ROYAL FREE COVID-19 ICU

BEDSIDE RESOURCE PACK

1. Daily ICU management algorithm

2. ICU COVID-19 Ventilation strategy
3. ICU Hypoxaemia Guideline
4. ICU Proning Guideline
5. COVID-19 Intubation Checklist
6. ICU Infusion Chart
7. ICU COVID-19 Enteral Feeding Protocol
8. Useful contact numbers

Useful links
MicroGuide
https://viewer.microguide.global/RFL-RNOH/ADULT
RFH Anaesthesia COVID-19 guidelines
https://rfanaesthesia.org/covid-19
 Suggested ICU management for COVID-19 patient with respiratory
DAILY COVID-19 ICU failure requiring ventilatory support
MANAGEMENT ALGORITHM For nursing & medical staff who do not regularly work in ICU
Please ask ICU for urgent review if concerns not met by algorithm

Intubation See intubation SOP

Subglottic suction ETT with in-line tracheal suction
Size: Female 7 / Male 8. Do NOT cut tube
Tubes & Lines

Daily check of length of ETT at incisors/ cuff pressure

ETT ETT clamp at bedside for disconnections (essential only eg transfer between ventilators)
HME filter & ETCO2 monitor attached within circuit
Cuff leak – discuss with Anaes/ICU ?tube change / direct laryngoscopy (?herniation through cords)
>10-14 days ventilated – discuss with ICU ?tracheostomy
Arterial line & CVC 4 lumen - consider changing after 7 days
Lines & NG PVC – 3-5 days with daily review (VIP)
Fine bore NG
Targets Aim: pH>7.2, SpO2 90 - 96%, pO2 >8kPa + permissive hypercapnia

Tidal volume 6ml/kg predicted body weight

Initial ventilator Pressure Control Ventilation / SIMV (PC) +PS
settings FiO2 1.0, PEEP 10 cmH2O, I:E ratio 1:1.5, RR 15-25, plateau airway pressure < 30 cmH2O
- Discuss with Anaes/ICU before increas
See ICU Hypoxaemia Guideline - consider:
Ventilation

1. I:E ratio to 1:1

Refractory 2. Increase PEEP as per guideline
hypoxaemia 3. Neuromuscular blockade – Atracurium 50mg bolus ± 40mg/hr infusion, aim TOF 2
- Alternatives: Rocuronium 50mg / Pancuronium 4mg (every 1-1.5hrs)
(P/F ratio < 4. Prone ventilation (ideally overnight for 16hrs) – see ICU Proning Guideline
20kPa) - Discuss with Anaes/ICU + refer to proning team
- Clamp ETT when turning
Assess for sputum plugging, pneumothorax, secondary infection
Aim wean to Pressure Support CPAP if able
FiO2 40%
Stable for 12 hours – discuss with Anaes/ICU ?plan for extubation to facemask / ?Optiflow
Propofol 1% (max 4mg/kg/hour IBW) & Fentanyl 2500mcg/50ml (1-4ml/hr)
Sedation

Agents Switch to Midazolam & Fentanyl if hypotension problematic

Titrate to RASS score (aim -4 to -5 if refractory hypoxaemia)
Consider sedation hold - discuss with Anaes/ICU
FiO2 40%
Consider Clonidine (750mcg/50ml) if agitated and high BP (start at 15mcg/hr)
Targets MAP>65; 70-75 if PMH hypertension
Pressure

1st line vasopressor is Noradrenaline - use 8mg/50ml (160mcg/ml) to minimise syringe changes
Blood

Noradrenaline >0.5mcg/kg/min – discuss with Anaes/ICU to consider:

Vasopressor - Argipressin 20units/50ml- stored in fridge (0.6-2.4 units/hr)
- Echo/Flotrac and adding Dobutamine
- Hydrocortisone 50mg IV QDS
Aim negative to neutral FB
No maintenance fluids - cautious fluid bolus (Hartmanns 250ml) only if increasing NAd requirement
Fluids & Feed

Fluid balance
Accept UO >0.5ml/kg/hr
Refer to ICU for CRRT if fluid overload, acidosis, severe electrolyte disturbance
See ICU Enteral Feeding Protocol
NG tube placement checked with CXR
NG feed
Start NG feed (Jevity Plus HP) as per ICU protocol (start at 20ml/hr & increase) -
Add prokinetics if high NG aspirates (Metoclopramide 10mg IV TDS)
ICU Daily Orderset on Cerner (à ICU Covid Daily)
Daily panel Procalcitinon days 1&3
Blood Tests

Admission – ICU Admission Orderset (à ICU Covid Admission) + bHCG if female <55yrs
Hb Target Hb >70 unless symptomatic cardiac disease
Electrolytes Aim K 4.5-5, Mg >1.0, iCa >1.2, PO4 >0.7 (pre-printed on ICU drug chart, KCl & Mg via CVC only)
Glucose Insulin (Actrapid) sliding scale if blood glucose >11
Drugs &
See ICU infusion chart for guidance on dosage, administration and dilution
Infusions
Prescription

Ulcer prophylaxis Ranitidine 50mg IV TDS or Omeprazole 40mg IV OD (if on dual antiplatelet therapy)
VTE prophylaxis Inhixa 40mg SC OD (if 50-100kg, BD if >100kg) – alter dose for GFR < 30ml/min or other weights
Micro Antibiotics as per Microguide / ID advice (eg VAP)
Bowels Consider senna/ lactulose or enema if BNO 3 days
Positioning Head up 30 degrees
Other

Temperature Paracetamol, cold cloths, clothing removal as required

This guide aims to achieve a standard of care for staff in remote areas with COVID-19 patients and will NOT cover all scenarios
Refer to ICU for help/advice and for clarification on resuscitation limits if clinical deterioration
 ICU management of respiratory failure
in suspected or confirmed COVID-19

Confirmation of CV19 ARDS:

• Positive RT-PCR
• High clinical suspicion of CV19
• Bilateral patchy consolidation
• ± lobar consolidation

Conventional O2 therapy
FAILURE = SpO2 < 92% on 60% oxygen

Trial of CPAP / NIV*

FAILURE =↓SpO2, ↓RR, ↑work of breathing

Intubation +
mechanical ventilation

Best practice: Ventilation targets:

