• Users Online: 2214
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 16-23

Critical care preparedness and conduct in COVID-2019 crisis

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission13-Aug-2020
Date of Decision08-Mar-2021
Date of Acceptance17-Mar-2021
Date of Web Publication24-Apr-2021

Correspondence Address:
Manoj Kumar Sahu
Department of Cardiothoracic and Vascular Surgery, CTVS office, 7th floor, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_79_20

Rights and Permissions

Background: COVID-19 pandemic has stirred an unexpected turmoil in health care worldwide. The strategic conduct of critical care would warrant an effective preparedness plan, thorough knowledge of the disease manifestations, and relevant therapeutic strategy to sail through this crisis. Methods: English medical literature with MeSh database was searched using the key words such as “COVID-19 pandemic,” “ICU preparedness,” “COVID-19 management,” “COVID-19 therapy,” and “COVID-19 systemic effects.” The relevant studies were included with significant inputs from interdepartmental meetings for the formulation of a plan. Results: The analysis of the respective studies highlighted the requirements of COVID-19 designated intensive care units (ICUs) with special provisions and the therapeutic agents being used in critical patients with emphasis on Remdesivir, Dexamethasone, Convalescent Plasma, and insight into newer agents. The systemic manifestations of COVID-19 requiring ICU care such as acute respiratory distress syndrome, myocardial injury, arrhythmias, hypercoagulable state, and acute renal dysfunction have been highlighted. The need of updating records with research protocols cannot be disregarded. The care of patients should not compromise the health-care personnel requirements. Conclusion: The evidence-based preparedness strategy can curtail the critical care crunch in COVID-19 management; however, institutional specific approach should be formulated.

Keywords: COVID-19 current treatment, COVID-19 pandemic, intensive care unit preparedness, personal protective equipment, reverse-transcriptase polymerase chain reaction

How to cite this article:
Sahu MK, Vaswani P. Critical care preparedness and conduct in COVID-2019 crisis. J Pract Cardiovasc Sci 2021;7:16-23

How to cite this URL:
Sahu MK, Vaswani P. Critical care preparedness and conduct in COVID-2019 crisis. J Pract Cardiovasc Sci [serial online] 2021 [cited 2022 Oct 4];7:16-23. Available from: https://www.j-pcs.org/text.asp?2021/7/1/16/314475

  Introduction Top

The 3rd pandemic of coronavirus in this century, the severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) is highly contagious. Although less fatal than the previous two of its kind (SARS-2002 and MERS-Middle East Respiratory Syndrome 2012),[1],[2] COVID-19 is spreading like wildfire throughout the globe with overwhelming effects on health care which has led to a crisis situation. The preservation of critical care resources without denying the level of care in COVID-19 patients has been the strategy globally adopted. The intensive care unit (ICU) management protocols revolve around preparing, early identifying, and provision of supportive care with an expectant management till a vaccine or herd immunity are developed. There is also a need to watch the newer treatment modalities and their upcoming researches in order for an effective management of COVID-19 situation. Here, we discuss the care of severe COVID-19 infection with preparedness of ICU, management of complications, and an insight into the newer modalities against COVID-19.

  Methods Top

The English medical literature in MeSh database was searched utilizing keywords such as “COVID-19 pandemic,” “ICU preparedness,” “COVID-19 management,” “COVID-19 therapy,” and “COVID-19 systemic effects,” and the relevant studies were included for the formulation of the effective critical care conduct. The multidisciplinary meetings also contributed to the formulation of ICU care strategy.

  Results and Recommendations Top

Intensive care unit preparedness

The policy for ICU admission should be in liaison with advice from epidemiological experts studying the local and national viral trends. The false-negative rates of 30%–50% with reverse-transcriptase polymerase chain reaction (RTPCR) test should be borne in mind during patient evaluation; however, testing should be mandatory before receiving in the ICU.[3] The maintenance of adequate distance between beds (6 feet) and provision of appropriate donning and doffing areas in the ICU premises should be given utmost regard. Regular drills in intubating COVID-19 patients, identification of skilled member of the team as team leader, availability of video-laryngoscope for intubation which is being performed by the most skilled team member who is identified at commencement of the shift, limited yet adequate number of health personnel in every shift, use of N-95 or equivalent masks, availability of personal protective equipment kit, negative ventilation rooms if feasible/or well-ventilated single rooms, enhanced record keeping, minimizing transfer for radiological investigations with increasing reliance on portable point of care ultrasonography, and coherence with the development of team approach should be the ICU norms.

Proper training on how to don and doff the protective gear emphasizing more on appropriate doffing, strict prohibition on personal mobiles or other accessories use in the ICU with emphasis on regular disinfection of contact areas, waste disposal strategy, and restricted visitor entry with use of teleconferencing between patients and their family members should be considered. The ICU staff must have expert working personnel too who are well versed with proning maneuvers. The provision of mental boost should not be neglected both for patients and health care personnel in optimizing their mental health in such crisis times.

