COVID-19: A View from the Scottish Critical Care Frontline (March 2020)

So what we’ll do is move on to our next talk. And I can see that our next speaker is there. So hopefully, we’ll get pictures and sound from Dr. Gregor McNeill. He’s a consultant in intensive care medicine, again, here in the Royal Infirmary of Edinburgh. And he’s also the advanced critical care practise lead for NHS Lothian and deteriorating patient lead for NHS Lothian. And his talk was designed really to dovetail with David, who will come back to at the end, again, about aspects of critical care of patients with COVID-19. So Gregor, over to you. Thank you very much. Thank you very much. And again, thank you very much for the opportunity to speak to you all tonight.

And it’s very heartening to hear some similarity to our experience in Edinburgh and that of Brian’s across the water in the United States. So what I’m going to do is really, hopefully my talk will compliment that of David. David’s going to talk about some of the higher level research aspects and trial aspects of COVID-19. I’m really going to give you a view from the critical care trenches based on what we’ve experienced locally in Edinburgh over the past three weeks. I should say we work very closely with colleagues on the wards and also in primary care in terms of our joined up approach to tackling on the pandemic.

I’m going to touch on our organisational response, our clinical response, and as we go forward, where I see our organisational response going and also the clinical care of this increasingly large patient group. So if you look at a clinical timeline, it was really on the 3rd of March when I was working clinically in our sister hospital in Edinburgh, in the Western General, in the intensive care unit that we were aware of the first patients coming into the regional infectious diseases unit in the Western General who were with COVID-19. These patients were generally well and did not require oxygen at that time.

If we scroll forward a week, at that time, the patients that were in the infectious disease unit were starting to become sick. And it was at that time that we needed to intubate our first patients. Scroll forward a further week, and patients were presenting de novo into the Royal Infirmary, and they’ve been cohorted in a cohort ward in the Royal Infirmary. And they were developing slowly, slowly an oxygen environment and also requiring intubation. And really, from the 17th of March onwards, we’ve seen a constant stream of patients deteriorating, requiring intubation at the Royal Infirmary of Edinburgh. And since this last weekend, we’ve seen this change.

Rather than patients coming into hospital early and slowly deteriorating, particularly since the UK government lockdown, we’ve seen patients presenting much later in extremists in the emergency department with severe hypoxia requiring almost immediate intubation and escalation to critical care. And this is where we start to see additional cardiovascular instability, tachyarrhythmias at the time of this presentation. And again, I would echo Brian’s comments. This is all based on a series of anecdotes that is not– it’s not data. And what I’m saying to you know is what we see at the time. And again, we may know more in the coming days, weeks, and months. At the same time of that clinical picture, we were really ramping up our response organizationally.

Prior to March, we’ve been looking at a lot of our PPE provision, state testing masks, et cetera, et cetera. And as the patients rolled into the door, we were really working to focus on our SOPs about how we would intubate these patients, how we would transfer them. And certainly on the 3rd of March, with our first patients coming in, we developed these SOPs and how we do that. We learned a lot by intubating our very first patient in terms of how we did that. We also learned about how we managed those patients.

Initially, with our response, we envisaged moving our patients from the infectious disease unit at the Western General to our ICU at the Royal, really, because of our high number of negative pressure isolation rooms at the Royal site. We had to really change that really due to complexities of transferring these patients. And that initial transport took upwards of seven to nine hours. And since then, we’ve managed to cohort these type of patients presenting to the Western General in the Western General ICU. And that’s been reasonably successful. As of the 17th, when patients started to arrive at the Royal Infirmary, we also looked at how we were going to expand our ICU. We had long held embedded pandemic plans.

As with everything, it’s not really until you roll out these plans that you work out the small change of it. So we rapidly looked at doubling our ICU capacity. And really of this week, we’re firming up plans of how we would cope as we fill our ICU capacity our ICU capacity as per government guidance to deal with the influx of these patients. And I’d like to just talk a little bit more about our pandemic plan and how the specifics of that relating to COVID-19– the difficulty of transfer to PPE. So PPE, as you heard in the instruction, is a key issue for all health care providers globally.

And certainly one of the challenges we had at the start of this dispute in March was a different guidance across the UK. It was very useful that all the UK health protection agencies really two weeks ago came together to give us one unified guidance. And that allowed us to really give a clear message to our staff on the ICU floor about what we need to do with their PPE. We looked very closely at stock levels and at fit testing. And we’ve worked very, very closely with the Scottish government to maintain that. We have had challenges. But we continue to work through those. The other thing we’ve looked very closely at are protocols.