• Adequate sedation
• Pressure control OR pressure
regulated volume control modes
• Tidal volume 6 ml/kg
• Initial PEEP 8 cmH2O
• RR to keep PaCO2 4.5-5.5 kPa
• Maintain neutral fluid balance if not
in septic shock
• Use low dose vasopressor to
maintain adequate MAP
If mechanical ventilation fails to
resolve hypoxaemia consider
ECMO referral. General criteria:
• PaO2/FIO2 < 13.3kPa
• Severe hypercapnic acidosis (pH <
7.20)
• Inability to achieve tidal volume < 6
ml/kg & plateau pressure <
30cmH2O
• Failure of proning
• Significant air leak / bronchopleural
fistula
• SpO2 92-96%
• PaO2 ≥ 8kPa
• PaCO2 < 6 kPa or pH > 7.30
• Pplat ≤ 28 cmH2O
FAILURE = SpO2 < 92% on
60% oxygen
Secondary measures:
• Neuromuscular blockade
• Increase PEEP as per
ARDSnet table** (PEEP > 15
cmH2O may not be of benefit)
FAILURE • Proning**
• APRV mode (Maquet only)
• Lower SpO2 target (90-94%)
*See trust CPAP guidance
**See ARDSnet table on next page
***see ICU proning guidelines

Royal Free Hospital CV19 Respiratory Failure Guidance March 2020. Adapted from St Thomas’ Hospital Guidance.
 ARDSnet suggested PEEP levels

F IO 2 Low High PEEP table does not need to be

PEEP PEEP followed precisely, it is meant to act
as a guide. The WHO recommend
0.3 5 5-14 following the high PEEP strategy for
0.4 5 14-16 COVID-19. Tidal volume may have
to be lowered if the high PEEP
0.5 8 16-18 strategy is followed in order avoid
0.6 8 20 excessive plateau pressures.

0.7 12-14 20
0.8 14 20
0.9 14-18 22
1.0 18-24 22-24

Royal Free Hospital CV19 Respiratory Failure Guidance March 2020. Adapted from St Thomas’ Hospital Guidance.
 Adequate haemoglobin is therefore essential for optimal oxygen DO2 = 3.5 6 {[0.9 6 100 6 1.3] + [60 6 0.003 6 10]}
content (CaO2) of blood. The ideal haemoglobin level for Although this value is still above the V̇O2 at resting
optimal CaO2 and therefore for optimal DO2 has long been a physiology, in practice the V̇O2 would most likely have risen
subject of debate. Previous practices have favoured haemoglobin owing to a number of factors such as increased work of
Intensive
levels close to Care Unit
100 g/l (10 g/dl), providing adequate CaO2 as well breathing and increased catabolic state of sepsis. This example is
as reducing viscosity of blood for better perfusion in critically ill not rare and occurs daily in clinical practice. It is therefore
ROYAL FREE HOSPITAL
patients. However, studies by Canadian researchers in the late important not to consider oxygen therapy in isolation. As many
1990s have shown that haemoglobin levels of 70 g/l (7 g/dl) patients may not have adequate haemoglobin, cardiac output or
were as safe as higher levels and may produce fewer complica-GUIDELINES FOR THE MANAGEMENT OF HYPOXAEMIA
blood volume, they may suffer from tissue hypoxia when they
tions in the critically ill.55 However, this study was conducted become acutely ill. All such patients should have supplemental
using non-leucocyte depleted blood and it is possible that some oxygen therapy until they are evaluated by a responsible
Aim:
of theTo provide
infective guidanceinfor
complications thethe management
group of patients
who were given withprofessional.
healthcare hypoxaemia on ICU.
more transfusions might have been avoided by the use of
Scope: All adult patients on the ICU with hypoxaemia.
leucocyte-depleted blood. The optimal transfusion target for
SECTION 6: HYPOXIA, HYPEROXIA, HYPERCAPNIA AND THE
critically ill patients therefore remains the subject of ongoing
Definitions: Hypoxaemia is a blood oxygen level
discussion among experts in critical care medicine. Although the
that is less than
RATIONALE OF normal,
TARGETEDwhich
OXYGENisTHERAPY
age dependent. In terms
ofissue
arterial partialhaemoglobin
of optimal pressure of in oxygen (PaOunstable
patients with 2), normal
or is 6.1
approximately 10.5
Effects and risks to 13.5
of hypoxia andkPa. Oxygenation
rationale can also
for target oxygen
besymptomatic
assessed using
coronaryarterial oxygen
artery disease saturation
is not (SaO2) from
settled, haemoglo- a bloodrange
saturation gas and peripheral oxygen saturation (SpO2)
As this guideline is addressing emergency oxygen therapy, this
from an oxygen
bin levels of 100 g/lsaturation
(10 g/dl) areprobe. Hypoxaemia
recommended can be
for adequate defined
section by focus
will only the onPaO to fractional
the2 effects and risks ofinspired oxygen
acute hypoxia.
DO2 (see box).
concentration ratio (FIO2) ratio (P/F ratio). For patients with acute respiratory distress syndrome
Section 8 will discuss the emergency treatment of acute hypoxia (ARDS),
the severity
5.6.3 Optimisingofdelivery
hypoxaemia according to the P/F ratio is: in mild = 40.0
patients – 26.8; moderate
with long-term = 26.7 with
diseases associated – 13.4; severe
chronic
Besides adequate CaO2 and PaO2, delivery of oxygen depends upon hypoxia. The approximate relationship between PaO2 and SaO2
=adequate
<13.3.flow Respiratory failure can be categorised
of oxygenated blood. Cardiac output in turn
into type 1 (normocapnic hypoxaemia)
is shown in table 8 and fig 3 (oxygen dissociation curve).
and type 2
(hypercapnic
depends upon hypoxaemia).
adequate blood (circulating) volume, adequate The effects and risks of hypoxia are summarised in table 9.
venous return and adequate and optimal myocardial function. To Severe hypoxia may lead to brain damage and death. In general,
Table relating SaO2 to PaO2
Table 8 Approximate relationship between arterial blood saturation (SaO2) and arterial oxygen tension (PaO2) 60