The discharge from the ICU should be based on at least two negative RTPCR assays performed at 24–48 h' interval as dispersion of virus continues till 2 weeks' time.[4]

The ICU awareness regarding the spectrum of clinical manifestations for ready identification, the various organ systems involved during disease course, the grading of severity [Figure 1], associated comorbidities potentiating further risk of mortality (including cardiovascular, diabetes, hypertension, preexisting chronic pulmonary conditions, malignancy, chronic renal dysfunction, obesity, smoking, etc.,), enlisting serum investigations in monitoring the course, discharge policy [Institutionalized, [Figure 1], and finally, the record keeping for mortality trends in the ICU. The altering mortality trends may give indirect evidence of the ICU preparedness and management strategy.
Figure 1: Grading of coronavirus disease 2019 with institutional discharge policy. RA–Room air, SpO2-Oxygen saturation, Room air, PaO2/FiO2-Partial pressure of oxygen to Fraction of oxygen in inspired air. *Recommended, but may vary based on institutional feasibility

Click here to view

Drug therapy requiring special mention


It is now recommended in cases of severe COVID-19 infection.[5] Remdesivir is prepared in a cyclodextrin vehicle that interferes in glomerular filtration which may add to nephrotoxicity; however, the short duration therapeutic strategy of 7–10 days, discontinuation before discharge from the hospital and minimal amount of cyclodextrin being bound seldom amounts to grave kidney damage. Therefore, it has been considered safe in both acute and chronic renal disease states.[6],[7] In addition, in cases of hepatic dysfunction, it must be judiciously used. There are in vitro studies that have established its activity in suppressing coronavirus as an analogous nucleotide in the viral agent. The recommended dosage in adults in 200 mg intravenously (I/V) on the 1st day followed by 100 mg I/V for 5–10 days depending on individual response. It also interferes and interacts with hydroxychloroquine. Beigel et al. in their double blinded, randomized trial which concluded the superiority of Remdesivir over placebo in the reduction of duration of recovery in patients with pulmonary involvement as observed in 1062 patients where the median duration was reduced from 15 to 10 days (95% confidence interval [CI] 1.12–1.49, odds ratio = 1.32, P < 0.001). There was also a statistically insignificant benefit over placebo group in terms of 1-month survival. Its benefit, however, could not be established in mortality reduction over a 2-week period. The study also did not reveal co-therapeutic agents being used.[8] The results of this study could not be confirmed in a multicentric randomized trial by Wang et al.[9] The overall results from various randomized studies, however, do not depict a substantial advantage with the use of Remdesivir.[9],[10],[11],[12],[13],[14]

In a meta-analysis of 85 trials enrolling 41,669 study subsets by Siemieniuk et al., Remdesivir failed to illustrate an advantage on reduction of mortality, mechanical ventilatory support, duration of institutional admission, or symptom duration.[10] The WHO funded SOLIDARITY trial involving patients from multiple nations, in an interim report failed to demonstrate a difference in a 1-month mortality between Remdesivir and placebo group.[12] However, the meta-analysis also included patients from SOLIDARITY trial, the trend showed in favor of Remdesivir which could not reach statistical significance.[10] There is also a debate regarding the duration of use of Remdesivir for 5 days versus 10 days of administration as studied in 397 patients having severe COVID 19 revealing no difference among the two durations; however, these patients did not require any ventilatory support.[15] Therefore, the duration should vary based on ICU protocols and individualized to different clinical scenarios. The adverse effects observed with Remdesivir have been primarily gastrointestinal with others being drop in hemoglobin, acute onset renal insult, hyperpyrexia, altered blood sugar profile, and raised transaminases.[8] A study by Beigel et al. revealed no difference in the incidence of these adverse events in placebo versus Remdesivir. Wang et al., however, reported discontinuation of Remdesivir due to worsening cardiopulmonary profile in addition to other adverse effects.[9]

The combination with Janus kinase inhibitor Baricitirib seems to potentiate antiviral effects with Remdesivir. In a double-blind randomized study by Kalil et al. comparing combination therapy of the two versus placebo in 1033 COVID-19 afflicted patients showed earlier symptomatic relief with improved clinical profile, especially in those requiring higher flow rates of oxygen or on ventilator support without potentiation of adverse effects. The median duration of recovery was 18 days in placebo group versus 10 days on combination group among 216 patients with higher oxygen requirements (respiratory rate 1.51, 95% CI 1.10–2.08).[16]


The early results of RECOVERY trial, which is a randomized study administering low dose dexamethasone (oral or I/V route), have revealed significant reductions in a 4-week mortality in admitted patients in comparison with home care. The entire study population had 17% decline in mortality; however, those who required ventilator support or extracorporeal membrane oxygenation (ECMO), there was an even higher benefit with 35% decline in mortality. The ones requiring noninvasive support modes had 20% reduction in mortality. Similar benefit was not observed in patients not requiring any support for oxygenation.[17] The theoretical risks of altered blood sugar profile and elevated incidence of infections were not observed in any of the subgroups.[18],[19] This portends the use of steroids in ICU as part of critical care.

Convalescent plasma

This is still under trial; however, early evidence has propagated its use in special situations.

