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Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review. Chest 2023; 164:1216-1227. [PMID: 37479058 PMCID: PMC10635838 DOI: 10.1016/j.chest.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023] Open
Abstract
TOPIC IMPORTANCE This review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock. REVIEW FINDINGS Patients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation. SUMMARY Experimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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2
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Bauer SR, Wieruszewski PM, Bissell BD, Dugar S, Sacha GL, Sato R, Siuba MT, Schleicher M, Vachharajani V, Falck-Ytter Y, Morgan RL. Adjunctive Vasopressors in Patients with Septic Shock: Protocol for a Systematic Review and Meta-Analysis. medRxiv 2023:2023.07.29.23293364. [PMID: 37546921 PMCID: PMC10402239 DOI: 10.1101/2023.07.29.23293364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background Over one-third of patients with septic shock have adjunctive vasopressors added to first-line vasopressors. However, no randomized trial has detected improved mortality with adjunctive vasopressors. Published systematic reviews and meta-analysis have sought to inform the use of adjunctive vasopressors, yet each published review has limitations that hinder its interpretation. This review aims to overcome the limitations of previous reviews by systematically synthesizing the direct evidence for adjunctive vasopressor therapy use in adult patients with septic shock. Methods We will conduct a systematic review and meta-analysis of randomized controlled trials evaluating adjunctive vasopressors (vasopressin analogues, angiotensin II, hydroxocobalamin, methylene blue, and catecholamine analogues) in adult patients with septic shock. Relevant studies will be identified through comprehensive searches of MEDLINE, Embase, CENTRAL, and reference lists of previous systematic reviews. Only randomized trials comparing adjunctive vasopressors (>75% of subjects on vasopressors at enrollment) to standard care vasopressors in adults with septic shock (>75% of subjects having septic shock) will be included. Titles and abstracts will be screened, full-text articles assessed for eligibility, and data extracted from included studies. Outcomes of interest include short-term mortality, intermediate-term mortality, kidney replacement therapy, digital/peripheral ischemia, and venous thromboembolism. Pairwise meta-analysis using a random-effects model will be utilized to estimate the risk ratio for the outcomes. Risk of bias will be adjudicated with the Cochrane Risk of Bias 2 tool, and GRADE will be used to rate the certainty of the body of evidence. Discussion Although adjunctive vasopressors are commonly used in patients with septic shock their effect on patient-important outcomes is unclear. This study is planned to use rigorous systematic review methodology, including strict adhere to established guidelines, in order to overcome limitations of previously-published reviews and inform clinical practice and treatment guidelines for the use of adjunctive vasopressors in adults with septic shock. Systematic review registration PROSPERO CRD4202327984.
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Affiliation(s)
- Seth R. Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Patrick M. Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Brittany D. Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Siddharth Dugar
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Ryota Sato
- Department of Critical Care Medicine, The Queen’s Health System, Honolulu, HI
| | - Matthew T. Siuba
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Mary Schleicher
- The Cleveland Clinic Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH
| | - Vidula Vachharajani
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Yngve Falck-Ytter
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
- Division of Gastroenterology and Hepatology, VA Northeast Ohio Healthcare System, Cleveland, OH
| | - Rebecca L. Morgan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario
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3
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Böcklein M, Beck M, Shmygalev S. [Distributive shock]. Anaesthesiologie 2023:10.1007/s00101-023-01304-1. [PMID: 37493826 DOI: 10.1007/s00101-023-01304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 07/27/2023]
Abstract
In shock there is a significant mismatch between oxygen supply and consumption. In recent years the classification of forms of shock has been established based on pathophysiological and clinical aspects. The term distributive shock includes septic, anaphylactic and neurogenic shock. All these forms share a distinct vasoplegia with a relative volume deficiency. The adequate treatment of patients with distributive shock includes a rapid diagnosis and a consistent emergency treatment consisting of volume and catecholamine administration as well as additional specific emergency procedures when necessary.
