Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

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SCOPE OF THE GUIDE

This guideline provides recommendations to support the work of hospital clinicians managing critically ill adult patients with COVID-19 in the intensive care unit (ICU). The professionals for whom this guide is intended are frontline clinicians, supporting health professionals and policy makers involved in the care of patients with COVID-19.

KEY POINTS OF THE GUIDE

1. Infection control

A recent report from the Chinese Center for Disease Control and Prevention described 72.314 cases of COVID-19 in China, of which 44.672 were laboratory confirmed. Among the laboratory-confirmed cases, 1.716 (3.8%) were healthcare workers, the majority of whom, 63% (1.080 of 1.716), acquired the infection in Wuhan. The report describes that 14.8% (247 of 1668) of infected health workers had a serious or critical illness, and that 5 died.
In Italy, as of March 15, 2020, there are 2.026 documented cases of COVID-19 among healthcare workers.
Although incidence data is not available, these data point to a considerable burden of infection among healthcare workers The risk of patient-to-patient transmission in the ICU is currently unknown, therefore adherence to precautions in monitoring of infections is paramount. Healthcare workers must follow infection control. policies and procedures already in force in their health protocols.

2. Samples and laboratory diagnosis

Indications for evaluating ICU patients for SARS CoV-2: The WHO recently declared a COVID-19 pandemic. Consequently, every critically ill patient who arrives with evidence of respiratory infection should be considered potentially infected with SARS-CoV-2. Real-time polymerase chain reaction (PCR) (RT-PCR) is the gold standard for similar viral infections, including SARS. Of note, COVID-19 poses several diagnostic challenges due to a long incubation period (approximately 2 weeks) including a long interval (approximately 5 days) of virus shedding before symptom onset. Furthermore, the duration of asymptomatic shedding is not only variable, but may also differ depending on the anatomical level (upper versus lower) of the infection in the respiratory system. Consequently, the performance of the biomolecular assay may vary depending on the sampling site.

3. Support treatments

Hemodynamic support: The reported prevalence of shock and cardiac injury in adult patients with COVID-19 is highly variable (from 1 to 35%), depending on the patient population studied, the severity of the disease, and the definition of shock.
In a recent report summarizing the epidemiological characteristics of 44.415 Chinese COVID-19 patients, 2.087 (5%) were diagnosed as critical cases, defined as severe hypoxemia and/or the presence of other organ failure, including shock.
In another Chinese study of 1.099 COVID-19 patients with similar disease severity, only 12 (1.1%) developed shock.
In hospitalized patients, the incidence is probably higher and may reach 20-35% among ICU patients.
The presence of cardiac injury (elevation of biomarkers of cardiac injury above the 99th percentile upper reference limit) has been reported in 7–23% of patients with COVID-19 in Wuhan, China. While the prevalence of cardiac injury can be correlated with the prevalence of shock, a lack of systematic detection of cardiac dysfunction in hemodynamically stable patients implies that this association cannot be taken as certain.

3. Support treatments

Hemodynamic support: The reported prevalence of shock and cardiac injury in adult patients with COVID-19 is highly variable (from 1 to 35%), depending on the patient population studied, the severity of the disease, and the definition of shock.
In a recent report summarizing the epidemiological characteristics of 44.415 Chinese COVID-19 patients, 2.087 (5%) were diagnosed as critical cases, defined as severe hypoxemia and/or the presence of other organ failure, including shock.
In another Chinese study of 1.099 COVID-19 patients with similar disease severity, only 12 (1.1%) developed shock.
In hospitalized patients, the incidence is probably higher and may reach 20-35% among ICU patients.
The presence of cardiac injury (elevation of biomarkers of cardiac injury above the 99th percentile upper reference limit) has been reported in 7–23% of patients with COVID-19 in Wuhan, China. While the prevalence of cardiac injury can be correlated with the prevalence of shock, a lack of systematic detection of cardiac dysfunction in hemodynamically stable patients implies that this association cannot be taken as certain.

The prognosis of patients with COVID-19 and shock has not been systemically reported.

• In a study of 150 patients from 2 hospitals in Wuhan, China, shock was the primary reason for death in 40%, and may, at least in part, be due to fulminant myocarditis.

Studies on risk factors associated with shock in COVID-19 patients are lacking and most of those available are unadjusted estimated reports.
Despite methodological limitations, these studies suggest that older age, comorbidities (especially diabetes and cardiovascular disease including hypertension), low lymphocyte count, higher D-dimer level, and possibly cardiac lesions are risk factors to consider. .

Vent Support: The prevalence of hypoxic respiratory failure in patients with COVID-19 is 19%. Recent reports from China showed that 4-13% of COVID-19 patients in these studies received non-invasive positive pressure ventilation (NIPPV) and 2,3-12% required invasive mechanical ventilation.
Although the true incidence of hypoxic respiratory failure in COVID-19 patients is unclear, it appears that around 14% will develop severe illness requiring oxygen therapy, and 5% will require ICU admission and mechanical ventilation.
Another study reported on 52 critically ill patients with COVID-19: 67% of these patients.
They had Acute Respiratory Distress Syndrome (ARDS), 33 (63,5%) received high-flow nasal cannula (HFNC), 56% invasive mechanical ventilation and 42% NIPPV.

Summary of recommendations for the initial management of hypoxic patients with COVID-19

4. TREATMENT FOR COVID-19

Cytokine release syndrome (CRS): Cytokine release syndrome is a hyperinflammatory state characterized by multiple organ failure and elevated cytokine levels.
A recent study from China demonstrated that COVID-19 is associated with an elevated cytokine profile reminiscent of secondary hemophagocytic lymphohistiocytosis (HLH).
Some authors even suggest that we screen critically ill patients with COVID-19 for secondary HLH using the Hscore, and that corticosteroids and other immunosuppressive agents can be used in patients with a high probability of HLH.
More evidence is needed before we can make recommendations on treatment options for cytokine elevation syndrome.