Ideally, plasma from convalescent individuals obtained should consist of:-

  • Optimum concentration of antibodies devoid of microorganisms
  • Proven efficiency and safety profile for the relevant condition.[20],[21]

The neutralizing antibodies binding to viral particles reduce cellular entry of the virus simultaneously enhancing their clearance through phagocytosis or cellular toxicity response.[22] These are produced against spike protein and nucleo-capsid protein.[23],[24],[25] The various randomized trials, however, did not demonstrate superiority in clinical improvement and mortality reduction.[26],[27],[28],[29] Simonovich et al.[29] in their study of 333 patients, in which 228 received plasma versus 105 receiving placebo found no difference among the two in clinical benefit or survival.

In a Chinese study, 103 patients with severe COVID 19 disease were enrolled and random allocation to standard versus plasma therapy was done. These patients received plasma with elevated levels of neutralizing antibodies, although a major proportion of patients were administered only a single dose. The median duration from the symptom onset to treatment with convalescent plasma was 30 days, quite late in the disease course. This study revealed that although, the RTPCR tests (detecting virus) done over a 3-day interval became negative earlier in plasma therapy group (87% vs. 38% in standard therapy group), there was no significant difference in the rate of clinical improvement or improved overall survival. The mere clearance of virus did not lead to mortality reduction signifying the cytokine storm being stirred by viral epitopes as a significant contributor for the disease severity. The late administration of plasma also could have been a significant factor.[27] Joyner et al. demonstrated the safety and toleration profile of plasma in individuals in their report in Mayo Clinic of 20,000 patients.[30] In a report by Wang et al., monoclonal antibody targeting viral epitope has been documented which may have a significant therapeutic impact.[31] This has not yet been corroborated in other studies and continues to be under trial.

A study by Li et al. from China enrolling 103 patients demonstrated that although, rate of clearance of viral RNA was quicker in the plasma group, however was not translated into clinically appreciable benefit or mortality reduction.[27] The trend was toward reduced mortality but could not reach statistical significance in those with life-threatening COVID-19. Similarly, PLACID trial from India by Agarwal et al. which enrolled 464 adults over 39 health-care institutions demonstrated suboptimal results showing no superiority over optional standardized institutional care. In this study, however, no titer measurement was provided before and after the institution of plasma.[28]

Interleukin 6 pathway inhibitors

The elevations in the markers of inflammation, for example, D-Dimer, Ferritin, and interleukin 6 (IL-6) have been observed in the initial stages of COVID 19, setting up a cytokine storm contributing to mortality.[32] A pilot study by Sciascia et al. has evaluated the use of Tocilizumab as an IL-6 antagonist in 63 patients with severe disease. There was significant improvement in PaO2/FiO2 (partial pressure of oxygen to fraction of inspired oxygen) and laboratory marker profile with a reduced overall rate of demise. The mortality benefit was observed when Tocilizumab was administered within 6 days of hospitalization.[33] Therefore, we advocate the serial levels of biomarkers to guide the administration of this agent early in course of the disease.


It acts against RNA polymerase and has been used for influenza; however, its use has not been advocated in severe category patients. There has been observed radiological improvement and faster clearance of virus in mild-to-moderate cases in comparison with lopinavir-ritonavir combination, although the nondisclosure of co-therapeutic confounder agents is a matter of concern while interpreting the results of this study.[34] However, further studies ongoing may reveal its use in critical care support of COVID-19 patients.

Interferon beta

The growing interest in this agent stems its roots in the animal-based study by Chan et al. owing to similarity between COVID 19 and MERS virus.[35] The beneficial effects of this agent versus lopinavir-ritonavir have been established in a single-center study by Hung et al., however, not for severe patient subset and improved clinical profile was observed when interferon IFN-beta was administered within 1 week of illness.[36] Other immune-modulatory agents are being evaluated, however, in small case series with multiple confounders. Anakinra (IL-1 inhibitor), similarly, has been studied in severe patients maintained on noninvasive ventilatory support in a retrospective study by Cavalli et al.; however, since the group receiving hydroxychloroquine/lopinavir-ritonavir was older in age in comparison and the presence of confounding variables which could not be measured, it has raised questions about the results of this study.[37] These immunemodulators may have role, however, currently are far from being established. In addition, there have been the reports of some traditional Chinese medications such as XueBiljing and others being employed for the management of COVID-19; however, no peer reviewed safety and efficacy data are available regarding them. These are being further evaluated in a study by Chan et al.[38]

Vitamin D

It has been postulated to enhance the innate immunity responding against COVID-19 disease.[39] In addition, critical illness is usually associated with reduced serum concentration. In a pilot study from Spain by Entrenas Castillo et al. enrolling 50 patients who received Vitamin D metabolite and 26 patients who didn't, demonstrated that there was a statistically significant reduction in ICU admission (2% vs. 50%, P < 0.001) and reduced disease severity; however, they stressed on the need of larger studies in this regard. There were various confounding factors such as hypertension and diabetes by being more predominant in the control arm, jeopardizing their results.[40] The randomized trial by Murai et al. from the Brazilian population constituting 237 randomizes patients failed to the establishment of Vitamin D in severe or moderate COVID-19 infection.[41] There was no statistically significant difference in duration of hospital stay, survival (7.6% vs. 5.1%), ICU admission (16% vs. 21.2%), and ventilatory support (7.61% vs. 14.4%).[41] However, Vitamin D role in COVID-19 acute respiratory distress syndrome (ARDS) is still under debate[42] and still being researched.[43]

