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Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus
Disease 2019 (COVID‐19)
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Disclaimer
The content provided is intended to provide information only. However, it is shared with the understanding that the Society of Critical Care Medicine is not engaged in the rendering of medical, legal, financial, accounting, or other professional service and THE SOCIETY OF CRITICAL CARE MEDICINE HEREBY DISCLAIMS ANY AND ALL LIABILITY TO ALL THIRD PARTIES ARISING OUT OF OR RELATED TO THIS CONTENT. The information is subject to change at any time without notice and should not be relied upon as a substitute for professional advice from an experienced, competent practitioner in the relevant field. THE SOCIETY OF CRITICAL CARE MEDICINE DOES NOT MAKE ANY GUARANTEES OR WARRANTIES CONCERNING THE INFORMATION CONTAINED HEREIN AND NO PERSON OR ENTITY IS ENTITLED TO RELY ON ANY STATEMENTS OR INFORMATION CONTAINED HEREIN. If expert assistance is required, please seek the services of an experienced, competent professional in the relevant field.
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Welcome to the Webcast!
Moderator:
Mitchell M. Levy, MD, MCCMProfessor of Medicine, Division Chief Pulmonary and Critical Care Medicine Brown University School of Medicine Providence, Rhode Island, USA Nothing to disclose
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Today’s SpeakersWaleed Alhazzani, MD, MSc, FRCPCDirector, GUIDE Methodology Group, McMaster UniversityAssociate Professor, Division of Critical Care and Department of MedicineAssociate Member Clinical Epidemiology and BiostatisticsActive Staff, Intensive Care, General Internal Medicine, and GastroenterologySt. Joseph’s HealthcareHamilton, Ontario, CanadaNothing to disclose
Laura E. Evans, MD, MS, FCCMCo‐Chair, Adult Surviving Sepsis Campaign GuidelinesAssociate Professor, Division of Pulmonary, Critical Care and Sleep MedicineMedical Director, Critical Care ServicesUniversity of Washington Medical CenterSeattle, Washington, USANothing to disclose
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SSC COVID Guidelines Panel Members
Waleed AlhazzaniMorten H. MøllerYaseen M. ArabiMark Loeb Michelle Ng GongEddy Fan Simon J.W. OczkowskiMitchell M. Levy Lennie DerdeAmy L. DzierbaBin DuMichael Aboodi
Hannah WunschMaurizio CecconiYounsuck KohDaniel S. Chertow Kathryn MaitlandFayez E. AlshamsiEmilie Belley‐Cote Massimiliano Greco Matthew LaundyJill S. MorganJozef KeseciogluAllison McGeer Leonard Mermel
Manoj J. MammenPaul E. AlexanderAmy ArringtonJohn E. CentofantiGiuseppe CiterioBandar BawZiad A. MemishNaomi E. Hammond Frederick G. Hayden Laura E. EvansAndrew Rhodes
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Expert Identified evidence
Evidence ProfileCertainty of Evidence
PICOquestions
Expedited Review & Publication
Dissemination
Panel Discussion
Recommendation
COVID-19
Summarize the evidence
Systematic reviewsARDS, MERS, SARS,
shock Assess quality
New evidence
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Desirable consequences
Undesirable consequences
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Strong Recommendation for the Intervention
Desirable consequences
Undesirable consequences
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Desirable consequences
Undesirable consequences
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Weak Recommendation for the Intervention
Desirable consequences
Undesirable consequences
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Patients
For Patients
Strong Recommendation Weak RecommendationMost individuals in this situation would want the recommended course of action, and only a small proportion would not.
The majority of individuals in this situation would want the suggested course of action, but many would not.
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Clinicians
For Clinicians
Strong Recommendation Weak RecommendationMost individuals should receive the recommended course of action.
Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.
Different choices are likely to be appropriate for different patients.
Therapy should be tailored to the individual patient’s circumstances, such as patient’s or family’s values and preferences.
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Policymakers
For Policymakers
Strong Recommendation Weak RecommendationCan be adapted as policy in most situations, including for use as performance indicators.
Policies will likely be variable.
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Infection Control
• Aerosol‐generating procedure versus not• Negative‐pressure room versus regular room• Surgical masks versus respirator masks
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Aerosol‐Generating Procedures
Procedure Studies EstimateIntubation 4 OR 6.6 (2.3, 18.9)
Manipulation of BiPAP mask 1 OR 6.2 (2.2, 18.1)CPR 1 OR 4.5 (1.5, 13.8)
Tracheostomy 1 OR 4.2 (1.5, 11.5)Noninvasive ventilation 2 OR 3.1 (1.4, 6.8)Manual ventilation 1 OR 2.8 (1.3, 6.4)
PLoS One. 2012;7(4):e35797.
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Infection Control
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 compared to surgical/medical masks, in addition to other personal protective equipment.
