A case report of attending to one critically ill patient with COVlD‑19

Ya‑Rong CHEN, Gui‑Ling ZHAO, Pei‑Fen MA,Fu‑Rong LIU, Xin‑Man DOU

1Department of Neurolgy, Lanzhou University Second Hospital,Lanzhou, Gansu, China; 2Department of Nursing, Lanzhou University Second Hospital, Lanzhou, Gansu, China

ABSTRACT

The outbreak of COVID‑19 in Wuhan began to spread rapidly in December 2019. It is highly infectious and widely spread. This article summarizes the care experience of one critically ill COVID‑19 patient, including the strict implementation of protective measures, avoiding infection, precautions for high‑risk caring of tracheal intubation, giving psychological care, improving the coordination, the importance of vital signs, food intake and excretion, and how to reduce the risk of infection during sample collection, as well as strengthening discharge guidance.

Keywords: Care, COVID‑19, hospital infection, protective measure

INTRODUCTION

COVID-19 is an acute infectious respiratory disease. It is mainly transmitted through droplets and close contact.According to epidemiological investigation, the incubation period is 14 days, mostly 7 days, it is contagious during that period, and people is generally susceptible.[1]Since the first case of infection was found in Wuhan in December 2019, COVID-19 has spread rapidly throughout the country.Because of its strong infectivity, wide spread, and rapid increase in infection cases, it has caused huge losses to the society and aroused widespread international concern. This reports experience of a cured patient with severe COVID-19 in Lanzhou, Gansu Province.

CASE PRESENTATION

The patient, a 63-year-old female, developed dyspnea and general fatigue 2 days after returning from Hainan and worsened after 6 days. She was admitted to the local hospital on January 16, 2020. The arterial blood analysis showed that the pressure of oxygen was 49.9 mmHg, and the result of the chest computed tomography (CT) scan showed ground-glass changes in both lungs, and the sputum was gray-white sticky.Oseltamivir and levofloxacin were used, but the dyspnea continued worsen and the breathing rate was fast reaching 45 times/min, the symptoms of intermittent fever and shortness of breath; sufentanil was given, tracheal intubation was connected with ventilator, intermittent prone position was performed to improve breathing, and throat swabs were collected. The patient was diagnosed as COVID-19 by the Gansu Provincial Center for Disease Control and Prevention on January 24, 2020. According to the definition of the National Health Commission,[2]it was identified as a critical illness and transferred to the negative pressure ward of the designated hospital. After care and treatment, the patient gradually became conscious and body temperature decreased on the 3rdday. The doctor used antibiotics for anti-inflammation and expectoration and tried to take off the machine after 10 days, and the patient inhaled oxygen through the artificial nose intermittently. The nucleic acid test was negative for 5 times (at least 1 day for each sample). After tracheal intubation, the patient, with her new coronavirus nucleic acid detection, was transferred to the general ward,and 7 days later, her vital signs gradually stabilized, the symptoms of pneumonia disappeared, and she was cured.

COUNTERMEASURES

Strengthening protective measures

The main transmission routes of the virus are via respiratory droplets and close contact, while aerosol transmission may exist when exposed to high-concentration aerosols for a long time in a relatively stuffy environment. Therefore, first,relatively independent areas shall set up in the treatment area, which are divided into clean area, potential pollution area, and pollution area. Meanwhile, buffer rooms between two channels and three zones are set up with clear boundaries and obvious signs[3]to avoid infection. Second, the severe patients were placed in the negative pressure ward, and the articles used by the patients were disinfected in time to avoid cross infection. Patients with coronavirus test turned negative were placed separately to avoid cross infection.Third, applying iodophor, alcohol, or fast hand disinfectant wipe on the surface of the goggles can prevent the goggles from fogging.[4]In the process of care, we found that liquid soap can also achieve this effect. Fourth, strictly abide by the disinfection sequence of the three areas after work.Undurable goods such as glasses and hairpins are wiped with alcohol in the clean area. The surface of the object was wiped,soaked, or sprayed with 1000 mg/L chlorine-containing disinfectant.[3]Fifth, we need to assist the patient with basic care such as sputum suction, turning over, nasal feeding,eating, and defecation. The secretions, vomits, and feces of the patients were collected in special containers, soaked in 5000–10,000 mg/L chlorine-containing disinfectant for 2 h according to the proportion of feces and drugs at 1:2. After a large number of pollutants are completely covered with disposable water-absorbing materials, pour sufficient amount of chlorine-containing disinfectant, for more than 30 min, and clean up. Finally, the patient was fumigated with peracetic acid to disinfect the ward after transfer or discharge.

Endotracheal intubation and ventilator

Put the patients with tracheal intubation in the intensive care unit (ICU) ward of negative pressure. Sedatives and muscle relaxants are used during intubation to avoid droplets transmission caused by choking.[5]After using muscle relaxants and sedatives, attention should be paid to whether there are adverse drug reactions. At the same time, we should closely monitor patient’s consciousness, pupil distribution and vital signs, control blood sugar, and blood pressure. Long-term bed rest will aggravate lung infection. Antibiotics and expectorants should be used reasonably and inhaled by atomization.Meanwhile, the bed should be raised properly so that the drugs can better reach the alveoli. Closed sputum suction was used and aseptic operation was strictly carried out. On artificial airway management, the mouth of the trachea duct should be covered with wet gauze, the ventilator tube should be properly fixed, and the bandage of the outer tube cannot be too tight to accommodate two fingers. Protective restraint should be given to the patient with delirium after use sedatives.

