International guidelines on COVID-19 provide algorithm for treating patients with severe disease

BUFFALO, N.Y. – A University at Buffalo faculty member is a co-author on the international Guidelines for the Management of Critically Ill Adults with Coronavirus Disease (COVID-19). The guidelines were published last Friday in Critical Care Medicine, the journal of the Society for Critical Care Medicine.

Manoj J. Mammen, MD, associate professor in the Department of Medicine at the Jacobs School of Medicine and Biomedical Sciences at UB and a physician with UBMD Internal Medicine, is among dozens of clinicians from around the world who participated in the accelerated effort to develop the guidelines to support hospital clinicians at the bedside taking care of critically ill patients in intensive care units.

“The guidelines are a rapid compilation of an evidence-based approach for the critically ill patient with COVID-19,” said Mammen.

Based on the best evidence available at the time, the 50 recommendations in the clinical practice guideline provide a recommended algorithm for the treatment of critically ill patients with COVID-19, according to Mammen.

The guidelines state that when performing aerosol-generating procedures — such as  intubation, bronchoscopy, open-suctioning, etc. — health care workers should wear fitted respirator masks, such as N-95, instead of surgical masks, in addition to other personal protective equipment (PPE), such as gowns, gloves and eye protection.

They also state that such procedures should be performed on ICU patients with COVID-19 in a negative pressure room, if available. Negative pressure rooms are engineered to prevent the spread of contagious pathogens from room to room. 

The guidelines also provide direction on how other procedures necessary in some patients with COVID-19 should be done and what kind of training is needed to properly conduct them.

“However, health care providers will be tailoring the recommendations to the conditions present at their health care system and at the patient’s bedside,” a fact that has become clearer since the guidelines were published last week, Mammen said.

The guidelines were developed as part of the Surviving Sepsis campaign, an international effort launched in 2002 to develop evidence-based guidelines to drive down the numbers of deaths around the world from sepsis and septic shock. Sepsis is the body’s extreme response to an infection, which, if not treated, can cause tissue damage, organ failure and death.

Mammen explained that a small percentage of patients with COVID-19 experience sepsis; it is more likely among the elderly and those with pre-existing chronic conditions.

Lack of PPE is main obstacle

The increasing difficulty in obtaining adequate PPE for health care workers looms as a primary obstacle to health care providers being able to closely follow the newly published guidelines, Mammen said.

“The biggest concern with following the guidelines would be the availability of adequate supplies of personal protective equipment for health care workers, and sufficient supply of ventilators, which has been a high priority for health care systems,” he said.

“Health care workers who do get infected further strain the health care system, in addition to the loss of that worker's ability to care for patients during this pandemic,” he continued. “Without enough health care workers who are healthy to care for patients in the intensive care unit, it would be difficult to operate the ventilators.”

Mammen recently treated a Western New York patient who appeared to have COVID-19, likely as the result of exposure at the patient’s workplace.

“The patient’s workplace did not let workers telecommute or work remotely, and the patient had to come to the clinic to request documentation to be excused from work for health reasons,” he explained.

This person’s inability to telecommute likely led to exposure from co-workers who have subsequently been confirmed as COVID-19 positive cases. This person’s disease could not, however, be confirmed since there was a lack of test kits at the time the patient was exhibiting symptoms.

“This experience has reinforced several vital lessons for me,” said Mammen. “One is the lack of test supplies in the United States has led to a diminished capacity to contain the virus. In addition, social distancing is the most important thing the public can practice to contain the disease. By stopping their normal activities and staying at home, everyone is helping to prevent disease spread. Social distancing is the key in ensuring that we succeed in controlling the disease.”

Mammen, who was trained in systematic review and guidelines by the American Thoracic Society, was invited to participate as a methodologist in this review of COVID-19.