Critical Care Management of the Adult Patient
In Ireland with
Ebola Virus Disease 2014 / 2015
Report of :
Critical Care Advisory Group on Ebola Virus Disease
Intensive Care Society of Ireland
Interim Guidelines Update 4th January 2015
(to be updated with evolving international guidelines)
Chair ICSI Advisory Group
Mater Misericordiae University Hospital
Mater Misericordiae University Hospital
St. James's Hospital
St. James's Hospital
St. James's Hospital
Dr G Fitzpatrick
Adelaide and Meath Hospital Dublin
Adelaide and Meath Hospital Dublin
St.Vincent's University Hospital
University College Hospital Galway
Cork University Hospital
University Hospital Waterford
University Hospital Limerick
University Hospital Limerick
Children's University Hospital, Temple St.
The information in this document is designed to draw together
available guidelines and information to assist the critical care clinical
teams access relevant materials. Best clinical practice remains the
responsibility of each doctor caring for these patients. When better
information becomes available regarding specific therapies for this
disease in an ICM context, these shall be added to this information
Glossary of Terms
Ebola Virus Disease
Viral Haemorrhagic Fever
Centers for Disease Control and Prevention
National Isolation Unit
Personal Protective Equipment
Aerosol Generating Procedure
Single use/disposable tight fitting filtering face-
Powered Air Purifying Respirator
Health Protection Surveillance Centre
Clinical Role of Critical Care
Although evidence is limited due to the difficulties providing advanced
healthcare and intervention in poorly resourced countries where viral hemorrhagic fever (Ebola / VHF) has been associated with a high mortality, it is
likely that in better resourced countries, both facility and outcomes should be
better. Critical Care consultation and engagement is therefore appropriate for
these patients when they fulfill standard ICM referral criteria. As for all ICM referrals, each referral shall be addressed on a case-by-case basis in conjunction
with the referring consultant1.
Specific diagnostics and treatments relevant to critical care medicine will include management of hypovolaemia, electrolyte abnormalities, refractory shock, hypoxaemia, hemorrhage, septic shock, multi-organ failure, DIC, vasopressors,
nutrition, secondary bacterial infections inter alia and therefore specific
interventions and expertise relevant to all of these is a part of critical care practice. Of note, although knowledge is evolving2,3 and critical care experience
is limited in this disease, respiratory failure appears to arise very late in the
evolution of the disease and associated multi-organ failure. This may suggest
that opportunities to reverse this progression are more likely early in the care
(management of hydration etc as above).
1. Location / Isolation
The Mater Misericordiae University Hospital (MMUH) contains the National
Isolation Unit (NIU) and all patients testing positive for Ebola shall be
transferred there where possible. The decision on whether a patient of the NIU
requires intensive care input is a clinical one and that decision making process
rests with the senior ICU and senior ID clinicians. This may include the determination not to proceed with ICU management or to define the scope of
such management and interventions1. The clinical management of each case
cannot be protocolised and will be determined on a case by case basis. It is
presumed that at the current sporadic level of western society exposure, capacity within the NIU and MMUH is appropriate.
However should there be an exceptional cluster of Ebola Virus Disease in Ireland
circumstances may arise where a patient requires critical care intervention at a different acute hospital prior to transfer, or it may be considered that a patient is
too unwell for transfer. In such circumstances, patient location is likely to be the emergency department, in an appropriate isolation room.
Planning around this requires that PPE is made available and the cohort of staff identified in the plan had been offered and completed the necessary training as
specified by CDC.
Current models suggest it is most unlikely that a patient with EVD would not be
transferred to the NIU, and that the NIU / MMUH have or can develop the
required capacity. It is sensible none-the-less to consider how to provide critical
care for these patients in the exceptional circumstance that a patient is not
transferred to the NIU. Whether isolation and/or critical care is provided within
or outside of critical care needs to be a component of such planning. Considerations should include most appropriate ICU within a network / region
to provide such care.
