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ESICM SSC Guideline for COVID-19

For use by members of the critical care and anaesthetic teams at ESH

1 For healthcare workers performing aerosol-generating procedures* on patients with COVID-19 in the ICU, we recommend using fitted respirator masks (N95 respirators, FFP2, or equivalent), as opposed to surgical/medical masks, in addition to other personal protective equipment (i.e. gloves, gown, and eye protection, such as a face shield or safety goggles)
Best Practice Statement
2 We recommend performing aerosol-generating procedures on ICU patients with COVID-19 in a negative pressure room
Best Practice Statement
3 For healthcare workers providing usual care for non-ventilated COVID-19 patients, we suggest using surgical/medical masks, as opposed to respirator masks, in addition to other personal protective equipment (i.e. gloves, gown, and eye protection, such as a face shield or safety goggles)
Weak
4 For healthcare workers who are performing non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients with COVID-19, we suggest using surgical/medical masks, as opposed to respirator masks, in addition to other personal protective equipment (i.e. gloves, gown, and eye protection, such as a face shield or safety goggles)
Weak
5 For healthcare workers performing endotracheal intubation on patients with COVID-19, we suggest using videoguided laryngoscopy, over direct laryngoscopy, if available
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6 For COVID-19 patients requiring endotracheal intubation, we recommend that endotracheal intubation be performed by the healthcare worker who is most experienced with airway management in order to minimize the number of attempts and risk of transmission
Best Practice Statement
7.1 For intubated and mechanically ventilated adults with suspicion of COVID-19: For diagnostic testing, we suggest obtaining lower respiratory tract samples in preference to upper respiratory tract (nasopharyngeal or oropharyngeal) samples
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7.2 For intubated and mechanically ventilated adults with suspicion of COVID-19: With regard to lower respiratory samples, we suggest obtaining endotracheal aspirates in preference to bronchial wash or bronchoalveolar lavage samples
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8 In adults with COVID-19 and shock, we suggest using dynamic parameters skin temperature, capillary reflling time, and/or serum lactate measurement over static parameters in order to assess fuid responsiveness
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9 For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fuid strategy
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10 For the acute resuscitation of adults with COVID-19 and shock, we recommend using crystalloids over colloids
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11 For the acute resuscitation of adults with COVID-19 and shock, we suggest using buffered/balanced crystalloids over unbalanced crystalloids
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12 For the acute resuscitation of adults with COVID-19 and shock, we recommend AGAINST using hydroxyethyl starches
Strong
13 For the acute resuscitation of adults with COVID-19 and shock, we suggest AGAINST using gelatins
Weak
14 For the acute resuscitation of adults with COVID-19 and shock, we suggest AGAINST using dextrans
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15 For the acute resuscitation of adults with COVID-19 and shock, we suggest AGAINST the routine use of albumin for initial resuscitation
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16 For adults with COVID-19 and shock, we suggest using norepinephrine as the first-line vasoactive agent, over other agents
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17 If norepinephrine is not available, we suggest using either vasopressin or epinephrine as the first-line vasoactive agent, over other vasoactive agents, for adults with COVID-19 and shock
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18 For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is available
Strong
19 For adults with COVID-19 and shock, we suggest adding vasopressin as a second-line agent, over titrating norepinephrine dose, if target mean arterial pressure (MAP) cannot be achieved by norepinephrine alone
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20 For adults with COVID-19 and shock, we suggest titrating vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets
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21 For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fuid resuscitation and norepinephrine, we suggest adding dobutamine, over increasing norepinephrine dose
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22 For adults with COVID-19 and refractory shock, we suggest using low-dose corticosteroid therapy (“shock-reversal”), over no corticosteroid Remark: A typical corticosteroid regimen in septic shock is intravenous hydrocortisone 200 mg per day administered either as an infusion or intermittent doses
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23 In adults with COVID-19, we suggest starting supplemental oxygen if the peripheral oxygen saturation (SpO2) is<92%, and recommend starting supplemental oxygen if SpO2 is<90%
Former Weak | Latter Strong
24 In adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, we recommend that SpO2 be maintained no higher than 96%
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25 For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, we suggest using HFNC over conventional oxygen therapy
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26 In adults with COVID-19 and acute hypoxemic respiratory failure, we suggest using HFNC over NIPPV
