NEW YORK — March 24, 2020 — The European Society of Intensive Care Medicine (ESICM), and the Society of Critical Care Medicine (SCCM) have released new guidance to help support healthcare workers caring for critically ill patients with coronavirus disease 2019 (COVID-19) in the intensive care unit (ICU), and details precautions which medical staff need to take to avoid being infected themselves.

The guidelines, which will be published in Intensive Care Medicine, were created by a panel of 36 experts from 12 countries. A search of the literature was performed for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU, and the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. The guideline is divided into 5 sections: (1) infection control; (2) laboratory diagnosis and specimens; (3) haemodynamic support; (4) ventilatory support; and (5) COVID-19 therapy.

Infection Control

The risk of patient-to-patient transmission in the ICU is currently unknown; therefore, adherence to infection control precautions is paramount. The following recommendations and suggestions are provided as considerations rather than a requirement to change institutional infection control policies.

For healthcare workers performing aerosol-generating procedures on patients with COVID-19 in the ICU, fitted respirator masks (N95 respirators, FFP2, or equivalent) are recommended, as opposed to surgical/medical masks, in addition to other personal protective equipment (PPE), such as gloves, gown, face shield or safety goggles (best practice statement).

Aerosol-generating procedures on ICU patients with COVID-19 should be performed in a negative pressure room to prevent the spread of contagious airborne pathogens from room to room. The main goal is to avoid the accidental release of pathogens into a larger space and open facility, thereby protecting healthcare workers and patients in a hospital setting (best practice statement).

For healthcare workers providing usual care for non-ventilated patients with COVID, or who are performing non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients with COVID-19, the panel suggests using surgical/medical masks, as opposed to respirator masks, in addition to other PPE (weak recommendation, low quality evidence).

For healthcare workers performing endotracheal intubation on patients with COVID-19, the panel suggests using video-guided laryngoscopy, over direct laryngoscopy, if available (weak recommendation, low quality evidence). For patients with COVID-19 requiring endotracheal intubation, the panel recommends that endotracheal intubation be performed by the healthcare worker who is most experienced with airway management in order to minimise the number of attempts and risk of transmission (best practice statement).

Laboratory Diagnosis and Specimens

For intubated and mechanically ventilated adults with suspicion of COVID-19, obtaining lower respiratory tract samples is suggested for diagnostic testing versus upper respiratory tract (nasopharyngeal or oropharyngeal) samples (weak recommendation, low quality evidence). With regard to lower respiratory samples, the panel suggests obtaining endotracheal aspirates in preference to bronchial wash or bronchoalveolar lavage samples (weak recommendation, low quality evidence). Haemodynamic Support

In adults with COVID-19 and shock, the panel suggests using dynamic parameters skin temperature, capillary refilling time, and/or serum lactate measurement over static parameters in order to assess fluid responsiveness (weak recommendation, low quality evidence).

For the acute resuscitation of adults with COVID-19 and shock, the panel suggests using a conservative over a liberal fluid strategy (weak recommendation, very low quality evidence); using crystalloids over colloids (strong recommendation, moderate quality evidence); and using buffered/balanced crystalloids over unbalanced crystalloids (weak recommendation, moderate quality evidence).

For the acute resuscitation of adults with COVID-19 and shock, the panel recommends against using hydroxyethyl starches (strong recommendation, moderate quality evidence), gelatins (weak recommendation, low quality evidence), and dextrans (weak recommendation, low quality evidence). For adults with COVID-19 and shock, the panel suggests using norepinephrine as the first-line vasoactive agent, over other agents (weak recommendation, low quality evidence). If norepinephrine is not available, vasopressin or epinephrine is suggested (weak recommendation, low quality evidence). The panel recommends against using dopamine if norepinephrine is available (strong recommendation, high quality evidence). The panel suggests titrating vasoactive agents to target a MAP of 60 to 65 mmHg, rather than higher MAP targets (weak recommendation, low quality evidence).

For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, the panel suggests adding dobutamine, over increasing norepinephrine dose (weak recommendation, very low quality evidence).

Ventilatory Support

In adults with COVID-19, the panel suggests starting supplemental oxygen if the peripheral oxygen saturation (SPO2) is < 92% (weak recommendation, low quality evidence), and recommends starting supplemental oxygen if SPO2 is < 90% (strong recommendation, moderate quality evidence). In adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, the panel recommends that SPO2 be maintained no higher than 96% (strong recommendation, moderate quality evidence).

In mechanically ventilated adults with COVID-19 and acute respiratory distress syndrome (ARDS), the panel recommends using low tidal volume (Vt) ventilation (Vt 4-8 mL/kg of predicted body weight), over higher tidal volumes (Vt>8 mL/kg) (strong recommendation, moderate quality evidence); targeting plateau pressures (Pplat) of < 30 cm H2O (strong recommendation, moderate quality evidence); and using a conservative fluid strategy over a liberal fluid strategy (weak recommendation, low quality evidence).

COVID-19 Therapy

In mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS), the panel suggests against the routine use of systemic corticosteroids (weak recommendation, low quality evidence). In mechanically ventilated adults with COVID-19 and ARDS, the panel suggests using systemic corticosteroids, over not using corticosteroids (weak recommendation, low quality evidence).

In mechanically ventilated patients with COVID-19 and respiratory failure, the panel suggests using empiric antimicrobials/antibacterial agents, over no antimicrobials (weak recommendation, low quality evidence).

For critically ill adults with COVID-19 who develop fever, the panel suggests using acetaminophen/paracetamol for temperature control, over no treatment (weak recommendation, low quality evidence).

For critically ill adults with COVID-19, the panel suggests against the routine use of lopinavir/ritonavir (weak recommendation, low quality evidence). There is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19. The complete guideline can be found here.

SOURCE: ESICM; SCCM