Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease
Recommendations and Statements
Infection Control and Testing
1. 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).
(, )2. We recommend performing aerosol-generating procedures on ICU patients with COVID-19 in a negative pressure room.
(, )3. For healthcare workers providing usual care for non-ventilated COVID-19 patients, 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).
(, Weak)4 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).
(, Weak)5. For healthcare workers performing endotracheal intubation on patients with COVID-19, we suggest using video-guided laryngoscopy, over direct laryngoscopy, if available.
(, Weak)6. 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.
(, )7.1. For intubated and mechanically ventilated adults with suspicion of COVID-19: For diagnostic testing, we suggest obtaining lower respiratory tract samples in preference to upper respiratory tract (nasopharyngeal or oropharyngeal) samples.
(, Weak)7.2. For intubated and mechanically ventilated adults with suspicion of COVID-19: With regard to lower respiratory samples, we suggest obtaining endotracheal aspirates in preference to bronchial wash or bronchoalveolar lavage samples.
(, Weak)Hemodynamics
8. In adults with COVID-19 and shock, we suggest using dynamic parameters skin temperature, capillary refilling time, and/or serum lactate measurement over static parameters in order to assess fluid responsiveness.
(, Weak)9. For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fluid strategy.
(, Weak)10. For the acute resuscitation of adults with COVID-19 and shock, we recommend using crystalloids over colloids.
(, Weak)11. For the acute resuscitation of adults with COVID-19 and shock, we suggest using buffered/ balanced crystalloids over unbalanced crystalloids.
(, Weak)12. For the acute resuscitation of adults with COVID-19 and shock, we recommend against using hydroxyethyl starches.
(, Strong)13. For the acute resuscitation of adults with COVID-19 and shock, we suggest against using gelatins.
(, Weak)14. For the acute resuscitation of adults with COVID-19 and shock, we suggest against using dextrans.
(, Weak)15. For the acute resuscitation of adults with COVID-19 and shock, we suggest against the routine use of albumin for initial resuscitation.
(, Weak)16. For adults with COVID-19 and shock, we suggest using norepinephrine as the first-line vasoactive agent, over other agents.
(, Weak)17 If norepinephrine is not available, we suggest using either vasopressin or epinephrine as the firstline vasoactive agent, over other vasoactive agents, for adults with COVID-19 and shock.
(, Weak)18. For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is available.
(, Strong)19. For adults with COVID-19 and shock, we suggest adding vasopressin as a second-line agent, over titrating norepinephrine dose, if target mean arterial pressure (MAP) cannot be achieved by norepinephrine alone.
(, Weak)20. For adults with COVID-19 and shock, we suggest titrating vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets.
(, Weak)21. For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, we suggest adding dobutamine, over increasing norepinephrine dose.
(, Weak)22. For adults with COVID-19 and refractory shock, we suggest using low-dose corticosteroid therapy (“shock-reversal”), over no corticosteroid.
(, Weak)Ventilation
- we suggest starting supplemental oxygen if the peripheral oxygen saturation (Spo2) is < 92%, and
- recommend starting supplemental oxygen if Spo2 is < 90%.
24. In adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, we recommend that Spo2 be maintained no higher than 96%.
(, Strong)25. For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, we suggest using HFNC over conventional oxygen therapy.
(, Weak)26. In adults with COVID-19 and acute hypoxemic respiratory failure, we suggest using HFNC over NIPPV.
(, Weak)27. In adults with COVID-19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no urgent indication for endotracheal intubation, we suggest a trial of NIPPV with close monitoring and short-interval assessment for worsening of respiratory failure.
(, Weak)28. We were not able to make a recommendation regarding the use of helmet NIPPV compared with mask NIPPV. It is an option, but we are not certain about its safety or efficacy in COVID-19.
(, )29. 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.
(, )30. 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).
(, Strong)31. For mechanically ventilated adults with COVID-19 and ARDS, we recommend targeting plateau pressures (Pplat) of <30 cm H2O.
(, Strong)32 For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest using a higher PEEP strategy, over a lower PEEP strategy.
(, Strong)33. For mechanically ventilated adults with COVID-19 and ARDS, we suggest using a conservative fluid strategy over a liberal fluid strategy.
(, Weak)34. 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.
(, Weak)35.1. For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest using, as needed, intermittent boluses of neuromuscular blocking agents (NMBA), over continuous NMBA infusion, to facilitate protective lung ventilation.
(, Weak)35.2. In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, we suggest using a continuous NMBA infusion for up to 48 hours.
(, Weak)36. In mechanically ventilated adults with COVID-19 ARDS, we recommend against the routine use of inhaled nitric oxide.
(, Weak)37. In mechanically ventilated adults with COVID-19, severe ARDS and hypoxemia despite optimizing ventilation and other rescue strategies, we suggest a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered off.
(, Weak)38. For mechanically ventilated adults with COVID-19 and hypoxemia despite optimizing ventilation, we suggest using recruitment maneuvers, over not using recruitment maneuvers.
(, Weak)39. If recruitment maneuvers are used, we recommend against using staircase (incremental PEEP) recruitment maneuvers.
(, Strong)40. In mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, we suggest using venovenous (VV) ECMO if available, or referring the patient to an ECMO center.
(, Weak)Therapy
41. In mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS), we suggest against the routine use of systemic corticosteroids.
(, Weak)42. In mechanically ventilated adults with COVID-19 and ARDS, we suggest using systemic corticosteroids, over not using corticosteroids.
(, Weak)43. In mechanically ventilated patients with COVID-19 and respiratory failure, we suggest using empiric antimicrobials/antibacterial agents, over no antimicrobials.
(, Weak)44. For critically ill adults with COVID-19 who develop fever, we suggest using acetaminophen/paracetamol for temperature control, over no treatment.
(, Weak)45. In critically ill adults with COVID-19, we suggest against the routine use of standard intravenous immunoglobulins (IVIG).
(, Weak)46. In critically ill adults with COVID-19, we suggest against the routine use of convalescent plasma.
(, Weak)47.1. In critically ill adults with COVID-19: we suggest against the routine use of lopinavir/ritonavir.
(, Weak)47.2. There is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19.
(, )48. There is insufficient evidence to issue a recommendation on the use of recombinant rIFNs, alone or in combination with antivirals, in critically ill adults with COVID-19.
(, )49. There is insufficient evidence to issue a recommendation on the use of chloroquine or hydroxychloroquine in critically ill adults with COVID-19.
(, )50. There is insufficient evidence to issue a recommendation on the use of tocilizumab in critically ill adults with COVID-19.
(, )Recommendation Grading
Overview
Title
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease
Authoring Organization
Society of Critical Care Medicine
Publication Month/Year
March 1, 2020
Last Updated Month/Year
February 5, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline provides recommendations to support hospital clinicians managing critically ill adults with COVID-19 in the intensive care unit (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 ICU.
Target Patient Population
Critically ill patients with COVID-19
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D007362 - Intensive Care Units, D017934 - Coronavirus, D018352 - Coronavirus Infections
Keywords
Coronavirus, intensive care unit, covid-19
Source Citation
Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-887. doi: 10.1007/s00134-020-06022-5. Epub 2020 Mar 28. PMID: 32222812; PMCID: PMC7101866.