Managing Critically Ill Adults with COVID-19

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Release Date : February 12 2021

Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update

Critical Care Nursing Infection Control-ID Pulmonary

About the Guideline

This guideline provides recommendations on the management of patients with severe or critical COVID-19 in the ICU.
The target users of this guideline are frontline clinicians, allied health professionals, and policymakers involved in the care of patients with COVID-19 in the intensive care unit (ICU).
A panel of 43 experts from 14 countries reviewed the literature and identified relevant and recent evidence on supportive care for COVID-19 patients in the ICU.
Recommendations were generated based on the balance between benefit and harm, resource and cost implications, equity, and feasibility.

Overview

Key Clinical Considerations

Infection control

Current data points to significant burden of infection among healthcare workers.
Risk of patient-to-patient transmission in the ICU is currently unknown.
Adherence to infection control precautions is paramount.
Infection control policies and procedures already in place at healthcare institutions should be followed; the recommendations in this guideline should serve as considerations rather than a requirement to change policies.

Aerosol-generating procedures

Best Practice Statement: For healthcare workers performing aerosol-generating procedures on patients with COVID-19 in the ICU, the recommendation is to use 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).
Aerosol-generating procedures 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
- cardiopulmonary resuscitation

Use of negative pressure rooms

Best Practice Statement: The recommendation is to perform aerosol-generating procedures on ICU patients with COVID-19 in a negative pressure room.
Negative pressure rooms are intended to prevent the spread of contagious airborne pathogens from room to room and avoid the accidental release of pathogens into a larger space and open facility.
When not feasible, a portable high-efficiency particulate air (HEPA) filter should be used.
The presence of unnecessary staff in the room should be avoided.

Usual care of nonventilated patients

Weak recommendation: For healthcare workers providing usual care for non-ventilated COVID- 19 patients, the suggestion is to use 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).

Non-aerosol-generating procedures on ventilated (closed-circuit) patients

Weak recommendation: For healthcare workers who are performing non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients with COVID-19, the suggestion is to use 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).

Endotracheal intubation

Techniques that can reduce the number of attempts at endotracheal intubation and the duration of the procedure and minimize the proximity between the operator and the patient should be prioritized.
Best Practice Statement: For COVID-19 patients requiring endotracheal intubation, the recommendation is 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.
Weak recommendation: For healthcare workers performing endotracheal intubation on patients with COVID-19, the suggestion is to use video-guided laryngoscopy, over direct laryngoscopy, if available.

Laboratory diagnosis and specimens

Hemodynamic support

The incidence of shock in adult patients with COVID-19 may reach 20-35% among patients in the ICU.

Fluid therapy

Weak recommendation: In adults with COVID-19 and shock, the suggestion is to use dynamic parameters, skin temperature, capillary refilling time, and/or serum lactate measurement over static parameters in order to assess fluid responsiveness.
- Dynamic parameters include stroke volume variation, pulse pressure variation, and stroke volume change with passive leg raise or fluid challenge.
- Static parameters include central venous pressure and mean arterial pressure (MAP).

Weak recommendation: For the acute resuscitation of adults with COVID-19, the suggestion is to use a conservative over a liberal fluid strategy.
Weak recommendation: For the acute resuscitation of adults with COVID-19 and shock, the recommendation is to use crystalloids over colloids.
Weak recommendation: For the acute resuscitation of adults with COVID-19 and shock, thesuggestion is to use buffered/balanced crystalloids over unbalanced crystalloids.
Strong recommendation: For the acute resuscitation of adults with COVID-19 and shock, the recommendation is against using hydroxyethyl starches.
Weak recommendation: For the acute resuscitation of adults with COVID-19 and shock, the suggestion is against using gelatins.
Weak recommendation: For the acute resuscitation of adults with COVID-19 and shock, the suggestion is against using dextrans.
Weak recommendation: For the acute resuscitation of adults with COVID-19 and shock, the suggestion is against the routine use of albumin for initial resuscitation.

