Coronavirus Intensive Care Unit

The first time I heard about the word ‘Intensive Care Unit’ was when I was about 15 years of age. One of my friends informed me that he had to rush to the ICU as his brother was admitted in the ICU of Jubilee Mission Hospital, Thrissur, India. His bother developed coma after continuous vomiting on drinking alcohol. At that time he was being treated for alcoholism with Disulfiram (Antabuse) medication. After a week, the ICU doctors thought his brain was dead, and suspended all life support. From then on I was keen to know more about the patients in the ICU. I worked in cardiac surgery in Cardiac Centre at Cottingham, Yorkshire where 3-4 open heart operations were done daily. There I was a doctor in charge of the ICU, looking after post operative cardiac patients. Sometimes after the extubation(removal of endotracheal tube), patients cannot retain blood oxygen level, and then I need to intubate again and re-introduce an endotracheal tube to be connected to the ventilator. Those days, I was also good at getting subclavian vein central line under the clavicle for intravenous fluid administration. At times these patients on ventilation did not recover fully within a fortnight, then I had to to do a tracheostomy, to protect larynx and trachea.This also helps the nursing staff to clear secretions from the respiratory tract. The above involvement helped me to research more on the intensive care unit in order to write this blog.

Management of  Covid-19 patient in the ICU is only life supporting, and not a cure for the coronavirus infection. ICU is less effective for patients with Covid than for other types of respiratory failure. Most patients suffering from Covid are taken into intensive care unit because of difficulty in breathing as a direct consequence of virus affecting the lungs. The clinical features are laboured fast breathing, feeling of suffocation and incessant cough. This is evidenced by low partial pressure of oxygen, increased carbon dioxide and inability to maintain arterial gas even with high concentration of oxygen breathing. The research shows that about 50% patients admitted in the ICU require ventilation and 35.7% of the admitted patients in the ICU succumb to the virus. Looking back, we know that the prime minister, Boris Johnson just managed not requiring ventilation in the ICU.

There will be one to one trained ICU nurses, working in 8 hour shift in the ICU. The The doctor will be normally a specialist in anaesthesia and will be available at site 24 hours. In the ICU, all staff must wear personal protective equipments (PPE), which consist of wearing N95 respirator or face mask, an extra gown, gloves, goggles, and a visor.Despite these scrupulous measures, it is reported that a lot of healthcare workers were getting Covid. Medical interventions are frequent, invasive and performed at close proximity of the patient. Therefore contact with the body fluid is inevitable. In addition to doctors and nurses, physiotherapists, dieticians, laboratory technicians, and radiologist are involved in the care of the patient in the ICU.

Prior to discussing the management of a Covid patient in the ICU, I would like to familiarise the readers with the standard equipments and devices in the ICU. There are 4 types of ICU, they are: medical including coronary care, surgical including cardiovascular and trauma, neonatal and paediatric. Each ICU varies from 3- 18 bedded cubicles whose entrance width is 2.4 meters.High dependency units (HDU) are slightly less equipped and having fewer nurses than the ICU. In the UK there are 5900 critical Care/ICU beds and it comprises normally 12% of total hospital beds. Each cubicle should have hand washing and scrubbing facilities.Each cubicle with a bed should have the following equipments which can be either therapeutic or diagnostic in nature;

1  Patient  monitoring system  Used for continuous monitoring of clinical parameters of patient, showing blood pressure, pulse, respiratory rate,temperature and arterial blood gases.

2. Ventilator system. This machine provides mechanical respiratory support to critically ill patient. This needs intubation, and oxygen availability. Once on mechanical ventilation, the patient is sedated.

3. Syringe pump. This device is used for delivery of medications in a controlled manner. There will be central venous line or peripheral venous line access.

4. ECG machine . This is for printing ECG of the patient onto a graph paper.

5. Defibrillator. This is for delivery of electrical stimulation to heart of critical patient with ventricular fibrillation or cardiac arrest.

6. Mobile X ray machine to get image of chest, abdomen and limbs 

7. Ultrasonography machine. This is for scanning muscles, vessels, internal organs and abscesses.

8. Suction pump. This is to aspirate fluid and secretions from respiratory tract and  stomach, to avoid choking and asphyxia.

9. Arterial blood gas machine (ABG). This is for analysis of partial pressure of oxygen, carbon dioxide, pH, bicarbonate.

10. Intubation devices and tracheostomy set up. Naso-gastric tube and urinary catheter and Sterilization fluid.

Basically, the ICU patient needs advanced respiratory support requiring intubation with endotracheal tube. Since endotracheal tube cannot be left in the trachea and larynx for longer period a tracheostomy is normally done after two weeks. Prior to be on the ventilator, the patient should try 40% oxygen via a mask, physiotherapy and two hour aspiration of secretions. If the patient is connected to mechanical ventilator, the breathing is taken over by the machine. Then the patient should be given sedatives, so that he/she will not fight against the machine.Cardiovascular support consists of administering vasoactive drugs to stabilise hypotension, intravenous fluid to replace body fluid volume, and drugs to regularise cardiac rhythm. There will be a venous access for drawing blood for various tests. Neurological support is to check reflexes, evaluate the effect of sedative drugs and muscle relaxants. Renal support includes catheterisation of urinary bladder, sending urine for culture and sensitivity and haemodialysis. Measurement of urine passed and its biochemistry are very significant in assessing the improvement. In addition, the nurses need to feed the patient through a naso-gastric tube, to take care of bowel, skin and eyes. 

Once the vital signs such as blood pressure, respiration, pulse, temperature, arterial blood gases are normalised, the infection is subsided, the endotracheal tube is removed and the patient becomes conscious, then the patient will be transferred to a ward exclusively for patients recovering from covid-19. Prior to the discharge, hand over should be done scrupulously and all the drugs are to be continued. Multiple organ failure is the commonest cause of death in the ICU followed by cardiovascular,respiratory and renal causes. Should the patient die, the staff ought to notify the general practitioner, and relatives. The corpse ought to be covered and transported in such a way that contamination is minimised. Patients are known to occupy the ICU as long as one year, and have surprisingly come to life with some disabilities due to scarring of lungs. A good number of  the patients admitted in the ICU recover in 48-96 hours. Elderly patients, patients with chronic conditions like diabetes, stroke, hypertension and chronic obstructive pulmonary disease (COPD) succumb to the illness more often than younger patients.

  I have written this article with particular reference to the system in the National Health Service (NHS). The cost to treat a patient with mechanical ventilation is £8432 ($10794) per day, and without the ventilation it is £5209 ($6667) per day as given by an American literature. The rate will come down, if the patient occupies longer period. Working in the ICU is stressful to both nurses and doctors, not just because of the wearing of the PPE and other restrictions, but because of the poor outcome in the ICU. The only game changer for the present status will be an effective vaccination. The media report that certain group of people are not adhering to the regulations and the long arm of enforcement seldom take action. Boasting that “I do not mind dying of Covid-19 rather than existing” does  not wash, as he/she helps communal spread of Covid-19 and drains away NHS resources. If the exponential escalation of coronavirus continues, all the ICU beds will be occupied.