Surviving Sepsis Campaign: COVID-19 Recommendations

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The Surviving Sepsis Campaign (SSC) organized a 36-expert working group from 12 countries to create a set of guidelines released on March 20, 2020 for the management of critically ill adults with COVID-19.

Currently, there is little direct evidence published about COVID-19 treatment, so guideline writers supplemented what is available with indirect evidence from the two previous coronavirus epidemics, MERS-CoV and SARS. They also utilized accepted supportive care measures from ICU studies on influenza, acute respiratory distress syndromes (ARDS), and sepsis.

The drop-downs below summarize the SSC recommendations that are most pertinent to Emergency Medicine care. The details of the recommendations can be found at the bottom.

Infection Control

Lab Diagnosis

Hemodynamic Support

Ventilator Support

Treatment

Details

Infection Control

1. Wear fitted respirator masks rather than surgical masks for aerosol-generating procedures* for patients with COVID-19

  • From guideline Mar 20 “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)”

2. Perform aerosol-generating procedures* in negative pressure room

  • From guideline Mar 20 “We recommend performing aerosol-generating procedures on ICU patients with COVID-19 in a negative pressure room (best practice statement).”

3. Wear surgical/medical masks when providing routine care for non-ventilated COVID-19 patients

  • From guideline Mar 20 “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 recommendation, low quality evidence).”

4. Wear surgical/medical masks when providing non-aerosol-generating care for ventilated COVID-19 patients

  • From guideline Mar 20 “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 recommendation, low quality evidence).”
  • No direct evidence from COVID-19 – is indirect evidence from influenza and seasonal coronavirus which showed no statistical difference in lab confirmed illness with surgical/medical masks vs N95
  • If scarcity is not an issue, they do suggest that use of a fitted respirator mask is a reasonable option

5. Video-guided laryngoscopy is preferred over direct laryngoscopy when intubating COVID-19 patients

  • From guideline Mar 20 “For healthcare workers performing endotracheal intubation on patients with COVID-19, we suggest using video-guided laryngoscopy, over direct laryngoscopy, if available (weak recommendation, low quality evidence).”
  • No direct evidence for COVID-19, is from systematic review suggesting improved first pass success with VL vs DL
  • Recommendation is conditional on VL availability

6. Most-experienced health care provider should intubate COVID-19 patients

  • From guideline Mar 20 “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)”
  • Same rationale as 5. – want to improve first-pass success

Laboratory Diagnosis and Specimens

7. Lower respiratory tract samples are preferred over upper respiratory tract samples, with endotracheal aspirates preferred over bronchial wash or bronchoalveolar lavage samples

  • From guideline Mar 20 “For diagnostic testing, we suggest obtaining lower respiratory tract samples in preference to upper respiratory tract (nasopharyngeal or oropharyngeal) samples (weak recommendation, low quality evidence).”
  • From guideline Mar 20 “With regard to lower respiratory samples, we suggest obtaining endotracheal aspirates in preference to bronchial wash or bronchoalveolar lavage samples (weak recommendation, low quality evidence).”
  • Given COVID-19 diagnosis is based on RT-PCR of samples from respiratory tract. Samples from nasopharyngeal and oropharyngeal swabs may be falsely negative in patient with COVID-19 as confirmed by lower-respiratory tract swabs, and so lower respiratory tract samples are preferred.
  • Endotracheal swabs are preferred over samples that require bronchoscopy given the aerosolization risk with bronchoscopy

Supportive Care

Hemodynamic Support

8. Use dynamic parameters such as capillary refilling time, skin temperature, and/or serum lactate to assess fluid responsiveness in adults with COVID-19 and shock

  • From guideline Mar 20 “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 recommendation, low quality evidence).”
  • No direct evidence for resuscitation strategies in COVID-19, but resuscitation based on dynamic parameters such as cap refill, skin temp, and serum lactate has been shown to improve patient outcomes in the ICU in patients requiring fluid resuscitation

9. Use a conservative rather than liberal fluid resuscitation strategy for adults with COVID-19 and shock

  • From guideline Mar 20 “For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fluid strategy (weak recommendation, very low-quality evidence).”
  • No direct evidence from COVID-19, uses indirect evidence from critically ill patients with sepsis and ARDS

10. Through 15. Use balanced crystalloids (such as Lactated Ringer’s) rather than unbalanced crystalloids for resuscitation of adults with COVID-19. Recommend using crystalloids over colloids; suggest against hydroxyethyl starches, and recommend against gelatins, dextrans, and albumin for acute resuscitation of adults with COVID-19 and shock.

