Care of Critically Ill Adults With COVID-19

Hemodynamics

• For adults with COVID-19 and shock, the COVID-19 Treatment Guidelines Panel (the Panel) recommends using dynamic parameters, capillary refill time, and/or lactate levels over static parameters to assess fluid responsiveness (BIIa).
• For acute resuscitation in adults who have COVID-19 and shock, there is insufficient evidence for the Panel to recommend either for or against the use of balanced crystalloids, such as Ringer’s lactate solution, over normal saline.
• For acute resuscitation in adults with COVID-19 and shock, the Panel recommends against the initial use of albumin (BI).
• For adults with COVID-19 and shock, the Panel recommends norepinephrine as the first-choice vasopressor (AI).
• For adults with COVID-19 and shock, the Panel recommends titrating vasoactive agents and targeting a mean arterial pressure (MAP) of 60 to 65 mm Hg over targeting a higher MAP (BI).
• The Panel recommends against using hydroxyethyl starches for intravascular volume replacement in adult patients with COVID-19 and sepsis or septic shock (AI).
• As a second-line vasopressor, the Panel recommends adding either vasopressin (up to 0.03 units/min) (BIIa) or epinephrine (BIIb) to norepinephrine to raise MAP to the target or adding vasopressin (up to 0.03 units/min) (BIIa) to decrease the norepinephrine dose.
• The Panel recommends against using low-dose dopamine for renal protection (AI).
• The Panel recommends using dobutamine in adult patients with COVID-19 who show evidence of cardiac dysfunction and persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents (BIII).
• The Panel recommends that all adult patients with COVID-19 who require vasopressors have an arterial catheter placed as soon as practical, if resources are available (BIII).
• For adult patients with refractory septic shock who have completed a course of corticosteroids to treat COVID-19, the Panel recommends using low-dose corticosteroid therapy (“shock-reversal”) over no corticosteroid therapy (BIIa).

Oxygenation and Ventilation

• For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, the Panel recommends starting therapy with high-flow nasal cannula (HFNC) oxygen; if patients fail to respond, noninvasive ventilation or intubation and mechanical ventilation should be initiated (BIIa).
• For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy who do not have an indication for endotracheal intubation and for whom HFNC oxygen is not available, the Panel recommends performing a closely monitored trial of noninvasive ventilation (BIIa).
• For adults with persistent hypoxemia who require HFNC oxygen and for whom endotracheal intubation is not indicated, the Panel recommends a trial of awake prone positioning (BIIa).
• The Panel recommends against the use of awake prone positioning as a rescue therapy for refractory hypoxemia to avoid intubation in patients who otherwise meet the indications for intubation and mechanical ventilation (AIII).
• If intubation becomes necessary, the procedure should be performed by an experienced practitioner in a controlled setting due to the enhanced risk of exposing health care practitioners to SARS-CoV-2 during intubation (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 VT ventilation (VT >8 mL/kg) (AI).
  • The Panel recommends targeting plateau pressures of <30 cm H₂O (AIIa).
  • The Panel recommends using a conservative fluid strategy over a liberal fluid strategy (BIIa).
  • The Panel recommends against the routine use of inhaled nitric oxide (AIIa).
• For mechanically ventilated adults with COVID-19 and moderate to severe ARDS:
  • The Panel recommends using a higher positive end-expiratory pressure (PEEP) strategy over a lower PEEP strategy (BIIa).
  • 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 (BIIa).
  • The Panel recommends using, as needed, intermittent boluses of neuromuscular blocking agents or a continuous neuromuscular blocking agent infusion to facilitate protective lung ventilation (BIIa).
• 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 rapid improvement in oxygenation is not observed, the treatment should be tapered (CIII).
  • The Panel recommends using recruitment maneuvers rather than not using recruitment maneuvers (CIIa).
  • If recruitment maneuvers are used, the Panel recommends against the use of staircase (incremental PEEP) recruitment maneuvers (AIIa).

Pharmacologic Interventions

• In the absence of a proven or suspected secondary infection, the Panel recommends against the use of empiric broad-spectrum antimicrobials in patients with severe or critical COVID-19 (BIII).
• As with any hospitalized patient, patients with COVID-19 who receive antimicrobials should be reassessed daily to minimize the adverse consequences of unnecessary antimicrobial therapy (AIII). 

Extracorporeal Membrane Oxygenation

• There is insufficient evidence for the Panel to recommend either for or against the use of extracorporeal membrane oxygenation in adults with COVID-19–associated ARDS and refractory hypoxemia.