Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units

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"apellidos" => "Marcos Neira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "j" "identificador" => "aff0050" ] ] ] 34 => array:3 [ "nombre" => "M.C." "apellidos" => "Martín Delgado" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "ag" "identificador" => "aff0170" ] 1 => array:2 [ "etiqueta" => "ah" "identificador" => "aff0175" ] ] ] 35 => array:3 [ "nombre" => "M." "apellidos" => "Martín-Macho González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "ai" "identificador" => "aff0180" ] ] ] 36 => array:3 [ "nombre" => "L." "apellidos" => "Martín Villén" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "aj" "identificador" => "aff0185" ] ] ] 37 => array:3 [ "nombre" => "X." "apellidos" => "Nuvials Casals" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "u" "identificador" => "aff0110" ] ] ] 38 => array:3 [ "nombre" => "A." "apellidos" => "Ortiz Suñer" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "ak" "identificador" => "aff0190" ] 1 => array:2 [ "etiqueta" => "al" "identificador" => "aff0195" ] ] ] 39 => array:3 [ "nombre" => "M." "apellidos" => "Quintana Díaz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "am" "identificador" => "aff0200" ] 1 => array:2 [ "etiqueta" => "an" "identificador" => "aff0205" ] ] ] 40 => array:3 [ "nombre" => "P." "apellidos" => "Rascado Sedes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "añ" "identificador" => "aff0210" ] ] ] 41 => array:3 [ "nombre" => "M." "apellidos" => "Recuerda Núñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "ao" "identificador" => "aff0215" ] ] ] 42 => array:3 [ "nombre" => "L." "apellidos" => "del Río Carbajo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 43 => array:3 [ "nombre" => "M." "apellidos" => "Rodríguez Aguirregabiria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "am" "identificador" => "aff0200" ] ] ] 44 => array:3 [ "nombre" => "A." "apellidos" => "Rodríguez Oviedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] 45 => array:3 [ "nombre" => "I." "apellidos" => "Seijas Betolaza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "p" "identificador" => "aff0085" ] ] ] 46 => array:3 [ "nombre" => "C." "apellidos" => "Soriano Cuesta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "ap" "identificador" => "aff0220" ] ] ] 47 => array:3 [ "nombre" => "B." "apellidos" => "Suberviola Cañas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 48 => array:3 [ "nombre" => "C." "apellidos" => "Vera Ching" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "af" "identificador" => "aff0165" ] ] ] 49 => array:3 [ "nombre" => "Á." "apellidos" => "Vidal González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "aq" "identificador" => "aff0225" ] ] ] 50 => array:3 [ "nombre" => "L." "apellidos" => "Zapata Fenor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "ar" "identificador" => "aff0230" ] ] ] 51 => array:3 [ "nombre" => "R." "apellidos" => "Zaragoza Crespo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "as" "identificador" => "aff0235" ] ] ] ] "afiliaciones" => array:47 [ 0 => array:3 [ "entidad" => "Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicina Intensiva, Consorci Corporació Sanitaria Parc Taulí, Sabadell, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departament de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Reina Sofía, Córdoba, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Joan XXIII, Tarragona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Universitat Rovira i Virgili, Tarragona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Germans Trias i Pujol, Badalona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Virgen Macarena, Sevilla, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Intensive Care Medicine, St James's Hospital, Dublin, Ireland" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Trinity College Dublin, School of Medicine, Dublin, Ireland" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] 14 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Spain" "etiqueta" => "at" "identificador" => "aff0075" ] 15 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario HM Sanchinarro, Madrid, Spain" "etiqueta" => "o" "identificador" => "aff0080" ] 16 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario de Cruces, Bizkaia, Spain" "etiqueta" => "p" "identificador" => "aff0085" ] 17 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario de Áraba, Vitoria, Spain" "etiqueta" => "q" "identificador" => "aff0090" ] 18 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Son Llátzer, Palma de Mallorca, Spain" "etiqueta" => "r" "identificador" => "aff0095" ] 19 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario de Jerez, Jerez, Spain" "etiqueta" => "s" "identificador" => "aff0100" ] 20 => array:3 [ "entidad" => "Departamento de Medicina, INIBICA, Universidad de Cádiz, Cádiz, Spain" "etiqueta" => "t" "identificador" => "aff0105" ] 21 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "u" "identificador" => "aff0110" ] 22 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Río Hortega, Valladolid, Spain" "etiqueta" => "v" "identificador" => "aff0115" ] 23 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "w" "identificador" => "aff0120" ] 24 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Vega Baja Orihuela, Alicante, Spain" "etiqueta" => "x" "identificador" => "aff0125" ] 25 => array:3 [ "entidad" => "Medicina Intensiva, Hospital de Barbastro, Huesca, Spain" "etiqueta" => "y" "identificador" => "aff0130" ] 26 => array:3 [ "entidad" => "SAMUR-Protección Civil, Madrid, Spain" "etiqueta" => "z" "identificador" => "aff0135" ] 27 => array:3 [ "entidad" => "Medicina Intensiva, Hospital San Juan de Dios, Córdoba, Spain" "etiqueta" => "aa" "identificador" => "aff0140" ] 28 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain" "etiqueta" => "ab" "identificador" => "aff0145" ] 29 => array:3 [ "entidad" => "Medicina Intensiva, Hospital QuirónSalud Tenerife, Tenerife, Spain" "etiqueta" => "ac" "identificador" => "aff0150" ] 30 => array:3 [ "entidad" => "Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain" "etiqueta" => "ad" "identificador" => "aff0155" ] 31 => array:3 [ "entidad" => "Medicina Intensiva, Hospital de Sagunto, Sagunto, Spain" "etiqueta" => "ae" "identificador" => "aff0160" ] 32 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Doctor Josep Trueta, Girona, Spain" "etiqueta" => "af" "identificador" => "aff0165" ] 33 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain" "etiqueta" => "ag" "identificador" => "aff0170" ] 34 => array:3 [ "entidad" => "Universidad Francisco de Vitoria, Madrid, Spain" "etiqueta" => "ah" "identificador" => "aff0175" ] 35 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Virgen del Puerto, Plasencia, Spain" "etiqueta" => "ai" "identificador" => "aff0180" ] 36 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "aj" "identificador" => "aff0185" ] 37 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Arnau de Vilanova, Valencia, Spain" "etiqueta" => "ak" "identificador" => "aff0190" ] 38 => array:3 [ "entidad" => "Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia, Valencia, Spain" "etiqueta" => "al" "identificador" => "aff0195" ] 39 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "am" "identificador" => "aff0200" ] 40 => array:3 [ "entidad" => "Departamento de Medicina Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "an" "identificador" => "aff0205" ] 41 => array:3 [ "entidad" => "Medicina Intensiva, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain" "etiqueta" => "añ" "identificador" => "aff0210" ] 42 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Puerto Real, Cádiz, Spain" "etiqueta" => "ao" "identificador" => "aff0215" ] 43 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "ap" "identificador" => "aff0220" ] 44 => array:3 [ "entidad" => "Medicina Intensiva, Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "aq" "identificador" => "aff0225" ] 45 => array:3 [ "entidad" => "Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "ar" "identificador" => "aff0230" ] 46 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "as" "identificador" => "aff0235" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos" ] ] "textoCompleto" => "IntroductionAt the end of 2019, a new virus currently known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of 27 cases at a fish market in Wuhan, China. The virus then spread quickly throughout the world, and on 11 March 2020, the World Health Organization (WHO) declared that the disease produced by SARS-CoV-2 (COVID-19) had become a pandemic.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> By 22 May 2021, over 165 million cases of infection had been confirmed, with close to 3.5 million deaths worldwide.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Although most cases of COVID-19 are mild or only involve minor symptoms, between 5–10% of all affected individuals require hospital admission and oxygen therapy, and many of them suffer severe respiratory failure needing ventilatory support and admission to the Intensive Care Unit (ICU). In a considerable number of cases the volume of patients requiring admission overwhelmed the capacity of the ICUs, causing COVID-19 to become a serious challenge for healthcare systems throughout the world - including Spain.<a class="elsevierStyleCrossRefs" href="#bib0015">3–12</a>At the time when the ICUs were being overwhelmed by the number of patients requiring admission, different studies started to appear in the literature,<a class="elsevierStyleCrossRefs" href="#bib0065">13–16</a> not always warranted by sufficient scientific evidence,<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> recommending different management strategies for a disease in which no effective treatment was available.Although not even two years have gone by since COVID-19 first appeared, extraordinary efforts by different research groups have produced results from numerous clinical trials and other studies that allow us to establish a series of recommendations based on more solid scientific evidence - though many gaps in our knowledge remain. Some of the mentioned documents have been updated using different methodologies.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> We consider it necessary to offer a consensus document including recommendations based on the available evidence, referred to the diagnosis and treatment of COVID-19, but also addressing aspects which other guides have not contemplated and which we feel to be crucial for the management of critical patients with COVID-19.MethodologyScope and objectivesThe purpose of this document is to offer a number of recommendations based on the available scientific evidence for the diagnosis and management of adults admitted to the ICU due to COVID-19.It is addressed to medical staff in intensive care, and seeks to be of help both in decision making and in establishing standards of care, while also contributing to organizational planning of the ICU.Selection of the document drafting committeeThe structure, questions to be answered, and the methodology of the consensus document were defined through coordination of the Infectious Diseases and Sepsis Working Group (Grupo de Trabajo de Enfermedades Infecciosas y Sepsis [GTEIS]) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias [SEMICYUC]). Subsequently, the coordinators of the working groups centered on the different proposed sections of the document were invited to select the experts who would be in charge of answering the questions raised and to generate possible additional questions as considered opportune.MethodologyA working team and a coordinator were established for each of the 11 sections.The scientific evidence available from the start of the pandemic (December 2019) and up until 28 February 2021 was reviewed.From the coordinating board of the project, and with the agreement of the coordinators of each of the individual sections, in the awareness of the lack of clinical trials in many of the areas considered to be important, priority was placed more on the drafting of a practical document than on rigid methodological considerations.After evaluating and analyzing the available literature, the recommendations were defined by consensus among the members of each working group, followed by review on the part of the rest of the drafting committee. Each recommendation was graded considering the strength of the recommendation and the quality of the evidence (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The document contains the recommendations issued by each working group. The justification and analysis of the evaluated evidence, as well as some additional recommendations (in general negative or less specific recommendations referred to critical COVID-19 cases) are compiled as electronic supplementary material (ESM).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The document has been subjected to external review by the members of the SEMICYUC.RecommendationsDiagnosis (justification of the recommendations can be found in ESM 1)Question 1. In which critical patients should SARS-CoV-2 be suspected?We recommend diagnostic testing for SARS-CoV-2 in all patients admitted to the Department of Intensive Care Medicine, particularly in the presence of any respiratory sign or symptom such as cough or dyspnea, or general manifestations such as a rise in temperature, even if of small magnitude. A-IIIQuestion 2. If COVID-19 is suspected, which is the best sample for diagnosing SARS-CoV-2 infection?We recommend basing the etiological diagnosis of SARS-CoV-2 infection on a sample of nasopharyngeal exudate. In the case of negative results and a strong clinical suspicion, we recommend a second sample, and if a negative result is again obtained, we advise a lower respiratory tract sample – preferably through bronchoalveolar lavage (BAL). A-IIQuestion 3. If COVID-19 is suspected, which is the best technique for diagnosing SARS-CoV-2 infection (PCR, serological tests, etc.)