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Revista Brasileira de Terapia Intensiva
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How to Cite
Mendes JJ, Mergulhão P, Froes F, Paiva JA, Gouveia J. Recomendações da Sociedade Portuguesa de Cuidados Intensivos e Grupo de Infeção e Sépsis para a abordagem do COVID-19 em medicina intensiva. Rev Bras Ter Intensiva. 2020;32(1):2-10
10.5935/0103-507X.20200002
Recomendações da Sociedade Portuguesa de Cuidados Intensivos e Grupo de Infeção e Sépsis para a abordagem do COVID-19 em medicina intensiva
João João Mendes1,2,3,4, Paulo Mergulhão1,5,6, Filipe Froes7, José Artur Paiva5,8,9, João Gouveia1,10
1
Sociedade Portuguesa de Cuidados Intensivos -
Lisboa, Portugal.
2
Serviço de Medicina Intensiva, Hospital Prof.
Doutor Fernando da Fonseca EPE - Lisboa, Portugal.
3
Unidade de Cuidados Intensivos Polivalente,
Hospital CUF Infante Santo - Lisboa, Portugal.
4
Instituto de Microbiologia, Faculdade de
Medicina, Universidade de Lisboa - Lisboa, Portugal.
5
Grupo de Infeção e Sépsis - Lisboa,
Portugal.
6
Unidade de Cuidados Intensivos Polivalente,
Hospital Lusíadas Porto - Porto, Portugal.
7
Unidade de Cuidados Intensivos
Médico-Cirúrgicos, Hospital Pulido Valente, Centro Hospitalar Universitário de
Lisboa Norte EPE - Lisboa, Portugal.
8
Colégio da Especialidade de Medicina Intensiva,
Ordem dos Médicos - Lisboa, Portugal.
9
Faculdade de Medicina, Universidade do Porto -
Porto, Portugal.
10
Serviço de Medicina Intensiva, Centro
Hospitalar Universitário de Lisboa Norte EPE - Lisboa, Portugal.
Conflicts of interest: None.
Responsible editor: Felipe Dal-Pizzol
Submitted on March 12, 2020
Accepted on March 16, 2020
Corresponding author: João João Mendes, Sociedade Portuguesa de Cuidados Intensivos, Rua Rodrigo da Fonseca, 204, Lisbon 1070-196, Portugal. E-mail: [email protected]
Current COVID-19 epidemics was declared on December 31, 2019 at the Wuhan city
seafood market, rapidly spreading throughout China, and later reaching several
countries (mainly South Korea, Japan, Italy and Iran) and, since March 1,
reaching Portugal. Most of the infected patients present with mild symptoms, not
requiring hospitalization. Among those admitted to the hospital, 6% to 10%
require admission to the intensive care unit. These recommendations are aimed to
support the organization of intensive care services to respond COVID-19,
providing optimized care to the patient and protection for healthcare
professionals.
Keywords: Coronavirus infections; COVID-19; SARS virus; Sepsis; Intensive care units.
INTRODUCTION
COVID-19, short for coronavirus disease 2019, is a clinical disease caused by SARS-CoV-2, a simple positive-sense RNA genome virus, belonging to the coronaviruses (CoV) family. There are four strains (HCoV-229E, HCoV-NL63, HCoV-OC43, and HCoV-HKU1) with seasonal circulation among human populations, most frequently causing mild-severity respiratory infections (such as common cold) and, rarely, viral pneumonia.(1) Before the emergence of SARS-CoV-2,(2) two strains causing epidemic outbreaks from zoonotic origin were described: SARS-CoV-1, causing severe acute respiratory syndrome (SARS) originated from bats and transmitted to the African civet, and later to humans in 2002; and MERS-CoV, causing the Middle East respiratory syndrome (MERS) originated from bats, transmitted to camelids, and later, to humans in 2012.(1)
On December 31, 2019, a pneumonia cluster from an unknown cause was identified in the Chinese city of Wuhan (Hubei province), later associated with the Huanan Seafood Wholesale Market. The respiratory samples from these patients lead to the identification of a new virus (SARS-CoV-2) with an epidemic dissemination throughout China and progressively spreading to multiple countries (mostly South Korea, Japan, Italy, and Iran),(3) and since March 2, to Portugal.(4) Its contagion capacity is due to a significant attack rate (R⌀, number of new cases generated from one single confirmed case) that has been estimated to be from 2.5 to 2.9, although potentially affected by public health interventions.(5) High risk of nosocomial transmission has been observed, as well as contamination of healthcare professionals.(6)
The median incubation time is four days, but it may last until 14 days,(6) and the SARS-CoV-2, similar to SARS-CoV-1, links to angiotensin 2 converting enzyme receptors located on type II alveolar cells, causing diffuse alveolar and direct cytopathic injury.(7) Most of the infected patients (> 80%) present with mild disease, with no need for admission to the hospital. Among those admitted to the hospital, 6% to 10% require referral to intensive care.(3,6
These recommendations are aimed to support the organization of intensive care services to respond to COVID-19, providing optimized care for patients and protection of healthcare professionals.
