Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update

Abstract

BACKGROUND:The coronavirus disease 2019 pandemic continues to affect millions worldwide. Given the rapidly growing evidence base, we implemented a living guideline model to provide guidance on the management of patients with severe or critical coronavirus disease 2019 in the ICU. METHODS:The Surviving Sepsis Campaign Coronavirus Disease 2019 panel has expanded to include 43 experts from 14 countries; all panel members completed an electronic conflict-of-interest disclosure form. In this update, the panel addressed nine questions relevant to managing severe or critical coronavirus disease 2019 in the ICU. We used the World Health Organization's definition of severe and critical coronavirus disease 2019. The systematic reviews team searched the literature for relevant evidence, aiming to identify systematic reviews and clinical trials. When appropriate, we performed a random-effects meta-analysis to summarize treatment effects. We assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach, then used the evidence-to-decision framework to generate recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS:The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued nine statements (three new and six updated) related to ICU patients with severe or critical coronavirus disease 2019. For severe or critical coronavirus disease 2019, the panel strongly recommends using systemic corticosteroids and venous thromboprophylaxis but strongly recommends against using hydroxychloroquine. In addition, the panel suggests using dexamethasone (compared with other corticosteroids) and suggests against using convalescent plasma and therapeutic anticoagulation outside clinical trials. The Surviving Sepsis Campaign Coronavirus Diease 2019 panel suggests using remdesivir in nonventilated patients with severe coronavirus disease 2019 and suggests against starting remdesivir in patients with critical coronavirus disease 2019 outside clinical trials. Because of insufficient evidence, the panel did not issue a recommendation on the use of awake prone positioning. CONCLUSION:The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued several recommendations to guide healthcare professionals caring for adults with critical or severe coronavirus disease 2019 in the ICU.

Outcome Improvement Between the First Two Waves of the Coronavirus Disease 2019 Pandemic in a Single Tertiary-Care Hospital in Belgium

“…However, later studies in the first wave showed the risk of aerosolization was limited even when using HFNO at flow as high as 60 L/min ( 9 ). All these results show substantial, progressive, and evidence-driven modification in the management of COVID-19 in our hospital, and internationally ( 7 , 10 ).…”

“…In addition, remdesivir was also recommended in patients with oxygen support in the first and subsequent second waves of the COVID-19 pandemic ( 6 ). In contrast, hydroxychloroquine was not recommended by the time of the second wave due to the lack of evidence ( 7 ). Finally, high-flow nasal oxygen (HFNO) was initially suspected to aerosolize severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in room air ( 8 ), and its use was limited to flows under 30 L/min.…”

Use of Remdesivir in Myasthenia gravis and COVID‐19

“…Although there is additional conflicting evidence regarding use of remdesivir in COVID-19, it is currently approved by the United States Food and Drug Administration for the treatment of COVID-19 in appropriate hospitalized patients requiring supplemental oxygen but are not requiring mechanical ventilation 7,9,10 . Remdesivir is an adenosine nucleotide prodrug that is rapidly converted to two initial metabolites (alanine metabolite and nucleoside monophosphate metabolite) 7,11 Since some antivirals and other classes of medications can worsen MG, we had initial hesitancy to prescribe remdesivir in these critically ill patients with SARS-CoV-2 infection.…”

Clinical Characteristics and Outcomes of Critically ill Mechanically Ventilated COVID-19 Patients Receiving interleukin-6 Receptor Antagonists and Corticosteroid Therapy: A Multicenter International Observational Study

“…Defined by the WHO criteria for ARDS, sepsis, septic shock or other conditions that would normally require the provision of life-sustaining therapies, such as mechanical ventilation (invasive or non-invasive) or vasopressor therapy [2].…”

“…Severe coronavirus disease 2019 (COVID-19) can manifest as rapid decompensation and respiratory failure with elevated inflammatory markers, resulting in cytokine release syndrome, for which interleukin-6 receptor (IL-6R) antagonists are approved treatments [1][2][3][4]. An interest in IL-6R antagonists and corticosteroids has increased recently due to their potential role as immunomodulators in the treatment of cytokine storms related to COVID-19 [5].…”