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27 In adults with COVID-19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no urgent indication for endotracheal intubation, we suggest a trial of NIPPV with close monitoring and short-interval assessment for worsening of respiratory failure
Weak
28 We were not able to make a recommendation regarding the use of helmet NIPPV compared with mask NIPPV. It is an option, but we are not certain about its safety or efficacy in COVID-19
No recommendation
29 In adults with COVID-19 receiving NIPPV or HFNC, we recommend close monitoring for worsening of respiratory status, and early intubation in a controlled setting if worsening occurs
Best Practice Statement
30 In mechanically ventilated adults with COVID-19 and ARDS, we recommend using low tidal volume (Vt) ventilation (Vt 4–8 mL/kg of predicted body weight), over higher tidal volumes (Vt>8 mL/kg)
Strong
31 For mechanically ventilated adults with COVID-19 and ARDS, we recommend targeting plateau pressures (Pplat) of<30 cm H2O
Strong
32 For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest using a higher PEEP strategy, over a lower PEEP strategy. Remarks: If using a higher PEEP strategy (i.e. PEEP>10 cm H2O), clinicians should monitor patients for barotrauma
Strong
33 For mechanically ventilated adults with COVID-19 and ARDS, we suggest using a conservative fuid strategy over a liberal fuid strategy
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34 For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest prone ventilation for 12–16 h, over no prone ventilation
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35.1 For mechanically ventilated adults with COVID-19 and moderate to severe ARDS: we suggest using, as needed, intermittent boluses of neuromuscular blocking agents (NMBA), over continuous NMBA infusion, to facilitate protective lung ventilation
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35.2 In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, we suggest using a continuous NMBA infusion for up to 48 h
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36 In mechanically ventilated adults with COVID-19 ARDS, we recommend against the routine use of inhaled nitric oxide
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37 In mechanically ventilated adults with COVID-19, severe ARDS and hypoxemia despite optimizing ventilation and other rescue strategies, we suggest a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered of
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38 For mechanically ventilated adults with COVID-19 and hypoxemia despite optimizing ventilation, we suggest using recruitment maneuvers, over not using recruitment maneuvers
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39 If recruitment maneuvers are used, we recommend against using staircase (incremental PEEP) recruitment maneuvers
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40 In mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, we suggest using venovenous (VV) ECMO if available, or referring the patient to an ECMO center Remark: Due to the resource-intensive nature of ECMO, and the need for experienced centers and healthcare workers, and infrastructure, ECMO should only be considered in carefully selected patients with COVID-19 and severe ARDS
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41 In mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS), we suggest AGAINST the routine use of systemic corticosteroids
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42 In mechanically ventilated adults with COVID-19 and ARDS, we suggest USING systemic corticosteroids, over not using corticosteroids Remark: The majority of our panel support a weak recommendation (i.e. suggestion) to use steroids in the sickest patients with COVID-19 and ARDS. However, because of the very low-quality evidence, some experts on the panel preferred not to issue a recommendation until higher quality direct evidence is available
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43 In mechanically ventilated patients with COVID-19 and respiratory failure, we suggest using empiric antimicrobials/ antibacterial agents, over no antimicrobials Remark: if the treating team initiates empiric antimicrobials, they should assess for de-escalation daily, and re-evaluate the duration of therapy and spectrum of coverage based on the microbiology results and the patient’s clinical status
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44 For critically ill adults with COVID-19 who develop fever, we suggest using acetaminophen/paracetamol for tempera‑ ture control, over no treatment
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45 In critically ill adults with COVID-19, we suggest AGAINST the routine use of standard intravenous immunoglobulins (IVIG)
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46 In critically ill adults with COVID-19, we suggest AGAINST the routine use of convalescent plasma
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47.1 In critically ill adults with COVID-19: we suggest AGAINST the routine use of lopinavir/ritonavir
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47.2 There is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19
No recommendation
48 There is insufficient evidence to issue a recommendation on the use of recombinant rIFNs, alone or in combination with antivirals, in critically ill adults with COVID-19
No recommendation
49 There is insufficient evidence to issue a recommendation on the use of chloroquine or hydroxychloroquine in critically ill adults with COVID-19
No recommendation
50 There is insufficient evidence to issue a recommendation on the use of tocilizumab in critically ill adults with COVID-19
No recommendation

© Dr Theophilus Samuels 2020

Disclaimer: all information found on this website is intended for use by the critical care and anaesthetic teams at East Surrey Hospital. No responsibility is taken for any misuse, misinterpretation or errors that may exist or result from its use.