PaO2 (kPa) 4 5 6 7 8 9 10 11 12 13 14 15 16 >17

PaO2 (mm Hg) 30 37.5 45 52.5 60 67.5 75 82.5 90 97.5 104 112.5 120 >127.5
SaO2 (%) 57.4 71.4 80.7 86.8 90.7 93.2 94.9 96.2 97.0 97.8 98.2 98.6 98.8 >99.0

Table to calculate
Thorax 2008;63(Suppl VI):vi1–vi68.P:F ratio from PaO2 and FIO2
doi:10.1136/thx.2008.102947 vi21

Fractional inspired oxygen concentraion (FIO2)

0.21 0.25 0.30 0.35 0.40 0.45 0.50 0.55 0.60 0.65 0.70 0.75 0.80 0.85 0.90 0.95 1.00
4.0 19.0 16.0 13.3 11.4 10.0 8.9 8.0 7.3 6.7 6.2 5.7 5.3 5.0 4.7 4.4 4.2 4.0
4.5 21.4 18.0 15.0 12.9 11.3 10.0 9.0 8.2 7.5 6.9 6.4 6.0 5.6 5.3 5.0 4.7 4.5
5.0 23.8 20.0 16.7 14.3 12.5 11.1 10.0 9.1 8.3 7.7 7.1 6.7 6.3 5.9 5.6 5.3 5.0
5.5 26.2 22.0 18.3 15.7 13.8 12.2 11.0 10.0 9.2 8.5 7.9 7.3 6.9 6.5 6.1 5.8 5.5
Arterial partial pressure of oxygen (PaO2)

6.0 28.6 24.0 20.0 17.1 15.0 13.3 12.0 10.9 10.0 9.2 8.6 8.0 7.5 7.1 6.7 6.3 6.0
6.5 31.0 26.0 21.7 18.6 16.3 14.4 13.0 11.8 10.8 10.0 9.3 8.7 8.1 7.6 7.2 6.8 6.5
7.0 33.3 28.0 23.3 20.0 17.5 15.6 14.0 12.7 11.7 10.8 10.0 9.3 8.8 8.2 7.8 7.4 7.0
7.5 35.7 30.0 25.0 21.4 18.8 16.7 15.0 13.6 12.5 11.5 10.7 10.0 9.4 8.8 8.3 7.9 7.5
8.0 38.1 32.0 26.7 22.9 20.0 17.8 16.0 14.5 13.3 12.3 11.4 10.7 10.0 9.4 8.9 8.4 8.0
8.5 40.5 34.0 28.3 24.3 21.3 18.9 17.0 15.5 14.2 13.1 12.1 11.3 10.6 10.0 9.4 8.9 8.5
9.0 42.9 36.0 30.0 25.7 22.5 20.0 18.0 16.4 15.0 13.8 12.9 12.0 11.3 10.6 10.0 9.5 9.0
9.5 45.2 38.0 31.7 27.1 23.8 21.1 19.0 17.3 15.8 14.6 13.6 12.7 11.9 11.2 10.6 10.0 9.5
10.0 47.6 40.0 33.3 28.6 25.0 22.2 20.0 18.2 16.7 15.4 14.3 13.3 12.5 11.8 11.1 10.5 10.0
10.5 50.0 42.0 35.0 30.0 26.3 23.3 21.0 19.1 17.5 16.2 15.0 14.0 13.1 12.4 11.7 11.1 10.5
11.0 52.4 44.0 36.7 31.4 27.5 24.4 22.0 20.0 18.3 16.9 15.7 14.7 13.8 12.9 12.2 11.6 11.0
11.5 54.8 46.0 38.3 32.9 28.8 25.6 23.0 20.9 19.2 17.7 16.4 15.3 14.4 13.5 12.8 12.1 11.5
12.0 57.1 48.0 40.0 34.3 30.0 26.7 24.0 21.8 20.0 18.5 17.1 16.0 15.0 14.1 13.3 12.6 12.0
12.5 59.5 50.0 41.7 35.7 31.3 27.8 25.0 22.7 20.8 19.2 17.9 16.7 15.6 14.7 13.9 13.2 12.5
13.0 61.9 52.0 43.3 37.1 32.5 28.9 26.0 23.6 21.7 20.0 18.6 17.3 16.3 15.3 14.4 13.7 13.0
13.5 64.3 54.0 45.0 38.6 33.8 30.0 27.0 24.5 22.5 20.8 19.3 18.0 16.9 15.9 15.0 14.2 13.5
14.0 66.7 56.0 46.7 40.0 35.0 31.1 28.0 25.5 23.3 21.5 20.0 18.7 17.5 16.5 15.6 14.7 14.0
14.5 69.0 58.0 48.3 41.4 36.3 32.2 29.0 26.4 24.2 22.3 20.7 19.3 18.1 17.1 16.1 15.3 14.5
15.0 71.4 60.0 50.0 42.9 37.5 33.3 30.0 27.3 25.0 23.1 21.4 20.0 18.8 17.6 16.7 15.8 15.0

SEVERITY OF HYPOXAEMIA Severe

According to P:F Ratio Moderate
Mild
Nil

Key points:
1. Identify the presence of hypoxaemia
• SpO2, PaO2, P/F ratio, Alveolar-arterial (Aa) oxygen difference, clinical cyanosis, high FIO2.
2. Identify the cause of hypoxaemia
• Physiologically, the causes could be:
o Ventilation:perfusion (V/Q) mismatch: the commonest cause of hypoxaemia on ICU e.g.
pneumonia and pulmonary embolism
o Right-to-left shunt (cardiac abnormality or pulmonary pathophysiology)
o Diffusion impairment at the alveolar membrane
o Hypoventilation e.g. secondary to opioids
o Low inspired FIO2 (only usually encountered at high altitude)
• History of acute and chronic respiratory disease and full clinical examination
• Laboratory tests:
o Haematology and biochemistry.