The Ebola Clinical Care Guidelines, a guide for clinicians in Canada, Interim
Report August 29th 2014, updated October 28th, from the Canadian Critical Care
Society, the Canadian Association of Emergency Physicians, and the Assoc. of
Medical Microbiology and Infectious Diseases Canada4 provides useful guidance for the management of the critically ill Ebola patient, and will be referenced
throughout this document (ref. CCCS – CCAEP – AMMI Ebola Clinical Care
Guidelines). These guidelines include specific considerations for the in-hospital location and environment of such a patient. For the patient requiring critical care, the intensive care unit is likely the best place to provide such care for the
reasons identified in the guidelines, including quality of the facility, accessibility
to isolation rooms with negative pressure capability, and staff skill-mix. Isolation
room facility must therefore be guided by the above considerations, the severity
of illness, and whether aerosol generating procedures (AGPs) are likely to be required. Planning needs to include identified clean gowning-up (full PPE) area
separate from dirty areas, areas for removing PPE safely, and waste (see Waste
section below). A work area is required outside of this isolated zone to allow
case discussion and communication. IT and communication facilities need to be suitable for staff, patient and visitor use. The defined isolation and work area will
need to be segregated physically from the rest of the intensive care unit where
non-Ebola Virus Disease (non-EVD) patients are being cared for.
2. Personal Protective Equipment (PPE)
Use of PPE shall be as per the The Management of Viral Haemorrhagic Fevers in Ireland, November,2012 5 and Ebola Virus Risk Assessment for use in Hospital
Settings6 guidelines, or as advised by the National PPE Group. For the critically
ill, these patients shall all be considered to be at the high risk category and PPE
and isolation procedures consistent with that level of risk. Current standards include the use of Airborne Infection Isolation rooms for these
patients when feasible for aerosol generating procedures (AGPs) [see CDC Guideline for the Infection Prevention and Control Recommendations for
Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals August 20147].
Specific PPE recommendations for the Critically ill patient:
The Critical Care Advisory Group recommends and adopts the CDC Guideline as
the reference standard.
CDC updated guidelines October 20th 2014 make the following
"CDC is recommending all of the same PPE included in the August 1, 2014 guidance,
with the addition of coveralls and single-use, disposable hoods. Goggles are no
longer recommended as they may not provide complete skin coverage in
comparison to a single use disposable full face shield. Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to
manipulate them with contaminated gloved hands. PPE recommended for U.S.
healthcare workers caring for patients with Ebola includes:
Boot covers that are waterproof and go to at least mid-calf or leg covers
Single use fluid resistant or impermeable gown that extends to at least
mid-calf or coverall without intergraded hood.
Respirators, including either N95 respirators or powered air purifying
Single-use, full-face shield that is disposable Surgical hoods to ensure complete coverage of the head and neck Apron that is waterproof and covers the torso to the level of the mid-calf
should be used if Ebola patients have vomiting or diarrhea
￼The guidance describes different options for combining PPE to allow a facility to
select PPE for their protocols based on availability, healthcare personnel
familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel.
The guidance includes having:
Two specific, recommended PPE options for facilities to choose from.
Both options provide equivalent protection if worn, donned and doffed
correctly. [these two options are highlighted above]
Designated areas for putting on and taking off PPE. Facilities should ensure
that space and lay-out allows for clear separation between clean and
potentially contaminated areas
Trained observer to monitor PPE use and safe removal
Step-by-step PPE removal instructions that include:
Disinfecting visibly contaminated PPE using an EPA-registered disinfectant
wipe prior to taking off equipment
Disinfection of gloved hands using either an EPA-registered disinfectant
wipe or alcohol-based hand rub between steps of taking off PPE."
This guideline and web-based training can be read in full at:
The CDC and WHO have now issued specific guidelines which addresses the PPE
qualities and technical specifications.
The HPSC PPE Subcommittee report / guidance has published a guidance document on PPE 17th December 2014.
It is essential that procedures be put in place to practice the wearing of this PPE with an emphasis on the "buddy" system to ensure safe and supervised PPE use.
