The European Society of Intensive Care Medicine ESICM and the Society of Critical Care Medicine SCCM have been very efficient in providing us health care workers with a guideline manuscript giving recommendations on the treatment of COVID-19 patients in a critical care setting. It is imperative to keep in mind that research is moving forward very quickly in these times and changes to these recommendations are likely to occur.
A collection of many reliable OPEN ACCESS platforms on SARS-CoV-2 can be found on www.foam.education.
When performing aerosol-generating procedures on patients with COVID-19 in the ICU, fitted respirator masks (N95 respirators, FFP2) should be used (in combination with full Personal Protective Equipement PPE)
Aerosol-generating procedures on ICU patients with COVID-19 should be performed in a negative pressure room
During usual care for non-ventilated and non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients surgical masks are adequate
For endotracheal intubation video-guided laryngoscopy should be used, if available
In intubated and mechanically ventilated patients, endotracheal aspirates should be used for diagnostic testing
In COVID-19 patients with shock, dynamic parameters like skin temperature, capillary refilling time, and/or serum lactate measurement should be used in order to assess fluid responsiveness
For the acute resuscitation of adults with COVID-19, a conservative over a liberal fluid strategy is recommended
For the acute resuscitation of adults cristalloids should be used - avoid colloids!
Buffered/balanced crystalloids should be used over unbalanced crystalloids
Do NOT use hydroxyethyl starches!
Do NOT use gelatins!
Do NOT use dextrans!
Avoid the routine use of albumin for initial resuscitation!
In shock use norepinephrine/ noradrenaline as the first-line vasoactive agent
The use of dopamine is NOT recommended
Add vasopressin, if target MAP cannot be reached
Titrate vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets
For patients in shock and with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, adding dobutamine should be used
For persistent shock despite all these measures, low-dose corticosteroids should be tried
Keep peripheral saturation SpO2 above 90% with supplemental oxygen
There is NO need for supplemental oxygen with SpO2 above 96%
In acute hypoxemic respiratory failure despite conventional oxygen therapy, high-flow nasal cannulas (HFNC or High-Flow) should be used next
High-Flow should be used over non-invasive ventilation (NIV)
If High-Flow is not available and there is no urgent need for endotracheal intubation, NIV with close monitoring can be tried
In the event of worsening respiratory status, early endotracheal intubation should be performed
In mechanically ventilated patients, low-tidal volume ventilation should be used: 4 to 8 ml/kg
In mechanically ventilated patients with ARDS targeting plateau pressures (Pplat) of < 30 cm H2O should be aimed for
In patients with moderate to severe ARDS, a high-PEEP strategy should be used (PEEP >10cmH2O). Patients have to be monitored for potential barotrauma
NOTE by Crit.Cloud:
The strategy for high PEEP levels in general is currently discussed controversially. Observations in our own unit showed, that high PEEP levels tend to impaire compliance and therefor the quality of ventilation. Read also: "Less is More" in mechanical ventilatio, Gattinoni L. et al. Intensive Care Med (2020) 46:780-782
Patients with ARDS should receive a conservative/restrictive fluid strategy
In moderate to severe ARDS, prone positioning for 12-16 hours is recommended
To facilitate lung protective ventilation in moderate to severe ARDS, intermittent boluses of neuromuscular blocking agents (NMBA) should be used first
In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, a continuous NMBA infusion for up to 48 hours should be used next
Do NOT use inhaled nitric oxide in COVID-19 patients with ARDS routinely
In severe ARDS and hypoxemia despite optimising ventilation and other rescue strategies, a trial of inhaled pulmonary vasodilator as a rescue therapy can be considered; if no rapid improvement in oxygenation is observed, the treatment should be tapered off
If hypoxemia persists despite optimising ventilation, recruitment manoeuvres should be applied
If recruitment manoeuvres are used, DO NOT use staircase (incremental PEEP) recruitment manoeuvres
If all these measures fail, the patient should be considered for venovenous ECMO
In mechanically ventilated patients WITHOUT ARDS, systemic corticosteroids should NOT be used routinely
In contrast, mechanically ventilated patients WITH ARDS, the use of systemic corticosteroids is recommended
Mechanically ventilated patients with respiratory failure should be treated with empiric antimicrobials/antibacterial agents
Critically ill patients with fever should be treated with paracetamol (acetominophen) for temperature control
In critically ill patients standard intravenous immunoglobulins (IVIG) should NOT be used routinely
Also, the routine use of convalescent plasma is NOT recommended
The routine use of lopinavir/ritonavir (Kaletra®) is NOT recommended
Currently, there is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19
Currently, there is insufficient evidence to issue a recommendation on the use of recombinant interferons (rIFNs); chloroquine or hydroxychloroquine; tocilizumab (humanised immunoglobulin)
The headlines in the news 2017 were remarkable indeed: "Doctor believes he has found the cure for sepsis..." or "Doctor says improvised 'cure' for sepsis has had remarkable results".