Written by: Daniel Martin Date of RFL Drugs and Therapeutics Committee approval: March 2019 Date of review: March 2021
This guide is for reference only and for interpretation by clinical healthcare professionals. The authors do not accept any responsibilities in any form
in relation to the use and interpretation of this document.
 Intensive Care Unit
ROYAL FREE HOSPITAL
o Microbiology: Sputum sample, viral nasopharyngeal aspirate, atypical pneumonia screen, blood
cultures, immunoassays e.g. PCP, HIV, Tuberculosis, immunoglobulins, antigens, and consider
airborne high consequence infectious diseases (HCID).
o Autoimmune screen e.g. vasculitis and complement screen.
• Imaging:
o Chest x-ray.
o CT chest (± high resolution CT chest).
o CT pulmonary angiogram.
o Echocardiogram, in particular to assess right sided function and pulmonary artery pressure.
o Doppler studies of lower limbs for deep vein thrombosis.
• Bronchoalveolar lavage (if intubated).
3. Respiratory support
• Basic oxygen supplementation:
o Variable performance mask: nasal cannulae, ‘Hudson’ mask.
o Fixed performance mask: Venturi mask, non-rebreathe mask, Water’s circuit.
• High flow nasal cannulae e.g. Optiflow™ for hypoxaemia without high CO2.
• Continuous positive airway pressure (CPAP) for hypoxaemia without high CO2.
• Non-invasive ventilation (BiPAP) for hypoxaemia with high CO2.
• Invasive mechanical ventilation via an endotracheal tube – when other measures have failed.
INVASIVE VENTILATION
• Basic ventilator settings:
o “Protective lung ventilation” should be the standard for all patients.
o Calculate predicted body weight and document target tidal volume clearly on patient chart, which
should be no greater than 6-7 ml/kg.
o Use the pressure control mode of ventilation unless contraindicated.
o Use positive end-expiratory pressure (PEEP) to improve PaO2; this will increase the surface area
OXYGENATION GOAL:
for gas PaO2 55-80
exchange, mmHg
reduce or SpO2 88-95%
atelectasis and redistribute lung water.
Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP
combinations
Table such as shown
of suggested PEEPbelow (notFrequired)
and to achieve
IO2 settings goal. the ARDSnet guidelines)
(from
Lower PEEP/higher FiO2
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7
PEEP 5 5 8 8 10 10 10 12

FiO2 0.7 0.8 0.9 0.9 0.9 1.0

y PEEP 14 14 14 16 18 18-24

Higher PEEP/lower FiO2

FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5
PEEP 5 8 10 12 14 14 16 16
consistent with
FiO2 0.5 0.5-0.8 0.8 0.9 1.0 1.0
PEEP 18 20 22 22 22 24

o Consider equal or inverse ratio ventilation (i.e. increasing the inspiratory time) if hypoxaemia
__________________________________________________________
does not resolve
PLATEAU PRESSURE GOAL: 30 andcmCO 2 retention is not a significant issue. Note, this has no proven survival
H 2O
Check Pplatbenefit butinspiratory
(0.5 second may provide temporary
pause), at least q 4hrelief of hypoxaemia.
and after each
• change in PEEPtargets
Suggested or VT. in the hypoxaemic patient:
BW If Pplat > 30 cm H2O: decrease VT by 1ml/kg steps (minimum = 4
6ml/kg PBW. ml/kg).o Plateau pressure <30 cmH2O.
ion (not > 35 o < PaO
If Pplat 25 cm2 8-9
H2OkPaand or
VT<SpO 2 of 88-92%.
6 ml/kg, increase VT by 1 ml/kg until
Pplat >
o25 Absolute
cm H2O or VPaCO
T = 6 ml/kg.
2 may not necessarily be important to target, if pH <7.30 then increase respiratory
goals below. If Pplat < 30 and breath stacking or dys-synchrony occurs: may
increase VT rate to reduce
in 1ml/kg PaCO
increments 2. 8 ml/kg if Pplat remains < 30 cm
to 7 or
H2O.
ADJUNCTS TO INVASIVE VENTILATION
• Sedation and paralysis:
o Adequate sedation will facilitate better patient synchronisation with ventilator. Do not under
sedate, particularly in first 24-48 hours if severely hypoxaemic.

Written by: Daniel Martin Date of RFL Drugs and Therapeutics Committee approval: March 2019 Date of review: March 2021
This guide is for reference only and for interpretation by clinical healthcare professionals. The authors do not accept any responsibilities in any form
in relation to the use and interpretation of this document.
Intensive Care Unit
ROYAL FREE HOSPITAL
o Paralysis reduces oxygen consumption and CO2 production, and further improves
synchronisation with ventilator.
• Fluid balance:
o Careful fluid balance is essential, neutral balance is preferable if tolerated from a haemodynamic
perspective.
• Positioning:
o Head up 30 degrees is ideal. Observe the effect of left-right tilting.
o For patients with moderate/severe ARDS (PF ratio <20 kPa), prone positioning is recommended
for a minimum of 12 hours per day. Consider proning EARLY – seek senior advice before proning
a patient (see ICU proning guideline).
• Physiotherapy for secretion management and patient optimisation.
• Referral to respiratory team.
• Recruitment manoeuvres:
o There is no evidence to support the use of recruitment procedures and they may result in
significant harm if performed incorrectly.
4. Referral to tertiary respiratory centre
• The Royal Brompton Hospital (Tel: 02073518585) is our referral centre.
• The general referring criteria are as follows:
o Severe hypoxaemia (PF ratio <13.3 kPa).
o Severe hypercapnic acidosis (pH <7.20).
o Inability to achieve lung protective tidal volumes and pressures (tidal volume <6ml/kg predicted
body weight, plateau pressure <30 cmH2O).
o Failure to improve with rescue therapies such as high-frequency oscillation and prone positioning.
o Significant air leak/bronchopleural fistula.

5. Other points to consider

• Consider more than one pathology if treatment and support is ineffective.
• Respiratory isolation will be necessary if a HCID is suspected (see specific ICU guidelines).

