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CME / ABIM MOC / CE

COVID-19: Strategies in Caring for Critically Ill Patients

  • Authors: News Authors: Liam Davenport and Marcia Frellick; CME Authors: Charles P. Vega, MD and Esther Nyarko, PharmD
  • CME / ABIM MOC / CE Released: 7/13/2020
  • Valid for credit through: 7/13/2021
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  • Credits Available

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    ABIM Diplomates - maximum of 1.00 ABIM MOC points

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Target Audience and Goal Statement

This article is intended for all healthcare providers who may treat and manage critically ill patients with coronavirus disease (COVID-19).

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Outline recommendations for appropriate protection and care for healthcare workers (HCW) seeing patients with COVID-19 in the intensive care unit (ICU)
  • Analyze treatment recommendations for severely ill patients with COVID-19
  • Outline implications for the healthcare team


Disclosures

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News Authors

  • Liam Davenport

    Freelance journalist, Medscape

    Disclosures

    Disclosure: Liam Davenport has disclosed no relevant financial relationships.

  • Marcia Frellick

    Freelance writer, Medscape

    Disclosures

    Disclosure: Marcia Frellick has disclosed no relevant financial relationships.

CME Authors

  • Charles P. Vega, MD, FAAFP

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Shire

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Editor

  • Hazel Dennison, DNP, RN, FNP, CPHQ, CNE

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Hazel Dennison, DNP, RN, FNP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer

  • Esther Nyarko, PharmD

    As listed above.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


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CME / ABIM MOC / CE

COVID-19: Strategies in Caring for Critically Ill Patients

Authors: News Authors: Liam Davenport and Marcia Frellick; CME Authors: Charles P. Vega, MD and Esther Nyarko, PharmDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/13/2020

Valid for credit through: 7/13/2021

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Note: This is the forty-first of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context

COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which emerged as an outbreak in Wuhan, China in 2019. Since then, the infectious disease has caused a rampage around the world, with confirmed cases exceeding 10 million (deaths more than 499,000) as of June 29, 2020. [1] Key areas feeling the brunt of this pandemic have been ICUs in variable healthcare settings, which have experienced a substantial increase in critical care beds and shortages of supplies and HCW. The World Health Organization (WHO) indicated that the market demand for clinical care equipment, such as ventilators and oxygen concentrators, has been 20 times more than historical demand.[2] Of note, causes of deaths in previous pandemics were a result of respiratory failure.[3]

It is estimated that a majority of the patients who get infected with COVID-19 can be managed outside the ICU.[4] What do we know of patients who are admitted to critical care management? They tend to be older (age ≥ 65 years), have more comorbidities (ie, hypertension and other heart conditions, diabetes, chronic kidney disease, liver disease, chronic lung disease or severe to moderate asthma, immunocompromised).[5]

HCW are seeking effective ways to manage severely ill patients with COVID and address other concerns such as patient-to-patient transmission of COVID-19 in the ICU, significance of myocardial dysfunction and impact on deterioration into shock, and use of noninvasive ventilation, high-flow nasal cannula (HFNC), and other therapies such as corticosteroids.

The current guidelines,[6] as determined by a panel of 36 experts from 12 countries, provide recommendations for the management of patients with COVID-19 with severe infection. They begin with guidance on protecting HCW from COVID-19 in inpatient settings, and the recommendations reflect those of the Centers for Disease Control and Prevention (CDC). Fitted respirator masks, commonly known as N95 masks, are necessary for HCW participating in procedures that might produce aerosols. Patients undergoing procedures that may aerosolize COVID-19 require negative-pressure rooms, but negative-pressure rooms are not necessary for the routine care of patients with COVID-19. For intubation, a video-guided procedure is preferred to direct laryngoscopy.

Surgical masks are acceptable in the routine care of patients with COVID-19, which speaks to the shortage of fitted respirator masks. The guidelines also include a large number of recommendations for the management of patients with COVID-19. These recommendations are summarized in "Highlights."

What is the impact of this pandemic on intensive care?

