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International Panel Releases Guidelines on Management of ICU Patients with COVID-19

The Surviving Sepsis Campaign COVID-19 panel, which includes 36 experts from 12 countries, has issued new guidelines for health-care workers treating intensive care unit (ICU) patients with COVID-19. The guidelines, co-published in the journal Critical Care Medicine and the journal Intensive Care Medicine, include 54 recommendations on such topics as infection control, laboratory diagnosis and specimens, the dynamics of blood flow support, ventilation support, and COVID-19 therapy.

The Surviving Sepsis Campaign COVID-19 panel issued recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. Image credit: Rosario ‘Charo’ Gutierrez, U.S. Air Force.

The Surviving Sepsis Campaign COVID-19 panel issued recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. Image credit: Rosario ‘Charo’ Gutierrez, U.S. Air Force.

“Previously there was limited guidance on acute management of critically ill patients with COVID-19, although the World Health Organization and the United States Centers for Disease Control and Prevention have issued preliminary guidance on infection control, screening and diagnosis in the general population,” said Dr. Waleed Alhazzani of McMaster University and St. Joseph’s Healthcare Hamilton.

“Usually, it takes a year or two to develop large clinical practice guidelines such as these ones. Given the urgency and the huge need for these guidelines, we assembled the team, searched the literature, summarized the evidence, and formulated recommendations within 18 days.”

“Everyone worked hard to make this guideline available to the end user rapidly while maintaining methodological rigor.”

“The guidelines will be used by frontline clinicians, allied health professionals and policy makers involved in the care of patients with COVID-19.”

The Surviving Sepsis Campaign COVID-19 panel included experts in guideline development, infection control, infectious diseases and microbiology, critical care, emergency medicine, nursing, and public health.

The researchers started off by proposing 53 questions they considered to be relevant to the management of COVID-19 in the ICU.

They then searched the literature for direct and indirect evidence on the management of COVID-19 in the ICU.

They found relevant and recent systematic reviews on most questions relating to supportive care.

The panel then assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

GRADE is a way to assess previous work, a transparent framework for developing and presenting summaries of evidence and provides a systematic approach for making clinical practice recommendations for health-care professionals.

The resulting 54 recommendations include four best practice statements, nine strong recommendations, and 35 weak recommendations. No recommendation was provided for six questions.

The four best practice statements based on high-quality evidence include:

(i) health-care workers performing aerosol-generating procedures, such as intubation, bronchoscopy, open suctioning, on patients with COVID-19 should wear fitted respirator masks, such as N95, FFP2 or equivalent — instead of surgical masks — in addition to other personal protective equipment, such as gloves, gown and eye protection;

(ii) aerosol-generating procedures should be performed on ICU patients with COVID-19 in a negative pressure room, if available; negative pressure rooms are engineered to prevent the spread of contagious pathogens from room to room;

(iii) endotracheal intubation of patients with COVID-19 should be performed by health-care workers with experience in airway management to minimize the number of attempts and risk of transmission;

(iv) adults with COVID-19 who are being treated with non-invasive positive pressure ventilation or a high flow nasal cannula should be closely monitored for worsening respiratory status and intubated early if needed.

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Waleed Alhazzani et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Critical Care Medicine, published online March 27, 2020; doi: 10.1097/CCM.0000000000004363

Waleed Alhazzani et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med, published online March 28, 2020; doi: 10.1007/s00134-020-06022-5

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