Management of COVID-19 in critically ill adults: Surviving Sepsis Campaign guidelines
Surviving Sepsis Campaign (SSC) has released its guidelines on the management of COVID-19 in critically ill adults. These guidelines were authored by 36 experts from 12 countries. The recommendations were developed based on limited direct evidence with COVID-19 cases and indirect evidence derived from previous pandemics such as the Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), and other coronavirus infections. Overall, the panel issued 54 statements: 4 best practice statements, 9 strong recommendations, and 35 weak recommendations. (No recommendations were made for the remaining 6 topics.)
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of COVID-19, a pandemic that has affected more than 700 000 individuals out of which approximately 5% to 10% of patients require intensive care unit (ICU) admission and mechanical ventilation.
Major recommendations are-
Infection Control and Testing
For health care workers performing aerosol-generating procedures (eg, endotracheal intubation, nebulizer treatments, open suctioning) use of fitted respirator masks is recommended (N95 respirators, FFP2), instead of surgical masks, in addition to other personal protective equipment (PPE) (best practice statement).
For usual care of nonventilated patients, or for performing non–aerosol-generating procedures on patients receiving mechanical ventilation, the use of medical masks is recommended, instead of respirator masks, in addition to other PPE (weak recommendation, low-quality evidence [LQE]).
Diagnostic lower respiratory tract samples (endotracheal aspirates) are preferred over bronchial washings, bronchoalveolar lavage, and upper respiratory tract (nasopharyngeal or oropharyngeal) samples (weak recommendation, LQE).
Hemodynamic Support
For acute resuscitation of adults with shock, the following are suggested: measuring dynamic parameters to assess fluid responsiveness (weak recommendation, LQE), using a conservative fluid administration strategy (weak recommendation, very LQE), and using crystalloids over colloids (strong recommendation; moderate QE). Balanced crystalloids are preferred over unbalanced crystalloids (weak recommendation, moderate QE).
For adults with shock, the following are suggested: using norepinephrine as the first-line vasoactive (weak recommendation, LQE), use of either vasopressin or epinephrine as the first line if norepinephrine is not available (weak recommendation, LQE). Dopamine is not recommended if norepinephrine is not available (strong recommendation, high QE). Adding vasopressin as a second-line agent is suggested if the target (60-65 mm Hg) mean arterial pressure cannot be achieved by norepinephrine alone (weak recommendation, moderate QE).
Ventilatory Support
Starting supplemental oxygen is recommended if the Spo2 is less than 90% (strong recommendation, moderate QE). Spo2 should be maintained no higher than 96% (strong recommendation, moderate QE).
For acute hypoxemic respiratory failure despite conventional oxygen therapy, the use of a high-flow nasal cannula (HFNC) is suggested relative to conventional oxygen therapy and noninvasive positive pressure ventilation (NIPPV) (weak recommendation, LQE). If HFNC is not available, a trial of NIPPV is suggested (weak recommendation, very LQE). Close monitoring for worsening of respiratory status and early intubation if worsening occurs is recommended (best practice statement).
For adults receiving mechanical ventilation who have acute respiratory distress syndrome (ARDS), use of low tidal volume ventilation (4-8 mL/kg of predicted body weight) is recommended and preferred over higher tidal volumes (>8 mL/kg) (strong recommendation, moderate QE). Targeting plateau pressures of <30 cm H2O (strong recommendation, moderate QE) is recommended. Using a higher positive end-expiratory pressure (PEEP) strategy over the lower PEEP strategy is suggested (weak recommendation, LQE).
For adults receiving mechanical ventilation who have moderate to severe ARDS, prone ventilation for 12 to 16 hours is suggested over no prone ventilation (weak recommendation, LQE). Using as-needed neuromuscular blocking agents (NMBAs) instead of continuous NMBA infusion to facilitate protective lung ventilation is suggested (weak recommendation, LQE).
For adults receiving mechanical ventilation who have severe ARDS and hypoxemia despite optimizing ventilation, a trial of inhaled pulmonary vasodilator is suggested. If no rapid improvement in oxygenation is observed, the treatment should be tapered (weak recommendation, very LQE). The use of lung recruitment maneuvers (intended to open otherwise closed lung segments, such as 40 cm H2O inspiratory hold for 40 seconds) is suggested, over not using recruitment maneuvers (weak recommendation, LQE), but using staircase (incremental PEEP) recruitment maneuvers is not recommended (strong recommendation, moderate QE). Use of venovenous circulation for extracorporeal membrane oxygenation (ECMO) or referral to an ECMO center is suggested, if available, for selected patients (weak recommendation, LQE).
Therapy
In adults receiving mechanical ventilation who do not have ARDS, routine use of systematic corticosteroids is suggested against (weak recommendation, LQE). In those with ARDS, the use of corticosteroids is suggested (weak recommendation, LQE).
In COVID-19 patients receiving mechanical ventilation who have respiratory failure, the use of empiric antimicrobial/antibacterial agents is suggested (no evidence rating); assess for de-escalation.
In critically ill adults with fever, the use of pharmacologic agents for temperature control is suggested over nonpharmacologic agents or no treatment. Routine use of standard IV immunoglobulins is not suggested. Convalescent plasma is not suggested. There is insufficient evidence to issue a recommendation on the use of any of the following: antiviral agents, recombinant interferons, chloroquine/hydroxychloroquine, or tocilizumab.
The COVID-19 pandemic is challenging as the disease has overwhelmed health care systems. This SSC guideline2 will be frequently updated online as global evidence accrues, but it reflects the central tenants of best practices for ARDS: low tidal volume strategy, PEEP titration, avoidance of hyperoxia, and a conservative fluid strategy.
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