*FFP3 respirators are more commonly used in many parts of the world.
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Infection Control
For healthcare workers providing usual care for nonventilated COVID‐19 patients, we suggest using surgical/medical masks, as compared to respirator masks in addition to other personal protective equipment.
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Infection Control
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 compared to respirator masks in addition to other personal protective equipment.
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Oxygen Targets
SPO2
Mortality
?92% 96%90%
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Oxygen TargetsMortality
?92% 96%90%
We recommend that SPO2 be maintained no
higher than 96%.
SPO2
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Oxygen TargetsMortality
?92% 96%90%
We suggest starting supplemental oxygen if
SPO2 < 92%.
SPO2
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Oxygen TargetsMortality
?92% 96%90%
We recommend starting oxygen if SPO2 < 90%.
SPO2
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SPO2 and Mortality
Lancet. 2018 Apr 28;391(10131):1693‐1705.
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Hypoxemia
For adults with COVID‐19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, we suggestusing high‐flow nasal cannula (HFNC) over conventional oxygen therapy.
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Hypoxemia
For adults with COVID‐19 and acute hypoxemic respiratory failure, we suggest using HFNC over noninvasive positive‐pressure ventilation (NIPPV).
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Hypoxemia
For adults with COVID‐19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no emergent indication for endotracheal intubation, we suggest a trial of NIPPV with close monitoring and short interval assessment for worsening of respiratory failure.
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27JAMA. 2016 Jun 14;315(22):2435‐41
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Endotracheal Intubation
For healthcare workers performing endotracheal intubationon patients with COVID‐19, we recommend endotracheal intubation be performed by healthcare workers experienced with airway management, to minimize the number of attempts and risk of transmission.
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Videolaryngoscopy
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Endotracheal Intubation
For healthcare workers performing endotracheal intubationon patients with COVID‐19, we suggest using video‐guided laryngoscopy over direct laryngoscopy, if available.
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COVID‐19 with hypoxia
Indication for endotracheal intubation?
Tolerating supplemental oxygen?
Do it:Endotracheal intubation
Do it:Expert in airway to intubate
Do it:Use N95/FFP2 or equivalent and other PPE/infection control precautions
Do it:Minimize staff in the room
Consider: if availableVideolaryngoscopy
Yes
No
Do it:Monitor closely for worsening
Do it:Target SPO2 92 to 96%
Do it:Appropriate infection control precautions
Do not:Delay intubation if worsening
Yes
No
Indication for endotracheal intubation?Yes
No
Consider: HFNC Tolerating HFNC
Not tolerating HFNC or HFNC is not available
Consider: Trial of NIPPVDo it: Monitor closely at short intervalsDo not: Delay intubation if worsening
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Acute Respiratory Distress Syndrome
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We recommend using lowVt (4‐8 mL/kg) and targeting
Pplat < 30 cm H2O.
ARDS
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We recommend using lowVt (4‐8 mL/kg) and targeting
Pplat < 30 cm H2O.We suggest using ahigher PEEP strategy.
Moderate to Severe ARDS
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We recommend using lowVt (4‐8 mL/kg) and targeting
Pplat <30 cmH2O.We suggest using a higherPEEP strategy.
We suggest using aconservative, over a liberal,
fluid strategy.
Moderate to Severe ARDS
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Prone Ventilation
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.
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Outcomes № of participants(studies)
Relative effect(95% CI)
Certainty of the evidence
Mortality >12 hours prone
1,002(5 RCTs)
RR 0.71(0.52 to 0.97)
MODERATE
Mortality <12 hours prone
1,135(3 RCTs)
RR 1.04(0.89 to 1.21)
MODERATE
Mortality –Moderate to severe ARDS
1,002(5 RCTs)
RR 0.71(0.52 to 0.97)
MODERATE
Mortality ‐ All ARDS 1,135(3 RCTs)
RR 1.04(0.89 to 1.21)
MODERATE
Accidental CVC Removal 635(2 RCTs)
RR 1.72(0.43 to 6.84)
VERY LOW
Pressure Sores 1087(3 RCTs)
RR 1.22(1.06 to 1.41)
HIGH
Airway Complications –Unplanned extubation
2067(6 RCTs)
RR 1.14(0.78 to 1.67)
LOW
Airway Complications –ETT Obstruction
1594(3 RCTs)
RR 1.76(1.24 to 2.50)
MODERATE
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Neuromuscular Blocking Agents?
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For mechanically ventilated adults with COVID‐19 and moderate to severe ARDS, we suggest using as‐needed intermittent boluses of NMBA, over a continuous NMBA infusion, to facilitate protective lung ventilation.
Neuromuscular Blocking Agents
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In case of persistent ventilator dyssynchrony, requirement of ongoing deep sedation, prone ventilation, or persistently high Pplt, we suggest using a continuous NMBA infusion for up to 48 hours.