Dr. Paul Marik described his observation in an interview in 2017, where he mentions several cases of sepsis that have almost miraculously responded to the application of vitamin c (watch here: Interview on WAVY TV). He even continues, that since then they see "the same thing over and over again". This implicated that these results were reproducible. He finally stated that the current data at that stage were "impressive" and that there was enough basic science to show that it works.
Vitamin C has many interesting properties that theoretically could be on benefit in sepsis. (read here: Crit☁ post on Vitamin C). Its application was already proposed for the treatment of other diseases like the common cold of Influenza. Despite some moderate positive influence observed, these results could not be reproduced in trials.
While the news picked up on this story as a miracle drug, Paul Marik et al. published their results of a before-and-after single-centre, retrospective cohort study in Chest 2017. In this paper, they compared 47 patients with sepsis that received the metabolic cocktail (Vitamin C 1.5g 6-hourly, hydrocortisone 50mg 6-hourly and thiamine 200mg 12-hourly) to 47 patients which did not - notably in a non-double-blinded, non-randomized fashion. Their results showed overall hospital mortality of 8.5% with the 'cocktail' and 40.4% without its application.
This publication was reason enough to launch a small war of faith about sense and nonsense of this cocktail for sepsis.
The VITAMINS Trial - First Failure
Since 2017 a tiny bunch of studies were published, many of them with significant limitations like a small number of patients, often not randomized-controlled and with conflicting results.
Nabil Habib T, Ahmed I (2017) Early Adjuvant Intravenous Vitamin C Treatment in Septic Shock may Resolve the Vasopressor Dependence. Int J Microbiol Adv Immunol. 05(1), 77-81.
Shin et al. J Clin Med. 2019 Jan; 8(1): 102.
Fowler et al. JAMA. 2019 Oct 1;322(13):1261-1270.
Fujii et al. have just now published the first more substantial and rigorous trial taking a closer look at the influence on vitamin c in sepsis.
They performed an
international, multicenter, randomized-controlled open label trial
In which they enrolled 211 patients with septic shock admitted to an ICU.
Treatment with Vitamin C 1.5g 6-hourly IV, hydrocortisone 50mg 6-hourly IV and thiamin 200mg 12-hourly IV
Hydrocortisone 50mg 6-hourly IV only.
No difference in time alive and time free of vasopressors (primary endpoint) and
No difference 28 days or 90 days mortality (secondary endpoint)
This first study on a larger scale, unfortunately, disappoints. More trials are on the way and might give a clearer picture of this topic to come to a final decision eventually.
For the moment it is appropriate to state:
Just as a reminder: Guidelines recommend against the routine use of glucocorticoids in patients with sepsis. However, corticosteroid therapy is appropriate in patients with septic shock that is refractory to adequate fluid resuscitation and vasopressor administration.
Fujii et al. JAMA. Published online January 17, 2020. doi:10.1001/jama.2019.22176
Teaching in medical school and opinions in literature are in agreement: The application of vasopressors requires central venous access. The reason for this are concerns that vasopressors given over a peripheral venous catheter (PCV) may cause phlebitis or even worse necrosis or ischemia through extravasation.
While irritation of a peripheral vein is often observed with the administration of drugs like potassium or amiodarone, this usually is not the case with the application of, e.g. norepinephrine. Besides, it is essential to keep in mind that the insertion of a central venous catheter (CVC) is technically demanding and takes a certain amount of time when performed correctly. The procedure is also associated with potentially dangerous complications that might be hazardous to the patient.
Therefore a fundamental question arises:
Do all patients that require vasopressors need a central venous catheter?
What about the peripheral access (PVC) - Any dangers there?