And we’ve really focused on what we need to do in terms of protocols. Prior to the ICU, there was a real focus on a good anticipated care planning. There were also protocols about how we manage these patients when they arrive in the ICU. Many of these things are really focused on dealing with severe hypoxia that we’re seeing, but also reducing droplet spread and aerosolization at the time that we are intubating these patients. We are quite fortunate at the Royal Infirmary that we do have a large number of ICU beds that were not currently being used at the start of this outbreak.

This is primarily because we were looking into this year to move some of our services from the Western General hospital to the Royal Infirmary. Now that hasn’t happened, but that’s given us an advantage. And it would be relatively straightforward for us to expand our footprint rapidly. But even given that, we’re still looking to expand our capacity beyond into a non-ICU area, such as general theatre recovery areas. In terms of staffing again, we work very hard and closely with our anaesthetic colleagues to upskill them to come back to ICU so we can really expand our ICU provision. And that goes for nursing staff as well and AHPs.

And we are currently upskilling a large number of these staff members from other areas to deal with the ICU going forward. The clinical response. So that has been interesting. And I would echo many of the points that professor Hill has made. Certainly over time, we have seen a change. We know these patients who get relatively slowly hypoxic. And we saw that in the initial weeks this month, a patient coming into a hospital early will very slowly become hypoxic. And that allowed us to plan how and when we admitted them to critical care.

But as I’ve alluded to already, that has changed in the past week since we’ve seen a large volume of patients coming in a different state, often severely hypoxic from the get-go. And that’s meant a lot of our focus has been seeing patients in the emergency department more recently. And again, I’m not going to dwell on this too much. But certainly, there are the features of the classic presentation of COVID-19. We have also seen increasingly over the past couple of days tachyarrhythmias, chronic instability.

We’ve also seen a large number of patients being picked up in roundabout ways, certainly patients presenting with acute appendicitis, going for a CT scan, and that CT scan showing a classic appearance on COVID-19 has already been discovered. And that’s a challenge of what we do with those patients and what we do with that diagnostic information. This is very much our own very limited experience of upwards of over 10 cases. But certainly, we are seeing that the vast majority of our patients, as described in the international literature, are male, are relatively elderly, although we have a reasonable number of patients in their 50s in the ICU at the moment. But they have hypertension. And they have diabetes.

We are also seeing one or two few patients with no documented form of liquidity. From the national and international data, we would echo that we’re not seeing children who are severely unwell. Just a point about pregnant women– I think David may talk about this more– the data from Italy suggested they were not being affected. But in our most recent audit report from NHS England in ICUs, there were a small number of patients who were in the postpartum period who required critical care admission. And that’s reflected in the next slide. Again, that data also suggests, which is why they’ll report in the media that the current centre of activity in the UK is around the London region.

And again, I’m not going to ask too much. Suffice it to say, the vast majority of patients that we’ve seen so far, it’s that leucopenia that we’re picking up. We are interested in other measures that may predict outcomes such as D dimer or where they maybe come in with a second diagnosis such as SIRS. And a clear message on testing, we, in common with other centres have found If the patient’s got a good going story of ARDS, hypoxic and respiratory failure, once we intubate those patients and get a deep tracheal sample, then the testing has come back as positive. And I’m not going to go over in detail the information we got in chest x-rays with a CT.

Suffice to say, though, I would echo what Brian said in that we found ultrasound bedside also and very, very useful and does give a characteristic appearance and we are in common with colleagues at Hopkins, rolling out that expectance in terms of diagnostic critical care ultrasound to deal with these patient loads. CT scanning is difficult for technical reasons in terms of logistics. And it’s not something we do routinely here at Edinburgh. When we do pick it up, we have seen imaging very similar to this, as described by Italian colleagues. And again, that CT imaging can be patchy as this disease progresses with a similar chest x-ray appearance.

So in terms of the ward management– and this is very much what we were trying to focus on in the Royal Infirmary of Edinburgh– oxygen, watch for deterioration. But the key thing at admission to hospital we feel is anticipatory care planning. Is this patient going to benefit from critical care? And can we decide that at the front door? We feel this is key.

So and this is a Clinical Frailty Score that we have used reasonably broadly in critical care. But that score of Mild Frailty is really what we’re looking at. How we incorporate that into our clinical assessments can be shown in the algorithm on the next slide. So really, if the patient displays a frailty greater than five, that should prompt an early discussion about the patient’s wishes. Clearly, in difficult cases, you should involve your critical care colleagues. And given the volume of cases that we’re expecting, it’s very good to be as proactive as possible. Now there’s a lot of debate. And we have a National ICU group that we’re actively talking about that’s in the UK about when we escalate patients.

