Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

doi:10.1007/s00134-020-06022-5

Practice Guideline

. 2020 May;46(5):854-887.

doi: 10.1007/s00134-020-06022-5. Epub 2020 Mar 28.

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

Waleed Alhazzani^{1

2}, Morten Hylander Møller^{3

4}, Yaseen M Arabi⁵, Mark Loeb^{1

2}, Michelle Ng Gong⁶, Eddy Fan⁷, Simon Oczkowski^{1

2}, Mitchell M Levy^{8

9}, Lennie Derde^{10

11}, Amy Dzierba¹², Bin Du¹³, Michael Aboodi⁶, Hannah Wunsch^{14

15}, Maurizio Cecconi^{16

17}, Younsuck Koh¹⁸, Daniel S Chertow¹⁹, Kathryn Maitland²⁰, Fayez Alshamsi²¹, Emilie Belley-Cote^{1

22}, Massimiliano Greco^{16

17}, Matthew Laundy²³, Jill S Morgan²⁴, Jozef Kesecioglu¹⁰, Allison McGeer²⁵, Leonard Mermel⁸, Manoj J Mammen²⁶, Paul E Alexander^{2

27}, Amy Arrington²⁸, John E Centofanti²⁹, Giuseppe Citerio^{30

31}, Bandar Baw^{1

32}, Ziad A Memish³³, Naomi Hammond^{34

35}, Frederick G Hayden³⁶, Laura Evans³⁷, Andrew Rhodes³⁸

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, Canada.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
³ Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, 4131, Copenhagen, Denmark.
⁴ Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI), Copenhagen, Denmark.
⁵ Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.
⁶ Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA.
⁷ Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
⁸ Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
⁹ Rhode Island Hospital, Providence, RI, USA.
¹⁰ Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
¹¹ Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands.
¹² Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA.
¹³ Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China.
¹⁴ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁵ Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁶ Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
¹⁷ Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy.
¹⁸ Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
¹⁹ Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Baltimore, USA.
²⁰ Faculty of Medicine, Imperial College, London, UK.
²¹ Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates.
²² Population Health Research Institute, Hamilton, Canada.
²³ Microbiology and Infection Control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.
²⁴ Emory University Hospital, Atlanta, USA.
²⁵ Division of Infectious Diseases, University of Toronto, Toronto, Canada.
²⁶ Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA.
²⁷ GUIDE Research Methods Group, Hamilton, Canada.
²⁸ Houston Children's Hospital, Baylor College of Medicine, Houston, USA.
²⁹ Department of Anesthesia, McMaster University, Hamilton, Canada.
³⁰ Department of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.
³¹ ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy.
³² Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
³³ Director, Research and Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia.
³⁴ Critical Care Division, The George Institute for Global Health and UNSW, Sydney, Australia.
³⁵ Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia.
³⁶ Division of Infectious Diseases and International Health, Department of Medicine, University, of Virginia, School of Medicine, Charlottesville, VA, USA.
³⁷ Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA.
³⁸ Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK. andrewrhodes@nhs.net.

PMID: 32222812
PMCID: PMC7101866
DOI: 10.1007/s00134-020-06022-5

Practice Guideline

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

Waleed Alhazzani et al. Intensive Care Med. 2020 May.

. 2020 May;46(5):854-887.

doi: 10.1007/s00134-020-06022-5. Epub 2020 Mar 28.

Authors

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, Canada.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
³ Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, 4131, Copenhagen, Denmark.
⁴ Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI), Copenhagen, Denmark.
⁵ Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.
⁶ Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA.
⁷ Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
⁸ Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
⁹ Rhode Island Hospital, Providence, RI, USA.
¹⁰ Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
¹¹ Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands.
¹² Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA.
¹³ Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China.
¹⁴ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁵ Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁶ Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
¹⁷ Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy.
¹⁸ Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
¹⁹ Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Baltimore, USA.
²⁰ Faculty of Medicine, Imperial College, London, UK.
²¹ Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates.
²² Population Health Research Institute, Hamilton, Canada.
²³ Microbiology and Infection Control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.
²⁴ Emory University Hospital, Atlanta, USA.
²⁵ Division of Infectious Diseases, University of Toronto, Toronto, Canada.
²⁶ Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA.
²⁷ GUIDE Research Methods Group, Hamilton, Canada.
²⁸ Houston Children's Hospital, Baylor College of Medicine, Houston, USA.
²⁹ Department of Anesthesia, McMaster University, Hamilton, Canada.
³⁰ Department of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.
³¹ ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy.
³² Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
³³ Director, Research and Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia.
³⁴ Critical Care Division, The George Institute for Global Health and UNSW, Sydney, Australia.
³⁵ Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia.
³⁶ Division of Infectious Diseases and International Health, Department of Medicine, University, of Virginia, School of Medicine, Charlottesville, VA, USA.
³⁷ Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA.
³⁸ Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK. andrewrhodes@nhs.net.