2. CRITERIA FOR ADMISSION TO INTENSIVE CARE SERVICES
Recommendation 1
It is recommended that patients with criteria for severe pneumonia (Attachment 1) are early referred to intensive care services, in order to discuss the decision and timing for referring to the intensive care service.
3. ISOLATION AND INDIVIDUAL PROTECTION EQUIPMENT
Recommendation 1
Isolation in individual rooms with negative pressure and gates, privative toilet and ventilation system with capacity for 6 - 12 air changes per hour. Once exhausted these resources, patients are recommended to be isolated in individual rooms with a ventilation system with capacity for 6 - 12 air changes per hour. When no isolation individual rooms are available, cohort isolation is recommended, keeping a minimum distance of 1 meter between patients’ units.
Recommendation 2
Visits restriction is recommended for all patients and limiting the number of professionals in contact with the patient (ideally, dedicated professionals), implementing alternative remote ways for communication between patient and family, and the clinical team, patient and family, independent of the isolation site.
Recommendation 3
All healthcare professionals involved in clinical care are recommended to use universal precautions, contact precautions, and droplet precautions. These include wearing specific individual protection equipment, disposable (one use) and impermeable coat, surgical mask, eye protection, and clean gloves. During potentially generating aerosols care (e.g. intubation, aspiration of secretions and bronchoscopy), or prolonged contact (> 15 minutes), and/or close contact (e.g. placing central venous catheter, surgery, cardiorespiratory reanimation maneuvers), airway precautions are recommended. These include wearing specific individual protection equipment, disposable (one use) and impermeable: coat (with long sleeve and elastic cuff, and covering until the mid of legs or ankles), cap, FFP2/FFP3 mask (appropriately fit to the face), eye protection (with lateral protection), gloves (reaching above the coat sleeves), and shoe protection (ideally impermeable shoes for exclusive use on the isolation area or impermeable shoe protection). It is recommended that the integral protection outfit (impermeable, including hat and neck protection) is limited to trained professionals with practical experience in their use. Once the use of nebulizers, noninvasive mechanic ventilation, and high-flow nasal cannulas are potential aerosol generators, airway protection measures are recommended to be equally used during the clinical care of these patients.
Recommendation 4
Order and technic for putting on and removing individual protection equipment should be strictly adhered to (ideally using a mirror or observation by another healthcare professional). Particularly during removal, it is recommended additional care to prevent self-contamination and contamination other people and the environment.
Recommendation 5
It is recommended that all healthcare professionals are trained and have practical experience putting on and removing individual protection equipment before any contact with patients.
Rational
We followed the recommendations from the Portuguese General Health Management(8) based on WHO(9) and European Centre for Disease Prevention and Control (ECDC)(10) on strategies for prevent and control SARS-CoV-2 infection mainly on the prevention of transmission in healthcare facilities, based on recommendations previously issued for MERSCoV1 and SARS-CoV1.
4. HOSPITAL ORGANIZATION
5. INFECTION DIAGNOSIS
Recommendation 1
It is recommended that the microbiologic diagnosis use a real-time polymerase chain reaction test (real-time PCR) to analyze samples from upper airways (swabs of nasopharynx and oropharynx exudates), whenever possible associated with a lower respiratory tract sample (bronchial secretions collected from endotracheal aspirate).
Recommendation 2
It is not recommended to perform bronchoscopy exclusively to collect samples from the lower respiratory tract.
Recommendation 3
Whenever there is high clinical suspicion (especially if a computed tomography scan shows disease evidence) and microbiologic testing is negative, it is recommended to repeat the test to either confirm or rollout infection, preferably with samples from the lower respiratory tract.
Recommendation 4
Blood culture samples are recommended (at least two blood culture sets, aerobic and anaerobic) and a sample from the lower respiratory tract to search for other microbiologic agents.