But certainly, in patients starting critical care, I would echo comments of professor Hill that we’re not using high flow oxygen therapy. We don’t know about NIV. We’ve not used that so far. There is also some debate about non-invasive CPAP. But certainly, if the patient is for full ICU escalation, we want to get these patients early and intubate them early. And if the patient is requiring more than than about 60% low-flow oxygen, we really want to be assessing these patients and potentially escalating them to critical care. And often the respiratory rate can be falsely reassuring. I use NEWS 2 a lot when I’m assessing patients on the ward. We have rolled out in NHS Lothian.

I’m not sure about its use in COVID-19. And we are hoping for national UK guidance from the ICU community on that. When a patient arrives in the ICU, we place an arterial line to monitor blood pressure and gas exchange. And we’ll generally, so far in the Royal, proceed to intubation if the patient continues to require 60% or more oxygen therapy.

Certainly, we see desaturation in these patients if we wait much longer. And we found a way of a rapid sequence induction for these patients to minimise droplet spread and combat desaturation. How we do that? Well, you can see the link to our Royal Infirmary simulation video on the screen there. And that shows you how we do that in Edinburgh, which is in common with many of the other ICUs across the UK and internationally. The key about that, the protocolized way of intubating the patients is to really focus on your own PPE, so you keep yourself safe. We make our plans and checklist prior to entering the room with all our kits available.

Then we do a good five minute preoxygenation to avoid a desaturation. If we can, we’ll avoid bagging these patients prior to intubation. Often we’ve had to, because they’re– of their level of instability. We use a video laryngoscope, so we can intubate as rapidly as possible. And we also use tube clamps. We don’t normally use it intubation when we’re changing circuits over, again, to prevent– to minimise as much as possible droplet spread. It’s key then for our information team to focus on their doffing PPE at the end of the procedure. We haven’t done a lot of bronchoscopy. And this slide is taken from colleagues in China. But the oedema and swelling seen with COVID-19 is profound hypoxia.

Compliance is roughly about the same. They do not have high peak pressures. I’d echo that find that Brian has mentioned. But they do require high peak to preserve oxygenation. We manage these patients with relatively high peak using standard lung protective methods that we use for anyone with ARDS in ICU, limiting peak pressure and also limiting tidal volume to 6 mls per kilogramme ideal body weight. As they’re on the ventilator, we do see a degree of cardiovascular instability. That has been described by colleagues in China and also Italy. These patients on the whole are very proning responsive. And that allows us to access the exterior lung units well. And certainly, we will do that.

I would echo the comments previously about doing that early when the PF ratio goes less than 20 using kilopascals.

We keep the patients prone for 16 hours. And as part of our organisational response, we’re already looking about developing proning teams in our ICU, so we can one, effectively prone these patients, and two, make good use of our orthopaedic surgery colleagues. There’s been a lot of discussion about ECMO. And certainly in the UK, we have five ECMO centres and one satellite centre up in Aberdeen.

Often, COVID isn’t quite bad enough to require ECMO. The hypoxia is bad, but it’s not as severe that we might think about ECMO. But it is being used. Currently as of this week, I think there was around nine patients in the UK on ECMO who are COVID-19 positive. And certainly, we in Edinburgh have some experience with ECMO. We use ECMO mainly in the venoarterial ECMO setup on the left. There’s a panel there. We use that for providing cardiogenic shock, cardiotoxic overdoses, and hypothermia. The panel on your right, VV ECMO is really the setup used for severe hypoglycemia, where venous blood is drained and returned to the right internal jugular vein after going through an oxygenator.

And the international ECMO organisation, ELSO, have published a guidance on this this week. And really, if you look down on the left side of this tree here, you’re about talking about pretty severe hypoxia, when we should be referring these patients. So level two of around seven or eight on 80% to 90% on a ventilator after all other strategies have been instituted. Our own local centre here in the UK, currently Scotland is supported by Glenfield Hospital has given us clear guidance on that. And you can see that really the group that may benefit is small. If less than 70, be on a ventilator for five days or less. And beyond that, the usefulness of therapy is not clear.

