International panel releases ICU guidelines for COVID-19

An international panel of 36 experts has issued guidelines for healthcare workers treating intensive care unit (ICU) patients with COVID-19, compressing what would have been more than a year of work into less than three weeks.

The Surviving Sepsis Campaign COVID-19 panel has released 54 recommendations, covering topics such as infection control, laboratory diagnosis and specimens, the dynamics of blood flow support, ventilation support and COVID-19 therapy. The guidelines are co-published in Critical Care Medicine and Intensive Care Medicine.

“Usually, it takes a year or two to develop large clinical practice guidelines such as these ones,” said first author Associate Professor Waleed Alhazzani from McMaster University.

“Given the urgency and the huge need for these guidelines, we assembled the team, searched the literature, summarised the evidence, and formulated recommendations within 18 days. Everyone worked hard to make this guideline available to the end user rapidly while maintaining methodological rigour.”

Alhazzani, who is also an intensive care physician at St Joseph’s Healthcare Hamilton, added that the guidelines will be used by frontline clinicians, allied health professionals and policymakers involved in the care of patients with COVID-19.

The panel began by proposing 53 questions they considered to be relevant to the management of COVID-19 in ICUs. The team then searched the literature for direct and indirect evidence on the management of COVID-19 in the ICU. They found relevant and recent systematic reviews on most questions relating to supportive care.

The group assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, developed at McMaster. GRADE is a way to assess previous work — a transparent framework for developing and presenting summaries of evidence — and provides a systematic approach for making clinical practice recommendations for healthcare professionals.

The resulting 54 recommendations include four best practice statements, nine strong recommendations and 35 weak recommendations. No recommendation was provided for six questions. Four best practice statements based on high-quality evidence include:

1. Healthcare workers performing aerosol-generating procedures, such as intubation, bronchoscopy or open suctioning, on patients with COVID-19 should wear fitted respirator masks, such as N95, FFP2 or equivalent — instead of surgical masks — in addition to other personal protective equipment, such as gloves, gowns and eye protection.
2. Aerosol-generating procedures should be performed on ICU patients with COVID-19 in a negative-pressure room, if available. Negative-pressure rooms are engineered to prevent the spread of contagious pathogens from room to room.
3. Endotracheal intubation of patients with COVID-19 should be performed by healthcare workers with experience in airway management to minimise the number of attempts and risk of transmission.
4. Adults with COVID-19 who are being treated with non-invasive positive pressure ventilation or a high-flow nasal cannula should be closely monitored for worsening respiratory status and intubated early if needed.

McMaster University’s Vice-Dean of Research for the Faculty of Health Sciences, Jonathan Bramson, said, “This will have a tremendous impact, right now and worldwide, on how the most serious patients with COVID-19 are treated.”

The Surviving Sepsis Campaign COVID-19 panel said it plans to issue further guidelines in order to update the recommendations or formulate new ones, if needed.

Image credit: ©stock.adobe.com/au/Tyler Olsen