  • These recommendations are not founded on direct evidence in COVID-19, but rather indirect evidence from critically ill patients in general

16. Use norepinephrine as first line vasoactive agent over other agents for adults with   COVID-19 and shock

  • From guideline Mar 20 “For adults with COVID-19 and shock, we suggest using norepinephrine as the first-line vasoactive agent, over other agents (weak recommendation, low quality evidence).”

17. If norepinephrine is not available, either vasopressin or epinephrine is preferred as the first-line vasoactive agent over other agents for adults with COVID-19 and shock

  • From guideline Mar 20 “If norepinephrine is not available, we suggest using either vasopressin or epinephrine as the first-line vasoactive agent, over other vasoactive agents, for adults with COVID-19 and shock (weak recommendation, low quality evidence).”

18. Do not use dopamine if norepinephrine is available for adults with COVID-19 and shock

  • From guideline Mar 20 “For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is available (strong recommendation, high quality evidence).”

19. Add vasopressin as a second-line agent to adults with COVID-19 and shock on norepinephrine who are not achieving target mean arterial pressure (MAP)

  • From guideline Mar 20 “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 recommendation, moderate quality evidence).”

20. Titrate vasoactive agents to a target MAP of 60-65 mmHg for adults with COVID-19 and shock

  • From guideline Mar 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 recommendation, low quality evidence)”

21. Add dobutamine to adults with COVID-19 and shock who have cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine

  • From guideline Mar 20 “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 recommendation, very low quality evidence).”

22. Use low dose-corticosteroid therapy (IV hydrocortisone 200mg per day – as an infusion or intermittent bolus) for adults with COVID-19 and refractory shock

  • From guideline Mar 20 “For adults with COVID-19 and refractory shock, we suggest using low-dose corticosteroid therapy (“shock-reversal”), over no corticosteroid therapy (weak recommendation, low quality evidence).”

Ventilatory Support

23. Start supplemental oxygen if peripheral oxygen saturation (SPO2) is less than 90 – 92% in adults with COVID-19

  • From guideline Mar 20 “In adults with COVID-19, we suggest starting supplemental oxygen if the peripheral oxygen saturation (SPO2) is < 92% (weak recommendation, low quality evidence), and recommend starting supplemental oxygen if SPO2 is < 90% (strong recommendation, moderate quality evidence).”

24. Maintain SPOno greater than 96% for adults with COVID 19 in acute hypoxemic respiratory failure on oxygen

  • From guideline Mar 20 “In adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, we recommend that SPO2 be maintained no higher than 96% (strong recommendation, moderate quality evidence).”

25. Use high flow nasal cannula (HFNC) over conventional oxygen therapy in adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy

  • From guideline Mar 20 “For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, we suggest using HFNC over conventional oxygen therapy (weak recommendation, low quality evidence).”

26. Use HFNC over non-invasive positive pressure ventilation (NIPPV) in adults with COVID-19 and acute hypoxemic respiratory failure 

  • From guideline Mar 20 “In adults with COVID-19 and acute hypoxemic respiratory failure, we suggest using HFNC over NIPPV (weak recommendation, low quality evidence).”

27. Consider trial NIPPV if HFNC not available and intubation not urgently indicated in adults with COVID-19 and acute hypoxemic respiratory failure

  • From guideline Mar 20 “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 recommendation, very low-quality evidence).”