?We recommend the use of a nucleic acid amplification test such as reverse transcriptase polymerase chain reaction (RT-PCR) for diagnosing acute SARS-CoV-2 infection. A-IIWe suggest repetition of the RT-PCR test in the event of discrepancies between the pre-test probability and the result obtained, preferably using different targets. C-IIWe suggest the use of fast antigen testing for rapid decision making, provided there is agreement between the pre-test probability and the result obtained. C-IIIWe do not recommend the isolated use of serological tests for diagnosing acute SARS-CoV-2 infection. D-IIWe do not recommend the use of serological tests for determining the existence of host immunity against SARS-CoV-2. D-IIWe suggest serological tests in the event of a strong suspicion of SARS-CoV-2 infection and a repeatedly negative RT-PCR test, particularly in the presence of a delay of >9–14 days from symptoms onset. C-IISpecific treatment (justification of the recommendations can be found in ESM 2)Question 4. Does antiviral therapy improve the prognosis of critical patients with COVID-19?We suggest the use of remdesivir in patients with COVID-19 admitted to the ICU who do not require invasive mechanical ventilation, and preferably on an early basis (in the first three days following the microbiological diagnosis). C-IIRecommendations against the use of hydroxychloroquine, chloroquine, lopinavir-ritonavir, interferon β-1a, favipiravir and ivermectin can be found in ESM 2.Question 5. Is there an inflammatory response specific of SARS-CoV-2 infection?An analysis of the existence of a specific inflammatory response can be found in ESM 2.Question 6. Should we administer corticosteroids in critical patients with COVID-19? At what dose? For how long?We recommend corticosteroid therapy as treatment for seriously ill patients with COVID-19 (need for mechanical ventilation). A-IWe recommend low-dose systemic corticosteroids: dexamethasone 6 mg/d for 10 days (A-I) or hydrocortisone 200 mg/d for 7 days (A-II)We suggest dexamethasone 20 mg/d for 5 days, followed by dexamethasone 10 mg/d for 5 days in patients with moderate to severe acute respiratory distress syndrome (ARDS) (B-II).Question 7. Should we try to modulate the inflammatory response with other immunosuppressors/immune modulators in critical patients with COVID-19?We recommend the administration of tocilizumab (8 mg/kg, maximum 800 mg), associated to corticosteroids, in patients requiring admission to the ICU for respiratory or hemodynamic support, on an early basis (first dose in the first 24 h of admission, with the possibility of a second dose 12−24 h after the first, if the treating physician considers the response to be insufficient). A-IIWe suggest the use of sarilumab (400 mg) in patients requiring admission to the ICU for respiratory or hemodynamic support, on an early basis (first dose in the first 24 h of admission), as an alternative to tocilizumab if the latter drug is not available. B-IIWe suggest adding baricitinib (4 mg/d, 14 days) in patients receiving remdesivir and high-flow oxygen therapy (HFOT) or noninvasive mechanical ventilation (NIMV), with the aim of shortening the recovery period (the criteria for using remdesivir are those established above: patients not requiring invasive mechanical ventilation, and in the first three days after the microbiological diagnosis). C-IWe do not recommend the use of convalescent plasma to treat patients admitted to the ICU due to severe COVID-19 pneumonia. D-IRecommendations against the use of ruxolitinib, intravenous immune globulin (IVIG), colchicine, auxora, itolizumab and anakinra can be found in ESM 2.Coinfections and superinfections (justification of the recommendations can be found in ESM 3)Question 8. What patients with COVID-19 should start to receive antibiotic treatment upon admission to the ICU?We recommend early empirical treatment of possible bacterial pulmonary coinfection (strong clinical suspicion, purulent secretions, biomarker elevation, positive antigens, etc.) upon admission to the ICU of patients with COVID-19, since such coinfection is associated to increased mortality. A-IIIWe recommend daily evaluation of antibiotic treatment adjustment or suspension. A-IIWe recommend the early suspension of antimicrobial treatment once coinfection is ruled out. A-IIIQuestion 9. What is the indicated diagnostic strategy in these patients with suspected superinfection during admission to the ICU?We suggest an early diagnostic strategy and empirical treatment, in view of the high risk of bacterial and fungal superinfection in patients with COVID-19 subjected to mechanical ventilation. A-IIIWe suggest active microbiological assessment in all patients with prolonged ICU stays (over 7 days) in the event of suspected superinfection. A-IIIWe suggest lower respiratory tract sampling in patients with COVID-19 suspected to have superinfection in relation to ventilator-associated pneumonia (VAP) or ventilator-associated tracheobronchitis, before starting antibiotic treatment. We suggest the quantitative analysis of distal samples obtained through bronchoalveolar lavage (BAL), mini-BAL or bronchial aspirate - provided these procedures can be carried out safely for both the operator and the patient. If not possible, the alternative would be a lower respiratory tract sample in the form of a quantitative or semi-quantitative tracheal aspirate. A-IIWe recommend basing the diagnosis of pulmonary aspergillosis associated to COVID-19 on galactomannan detection in BAL. We recommend BAL with culture and galactomannan determination in patients in which Aspergillus is identified in respiratory samples, with signs of pulmonary superinfection, and also in those with suspected ventilator-associated pneumonia or tracheobronchitis, with negative respiratory sample cultures. A-IIQuestion 10. How should the healthcare associated infection (HAI) preventive measures be applied in these patients?We recommend application of the guidelines of the prevention programs (Zero Projects), i.e., Bacteremia Zero, Pneumonia Zero and Resistances Zero, adapted to COVID-19. A-IIIRecommendations on hand hygiene and training in prevention programs can be found in ESM 3.Thrombotic complications (justification of the recommendations can be found in ESM 4)Question 11. How should thrombotic events be prevented in critical patients with COVID-19?We recommend that venous thromboembolic disease (VTED) prevention in patients with severe COVID-19 pneumonia be based on low molecular weight heparin (LMWH) instead of unfractionated heparin (UFH). Dose adjustment of LMWH to patient weight, kidney function and platelet count is advised. A-IIWe recommend treatment with intermediate LMWH doses in patients with severe COVID-19 pneumonia presenting elevated D-dimer levels (>6 times the upper limit of normal) and/or a sepsis-induced coagulopathy (SIC) score ≥4. B-IIWe suggest that full-dose anticoagulation should not be used in patients with severe COVID-19 pneumonia in which no thrombotic event has been diagnosed, except if clinical suspicion is very strong and the patient cannot be mobilized to perform complementary explorations. D-IIWe suggest ultrasound screening to discard deep venous thrombosis (DVT) in the lower and upper extremities when D-dimer >2000 ng/mL. We suggest thoracic CT angiography and ultrasound in the presence of strong clinical suspicion of pulmonary thromboembolism (PTE) and/or D-dimer >10,000 ng/mL. B-IIAdditional recommendations on the prevention of venous thromboembolic disease in patients with COVID-19 can be found in ESM 4.Question 12. What is the best diagnostic strategy when PTE is suspected in critical patients with COVID-19?We recommend CT angiography as the best diagnostic tool when PTE is suspected, both in patients with mild manifestations and in those with severe manifestations of the disease. A-IAdditional recommendations on the diagnosis of PTE in patients with COVID-19 can be found in ESM 4.Question 13. What treatment is indicated in critical patients with COVID-19 in which PTE is suspected/confirmed?We recommend anticoagulation of all patients with COVID-19 in which PTE has been confirmed, provided it is not contraindicated. A-IWe recommend the start of anticoagulation when PTE is suspected, when no firm diagnosis can be established, and provided it is not contraindicated. A-IIIWe recommend systemic fibrinolysis of all patients with COVID-19 in which PTE has been confirmed and who suffer hemodynamic instability, provided it is not contraindicated. A-IIIWe recommend avoiding fibrinolysis in patients with COVID-19 who suffer ARDS without hemodynamic instability or data indicating PTE. D-IIIAdditional recommendations on the management of PTE in patients with COVID-19 can be found in ESM 4.Respiratory management (justification of the recommendations can be found in ESM 5)Question 14. In which patients can noninvasive respiratory support (NIRS) be considered safe?We suggest the use of high-flow oxygen therapy as the next step after conventional oxygen therapy, and the guidance of treatment based on the ROX index in adults with SARS-CoV-2 infection and moderate to severe hypoxemic acute respiratory failure (ARF) (p02 < 80 mmHg or Sat02 < 90% with Fi02 > 40%), with no increase in respiratory effort. C-IIIWe suggest evaluating noninvasive mechanical ventilation in patients with SARS-CoV-2 infection and hypoxemic acute respiratory failure in which high-flow oxygen therapy has failed or is not available, and in the absence of an urgent indication of orotracheal intubation or when the order is to not intubate. This always must be done with close monitoring, in a setting where intubation can be performed safely. C-IIIQuestion 15. In the event invasive mechanical ventilation proves necessary, should a protective ventilation strategy be used?We recommend a protective ventilation strategy similar to that used in ARDS due to other causes, with a tidal volume of 4−8 ml/kg body weight (predicted), in the case of ARDS secondary to COVID-19 pneumonia. C-IIOnce the tidal volume has been adjusted to 4−8 ml/kg body weight (predicted), we recommend monitoring of the plateau pressure, which should not exceed 30 cmH2O. C-IIWe recommend maintaining a driving pressure <15 cmH2O. C-IIQuestion 16. What is the indication of ventilation in prone decubitus in patients with ARDS secondary to COVID-19?We recommend prone decubitus in all intubated patients with moderate to severe ARDS, provided it is not contraindicated. A-IIWe recommend keeping the patient in prone decubitus for at least 16 consecutive hours; this period may be prolonged, conditioned to patient tolerance and response. B-IIIThere is no evidence to establish recommendations regarding prone decubitus in waking state patients with respiratory failure under conditions of spontaneous ventilation. C-IIIQuestion 17. What is the indication of extracorporeal membrane oxygenation (ECMO) in patients with ARDS secondary to COVID-19?We recommend veno-venous (VV) ECMO in experienced units or reference centers, in selected patients with severe ARDS and refractory and/or hypercapnic hypoxemic respiratory failure, in the absence of contraindications, when conventional therapies prove ineffective, particularly in the context of prone decubitus. B-IIWe recommend cannulation at the patient beside (point of care), in order to minimize the risks for the healthcare staff. B-IIIWe recommend continued assessment of the risk/benefit ratio of ECMO. B-IIIWe advocate the usual anticoagulation protocols in patients with COVID-19 subjected to veno-venous ECMO. C-IIIManagement of sedation and delirium (justification of the recommendations can be found in ESM 6)Question 18. What is the best sedoanalgesia strategy in critical patients with COVID-19?We recommend sequential sedation strategies that facilitate adaptation to mechanical ventilation, guaranteeing adequate analgesia and avoiding oversedation. B-IIIQuestion 19. Is there a higher incidence of delirium among critical patients with COVID-19 than in other similar groups of patients?An analysis of the incidence of delirium associated to COVID-19 can be found in ESM 6.Question 20. What is the best strategy for controlling delirium in critical patients with COVID-19?We suggest the best strategy for controlling delirium in critical patients with COVID-19 to be prevention with the ABCDEF-R bundle of measures adapted to patients with COVID-19, and the early detection of delirium using validated scales such as the CAM-ICU and ICDSC. B-IIIWe suggest treatment based on non-pharmacological measures and dexmedetomidine i.v., especially in patients with hyperactive delirium complicating weaning from mechanical ventilation. B-IIINutritional management (justification of the recommendations can be found in ESM 7)Question 21. What is the most advisable nutritional strategy in critical patients with COVID-19?We recommend identification within the first 24−48 h of admission of possible nutritional risk or the presence of malnutrition based not only on the clinical history but also on some of the available nutritional screening tools, such as the NUTRIC score. A-IIIWe recommend evaluation of the nutritional and metabolic parameters (proteins, prealbumin, albumin, cholesterol, triglycerides, ion profile, vitamins and oligoelements) in order to avoid possible refeeding syndrome. A-IIIIn the event of risk of refeeding syndrome, we recommend nutrition to start with half of the calculated calories (hypocaloric diet) and to gradually increase the amount (every 3 days) until the goal is reached (70–80% of the requirements) within 4–7 days. In this period regular controls of the serum levels of phosphorus, magnesium and potassium are required (especially during the first 3 days, when risk is higher). A-IIIWe recommend adjustment of the energy needs on a daily basis, adapting the regimen according to the type of nutrition used and the stage of the disease. A-IIIWe recommend the use of simple equations based on body weight and accessible to all the staff caring for these patients. A-IIIIn non-intubated patients we recommend starting oral feeding as soon as possible. If intake is <60% of energy expenditure for more than two days, it is advisable to add oral hyperproteic nutritional supplements, and if the needs are not met despite this measure, the introduction of complementary enteral or parenteral nutrition is advisable. A-IIIIn intubated patients, we recommend the start of nutrition in the first 24−48 h of admission, once hemodynamic stability has been achieved, or in the first 12 h after intubation and the start of mechanical ventilation. A-IIIIn intubated patients, we recommend enteral nutrition as the preferred strategy, even in patients subjected to neuromuscular block or ventilated in prone decubitus. A-IIIIn patients with a non-functioning digestive tract or unable to tolerate enteral