Synopsis and Perspective

The CDC has outlined the wide spectrum of disease with COVID-19 from mild illness to critical illness:

Mild illness

Uncomplicated upper respiratory tract viral infection

Moderate pneumonia

Pneumonia without the need for supplemental oxygen

Severe pneumonia

Pneumonia with dyspnea, respiratory distress, SpO2 ≤ 93% on right artery, P/F ratio < 300

Critical illness

Respiratory failure, septic shock, multiple organ dysfunction/failure

P/F = partial pressure arterial oxygen/fraction of inspired oxygen; SpO2 = oxygen saturation as measured by pulse oximetry.

CDC website.[7]

According to a report on COVID-19, published in the CDC's Morbidity and Mortality Weekly Report (MMWR) on March 27,[8] using early data from China during the period of February 12 through March 16 (N = 4226), it was shown that older adults were more likely to require ICU care and experience higher morbidity, with a tendency for deterioration in the second week of illness.

Wu Z, McGoogan JM.[9]

CDC COVID-19 Response Team.[8]

In a CDC MMWR April 3 report,[10] among reported outcomes for hospitalized patients with COVID-19 (all ages), 71% had had one or more comorbid conditions (78% for ICU):

  • 24% had diabetes (32% for ICU)
  • 15% had chronic lung disease (21% for ICU)
  • 23% had cardiovascular disease (29% for ICU)
  • 6% had immunocompromised conditions (9% for ICU)
  • 9% had chronic renal disease (12% for ICU )
  • 35% had other chronic disease conditions (37% for ICU).

Jean-Louis Vincent and Fabio S. Taccone, in a commentary published online April 6 in The Lancet,[11] described the pathways to death for patients with COVID-19, which includes ICU admission, often followed by an increased number of infections and associated deaths. Case fatality rates, which currently range from 1% to 7%, need to be carefully interpreted, as they vary according to location and size of denominators (ie, mild or asymptomatic cases vs those requiring hospitalization) and specific cause of death (eg, respiratory failure, bacterial infection, treatment barriers or limitation). Case fatality rates tend to be higher according to how strained the healthcare facility is. The CFR in Italy was reported to be as high as 12% up until March 31.[12] Case fatality tends to be disproportionately higher among older adults and tends to be higher among persons with underlying medical conditions.

Unlike previous early disasters, there is a better chance of survival in this age because of mechanical ventilation, which can support patients’ lungs until recovery. That said, with the impact and rapid rise of this COVID-19, there have been significant challenges, as pointed out by the guideline authors, and death could be a result of one of the following[10]:

  • COVID related: Poor predicted outcomes because of old age, frailty, comorbidities or profound disability, and lack of personnel, beds, or materials
  • Not COVID-related: High infection rate because of underlying injury, such as severe trauma or acute brain injury, metastatic cancer, or terminal organ failure

A recent review by Jason Phua et al, published online April 6 in The Lancet Respiratory Medicine,[13] summarized the challenges and recommendations of ICU management of COVID-19. The leading complication in ICU patients with COVID-19 was pneumonia (91%).[7] The median time to development of pneumonia from symptom onset was approximately 5 days. The time from symptom onset to severe hypoxemia and ICU admission was noted to be approximately 7 to 12 days.[13]

Of patients who were critically ill, conditions were noted as follows[7]:

  • Acute respiratory distress syndrome (ARDS) (61%)
  • Shock or septic shock (31%-67%)
  • Acute kidney (8%-29%)/renal failure (5%-19%) injury
  • Acute hepatic injury (14%)
  • Cardiac abnormalities
    • Acute cardiac injury (12%-23%)
    • Cardiomyopathy (33%)
    • Arrhythmia (44%)

The following elevated laboratory levels were associated with severe disease: increased neutrophils; increased levels of alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, procalcitonin, C-reactive protein, and ferritin; and increased serum levels of pro-inflammatory cytokines and chemokines. In contrast, low lymphocytes were associated with severe or critical illness. Elevated D-dimers and lymphopenia were associated with mortality.

Radiographic findings showed most patients have bilateral opacities on chest radiograph and computed tomography (CT).[14] Ground glass opacities and consolidation were found on CT as well.