Management of special situations

Acute respiratory distress syndrome

The discussion of ARDS associated with COVID-19 would be incomplete without emphasizing on the types of pneumonitis induced by the viral progression. It has been described in the study by Gattinoni et al. into two time-related processes, namely the “L” type and “H” type.[44] The “L” type which is characterized by lower elasticity depicting near normal lung compliance, lower ventilation-perfusion mismatch, lower lung weight associated with the radiological features of ground-glass opacities predominantly without additional appreciable sequelae and lower amounts of nonaerated areas in lung parenchyma, thereby less reliance on pulmonary recruitment maneuvers. However, the advanced progressive form seen later in the disease course known as the 'H' type is characterized by higher lung elasticity owing to edematous tissues, higher ventilation-perfusion mismatch attributed to left-to-right shunt wherein gravity-dependent pulmonary areas receiving higher proportion of circulation without corresponding aeration, substantially increased lung weight quantifying severe respiratory distress syndrome in the ranges of more than 1.5 kg[45] and higher need for pulmonary recruitment manoeuvres in order to recruit the higher amount of nonaerated pulmonary segments.[44] The phenomenon of patient induced self-inflicted lung injury described by Barach and Mascheroni et al. forms the basis of progression of one type of pneumonia to other.[46],[47] The synergy of negative intra-thoracic pressure while inhalation in the background of ongoing inflammatory process associated pulmonary permeability potentiates this transition and culminates in disastrous sequelae. This clinical picture reveals worsening nature of shortness of breath with increasing inspired fraction of oxygen requirement leading to adoption of ventilatory support both noninvasive and invasive type depending on clinical profile. The reversal of hypoxia at the earliest may prevent progression to 'H' type. This can be achieved through adoption of high flow nasal cannulas, positive pressure support or noninvasive ventilatory support in selected cases with dyspnea.[44] The pleural pressure changes measured indirectly through central venous pressure tracings may guide toward invasive ventilation conversion as delaying this may aggravate self-inflicted lung injury.[48] The “H” type pneumonitis may respond to prone positioning with ventilatory support, higher end expiratory pressures, and finally, resorting to mechanical circulatory support in subsets with hemodynamic compromise. This understanding of pathophysiological process marks an indispensable tool for adoption of appropriate therapeutic strategy averting clinical decline.[49]

The strategy in managing ARDS is based on supportive care keeping a close watch for involvement of the liver, kidney, and heart.[50] The routine estimations of renal and liver function tests should be considered at specified intervals (at least on alternate days) as a part of the ICU strategy. The super-added infections and preexisting comorbid conditions must be managed appropriately. This involves exchange of ideas among the specialist in critical care, pulmonary medicine, and cardiologist together as an expert team. Close eye should be kept on serum levels of biomarkers-(IL-6, D-dimer, Ferritin, C-reactive protein, and lactate dehydrogenase). The placement of central venous line for guiding fluid therapy, checking blood gases at regular intervals with invasive vital monitoring by arterial lines, supervised undertaking of these procedures, using inotropes whenever unresponsive to fluid boluses or in cases with myocardial injury, avoiding frequent nebulization, use of metered dose inhalation devices even in those on ventilator support minimizing the aerosol dispersion or use of separate rooms for patients with exacerbation of chronic pulmonary illness, targeting SpO2 above 90% with frequent reassessment of those on high flow nasal oxygen (HFNO) and noninvasive ventilation (NIV) support are a few essential steps to be catered to while managing these patients.[51] There is a risk of spread of aerosols in NIV and HFNO, however, they may have a role in avoiding invasive mechanical ventilation which has poorer prognosis.[52] HFNO is preferred over NIV whenever used for such patients with moderate to severe COVID 19 illness, however, NIV has established role in management of COPD exacerbations.[53],[54] The use of appropriate fitting masks is mandatory for an adequate seal. The enlistment of intubation criteria with use of a rapid sequence technique while avoiding bag-mask ventilation and using special viral or double bacterial filters in the breathing circuit effectively reducing aerosol generation. The utilization of lung protective ventilation with prone positioning,[55] alveolar recruitment maneuvers, inhalational pulmonary vasodilatation agents like inhaled nitric oxide, paralytic agents in patients with unresponsive hypoxemia with use of Veno-venous or Veno-arterial ECMO as a last rescue therapy should be laid out clearly in ICU protocols.[50] ECMO device with circuit accessories including cannulae, tubing kit, oxygenator, etc., should be ready for disposal in case need arises with special laid down criteria for ECMO institution.[56] Cardiologists, intensivists, pulmonologists and cardiac surgeons should be involved in formulation of comprehensive ECMO use algorithm.[57] The adoption of prone position in conjunction with mechanical ventilation should be the institutional practice. In a retrospective study by Sartini et al., 12 of 15 patients afflicted with COVID-19 were subjected to prone position alternating with NIV. These patients showed improved peripheral oxygen levels compound with the rest.[58] In a prospective cohort study (PRON-COVID) done by Coppo et al. including 56 patients, feasibility for prone position was found in 84% patients. There was statistically significant elevation of PaO2/Fio2 (180.5 ± 76.6 in supine to 285.5 ± 112.9, P < 0.0001). This improvement persisted in 50% of the patients.[59] Prone ventilation has been adopted as standard of care in patients develops COVID-19 ARDS where there is failure of oxygenation.[60],[61]

The start of empirical broad antibiotics based on ICU cultures and in-hospital trend with early tracing of the culture reports to convert into narrow spectrum, bed sore prevention with air mattress use and regular position changes, ulcer prophylaxis with proton pump inhibitors, early institution of nutritional support is essential. Additionally, systemic administration of steroids and other agents should be evidence based as highlighted above. The use of investigational agents should be considered in individualized situations as these therapeutic agents continue to evolve.

