Management of critically ill adults with COVID-19 - JAMA

Bron: JAMA; 26-3-2020; doi:10.1001/jama.2020.4914
By: J.T. Poston et al.

Aim
Provide guidelines for management of critically ill adults with COVID-19

Recommendations

• In aerosol generating procedures (e.g. intubation) personnel should wear fitted masks (FFP2 / N95) and other PPE instead of surgical masks
• For non aerosol generating procedures use medical masks, no respirator masks. 
• Endotracheal aspirates are preferred over bronchial lavage, washing and upper respiratory tract swabs
• Acute resuscitation for adults in shock:
  • Measure dynamics to assess fluid responsiveness
  • Conservative fluid administration strategy with crystalloids instead of colloids. Balanced crystalloids are preferred over unbalanced.
  • Norepinephrine is first-line vasopressor. (other options: vasopressin, epinephrine). Second-line addition: vasopressin. Do not use dopamine!
• Supplemental oxygen if SPO2 < 90%. Maintain SPO2 no higher than 96%
• For acute hypoxemic resp failure despite conventional oxygen therapy use high-flow nasal cannula. If unavailable use NIPPV. Monitor closely and in case of deterioration: intubate!
• Ventilated patients with ARDS use low tidal volume ventilation (4-8 ml/kg). Targetting a plateau pressure of < 30 cm H20. Use of higher PEEP over lower PEEP is recommended. 
• ARDS and mechanical ventilation:prone ventilation for 12-16 hours is suggested. Us as-needed neuromuscular blocking agents instead of continuous NMBAs.
• In severe ARDS trial inhaled pulmonary vasodilator is suggested. No effect? taper trial. The use of lung recruitment maneuvers (intended to open otherwise closed lung segments, such as 40 cm H₂O inspiratory hold for 40 seconds) is suggested, but using staircase (incremental PEEP) recruitment maneuvers is not recommended. 
• Use of veno-venous circulation for extracorporeal membrane oxygenation (ECMO) or referral to an ECMO center is suggested, if available, for selected patients.
• Do not use systemic corticosteroids in ventilated patients without ARDS. It is suggested for patients with ARDS.
• Empiric antibiotics is suggested in ventilated patients
• Pharmacological temperature control is suggested for critically ill. 
• Insufficient evidence on the use of antiviral agents