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, Canada.
³ Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark.
⁴ Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI).
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, New York, USA.
⁷ Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
⁸ Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA.
⁹ Rhode Island Hospital, Providence, Rhode Island, USA.
¹⁰ Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands.
¹¹ Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands.
¹² Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA.
¹³ Medical ICU, Peking Union Medical College Hospital, Beijing.
¹⁴ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹⁵ Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, 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, USA.
²⁰ Faculty of Medicine, Imperial College, London, UK.
²¹ Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, 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, Georgia, 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, New York, USA.
²⁷ GUIDE Research Methods Group, Hamilton, Canada (https://guidecanada.org).
²⁸ Houston Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
²⁹ Department of Anesthesia, McMaster University, Hamilton, Canada.
³⁰ Department of Medicine and Surgery, Milano-Bicocca University, Milano, 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 & 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, Virginia, USA.
³⁷ Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA.
³⁸ Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.

PMID: 32224769
PMCID: PMC7176264
DOI: 10.1097/CCM.0000000000004363

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Waleed Alhazzani et al. Crit Care Med. 2020 Jun.

. 2020 Jun;48(6):e440-e469.

doi: 10.1097/CCM.0000000000004363.

Authors

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, Canada.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada.
³ Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark.
⁴ Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI).
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, New York, USA.
⁷ Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
⁸ Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA.
⁹ Rhode Island Hospital, Providence, Rhode Island, USA.
¹⁰ Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands.
¹¹ Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands.
¹² Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA.
¹³ Medical ICU, Peking Union Medical College Hospital, Beijing.
¹⁴ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹⁵ Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, 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, USA.
²⁰ Faculty of Medicine, Imperial College, London, UK.
²¹ Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, 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, Georgia, 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, New York, USA.
²⁷ GUIDE Research Methods Group, Hamilton, Canada (https://guidecanada.org).
²⁸ Houston Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
²⁹ Department of Anesthesia, McMaster University, Hamilton, Canada.
³⁰ Department of Medicine and Surgery, Milano-Bicocca University, Milano, 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 & 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, Virginia, USA.
³⁷ Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA.
³⁸ Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.

PMID: 32224769
PMCID: PMC7176264
DOI: 10.1097/CCM.0000000000004363

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 four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six 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 evidence in further releases of these guidelines.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: 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). The remaining authors have disclosed that they have no potential conflicts of interest.

Figures

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

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

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

See this image and copyright information in PMC

Comment in

High-flow nasal cannula may be no safer than non-invasive positive pressure ventilation for COVID-19 patients.
Remy KE, Lin JC, Verhoef PA. Remy KE, et al. Crit Care. 2020 Apr 23;24(1):169. doi: 10.1186/s13054-020-02892-9. Crit Care. 2020. PMID: 32326959 Free PMC article. No abstract available.

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1. European Centre for Disease Prevention and Control, Situation update worldwide, 4 March 2020. https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases.
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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)

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Comment in

References

MeSH terms

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

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