[CG] COVID 19 HDU Level Admission

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Inform consultant obstetrician and consultant anaesthetist on admission

Transmission

Droplets produced when an infected person breathes or coughs carry viruses that may be inhaled. Droplets spread about 1-2 metres. Droplets remain infectious when they settle on surfaces, can contaminate hands and then be carried to nose or mouth. Incubation time 1 - 14 days, average 5 days. Duration of infectivity unknown – up to 21 days?

PPE

Contact precautions (gloves, waterproof apron, eye protection, FRSM) - minimal acceptable standard.

Clinical features

65-80% cough; 45% febrile on presentation (85% febrile during illness); 20-40% dyspnoea; 15% URTI symptoms; 10% GI symptoms. Symptom duration up to 3 weeks. Respiratory failure / pneumonia occurs after 5 - 7 days of symptoms

Investigations

FBC, U&E, LFTs, CRP, Coag (use COVID blood set on trakcare)

ABG are not req’d for initiating O2 Rx. ABGs should be measured as standard in deteriorating or drowsy patients if results would potentially alter management

Nasal and throat swab and if producing sputum, a sputum sample are mandatory – send both on admission. Repeat at 24hrs if -ve and ongoing high clinical suspicion

Other as clinically appropriate e.g. blood/urine/stool cultures, troponin, ECG, viral gargle if influenza-like illness

CXR: compulsory. May be normal or show hazy bilateral, peripheral opacities or other condition.

Consider CT if would change Rx (eg ?PE)

Laboratory features

Renal failure, leukopenia/lymphopenia (80%), ↑AST/ALT/bilirubin, ↑D-dimer, ↑ CRP, ↑ LDH, ↑ferritin

Management

Airway Anaesthetic assessment on admission
Breathing Continuous SpO2, hourly RR, CXR
Art line
O2 to maintain SpO2 ≥ 94%
If SpO2 <94% on 4L NC or 35% O2 or rising RR (≥30) - Immediate anaesthetic review, ABG and discussion with ICU / obstetrician / neonatology to plan immediate care

Circulation


Remember left lat tilt

HR, BP, CRT, catheterise, hourly UOP
Fluid resus on admission if required with 250ml boluses of Hartmanns then review
Accurate hourly fluid balance
Aim even fluid balance after initial resus
Echo if unstable
Disability AVPU / GCS / BM
Exposure Hourly temp
Ensure all relevant cultures sent
Don’t forget other common causes of sepsis
LMWH as protocol
Fetus Consider delivery on a case by case basis based on maternal condition, disease trajectory and gestation of fetus (consult with neonatology)
Fetal monitoring as directed by obstetricians
Steroids / MgSO4 as required for fetus

Other - The RECOVERY trial states that steroid therapy should be considered for 10 days or to hospital discharge, whichever is sooner, for adults unwell with COVID-19 and requiring oxygen (in pregnant adults, use oral prednisolone 40 mg once a day or intravenous hydrocortisone 80 mg twice a day).

Tocilizumab may be considered if SpO2<92% on air or requiring O2 and CRP ≥ 75 – discuss with a named consultant familiar with the management of covid pneumonitis within office hours - refer to PRM anaesthetic COVID guide and GGC guidance on Staffnet re exclusions / cautions. Data limited in pregnancy-consider risks vs benefits and discuss in multi-disciplinary forum.

Last reviewed: 01 March 2021

Next review: 01 March 2022

Author(s): PRM HDU

Version: 8.1