussions cannot be overstated.
| Size Does Matter–Everything, Including Patient Size, Endotracheal Tube Size, Is Big and I Don't Know How to Prone Them|| |
We adjusted. The nurses and therapy staffs that formed the proning teams cannot be complemented enough. They did it twice a day for weeks on end. It was tough duty with a very high risk of infectious exposure. There were few events. The sizes of the patient were shocking.
Early on, in an effort to ensure to the best of our ability that tracheal intubation went smoothly with a high rate of first attempt success, the decision was made for anesthesia to perform intubations on adult patients in the ICU and on the COVID-19 adult floor. Intubations were done by the ICU staff with videolaryngoscopy and maximal PPE protection.
In short, from the recent COVID-19 pandemic, we, pediatric intensivists learned how to work as a team in quickly adapting to a big change and manage patients bigger in size and older than our usual comfort zone. We very well learned that “Adults are NOT Big Children.”
Our experience from various parts of the world affirms that PICU staff can adapt to the needs of critically ill adults very quickly in an emergency situation. The critical care community should take this experience as an opportunity to redesign future critical care facilities across various health-care facilities, so that critical care resources are utilized in a better way. In long term, this practice will also enable the PICU staff to care for adults more efficiently in the event of a future pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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