Concise Critical Appraisal: Surviving Sepsis Campaign COVID-19 Guidelines Update

Lifelong learning through education and career continuum enhances competence and is paramount to promoting professional development and improving clinical outcomes through efficient state-of-the-art practices. The rapidly evolving critical care medical literature mixed with the long hours, life-altering decisions, and stress at the bedside often make it difficult for physicians to take advantage of—or even notice—the constant medical updates. Throw a COVID-19 pandemic into the mix and critical care professionals find themselves in the midst of a rapidly changing field of medicine different from the one in which they were trained. In the early stages of the pandemic, when data were sparse, COVID-19 clinicians were faced with an unprecedented challenge of managing patients with an infection about which little to nothing was known. Now, nearly a year later, knowing this infection will persist for years to come and with increasing evidence-based literature supporting and discouraging various therapeutic options, it is imperative that clinicians continually update their knowledge.
 
The SSC has published a first update to its COVID-19 guidelines.¹ The first update highlights the clinical research being done on COVID-19 despite the stress factors of a global emergency. The recommendations were supported by the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM). The first update also brings to light the significant lack of direct evidence to strongly recommend or discourage many of the questions people have regarding COVID-19 patient care.
 
In several areas, recommendations were altered based on advancements in COVID-19-specific clinical research. These include:
 

1. In the original guidelines, the SSC panel did not mention awake prone positioning in nonintubated patients. In this first update to the guidelines, the panel recognized the increase in awake prone positioning in this cohort of patients and states that there remains insufficient evidence to issue a recommendation while awaiting ongoing randomized controlled trials (RCTs).
2. The panel previously stated that there was insufficient evidence to issue a recommendation on the use of hydroxychloroquine in critically ill adults with COVID-19. The updated recommendation discourages the use of hydroxychloroquine due to the moderate-quality evidence that showed no effect on mortality or need for mechanical ventilation.²
3. Thanks to the RECOVERY trial and supporting high-quality evidence showing a reduction in mortality, affordability, and minimal adverse effects with short courses of corticosteroids in mechanically ventilated adults with acute respiratory distress syndrome, the panel changed the strength of its recommendation in support of steroids from weak to strong.³ They also recommended using dexamethasone, if available, over other corticosteroids.
4. After the placebo-controlled trial that showed a large reduction in the time to recovery and hospital stay, the panel changed its recommendation to support the use of IV remdesivir within 72 hours of diagnosis in nonmechanically ventilated patients.⁴ The panel also now discourages the use of IV remdesivir in mechanically ventilated patients. Appropriately, the panel mentioned the subgroup analysis from the three trials that showed a discordant effect on mortality, high costs, and limited availability.^5,6
5. Venous thromboembolisms (VTE) were found in 26% of COVID-19 patients.⁷ Moreover, high-quality indirect evidence from non-COVID-19 patients show that prophylaxis is superior to no prophylaxis. The panel updated its recommendations to strongly encourage the use of pharmacologic VTE prophylaxis. While awaiting the publication of ongoing RCTs, the panel discourages the use of therapeutic—rather than prophylactic—anticoagulation use in patients without VTE and outside of clinical trials.

 
The greatest limitation of the guidelines is that the rest of the recommendations have remained unchanged solely because there remains a lack of evidence supporting or discouraging the use of various therapeutic options directly in patients with COVID-19. Fortunately, a tremendous amount of research examining different SARS-CoV-2 therapeutic options is currently under way and is being published weekly. Therefore, changes in the SSC recommendations are nearly certain. Because of the volatile state of current guidance, healthcare professionals are encouraged to stay tuned for the latest scientific knowledge, challenge status quo data, and constantly enhance their clinical skills. It is our duty to stay afloat with these updated recommendations and continue lifelong learning. Although formal education ends after graduation, learning is infinite, and it is imperative, especially during a global emergency.
 
Author of this installment of Concise Critical Appraisal:
 
Ramzy H. Rimawi, MD, is an assistant professor in the Division of Pulmonary, Critical Care, Sleep and Allergy Medicine in the Department of Internal Medicine at Emory University. Dr. Rimawi is an editor of Concise Critical Appraisal.

References

1. Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-e234.
2. Cavalcanti AB, Zampieri FG, Rosa RG, et al; Coalition Covid-19 Brazil I Investigators. Hydroxychloroquine with or without azithromycin in mild-to-moderate Covid-19. N Engl J Med. 2020 Nov 19;383(21):2041-2052.
3. RECOVERY Collaborative Group; Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med. 2021 Feb 25;384(8):693-704.
4. Beigel JH, Tomashek KM, Dodd LE, et al; ACTT-1 Study Group Members. Remdesivir for the treatment of Covid-19: final report. N Engl J Med. 2020 Nov 5;383(19):1813-1826.
5. Spinner CD, Gottlieb RL, Criner GJ, et al; GS-US-540-5774 Investigators. Effect of remdesivir vs standard care on clinical status at 11 days in patients with moderate COVID-19: a randomized clinical trial. JAMA. 2020 Sep 15;324(11):1048-1057.
6. Goldman JD, Lye DC, Hui DS, et al; GS-US-540-5774 Investigators. Remdesivir for 5 or 10 days in patients with severe Covid-19. N Engl J Med. 2020 Nov 5;383(19):1827-1837.
7. Porfidia A, Valeriani E, Pola R, Porreca E, Rutjes AWS, Di Nisio M. Venous thromboembolism in patients with COVID-19: systematic review and meta-analysis. Thromb Res. 2020 Dec;196:67-74.