Authors outlined the challenges in managing ICU patients such as ICU infrastructure and capacity, infection prevention, staffing, triage, and research. They summarized their findings and recommendations below based on their experiences[13]:

 

Challenges

Authors' Recommendations

Infection prevention

  • A global shortage of personal protective equipment (PPE) (medical masks, respirators)
  • Ill-fitting N95 respirators
  • Self-contamination during removal of PPE
  • Contamination of HCW mobile phones and hospital equipment
  • Fecal transmission of virus
  • Risk for infection to ICU visitors
  • Consider reuse in between patients*
  • Conduct regular fit testing
  • Train on donning and doffing of PPE
  • Conduct surface decontamination and proper wrapping of mobile phones
  • Practice immediate and appropriate disposal of soiled objects
  • Restrict or ban visits; use video conferencing

*Note: Guideline authors recommended the reuse of PPE in between patients and use beyond manufacturer-designated shelf life. Routine decontamination and reuse of filtering facepiece respirators (FFRs) -- which includes N95 -- are not approved by the CDC as standard of care; however, the CDC indicates this may be allowed as a crisis capacity strategy to ensure continued availability. Ultraviolet germicidal irradiation, vaporous hydrogen peroxide, and moist heat have been shown to be the most advantageous methods to decontaminate FFRs.[15]

ICU infrastructure

  • Airborne infection isolation rooms with negative pressure are not universally available, especially in resource-limited settings
  • Consider adequately ventilated single rooms without negative pressure or, if necessary, cohort cases in shared rooms with beds spaced apart

ICU capacity

  • Rapid surges in numbers of critically ill patients with COVID-19
  • Insufficient ICU beds (bigger impact in low-income and middle-income countries)
  • Equipment shortages because of increased capacity (eg, ventilators) as well as consumables and pharmaceuticals
  • Short supply of ventilators
  • Implement national and regional modeling of needs for intensive care
  • Plan for anticipated increase in capacity (ie, intensive care provision in areas outside ICUs and centralizing intensive care in designated ICUs)
  • Close attention should be given to addressing logistical support and the supply chain; reducing the inflow of patients who do not urgently require intensive care (eg, postponing elective surgeries)
  • Consider transport, operating theater, and military ventilators

ICU staffing

  • Increasing ICU bed numbers and workload without increasing ICU staff, leading to increased mortality
  • Infection of HCW because of unprotected exposure, which affects staff load and morale
  • Increase in mental health problems (ie, depression, anxiety)
  • Make plans for augmentation of staff; cross-train
  • Minimize risk for infection; implement segregation of teams and physical distancing and impose travel restrictions
  • Reassure staff through infection prevention measures, clear communication, limit shift hours, provide rest areas and mental health support

ICU triage

  • ICUs can become overwhelmed, as surge strategies might not be sufficient in an emerging pandemic such as COVID-19
  • Consider implementing a triage policy that prioritizes patients for intensive care and rations scarce resources

ICU research

  • The traditional pace of research might not match pace of the outbreak
  • Studies are often single-centered and underpowered
  • Rapid conduct and sharing of research might compromise scientific quality and ethical integrity
  • Use and adapt preapproved research plans and platforms
  • Collaborate through international research networks and platforms
  • Cautiously analyze the study methodology when interpreting the literature

Phua J, et al.[13]

Recently, a panel of 36 experts from 12 countries from across the globe developed the first international guidelines on the management of critically ill patients with COVID-19. The guidelines present 50 recommendations within 4 domains, under the auspices of the Surviving Sepsis Campaign. They were issued by the European Society of Intensive Care Medicine (ESICM) and were subsequently published in Intensive Care Medicine.[6]

A central aspect of the guidance is what works and what does not in treating critically ill patients with COVID-19 in intensive care.

The guideline document details all 50 recommendations, along with the associated level of evidence. Ten of the recommendations cover potential pharmacotherapies, most of which have only weak or no evidence of benefit. There is also an algorithm for the management of patients with acute hypoxemic respiratory failure secondary to COVID-19 and a summary of clinical practice recommendations.