Additional information:
Intensive Care Society Guidelines on the management of ARDS (2018):
https://www.ficm.ac.uk/sites/default/files/ficm_ics_ards_guideline_-_july_2018.pdf

Written by: Daniel Martin Date of RFL Drugs and Therapeutics Committee approval: March 2019 Date of review: March 2021
This guide is for reference only and for interpretation by clinical healthcare professionals. The authors do not accept any responsibilities in any form
in relation to the use and interpretation of this document.
Intensive Care Unit
ROYAL FREE HOSPITAL
GUIDE TO PRONE POSITIONING FOR PATIENTS
WITH SEVERE HYPOXAEMIA
Aim: To provide guidance on the use of prone position ventilation on the ICU.
Scope: Adult mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS) and
refractory hypoxaemia who have failed to improve with other interventions.
Definitions: The turning of a patient prone (face down) in order to improve oxygenation when there is
severe hypoxaemia, often secondary to ARDS.
Key points
• Early proning in patients with severe ARDS has been shown to reduce 28 day mortality and increase
ventilator free days (PROSEVA trial) and should therefore be considered early in patients with severe
ARDS with refractory hypoxamia.
• Consider proning in patients with moderate/severe ARDS with a (PaO2/FIO2) P/F ratio of <20 kPa, after
other attempts have been made to improve oxygenation.
• Seek senior advice before proning a patient.
• Complications include endotracheal tube displacement, pressure sores, loss of venous access, and
haemodynamic instability.
• The benefits of pronong are often sustained for a number of hours after returning to supine; if there is
no benefit then repeated attempts are unlikely to be successful.
Contraindications to proning:
Relative:
• Cardiovascular instability
Absolute:
• Recent thoracic/abdominal surgery
• Spinal instability
• Increased intra-abdominal pressure
• Open wounds to abdomen/face
• Extreme obesity/gross ascites
• Life threatening cardiac arrhythmias
• Intra-aortic balloon pump
• Pregnancy in 2nd/ 3rd trimester
• Pelvic fractures
• Tracheostomy <24 hours
• Massive haemoptysis
• Raised intracranial pressure
• Facial/eye injury
• Anterior chest drains

Considerations prior to proning:

• Ensure relevant clinical activities have happened, e.g. scans, line changes, drain insertion/removal,
pressure areas checked and documented, wound dressings.
• Ensure appropriate staff available: airway trained person and four additional people.
• Clean and lubricate the eyes, then tape shut.
• Assess pressure areas and apply dressings to bony prominences, apply soft silicone gel pads to facial
pressure areas.
• Ensure nasogastric tube is secured, length documented and aspirated.
• Ensure adequate sedation/paralysis.
• Document observations prior to turning prone.
• Disconnect non-essential infusions and ensure all essential infusion lines have enough slack in them.
• Reposition infusion lines so that all lines above the waist go upwards and those below waist go
downwards.
• Ensure airway trolley is available by the bed space.
• Remove ECG electrodes from patient’s chest and reposition on their back and sides.
• Ensure the endotracheal tube is secured and move to side of mouth that will be upwards; check the
length of the endotracheal tube at teeth and record it.

Written by: Daniel Martin Date of RFL Drugs and Therapeutics Committee approval: March 2019 Date of review: March 2021
This guide is for reference only and for interpretation by clinical healthcare professionals. The authors do not accept any responsibilities in any form
in relation to the use and interpretation of this document.
Intensive Care Unit
ROYAL FREE HOSPITAL
Suggested method for proning (“Cornish Pasty” technique):

1. Ensure the team is briefed and that everyone knows their role.
2. Place patient on 100% oxygen.
3. Place slide sheet and sheet underneath patient.
4. Place pillow on chest and pelvis.
5. Place further sheet and slide sheet on patients front.
6. Move patient to opposite side of bed from direction of roll to create space for the turn.
7. Place patient’s arms under patient’s hip palm upwards.
8. Roll sheets together at side of patient.
9. Roll to lateral position and recheck endotracheal tube and lines.
10. Continue to roll to prone position and recheck position of endotracheal tube and lines.
11. Tilt the whole bed so the patient is 10-20 degrees head up to reduce facial swelling.
12. Move head and limbs to desired position as shown below.
13. Rotate through positions shown below every 1-2 hours and then repeat with other arm raised.
14. Reconnect lines and restart enteral feed at slow rate.

For return to supine position similar technique should be adopted with the same attention to pre-turn
considerations

Considerations during proning:

• An arterial blood gas should be taken 1 hour after proning.
• Wean down the FIO2 as able to.
• Prone position should be maintained for 12 to 18 hours where possible; suggested times are 1600 to
0800 if possible.
• If the patient’s SpO2 falls below supine level for >10 minutes, a return to supine should be considered.
• Cessation of proning is reasonable after signs of improved oxygenation or for acute emergencies,
prolonged interventions or surgical procedures.
• Monitor for new pressure area formation.

Further information:
PROSEVA trial: https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
New England Journal of Medicine video on proning: http://www.youtube.com/watch?v=E_6jT9R7WJs

Written by: Daniel Martin Date of RFL Drugs and Therapeutics Committee approval: March 2019 Date of review: March 2021
This guide is for reference only and for interpretation by clinical healthcare professionals. The authors do not accept any responsibilities in any form
in relation to the use and interpretation of this document.
COVID Intubation in Theatres premala.nadarajah@nhs.net
Team: Royal Free Hospital, London

Staff Safety is the Priority – Read this Protocol

S Anaesthetist 1 Anaesthetist 2 O D P/A n a e s N u r s e
Prepare drugs Assemble Airway Tray (remove packaging)
T
Facemasks Size 4 & 5 x2
E
OUTSIDE

Tray 1
Catheter mount
Fentanyl 500mcg / 10ml
Check walkie talkies In-line suction mount
P Review Patient history
Ketamine 200mg/20ml
Propofol 200mg/20ml
HME x2
Guedel airway 2x sizes
S Lead Team Brief
Rocuronium 100mg/10ml
Saline flush 20 ml
Bougie x2
COETT 7 & 8
Syringe 20 ml
This is a Modified Rapid Tray 2 Tube tie + Eye tape
Sequence Induction Atropine 600mcg/2ml Yankauer suction

