SCCM has released its Surviving Sepsis Campaign COVID-19 guidelines to manage critically ill adults with COVID-19 in the intensive care unit (ICU). This guideline is expected to be updated as new evidence becomes available.
These guidelines were updated in 2021. View updated guidelines.
Guideline Type: Clinical
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Additional resources are avilable at survivingsepsis.org
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For healthcare workers performing aerosol-generating procedures* on patients with COVID-19 in the ICU, we recommend using fitted respirator masks (N95 respirators, FFP2, or equivalent), as opposed to surgical/medical masks, in addition to other personal protective equipment (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles).
Aerosol-generating procedures on ICU patients with COVID-19 should be performed in a negative pressure room.
For healthcare workers providing usual care for non-ventilated COVID-19 patients, we suggest using surgical/medical masks, as opposed to respirator masks, in addition to other personal protective equipment (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles).
Quality of evidence: Low
For healthcare workers who are performing non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients with COVID-19, we suggest using surgical/medical masks, as opposed to respirator masks, in addition to other personal protective equipment (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles).
Quality of evidence: Low
For healthcare workers performing endotracheal intubation on patients with COVID-19, we suggest using video-guided laryngoscopy, over direct laryngoscopy, if available.
Quality of evidence: Low
For COVID-19 patients requiring endotracheal intubation, we recommend that endotracheal intubation be performed by the healthcare worker who is most experienced with airway management in order to minimize the number of attempts and risk of transmission.
For intubated and mechanically ventilated adults with suspicion of COVID-19, for diagnostic testing, we suggest obtaining lower respiratory tract samples in preference to upper respiratory tract (nasopharyngeal or oropharyngeal) samples.
Quality of evidence: Low
For intubated and mechanically ventilated adults with suspicion of COVID-19, with regard to lower respiratory samples, we suggest obtaining endotracheal aspirates in preference to bronchial wash or bronchoalveolar lavage samples.
Quality of evidence: Low
In adults with COVID-19 and shock, we suggest using dynamic parameters skin temperature, capillary refilling time, and/or serum lactate measurement over static parameters in order to assess fluid responsiveness.
Quality of evidence: Low
For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fluid strategy.
Quality of evidence: Very low
For the acute resuscitation of adults with COVID-19 and shock, we recommend using crystalloids over colloids.
Quality of evidence: Moderate
For the acute resuscitation of adults with COVID-19 and shock, we suggest using buffered/balanced crystalloids over unbalanced crystalloids.
Quality of evidence: Moderate
For the acute resuscitation of adults with COVID-19 and shock, we recommend against using hydroxyethyl starches.
Quality of evidence: Moderate
For the acute resuscitation of adults with COVID-19 and shock, we suggest against using gelatins.
Quality of evidence: Low
For the acute resuscitation of adults with COVID-19 and shock, we suggest against using dextrans.
Quality of evidence: Low
For the acute resuscitation of adults with COVID-19 and shock, we suggest against the routine use of albumin for initial resuscitation.
Quality of evidence: Moderate
For adults with COVID-19 and shock, we suggest using norepinephrine as the first-line vasoactive agent, over other agents.
Quality of evidence: Low
If norepinephrine is not available, we suggest using either vasopressin or epinephrine as the first-line vasoactive agent, over other vasoactive agents, for adults with COVID-19 and shock.
Quality of evidence: Low
For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is available.
Quality of evidence: High
For adults with COVID-19 and shock, we suggest adding vasopressin as a second-line agent, over titrating norepinephrine dose, if target mean arterial pressure (MAP) cannot be achieved by norepinephrine alone.
Quality of evidence: Moderate
For adults with COVID-19 and shock, we suggest titrating vasoactive agents to target a MAP of 60–65 mm Hg, rather than higher MAP targets.
Quality of evidence: Low
For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, we suggest adding dobutamine, over increasing norepinephrine dose.
Quality of evidence: Very low
For adults with COVID-19 and refractory shock, we suggest using low-dose corticosteroid therapy (“shock-reversal”), over no corticosteroid therapy.
Quality of evidence: Low
In adults with COVID-19, we suggest starting supplemental oxygen if the peripheral oxygen saturation (Spo2) is < 92%.
Quality of evidence: Low
In adults with COVID-19, we recommend starting supplemental oxygen if Spo2 is < 90%.
Quality of evidence: Moderate
In adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, we recommend that Spo2 be maintained no higher than 96%.
Quality of evidence: Moderate
For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, we suggest using HFNC over conventional oxygen therapy.