The guidelines highlight the importance of protecting our HCW at risk for SARS CoV-2 infection. Below are some of their key recommendations.

Best Practice Recommendations

Infection Control and Testing

Current evidence indicates a high risk for potential infection among HCW. The Chinese Center for Disease Control and Prevention recently reported 44,672 laboratory-confirmed cases of COVID-19. Of these, 1716 (3.8%) were HCW. About 14.8% (247/1668) of infected HCW had severe or critical illness, and it was reported that 5 died. As of March 15, a total of 2026 documented cases of infection among HCW were identified in Italy. The guidelines stress the importance of adherence to infection-control precautions and making that a top priority. The guidelines also recommend the use of respiratory masks such as N95 and FFP2 in the ICU, as they are designed to block 95% to 99% of aerosol particles. As an alternative, powered air-purifying respirators (PAPRs) can be used by HCW if N95 masks are not available or are in limited supply. Surgical/medical masks are less effective in blocking small particle sizes < 5 µm. Because of the need to preserve the use of N95 masks for more aerosol-producing procedures, guidance recommends HCW caring for nonventilated patients with COVID-19 use surgical/medical masks, as should HCW who are performing non--aerosol-generating procedures along with other recommended PPE.

Recommendation:

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).

*Aerosol-generating procedures in the ICU include: endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, physical proning of the patient, disconnecting the patient from the ventilator, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation.

ICU patients should be placed in negative-pressure rooms when performing aerosol-generating procedures such as bronchoscopies, tracheal intubation, and noninvasive positive pressure ventilation (NIPPV). Negative-pressure rooms are engineered to prevent diffusion of pathogens into a larger space and consequently from room to room, thus preventing the spread of transmission and minimizing the risk for cross-contamination of contagious airborne pathogens among other patients and staff outside the room. Designated staff only should be allowed entry into the negative-pressure room. See WHO guidance for further information on negative-pressure room requirements. The guidance cautions against the excessive or unnecessary use of bronchoscopies, as they carry the highest risk for aerosolization.

Recommendation:

We recommend performing aerosol-generating procedures on ICU patients with COVID-19 in a negative pressure room (best practice statement).

For HCW safety, it is important to reduce the number of attempts to intubate a patient, as intubation is associated with high-risk probability of transmission and/or contamination. The guidelines recommend experienced personnel perform intubation techniques.

Recommendation:

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).

Hemodynamics

For the acute resuscitation of adults with COVID-19 and shock, we recommend against using hydroxyethyl starches.

For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is available.

The following are strong recommendations for mechanically ventilated patients:

In adults with COVID-19, we recommend starting supplemental oxygen if SPO2 is < 90%

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).

For mechanically ventilated adults with COVID-19 and ARDS, we recommend targeting plateau pressures (Pplat) of < 30 cm H2O.

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.

If recruitment maneuvers are used, we recommend against using staircase (incremental PEEP) recruitment maneuvers.

The guidance provided no recommendations for the use of recombinant interferons (rIFNs) (alone or in combination with antivirals), chloroquine or hydroxychloroquine, tocilizumab, or other antiviral agents in critically ill adults because of insufficient evidence.

In June, the FDA revoked the EUA for Chloroquine and Hydroxychloroquine due to emerging scientific data that determined that either are unlikely to be effective in the treatment of COVID-19 and that risks (I.e serious cardiac adverse events and other potential serious side effects) outweigh any potential benefits of these agents for the authorized use.

In an editorial in the Journal of the American Medical Association issued just days after these new guidelines,[16] Francois Lamontagne, MD, MSc, and Derek C. Angus, MD, MPH, said they "represent an excellent first step toward optimal, evidence-informed care for patients with COVID-19."

Lamontagne is from the University of Sherbrooke, Sherbrooke, Québec, Canada, and Angus is from the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and is an associate editor with JAMA.

Dealing With Tide of Patients With COVID-19; Protecting Healthcare Workers

Editor-in-chief of Intensive Care Medicine Giuseppe Citerio, MD, from the University of Milano-Bicocca, Monza, Italy, said in a press release from ESICM,[17] "COVID-19 cases are rising rapidly worldwide, and so we are increasingly seeing that intensive care units [ICUs] have difficulty in dealing with the tide of patients.

