In this episode, I’ll discuss pharmacy-related recommendations from the surviving sepsis COVID-19 critical care guidelines.
The Surviving Sepsis Campaign has published guidelines on the management of critically ill adults with COVID-19. These guidelines were last updated on March 20th 2020. Information and recommendations are changing rapidly in this area and the authors state they will be updating the guidelines when new evidence becomes available. Recommendations are not currently based on direct evidence with COVID-19 patients. These guidelines make no mention of the small case control study from France about using hydroxychloroquine with azithromycin at the time of this writing.
The guidelines make no recommendations on specific therapeutic treatment for COVID-19; all recommendations are regarding supportive care. The recommendations are in 5 broad categories: Fluids, vasopressors, steroids, neuromuscular blockers, and other interventions.
Fluids
For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fluid strategy (weak recommendation, very low-quality evidence).
The authors suggest a conservative fluid strategy based on data from critically ill patients with ARDS favoring restricted fluid volumes during initial resuscitation.
For the acute resuscitation of adults with COVID-19 and shock, we recommend using crystalloids
over colloids (strong recommendation, moderate quality evidence)For the acute resuscitation of adults with COVID-19 and shock, we suggest using
buffered/balanced crystalloids over unbalanced crystalloids (weak recommendation, moderate quality
evidence).
Balanced crystalloids are the recommended resuscitation fluid if the COVID-19 patient is in shock. For most hospitals, this will mean choosing lactated ringer’s solution as the resuscitation fluid. This is recommended over normal saline by the guidelines authors because less kidney injury is expected with the lower chloride levels in lactated ringer’s.
Vasopressors
For adults with COVID-19 and shock, we suggest using norepinephrine as the first-line vasoactive
agent, over other agents (weak recommendation, low quality evidence).If norepinephrine is not available, we suggest using either vasopressin or epinephrine as the first-line
vasoactive agent, over other vasoactive agents, for adults with COVID-19 and shock (weak
recommendation, low quality evidence).
The preferred initial vasopressor is norepinephrine, however vasopressin or epinephrine may be used if norepinephrine is not available.
For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is
available (strong recommendation, high quality evidence).
If norepinephrine is available, the authors recommend against using dopamine.
For adults with COVID-19 and shock, we suggest adding vasopressin as a second-line agent, over
titrating norepinephrine dose, if target mean arterial pressure (MAP) cannot be achieved by
norepinephrine alone (weak recommendation, moderate quality evidence).
If norepinephrine is not enough, the recommendation is to add vasopressin rather than to titrate the norepinephrine dose higher. Specific dose recommendations are not provided by the guidelines authors.
For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent
hypoperfusion despite fluid resuscitation and norepinephrine, we suggest adding dobutamine,
over increasing norepinephrine dose (weak recommendation, very low quality evidence).
If the patient has shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, the authors suggest adding dobutamine. This is based on physiologic rationale only.
Steroids
In mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS), we
suggest against the routine use of systemic corticosteroids (weak recommendation, low quality
evidence).In mechanically ventilated adults with COVID-19 and ARDS, we suggest using systemic
corticosteroids, over not using corticosteroids (weak recommendation, low quality evidence)For adults with COVID-19 and refractory shock, we suggest using low-dose corticosteroid therapy
(“shock-reversal”), over no corticosteroid therapy (weak recommendation, low quality evidence).
Recommendations are against using steroids in COVID-19 patients with respiratory failure unless they have another condition that warrants them such as ARDS or refractory shock.
Neuromuscular blockers
For mechanically ventilated adults with COVID-19 and moderate to severe ARDS:
We suggest using, as needed, intermittent boluses of neuromuscular blocking agents
(NMBA), over continuous NMBA infusion, to facilitate protective lung ventilation
(weak recommendation, low quality evidence).In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation,
prone ventilation, or persistently high plateau pressures, we suggest using a
continuous NMBA infusion for up to 48 hours (weak recommendation, low quality
evidence).
If a patient with COVID-19 develops ARDS, the guideline authors recommend trying intermittent neuromuscular blocking agents if needed to facilitate proper ventilation. Only if these intermittent boluses fail to produce adequate results do they recommend a continuous infusion of neuromuscular blockers for up to 48 hours.
Other
In mechanically ventilated patients with COVID-19 and respiratory failure, we suggest using empiric
antimicrobials/antibacterial agents, over no antimicrobials (Weak recommendation, low quality
evidence).
If empiric antibiotics are used, the authors recommend to assess for de-escalation daily, and to re-evaluate the duration.
For critically ill adults with COVID-19 who develop fever, we suggest using
acetaminophen/paracetamol for temperature control, over no treatment (Weak recommendation, low
quality evidence).In critically ill adults with COVID-19, we suggest against the routine use of standard intravenous
immunoglobulins (IVIG) (Weak recommendation, very low-quality evidence).We suggest against the routine use of lopinavir/ritonavir (weak recommendation, low
quality evidence).
This is based on reported but yet to be published trial results from China suggesting lack of efficacy.
All other therapeutics did not have enough data for the authors to make a recommendation for or against.
When evaluating the care of a COVID-19 patient against these guideline recommendations it is important to remember that evidence is rapidly emerging and that these recommendations are not based on direct evidence in patients with COVID-19. Other treatment strategies may be perfectly acceptable depending on patient-specific factors.
To those APPE students whose hospital rotation has been disrupted by recent events: One way I’d like to help is by providing free access to 8 essential training videos on topics that I discuss with students on my rotation. Get free 14-day access by going to pharmacyjoe.com/virtual.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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