Neuromuscular Blocking Agents
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Corticosteroids
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Steroids in ARDS: Mortality Outcome
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Steroids in ARDS: Mortality Outcome
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Steroids in ARDS: DMV
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Steroids in ARDS: VFD
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Steroids for Viral ARDS: Mortality
All observational studies
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Direct Evidence
Retrospective studyN = 201With COVID‐19 pneumonia
JAMA Intern Med. 2020 Mar 13.
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Corticosteroids• For mechanically ventilated adults with COVID‐19 and ARDS, we suggest using systemic corticosteroids over not using corticosteroids.
• Remark: The majority of our panel support a weak recommendation (i.e., suggestion) to use steroids in the sickest patients with COVID‐19 and ARDS. However, because of the very low‐quality evidence, some experts on the panel preferred not to issue a recommendation until higher‐quality direct evidence is available.
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Steroids for Viral Pneumonia: Mortality
All observational studies
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Corticosteroids
For mechanically ventilated adults with COVID‐19 and respiratory failure (without ARDS), we suggest against the routine use of systemic corticosteroids.
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Do: Vt 4‐8 mL/kg and Pplat <30 cm H2O
CONSIDER: NMBA boluses to facilitate ventilation targets
CONSIDER:Prone ventilation 12‐16 hr
COVID‐19 with mild ARDS
CONSIDER : if proning, high Pplt, asynchronyNMBA infusion for 24 hr
COVID‐19 with Mod to Severe ARDS
CONSIDER: if PEEP responsiveTraditional Recruitment maneuvers
CONSIDER: Conservative fluid strategy
Rescue/Adjunctive therapy
CONSIDER : if proning, high Pplt, asynchronyNMBA infusion for 24 h
CONSIDER:Prone ventilation 12‐16 hr
Don’t do: Staircase recruitment maneuvers
CONSIDER : STOP if no quick responseTrial of inhaled nitric oxide
CONSIDER : Follow local criteria for ECMO
VV ECMO or referral to ECMO center
Uncertain: Systemic corticosteroids
Do: Investigate for bacterial infection
CONSIDER: Empiric antibiotics
Do: Target SPO2 92%‐96%
CONSIDER:Higher PEEP
CONSIDER:Short course of systemic corticosteroids
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Antibiotics• For mechanically ventilated patients with COVID‐19 and respiratory failure, we suggest using empiric antimicrobials/antibacterial agents, compared to no antimicrobials.
• Remark: If the treating team initiates empiric antimicrobials, they should assess for de‐escalation daily, and reevaluate the duration of therapy and spectrum of coverage based on the microbiology results and the patient’s clinical status.
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Therapy• For critically ill adults with COVID‐19, we suggest againstthe routine use of standard intravenous immunoglobulins.
• For critically ill adults with COVID‐19, we suggest againstthe routine use of convalescent plasma.
• For critically ill adults with COVID‐19, we suggest againstthe routine use of lopinavir/ritonavir.
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Therapy
• Insufficient evidence to support recommendations for:– Antivirals– Hydroxychloroquine– Immunomodulators
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Hemodynamic Support
For adults with COVID‐19 and shock, we suggest using dynamic parameters, skin temperature, capillary refilling time, and/or lactate over static parameters to assess fluid responsiveness.
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Hemodynamic SupportFor the acute resuscitation of adults with COVID‐19 and shock, we suggest using a conservative, over a liberal, fluid strategy.
Outcomes № of participants
(studies)
Relative effect
(95% CI)
Certainty of the
evidence
All‐cause Mortality 637
(9 RCTs)
RR 0.87
(0.69–1.10)
VERY LOW
Serious Adverse Events 637
(9 RCTs)
RR 0.91
(0.78–1.05)
VERY LOW
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Hemodynamic Support• For adults with COVID‐19 and refractory shock, we suggestusing low‐dose corticosteroid therapy (shock reversal), over no corticosteroid therapy.
• Remark: Typical corticosteroid regimen in septic shock is intravenous hydrocortisone, 200 mg/day, either as an infusion or intermittent doses.
Outcomes № of participants
(studies)
Relative effect
(95% CI)
Certainty of the
evidence
Short‐term Mortality (<90 days) 7297
(22 RCTs)
RR 0.96
(0.91–1.02)
HIGH
Long‐term Mortality (>90 days) 5667
(5 RCTs)
RR 0.96
(0.90–1.02)
MODERATE
Serious Adverse Events 5908
(10 RCTs)
RR 0.98
(0.90–1.08)
LOW
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Questions and Answers
Speaker:Laura E. Evans, MD, MS, FCCM
Moderator:Mitchell M. Levy, MD, MCCM
Speaker:Waleed Alhazzani, MD, MSc, FRCPC
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A Special Thank You
• Guidelines panelists• Methodologists• SCCM and ESICM• Colleagues around the world who are caring for patients