Experts Issue Best Practices, Recommendations for ICU COVID-19 Workers

Waleed Alhazzani, MBBS, MSc

The Surviving Sepsis Campaign COVID-19 panel released 54 recommendations for healthcare workers treating intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19).

The 54 recommendations included 4 best practice statements, 9 strong recommendations, and 35 weak recommendations.

The 4 best practice statements were based on high-quality evidence and included:

1. Healthcare workers performing aerosol-generating procedures on patients with COVID-19 should wear fitted respirator masks instead of surgical masks, along with other personal protective equipment.
2. Aerosol-generating procedures should be performed on ICU patients with coronavirus in a negative pressure to prevent the spread of contagious pathogens from room to room.
3. Healthcare workers with experience in airway management should perform endotracheal intubation of patients to minimize the number of attempts and risk of transmission.
4. Adults treated with non-invasive positive pressure ventilation or a high flow nasal cannula should be closely monitored for worsening respiratory status and intubated early if necessary.

First author Waleed Alhazzani, MBBS, MSc (Epid.), and a panel of 35 other experts, issued recommendations that cover topics including infection control; laboratory diagnosis and specimens; the dynamics of blood flow support; ventilation support; and COVID-19 therapy.

“Given the urgency and the huge need for these guidelines, we assembled the team, searched the literature, summarized the evidence, and formulated recommendations within 18 days,” Alhazzani, assistant professor of medicine at McMaster University in Canada, said in a statement. “Everyone worked hard to make this guideline available to the end user rapidly while maintaining methodological rigor.”

Alhazzani developed the guidelines for use by frontline clinicians, allied health professionals, and policy makers involved in caring for patients with COVID-19.

The team, which comprised experts in guideline development; infection control; infectious diseases and microbiology; critical care; emergency medicine; nursing; and public health, proposed 53 questions considered relevant to manage COVID-19 in the ICU. Then the investigators searched systematic reviews for direct and indirect evidence on the management of the virus in the intensive care setting.

The experts had strong recommendations for many categories of the guidelines, including hemodynamics, which included a strong suggestion against the use of hydroxyethyl starches for the acute resuscitation of adults with coronavirus and a strong recommendation against using dopamine for adults with COVID-19 and shock if norepinephrine was available.

For ventilation, it was strongly recommended that Spo₂ be maintained no higher than 96% in adults with COVID-19 and acute hypoxemic respiratory failure on oxygen. The experts also strongly suggested that if recruitment maneuvers were used, not to use the staircase (incremental PEEP) recruitment maneuvers.

Alhazzani and the team had weak recommendations for approaching COVID-19 therapy, including 1 which called for the use of acetaminophen/paracetamol for temperature control over no treatment for critically ill adults with COVID-19 who developed fever.

Due to insufficient evidence, the experts had no recommendations on the use of other antiviral agents, recombinant rIFNs alone or in combination with antivirals, chloroquine or hydroxychloroquine, or tocilizumab in critically ill adults with COVID-19.

The Surviving Sepsis Campaign COVID-19 panelists said it will provide new evidence in further releases of the guidelines.

The recommendations, “Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019,” were co-published in the journals Critical Care Medicine and Intensive Care Medicine.