We’re very fortunate in Scotland in that although there are five ECMO centres in England, our own ECMO centre is very soon coming online up in Aberdeen. They have a long history of acting as a satellite centre for ECMO. And it be a great benefit to us, I’m sure, as the pandemic develops to have their ECMO centre fully running. In terms of weaning off the ventilator, well, in terms of our own local experience, we don’t know. But our impression is that these patients are going to be on the ventilator for a long time. They’re taking a long time to get better, and expect many of them will require a tracheostomy to wean off the ventilator. And it will be slow.

These patients will all have complications that a prolonged ICU stay gives you, including weakness, and delirium, and other complications. One thing I would like to emphasise, and as with other colleagues, is the need for robust protocols for PPE. Whatever we do as caregivers and clinicians, we need to stay safe and use our PPE appropriately. And whatever you do, in terms of your interactions with these patients, you should follow carefully your local guidance. So I’ve taken you through our organisational and clinical response. And I’ve given you a flavour of where we see this pandemic going locally, in terms of our organisation and also clinically. I’d be very happy to take some questions.

Well, Gregor, thank you very much indeed for such a comprehensive talk. We had a wee glitch in the middle when you were stressing the importance of anticipatory care planning, or advance directives. And I couldn’t agree with you more about that. And I guess that we’ll be seeing more of that in the community as well, rather than just simply waiting until the patient comes up to a hospital. We know that the volume of net traffic is such at the moment that these kind of drop outs are happening more than they usually do. But I suspect everything that Gregor said will be recorded on the recorded version that will be on the website. There’s a lot of questions, many with common themes.

So one specific one here is in Singapore I hear that they are avoiding nebulizers, because of higher risk of transmission to health care workers. What are your thoughts on this?

Yes, I mean, I think we are doing that too. We’re certainly considering carefully the needs of nebulization. And I think we still our usual practice in hypoxic respiratory failures, we use a lot of high-flow oxygen as well. We have two concerns about that, risk of droplet spread and aerosolization, but also as the pandemic develops, the amount of oxygen the therapy uses. So we are trying to be very careful about anything that will generate aerosolization. OK, and again, a lot of questions about ultrasound. And Brian Garibaldi touched on that as well. But I think people are asking really what specific features are you looking for, or finding, or finding most helpful?

And again, this is– we’re feeling our way on this. I would say anything I say on this with a pinch of salt. But certainly in common with colleagues in China and Italy, when we have these patients on the ICU floor, we are seeing a characteristic appearance consistent with the ARDS with B lines at the base of the lungs. There is some evidence that these oft sudden changes can be seen while the patients are well. I’m not sure about that, certainly when we’re going to see referrals we were also– often taking that machine to have a look, and to have a look at the lung appearance. So it’s interesting. And then certainly the logistics of doing a CT are very challenging.

The point of care ultrasound is very valuable whether we’re looking for those characteristic changes, or indeed making sure the patient hasn’t developed complications, such as pneumothorax or secondary bacterial infection with consolidation. OK, another common theme is on the value of proning. Specific question here saying that you’ve talked about the volume of proning, as Brian Garibaldi did, in intubated patients. But is there any value in patients earlier in the course of the disease, you know, say in a level one medical type ward?

I don’t have data on that, but it is described, and it is being actively discussed within ICU community here in the UK. And I understand that it is being used in a number of locations across the world. And colleagues in Canada have been using that, but I don’t know. It’s not something we’ve tried locally. OK, and any local data or knowledge from your reading about nosocomial spread of– or hospital acquired COVID infection, or in any particular measures that are being taken here in Edinburgh to try and limit that?

So I think that’s very challenging. We are seeing patients in our non-COVID develop symptoms. And it is a challenge to move those patients around the hospital floor. Here in Edinburgh, we are in advanced stage of planning to separate the ICU in terms of having a floor with COVID patients, a floor with non-COVID patients. That’s a huge challenge. And it’s going to get more difficult over the coming weeks. OK, and finally, I mean, it’s still I guess relatively early on in the course of all this here in Edinburgh. But what are you seeing at the moment in terms of, or can you comment at all on survival rate for those who end up being ventilated?

It is too early to call. I mean, many of our patients, they do have comorbidities, but these are comorbitities, such as hypertension, diabetes that are not necessarily limiting a patient’s activities in any way at normal times. So we would hope, and if we can keep the health care system going, that we would be able to liberate these patients from invasive ventilation. But they are going to be very weakened by their illness. But it’s going to take time. Too early. OK, well, Greg, I just thank you again. I know you, like everybody else, as I’ve commented, is extremely busy. And we’re very grateful to you for giving up your time. Thank you very much.