Managing arrhythmias and myocardial insult

Sinus tachycardia manifests in majority of COVID 19 patients, however, atrial fibrillation, atrial flutter and mono or polymorphic ventricular tachycardia have been reported.[62] The QT interval should be monitored in serial 12 lead electrocardiographic (ECG's). QT interval values more than 500 msonds have been observed in 6.1% cases in a study of 4250 patients.[62] In another study involving 393 patients, it was found that atrial rhythm abnormalities were more frequent among patients on ventilatory support (17.7% vs. 1.9% of those not on ventilator) with additional need for inotropic support (95.4% vs. 1.5%) and evidence of new onset kidney dysfunction with requirement of dialysis (13.3% vs. 0.4%) in those on mechanical ventilation support.[63] The management ensues on ambient temperature monitoring, avoiding hyper or hypothermic situations, controlling electrolyte imbalances especially potassium levels, administration of intravenous magnesium whenever necessary, anti-arrhythmic agents and utilization of pharmacological or electrical cardioversion in cases with hemodynamic alterations with cardiologist consultation.[64]

Myocardial insult has been reported in rates varying from 7% to 28%.[65],[66],[67] Prevalence of heart failure has been seen as high as 49% in patients who succumbed (113 patients) versus only 3% in those who recovered (161 patients) in a retrospective study by Chen et al. involving 799 patients.[68] The levels of Troponin are estimated at baseline on ICU admission as a marker for myocardial insult with ECG monitoring for ST segment changes and bedside echocardiography for abnormalities in regional wall motion. Levels of B-type natriuretic peptide can be corroborated closely with heart failure, although, elevated levels are often observed in early periods of severe COVID-19.[65] The appropriate management entails quick diagnosis and supportive care with inotropes, vasodilator agents and inclusion of mechanical assist devices whenever deemed necessary in consultation with cardiac team. The indications for ECMO use in such patients should be discussed.

Management of hypercoagulable state

There have been noted complications related to development of a hypercoagulable state in COVID 19 such as deep vein thrombosis, pulmonary thrombo-embolism, stroke, acute limb ischemia and microvascular thrombosis. The ICU protocol devised must entail the conduct of complete blood profile with thrombocyte count, prothrombin time, activated partial thromboplastin time, fibrinogen and D-dimer levels with further evaluation by thromboelastographic tests whenever available for a timely intervention.[69],[70],[71] All admitted patients in moderate category must receive prophylactic dose of low molecular weight heparin with escalation to therapeutic dose in ICU admissions.[72],[73],[74],[75],[76] Limb physiotherapy with use of sequential intermittent pneumatic compression devices can be considered in synergism. Thrombolysis must be reserved for cases with limb threatening scenario, hemodynamically significant pulmonary embolus, acute ischemic stroke and acute myocardial infarction after consult with stroke and cardiac team.[75],[77] The thrombo-prophylaxis should be continued in patients with higher risk of thrombosis based on clinical judgment for the entire convalescent phase till they resume the routine activities with the use of compression stockings.[76] The anticoagulation must be strived at a higher level due to the hypercoagulable state induced by COVID-19 infection.

Management of acute renal dysfunction

Acute kidney injury (AKI) has been observed in 37% of 5449 COVID-19 patients in a study by Hirsch et al. with severe grade AKI in 31% of them. Hematuria and proteinuria have been associated with higher predisposition to mortality when present in association with AKI.[77] The pathophysiology behind AKI either due to poor hemodynamics or cytokine storm, is yet unclear.[32] The patients requiring renal replacement therapy can be grouped together or kept in the separate isolation rooms if feasible with provision of bedside dialysis avoiding transfer-related adverse scenarios, preference being given to continuous renal replacement therapy over intermittent hemodialysis, expert nephrology staff at bedside and audio or video surveillance of these rooms preventing the need for continuous monitoring with reduction in the exposure of personnel involved. The circuit tubing's should be thoroughly anticoagulated considering the hypercoagulable pathological state created by COVID-19. The presence of COVID-19 or other viruses has not been revealed in the dialysis effluent; hence, no special provisions for disposing this are required.[78]

Intensive care unit research

The evolving pandemic situation requires the conduct of research with strenuous record keeping, collaboration with multiple centers both national and worldwide for optimal networking platform. This also requires patiently and cautiously analyzing the study results with emphasis on methodology for the provision of a comprehensive care policy.