1 Ephedrine 30 mg/10ml
Metaraminol 10mg/20ml
Adrenaline 100mcg/10ml
Saline flush 20 ml
Bags for infected equipment
iGEL 4 and 5,
Surgical blade size 10, COETT Size 6
Pre-load COETT to Bougie
Check Videolaryngoscope (VL) + 2x blades

2 D ON N IN G PPE + 3 rd Set of G LOVES

Confirm machine check
3 Connect normal catheter mount
Attach monitoring to patient

Pre- Oxygenate
4 Facemask 2 handed
Avoid bagging/high flows
Fentanyl 1- 2 mcg/kg
5 Ketamine 1-2 mg/kg
or Propofol 2mg/kg
Rocuronium 1 mg/kg
INSIDE

Intubate
Switch to in-line
6 Video laryngoscope
Pre-loaded bougie suction mount
Assist
Connect to circle circuit

Inflate cuff 5-10 ml

7 Do not listen for cuff leak

Capnography to confirm
8 COETT placement only

9 Dispose of guedel, bougie, facemask

Keep VL blades in small bag

10 D I S P O S E O F 3 r d S E T o f G L O V E S
RFH ICU IV Drug Infusion Prescription Chart *$PRPR*

PATIENT NAME: Hospital Number: Date of Birth:

ALLERGIES: IBW: D c ignature to be

ABW: actual estimated signed each day
Drug Concentration Diluent Dose Range Adjusted Dose Range Date Date Date Date Date Date Date

Analgesia & Sedation use IBW unless stated otherwise

Fentanyl 50 0 – 300 (for IBW 70Kg) ___________ Doctor
Neat
2.5 mg in 50 ml microgram /ml microgram/hr
microgram/hr Pharm
Propofol 0 – 280 (for IBW 70Kg) ________mg/hr Doctor
10 mg/ml Neat
1 g in 100 ml mg/hr Max 4mg/kg/hr Pharm
Midazolam 0.9% 0 – 7 (for IBW 70Kg) ___________ Doctor
1 mg/ml
50mg in 50 ml NaCl mg/hr mg/hr Pharm

Clonidine 15 0.9% 0–140 (for ABW 70Kg) ___________ Doctor

750 microgram in 50ml microgram /ml NaCl microgram/hr microgram/hr Pharm

Acute Doctor
0.1
mg/kg/hr
__________
Ketamine Pain Pharm
0.9% mg/kg/hr
10 mg/ml
500 mg in 50 ml NaCl Doctor
Other
0.5 - 2
mg/kg/hr
_________
mg/kg/hr Pharm
Vasopressors and Inotropes
Noradrenaline CVC 160 5% 0.01 – 1 ___________ Doctor
8 mg in 50 ml microgram/ml Glucose microgram/kg/min microgram/kg/min Pharm
Adrenaline CVC 160 5% 0.01 – 1 ___________ Doctor
8 mg in 50 ml microgram/ml Glucose microgram/kg/min microgram/kg/min Pharm
Argipressin CVC 5% 0.6 – 2.4 ________ Doctor
0.4 unit/ml
20 units in 50 ml Glucose unit/hr unit/hr Pharm
Dobutamine CVC 5% 0.5 – 10 ___________ Doctor
5 mg/ml
250 mg in 50 ml Glucose microgram/kg/min
microgram/kg/min Pharm
Anti-Hypertensives and Anti-Arrhythmics
Labetalol CVC 20 - 150 ___________ Doctor
5 mg/ml Neat
300 mg in 60 ml mg/hr mg/hr Pharm
Esmolol 15 – 200 Doctor
10 mg/ml Neat microgram/kg/min ___________
2500 mg in 250 ml microgram/kg/min Pharm

5% Doctor
900mg in 50 ml 39mg/hr 23 hour infusion
Amiodarone CVC Glucose Pharm

5% Doctor
600mg in 50 ml 25mg/hr 24 hour infusion
Glucose Pharm
Glyceryl Trinitrate ___________ Doctor
50 mg in 50 ml 1mg/ml Neat 0.5 – 12 mg/hr
mg/hr Pharm
Insulin and Glucose
Actrapid 0.9% To maintain blood sugar Doctor
1 unit/ml
50 units in 50 ml NaCl between 4 10 mmol/l Pharm
5% 20 – 60 ml/hr ml/hr
Glucose 10% 30 – 40ml/hr ml/hr Doctor

20% - CVC 20 – 40ml/hr ml/hr

Other Pharm

Heparin MUST USE Unfractionated heparin Doctor

1000 unit/ml Neat ABW weight based IV infusion protocol
30,000 units in 30 ml Pharm

Epoprostenol 0.9% 0–5 ABW ___________ Doctor

5 microgram/ml
250microgram in 50ml NaCl nanogram/kg/min nanogram/kg/min Pharm
Vancomycin Initial rate: ________ ml/hr. See protocol Doctor
CVC:500 mg in 50ml 0.9% Saline OR and adjust rate according to levels.
P: 250 mg in 50 ml 5%Glucose Target range: 15 25 mg/l Pharm

Atracurium 20 – 60 Doctor
10 mg/ml Neat ___________
500 mg in 50 ml mg/hr mg/hr Pharm
Salbutamol 100 5% 3 - 20 ___________ Doctor
5 mg in 50 ml microgram/ml Glucose microgram/min microgram/min Pharm
IV fluids
Sodium chloride To maintain patency of arterial and venous 1 Litre Doctor
0.9% transduced lines over 72 hours Pharm
Hartmann s 250 ml Doctor
Solution FLUID BOLUS
over 5-10 min Pharm
Ha mann Doctor
Solution Maintenance ml/hr Pharm
Additional Infusions
Doctor
Pharm
Doctor
Pharm
Doctor
Pharm

F eci i fi f i i cl ded ab e lea e efe S a da d C ce ai f IV I f i ICU ICU hared drive. Feb 2018
 RFH ICU IV Drug Infusion Prescription Chart

ICU NURSING RECORD OF IV INFUSION ADMINISTRATION

Signatures
Date Time Drug Infusion Batch Time
Prepared Checked
Prepared Number Started
By by

F eci i fi f i i cl ded ab e lea e efe S a da d C ce ai f IV I f i ICU ICU hared drive. Feb 2018
Memo
To: All ICU Clinical Staff
From: Critical Care Pharmacy Team
Subject: Reducing Need for IV Syringe/Infusion Pumps
Date: 27th March 2020
As more patients are admitted IV infusion/syringe pumps may soon be in short
supply. To reduce the need for IV syringe/infusion pumps please follow
steps 1 to 5:
1. Administer FUROSEMIDE by BOLUS Injection (4mg/min) – no infusions.
2. Administer the following by BOLUS injection:
CEFTRIAXONE
MEROPENEM
TAZOCIN (Piperacillin/Tazobactam)
TEMOCILLIN
3. Use ENTERAL ELECTROLYTES where possible.
4. Consider using ENTERAL CLONIDINE 25 to 100micrograms QDS to wean
from IV clonidine.
5. If more infusion pumps are available than syringe pumps prepare
NORADRENALINE in a bag and use IV infusion pump instead of syringe pump.