nutrition in which feeding via the digestive tract is unable to cover >60% of energy expenditure for over 48 h, we recommend the start of parenteral nutrition from day four, maintaining trophic enteral feeding whenever possible. A-IIIAdditional recommendations on the nutritional management of patients with COVID-19 can be found in ESM 7.Management of cardiovascular complications (justification of the recommendations can be found in ESM 8)Question 22. What is the best resuscitation strategy in critical patients with COVID-19 and hemodynamic instability?We recommend exhaustive evaluation of the cause of shock in patients with COVID-19, in order to allow the introduction of adequate treatment and supportive measures. A-IIAdditional recommendations on shock resuscitation in patients with COVID-19 can be found in ESM 8.Question 23. How do we evaluate heart-lung interaction in critical patients with COVID-19 and ARDS?We recommend the use of dynamic parameters to predict cardiovascular response to volume supply. B-IIWe recommend the passive leg elevation maneuver (tidal volume challenge) in patients with ARDS ventilated with tidal volumes ≤8 ml/kg. B-IIWe recommend echocardiography as the technique of choice for the initial hemodynamic evaluation of patients with COVID-19 under conditions of shock and for detecting cor pulmonale. The echocardiographic exploration must be performed under conditions of asepsis and sterility in order to minimize the infection risk. A-IIWe recommend advanced hemodynamic monitoring in complex situations of shock (such as ARDS and sepsis, ARDS and right ventricular dysfunction) or in cases of difficult stabilization. B-IIQuestion 24. What are the best therapeutic options in critical patients with COVID-19 and arterial hypertension?Additional recommendations on the management of arterial hypertension in patients with COVID-19 can be found in ESM 8.Question 25. What are the clinical manifestations and treatment options in cardiac disorders in critical patients with COVID-19?We recommend the monitoring of myocardial damage biomarkers (troponin or natriuretic peptide) upon admission and in the course of hospital stay, due to the poorer prognosis of those patients with elevation of such markers. A-IIWe recommend the use of echocardiography in the case of elevated myocardial damage biomarkers, as it is safe and useful for establishing the differential diagnosis and allows us to guide and assess the therapeutic strategy on an individualized basis. A-IIAdditional recommendations on cardiac disorders in patients with COVID-19 can be found in ESM 8.Management of neurological complications (justification of the recommendations can be found in ESM 9)Question 26. What are the priorities for managing the associated neurological manifestations in critical patients with COVID-19?We recommend a high index of suspicion of potential neurological manifestations (confusion, stroke, encephalopathy, meningoencephalitis and weakness acquired in the ICU) in critical patients with COVID-19. A-IIIWe suggest the use of noninvasive neurological monitoring. C-IIIAdditional recommendations on the management of neurological complications in patients with COVID-19 can be found in ESM 9.Organization (justification of the recommendations can be found in ESM 10)Question 27. If the usual capacity of the ICU is exceeded, should we modify our regular screening protocol?We recommend the development of specific screening guides in the context of the pandemic, with a view to defining objective and transparent criteria and thus rationalize the limited available resources and lessen the emotional impact of decision making among the professionals. These guides must have legal backing to protect the professionals and institutions from possible future lawsuits, including public emergency declarations on the part of the government or authorities. B-IIIBefore introducing these specific screening guides, we suggest that maximum resource expansion be ensured, including patient and/or resource transfers between institutions at local or national level. The guides are to be adapted to the different phases of the pandemic, and their evaluation should include the perspective of society. C-IIIWe recommend that the objective should be to secure the greatest healthcare benefit possible for the largest number of patients, with the resources available at the time of the decision. All patients with a comparable prognosis should have equal and fair access to the limited resources based on medical and ethical criteria, with no discrimination of any kind. This implies the inclusion of both COVID-19 cases and non-COVID-19 cases in the screening process. B-IIIWe recommend the individual and dynamic evaluation of all patients, and the use of objective tools to help establish the priorities. Use of the Sequential Organ Failure Assessment (SOFA) score as a criterion for establishing priority in patients with COVID-19 is not advised. A-IIIWe recommend the definition of specific screening criteria for certain procedures where the resources are greatly limited and the opportunity cost is high, such as extracorporeal support techniques (e.g., ECMO). B-IIIWe recommend the introduction of psychological support measures to reduce the emotional impact, particularly moral suffering among the professionals, and the creation of multidisciplinary screening teams. B-IIIQuestion 28. If the usual capacity of the ICU is exceeded, how do we increase the number of available beds for critical patients?We recommend the definition of contingency plans allowing us to expand the structural and professional resources. Resource expansion can be applied at different levels, considering the transfer of resources between units and the use of telemedicine. B-IIIWe recommend the use of predictive models based on dynamic indicators in different scenarios. A-IIIWe recommend that expanded ICUs should have the means necessary to ensure quality care, with assignment of the most seriously ill patients to the usual units. A-IIWe suggest the development of pyramidal multidisciplinary cooperative models led by specialists in Intensive Care Medicine and nurses with expertise in the care of the critically ill, in those situations where the expansion of professional teams proves necessary. C-IIIQuestion 29. Is the grouping of these patients in open cohort units an option?We suggest the use of open cohort units in those cases where expansion of the ICU beyond its usual structure is not possible, involving units with the same capacities and functions. C-IIIWe recommend efforts to avoid the complications associated with organizations of this kind (nosocomial infections, delirium, impossibility of early mobilization protocols, etc.). B-IIIWe recommend that priority be placed on admission to closed units, with individual rooms, for patients in the awakening stage and undergoing weaning from mechanical ventilation, where the presence of the family of the patient and physiotherapy and rehabilitation pose fewer difficulties - reserving admission to open units for patients subjected to deep sedation. B-IIIPersonal protection and isolation measures (justification of the recommendations can be found in ESM 11)Question 30. What personal protection equipment (PPE) is needed in caring for critical patients with COVID-19?We recommend the use of materials certified according to European Union standards. A-IIWe recommend the use of individual PPE made of impermeable, water-repelling material. A-IIWe recommend the use of disposable PPE. A-IIWe recommend the combined use of a long coat and sealed gloves with good fitting around the neck, wrists and hands. A-IIWe recommend the use of FFP2 or FFP3 self-filtering masks. A-IIWe recommend the use of FFP3 self-filtering masks when performing aerosol-generating procedures, particularly cardiopulmonary resuscitation. A-IIIWe recommend the use of integrally fitting or full-face eye protection measures. B-IIIWe recommend following the clinical practice guides for removing PPE. A-IIWe recommend removal of the gloves and coat in a single step. A-IIWe suggest double gloving, especially in aerosol-generating procedures. B-IIWe suggest cleaning of the gloves with disinfectant before removing the equipment. B-IIWe suggest the use of additional verbal instructions for removing PPE. B-IIWe suggest the use of tabs to affix and facilitate the removal of masks or gloves. C-IIQuestion 31. Should systematic vaccination be recommended for the staff working in the ICU?Vaccination of all the healthcare staff working in the ICU is recommended, provided there are no specific contraindications. A-IQuestion 32. What are the required isolation measures for patients of this kind?We recommend the observation of airborne transmission and contact isolation measures in the care of all patients with COVID-19 admitted to the ICU. A-IIWe suggest measures of caution referred to airborne transmission in open units for patients with COVID-19 where procedures involving a high risk of generating aerosols are frequently performed. B-IIIQuestion 33. When can these measures be suspended?We recommend suspending the isolation of critical patients with COVID-19 from 21 days after onset of the clinical condition, and provided three days have gone by without clinical manifestations. A-IIIWe recommend two oropharyngeal PCR tests (spaced at least 24 h apart) to confirm that isolation can be suspended in those patients where there are clinical doubts. A-IIIQuestion 34. Can usual family accompaniment be maintained in patients with COVID-19?We recommend avoiding the isolation of critical patients in the ICU, adopting all the accompaniment and communication strategies available, under safe conditions. A-IIIIn end-of-life situations, we recommend that the family should be allowed to be present at the patient bedside, explaining the risks of contagion and offering all the PPE means needed to ensure safety. A-IIIFinancial supportThis study has received no funding.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1657461" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1473197" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1657460" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1473198" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methodology" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Scope and objectives" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Selection of the document drafting committee" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Methodology" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Recommendations" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Financial support" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-24" "fechaAceptado" => "2021-08-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1473197" "palabras" => array:6 [ 0 => "COVID-19" 1 => "SARS-CoV-2" 2 => "COVID-19 Testing" 3 => "COVID-19 drug treatment" 4 => "Critical care" 5 => "Intensive Care Units" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1473198" "palabras" => array:6 [ 0 => "COVID-19" 1 => "SARS-CoV-2" 2 => "Prueba de COVID-19" 3 => "Tratamiento farmacológico de la COVID-19" 4 => "Críticos" 5 => "Unidades de Cuidados Intensivos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La pandemia por COVID-19 ha provocado el ingreso de un elevado número de pacientes en UCI, generalmente por insuficiencia respiratoria severa. Desde la aparición de los primeros casos de infección por SARS-CoV-2, a finales de 2019, en China, se ha publicado una cantidad ingente de recomendaciones de tratamiento de esta entidad, no siempre respaldadas por evidencia científica suficiente ni con el rigor metodológico necesario. Gracias al esfuerzo de distintos grupos de investigadores, actualmente disponemos de resultados de ensayos clínicos, y otro tipo de estudios, de mayor calidad. Consideramos necesario realizar un documento que incluya recomendaciones que recojan estas evidencias en cuanto al diagnóstico y el tratamiento de COVID-19, pero también aspectos que otras guías no han contemplado y que consideramos fundamentales en el manejo del paciente crítico con COVID-19. Para ello se ha creado un comité redactor, conformado por miembros de los Grupos de Trabajo de SEMICYUC más directamente relacionados con diferentes aspectos específicos del manejo de estos pacientes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Vidal-Cortés P, Díaz Santos E, Aguilar Alonso E, Amezaga Menéndez R, Ballesteros MÁ, Bodí MA, et al., Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos. Med Intensiva. 2022;46:81–89." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Strength of recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong support of a recommendation for use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate support of a recommendation for use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild support of a recommendation for use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Support of a recommendation against use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quality of evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Definition \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence from at least one well designed randomized clinical trial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence from at least one well designed non-randomized study (case-control or cohort), multiple time series or very evident results from non-controlled studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence based on expert opinions, fundamented upon clinical experience or descriptive studies \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2822140.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Grading of recommendations." ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.zip" "ficheroTamanyo" => 2250212 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "WHO. WHO Director-General’s opening remarks at the media briefing on COVID-19-11 March 2020 [Internet]. [Accessed 13 April 2020]. Available from: <a target="_blank" href="https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-.--11-march-2020">https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-.--11-march-2020</a>." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "World Health Organization. Coronavirus disease (COVID-19) – World Health Organization [Internet]. [Accessed 22 May 2021]. 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Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units

Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos

P. Vidal-Cortésa,

Corresponding author

pablo.vidal.cortes@sergas.es

Corresponding author.

, E. Díaz Santosb,c, E. Aguilar Alonsod, R. Amezaga Menéndeze, M.Á. Ballesterosf,g, M.A. Bodíh,i, M.L. Bordejé Lagunaj, J. Garnacho Monterok, M. García Sánchezk, M. López Sánchezf, I. Martín-Loechesl,m, A. Ochagavía Calvob, P. Ramírez Galleymoren, S. Alcántara Carmonaat, D. Andaluz Ojedao, O. Badallo Arébalop, H. Barrasa Gonzálezq, M. Borges Sar, Á. Castellanos-Ortegan, Á. Estellas,t..., R. Ferrer Rocau, V. Fraile Gutiérrezv, M. Fuset Cabanesw, C. Giménez-Esparza Vichx, C. González Iglesiasy, A. Hernández-Tejedorz, J.C. Igeño Canoaa, D. Iglesias Posadillap, J.J. Jiménez Riveraab, C. Llanos Jorgeac, J.A. Llompart-Poue,ad, V. López Campsae, C. Lorencio Cárdenasaf, P. Marcos Neiraj, M.C. Martín Delgadoag,ah, M. Martín-Macho Gonzálezai, L. Martín Villénaj, X. Nuvials Casalsu, A. Ortiz Suñerak,al, M. Quintana Díazam,an, P. Rascado Sedesañ, M. Recuerda Núñezao, L. del Río Carbajoa, M. Rodríguez Aguirregabiriaam, A. Rodríguez Oviedoh, I. Seijas Betolazap, C. Soriano Cuestaap, B. Suberviola Cañasf, C. Vera Chingaf, Á. Vidal Gonzálezaq, L. Zapata Fenorar, R. Zaragoza CrespoasVer más

a Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain

b Medicina Intensiva, Consorci Corporació Sanitaria Parc Taulí, Sabadell, Spain

c Departament de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain

d Medicina Intensiva, Hospital Universitario Reina Sofía, Córdoba, Spain

e Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain

f Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain

g Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain

h Medicina Intensiva, Hospital Universitario Joan XXIII, Tarragona, Spain

i Universitat Rovira i Virgili, Tarragona, Spain

j Medicina Intensiva, Hospital Universitario Germans Trias i Pujol, Badalona, Spain

k Medicina Intensiva, Hospital Virgen Macarena, Sevilla, Spain

l Intensive Care Medicine, St James's Hospital, Dublin, Ireland

m Trinity College Dublin, School of Medicine, Dublin, Ireland

n Medicina Intensiva, Hospital Universitari i Politècnic La Fe, Valencia, Spain

at Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Spain

o Medicina Intensiva, Hospital Universitario HM Sanchinarro, Madrid, Spain

p Medicina Intensiva, Hospital Universitario de Cruces, Bizkaia, Spain

q Medicina Intensiva, Hospital Universitario de Áraba, Vitoria, Spain

r Medicina Intensiva, Hospital Universitario Son Llátzer, Palma de Mallorca, Spain