Vasoactive agents

Weak recommendation: For adults with COVID-19 and shock, the suggestion is to use norepinephrine as the first line vasoactive agent, over other agents.
Weak recommendation: If norepinephrine is not available, the suggestion is to use either vasopressin or epinephrine as the first line vasoactive agent, over other vasoactive agents for adults with COVID-19 and shock.
- The decision between vasopressin and epinephrine may be based on availability and contraindications to the two agents.
  - With vasopressin, digital ischemia may be a concern.
  - With epinephrine, tachycardia and excess lactate production may be concerns.
Strong recommendation: For adults with COVID-19 and shock, the recommendation is against using dopamine if norepinephrine is available.
- This recommendation is based on increased harm, including increased risk of mortality, in patients treated with dopamine.
Weak recommendation: For adults with COVID-19 and shock, the suggestion is to add vasopressin as a second line agent, over titrating norepinephrine dose, if target MAP cannot be achieved by norepinephrine alone.
Weak recommendation: For adults with COVID-19 and shock, the suggestion is to titrate vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets.
Weak recommendation: For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, the suggestion is to add dobutamine, over increasing norepinephrine dose.
- It is also suggested to add dobutamine, over no treatment, in these patients; this is based on physiological rationale.

Ventilatory support

The true incidence of hypoxic respiratory failure in patients with COVID-19 is unclear, however about 14% will develop severe disease requiring oxygen therapy and 5% will require ICU admission and mechanical ventilation.
In another study, 67% of critically ill COVID-19 patients had ARDS, 63.5% received high flow nasal cannula (HFNC), 56% required invasive mechanical ventilation, and 42% received non- invasive positive pressure ventilation (NIPPV).

Oxygen therapy

A reasonable SPO2 range for patients on oxygen therapy is 92% to 96%.
- Strong recommendation: In adults with COVID-19, the suggestion is to start supplemental oxygen if the peripheral SPO2 is less than 92%, and the recommendation is to start supplemental oxygen if the SPO2 is less than 90%.
- Strong recommendation: In adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, the recommendation is that SPO2 be maintained no higher than 96%.
Weak recommendation: For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, the suggestion is to use HFNC over conventional oxygen therapy.
Weak recommendation: For adults with COVID-19 and acute hypoxemic respiratory failure, the suggestion is to use HFNC over NIPPV.
There is evidence for decreased risk of intubation with HFNC compared with NIPPV in acute respiratory failure.
Some studies suggest that NIPPV may carry a greater risk of nosocomial infection of healthcare providers.
Weak recommendation: In adults with COVID-19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no urgent indication for endotracheal intubation, the suggestion is a trial of NIPPV with close monitoring and short interval assessment for worsening of respiratory failure.
Best Practice Statement: In adults with COVID-19 receiving NIPPV or HFNC, the recommendation is for close monitoring for worsening of respiratory status and early intubation in a controlled setting if worsening occurs.
- Limited experience with NIPPV in pandemics suggests a high failure rate.
- When resources become stretched, if there is insufficient ability to provide invasive ventilation, a moderate chance of success with NIPPV may justify its use.
No recommendations:
- The use of helmet NIPPV compared with mask NIPPV
- The use of awake prone positioning in nonintubated adults with severe COVID-19

Invasive mechanical ventilation

Strong recommendation: In mechanically ventilated adults with COVID-19 and ARDS, the recommendation is to use low tidal volume (Vt) ventilation (Vt 4-8 mL/kg of predicted body weight) over higher tidal volumes (Vt greater than 8 mL/kg).
- The panel of experts believes that COVID-19 patients should be managed as others with acute respiratory failure in the ICU.
- Low Vt ventilation is one of the main strategies to minimize ventilator-induced lung injury (VILI).
- The ARDSNet study protocol set the initial Vt at 6 mL/kg which can be increased to 8 mL/kg if the patient is double triggering or if inspiratory airway pressure decreases below PEEP.

Strong recommendation: For mechanically ventilated adults with COVID-19 and ARDS, the recommendation is targeting plateau pressures (Pplat) of less than 30 cm H2O.
Pplat limitation is a lung protective strategy to minimize VILI.
The ARDSNet study protocol set the initial Vt at 6 mL/kg, and then measured Pplat (after a 0.5 second inspiratory pause). If the Pplat was greater than 30 cmH2O, Vt could be reduced in 1 mL/kg (to 4 mL/kg) steps until Pplat was within range.
Strong recommendation: For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, the suggestion is to use a higher PEEP strategy over a lower PEEP strategy.
- PEEP increases and sustains alveolar recruitment, which improves oxygenation.
- If using a higher PEEP strategy (i.e. PEEP greater than 10 cm H2O), monitor patients for barotrauma.
Weak recommendation: For mechanically ventilated adult patients with COVID-19 and ARDS, the suggestion is to use a conservative fluid strategy over a liberal fluid strategy.
- Limited data show that cardiac failure, alone or with respiratory failure, caused 40% of COVID-19 deaths.
Weak recommendation: For mechanically ventilated adult patients with COVID-19 and moderate to severe ARDS, the suggestion is to use prone ventilation for 12 to 16 hours, over no prone ventilation.
- The progression of radiographic features in a series of COVID-19 patients suggests a role for prone ventilation.
- Theoretically, prone positioning decreases ventral alveolar distention and dorsal alveolar collapse.
- A protocol for proning should be used.
- Clinicians should be aware of the following complications:
  - Pressure sores
  - Vascular line and endotracheal tube displacement
  - Facial edema
  - Transient hemodynamic instability
  - Corneal abrasions
  - Brachial plexus injury
  - Hemodialysis vascular flow issues
- Absolute contraindications for prone ventilation are:
  - Unstable spine
  - Open abdomen or open chest
- Enteral nutrition (via nasogastric or nasoduodenal tube) can be continued during proning.

Weak recommendation: For mechanically ventilated adult patients with COVID-19 and moderate to severe ARDS, the suggestion is to use intermittent boluses of neuromuscular blocking agents (NMBA) as needed, over continuous NMBA infusion.
Weak recommendation: In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, for mechanically ventilated adult patients with COVID-19 and moderate to severe ARDS, the suggestion is to use a continuous NMBA infusion for up to 48 hours.
Weak recommendation: For mechanically ventilated adult patients with COVID-19 and ARDS, the recommendation is against routine use of inhaled nitric oxide.
Weak recommendation: For mechanically ventilated adult patients with COVID-19, severe ARDS, and hypoxemia despite optimizing ventilation and other rescue strategies, the suggestion is a trial of inhaled pulmonary vasodilator as a rescue therapy; treatment should be tapered off if there is no rapid improvement in oxygenation.
Weak recommendation: For mechanically ventilated adult patients with COVID-19 and hypoxemia despite optimizing ventilation, the suggestion is to use recruitment maneuvers (RM) over not using RM.
- Strong recommendation: If RM are used, the recommendation is against using staircase (incremental PEEP).
- Monitor patients closely for severe desaturation, hypotension, or barotrauma.
- Stop RMs if they lead to patient deterioration.
Weak recommendation: For mechanically ventilated adult patients with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, the suggestion is to use venovenous (VV) extracorporeal membrane oxygenation (ECMO) if available, or referring patient to an ECMO center.
- ECMO is a resource intensive technique and remains a limited resource; its use should be reserved for carefully selected patients.

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Managing Critically Ill Adults with COVID-19

Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update

About the Guideline

Overview

Key Clinical Considerations

Infection control

Laboratory diagnosis and specimens

Hemodynamic support

Ventilatory support

COVID-19 therapy

References

CE Resources

Nursing Resources

About NursingCenter

Managing Critically Ill Adults with COVID-19

Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update

About the Guideline

Overview

Key Clinical Considerations

Infection control

Laboratory diagnosis and specimens

Hemodynamic support

Ventilatory support

COVID-19 therapy

References

CE Resources

Nursing Resources

About NursingCenter

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