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Affiliation(s)
- M Böcklein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland.
| | - M Beck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
| | - S Shmygalev
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
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4
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Sacha GL, Kiser TH, Wright GC, Vandivier RW, Moss M, Burnham EL, Ho PM, Reynolds PM, Bauer SR. Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock. Crit Care Med 2022; 50:644-654. [PMID: 34605778 DOI: 10.1097/ccm.0000000000005305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Vasopressin is suggested as an adjunct to norepinephrine in patients with septic shock. However, after vasopressin was rebranded in November 2014, its cost exponentially increased. Utilization patterns of vasopressin after its rebranding are unclear. The objective of this study was to determine if there is an association between the rebranding of vasopressin in November 2014 and its utilization in vasopressor-dependent patients with severe sepsis or septic shock. DESIGN Retrospective, multicenter, database study between January 2010 and March 2017. SETTING Premier Healthcare Database hospitals. PATIENTS Adult patients admitted to an ICU with severe sepsis or septic shock, who received at least one vasoactive agent for two or more calendar days were included. INTERVENTIONS The proportion of patients who received vasopressin and vasopressin cost was assessed before and after rebranding, and evaluated with segmented regression. MEASUREMENTS AND MAIN RESULTS Among 294,733 patients (mean age, 66 ± 15 yr), 27.8% received vasopressin, and ICU mortality was 26.5%. The proportion of patients receiving vasopressin was higher after rebranding (31.2% postrebranding vs 25.8% prerebranding). Before vasopressin rebranding, the quarterly proportion of patients who received vasopressin had an increasing slope (prerebranding slope 0.41% [95% CI, 0.35-0.46%]), with no difference in slope detected after vasopressin rebranding (postrebranding slope, 0.47% [95% CI, 0.29-0.64%]). After vasopressin rebranding, mean vasopressin cost per patient was higher ($527 ± 1,130 vs $77 ± 160), and the quarterly slope of vasopressin cost was higher (change in slope $77.18 [95% CI, $75.73-78.61]). Total vasopressin billed cost postrebranding continually increased by ~$294,276 per quarter from less than $500,000 in Q4 2014 to over $3,000,000 in Q1 2017. CONCLUSIONS After vasopressin rebranding, utilization continued to increase quarterly despite a significant increase in vasopressin cost. Vasopressin appeared to have price inelastic demand in septic shock.
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Affiliation(s)
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Garth C Wright
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
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O'Shaughnessy SM, Lee JY, Rong LQ, Rahouma M, Wright DN, Demetres M, Kachulis B. Quality of recent clinical practice guidelines in anaesthesia publications using the Appraisal of Guidelines for Research and Evaluation II instrument. Br J Anaesth 2022; 128:655-663. [PMID: 35090727 PMCID: PMC9074794 DOI: 10.1016/j.bja.2021.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 12/15/2022] Open
Abstract
Clinical practice guidelines are a valuable resource aiding medical decision-making based on scientific evidence. In anaesthesia, guidelines are increasing in both number and scope, influencing individual practice and shaping local departmental policy. The aim of this review is to assess the quality of clinical practice guidelines published in high impact anaesthesia journals over the past 5 yr using the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A literature search was conducted in Scopus to identify all guidelines published in the top 10 anaesthesia journals as per Clarivate Analytics Impact Factor from 2016 and 2020. Fifty-one guidelines were included for analysis by five independent appraisers using AGREE II. Each guideline was assessed across six domains and 23 items. Individual domain scores were calculated with a threshold agreed via consensus to represent high-quality guidelines. There was a significant increase in overall score over time (P=0.041), driven by Domain 3 (Rigour of Development, P=0.046). The raw overall score for Domain 3, however, was low. The other domains performed as expected based on previous studies, with Domains 1, 4, and 6 achieving high scores and Domains 2 and 5 incurring poor ratings. Most guidelines studied involved international collaboration but emerged from a single professional society. Use of an appraisal tool was stated as high but poorly detailed. The improvement in the overall score of guidelines and rigour of development is promising; however, only seven guidelines met high-quality criteria, suggesting room for improvement for the overall integrity of guidelines in anaesthesia.