s Medicina Intensiva, Hospital Universitario de Jerez, Jerez, Spain

t Departamento de Medicina, INIBICA, Universidad de Cádiz, Cádiz, Spain

u Medicina Intensiva, Hospital Universitario Vall d’Hebron, Barcelona, Spain

v Medicina Intensiva, Hospital Universitario Río Hortega, Valladolid, Spain

w Medicina Intensiva, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain

x Medicina Intensiva, Hospital Vega Baja Orihuela, Alicante, Spain

y Medicina Intensiva, Hospital de Barbastro, Huesca, Spain

z SAMUR-Protección Civil, Madrid, Spain

aa Medicina Intensiva, Hospital San Juan de Dios, Córdoba, Spain

ab Medicina Intensiva, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain

ac Medicina Intensiva, Hospital QuirónSalud Tenerife, Tenerife, Spain

ad Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain

ae Medicina Intensiva, Hospital de Sagunto, Sagunto, Spain

af Medicina Intensiva, Hospital Universitario Doctor Josep Trueta, Girona, Spain

ag Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain

ah Universidad Francisco de Vitoria, Madrid, Spain

ai Medicina Intensiva, Hospital Virgen del Puerto, Plasencia, Spain

aj Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain

ak Medicina Intensiva, Hospital Arnau de Vilanova, Valencia, Spain

al Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia, Valencia, Spain

am Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain

an Departamento de Medicina Universidad Autónoma de Madrid, Madrid, Spain

añ Medicina Intensiva, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain

ao Medicina Intensiva, Hospital Universitario Puerto Real, Cádiz, Spain

ap Medicina Intensiva, Hospital Universitario Ramón y Cajal, Madrid, Spain

aq Medicina Intensiva, Fundación Jiménez Díaz, Madrid, Spain

ar Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

as Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, Spain

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            "etiqueta" => "am"
            "identificador" => "aff0200"
          ]
          40 => array:3 [
            "entidad" => "Departamento de Medicina Universidad Aut&#243;noma de Madrid&#44; Madrid&#44; Spain"
            "etiqueta" => "an"
            "identificador" => "aff0205"
          ]
          41 => array:3 [
            "entidad" => "Medicina Intensiva&#44; Complexo Hospitalario Universitario de Santiago de Compostela&#44; Santiago de Compostela&#44; Spain"
            "etiqueta" => "a&#241;"
            "identificador" => "aff0210"
          ]
          42 => array:3 [
            "entidad" => "Medicina Intensiva&#44; Hospital Universitario Puerto Real&#44; C&#225;diz&#44; Spain"
            "etiqueta" => "ao"
            "identificador" => "aff0215"
          ]
          43 => array:3 [
            "entidad" => "Medicina Intensiva&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#44; Spain"
            "etiqueta" => "ap"
            "identificador" => "aff0220"
          ]
          44 => array:3 [
            "entidad" => "Medicina Intensiva&#44; Fundaci&#243;n Jim&#233;nez D&#237;az&#44; Madrid&#44; Spain"
            "etiqueta" => "aq"
            "identificador" => "aff0225"
          ]
          45 => array:3 [
            "entidad" => "Medicina Intensiva&#44; Hospital de la Santa Creu i Sant Pau&#44; Barcelona&#44; Spain"
            "etiqueta" => "ar"
            "identificador" => "aff0230"
          ]
          46 => array:3 [
            "entidad" => "Medicina Intensiva&#44; Hospital Universitario Doctor Peset&#44; Valencia&#44; Spain"
            "etiqueta" => "as"
            "identificador" => "aff0235"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Recomendaciones para el manejo de los pacientes cr&#237;ticos con COVID-19 en las Unidades de Cuidados Intensivos"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">At the end of 2019&#44; a new virus currently known as severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41; caused an outbreak of 27 cases at a fish market in Wuhan&#44; China&#46; The virus then spread quickly throughout the world&#44; and on 11 March 2020&#44; the World Health Organization &#40;WHO&#41; declared that the disease produced by SARS-CoV-2 &#40;COVID-19&#41; had become a pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> By 22 May 2021&#44; over 165 million cases of infection had been confirmed&#44; with close to 3&#46;5 million deaths worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although most cases of COVID-19 are mild or only involve minor symptoms&#44; between 5&#8211;10&#37; of all affected individuals require hospital admission and oxygen therapy&#44; and many of them suffer severe respiratory failure needing ventilatory support and admission to the Intensive Care Unit &#40;ICU&#41;&#46; In a considerable number of cases the volume of patients requiring admission overwhelmed the capacity of the ICUs&#44; causing COVID-19 to become a serious challenge for healthcare systems throughout the world - including Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At the time when the ICUs were being overwhelmed by the number of patients requiring admission&#44; different studies started to appear in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;16</span></a> not always warranted by sufficient scientific evidence&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> recommending different management strategies for a disease in which no effective treatment was available&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although not even two years have gone by since COVID-19 first appeared&#44; extraordinary efforts by different research groups have produced results from numerous clinical trials and other studies that allow us to establish a series of recommendations based on more solid scientific evidence - though many gaps in our knowledge remain&#46; Some of the mentioned documents have been updated using different methodologies&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> We consider it necessary to offer a consensus document including recommendations based on the available evidence&#44; referred to the diagnosis and treatment of COVID-19&#44; but also addressing aspects which other guides have not contemplated and which we feel to be crucial for the management of critical patients with COVID-19&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Scope and objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">The purpose of this document is to offer a number of recommendations based on the available scientific evidence for the diagnosis and management of adults admitted to the ICU due to COVID-19&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is addressed to medical staff in intensive care&#44; and seeks to be of help both in decision making and in establishing standards of care&#44; while also contributing to organizational planning of the ICU&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Selection of the document drafting committee</span><p id="par0035" class="elsevierStylePara elsevierViewall">The structure&#44; questions to be answered&#44; and the methodology of the consensus document were defined through coordination of the Infectious Diseases and Sepsis Working Group &#40;Grupo de Trabajo de Enfermedades Infecciosas y Sepsis &#91;GTEIS&#93;&#41; of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#91;SEMICYUC&#93;&#41;&#46; Subsequently&#44; the coordinators of the working groups centered on the different proposed sections of the document were invited to select the experts who would be in charge of answering the questions raised and to generate possible additional questions as considered opportune&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methodology</span><p id="par0040" class="elsevierStylePara elsevierViewall">A working team and a coordinator were established for each of the 11 sections&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The scientific evidence available from the start of the pandemic &#40;December 2019&#41; and up until 28 February 2021 was reviewed&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">From the coordinating board of the project&#44; and with the agreement of the coordinators of each of the individual sections&#44; in the awareness of the lack of clinical trials in many of the areas considered to be important&#44; priority was placed more on the drafting of a practical document than on rigid methodological considerations&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">After evaluating and analyzing the available literature&#44; the recommendations were defined by consensus among the members of each working group&#44; followed by review on the part of the rest of the drafting committee&#46; Each recommendation was graded considering the strength of the recommendation and the quality of the evidence &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The document contains the recommendations issued by each working group&#46; The justification and analysis of the evaluated evidence&#44; as well as some additional recommendations &#40;in general negative or less specific recommendations referred to critical COVID-19 cases&#41; are compiled as electronic supplementary material &#40;ESM&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The document has been subjected to external review by the members of the SEMICYUC&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Recommendations</span><p id="par0065" class="elsevierStylePara elsevierViewall">Diagnosis &#40;justification of the recommendations can be found in ESM 1&#41;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Question 1&#46; In which critical patients should SARS-CoV-2 be suspected&#63;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We recommend diagnostic testing for SARS-CoV-2 in all patients admitted to the Department of Intensive Care Medicine&#44; particularly in the presence of any respiratory sign or symptom such as cough or dyspnea&#44; or general manifestations such as a rise in temperature&#44; even if of small magnitude&#46; A-III</p><p id="par0080" class="elsevierStylePara elsevierViewall">Question 2&#46; If COVID-19 is suspected&#44; which is the best sample for diagnosing SARS-CoV-2 infection&#63;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We recommend basing the etiological diagnosis of SARS-CoV-2 infection on a sample of nasopharyngeal exudate&#46; In the case of negative results and a strong clinical suspicion&#44; we recommend a second sample&#44; and if a negative result is again obtained&#44; we advise a lower respiratory tract sample &#8211; preferably through bronchoalveolar lavage &#40;BAL&#41;&#46; A-II</p><p id="par0090" class="elsevierStylePara elsevierViewall">Question 3&#46; If COVID-19 is suspected&#44; which is the best technique for diagnosing SARS-CoV-2 infection &#40;PCR&#44; serological tests&#44; etc&#46;&#41;&#63;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We recommend the use of a nucleic acid amplification test such as reverse transcriptase polymerase chain reaction &#40;RT-PCR&#41; for diagnosing acute SARS-CoV-2 infection&#46; A-II</p><p id="par0100" class="elsevierStylePara elsevierViewall">We suggest repetition of the RT-PCR test in the event of discrepancies between the pre-test probability and the result obtained&#44; preferably using different targets&#46; C-II</p><p id="par0105" class="elsevierStylePara elsevierViewall">We suggest the use of fast antigen testing for rapid decision making&#44; provided there is agreement between the pre-test probability and the result obtained&#46; C-III</p><p id="par0110" class="elsevierStylePara elsevierViewall">We do not recommend the isolated use of serological tests for diagnosing acute SARS-CoV-2 infection&#46; D-II</p><p id="par0115" class="elsevierStylePara elsevierViewall">We do not recommend the use of serological tests for determining the existence of host immunity against SARS-CoV-2&#46; D-II</p><p id="par0120" class="elsevierStylePara elsevierViewall">We suggest serological tests in the event of a strong suspicion of SARS-CoV-2 infection and a repeatedly negative RT-PCR test&#44; particularly in the presence of a delay of &#62;9&#8211;14 days from symptoms onset&#46; C-II</p><p id="par0125" class="elsevierStylePara elsevierViewall">Specific treatment &#40;justification of the recommendations can be found in ESM 2&#41;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Question 4&#46; Does antiviral therapy improve the prognosis of critical patients with COVID-19&#63;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We suggest the use of remdesivir in patients with COVID-19 admitted to the ICU who do not require invasive mechanical ventilation&#44; and preferably on an early basis &#40;in the first three