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Toward Universal Deployable Guidelines for the Care of Patients With COVID-19.

Guidelines are developed for various reasons, including the emergence of new, potentially practice-changing evidence or a perceived need for guidance in times of uncertainty. The COVID-19 pandemic presents an almost unparalleled example of the latter, prompting the Surviving Sepsis Campaign (SSC) Task Force to rapidly produce Guidelines on the Management of Critically Ill Adults With Coronavirus Disease 2019 (COVID-19).1 These guidelines are adapted from the well-known 2016 SSC guidelines,2 and highlights are excerpted in this issue of JAMA.3 In a brief amount of time, the authors have produced an impressively thorough and expansive set of guidelines, organized as more than 50 recommendations under 4 domains. The intended goal is to reduce unwanted practice variation and provide a focused and informed distillation of the existing evidence in a manner that will be practical for, and accessible to, clinicians in a wide variety of settings around the world. Because COVID-19 is a new disease, the SSC Task Force relied on the expert interpretation of available evidence from analogous conditions, such as sepsis, when generating its recommendation. The intent of the guideline committee is to update the guidelines as evidence specific to the care of patients with COVID-19 emerges. The COVID-19 Guidelines will likely be embraced by clinicians already familiar with the SSC, particularly in highincome countries when demand for critical care does not exceed capacity. Building on previous guidelines undoubtedly aided the rapid production of the SSC guidelines. One tradeoff is that the recommendations are generally a tailoring and modification of the broader sepsis guidelines. There is less emphasis on some other domains of care that are particular features of critical care management of contagious disease outbreaks. For example, there is less focus on recommendations regarding how to manage the outbreak as a whole (including the considerable disruption to normal health care delivery) and regarding how to address issues such as how enforced isolation to manage contagion can affect patients’ psychological and end-of-life care. Presumably, some of these topics will be addressed in subsequent guidelines or updates. Currently, the guidelines emphasize the inadequacy of evidence supporting the routine use of many interventions, such as extracorporeal life support and inhaled vasodilators. However, many of the recommendations suggest that such therapies might be tried as rescue therapies in patients who become extremely ill. Such caveats for rescue therapies in extremis may be interpreted as an obligation to try anything before transitioning to end-of-life care. However, that approach may not be desirable or practical during a pandemic, especially when resources are scarce, or when interventions are likely to do more harm than good.4 Another issue is that it is difficult to create one set of guidelines that can apply in all settings. Rather, a number of the recommendations may have to be carefully analyzed and adapted to each local setting. The recommendations for the use of highflow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NIPPV) are a case in point. For HFNC and NIPPV, the panel placed a high value on the possibility of avoiding intubation. The risk of airborne transmission is acknowledged for NIPPV, but judged minimal for HFNC on the basis of a single study evaluating environmental bacterial contamination with HFNC vs oxygen masks.5 Given the potential risks of inadvertent viral aerosolization using high-flow open circuits such as HFNC, more thorough examination of this potential source for disease transmission may be warranted. Currently, clinicians and decision-makers who are trying to contain the outbreak may be uncomfortable with the liberal use of HFNC and NIPPV, especially if prolonged, in crowded emergency departments or on hospital wards. At a minimum, therefore, the recommendation for HFNC could be interpreted with consideration of the local epidemiological context. For example, when clinicians have adequate personal protection equipment and there are enough negative pressure rooms for hypoxemic patients treated with HFNC, the benefits would almost certainly outweigh the risks. Similarly, when there is a surge of cases and large numbers of confirmed cases are cohorted together but with inadequate access to ventilators, use of HFNC and NIPPV will be necessary. However, under intermediate circumstances (eg, where infected and uninfected patients are potentially together), clinicians may conclude that the risks of using HFNC outweigh the benefits. One of the many strengths of the COVID-19 guidelines is their emphasis on the importance of providing optimal supportive care. The panel is explicit about the need to intubate patients who require invasive mechanical ventilation. Even though this point may seem obvious, it was nonetheless important to emphasize. Otherwise, any tendency to limit the care of critically ill patients with COVID-19 on the basis of poor prognosis might quickly become a self-fulfilling prophecy.6 The guidelines also address resource scarcity (eg, N95 masks) and the effect on clinical care. This is important because scarcity of staff, ventilators, negative pressure rooms, and personal protective equipment is likely be a critical issue in lowand middle-income countries experiencing any reasonably large number of cases, and in high-income countries Related article Opinion