Guidelines From The Surviving Sepsis Campaign for COVID-19 Critical Care

The Surviving Sepsis Campaign panel has issued recommendations to help support healthcare workers caring for critically ill patients in the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19). These guidelines were published in Critical Care Medicine.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged at the end of 2019 and resulted in an acute respiratory illness epidemic in China and eventually spread worldwide. COVID-19 has since become a pandemic that has affected more than 80 countries to date and has caused more than 150,000 deaths globally. For the general population, preliminary guidance on infection control, screening, and diagnosis was issued by the World Health Organization and the United States Centers for Disease Control and Prevention, however there is limited guidance on the management of patients with severe COVID-19 illness. Therefore, the Surviving Sepsis Campaign sought to provide clinicians clear guidance on how to care for the sickest COVID-19 patients.

A COVID-19 panel was created consisting of 36 experts from 12 countries. They proposed key questions that were relevant to the management of COVID-19 in the ICU. All actionable guideline questions were structures in the Population, Intervention, Control, and Outcome(s) (PICO) format. These PICO-formatted questions were posed and literature was searched for direct and indirect evidence on the management of critically ill COVID-19 patients, and included relevant systemic reviews for support on questions regarding to supportive care. The certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach where recommendations were generated based on a balance of benefit/harm, resource and cost implications, equity, and feasibility.

Each statement has an attached recommendation of either “strong recommendation or best practice statement” or “weak recommendation.” Strong recommendations/best practice statements should be interpreted as must do or must avoid and can be adapted as policy in most situations. Weak recommendations should be interpreted as consider doing or avoiding, but different choices may be appropriate for different patients and the recommendation should be tailored to individual circumstances resulting in various policies.

In total, 54 statements were issued by the campaign’s COVID-19 panel that fell under the following topics: infection control, laboratory diagnosis and specimens, hemodynamic support, ventilatory support, and COVID-19 therapy.

Of the 54 statements, 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. There were 6 questions with no recommendations due to insufficient evidence which included the use of antiviral agents, recombinant interferons, chloroquine/hydroxychloroquine, or tocilizumab in critically ill COVID-19 patients, and the safety or efficacy of the use of helmet NIPPV compared with noninavasiave positive pressure ventilation.

The best practice statements include:

1. Fitted respirator masks should be used by healthcare workers performing aerosol-generating procedures on patients with COVID-19 as opposed to surgical masks.
2. Aerosol-generating procedures on patients with COVID-19 should be done in a negative pressure room.
3. Endotracheal intubation should be performed by the healthcare worker with the most experience in airway management (to minimize intubation attempts).
4. Close monitoring for worsening respiratory status in patients with COVID-19 receiving noninvasive positive pressure ventilation or oxygen by high flow nasal cannula, with early intubation in an appropriate setting if respiratory deterioration occurs.

A selection of guidance receiving a strong recommendations include:

1. Hydroxyethyl starches are not recommended for the acute resuscitation of adults with COVID-19 in shock.
2. Dopamine is not recommended for adults with COVID-19 and shock if norepinephrine is available.
3. Oxygen saturation should be maintained at no higher than 96% in adults with COVID-19 with acute hypoxemic respiratory failure receiving oxygen therapy.
4. The use of incremental (“staircase”) positive end expiratory pressure recruitment maneuvers is not recommended.

Overall, the study authors conclude that “We will have periodic automated electronic searches sent to assigned panel members every week to identify relevant new evidence as it emerges. Accordingly, we will issue further guideline releases in order to update the recommendations, if needed, or formulate new ones.”

Reference

Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the management of critically ill adults with Coronavirus Disease 2019 [published online March 27, 2020]. Crit Care Med. doi:10.1097/CCM.0000000000004363