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27 maart 2020

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.

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


  • 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