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Care of Critically Ill Patients with COVID-19

Last Updated: July 30, 2020

Summary Recommendations
Summary Recommendations

Infection Control:

  • For health care workers who are performing aerosol-generating procedures on patients with COVID-19, the COVID-19 Treatment Guidelines Panel (the Panel) recommends using fit-tested respirators (N95 respirators) or powered air-purifying respirators, rather than surgical masks, in addition to other personal protective equipment (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) (AIII).
  • The Panel recommends that endotracheal intubation for patients with COVID-19 be performed by health care providers with extensive airway management experience, if possible (AIII).
  • The Panel recommends that intubation be achieved by video laryngoscopy, if possible (CIII).

Hemodynamic Support:

  • The Panel recommends norepinephrine as the first-choice vasopressor (AII).
  • For adults with COVID-19 and refractory shock, the Panel recommends using low-dose corticosteroid therapy (“shock-reversal”) over no corticosteroid (BII).

Ventilatory Support:

  • For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, the Panel recommends high-flow nasal cannula (HFNC) oxygen over noninvasive positive pressure ventilation (NIPPV) (BI).
  • In the absence of an indication for endotracheal intubation, the Panel recommends a closely monitored trial of NIPPV for adults with COVID-19 and acute hypoxemic respiratory failure for whom HFNC is not available (BIII).
  • For adults with COVID-19 who are receiving supplemental oxygen, the Panel recommends close monitoring for worsening respiratory status and that intubation, if it becomes necessary, be performed by an experienced practitioner in a controlled setting (AII).
  • For patients with persistent hypoxemia despite increasing supplemental oxygen requirements in whom endotracheal intubation is not otherwise indicated, the Panel recommends considering a trial of awake prone positioning to improve oxygenation (CIII).
  • The Panel recommends against using awake prone positioning as a rescue therapy for refractory hypoxemia to avoid intubation in patients who otherwise require intubation and mechanical ventilation (AIII).
  • For mechanically ventilated adults with COVID-19 and acute respiratory distress syndrome (ARDS), the Panel recommends using low tidal volume (VT) ventilation (VT 4–8 mL/kg of predicted body weight) over higher tidal volumes (VT >8 mL/kg) (AI).
  • For mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimized ventilation, the Panel recommends prone ventilation for 12 to 16 hours per day over no prone ventilation (BII).
  • For mechanically ventilated adults with COVID-19, severe ARDS, and hypoxemia despite optimized ventilation and other rescue strategies, the Panel recommends using an inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered off (CIII).
  • There are insufficient data to recommend either for or against the routine use of extracorporeal membrane oxygenation (ECMO) for patients with COVID-19 and refractory hypoxemia.

Acute Kidney Injury and Renal Replacement Therapy:

  • For critically ill patients with COVID-19 who have acute kidney injury and who develop indications for renal replacement therapy, the Panel recommends continuous renal replacement therapy (CRRT), if available (BIII).
  • If CRRT is not available or not possible due to limited resources, the Panel recommends prolonged intermittent renal replacement therapy rather than intermittent hemodialysis (BIII).

Pharmacologic Interventions:

  • See the Remdesivir section for a detailed discussion of these recommendations.
  • On the basis of the preliminary report from the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, the Panel recommends using dexamethasone 6 mg per day for up to 10 days for the treatment of COVID-19 in patients who are mechanically ventilated (AI) and in patients who require supplemental oxygen but who are not mechanically ventilated (BI).
  • The Panel recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen (AI).
  • If dexamethasone is not available, the Panel recommends using alternative glucocorticoids such as prednisone, methylprednisolone, or hydrocortisone (AIII).
  • There are insufficient data for the Panel to recommend either for or against any other immunomodulatory therapy in patients with severe COVID-19 disease.
  • In patients with COVID-19 and severe or critical illness, there are insufficient data to recommend empiric broad-spectrum antimicrobial therapy in the absence of another indication.
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion