Clinical Guideline: Management of Critically Ill Adults With COVID-19

A new clinical guideline on the management of critically ill adults who are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), has been published in JAMA. The guideline offers recommendations for infection control and testing, hemodynamic and ventilatory support, and therapy.

The guideline, authored by 36 experts from 12 countries, was developed by the Surviving Sepsis Campaign and was based on direct experience with patients with COVID-19 as well as evidence from prior pandemics. Other pandemics included the Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), and several other infections caused by coronavirus. The panel used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) method as well as the PICO (Population, Intervention, Comparator, Outcomes) format in the actionable guideline questions.

For infection control and testing recommendations, the guideline authors first recommended the use of fitted respirator masks vs surgical masks for healthcare workers who perform endotracheal intubation, nebulized treatments, or open suctioning in patients with infection. The use of personal protective equipment (PPE) is also recommended to workers in these settings. In contrast, medical masks and PPE are recommended over respirator masks for healthcare workers who provide usual care of nonventilated patients with COVID-19.

The guideline recommends fluid resuscitation guided by dynamic assessment of fluid responsiveness in critically ill patients with COVID-19 who develop septic shock (weak recommendation, low quality of evidence). In these patients, the authors do not recommend the use of dopamine if norepinephrine is not available (strong recommendation, high quality of evidence). An additional recommendation is to use either vasopressin or epinephrine as first line therapy in the case of norepinephrine unavailability (weak recommendation, low quality of evidence)

For therapy recommendations of patients who are receiving mechanical ventilation, the guideline panel recommends against routine systemic corticosteroid use for patients with COVID-19 but without ARDS (weak recommendation, low quality of evidence). In patients with ARDS, the panel suggests corticosteroid use (weak recommendation, low quality of evidence).

In terms of ventilatory support, the guideline recommends starting supplemental oxygen if peripheral capillary oxygen saturation (Spo₂) is <90% (strong recommendation, moderate quality of evidence). The guideline recommends maintaining Spo₂ no higher than 96% (strong recommendation, moderate quality of evidence). If high-flow nasal cannula is unavailable or ineffective in patients with acute hypoxemic respiratory failure despite conventional oxygen therapy, the guideline recommends a trial of noninvasive positive pressure ventilation (weak recommendation, low quality of evidence).

According to the authors, “[f]ollowing these recommendations may prevent intubation and the need for ventilator support, a scarce resource when there are large numbers of COVID-19 cases.”

“Many of these recommendations are extrapolated from studies and experience in critically ill patients without COVID-19,” they noted. “However, this pandemic has necessitated flexibility and ingenuity to address unique challenges, and it will require continued rapid and judicious synthesis of heterogeneous and rapidly evolving data and clinical experience shared by clinicians.”

Reference

Poston JT, Patel BK, Davis AM. Management of critically ill adults with COVID-19 [published online March 26, 2020]. JAMA. doi:10.1001/jama.2020.4914