Rational
Real-time PCR test (RT-PCR) is a highly specific test to identify the presence of SARS-CoV-2, and patients with greater viral load (most frequently during the disease) may be more likely to show a positive test. However, for patients with suspected COVID-19 and a negative RT-PCR test, repeating the test was positive in 23% of the cases (conversion over time), pointing to a sensitivity lower than 80%. In these cases, whenever possible a chest computed tomography scan should be performed, searching for disease evidence before real-time PCR.(11,12) Coinfection with other microbiological agents, especially in the event of a septic shock, is frequent.(11
6. INITIAL THERAPY FOR SUSPECTED/CONFIRMED CASES
Recommendation 1
All severe pneumonia patients are recommended to receive oxygen therapy, started with 4L/minute nasal cannula and titrated to oxygen saturation (SpO2) ≥ 92%, without humidification.
Recommendation 2
A conservative fluid therapy strategy is recommended, especially in the absence of shock.
Rational
We adhered to WHO recommendations,(13) highlighting that no humidification is required for oxygen flows < 4L/minute(14) and that the use of bubble humidifiers with oxygen flows ≥ 5L/minute produces aerosols that increase the risk of transmitting microorganisms.(15) The initial presentation of COVID-19 is rarely of a septic shock, and the most frequent cause of death is hypoxemic respiratory failure,(16) aggravated by inappropriate fluid therapy.(17
7. INDICATIONS AND STRATEGY FOR HIGH-FLOW NASAL CANNULA OXYGEN THERAPY
Recommendation 1
It is recommended not to use high-flow nasal cannula oxygen therapy in patients during the active viral replication phase.
Recommendation 2
It is recommended that, if a decision to start a high-flow nasal cannula oxygen therapy is made:
(1) that the technique is started at the intensive care service in a highly monitored environment, allowing to prevent delaying intubation in cases of failure to respond;
(2) that low flows are preferred (15 - 30L/minute), with the patient wearing a surgical mask (whenever possible); and
(3) that healthcare professionals use contact precautions for droplets and airway (ideally in negative pressure rooms).
8. NONINVASIVE VENTILATION: INDICATIONS AND STRATEGY
Recommendation 1
In these patients it is recommended not to use noninvasive ventilation, especially during the viral active replication phase.
Recommendation 2
It is recommended that, if a decision to start noninvasive ventilation is made:
(1) it is started at the intensive care service under intensive monitorization, preventing delays of endotracheal intubation in case of failure to respond;
(2) to use maximal sealing masks or helmets, as well double-circuit ventilators (e.g. with an expiratory loop) with a high-efficiency application; and
(3) the healthcare professionals use contact precautions, both for droplets and airways (ideally in negative pressure rooms).
Rational
Results of noninvasive ventilation are worse than conventional oxygen therapy, and high-flow nasal cannula oxygen therapy in patients with hypoxemic respiratory failure,(18) and was associated with increased therapeutic failure in patients with MERS,(21) as well as it leads to an increased risk of generating aerosols.(20,22
9. INDICATIONS FOR OROTRACHEAL INTUBATION
Recommendation 1
An early intubation strategy is recommended as opposed to a late intubation strategy (Figure 1).
10. OROTRACHEAL INTUBATION STRATEGY
Recommendation 1
It is recommended that endotracheal intubation is performed by an experienced professional (who is more likely to succeed in a first attempt), wearing contact precautions for droplets and airway (ideally in a negative pressure room).
Recommendation 2
It is recommended that endotracheal intubation is performed using:
(1) pre-oxygenation with a high-concentration facial mask or a Mapleson C type balloon, connected to a high-efficiency respiratory filter, always avoiding manual inflations;
(2) rapid sequence intubation technique;
(3) video laryngoscopy using a disposable blade;
(4) after intubation, clamping the tube until connection to a manual ventilator (or a Mapleson C type balloon) or to the mechanical ventilator adapted to a high efficiency filter;
(5) confirm the intubation by capnography/capnometry followed by chest X-ray (no auscultation).
11. INDICATIONS AND STRATEGY FOR INVASIVE MECHANIC VENTILATION AND THERAPEUTIC ADJUVANTS
Recommendation 1
A classic ventilation strategy is recommended, based on the Acute Respiratory Distress Syndrome Network protocol (tidal volume of 6mL/kg ideal body weight, with an upper limit for plateau pressures < 30cmH2O), using a table for high positive end-expiratory pressure (PEEP) in patients with moderate to severe acute respiratory distress syndrome (ARDS), associated with a driving pressure < 15cmH2O and a respiratory rate to maintain pH > 7.25.
Recommendation 2
It is recommended early prone position ventilation in patients with partial oxygen pressure/fraction of inspired oxygen (PaO2/FiO2) < 150mmHg, for minimum 16 hours periods.
Recommendation 3
Neuromuscular blockers are recommended to be used for ≤ 48 hours in patients with PaO2/FiO2 < 150mmHg.
