I’ve been on an ICU rotation for 10 days so far. We have several COVID patients on the unit right now on ventilators and I’m part of the team that rounds on them twice a day

I wanted to share some interesting things about COVID that I wouldn’t have known without being in the ICU

So first of all, the number one thing you can’t help but notice is that COVID patients stay longer than anyone else in the ICU.

The patients I’ve seen with massive hemorrhage, pulmonary embolisms, septic shock and all kinds of other serious conditions leave the ICU much quicker

Progress seems to be incredibly slow with COVID patients. It could be we don’t have sufficient understanding of their disease processes or well-developed treatments but we’re really throwing everything we can at these patients

Massive doses of steroid, Remdesevir, incredibly aggressive diuresis, proning etc... You name it, they’re getting it

Even with their vent settings, we’ll have them stable for days and then try to wean them down with incredibly minor adjustments like decreasing PEEP something small from like 8 to 7, they tank immediately and sat at 80%. Then we have no choice but to go back to what we were doing

This makes treating them incredibly difficult. In other patients on vents, we can make huge jumps in PEEP or FiO2 or tidal volumes in a single day or two once we’ve addressed their underlying problem, but you cannot achieve this COVID patients whatsoever.

Ive yet to actually see a COVID patient successfully taken off the ventilator. Of the four patients my team follows, three were already here before I started rotating, only one of which is getting close to a spontaneous breathing trial on what I believe is hospital day 17 for him

Getting off the vent, I imagine, is really only the beginning of their problems. There are consequences to having COVID pneumonia and being on ventilator support for weeks at a time, most of which I think will become lifelong issues for these people.

The main thing occurring in patients’ lungs with COVID is ARDS, where their lung parenchyma is basically soaked like a sponge in its own inflammatory fluid

No doubt this will end up causing irreversible lung fibrosis. I’m certain if these patients survive, theyll require home O2

So aside from never returning to baseline in terms of respiratory status, the other problem I foresee is severe muscle atrophy

The entire time these patients are on vents, they’re on neuromuscular blocking agents and sedatives like midazolam, cisatracurium and dexmedetomidine

These medications are necessary to have a ventilator tube sitting in your trachea for days on end.

Accordingly these patients essentially lie motionless the entire time here and their muscle mass, including that of their diaphragm which they aren’t using, is slowly wasting away

In addition to the neuromuscular damage from disuse, their already weak muscles are being attacked in another way; via the incredibly large amounts of steroids we’re giving them.

I was taught that the goal of putting a patient on steroids is to get them off steroids, because the side effects are both countless and severe.

The side effects of steroids I’m primarily concerned with here is the myopathy which further exacerbated their muscle damage.

For our COVID patients however, we have no choice but to hit them with a ton of IV steroids for how ever long it takes to reduce their lung inflammation

I think when you combine the severe and persistent ARDS that COVID causes, the lung fibrosis imminent for patients, and the damage to their diaphragm from long periods of immobilization and drug induced myopathy, it’s no surprise that weaning them off the vent is a difficult task

But that’s just how it goes with COVID, it seems. Progress is slow, and patients need ventilators for a long time to keep breathing and stay alive, but the longer they stay on the ventilator, the harder it becomes to get them off of the ventilator.