Clinical Guidelines 

Hemodynamics

For adults with COVID-19 and shock

From: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Acute Resuscitation

  1. We suggest using dynamic parameters skin temperature, capillary refilling time, and/or serum lactate measurement over static parameters in order to assess fluid responsiveness. 

  2. We suggest using a conservative over a liberal fluid strategy. 

  3. We recommend using crystalloids over colloids. 

  4. We suggest using buffered/balanced crystalloids over unbalanced crystalloids.

  5. We recommend against using hydroxyethyl starches. 

  6. We suggest against using gelatins. 

  7. We suggest against using dextrans. 

  8. We suggest against the routine use of albumin for initial resuscitation. 


Use of Vasoactive Agents

  1. We suggest using norepinephrine as the first- line vasoactive agent, over other agents. 
  2. If norepinephrine is not available, we suggest using either vasopressin or epinephrine as the first-line vasoactive agent, over other vasoactive agents, for adults with COVID-19 and shock. 

  3. We recommend against using dopamine if norepinephrine is available.

  4. We suggest adding vasopressin as a second-line agent, over titrating norepinephrine dose, if target mean arterial pressure (MAP) cannot be achieved by norepinephrine alone.

  5. We suggest titrating vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets. 

  6. For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, we suggest adding dobutamine, over increasing norepinephrine dose. 

  7. For adults with COVID-19 and refractory shock, we suggest using low-dose corticosteroid therapy ("shock-reversal"), over no corticosteroid.

    Remark: A typical corticosteroid regimen in septic shock is intravenous hydrocortisone 200 mg per day administered either as an infusion or intermittent doses. 


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