[Artigo] Care for Critically Ill Patients With COVID-19
Care for Critically Ill Patients With COVID-19
Initial reports suggest that COVID-19 is associated with severe disease that requires intensive care in approximately 5% of proven infections. Given how common the disease is becoming, as in prior major severe acute respiratory infection outbreaks — SARS (severe acute respiratory syndrome), MERS (Middle East respiratory syndrome), avian influenza A(H7N9), and influenza A(H1N1)pdm09 — critical care will be an integral component of the global response to this emerging infection.
The rapid increase in the number of cases of COVID-19 in Wuhan, China, in late 2019 highlighted how quickly health systems can be challenged to provide adequate care. Case-fatality proportions were 7-fold higher for patients in Hubei Province compared with those outside of the region, 2.9% vs 0.4%, emphasizing the importance of health system capacity in the care of patients who are critically ill with COVID-19.
This article discusses issues pertaining to regions where critical care units have the capacity to provide mechanical ventilation, acknowledging that this capacity does not exist in many regions and that capacity could be exceeded in many places. This differential ability to manage the disease will likely have a substantial influence on patient outcomes.
Factors Associated With Requiring Intensive Care
Appreciating typical clinical features and disease course are crucial both to prepare for increasing numbers of patients and to determine how to best treat infected persons. Patients who have required critical care have tended to be older (median age ≈60 years), and 40% have had comorbid conditions,commonly diabetes and cardiac disease. Children generally have been observed to experience a milder illness, although perinatal exposure may be associated with substantial risk. The small numbers of pregnant women infected thus far have had a mild course, but limited cases make predictions about disease course uncertain; however, severe illness in pregnant women was amajor concern with influenza A(H1N1)pdm2009. The median duration between on set of symptoms and ICU admission has been 9 to 10 days, suggesting a gradual deterioration in the majority of cases. The most documented reason for requiring intensive care has been respiratory support, of which two-thirds of patients have met criteria for acute respiratory distress syndrome (ARDS).
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