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Bayerl S, Wöhrle T, Kilger E. [Vasopressin in distributive shock : Brief summary of the guidelines of the Canadian Critical Care Society published in December 2019]. Anaesthesist 2021; 69:159-161. [PMID: 32055884 DOI: 10.1007/s00101-020-00742-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The Canadian Critical Care Society performed a meta- analysis to assess the benefits and risks of the application of vasopressin and vasopressin- analogues in distributive shock. Their results were formulated as a Guideline in 2019. In the meta- analysis mainly included were studies with patients suffering from sepsis causing the distributive shock. The recommendations of the Surviving Sepsis Campaign 2016 concerning catecholamine therapy clearly prefer norepinephrin as the first- choice vasopressor, the use of vasopressin as an additionally administered drug is rated more tentative. Also the Canadian guideline now, implicating recently published studies, argues for the use of vasopressin or vasopressin- analogues in addition to an existing norepinephrine therapy, even though the level of evidence remains still low and there's no simple therapeutic algorithm formulated. This is based on a lowered incidence of newly- diagnosed atrial fibrillation and decreased mortality rate while administration remains safe.
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Affiliation(s)
- S Bayerl
- Klinik für Anästhesiologie, Klinikum der Universität München, München, Deutschland.
| | - T Wöhrle
- Klinik für Anästhesiologie, Klinikum der Universität München, München, Deutschland
| | - E Kilger
- Klinik für Anästhesiologie, Klinikum der Universität München, München, Deutschland
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7
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Lo Bianco G, Di Pietro S, Mazzuca E, Imburgia A, Tarantino L, Accurso G, Benenati V, Vernuccio F, Bucolo C, Salomone S, Riolo M. Multidisciplinary Approach to the Diagnosis and In-Hospital Management of COVID-19 Infection: A Narrative Review. Front Pharmacol 2020; 11:572168. [PMID: 33362541 PMCID: PMC7758731 DOI: 10.3389/fphar.2020.572168] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2 or COVID-19 disease) was declared a pandemic on 11th March 2020 by the World Health Organization. This unprecedented circumstance has challenged hospitals' response capacity, requiring significant structural and organizational changes to cope with the surge in healthcare demand and to minimize in-hospital risk of transmission. As our knowledge advances, we now understand that COVID-19 is a multi-systemic disease rather than a mere respiratory tract infection, therefore requiring holistic care and expertise from various medical specialties. In fact, the clinical spectrum of presentation ranges from respiratory complaints to gastrointestinal, cardiac or neurological symptoms. In addition, COVID-19 pandemic has created a global burden of mental illness that affects the general population as well as healthcare practitioners. The aim of this manuscript is to provide a comprehensive and multidisciplinary insight into the complexity of this disease, reviewing current scientific evidence on COVID-19 management and treatment across several medical specialties involved in the in-hospital care of these patients.
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Affiliation(s)
- Giuliano Lo Bianco
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, Catania, Italy
- Anesthesiology and Pain Department, Fondazione Istituto G.Giglio, Cefalù, Italy
| | - Santi Di Pietro
- Emergency Medicine Fellowship Programme, University of Pavia, Pavia, Italy
- Emergency Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Emilia Mazzuca
- Unità operativa Complessa di Pneumologia, A.O. Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
| | | | - Luca Tarantino
- Cliniche Humanitas Gavazzeni, U.O. Elettrofisiologia, Bergamo, Italy
| | - Giuseppe Accurso
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | | | - Federica Vernuccio
- Section of Radiology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BIND), University of Palermo, Palermo, Italy
| | - Claudio Bucolo
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, Catania, Italy
| | - Salvatore Salomone
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, Catania, Italy
| | - Marianna Riolo
- Struttura Complessa di Neurologia, Ospedale Santa Croce di Moncalieri, Asl TO5, Moncalieri (TO), Italy
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8
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Bauer SR, Sacha GL, Lam SW, Wang L, Reddy AJ, Duggal A, Vachharajani V. Hemodynamic Response to Vasopressin Dosage of 0.03 Units/Min vs. 0.04 Units/Min in Patients With Septic Shock. J Intensive Care Med 2020; 37:92-99. [PMID: 33251906 DOI: 10.1177/0885066620977181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Arginine vasopressin (AVP) is suggested as an adjunct to norepinephrine in patients with septic shock. Guidelines recommend an AVP dosage up to 0.03 units/min, but 0.04 units/min is commonly used in practice based on initial studies. This study was designed to compare the incidence of hemodynamic response between initial fixed-dosage AVP 0.03 units/min and AVP 0.04 units/min. METHODS This retrospective, multi-hospital health system, cohort study included adult patients with septic shock receiving AVP as an adjunct to catecholamine vasopressors. Patients were excluded if they received an initial dosage other than 0.03 units/min or 0.04 units/min, or AVP was titrated within the first 6 hours of therapy. The primary outcome was hemodynamic response, defined as a mean arterial pressure ≥65 mm Hg and a decrease in catecholamine dosage at 6 hours after AVP initiation. Inverse probability of treatment weighting (IPTW) based on the propensity score for initial AVP dosage receipt was utilized to estimate adjusted exposure effects. RESULTS Of the 1536 patients included in the observed data, there was a nearly even split between initial AVP dosage of 0.03 units/min (n = 842 [54.8%]) and 0.04 units/min (n = 694 [45.2%]). Observed patients receiving AVP 0.03 units/min were more frequently treated at the main campus academic medical center (96.3% vs. 52.2%, p < 0.01) and in a medical intensive care unit (87.4% vs. 39.8%, p < 0.01). The IPTW analysis included 1379 patients with achievement of baseline covariate balance. There was no evidence for a difference between groups in the incidence of hemodynamic response (0.03 units/min 50.0% vs. 0.04 units/min 53.1%, adjusted relative risk 1.06 [95% CI 0.94, 1.20]). CONCLUSIONS Initial AVP dosing varied by hospital and unit type. Although commonly used, an initial AVP dosage of 0.04 units/min was not associated with a higher incidence of early hemodynamic response to AVP in patients with septic shock.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | - Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Lu Wang
