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Reviews and Summaries

Surviving Sepsis Campaign COVID-19 Guidelines - Short Summary

22/3/2020

 
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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.

Infection Control

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

Supportive Care

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


Ventilatory Support

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

COVID-19 Therapy

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)


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Direct Download of the pdf file:

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) by ESICM and SCCM
Mohammed Shalaby
23/3/2020 05:19:13

Hypoxemia and VC with good compliance is the main observation so avoid high peep as it may compromises the RV and the proning to redistribute the perfusion to improve the V/Q mismatch

Timothy link
31/3/2020 10:04:42

Dear Mohammed,

I think you have a very good point there. Also, our observation is, that high PEEP levels impair compliance and can negatively influence ventilation. The question is, whether these recommendations of high PEEP might have to be adjusted.

Errol Muller
31/5/2020 01:32:24

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Errol Muller
31/5/2020 01:33:03

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Jackie Hutchins
31/5/2020 02:19:48

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Lynne Wilson
8/6/2020 10:31:44

Irrespective of receiving daily oral or future injectable depot therapies, these require health care visits for medication and monitoring of safety and response. If patients are treated early enough, before a lot of immune system damage has occurred, life expectancy is close to normal, as long as they remain on successful treatment. However, when patients stop therapy, virus rebounds to high levels in most patients, sometimes associated with severe illness because i have gone through this and even an increased risk of death. The aim of “cure”is ongoing but i still do believe my government made millions of ARV drugs instead of finding a cure. for ongoing therapy and monitoring. ARV alone cannot cure HIV as among the cells that are infected are very long-living CD4 memory cells and possibly other cells that act as long-term reservoirs. HIV can hide in these cells without being detected by the body’s immune system. Therefore even when ART completely blocks subsequent rounds of infection of cells, reservoirs that have been infected before therapy initiation persist and from these reservoirs HIV rebounds if therapy is stopped. “Cure” could either mean an eradication cure, which means to completely rid the body of reservoir virus or a functional HIV cure, where HIV may remain in reservoir cells but rebound to high levels is prevented after therapy interruption.Dr Afrid Herbal Medicine makes me believes there is a hope for people suffering from,Parkinson's disease,Schizophrenia,Cancer,Scoliosis,Fibromyalgia,Fluoroquinolone Toxicity
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