PMID: 32222812
PMCID: PMC7101866
DOI: 10.1007/s00134-020-06022-5

Abstract

Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.

Methods: We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.

Results: The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.

Conclusion: The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.

Keywords: COVID-19; Clinical practice guidelines; Coronavirus; Critical illness; SARS CoV-2.

PubMed Disclaimer

Conflict of interest statement

Dr. Yaseen Arabi is the principal investigator on a clinical trial for lopinavir/ritonavir and interferon in Middle East respiratory syndrome (MERS) and he was a nonpaid consultant on antiviral active for MERS-coronavirus (CoV) for Gilead Sciences and SAB Biotherapeutics. He is an investigator on REMAP-CAP trial and is a Board Members of the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC). Dr. Eddy Fan declared receiving consultancy fees from ALung Technologies and MC3 Cardiopulmonary. Dr. Maurizio Cecconi declared consultancy work with Edwards Lifesciences, Directed Systems, and Cheetah Medical. Dr. Lennie Derde is the NVIC (Dutch National ICU society) chair of Taskforce Infectious Diseases (standing committee), member of ESICM Coronavirus Taskforce (started with this outbreak), chair ESICM Clinical Training Committee, all are unpaid positions. Dr. Frederick Hyden is non-compensated consultant to Gilead Sciences (antivirals for RVIS including remdesivir), Regeneraon (monoclonals for RVIs including MERS), and SAB Biotherapeutics (polyclonal antibodies for RVIs including MERS). Other authors declared no conflict of interest.

Figures

**Fig. 1**
COVID-19 guideline development process

**Fig. 2**
Summary of recommendations on the initial management of hypoxic COVID-19 patients

**Fig. 3**
Summary of recommendations on the management of patients with COVID-19 and ARDS

See this image and copyright information in PMC

Comment in

COVID-19: Respiratory support outside the intensive care unit.
McEnery T, Gough C, Costello RW. McEnery T, et al. Lancet Respir Med. 2020 Jun;8(6):538-539. doi: 10.1016/S2213-2600(20)30176-4. Epub 2020 Apr 9. Lancet Respir Med. 2020. PMID: 32278367 Free PMC article. No abstract available.
Hyperreninemia and low total body water may contribute to acute kidney injury in COVID-19 patients in intensive care.
Hultström M, von Seth M, Frithiof R. Hultström M, et al. J Hypertens. 2020 Aug;38(8):1613-1614. doi: 10.1097/HJH.0000000000002531. J Hypertens. 2020. PMID: 32472780 Free PMC article. No abstract available.
Role of Helmet-Delivered Noninvasive Pressure Support Ventilation in COVID-19 Patients.
Ing RJ, Bills C, Merritt G, Ragusa R, Bremner RM, Bellia F. Ing RJ, et al. J Cardiothorac Vasc Anesth. 2020 Oct;34(10):2575-2579. doi: 10.1053/j.jvca.2020.04.060. Epub 2020 May 8. J Cardiothorac Vasc Anesth. 2020. PMID: 32540245 Free PMC article. No abstract available.
How to evaluate intensive care unit performance during the COVID-19 pandemic.
Zampieri FG, Soares M, Salluh JIF. Zampieri FG, et al. Rev Bras Ter Intensiva. 2020 Jun;32(2):203-206. doi: 10.5935/0103-507x.20200040. Epub 2020 Jul 13. Rev Bras Ter Intensiva. 2020. PMID: 32667432 Free PMC article. No abstract available.

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[1] Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS, China Medical Treatment Expert Group for C Clinical characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 doi: 10.1056/NEJMoa2002032. - DOI - PMC - PubMed

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[6] Alhazzani W, Lewis K, Jaeschke R, Rochwerg B, Moller MH, Evans L, Wilson KC, Patel S, Coopersmith CM, Cecconi M, Guyatt G, Akl EA. Conflicts of interest disclosure forms and management in critical care clinical practice guidelines. Intensive Care Med. 2018;44:1691–1698. - PubMed

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[8] Vandvik PO, Alhazzani W, Moller MH. Understanding conflicts of interest. Intensive Care Med. 2018;44:1738–1740. - PubMed

[9] Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, Alderson P, Glasziou P, Falck-Ytter Y, Schunemann HJ. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011;64:395–400. - PubMed

[10] Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, Alderson P, Glasziou P, Falck-Ytter Y, Schunemann HJ. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011;64:395–400. - PubMed

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Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

Affiliations

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

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Abstract

Conflict of interest statement

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