days following the microbiological diagnosis&#41;&#46; C-II</p><p id="par0140" class="elsevierStylePara elsevierViewall">Recommendations against the use of hydroxychloroquine&#44; chloroquine&#44; lopinavir-ritonavir&#44; interferon &#946;-1a&#44; favipiravir and ivermectin can be found in ESM 2&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Question 5&#46; Is there an inflammatory response specific of SARS-CoV-2 infection&#63;</p><p id="par0150" class="elsevierStylePara elsevierViewall">An analysis of the existence of a specific inflammatory response can be found in ESM 2&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Question 6&#46; Should we administer corticosteroids in critical patients with COVID-19&#63; At what dose&#63; For how long&#63;</p><p id="par0160" class="elsevierStylePara elsevierViewall">We recommend corticosteroid therapy as treatment for seriously ill patients with COVID-19 &#40;need for mechanical ventilation&#41;&#46; A-I</p><p id="par0165" class="elsevierStylePara elsevierViewall">We recommend low-dose systemic corticosteroids&#58; dexamethasone 6&#8239;mg&#47;d for 10 days &#40;A-I&#41; or hydrocortisone 200&#8239;mg&#47;d for 7 days &#40;A-II&#41;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We suggest dexamethasone 20&#8239;mg&#47;d for 5 days&#44; followed by dexamethasone 10&#8239;mg&#47;d for 5 days in patients with moderate to severe acute respiratory distress syndrome &#40;ARDS&#41; &#40;B-II&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Question 7&#46; Should we try to modulate the inflammatory response with other immunosuppressors&#47;immune modulators in critical patients with COVID-19&#63;</p><p id="par0180" class="elsevierStylePara elsevierViewall">We recommend the administration of tocilizumab &#40;8&#8239;mg&#47;kg&#44; maximum 800&#8239;mg&#41;&#44; associated to corticosteroids&#44; in patients requiring admission to the ICU for respiratory or hemodynamic support&#44; on an early basis &#40;first dose in the first 24&#8239;h of admission&#44; with the possibility of a second dose 12&#8722;24&#8239;h after the first&#44; if the treating physician considers the response to be insufficient&#41;&#46; A-II</p><p id="par0185" class="elsevierStylePara elsevierViewall">We suggest the use of sarilumab &#40;400&#8239;mg&#41; in patients requiring admission to the ICU for respiratory or hemodynamic support&#44; on an early basis &#40;first dose in the first 24&#8239;h of admission&#41;&#44; as an alternative to tocilizumab if the latter drug is not available&#46; B-II</p><p id="par0190" class="elsevierStylePara elsevierViewall">We suggest adding baricitinib &#40;4&#8239;mg&#47;d&#44; 14 days&#41; in patients receiving remdesivir and high-flow oxygen therapy &#40;HFOT&#41; or noninvasive mechanical ventilation &#40;NIMV&#41;&#44; with the aim of shortening the recovery period &#40;the criteria for using remdesivir are those established above&#58; patients not requiring invasive mechanical ventilation&#44; and in the first three days after the microbiological diagnosis&#41;&#46; C-I</p><p id="par0195" class="elsevierStylePara elsevierViewall">We do not recommend the use of convalescent plasma to treat patients admitted to the ICU due to severe COVID-19 pneumonia&#46; D-I</p><p id="par0200" class="elsevierStylePara elsevierViewall">Recommendations against the use of ruxolitinib&#44; intravenous immune globulin &#40;IVIG&#41;&#44; colchicine&#44; auxora&#44; itolizumab and anakinra can be found in ESM 2&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Coinfections and superinfections &#40;justification of the recommendations can be found in ESM 3&#41;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Question 8&#46; What patients with COVID-19 should start to receive antibiotic treatment upon admission to the ICU&#63;</p><p id="par0215" class="elsevierStylePara elsevierViewall">We recommend early empirical treatment of possible bacterial pulmonary coinfection &#40;strong clinical suspicion&#44; purulent secretions&#44; biomarker elevation&#44; positive antigens&#44; etc&#46;&#41; upon admission to the ICU of patients with COVID-19&#44; since such coinfection is associated to increased mortality&#46; A-III</p><p id="par0220" class="elsevierStylePara elsevierViewall">We recommend daily evaluation of antibiotic treatment adjustment or suspension&#46; A-II</p><p id="par0225" class="elsevierStylePara elsevierViewall">We recommend the early suspension of antimicrobial treatment once coinfection is ruled out&#46; A-III</p><p id="par0230" class="elsevierStylePara elsevierViewall">Question 9&#46; What is the indicated diagnostic strategy in these patients with suspected superinfection during admission to the ICU&#63;</p><p id="par0235" class="elsevierStylePara elsevierViewall">We suggest an early diagnostic strategy and empirical treatment&#44; in view of the high risk of bacterial and fungal superinfection in patients with COVID-19 subjected to mechanical ventilation&#46; A-III</p><p id="par0240" class="elsevierStylePara elsevierViewall">We suggest active microbiological assessment in all patients with prolonged ICU stays &#40;over 7 days&#41; in the event of suspected superinfection&#46; A-III</p><p id="par0245" class="elsevierStylePara elsevierViewall">We suggest lower respiratory tract sampling in patients with COVID-19 suspected to have superinfection in relation to ventilator-associated pneumonia &#40;VAP&#41; or ventilator-associated tracheobronchitis&#44; before starting antibiotic treatment&#46; We suggest the quantitative analysis of distal samples obtained through bronchoalveolar lavage &#40;BAL&#41;&#44; mini-BAL or bronchial aspirate - provided these procedures can be carried out safely for both the operator and the patient&#46; If not possible&#44; the alternative would be a lower respiratory tract sample in the form of a quantitative or semi-quantitative tracheal aspirate&#46; A-II</p><p id="par0250" class="elsevierStylePara elsevierViewall">We recommend basing the diagnosis of pulmonary aspergillosis associated to COVID-19 on galactomannan detection in BAL&#46; We recommend BAL with culture and galactomannan determination in patients in which <span class="elsevierStyleItalic">Aspergillus</span> is identified in respiratory samples&#44; with signs of pulmonary superinfection&#44; and also in those with suspected ventilator-associated pneumonia or tracheobronchitis&#44; with negative respiratory sample cultures&#46; A-II</p><p id="par0255" class="elsevierStylePara elsevierViewall">Question 10&#46; How should the healthcare associated infection &#40;HAI&#41; preventive measures be applied in these patients&#63;</p><p id="par0260" class="elsevierStylePara elsevierViewall">We recommend application of the guidelines of the prevention programs &#40;Zero Projects&#41;&#44; i&#46;e&#46;&#44; Bacteremia Zero&#44; Pneumonia Zero and Resistances Zero&#44; adapted to COVID-19&#46; A-III</p><p id="par0265" class="elsevierStylePara elsevierViewall">Recommendations on hand hygiene and training in prevention programs can be found in ESM 3&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Thrombotic complications &#40;justification of the recommendations can be found in ESM 4&#41;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Question 11&#46; How should thrombotic events be prevented in critical patients with COVID-19&#63;</p><p id="par0280" class="elsevierStylePara elsevierViewall">We recommend that venous thromboembolic disease &#40;VTED&#41; prevention in patients with severe COVID-19 pneumonia be based on low molecular weight heparin &#40;LMWH&#41; instead of unfractionated heparin &#40;UFH&#41;&#46; Dose adjustment of LMWH to patient weight&#44; kidney function and platelet count is advised&#46; A-II</p><p id="par0285" class="elsevierStylePara elsevierViewall">We recommend treatment with intermediate LMWH doses in patients with severe COVID-19 pneumonia presenting elevated D-dimer levels &#40;&#62;6 times the upper limit of normal&#41; and&#47;or a sepsis-induced coagulopathy &#40;SIC&#41; score &#8805;4&#46; B-II</p><p id="par0290" class="elsevierStylePara elsevierViewall">We suggest that full-dose anticoagulation should not be used in patients with severe COVID-19 pneumonia in which no thrombotic event has been diagnosed&#44; except if clinical suspicion is very strong and the patient cannot be mobilized to perform complementary explorations&#46; D-II</p><p id="par0295" class="elsevierStylePara elsevierViewall">We suggest ultrasound screening to discard deep venous thrombosis &#40;DVT&#41; in the lower and upper extremities when D-dimer &#62;2000&#8239;ng&#47;mL&#46; We suggest thoracic CT angiography and ultrasound in the presence of strong clinical suspicion of pulmonary thromboembolism &#40;PTE&#41; and&#47;or D-dimer &#62;10&#44;000&#8239;ng&#47;mL&#46; B-II</p><p id="par0300" class="elsevierStylePara elsevierViewall">Additional recommendations on the prevention of venous thromboembolic disease in patients with COVID-19 can be found in ESM 4&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Question 12&#46; What is the best diagnostic strategy when PTE is suspected in critical patients with COVID-19&#63;</p><p id="par0310" class="elsevierStylePara elsevierViewall">We recommend CT angiography as the best diagnostic tool when PTE is suspected&#44; both in patients with mild manifestations and in those with severe manifestations of the disease&#46; A-I</p><p id="par0315" class="elsevierStylePara elsevierViewall">Additional recommendations on the diagnosis of PTE in patients with COVID-19 can be found in ESM 4&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Question 13&#46; What treatment is indicated in critical patients with COVID-19 in which PTE is suspected&#47;confirmed&#63;</p><p id="par0325" class="elsevierStylePara elsevierViewall">We recommend anticoagulation of all patients with COVID-19 in which PTE has been confirmed&#44; provided it is not contraindicated&#46; A-I</p><p id="par0330" class="elsevierStylePara elsevierViewall">We recommend the start of anticoagulation when PTE is suspected&#44; when no firm diagnosis can be established&#44; and provided it is not contraindicated&#46; A-III</p><p id="par0335" class="elsevierStylePara elsevierViewall">We recommend systemic fibrinolysis of all patients with COVID-19 in which PTE has been confirmed and who suffer hemodynamic instability&#44; provided it is not contraindicated&#46; A-III</p><p id="par0340" class="elsevierStylePara elsevierViewall">We recommend avoiding fibrinolysis in patients with COVID-19 who suffer ARDS without hemodynamic instability or data indicating PTE&#46; D-III</p><p id="par0345" class="elsevierStylePara elsevierViewall">Additional recommendations on the management of PTE in patients with COVID-19 can be found in ESM 4&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Respiratory management &#40;justification of the recommendations can be found in ESM 5&#41;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Question 14&#46; In which patients can noninvasive respiratory support &#40;NIRS&#41; be considered safe&#63;</p><p id="par0360" class="elsevierStylePara elsevierViewall">We suggest the use of high-flow oxygen therapy as the next step after conventional oxygen therapy&#44; and the guidance of treatment based on the ROX index in adults with SARS-CoV-2 infection and moderate to severe hypoxemic acute respiratory failure &#40;ARF&#41; &#40;p02&#8239;&#60;&#8239;80&#8239;mmHg or Sat02&#8239;&#60;&#8239;90&#37; with Fi02&#8239;&#62;&#8239;40&#37;&#41;&#44; with no increase in respiratory effort&#46; C-III</p><p id="par0365" class="elsevierStylePara elsevierViewall">We suggest evaluating noninvasive mechanical ventilation in patients with SARS-CoV-2 infection and hypoxemic acute respiratory failure in which high-flow oxygen therapy has failed or is not available&#44; and in the absence of an urgent indication of orotracheal intubation or when the order is to not intubate&#46; This always must be done with close monitoring&#44; in a setting where intubation can be performed safely&#46; C-III</p><p id="par0370" class="elsevierStylePara elsevierViewall">Question 15&#46; In the event invasive mechanical ventilation proves necessary&#44; should a protective ventilation strategy be used&#63;</p><p id="par0375" class="elsevierStylePara elsevierViewall">We recommend a protective ventilation strategy similar to that used in ARDS due to other causes&#44; with a tidal volume of 4&#8722;8&#8239;ml&#47;kg body weight &#40;predicted&#41;&#44; in the case of ARDS secondary to COVID-19 pneumonia&#46; C-II</p><p id="par0380" class="elsevierStylePara elsevierViewall">Once the tidal volume has been adjusted to 4&#8722;8&#8239;ml&#47;kg body weight &#40;predicted&#41;&#44; we recommend monitoring of the plateau pressure&#44; which should not exceed 30 cmH2O&#46; C-II</p><p id="par0385" class="elsevierStylePara elsevierViewall">We recommend maintaining a driving pressure &#60;15&#8239;cmH2O&#46; C-II</p><p id="par0390" class="elsevierStylePara elsevierViewall">Question 16&#46; What is the indication of ventilation in prone decubitus in patients with ARDS secondary to COVID-19&#63;</p><p id="par0395" class="elsevierStylePara elsevierViewall">We recommend prone decubitus in all intubated patients with moderate to severe ARDS&#44; provided it is not contraindicated&#46; A-II</p><p id="par0400" class="elsevierStylePara elsevierViewall">We recommend keeping the patient in prone decubitus for at least 16 consecutive hours&#59; this period may be prolonged&#44; conditioned to patient tolerance and response&#46; B-III</p><p id="par0405" class="elsevierStylePara elsevierViewall">There is no evidence to establish recommendations regarding prone decubitus in waking state patients with respiratory failure under conditions of spontaneous ventilation&#46; C-III</p><p id="par0410" class="elsevierStylePara elsevierViewall">Question 17&#46; What is the indication of extracorporeal membrane oxygenation &#40;ECMO&#41; in patients with ARDS secondary to COVID-19&#63;</p><p id="par0415" class="elsevierStylePara elsevierViewall">We recommend veno-venous &#40;VV&#41; ECMO in experienced units or reference centers&#44; in selected patients with severe ARDS and refractory and&#47;or hypercapnic hypoxemic respiratory failure&#44; in the absence of contraindications&#44; when conventional therapies prove ineffective&#44; particularly in the context of prone decubitus&#46; B-II</p><p id="par0420" class="elsevierStylePara elsevierViewall">We recommend cannulation at the patient beside &#40;point of care&#41;&#44; in order to minimize the risks for the healthcare staff&#46; B-III</p><p id="par0425" class="elsevierStylePara elsevierViewall">We recommend continued assessment of the risk&#47;benefit ratio of ECMO&#46; B-III</p><p id="par0430" class="elsevierStylePara elsevierViewall">We advocate the usual anticoagulation protocols in patients with COVID-19 subjected to veno-venous ECMO&#46; C-III</p><p id="par0435" class="elsevierStylePara elsevierViewall">Management of sedation and delirium &#40;justification of the recommendations can be found in ESM 6&#41;</p><p id="par0440" class="elsevierStylePara elsevierViewall">Question 18&#46; What is the best sedoanalgesia strategy in critical patients with COVID-19&#63;</p><p id="par0445" class="elsevierStylePara elsevierViewall">We recommend sequential sedation strategies that facilitate adaptation to mechanical ventilation&#44; guaranteeing adequate analgesia and avoiding oversedation&#46; B-III</p><p id="par0450" class="elsevierStylePara elsevierViewall">Question 19&#46; Is there a higher incidence of delirium among critical patients with COVID-19 than in other similar groups of patients&#63;</p><p id="par0455" class="elsevierStylePara elsevierViewall">An analysis of the incidence of delirium associated to COVID-19 can be found in ESM 6&#46;</p><p id="par0460" class="elsevierStylePara elsevierViewall">Question 20&#46; What is the best strategy for controlling delirium in critical patients with COVID-19&#63;</p><p id="par0465" class="elsevierStylePara elsevierViewall">We suggest the best strategy for controlling delirium in critical patients with COVID-19 to be prevention with the ABCDEF-R bundle of measures adapted to patients with COVID-19&#44; and the early detection of delirium using validated scales such as the CAM-ICU and ICDSC&#46; B-III</p><p id="par0470" class="elsevierStylePara elsevierViewall">We suggest treatment based on non-pharmacological measures and dexmedetomidine i&#46;v&#46;&#44; especially in patients with hyperactive delirium complicating weaning from mechanical ventilation&#46; B-III</p><p id="par0475" class="elsevierStylePara elsevierViewall">Nutritional management &#40;justification of the recommendations can be found in ESM 7&#41;</p><p id="par0480" class="elsevierStylePara elsevierViewall">Question 21&#46; What is the most advisable nutritional strategy in critical patients with COVID-19&#63;</p><p id="par0485" class="elsevierStylePara elsevierViewall">We recommend identification within the first 24&#8722;48&#8239;h of admission of possible nutritional risk or the presence of malnutrition based not only on the clinical history but also on some of the available nutritional screening tools&#44; such as the NUTRIC score&#46; A-III</p><p id="par0490" class="elsevierStylePara elsevierViewall">We recommend evaluation of the nutritional and metabolic parameters &#40;proteins&#44; prealbumin&#44; albumin&#44; cholesterol&#44; triglycerides&#44; ion profile&#44; vitamins and oligoelements&#41; in order to avoid possible refeeding syndrome&#46; A-III</p><p id="par0495" class="elsevierStylePara elsevierViewall">In the event of risk of refeeding syndrome&#44; we recommend nutrition to start with half of the calculated calories &#40;hypocaloric diet&#41; and to gradually increase the amount &#40;every 3 days&#41; until the goal is reached &#40;70&#8211;80&#37; of the requirements&#41; within 4&#8211;7 days&#46; In this period regular controls of the serum levels of phosphorus&#44; magnesium and potassium are required &#40;especially during the first 3 days&#44; when risk is higher&#41;&#46; A-III</p><p id="par0500" class="elsevierStylePara elsevierViewall">We recommend adjustment of the energy needs on a daily basis&#44; adapting the regimen according to the type of nutrition used and the stage of the disease&#46; A-III</p><p id="par0505" class="elsevierStylePara elsevierViewall">We recommend the use of simple equations based on body weight and accessible to all the staff caring for these patients&#46; A-III</p><p id="par0510" class="elsevierStylePara elsevierViewall">In non-intubated patients we recommend starting oral feeding as soon as possible&#46; If intake is &#60;60&#37; of energy expenditure for more than two days&#44; it is advisable to add oral hyperproteic nutritional supplements&#44; and if the needs are not met despite this measure&#44; the introduction of complementary enteral or parenteral nutrition is advisable&#46; A-III</p><p id="par0515" class="elsevierStylePara elsevierViewall">In intubated patients&#44; we recommend the start of nutrition in the first 24&#8722;48&#8239;h of admission&#44; once hemodynamic stability has been achieved&#44; or in the first 12&#8239;h after intubation and the start of mechanical ventilation&#46; A-III</p><p id="par0520" class="elsevierStylePara elsevierViewall">In intubated patients&#44; we recommend enteral nutrition as the preferred strategy&#44; even in patients subjected to neuromuscular block or ventilated in prone decubitus&#46; A-III</p><p id="par0525" class="elsevierStylePara elsevierViewall">In patients with a non-functioning digestive tract or unable to tolerate enteral nutrition in which feeding via the digestive tract is unable to cover &#62;60&#37; of energy expenditure for over 48&#8239;h&#44; we recommend the start of parenteral nutrition from day four&#44; maintaining trophic enteral feeding whenever possible&#46; A-III</p><p id="par0530" class="elsevierStylePara elsevierViewall">Additional recommendations on the nutritional management of patients with COVID-19 can be found in ESM 7&#46;</p><p id="par0535" class="elsevierStylePara elsevierViewall">Management of cardiovascular complications &#40;justification of the recommendations can be found in ESM 8&#41;</p><p id="par0540" class="elsevierStylePara elsevierViewall">Question 22&#46; What is the best resuscitation strategy in critical patients with COVID-19 and hemodynamic instability&#63;</p><p id="par0545" class="elsevierStylePara elsevierViewall">We recommend exhaustive evaluation of the cause of shock in patients with COVID-19&#44; in order to allow the introduction of adequate treatment and supportive measures&#46; A-II</p><p id="par0550" class="elsevierStylePara elsevierViewall">Additional recommendations on shock resuscitation in patients with COVID-19 can be found in ESM 8&#46;</p><p id="par0555" class="elsevierStylePara elsevierViewall">Question 23&#46; How do we evaluate heart-lung interaction in critical patients with COVID-19 and ARDS&#63;</p><p id="par0560" class="elsevierStylePara elsevierViewall">We recommend the use of dynamic parameters to predict cardiovascular response to volume supply&#46; B-II</p><p id="par0565" class="elsevierStylePara elsevierViewall">We recommend the passive leg elevation maneuver &#40;tidal volume challenge&#41; in patients with ARDS ventilated with tidal volumes &#8804;8&#8239;ml&#47;kg&#46; B-II</p><p id="par0570" class="elsevierStylePara elsevierViewall">We recommend echocardiography as the technique of choice for the initial hemodynamic evaluation of patients with COVID-19 under conditions of shock and for detecting cor pulmonale&#46; The echocardiographic exploration must be performed under conditions of asepsis and sterility in order to minimize the infection risk&#46; A-II</p><p id="par0575" class="elsevierStylePara elsevierViewall">We recommend advanced hemodynamic monitoring in complex situations of shock &#40;such as ARDS and sepsis&#44; ARDS and right ventricular dysfunction&#41; or in cases of difficult stabilization&#46; B-II</p><p id="par0580" class="elsevierStylePara elsevierViewall">Question 24&#46; What are the best therapeutic options in critical patients with COVID-19 and arterial hypertension&#63;</p><p id="par0585" class="elsevierStylePara elsevierViewall">Additional recommendations on the management of arterial hypertension in patients with COVID-19 can be found in ESM 8&#46;</p><p id="par0590" class="elsevierStylePara elsevierViewall">Question 25&#46; What are the clinical manifestations and treatment options in cardiac disorders in critical patients with COVID-19&#63;</p><p id="par0595" class="elsevierStylePara elsevierViewall">We recommend the monitoring of myocardial damage biomarkers &#40;troponin or natriuretic peptide&#41; upon admission and in the course of hospital stay&#44; due to the poorer prognosis of those patients with elevation of such markers&#46; A-II</p><p id="par0600" class="elsevierStylePara elsevierViewall">We recommend the use of echocardiography in the case of elevated myocardial damage biomarkers&#44; as it is safe and useful for establishing the differential diagnosis and allows us to guide and assess the therapeutic strategy on an individualized basis&#46; A-II</p><p id="par0605" class="elsevierStylePara elsevierViewall">Additional recommendations on cardiac disorders in patients with COVID-19 can be found in ESM 8&#46;</p><p id="par0610" class="elsevierStylePara elsevierViewall">Management of neurological complications &#40;justification of the recommendations can be found in ESM 9&#41;</p><p id="par0615" class="elsevierStylePara elsevierViewall">Question 26&#46; What are the priorities for managing the associated neurological manifestations in critical patients with COVID-19&#63;</p><p id="par0620" class="elsevierStylePara elsevierViewall">We recommend a high index of suspicion of potential neurological manifestations &#40;confusion&#44; stroke&#44; encephalopathy&#44; meningoencephalitis and weakness acquired in the ICU&#41; in critical patients with COVID-19&#46; A-III</p><p id="par0625" class="elsevierStylePara elsevierViewall">We suggest the use of noninvasive neurological monitoring&#46; C-III</p><p id="par0630" class="elsevierStylePara elsevierViewall">Additional recommendations on the management of neurological complications in patients with COVID-19 can be found in ESM 9&#46;</p><p id="par0635" class="elsevierStylePara elsevierViewall">Organization &#40;justification of the recommendations can be found in ESM 10&#41;</p><p id="par0640" class="elsevierStylePara elsevierViewall">Question 27&#46; If the usual capacity of the ICU is exceeded&#44; should we modify our regular screening protocol&#63;</p><p id="par0645" class="elsevierStylePara elsevierViewall">We recommend the development of specific screening guides in the context of the pandemic&#44; with a view to defining objective and transparent criteria and thus rationalize the limited available resources and lessen the emotional impact of decision making among the professionals&#46; These guides must have legal backing to protect the professionals and institutions from possible future lawsuits&#44; including public emergency declarations on the part of the government or authorities&#46; B-III</p><p id="par0650" class="elsevierStylePara elsevierViewall">Before introducing these specific screening guides&#44; we suggest that maximum resource expansion be