"This is the first guidance to lay out what works and what doesn't in treating coronavirus-infected patients in intensive care. It's based on decades of research on acute respiratory infection being applied to COVID-19 patients," added ESICM President-Elect Maurizio Cecconi, MD, from Humanitas University, Milan, Italy.

"At the same time as caring for patients, we need to make sure that health workers are following procedures which will allow themselves to be protected against infection," he stressed. "We must protect them, they are in the frontline. We cannot allow our healthcare workers to be at risk. On top of that, if they get infected they could also spread the disease further."

Although all 50 recommendations are key to the successful management of patients with COVID-19, busy clinicians on the front line need to zone in on those indispensable practical recommendations that they should implement immediately.

Waleed Alhazzani, MD, MSc, from the division of critical care, McMaster University, Hamilton, Ontario, Canada, and colleagues included the following in their choice recommendations in addition to the above[6]:

  • For adults with COVID-19 and acute hypoxemic respiratory failure, we suggest using HFNC over NIPPV
  • 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
  • For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest prone ventilation for 12 to 16 hours, over no prone ventilation
  • For mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS), we suggest against the routine use of systemic corticosteroids.

These choices are in broad agreement with those selected by Jason T. Poston, MD, University of Chicago, Chicago, Illinois, and colleagues in their synopsis of these guidelines, published online March 26 in JAMA,[18] although they also highlight another recommendation on infection control[6]:

  • 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).

Importance of Prone Ventilation, Perhaps for Many Days

One recommendation singled out by both Alhazzani and coauthors and Poston and colleagues relates to prone ventilation for 12 to 16 hours in adults with moderate to severe ARDS receiving mechanical ventilation.

Michelle N. Gong, MD, MS, chief of critical care medicine at Montefiore Medical Center, New York, New York, also highlighted this practice in a live-stream interview on March 23 with JAMA editor-in-chief Howard Bauchner, MD.[19]

She explained that in her institution they have been "very aggressive about proning these patients as early as possible, but unlike some of the past ARDS patients… they tend to require many, many days of proning in order to get a response."

Gong added that patients "may improve very rapidly when they are proned, but then when we supinate them, they lose [the improvement] and then they get proned for upwards of 10 days or more, if need be."

According to Alhazzani prone ventilation "is a simple intervention that requires training of healthcare providers but can be applied in most contexts."

He explained that the recommendation "is driven by indirect evidence from ARDS," not specifically those in COVID-19, with recent studies having shown that COVID-19 "can affect lung bases and may cause significant atelectasis and reduced lung compliance in the context of ARDS.

"Prone ventilation has been shown to reduce mortality in patients with moderate to severe ARDS," he continued. "Therefore, we issued a suggestion for clinicians to consider prone ventilation in this population."

"Impressively Thorough" Recommendations, With Some Caveats

In their JAMA editorial,[16] Lamontagne and Angus described the recommendations as "impressively thorough and expansive."

They noted that they address resource scarcity, which "is likely [to] be a critical issue in low- and middle-income countries experiencing any reasonably large number of cases, and in high-income countries experiencing a surge in the demand for critical care."

Lamontagne and Angus pointed out, however, that a "weakness" of the guidelines is that they make recommendations for interventions that "lack supporting evidence."

Consequently, "[w]hen prioritizing scarce resources, clinicians and healthcare systems will have to choose among options that have limited evidence to support them," they stated. "In future iterations of the guidelines there should be more detailed recommendations for how clinicians should prioritize scarce resources, or include more recommendations against the use of unproven therapies…

"The tasks ahead for the dissemination and uptake of optimal critical care are herculean," Lamontagne and Angus cautioned.

They include "a need to generate more robust evidence, consider carefully the application of that evidence across a wide variety of clinical circumstances, and generate supporting materials to ensure effective implementation of the guideline recommendations," they concluded.

