Surviving Sepsis – COVID-19 Version
May 4, 2020
Written by Meghan Breed
Spoon Feed
The Surviving Sepsis Campaign COVID-19 panel issued 54 statements to help support healthcare workers caring for critically ill COVID-19 patients. Here are the most relevant points.
Why does this matter?
Due to the rapidly evolving pandemic, there has been little time to study and provide direct evidence on the best way to care for patients with COVID-19. Therefore, the panel (36 experts from 12 countries) reviewed available literature on MERS, SARS, and sepsis as indirect evidence to establish their recommendations, including the literature that was reviewed and the quality of evidence.
It may be a novel virus, but it isn’t novel patient-care (for the most part)
By and large, the evidence-based management that has guided our approach to caring for hypoxic (ARDS) patients in shock applies to our COVID-19 patients.
During resuscitation, use dynamic parameters (skin temperature, capillary refill and lactate) to guide conservative administration of balanced-crystalloids for a target MAP of 60-65mmHg. Norepinephrine is the preferred vasoactive agent; however, dobutamine may be necessary if there is severe cardiac dysfunction. Supplemental oxygen should be initiated if SpO2 <90% (maintain no higher than 96%). Prior to intubation, consider a trial of HFNC (preferred over NIPPV). If intubation is ultimately required, lung protective strategies should be utilized to avoid ventilatory-induced lung injury. Preferentially use higher PEEP (>10cm H2O) if plateau pressures remain <30cm H2O to help improve oxygenation. For refractory hypoxemia, prone positioning (12-16 hours/day), neuromuscular blocking agents or VV-ECMO may be considered.
Not surprisingly, COVID-19 pharmacotherapy is the area of most uncertainty due to lack of clinical trials. In general, antimicrobials as well as corticosteroids should be considered. The panel recommended against the routine administration of convalescent plasma and lopinavir/ritonavir and felt there was insufficient evidence to evaluate other antivirals (remdesivir), recombinant rINFs, chloroquine/hydroxychloroquine and tocilizumab (inhibits IL-6 related inflammation).
The figure below is a nice summary:
Source
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020 Mar 27. doi: 10.1097/CCM.0000000000004363. [Epub ahead of print]
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