Abbreviated interview with Dr. Manuel Ignacio Monge Garcia, Staff Intensivist, Hospital del SAS de Jerez, Spain. Interviewers include Professor Monty Mythen, Editor in Chief, TopMedTalk, University College London and Desiree Chappell, CRNA, Managing Editor & Lead Anchor, TopMedTalk. Adapted with permissions from podcast: “Essential knowledge; management of the COVID patient,” recorded on April 18, 2020
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(Desiree Chappell) Ignacio, can you give us a little bit of background about the size of your hospital and the size of the ICU that you work in?
(Dr. Monge Garcia) Well, my hospital is a medium sized hospital at 500 beds. My ICU is a surgical and medical ICU. We are treating mostly medical patients. We have 20 beds for ICU patients but during the last weeks have had to increase the number of beds for covering the COVID patients. So, at this moment we have mostly COVID patients and only an isolated ICU for non-COVID patients.
(Desiree Chappell) We’ve heard a lot on the news here in the US that Spain has seen a major surge, and the trajectory has been very similar to the U.S. and the U.K. Are you seeing that in your area or is that in other areas in Spain?
(Dr. Monge Garcia) Spain in general has a similar pattern to Italy but we saw a difference in the North and the South of Spain. We don’t know exactly why, but we suspect that the weather and density of population [are factors]. For example, Madrid and Barcelona have a lot of patients and have been overwhelmed by the number of cases, but we saw an increasing number of patients during the last weeks and never at the same level as the North of Spain.
(Desiree Chappell) Talk to us about the management of these patients. Obviously when they get up to you in critical care, they’ve been through the emergency room and are having [an] escalation of care… To break it down [to] the ABCs, you know, airway, breathing, circulation; when it comes to airway, are you opting for early intubation? Are you trying to keep these patients off the ventilator?
(Dr. Monge Garcia) Well, the first thing that we have to say is we are very lucky because we have the knowledge from the Italian doctors and Chinese doctors. They put the alarm, and we had time to be prepared and prepare our protocols. We had time to prepare our ICU to [be ready to] admit all of these patients. We prepared protocols for intubation, for respiratory management, hemodynamic management, everything. We try to be prepared and probably the only reason [we were] prepared was the advice from the Italian and Chinese colleagues.
(Professor Monty Mythen) Are you doing a lot of [prone position]? Are you flipping patients over onto their front?
(Dr. Monge Garcia) Yeah. At the beginning we put all the patients in prone position, and we tried to decide if we should continue with the prone position depending on the oxygenation. But you know that things are changing within the last weeks with the two phenotypes, and we started to think that probably the prone position is not the right treatment for patients with normal [or nearly normal] respiratory compliance and we should keep that treatment only as a rescue therapy. But this is a learning curve. We are learning during all this. We have the recommendations that are changing a lot during the last days, so at this moment we cannot recommend one thing because probably the next day it will change.
(Professor Monty Mythen) Just practically on that front, it’s very physically demanding. It’s demanding for manpower. We know historically that the patient who is face down when intubated and ventilated is much more challenging to manage. There are issues with pressure points, etc. But there’s also, as you say, as we learn more about the biology of it, it seems to be the lungs, but in some patients also the kidneys become under attack, and lying face down is not necessarily good for your kidneys either because of the pressure consequences.
(Dr. Monge Garcia) Yeah, it’s a good second point. Honestly, I think that probably one of the main reasons for the impairment in the renal function could be related to our hemodynamic management of those patients. We try to do the same thing with the ARDS patient as with patients that are not ARDS patients. I mean we saw patients with normal chest x-rays or almost normal, but we tried to keep those lungs dry. You see a lot of diuretics or trying to reduce the intake of fluids and probably that kind of management could impair the renal function. And I suspect that part of that impairment on renal function is due to our hemodynamic management.
(Professor Monty Mythen) So I’ve just been watching the European Society of Intensive Care Medicine webinar recording on acute kidney injury. In the first lecture that comes through very clearly, that people are saying, “hang on a second, although it is ARDS of a form, it is an acute lung injury, but it’s not like many of the patients that were in the ARDSNet studies, and on reflection they came in probably very dehydrated and therefore probably needed both resuscitation, replacement and hydration. So, we sort of backed off to resuscitate, and then like everyone, try and avoid excess water and salt.”
(Desiree Chappell) There are a lot of reports of hemodynamic instability of these patients, and speaking to what you were saying about [prone position], that has consequences, I mean there are a lot of things that we’re doing to these patients that could potentially be causing iatrogenic hemodynamic instability versus being caused by the actual illness. Can you speak to that [regarding] management of these patients?
(Dr. Monge Garcia) Yes, I think the main hemodynamic problems in COVID patients are related to first, the hypovolemia that we could create with the fluid strategy, but also with our ventilatory support. [For example, if we] use high levels of PEEP in patients with normal respiratory compliance, we probably are impairing the preload of those patients and [may] decrease the cardiac output. The second main problem could be the vasoplegia that we create with the high level of sedation that patients require for being adapted to the mechanical ventilation and prone positioning. And also we saw a lot of secondary bacterial co-infection that could affect vasoplegia. But as you know, there [are also] a lot of patients with high troponin levels which has been clearly related with cardiac dysfunction. So I think it’s a mix of hypovolemia, vasoplegia and cardiac dysfunction. And probably in the latest stages we could see an increasing right ventricular afterload due to the prothrombotic state and the change in the pattern of the respiratory mechanics of those patients.
