Published April 2, 2020
Manoj J. Mammen, MD, has co-authored international guidelines — jointly published in Critical Care Medicine and Intensive Care Medicine — for the management of critically ill adults with coronavirus disease (COVID-19).
Mammen is an associate professor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine. He is among dozens of clinicians from around the world who participated in the accelerated effort to develop the guidelines that support hospital clinicians at the bedside taking care of critically ill patients in intensive care units (ICU).
“The guidelines are a rapid compilation of an evidence-based approach for the critically ill patient with COVID-19,” says Mammen, who is a physician with UBMD Internal Medicine.
Based on the best evidence available at the time, the 50 recommendations in the clinical practice guideline provide a recommended algorithm for patient care.
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.
Additionally, the guidelines provide direction on how other procedures necessary for 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, Mammen says.
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 says.
“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 explains.
“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 continues. “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 explains.
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,” says 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.”
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 explains 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.
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.
Critical Care Medicine is the official journal of the Society of Critical Care Medicine. Intensive Care Medicine is the official journal of the European Society of Intensive Care Medicine. The guidelines were published in late March.