28. No recommendations could be made comparing helmet NIPPV compared with mask NIPPV

  • From guideline Mar 20 “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. Closely monitor adults with COVID-19 receiving NIPPV or HFNC for worsening respiratory status , which may require early intubation

  • From guideline Mar 20 “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 (best practice statement).”

Invasive Mechanical Ventilation

30. Use low tidal volume (Vt) ventilation (Vt 4-8ml/kg of predicted body weight) over high tidal volumes for mechanically ventilated adults with COVID-19 and ARDS

  • From guideline Mar 20 “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 recommendation, moderate quality evidence).”

31. Target plateau pressures (Pplat) less than 30cm H2O for mechanically ventilated adults with COVID-19 and ARDS

  • From guideline Mar 20 “For mechanically ventilated adults with COVID-19 and ARDS, we recommend targeting plateau pressures (Pplat) of < 30 cm H2O (strong recommendation, moderate quality evidence).”

32. Use a higher positive end expiratory pressure (PEEP) strategy (PEEP > 10cm H2O) over a lower PEEP strategy for mechanically ventilated adults with COVID-19 and ARDS, although patients should be monitored for barotrauma

  • From guideline Mar 20 “ For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest using a higher PEEP strategy, over a lower PEEP strategy (weak recommendation, low quality evidence).”

33. Use fluids conservatively for mechanically ventilated adults with COVID-19 and ARDS

  • From guideline Mar 20 “For mechanically ventilated adults with COVID-19 and ARDS, we suggest using a conservative fluid strategy over a liberal fluid strategy (weak recommendation, low quality evidence).”

34. Through 40. Further vent discussion, not relevant to ED management of patients

COVID-19 Therapy

41. And 42. ARDS-related care less pertinent to the Emergency Department.

43. Use empiric antimicrobial agents for mechanically ventilated adults with COVID-19 and respiratory failure

  • From guideline Mar 20 “In mechanically ventilated patients with COVID-19 and respiratory failure, we suggest using empiric antimicrobials/antibacterial agents, over no antimicrobials (Weak recommendation, low quality evidence).”

44. Use acetaminophen for temperature control for adults with COVID-19 who develop fever

  • From guideline Mar 20 “For critically ill adults with COVID-19 who develop fever, we suggest using acetaminophen/paracetamol for temperature control, over no treatment (Weak recommendation, low quality evidence).”

45. Do not routinely use standard intravenous immunoglobulins for critically ill adults with COVID-19 

  • From guideline Mar 20 “In critically ill adults with COVID-19, we suggest against the routine use of standard intravenous immunoglobulins (IVIG) (Weak recommendation, very low-quality evidence).”

46. Do not routinely use convalescent plasma for critically ill adults with COVID-19 

  • From guideline Mar 20 “In critically ill adults with COVID-19, we suggest against the routine use of convalescent plasma (Weak recommendation, very low-quality evidence).”

47. Do not use lopinavir/ritonavir for critically ill adults with COVID-19. Insufficient evidence on the use of other antiviral agents in adults with COVID-19.

  • From guideline Mar 20 “In critically ill adults with COVID-19 we suggest against the routine use of lopinavir/ritonavir (weak recommendation, low quality evidence).”
  • From guideline Mar 20 “There is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19.”

48. Insufficient evidence on the use of recombinant interferons in adults with COVID-19.

  • From guideline Mar 20 “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. Insufficient evidence on the use of chloroquine or hydroxychloroquine in adults with COVID-19.

  • From guideline Mar 20 “There is insufficient evidence to issue a recommendation on the use of chloroquine or hydroxychloroquine in critically ill adults with COVID-19.”

50. Insufficient evidence on the use of tocilizumab in adults with COVID-19.

  • From guideline Mar 20 “There is insufficient evidence to issue a recommendation on the use of tocilizumab in critically ill adults with COVID-19.”

This post was copy-edited by Patrick Boreskie. Reviewed by Brent Thoma.

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Ben Forestell

Ben Forestell

Ben Forestell is a medical student and soon to be Emergency Medicine resident at McMaster University. His interests include FOAMed for medical learners (ClerkCast!), quality improvement, and simulation.
Ben Forestell

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