Practical aspects related to the wearing of PPE and other aspects of clinical care
for these patients is available on the CDC Webinar of 14th October:
Preparing for Ebola: What U.S. Hospitals Can Learn From Emory Healthcare and
Nebraska Medical Center
3. Critical Care Staffing
The demands of care for an Ebola patient, the extra risks for the nursing and
medical staff, and the difficulties inherent in working while dressed in PPE will
requires shorter shifts and therefore greater numbers of nurses and an extra rota of doctors for ICM separate (or supporting) those already rostered to the
care of the rest of the intensive care unit patients. Different hospitals will require
different configurations of such staffing, but presuming that 6 hour shifts would
be the maximum tolerable for any nursing staff in this context, there would be a need for a staffing ratio of 3:1 nursing to patient (normal 1:1) per standard shift. This will significantly drain the numerical pool of ICU nursing staff for any
institution and mandate closure of a number of ICU beds, impacting negatively
on the ability of that center to provide for other acutely ill patients. Restrictions
to major elective surgeries and redistribution of ambulance take may be required.
4. Clinical Care and Interventions for the Critically Ill
The significant escalation of interventions and therefore risk of needlestick injuries for a critically ill patient raises particular risks for healthcare workers in
this environment. A risk / benefit analysis shall be required as part of every
intervention and diagnostic test consistent with the 2012 Guidelines. It is
implicit in this that such patients shall undergo less invasive procedures and diagnostics than many intensive care patients.
Knowledge can be presumed to be expanding in the area of best clinical care, and
therefore best and most appropriate critical care, for these patients. The CCCS – CCAEP – AMMI Ebola Clinical Care Guidelines underline tenets of standard
critical care practice with particular reference to patients suffering from viral
haemorrhagic fever – fluid management, electrolytes, vasopressors and organ supports. Caution is advised in selection of invasive monitoring devices (arterial lines, CVP lines) but with a recognition that appropriate patient selection will
also dictate such choices. Table 1 below is extrapolated from the Canadian
Guidelines, modified here to include specific considerations related to patient
The clinical decision as to the appropriateness of intubation and mechanical
ventilation will be consultant based and patient specific. (see "Clinical Role of
Critical Care" above). The risk of aspiration and aerosolization in particular
should be a consideration if NIV is a clinical option, such that endotracheal intubation may offer a more controlled environment. NIV has however been
successfully used2 .Should intubation and mechanical ventilation be appropriate,
full PPE for aerosol generating procedures is required, and ideally an Airborne
Infection Isolation room (negative pressure room with 12 – 15 air exchanges / hr). Expired ventilator gasses should be HEPA filtered and scavenged. Similarly, a
HEPA filter should be placed in a c-circuit between angle piece and expiry valve
during bag and mask ventilation prior to intubation. Closed suctioning is advised.
Individual hospitals and intensive care units will need to consider systems in place to scavenge expired gasses and suction gas as these vary from institution to
The CDC has recently issued guidance with regard to haemodialysis for patients with Ebola Virus disease, both modalities of intermittent and continuous RRT.
Cardiopulmonary resuscitation in the context of full critical care management
requires case by case consideration (see P 41 CCCS – CCAEP – AMMI Ebola Clinical Care Guidelines), with the added complexities of providing safe and
effective CPR in such an environment.
The care of the pregnant patient ( P45. CCCS – CCAEP – AMMI Ebola Clinical Care Guidelines) raises specific issues and the potential for surgery for any patient
with VHF requires local consideration around such logistics, the principles of
which will be logically the same for the theatre environment as for elsewhere in
the hospital. These issues are beyond the scope of the critical care guidelines
which have been written to address specifics of critical care.
Table 1: Critical Care Management Considerations:
Close fluid balance.
Difficult IV access
replacement K, Ca.
Severe vomiting /
Early in disease
Caution re NGT and/or faecal
collection system with
Late in disease.
Ambu / C-Circuit
? Bacterial infection
Ominous and late
seizures. Check Na+, glucose
Intolerant of PO
Enteral Nutrition if
PN usually mandates CVC
Close fluid balance.
IHD case suitability
CDC Guidelines re dialysis
Ultrasound Guided Senior Clinician
Common in severe Monitor LFTs
Late in disease.
Blood Bank EVD protocol
Ability to provide safe and
5. Laboratory and ICU Point of Care testing
Laboratory and point-of-care testing shall comply with the EVD Laboratory
Biosafety Guidance, HPSC, 15th August 20149. Note, the blood bank / blood
transfusion service shall not cross-match blood for these patients and hence only
O-negative or type specific (if known) will be made available.