(Desiree Chappell) So you’re saying you think hypovolemia because they’re coming in dry because they’ve been sick for days up until this, and not taking adequate fluids, and febrile. It’s a vasoplegia actually caused from sedation from us; so the things that we’re doing to help mechanically ventilate them. And also a septicemia, so something that’s caused because they’re sick as well?
(Dr. Monge Garcia) Exactly. The secondary infection in those patients could be the reason for the vasoplegia too.
(Desiree Chappell) Yeah, and then cardiac dysfunction related to what we’re doing?
(Dr. Monge Garcia) Exactly. And the virus, because there is a direct effect of the virus on the cardiac function. It has things related to high levels of troponin, and patients with high levels of troponin have a worse prognosis.
(Desiree Chappell) So a direct attack on the heart and possibly the kidneys, as Monty said too.
(Professor Monty Mythen) So Ignacio, that’s a very common thing I’ve heard from lots of my colleagues, friends, people I’ve interviewed who are a number of weeks into this now. They say on reflection that if at the beginning they kept it simple had done what they usually do, you know… airway, breathing, circulation… and when it comes to the circulation, get their monitoring on and deal with preload, afterload, contractility and then think about hydration; they’re suspicious that they might’ve been in a better place now and that sort of ARDS label being the classical ARDS may have set them back a couple of weeks.
(Dr. Monge Garcia) Probably. [As the concept of how the virus is affecting different patients is changing], we should also consider [changing] the approach in terms of the hemodynamic monitoring. It’s not a matter of trying to keep the lungs dry or wet. It should be to keep the right amount of fluids and try to use parameters from hemodynamic monitoring to give fluids when it’s really necessary. So that should be the first step at the beginning. You don’t know if this patient has a wet or dry lung, but you should try to keep the amount the fluids in the between line. You should not try to keep the lungs dry but not wet, and the only way to do that is using hemodynamic monitoring. You can’t do that using diuretics or giving fluids without any rationale or only because you think it’s the best treatment for that patient. I think it’s very useful in this context, the hemodynamic monitoring.
(Desiree Chappell) Walk us through when you’re looking at these patients and what the parameters look like when you first put a monitor on these people who may not have been resuscitated.
(Dr. Monge Garcia) Surprisingly, we saw normal levels of cardiac output. Actually, we saw normal levels of cardiac output, normal levels of lactic acidosis, or normal levels of central venous oxygen saturation. So it seems that those patients with normal respiratory compliance have a different pattern than patients with ARDS pattern, so we should be very cautious in trying to do the same thing with all patients. If we are going to change how to treat the patient with our ventilatory support depending on two different phenotypes, we should also think that probably we’ll need to change our approach in the hemodynamic management depending on the respiratory pattern too.
(Desiree Chappell) Did you see a change whenever you had these patients and you were going up on their levels of PEEP and pressure support and things like that? Were you seeing a drop in the changes in their dynamic parameters?
(Dr. Monge Garcia) We still see changes, but probably the reasons are different. I mean it would be absolutely different if you try to increase PEEP level in a patient with a normal respiratory compliance, because the effects on the preload and afterload will be different [than] in a patient with a stiffer lung. [In] patients with normal respiratory compliance, the impact will likely be higher in the preload and also in the afterload, but in patients with ARDS lung, increasing PEEP level could have two effects. If you are able to recruit the lung you will see probably an improvement in right ventricular afterload, but if you increase the PEEP level and you are not able to recruit the lung, you probably increase the right ventricular afterload, and you are going to impair the right ventricular function. So in both patients you could see a decreasing cardiac output, but the reasons are absolutely different.
(Desiree Chappell) What about fluid responsiveness of these patients and doing fluid challenges and things like that? Is that something that you’ve employed?
(Dr. Monge Garcia) Yes, I think it’s important to use those parameters over the static parameters. Always try to use the dynamic parameters, but at the same time it’s important to remember what the limitations [are] of those parameters. If we are going to ventilate those patients with low tidal volumes or if those patients have a low respiratory compliance, we should remember that the reliability of those parameters are not good. So probably the threshold and the sensitivity and specificity of those parameters are not exactly the same as in patients with normal and healthy lungs. So it could be helpful, for example, to decide if we should give fluids or not, but always keeping in mind those limitations. It’s not only the PPV or SVV, the pulse pressure variation or the stroke volume variation; we have other maneuvers. For example, the passive leg raising and even you can try the modified version of the passive leg raising, in patients in prone position because the only thing that you have to do is to change the position of the patient with the bed down and you can check the increase in the cardiac output. So it’s easy to do at the bedside if you have a monitor to check the changing cardiac output. That’s the most important thing.
(Dr. Monge Garcia) In conclusion, I think it’s important to remember that the management of these patients is not only respiratory management. I think it’s important to remember that our ventilatory support will have effects on the hemodynamic status of the patients, and the only way to check the impact of respiratory management is checking the changes in cardiac output and blood pressure, and we should use hemodynamic monitoring. But I think it’s [also] important to remember that the information coming from the hemodynamic monitoring could help us to understand the underlying problems in these patients. So it’s not only a solution for giving a clue about what is happening to the patient, but it’s also useful for telling to us if our treatment is the right treatment or not.
(Desiree Chappell) That’s fantastic. Ignacio, thank you so much for taking the time out, and you did a fabulous job of explaining all that. Good luck in everything that you’re doing out there on the front lines. Thank you for everything that you’re doing and take care.
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