12. INDICATIONS FOR EXTRACORPOREAL MEMBRANE OXYGENATION
Recommendation 1
It is recommended adherence to current criteria for referral to extracorporeal membrane oxygenation (ECMO), based on a case-by-case assessment, including the perception of severity by the clinician and overall resources management.
13. INDICATIONS FOR BRONCHIAL FIBROSCOPY
Recommendation 1
It is recommended not to perform bronchial fibroscopy, except for well-established indications.
14. INHALATION THERAPY
15. INDICATION FOR CORTICOSTEROID THERAPY
16. INDICATIONS AND STRATEGY FOR ANTIBIOTIC THERAPY
Recommendation 1
In case of severe pneumonia (while waiting for SARS-CoV-2 identification) in times of seasonal influenza, in association with antibiotic therapy to start to start influenza therapy (Table 1), to be reassessed after laboratory tests and culture are available.
[Ceftriaxone 2g/day (or 1g every 12 hours) intravenously or amoxicillin/clavulanic acid 2.2g every 8 hour intravenously |
+ Azithromycin 500mg/day intravenously, or clarithromycin 500mg every 12 hours intravenously] * |
+ Oseltamivir 75mg (tablet), 2 tablets (150mg) every 12 horas, enteral |
* Levofloxacin 500mg/day intravenously (if intolerance/allergy to first-line agents).
Recommendation 2
It is recommended that in case of severe pneumonia (with identified SARS-CoV-2) with a septic shock, to start antibiotic therapy until culture results are available, allowing to confirm or rule out coexisting bacterial infection.
17. INDICATIONS AND STRATEGY OF ANTIVIRAL THERAPY
Recommendation 1
There is no evidence from randomized controlled trials to recommend any specific antiviral therapy for COVID-19 patients.
Recommendation 2
Experimental therapy (Table 2) may be considered for patients with clinical criteria for severity.
Remdesivir 200mg intravenously (loading dose, day 1) followed by remdesivir 100mg/day intravenously (maintenance dose, days 2 to 10)* |
+ |
Chloroquine phosphate 250 mg (tablet), 2 tablets (500 mg) every 12 hours, enteral† for 5 to 20 days (as determined by clinical progress) |
* Se/enquanto remdesivir não disponível: lopinavir/ritonavir 200/50mg (comprimido), 2 comprimidos (400/100mg) a cada 12 horas, via entérica OU lopinavir/ritonavir 80/20mg/mL (solução oral), 5mL (400/100mg) a cada 12 horas, por via entérica;
† ou, em alternativa, hidroxicloroquina 200mg (comprimido), 1 comprimido 2 vezes/dia, por via entérica.
Rational
No antiviral therapy was proven effective for COVID-19. Several randomized controlled trials are ongoing.(34) Limited evidence is available for the use of lopinavir/ritonavir,(35,36) chloroquine(37) and remdesivir,(38,39) that were included in the Italian therapy protocol.(40) Retrospective data on SARS-CoV point to higher efficacy of early started therapy (< 48 hours),(35) however efficacy after this time is not ruled out, consistent with data for influenza virus infection.
Adaptation for Brazilian Portuguese from “RECOMENDAÇÕES DA SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS PARA A ABORDAGEM DO COVID-19 EM MEDICINA INTENSIVA” published in Portuguese by Sociedade Portuguesa de Terapia Intensiva, available on https://www.spci.pt/client_files/COVID_19_R.pdf
Appendices
Uncomplicated disease | Upper respiratory symptoms (e.g. odynophagia, cough, and nasal congestion) either or not associated with fever and myalgias, with no criteria for severity. |
---|---|
Non-severe pneumonia | Fever associated with respiratory symptoms and a radiologic infiltrate, without criteria for severe pneumonia. |
Severe pneumonia | According to the IDSA/ATS(41) criteria |
SDRA | According to Berlin(42) defining criteria |
Sepse | According to the Surviving Sepsis Campaign43 criteria |
Choque séptico | According to the Surviving Sepsis Campaign43 criteria |
Source: adapted from World Health Organization (WHO). Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected. Interim guidance. 28 January 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf.(13)
IDS/ATS - Infectious Diseases Society of America/American Thoracic Society; PaO2/FiO2 - partial oxygen pressure/fraction of inspired oxygen; PEEP/CPAP - positive end-expiratory pressure/continuous positive airway pressure; ARDS - adult respiratory distress syndrome; SOFA - Sequential Organ Failure Assessment.
REFERENCES
Associação de Medicina Intensiva Brasileira - AMIB
Rua Arminda nº 93 - 7º andar - Vila Olímpia - São Paulo, SP, Brasil - Tel./Fax: (55 11) 5089-2642 | e-mail: [email protected]