ensured&#44; including patient and&#47;or resource transfers between institutions at local or national level&#46; The guides are to be adapted to the different phases of the pandemic&#44; and their evaluation should include the perspective of society&#46; C-III</p><p id="par0655" class="elsevierStylePara elsevierViewall">We recommend that the objective should be to secure the greatest healthcare benefit possible for the largest number of patients&#44; with the resources available at the time of the decision&#46; All patients with a comparable prognosis should have equal and fair access to the limited resources based on medical and ethical criteria&#44; with no discrimination of any kind&#46; This implies the inclusion of both COVID-19 cases and non-COVID-19 cases in the screening process&#46; B-III</p><p id="par0660" class="elsevierStylePara elsevierViewall">We recommend the individual and dynamic evaluation of all patients&#44; and the use of objective tools to help establish the priorities&#46; Use of the Sequential Organ Failure Assessment &#40;SOFA&#41; score as a criterion for establishing priority in patients with COVID-19 is not advised&#46; A-III</p><p id="par0665" class="elsevierStylePara elsevierViewall">We recommend the definition of specific screening criteria for certain procedures where the resources are greatly limited and the opportunity cost is high&#44; such as extracorporeal support techniques &#40;e&#46;g&#46;&#44; ECMO&#41;&#46; B-III</p><p id="par0670" class="elsevierStylePara elsevierViewall">We recommend the introduction of psychological support measures to reduce the emotional impact&#44; particularly moral suffering among the professionals&#44; and the creation of multidisciplinary screening teams&#46; B-III</p><p id="par0675" class="elsevierStylePara elsevierViewall">Question 28&#46; If the usual capacity of the ICU is exceeded&#44; how do we increase the number of available beds for critical patients&#63;</p><p id="par0680" class="elsevierStylePara elsevierViewall">We recommend the definition of contingency plans allowing us to expand the structural and professional resources&#46; Resource expansion can be applied at different levels&#44; considering the transfer of resources between units and the use of telemedicine&#46; B-III</p><p id="par0685" class="elsevierStylePara elsevierViewall">We recommend the use of predictive models based on dynamic indicators in different scenarios&#46; A-III</p><p id="par0690" class="elsevierStylePara elsevierViewall">We recommend that expanded ICUs should have the means necessary to ensure quality care&#44; with assignment of the most seriously ill patients to the usual units&#46; A-II</p><p id="par0695" class="elsevierStylePara elsevierViewall">We suggest the development of pyramidal multidisciplinary cooperative models led by specialists in Intensive Care Medicine and nurses with expertise in the care of the critically ill&#44; in those situations where the expansion of professional teams proves necessary&#46; C-III</p><p id="par0700" class="elsevierStylePara elsevierViewall">Question 29&#46; Is the grouping of these patients in open cohort units an option&#63;</p><p id="par0705" class="elsevierStylePara elsevierViewall">We suggest the use of open cohort units in those cases where expansion of the ICU beyond its usual structure is not possible&#44; involving units with the same capacities and functions&#46; C-III</p><p id="par0710" class="elsevierStylePara elsevierViewall">We recommend efforts to avoid the complications associated with organizations of this kind &#40;nosocomial infections&#44; delirium&#44; impossibility of early mobilization protocols&#44; etc&#46;&#41;&#46; B-III</p><p id="par0715" class="elsevierStylePara elsevierViewall">We recommend that priority be placed on admission to closed units&#44; with individual rooms&#44; for patients in the awakening stage and undergoing weaning from mechanical ventilation&#44; where the presence of the family of the patient and physiotherapy and rehabilitation pose fewer difficulties - reserving admission to open units for patients subjected to deep sedation&#46; B-III</p><p id="par0720" class="elsevierStylePara elsevierViewall">Personal protection and isolation measures &#40;justification of the recommendations can be found in ESM 11&#41;</p><p id="par0725" class="elsevierStylePara elsevierViewall">Question 30&#46; What personal protection equipment &#40;PPE&#41; is needed in caring for critical patients with COVID-19&#63;</p><p id="par0730" class="elsevierStylePara elsevierViewall">We recommend the use of materials certified according to European Union standards&#46; A-II</p><p id="par0735" class="elsevierStylePara elsevierViewall">We recommend the use of individual PPE made of impermeable&#44; water-repelling material&#46; A-II</p><p id="par0740" class="elsevierStylePara elsevierViewall">We recommend the use of disposable PPE&#46; A-II</p><p id="par0745" class="elsevierStylePara elsevierViewall">We recommend the combined use of a long coat and sealed gloves with good fitting around the neck&#44; wrists and hands&#46; A-II</p><p id="par0750" class="elsevierStylePara elsevierViewall">We recommend the use of FFP2 or FFP3 self-filtering masks&#46; A-II</p><p id="par0755" class="elsevierStylePara elsevierViewall">We recommend the use of FFP3 self-filtering masks when performing aerosol-generating procedures&#44; particularly cardiopulmonary resuscitation&#46; A-III</p><p id="par0760" class="elsevierStylePara elsevierViewall">We recommend the use of integrally fitting or full-face eye protection measures&#46; B-III</p><p id="par0765" class="elsevierStylePara elsevierViewall">We recommend following the clinical practice guides for removing PPE&#46; A-II</p><p id="par0770" class="elsevierStylePara elsevierViewall">We recommend removal of the gloves and coat in a single step&#46; A-II</p><p id="par0775" class="elsevierStylePara elsevierViewall">We suggest double gloving&#44; especially in aerosol-generating procedures&#46; B-II</p><p id="par0780" class="elsevierStylePara elsevierViewall">We suggest cleaning of the gloves with disinfectant before removing the equipment&#46; B-II</p><p id="par0785" class="elsevierStylePara elsevierViewall">We suggest the use of additional verbal instructions for removing PPE&#46; B-II</p><p id="par0790" class="elsevierStylePara elsevierViewall">We suggest the use of tabs to affix and facilitate the removal of masks or gloves&#46; C-II</p><p id="par0795" class="elsevierStylePara elsevierViewall">Question 31&#46; Should systematic vaccination be recommended for the staff working in the ICU&#63;</p><p id="par0800" class="elsevierStylePara elsevierViewall">Vaccination of all the healthcare staff working in the ICU is recommended&#44; provided there are no specific contraindications&#46; A-I</p><p id="par0805" class="elsevierStylePara elsevierViewall">Question 32&#46; What are the required isolation measures for patients of this kind&#63;</p><p id="par0810" class="elsevierStylePara elsevierViewall">We recommend the observation of airborne transmission and contact isolation measures in the care of all patients with COVID-19 admitted to the ICU&#46; A-II</p><p id="par0815" class="elsevierStylePara elsevierViewall">We suggest measures of caution referred to airborne transmission in open units for patients with COVID-19 where procedures involving a high risk of generating aerosols are frequently performed&#46; B-III</p><p id="par0820" class="elsevierStylePara elsevierViewall">Question 33&#46; When can these measures be suspended&#63;</p><p id="par0825" class="elsevierStylePara elsevierViewall">We recommend suspending the isolation of critical patients with COVID-19 from 21 days after onset of the clinical condition&#44; and provided three days have gone by without clinical manifestations&#46; A-III</p><p id="par0830" class="elsevierStylePara elsevierViewall">We recommend two oropharyngeal PCR tests &#40;spaced at least 24&#8239;h apart&#41; to confirm that isolation can be suspended in those patients where there are clinical doubts&#46; A-III</p><p id="par0835" class="elsevierStylePara elsevierViewall">Question 34&#46; Can usual family accompaniment be maintained in patients with COVID-19&#63;</p><p id="par0840" class="elsevierStylePara elsevierViewall">We recommend avoiding the isolation of critical patients in the ICU&#44; adopting all the accompaniment and communication strategies available&#44; under safe conditions&#46; A-III</p><p id="par0845" class="elsevierStylePara elsevierViewall">In end-of-life situations&#44; we recommend that the family should be allowed to be present at the patient bedside&#44; explaining the risks of contagion and offering all the PPE means needed to ensure safety&#46; A-III</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Financial support</span><p id="par0850" class="elsevierStylePara elsevierViewall">This study has received no funding&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0855" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The COVID-19 pandemic has led to the admission of a high number of patients to the ICU&#44; generally due to severe respiratory failure&#46; Since the appearance of the first cases of SARS-CoV-2 infection&#44; at the end of 2019&#44; in China&#44; a huge number of treatment recommendations for this entity have been published&#44; not always supported by sufficient scientific evidence or with methodological rigor necessary&#46; Thanks to the efforts of different groups of researchers&#44; we currently have the results of clinical trials&#44; and other types of studies&#44; of higher quality&#46; We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19&#44; but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19&#46; For this&#44; a drafting committee has been created&#44; made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La pandemia por COVID-19 ha provocado el ingreso de un elevado n&#250;mero de pacientes en UCI&#44; generalmente por insuficiencia respiratoria severa&#46; Desde la aparici&#243;n de los primeros casos de infecci&#243;n por SARS-CoV-2&#44; a finales de 2019&#44; en China&#44; se ha publicado una cantidad ingente de recomendaciones de tratamiento de esta entidad&#44; no siempre respaldadas por evidencia cient&#237;fica suficiente ni con el rigor metodol&#243;gico necesario&#46; Gracias al esfuerzo de distintos grupos de investigadores&#44; actualmente disponemos de resultados de ensayos cl&#237;nicos&#44; y otro tipo de estudios&#44; de mayor calidad&#46; Consideramos necesario realizar un documento que incluya recomendaciones que recojan estas evidencias en cuanto al diagn&#243;stico y el tratamiento de COVID-19&#44; pero tambi&#233;n aspectos que otras gu&#237;as no han contemplado y que consideramos fundamentales en el manejo del paciente cr&#237;tico con COVID-19&#46; Para ello se ha creado un comit&#233; redactor&#44; conformado por miembros de los Grupos de Trabajo de SEMICYUC m&#225;s directamente relacionados con diferentes aspectos espec&#237;ficos del manejo de estos pacientes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Vidal-Cort&#233;s P&#44; D&#237;az Santos E&#44; Aguilar Alonso E&#44; Amezaga Men&#233;ndez R&#44; Ballesteros M&#193;&#44; Bod&#237; MA&#44; et al&#46;&#44; Recomendaciones para el manejo de los pacientes cr&#237;ticos con COVID-19 en las Unidades de Cuidados Intensivos&#46; Med Intensiva&#46; 2022&#59;46&#58;81&#8211;89&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Mild support of a recommendation for use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Support of a recommendation against use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Quality of evidence&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Definition&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Evidence from at least one well designed randomized clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Evidence from at least one well designed non-randomized study &#40;case-control or cohort&#41;&#44; multiple time series or very evident results from non-controlled studies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Evidence based on expert opinions&#44; fundamented upon clinical experience or descriptive studies&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2021.11.019

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2024 October	75	49	124
2024 September	97	40	137
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2024 July	93	37	130
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2024 February	87	52	139
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2023 December	170	49	219
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2023 February	100	31	131
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