The care of the critically ill, through the intensity of management, generates considerable waste, including waste related to patient cleaning and care
procedures, urine containers, potentially CRRT bags, interventional procedures
including many sharps, medicine wrapping and packaging, and changes of PPE
for HCWs and others over many cycles per day.
The logistics of such waste management and containment, access and egress
from the patient area, need rigorous planning by each hospital caring for such
The management of waste is covered by the HPSC guidelines available on
Room cleaning and waste management and disposal is not a role for the critical
care nurse. Each hospital will need to review its procedures for same including appropriate training and education of cleaning staff.
7. Transfer of the Critically Ill
Transfer of the critically ill to the NIU / MMUH ICU complies with the National
Ambulance Service "Transportation of suspected VHF June 2012"10 document
(current) or later updates.
The decision to transfer such a patient requires multi-disciplinary discussion between the referring team, the NIU Consultant on duty, and the Mater Intensive
Care Consultant on duty. This may include the determination not to proceed with
ICU management or to define the scope of such management and interventions.
The clinical management of each case cannot be protocolised and will be
determined on a case by case basis.
A volunteer consultant rota has been established for the transport of the
critically ill EVD patient. This is to allow collaborative training with the NAS with
a small cohort of paramedics and doctors given the complexity of the PPE and
patient context. This service is only for the transport of critically ill EVD patients and requires critical care consultant referral, and assumes critical care team
involvement at the referring site at a level similar to that required for current
MICAS activation in a non-EVD patient.
The referring clinicians will need to identify with the ambulance service any
specific needs for a patient (eg. power for infusion pumps and ventilator /
oxygen supply needs etc). It is unclear at the time of writing whether equipment used for the transfer shall be decontaminated or destroyed after transfer. Full PPE for AGPs are required for such transfer of a critically ill patient. The use of a
portable ventilator where needed is recommended rather than ambu bag or c-
circuit ventilation where the risk of AGP is considered to be higher. A HEPA filter
should be placed in the expired gas limb of the ventilation tubing. The NAS is
currently investigating the purchase of isolation trollies for use in ambulance transport, designed to allow such established interventions as ventilation, but to
contain the patient on a stretcher as a mobile isolation system.
8. Supplementary Materials
These critical care guidelines are supplementary to the Management of Viral
Haemorrhagic Fevers in Ireland, November,2012 and Assessment Acute Hospital Setting guidelines both from HPSC and should be read in conjunction with these
The Ebola Clinical Care Guidelines, a guide for clinicians in Canada, Interim Report August 29th 2014, from the Canadian Critical Care Society, the Canadian
Association of Emergency Physicians, and the Assoc. of Medical Microbiology and
Infectious Diseases Canada is recognized by this Critical Care Advisory Group as
addressing many of the concerns for critical care as known to date. Readers to this site are reminded that knowledge and guidelines are evolving rapidly with a
need for clinicians to routinely source the latest evidence.
Recommended Core Information sites:
1. Health Protection Surveillance Centre
2. Centers for Disease Control and Prevention
1. FICM Statement: Ebola Clinical Management & Guidance. Thu.2004-10-16
2. A Case of Severe Ebola Virus Infection Complicated by gram-negative
septicaemia. KreuelsB et al. NEJM Oct23,2014
3. Clinical Care of two patients with Ebola Virus Disease in the United States.
Lyon et al. NEJM Nov 12th 20114.
4. The Ebola Clinical Care Guidelines, a guide for clinicians in Canada, Interim
Report October 28th 2014
5. The Management of Viral Haemorrhagic Fevers in Ireland, November,2012
6. Ebola Virus Risk Assessment for use in Hospital Settings.
7. CDC Guideline for the Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S.
Hospitals August 2014
8. Management of Hazard Group 4 viral haemorrhagic fevers and similar human
infectious diseases of high consequence. Advisory Committee on Dangerous Pathogens. September 2014
9. Interim Routine Diagnostic Laboratory Biosafety Guidance for Processing
Samples from Individuals with Suspected or Confirmed Ebola Virus Disease.
10. Transportation of patients suffering from suspected or confirmed Viral
Haemorrhagic Fever VHF June 2012
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