Management of Adults in Critical Condition with COVID-19: Expert Guidelines

Top recommendations

Infection control and testing

1. For healthcare workers performing aerosol-generating procedures (e.g., endotracheal intubation, nebulized treatments, open suctioning), the use of tight- fitting respirators (N95 respirators, FFP2) is recommended instead of surgical masks, in addition to other personal protective equipment (statement of best practices).
    
2. For routine care of non-ventilated patients, or for performing non-aerosol-generating procedures in patients receiving mechanical ventilation, the use of medical face masks , rather than respirator masks, is recommended in addition to other personal protective equipment (weak recommendation, low-quality evidence).
    
3. Endotracheal aspirate specimens are preferred over bronchial lavages, bronchoalveolar lavage, and upper respiratory tract (nasopharyngeal or oropharyngeal) specimens (weak recommendation, low-quality evidence).

hemodynamic support

1. For acute resuscitation of adults with shock, the following is suggested:

• Measure dynamic parameters to evaluate fluid responsiveness (weak recommendation, low quality evidence).
   
• Use a conservative fluid administration strategy (weak recommendation, very low level of evidence).
   
• Use crystalloids over colloids (strong recommendation; moderate quality of evidence). Balanced crystalloids are preferred to unbalanced crystalloids (weak recommendation, moderate quality of evidence).?

1. For adults with shock, the following is suggested:

• Use norepinephrine as a first-line vasoactive agent (weak recommendation, low-quality evidence).
   
• Use vasopressin or epinephrine as first line if norepinephrine is absent (weak recommendation, low level of evidence). 
   
• Dopamine is not recommended if norepinephrine is not available (strong recommendation, high quality of evidence).
   
• It is suggested to add vasopressin as a second-line agent if the target mean arterial pressure (60-65 mm Hg) cannot be achieved with norepinephrine alone (weak recommendation, moderate quality of evidence).

ventilatory support

1. It is recommended to start supplemental oxygen if oxygen saturation is less than 90% (strong recommendation, moderate level of evidence). Saturation should remain no higher than 96% (strong recommendation, moderate level of evidence).
    
2. For hypoxemic acute respiratory failure unresponsive to conventional oxygen therapy, the use of a high-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) is suggested (weak recommendation, low level of evidence). 
   
   If HFNC is not available, NIPPV testing is suggested (weak recommendation, very low level of evidence). Close monitoring for worsening respiratory status and early intubation if worsening occurs is recommended (best practice statement).
    
3. For mechanically ventilated adults who have acute respiratory distress syndrome (ARDS), the use of low tidal volume ventilation (4-8 ml/kg target body weight) is recommended and is preferred to higher volumes (> 8 ml/kg) (strong recommendation, moderate level of evidence). 
   
   It is recommended to aim for plateau pressures of <30 cm H2O (strong recommendation, moderate level of evidence). It is suggested to use a higher positive end-expiratory pressure (PEEP) strategy than a lower PEEP strategy (weak recommendation, low quality of evidence).
    
4. For mechanically ventilated adults who have moderate to severe ARDS , prone ventilation for 12 to 16 hours is suggested instead of supine ventilation (weak recommendation, low level of evidence). 
   
   The use of neuromuscular blocking agents (NMB) as needed instead of continuous NMB infusion is recommended to facilitate protective lung ventilation (weak recommendation, low level of evidence).
    
5. For mechanically ventilated adults who have severe ARDS and hypoxemia despite optimizing ventilation, a trial of inhaled vasodilators is suggested . If rapid improvement in oxygenation is not seen, treatment should be reduced (weak recommendation, very low quality evidence). 
   
   The use of pulmonary recruitment maneuvers (aimed at opening closed lung segments, such as pressures of 40 cm H2O with a 40-second inspiratory pause) is suggested over not using them (weak recommendation, low level of evidence), but not Recruitment maneuvers with stepwise increases in PEEP are recommended (strong recommendation, moderate quality of evidence). 
   
   e suggests the use of venovenous circulation for extracorporeal membrane oxygenation (ECMO) or referral to an ECMO center, if available, for selected patients (weak recommendation, low-quality evidence).

Therapy

1. In mechanically ventilated adults who do not have ARDS , routine use of systemic corticosteroids is not suggested (weak recommendation, low-quality evidence). In those with ARDS, the use of corticosteroids is suggested (weak recommendation, low-quality evidence).
    
2. In mechanically ventilated COVID-19 patients who have respiratory failure, the use of empiric antimicrobial/antibacterial agents is suggested (no evidence grading); evaluate de-escalation therapy.
    
3. In critically ill adults with fever , the use of pharmacological agents for temperature control is suggested over non-pharmacological agents or no treatment.

• Routine use of standard IV immunoglobulins is not suggested.
• Convalescent plasma is not suggested .
• There is insufficient evidence to make a recommendation on the use of any of the following: antiviral agents, recombinant interferons, chloroquine/hydroxychloroquine or tocilizumab.