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.,Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anita J Reddy
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Vidula Vachharajani
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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9
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Abstract
Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.
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Affiliation(s)
- A Haas
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - T Schürholz
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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10
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020; 48:e440-e469. [PMID: 32224769 PMCID: PMC7176264 DOI: 10.1097/ccm.0000000000004363] [Citation(s) in RCA: 603] [Impact Index Per Article: 150.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Morten Hylander Møller
- Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark
- Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI)
| | - Yaseen M Arabi
- 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
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
- GUIDE Research Methods Group, Hamilton, Canada (https://guidecanada.org)
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milano, Italy
- ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research & Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University of, Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
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11
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 2020; 46:854-887. [PMID: 32222812 PMCID: PMC7101866 DOI: 10.1007/s00134-020-06022-5] [Citation(s) in RCA: 1290] [Impact Index Per Article: 322.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023]
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 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 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 recommendations in further releases of these guidelines.
Electronic supplementary material The online version of this article (10.1007/s00134-020-06022-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, 4131, Copenhagen, Denmark.,Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI), Copenhagen, Denmark
| | - Yaseen M Arabi
- 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
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Rhode Island Hospital, Providence, RI, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Baltimore, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada.,Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection Control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,GUIDE Research Methods Group, Hamilton, Canada
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.,ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research and Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW, Sydney, Australia.,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University, of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.
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12
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Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, Singh MK, Gopal PB, Chaudhry D, Govil D, Dixit SB, Samavedam S. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020; 24:S254-S262. [PMID: 33354049 PMCID: PMC7724927 DOI: 10.5005/jp-journals-10071-23593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In a resource-limited country like India, rationing of scarce critical care resources might be required to ensure appropriate delivery of care to the critically ill patients suffering from COVID-19 infection. Most of these patients require critical care support because of respiratory failure or presence of multiorgan dysfunction syndrome. As there is no pharmacological therapy available, respiratory support in the form of supplemental oxygen, noninvasive ventilation, and invasive mechanical ventilation remains mainstay of care in intensive care units. As there is still dearth of direct evidence, most of the data are extrapolated from the experience gained from the management of general critical care patients. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020;24(Suppl 5):S254–S262.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Raymond D Savio
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - Rahul A Pandit
- Department of Intensive Care, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
| | - Suresh Ramasubban
- Department of Critical Care, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Pavan K Reddy
- Department of Critical Care, CARE-Banjara, Hyderabad, Telangana, India
| | - Manoj K Singh
- Department of Critical Care, Apollo Hospitals International Limited, Ahmedabad, Gujarat, India
| | - Palepu Bn Gopal
- Department of Critical Care, Continental Hospital, Hyderabad, Telangana, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta: The Medicity, Gurugram, Haryana, India
| | - Subhal B Dixit
- Department of Critical Care Medicine, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
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