If pumps are still needed after steps 1 to 5:

Administer NEUROMUSCULAR BLOCKERS by BOLUS injection
- Pancuronium 4mg PRN every 60-90mins (half-life 1 to 1.5hrs).
- Rocuronium initial load of 50mg, then 25mg (or 0.6mg/Kg) every 1-2 hours
according to TOF (half-life 1.4 to 2.4 hours).
*Note: Atracurium is too short-acting to allow bolus dosing.
Switch MIDAZOLAM infusion to bolus doses: 0.5 – 5mg bolus, repeated as
needed as per RASS score; midazolam half-life is ~ 3 hours.
If infusion pumps are still needed after all the above steps the NORADRENALINE back
up syringe could be kept pre-prepared at bedside but not set up in the syringe pump.
If you have any queries regarding drug administration please speak to a member of the
pharmacy team – bleep 1615, 4062, 1358, 1313.
 COVID-19
ICU Enteral Feeding Protocol
A restrictive fluid management strategy may be used for these patients, and the volume of enteral nutrition may need to be limited.
We recommend initiating with 1.3kcal/ml feed. If further restriction required switch to a 1.8kcal/ml (Nepro)
Some patients may experience GI intolerance and require periods of proning. Consider early initiation of prokinetics.
NJTs unlikely to be feasible in this patient group. Consider reserving a lumen on the central line if parenteral nutrition required
If persistent high GRVs despite prokinetic use please contact dietitians.

Day 1:
Start enteral feeding unless contraindicated within 24hrs of admission
Confirm nasogastric tube position as per Trust Guidelines before use

Commence feed using Jevity Plus HP @ 20ml/hr x 4 hours

Ensure head of bed at 35-45*
If feed stopped for procedure, restart at previous tolerated rate

Monitor gastric residual volume (GRV) 4 hourly

Aspirate with 50ml enteral syringe

GRV <300ml GRV 300-500ml GRV >500ml or Vomiting

Increase rate by 20ml/hr every 4
hours until target rate achieved
If GRV >200ml start
Metoclopramide 10mg IV TDS
(unless in acute liver failure)
Maintain feed rate, if 2 x
consecutive aspirates >300ml Reduce feed to 10ml/hr
reduce rate by 20ml/hr to a If vomiting, hold feed for 4
minimum of 10ml/hr hours& re-aspirate

Weight Target Rate Total Volume Target Rate Total Volume

(kg) Jevity Plus HP (ml) in 24hrs Nepro (ml) in 24hrs •Start Metoclopramide 10mg IV TDS
(1.3kcal/ml) (1.8kcal/ml) (unless in acute liver failure or suspicion of
(If further fluid
restriction
GI obstruction)
required) •Monitor GRVs 4 hourly
•If BNO refer to bowel management
<50 30ml/hr 720ml 25ml/hr 600ml
protocol
50-59 35ml/hr 840ml 30ml/hr 720ml

60 45ml/hr 1080ml 35ml/hr 840ml

Day 2:
•If GRVs remain >300mls after 24hrs of
metoclopramide, consider Erythromycin 250mg
IV BD
•Monitor GRVs 4 hourly
Day 3:
•If GRVs remain >300mls after 24hrs
Erythromycin and failure to progress enteral
feed due to ongoing GI intolerance – consider
TPN
•Contact ITU dietitian (bleep 1345/1003)
Stop all prokinetics after 4 days administration
If guideline cannot be followed for clinical reasons, please document rationale in medical notes
Produced by: Lauren Fixter (ICU Dietitian) and Dr Dhadwal (Lead ICU Consultant) March 2020
CRASH CALL & FAST BLEEP 2222 ANAESTHETICS
Fire Call 5555 Consultant - Theatre Blp. 71-4264
Security Emergency 6666 Consultant - Intubating team 1 Blp. 71-4265
Security (non-emergency) 33335/34342 Consultant - Intubating Team 2 Blp. 71-4266
Safeguarding ADULT Protection Blp. 71-2626 Senior Registrar Blp. 71-1707
Safeguarding CHILD Protection Blp. 71-1616 Obstetric SpR Blp. 71-1901
SHO Blp. 71-1420
Consultant on ICU West 24541
Consultant on ICU South 24542 Outreach Team/PARRT Blp. 71-2471/2525
Consultant on ICU East 24543 A & E Reception/Nurses Station 33379/33377
Consultant on SHDU 24540 A & E Resus 33385
Kay Dhadwal 24517 (24518 – Office) Bed Manager MEDICAL Blp. 71-2001
Agnieszka Walecka 24511 Bed Manager PRIVATE Blp. 71-1457
Banwari Agarwal 24513 Bed Manager SURGICAL Blp. 71-2002
Dan Martin 39481 Engineers Shift 34106 Blp. 71-1111
Jenny Price 39486 Site Manager Blp. 71-1112/2523
Jim Buckley 39484 Theatre Coordinator Blp. 71-1581
Amit Adlakha/Prash Nandhabalan 24511
Mike Spiro 39485 Pharmacy Dispensary/CD Room 33116/38426
Mark De Neef 39482 Lead Pharmacist (Bryan) Blp. 71-1615
Nasirul Ekbal 39483 Senior Pharmacist (Marisa) Blp. 71-1313
Nick Barnett 24520 Senior Pharmacist (Jenna) Blp. 71-4062
Sarah Bigham 24516 Rotational Pharmacist Blp. 71-2790
Mark Carrington 24515 Pharmacy Senior Technician (Jenny) Blp. 71-1358
Steve Ward 24523 Pharmacy, TPN Blp. 71-2752
Naz Unni/Nikul Patel (Yadhu) 24519 Pharmacy Technician

Sean Carroll - Matron 24546/7 Blp. 71-1566 Blood Bank 33406/38505 Blp. 71-1596
Sinead Hanton - Matron 24531 Blp. 71-1566 Chem Path lab/Technician 33302/33307 Blp. 71-1595
ICU Operational Nurse In-Charge 24533 Blp. 71-2400 CSSD (Alex) Blp. 71-1986
CT Scan 33853/ 50863
Paola - Bank & Agency Nurses 24530 Senior Dietician - Emily/Harriet 35731 Blp. 71-1345 - Blp. 71-2934
Caroline Butler – Data & IT 24522 Felicia Dike ABG/POCT Blp. 71 4027
CPE Office 24535/24505 Haematology 33220
Marion Fieldson – Service Manager 24527 Blp. 71-1334 Haemophilia 1st Floor 34207, G Floor 33806/33807
Peggy Tsang – Data Manager 24528 Platelet Coordinator Blp 4029
Band 7 Office 24533 Micro Reception 33541/33973
Research Team Office 24534/39673/39674 Micro Technician Blp. 71-1686
Victoria Orakpo – Audit Manager 24525 Neuro Physio Blp. 71-2925/34055
Danielle Kane – Rota Coordinator 24523 Clinical Lead Physio Blp. 71-1546
Coral Cole - ACCNP Blp. 71- 1228 Band 7 Physio Blp. 71-1552 or Blp. 71- 2969
Specialist Nurses - Organ Donation 03000 20 30 40 (24hrs) Occupational Therapy Blp. 71-1201
SNOD Alice Workman & Helen Foley 24521 SALT Aeron Blp. 71- 2605
SALT New Referral Bleep Blp. 71-2687
ICU 4 EAST Reg. Bleep Blp. 71-1188 Virology 34335 / 34176/ 35411
ICU 4 SOUTH Reg. Bleep Blp. 71-1211 X-Ray 33387 Blp. 71-1525
ICU 4 WEST Reg. Bleep Blp. 71-1999 COVID clean X-ray 36487
SHDU doctor Bleep Blp. 71-1169 IT Help Desk 82020
ICU Float Reg. Bleep 24541 Blp. 71-1030 Sumeet – ICU Equipment Manager 24503 Blp. 71-2733
Anaesthetic SpR Blp. 71-1707 MEDICAL Electronics 33197/ Blp. 71-1062
ODP Blp. 71-2305
ICU 4 SOUTH Nurses Station 24500/24501/24502
SHDU Nurse-in-charge Blp. 71-2120 ICU 4 SOUTH Direct Line 0207 830 2716 (x24500)
ICU 4 EAST Nurse-In-Charge Blp. 71-2410 ICU 4 SOUTH BED SPACES 240 + bed number
ICU 4 EAST Team Leader Blp. 71-4019 ICU 4 SOUTH Staff Room 24512
ICU 4 SOUTH Nurse In-Charge Blp. 71-2649 ICU 4 SOUTH Lab 24537
ICU 4 SOUTH Team Leader Blp. 71-4017 ICU SOUTH RED Phone 74009
ICU 4 WEST Nurse-In-Charge Blp. 71-2722
ICU 4 WEST Team Leader Blp. 71-4018 ICU 4 EAST Nurses Station 24552/24553/24554
ICU HCA’s Bleeps Blp 71 (S) 2670 (W) 2892 (E) 2718 ICU 4 EAST Direct Line 0207 317 7778 (x24552)
ICU Housekeeper’s (Gladys) (Dave) Blp. 71-4157 - 4158 ICU 4 EAST BED SPACES 240 + bed number
ICU Ward Clerks/Reception Desk 24544/24545/24509 ICU EAST RED Phone 74500
ICU4 EAST Staff Room 24551
ICU 4 WEST Nurses Station 24506/24507 ICU 4 EAST Lab 24555
ICU 4 WEST Direct Line 0207 317 7776 (x24506) ICU EAST RED Phone 74500
ICU 4 WEST BED SPACES 2400 + bed number Stores (East - Panna) Blp. 71- 1987
ICU 4 WEST Staff Room 24514
ICU 4 WEST Lab 24538 10N Consultant (COVID ward >70yr) Blp 4255
ICU WEST RED Phone 74036 10N SpR (COVID ward >70yr) Blp 1038
10E Renal SHO (COVID ward) Blp 1994, 2992
Stores (South & West - Ahmed) Blp. 71- 1926 11E & 11W Consultant (COVID ward) Blp 4256
Stores Manager (Ron) 36414 11E SpR (COVID ward) Blp 2162
11W SpR (COVID ward) Blp 1437
Radiology HotSeat ext. 34155 or Blp 1462 12S SpR (suspected COVID ward) Blp 2519
Cardiology SpR Blp 2876
Renal SpR Blp 2608 10 North 34015
Respiratory SpRs Blp 2083, 1144, 1816 10 North doctor's office 34328
Hepatology SpR Blp 2530 10 North Sister 31283, 34014, or Blp 2709
Gastro SpR (daytime) Blp 2910 10 East 39859, 34130
HSEP SpR Blp 2698 11 East 33910, 33909, 35367
Neurology SpR Blp 2548 11 East doctor Blp 1301
Vascular SpR Blp 2977 or ext 82028 11 West 37518, 34017
Surigcal SpR Blp 1187 12 South 35041, 31383
Orthopaedic SpR Blp 1190
Hepatobiliary SpR Blp 2929
Urology SpR Blp 1487
Palliative Care Blp 1889, 1203, 2869
Haematology SpR (non-clotting) Blp 1775
Haemophilia/Clotting SpR Blp 1811
Micro SpR ext. 35867 or 35866
ID SpR Blp 1437
HIV SpR Blp 1814