  Conclusion Top

The pandemic has stirred a turmoil in the critical care management while jeopardizing routine hospital functioning. The preservation of critical care resources is mandatory in crisis times with judicious allocation to those in dire need. Strict monitoring, supportive care provision, early diagnosis of the sequelae of COVID-19, vigilant surveillance of newer therapeutic agents with a holistic care of the patients, and staff would comprehensively address this situation. The herculean task of conducting research with a global collaboration is imperative for a successful critical care program.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Anderson RM, Fraser C, Ghani AC, Donnelly CA, Riley S, Ferguson NM, et al. Epidemiology, transmission dynamics and control of SARS: The 2002-2003 epidemic. Philos Trans R Soc Lond B Biol Sci 2004;359:1091-105.  Back to cited text no. 1
Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DA, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med 2013;369:407-16.  Back to cited text no. 2
Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Lessler J. Variation in false-negative rate of reverse transcriptase polymerase chain reaction-based SARS-CoV-2 tests by time since exposure. Ann Intern Med 2020;173:262-7.  Back to cited text no. 3
Liu Y, Yan LM, Wan L, Xiang TX, Le A, Liu JM, et al. Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis 2020;20:656-7.  Back to cited text no. 4
Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 2020;30:269-71.  Back to cited text no. 5
Adamsick ML, Gandhi RG, Bidell MR, Elshaboury RH, Bhattacharyya RP, Kim AY, et al. Remdesivir in patients with acute or chronic kidney disease and COVID-19. J Am Soc Nephrol 2020;31:1384-6.  Back to cited text no. 6
Thakare S, Gandhi C, Modi T, Bose S, Deb S, Saxena N, et al. Safety of remdesivir in patients with acute kidney injury or CKD. Kidney Int Rep 2021;6:206-10.  Back to cited text no. 7
Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the treatment of COVID-19 – Preliminary report. Reply N Engl J Med 2020;383:994.  Back to cited text no. 8
Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults with severe COVID-19: A randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2020;395:1569-78.  Back to cited text no. 9
Siemieniuk RA, Bartoszko JJ, Ge L, Zeraatkar D, Izcovich A, Pardo-Hernandez H, et al. Drug treatments for covid-19: Living systematic review and network meta-analysis. BMJ 2020;370:m2980.  Back to cited text no. 10
Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the treatment of COVID-19 – Final report. N Engl J Med 2020;383:1813-26.  Back to cited text no. 11
WHO Solidarity Trial Consortium; Pan H, Peto R, Henao-Restrepo AM, Preziosi MP, Sathiyamoorthy V, et al. Repurposed antiviral drugs for COVID-19 – Interim WHO solidarity trial results. N Engl J Med 2021;384:497-511.  Back to cited text no. 12
Rochwerg B, Agarwal A, Zeng L, Leo YS, Appiah JA, Agoritsas T, et al. Remdesivir for severe COVID-19: A clinical practice guideline. BMJ 2020;370:m2924.  Back to cited text no. 13
Wilt TJ, Kaka AS, MacDonald R, Greer N, Obley A, Duan-Porter W. Remdesivir for adults with COVID-19: A living systematic review for American College of Physicians Practice Points. Ann Intern Med 2021;174:209-20.  Back to cited text no. 14
Goldman JD, Lye DC, Hui DS, Marks KM, Bruno R, Montejano R, et al. Remdesivir for 5 or 10 days in patients with severe COVID-19. N Engl J Med 2020;383:1827-37.  Back to cited text no. 15
Kalil AC, Patterson TF, Mehta AK, Tomashek KM, Wolfe CR, Ghazaryan V, et al. Baricitinib plus remdesivir for hospitalized adults with COVID-19. N Engl J Med 2021;384:795-807.  Back to cited text no. 16
Horby P, Lim WS, Emberson J, Mafham M, Bell J, Linsell L, et al. Effect of dexamethasone in hospitalized patients with COVID-19: Preliminary report. medRxiv 2020. [doi: 10.1101/2020.06.22.20137273].  Back to cited text no. 17
Hirsch IB, Paauw DS. Diabetes management in special situations. Endocrinol Metab Clin North Am 1997;26:631-45.  Back to cited text no. 18
Migita K, Arai T, Ishizuka N, Jiuchi Y, Sasaki Y, Izumi Y, et al. Rates of serious intracellular infections in autoimmune disease patients receiving initial glucocorticoid therapy. PLoS One 2013;8:e78699.  Back to cited text no. 19
Casadevall A, Pirofski LA. The convalescent sera option for containing COVID-19. J Clin Invest 2020;130:1545-8.  Back to cited text no. 20
Bloch EM, Shoham S, Casadevall A, Sachais BS, Shaz B, Winters JL, et al. Deployment of convalescent plasma for the prevention and treatment of COVID-19. J Clin Invest 2020;130:2757-65.  Back to cited text no. 21
Wu F, Liu M, Wang A, Lu L, Wang Q, Gu C, et al. Evaluating the association of clinical characteristics with neutralizing antibody levels in patients who have recovered from mild COVID-19 in Shanghai, China. JAMA Intern Med 2020;180:1356-62.  Back to cited text no. 22
Sun B, Feng Y, Mo X, Zheng P, Wang Q, Li P, et al. Kinetics of SARS-CoV-2 specific IgM and IgG responses in COVID-19 patients. Emerg Microbes Infect 2020;9:940-8.  Back to cited text no. 23