Observe and care the patient

Observe the patient’s consciousness and general condition,especially the respiratory condition. Closely monitor the signs of illness, use infrared electronic thermometer to measure forehead temperature or neck temperature. After the use of antipyretic drugs, closely monitor the changes of the patient’body temperature, sweating, and replenish water in time.[3]Patients denied the previous history of diabetes, and their blood glucose increased many times after admission, up to 23.3 mmol/L, considering that stress hyperglycemia often exists in patients with ARDS, so the monitoring and regulation of blood glucose should be strengthened.[4]The insulin diluent was injected intravenously slowly with an injection pump. The blood glucose was measured every hour, and the injection speed was adjusted in time according to the change of blood glucose. Moreover, accurate recording of 24-hour intake and output, urine volume can directly reflect hemoperfusion, and timely report to the doctor when the urine volume per hour is <30 mL. Vomit and stool colors can reflect whether there is gastrointestinal bleeding or not, which provide an important basis for clinical diagnosis and treatment.

Specimen collection and management

In order to improve the positive rate of nucleic acid detection,sputum was collected as much as possible. If the symptoms were obvious but the nucleic acid monitoring is negative,sputum suction or bronchoalveolar lavage fluid could be considered for test under fiberoptic tracheoscope to increase the positive rate. Lower respiratory tract secretions were collected by patients with endotracheal intubation, and three-level protective measures were taken when pharynx swabs and sputum samples were collected in close contact with patients, to shorten the collection time and reduce the probability of infection. After collection, collection containers were covered at once and put in a sealed disposable bag for inspection. The medical waste is treated strictly in accordance with the regulations, double-layer packaging is used, the packaging is clearly marked and sealed in time, and the patient’s domestic waste is disposed of as medical waste.[3]

Diet

The patient could not eat because of tracheal intubation,so the enteral nutrition infusion pump was used to provide enteral nutrition through the nasogastric tube to maintain the nutritional status and enhance the resistance. During the use of enteral nutrition, adverse reactions such as gastrointestinal symptoms, edema, or dehydration are closely monitored. In the later stage, edema appeared in both lower limbs, dehydration diuretic should be taken, and the lower limbs should be raised properly to relieve it. Blood routine and electrolyte should be monitored, and corresponding treatment should be carried out. After extubation, oral feeding was gradually resumed. First, liquid food, then soft food, high-calorie, high-protein, high-vitamin, and digestible diet were taken, and gastric function was gradually restored.

Life care

The use of sedatives causes the decrease of muscle strength in the extremities, so it is necessary to prevent stress injuries through turning over frequently, keeping the body dry and clean, and use turn over mattresses and air cushions to prevent radical injury. Besides, the weight of the patient was overweight and the pressure ulcer occurred later. In addition to the above basic nursing, the sore face was washed with 0.9% normal saline, and the iodophor was sterilized after being dried. Then, the protective foam dressing was applied.If there was constipation or diarrhea, it should be replaced in time. Inform the patient to get enough sleep (no <7 h)every day.

Psychological caring

At the initial stage of isolation, the patient had negative emotions such as denial, anger, fear, anxiety, disappointment,and complaint. We should realize that this reaction is a normal stress reaction, understand and comfort her, and explain the importance and necessity of isolation treatment. Stabilize her mood and avoid the excessive behaviors. Using cured cases and the latest progress of research encourages the patient to have confidence in life, eliminate bad emotions, and actively cooperate with treatment.

Discharge guidance

After 4 days, the body temperature of the patient returned to normal, the respiratory symptoms were significantly improved, and the respiratory tract pathogens were negative for 5 times. According to COVID-19’s diagnosis and treatment plan, the patient was released from isolation and transferred to rehabilitation department for further treatment. Fourteen days after discharge, home isolation should be continued with health monitoring and medical observation.[6,7]It is necessary for her to have meals alone for 14 days to avoid mutual infection with family members, to strengthen nutrition and physical function exercise to enhance immunity, and to ensure adequate water consumption, not <1500 mL. Attentions should be also paid to do a good job of personal protection such as wearing masks in public places, washing hands frequently, and preventing colds.CT should be rechecked after half a month.

CONCLUSION

In order to take care of this patient, we learned a more knowledge of COVID-19. Strict disinfection and isolation system is an important factor in cutoff of transmission.COVID-19 has a long incubation period and strong infectivity.Its route of transmission is unclear, and the positive rate of nucleic acid test is low. Some patients have negative nucleic acid but with typical clinical symptoms, which requires us to cooperate with doctors and nurses. According to the latest national diagnosis and treatment plan, timely improve nursing measures, cannot blindly consider accounting and testing. If CT is positive or symptoms are similar, isolation treatment should be taken immediately. Some patients still have positive nucleic acid results after discharge. Considering that they are still contagious, it is recommended to continue isolation for 2 weeks after reaching the discharge standard. Therefore, the standard of discharge isolation needs to be considered and improved.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This work was supported the Lanzhou city science and technology project--Psychological Intervention Study of COVID-19 Isolation and Protection Medical Workers by Mindfulness Behavior Delivery isolation and protection medical staff.

Conflicts of interest

There are no conflicts of interest.