Quality of evidence: Low
In adults with COVID-19 and acute hypoxemic respiratory failure, we suggest using HFNC over NIPPV.
Quality of evidence: Low
In adults with COVID-19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no urgent indication for endotracheal intubation, we suggest a trial of NIPPV with close monitoring and short-interval assessment for worsening of respiratory failure.
Quality of evidence: Very low
We were not able to make a recommendation regarding the use of helmet NIPPV compared with mask NIPPV. It is an option, but we are not certain about its safety or efficacy in COVID-19.
In adults with COVID-19 receiving NIPPV or HFNC, we recommend close monitoring for worsening of respiratory status, and early intubation in a controlled setting if worsening occurs.
In mechanically ventilated adults with COVID-19 and ARDS, we recommend using low tidal volume (Vt) ventilation (Vt 4–8 mL/kg of predicted body weight), over higher tidal volumes (Vt > 8 mL/kg).
Quality of evidence: Moderate
For mechanically ventilated adults with COVID-19 and ARDS, we recommend targeting plateau pressures (Pplat) of < 30 cm H2O.
Quality of evidence: Moderate
For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest using a higher PEEP strategy, over a lower PEEP strategy.
Quality of evidence: Low
For mechanically ventilated adults with COVID-19 and ARDS, we suggest using a conservative fluid strategy over a liberal fluid strategy.
Quality of evidence: Low
For mechanically ventilated adults with COVID-19 and ARDS, we suggest using a conservative fluid strategy over a liberal fluid strategy.
Quality of evidence: Low
For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest prone ventilation for 12 to 16 hours, over no prone ventilation.
Quality of evidence: Low
For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest using, as needed, intermittent boluses of neuromuscular blocking agents (NMBA), over continuous NMBA infusion, to facilitate protective lung ventilation.
Quality of evidence: Low
For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, in the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, we suggest using a continuous NMBA infusion for up to 48 hours.
Quality of evidence: Low
In mechanically ventilated adults with COVID-19 ARDS, we recommend against the routine use of inhaled nitric oxide.
Quality of evidence: Low
In mechanically ventilated adults with COVID-19, severe ARDS and hypoxemia despite optimizing ventilation and other rescue strategies, we suggest a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered off.
Quality of evidence: Very low
For mechanically ventilated adults with COVID-19 and hypoxemia despite optimizing ventilation, we suggest using recruitment maneuvers, over not using recruitment maneuvers.
Quality of evidence: Low
If recruitment maneuvers are used, we recommend against using staircase (incremental PEEP) recruitment maneuvers.
Quality of evidence: Moderate
In mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, we suggest using venovenous (VV) ECMO if available, or referring the patient to an ECMO center.
Quality of evidence: Low
In mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS), we suggest against the routine use of systemic corticosteroids.
Quality of evidence: Low
In mechanically ventilated adults with COVID-19 and ARDS, we suggest using systemic corticosteroids, over not using corticosteroids.
Quality of evidence: Low
In mechanically ventilated patients with COVID-19 and respiratory failure, we suggest using empiric antimicrobials/antibacterial agents, over no antimicrobials.
Quality of evidence: Low
For critically ill adults with COVID-19 who develop fever, we suggest using acetaminophen/paracetamol for temperature control, over no treatment.
Quality of evidence: Low
In critically ill adults with COVID-19, we suggest against the routine use of standard intravenous immunoglobulins (IVIG).
Quality of evidence: Very low
In critically ill adults with COVID-19, we suggest against the routine use of convalescent plasma.
Quality of evidence: Very low
In critically ill adults with COVID-19, we suggest against the routine use of lopinavir/ritonavir.
Quality of evidence: Low
There is insufficient evidence to issue a recommendation on the use of other antiviral agents in critically ill adults with COVID-19.
There is insufficient evidence to issue a recommendation on the use of recombinant rIFNs, alone or in combination with antivirals, in critically ill adults with COVID-19.
There is insufficient evidence to issue a recommendation on the use of chloroquine or hydroxychloroquine in critically ill adults with COVID-19.
There is insufficient evidence to issue a recommendation on the use of tocilizumab in critically ill adults with COVID-19.
Abbreviations: ARDS, acute respiratory distress syndrome; ECMO, extracorporeal membrane oxygenation; HFNC, high-flow nasal cannula; NIPPV, non-invasive positive pressure ventilation; PEEP, positive end-expiratory pressure.
*Aerosol-generating procedures in the ICU include endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, physical proning of the patient, disconnecting the patient from the ventilator, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation.