Okba NM, Müller MA, Li W, Wang C, GeurtsvanKessel CH, Corman VM, et al. Severe acute respiratory syndrome coronavirus 2-specific antibody responses in coronavirus disease patients. Emerg Infect Dis 2020;26:1478-88.  Back to cited text no. 24
Wu Y, Wang F, Shen C, Peng W, Li D, Zhao C, et al. A noncompeting pair of human neutralizing antibodies block COVID-19 virus binding to its receptor ACE2. Science 2020;368:1274-8.  Back to cited text no. 25
Piechotta V, Chai KL, Valk SJ, Doree C, Monsef I, Wood EM, et al. Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: A living systematic review. Cochrane Database Syst Rev 2020;7:CD013600.  Back to cited text no. 26
Li L, Zhang W, Hu Y, Tong X, Zheng S, Yang J, et al. Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial. JAMA 2020;324:460-70.  Back to cited text no. 27
Agarwal A, Mukherjee A, Kumar G, Chatterjee P, Bhatnagar T, Malhotra P, et al. Convalescent plasma in the management of moderate COVID-19 in adults in India: Open label phase II multicentre randomised controlled trial (PLACID Trial). BMJ 2020;371:m3939.  Back to cited text no. 28
Simonovich VA, Burgos Pratx LD, Scibona P, Beruto MV, Vallone MG, Vázquez C, et al. A randomized trial of convalescent plasma in COVID-19 severe pneumonia. N Engl J Med 2021;384:619-29.  Back to cited text no. 29
Joyner MJ, Bruno KA, Klassen SA, Kunze KL, Johnson PW, Lesser ER, et al. Safety update: COVID-19 convalescent plasma in 20,000 hospitalized patients. Mayo Clin Proc 2020;95:1888-97.  Back to cited text no. 30
Wang C, Li W, Drabek D, Okba NM, van Haperen R, Osterhaus AD, et al. A human monoclonal antibody blocking SARS-CoV-2 infection. Nat Commun 2020;11:2251.  Back to cited text no. 31
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.  Back to cited text no. 32
Sciascia S, Aprà F, Baffa A, Baldovino S, Boaro D, Boero R, et al. Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe COVID-19. Clin Exp Rheumatol 2020;38:529-32.  Back to cited text no. 33
Cai Q, Yang M, Liu D, Chen J, Shu D, Xia J, et al. Experimental treatment with favipiravir for COVID-19: An open-label control study. Engineering (Beijing) 2020;6:1192-8.  Back to cited text no. 34
Chan JF, Yao Y, Yeung ML, Deng W, Bao L, Jia L, et al. Treatment with lopinavir/ritonavir or interferon-β1b improves outcome of MERS-CoV infection in a nonhuman primate model of common marmoset. J Infect Dis 2015;212:1904-13.  Back to cited text no. 35
Hung IF, Lung KC, Tso EY, Liu R, Chung TW, Chu MY, et al. Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: An open-label, randomised, phase 2 trial. Lancet 2020;395:1695-704.  Back to cited text no. 36
Cavalli G, De Luca G, Campochiaro C, Della-Torre E, Ripa M, Canetti D, et al. Interleukin-1 blockade with high-dose anakinra in patients with COVID-19, acute respiratory distress syndrome, and hyperinflammation: A retrospective cohort study. Lancet Rheumatol 2020;2:e325-31.  Back to cited text no. 37
Chan KW, Wong VT, Tang SCW. COVID-19: An update on the epidemiological, clinical, preventive and therapeutic evidence and guidelines of integrative Chinese-western medicine for the management of 2019 novel coronavirus disease. Am J Chin Med 2020;48:737-62.  Back to cited text no. 38
Bilezikian JP, Bikle D, Hewison M, Lazaretti-Castro M, Formenti AM, Gupta A, et al. Mechanisms in endocrinology: Vitamin D and COVID-19. Eur J Endocrinol 2020;183:R133-47.  Back to cited text no. 39
Entrenas Castillo M, Entrenas Costa LM, Vaquero Barrios JM, Alcalá Díaz JF, López Miranda J, Bouillon R, et al. “Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study”. J Steroid Biochem Mol Biol 2020;203:105751.  Back to cited text no. 40
Murai IH, Fernandes AL, Sales LP, Pinto AJ, Goessler KF, Duran CS, et al. Effect of a single high dose of vitamin D3 on hospital length of stay in patients with moderate to severe COVID-19: A randomized clinical trial. JAMA 2021;325:1053-60.  Back to cited text no. 41
Chakhtoura M, Napoli N, El Hajj Fuleihan G. Commentary: Myths and facts on vitamin D amidst the COVID-19 pandemic. Metabolism 2020;109:154276.  Back to cited text no. 42
Quesada-Gomez JM, Entrenas-Castillo M, Bouillon R. Vitamin D receptor stimulation to reduce acute respiratory distress syndrome (ARDS) in patients with coronavirus SARS-CoV-2 infections: Revised Ms SBMB 2020_166. J Steroid Biochem Mol Biol 2020;202:105719.  Back to cited text no. 43
Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: Different respiratory treatments for different phenotypes? Intensive Care Med 2020;46:1099-102.  Back to cited text no. 44
Maiolo G, Collino F, Vasques F, Rapetti F, Tonetti T, Romitti F, et al. Reclassifying acute respiratory distress syndrome. Am J Respir Crit Care Med 2018;197:1586-95.  Back to cited text no. 45
Barach AL, Martin J, Eckman M. Positive pressure respiration and its application to the treatment of acute pulmonary edema. Ann Intern Med 1938;12:754-95.  Back to cited text no. 46
Mascheroni D, Kolobow T, Fumagalli R, Moretti MP, Chen V, Buckhold D. Acute respiratory failure following pharmacologically induced hyperventilation: An experimental animal study. Intensive Care Med 1988;15:8-14.  Back to cited text no. 47
Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med 2017;195:438-42.  Back to cited text no. 48
Gattinoni L, Giosa L, Bonifazi M, Pasticci I, Busana M, Macri M, et al. Targeting transpulmonary pressure to prevent ventilator-induced lung injury. Expert Rev Respir Med 2019;13:737-46.  Back to cited text no. 49
Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Engl J Med 2020;382:999-1008.  Back to cited text no. 50
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.  Back to cited text no. 51
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.  Back to cited text no. 52
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 53
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 54
Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68.  Back to cited text no. 55
Hong X, Xiong J, Feng Z, Shi Y. Extracorporeal membrane oxygenation (ECMO): Does it have a role in the treatment of severe COVID-19? Int J Infect Dis 2020;94:78-80.  Back to cited text no. 56
Ramanathan K, Antognini D, Combes A, Paden M, Zakhary B, Ogino M, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med 2020;8:518-26.  Back to cited text no. 57
Sartini C, Tresoldi M, Scarpellini P, Tettamanti A, Carcò F, Landoni G, et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020;323:2338-40.  Back to cited text no. 58
Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): A prospective cohort study. Lancet Respir Med 2020;8:765-74.  Back to cited text no. 59
Shelhamer MC, Wesson PD, Solari IL, Jensen DL, Steele WA, Dimitrov VG, et al. Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: A cohort study and analysis of physiology. J Intensive Care Med 2021;36:241-52.  Back to cited text no. 60
Weiss TT, Cerda F, Scott JB, Kaur R, Sungurlu S, Mirza SH, et al. Prone positioning for patients intubated for severe acute respiratory distress syndrome (ARDS) secondary to COVID-19: A retrospective observational cohort study. Br J Anaesth 2021;126:48-55.  Back to cited text no. 61
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA 2020;323:2052-9.  Back to cited text no. 62
Goyal P, Choi JJ, Pinheiro LC, Schenck EJ, Chen R, Jabri A, et al. Clinical characteristics of COVID-19 in New York City. N Engl J Med 2020;382:2372-4.  Back to cited text no. 63
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Clinical characteristics of COVID-19 in New York City. N Engl J Med 2020;382:2372-4.  Back to cited text no. 64
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020;5:802-10.  Back to cited text no. 65
Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. COVID-19 and cardiovascular disease. Circulation 2020;141:1648-55.  Back to cited text no. 66
Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in Critically Ill patients in the seattle region – Case series. N Engl J Med 2020;382:2012-22.  Back to cited text no. 67
Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: Retrospective study. BMJ 2020;368:m1091.  Back to cited text no. 68
Menter T, Haslbauer JD, Nienhold R, Savic S, Hopfer H, Deigendesch N, et al. Postmortem examination of COVID-19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction. Histopathology 2020;77:198-209.  Back to cited text no. 69
Wichmann D, Sperhake JP, Lütgehetmann M, Steurer S, Edler C, Heinemann A, et al. Autopsy findings and venous thromboembolism in patients with COVID-19: A prospective cohort study. Ann Intern Med 2020;173:268-77.  Back to cited text no. 70
Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in COVID-19. N Engl J Med 2020;383:120-8.  Back to cited text no. 71
Lodigiani C, Iapichino G, Carenzo L, Cecconi M, Ferrazzi P, Sebastian T, et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res 2020;191:9-14.  Back to cited text no. 72
Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: A multicenter prospective cohort study. Intensive Care Med 2020;46:1089-98.  Back to cited text no. 73
Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 74
Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh IP, et al. Large-vessel stroke as a presenting feature of COVID-19 in the young. N Engl J Med 2020;382:e60.  Back to cited text no. 75
Bellosta R, Luzzani L, Natalini G, Pegorer MA, Attisani L, Cossu LG, et al. Acute limb ischemia in patients with COVID-19 pneumonia. J Vasc Surg 2020;72:1864-72.  Back to cited text no. 76
Hirsch JS, Ng JH, Ross DW, Sharma P, Shah HH, Barnett RL, et al. Acute kidney injury in patients hospitalized with COVID-19. Kidney Int 2020;98:209-18.  Back to cited text no. 77
El Shamy O, Vassalotti JA, Sharma S, Aydillo-Gomez T, Marjanovic N, Ramos I, et al. Coronavirus disease 2019 (COVID-19) hospitalized patients with acute kidney injury treated with acute peritoneal dialysis do not have infectious peritoneal dialysis effluent. Kidney Int 2020;98:782.  Back to cited text no. 78


  [Figure 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Results and Reco...
   Article Figures

 Article Access Statistics
    PDF Downloaded144    
    Comments [Add]    

Recommend this journal