In May 2020, the FDA issued an emergency use authorization (EUA) for remdesivir for the treatment of COVID-19 in adults and children hospitalized with severe disease.[20]

The investigational antiviral drug was shown in a preliminary analysis of a National Institutes of Health clinical trial to shorten recovery time in some patients; however, the results of the trial have not been published, and little is known about how safe and effective it is in treating people in the hospital with COVID-19.

The EUA designation means remdesivir can be distributed in the United States and administered intravenously by healthcare providers, as appropriate to treat severe disease, which the FDA defined in a press release as patients with low blood oxygen levels or who need oxygen therapy or more intensive support such as a mechanical ventilator.

FDA officials wrote, "Based on evaluation of the emergency use authorization criteria and the scientific evidence available, it was determined that it is reasonable to believe that remdesivir may be effective in treating COVID-19, and that, given there are no adequate, approved, or available alternative treatments, the known and potential benefits to treat this serious or life-threatening virus currently outweigh the known and potential risks of the drug's use."

The manufacturer advised that infusion-related reactions and liver transaminase elevations have been seen in patients treated with the drug.

Recommendation Highlights

  • A panel of 36 experts from 12 countries developed the recommendations.
  • The expert panel assessed databases for studies of COVID-19; however, it developed most of its recommendations based on studies of other infectious diseases and critically ill patients.
  • The panel recommends a conservative vs liberal fluid strategy in the acute resuscitation of critically ill patients with COVID-19 and shock. Conservative fluid resuscitation has been associated with shorter ICU stays in a previous meta-analysis.
  • Buffered/balanced crystalloids should be employed in the fluid resuscitation of patients with COVID-19 and shock. Hydroxyethyl starches should be avoided.
  • Norepinephrine is the first-line vasoactive agent in the resuscitation of patients with COVID-19 and shock. Vasopressin is a preferred second-line agent.
  • In cases of shock associated with COVID-19 infection, the mean arterial pressure should be titrated to 60 to 65 mm Hg.
  • Low-dose corticosteroid therapy is recommended for patients with COVID-19 and refractory shock. Previous research suggests that corticosteroids may help resolve shock faster and reduce the duration of ICU care.
  • Supplemental oxygen should be initiated in patients whose peripheral oxygen saturation falls to < 90%, although < 92% is an acceptable standard. Oxygen saturation should be maintained no higher than 96%.
  • In cases of acute hypoxemic respiratory failure, HFNC is preferred over conventional oxygen therapy.
  • In mechanically ventilated patients, the recommendations suggest using antimicrobial/antibacterial agents vs no agents, provided that this coverage is reviewed and revised daily.
  • The recommendations suggest not using the following agents among critically ill patients with COVID-19:
    • Intravenous immunoglobulin
    • Convalescent plasma
    • Lopinavir/ritonavir
  • There is insufficient evidence to recommend the following agents among critically ill patients with COVID-19:
    • Chloroquine or hydroxychloroquine
    • rIFNs (alone or in combination with antivirals)
    • Tocilizumab
  • In June, the FDA revoked the Emergency Use Authorization for Chloroquine and Hydroxychloroquine in COVID-19 patients.
  • Remdesivir is available for compassionate use in patients with COVID-19 hospitalized with severe disease.
  • Because of unpublished data, it is unclear if the use of remdesivir will become standard of care for patients with COVID-19.

Clinical Implications

  • The use of fitted respirator masks by HCW and negative-pressure rooms may be limited to the care of patients with COVID-19 undergoing procedures that might promote aerosol transfer of the virus. Otherwise, surgical masks can be part of PPE in routine care of the patient.
  • Among patients with COVID-19 and respiratory failure, antimicrobial agents should be initiated. Low-dose corticosteroid therapy is recommended for patients with COVID-19 and refractory shock. There is insufficient evidence to recommend hydroxychloroquine and tocilizumab, in critically ill patients with COVID-19. Remdesivir is available for compassionate use in patients with COVID-19 hospitalized with severe disease.
  • Implications for the Healthcare Team: The healthcare team needs to rely primarily on evidence from research based on patients who did not have COVID-19 in defining best practices, but this will begin to change as more studies emerge regarding the management of critically ill patients with COVID-19.

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