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

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面向 COVID-19 患者护理的通用可部署指南

指南的制定有多种原因，包括新的、可能改变实践的证据的出现或在不确定时期对指南的感知需求。COVID-19 大流行是后者的一个几乎无与伦比的例子，促使败血症幸存运动 (SSC) 工作组迅速制定了 2019 年冠状病毒病 (COVID-19) 重症成人管理指南。1 这些指南经过改编摘自著名的 2016 年 SSC 指南，2 并在本期 JAMA 中摘录了重点内容。3 在很短的时间内，作者们制定了一套令人印象深刻的全面和广泛​​的指南，分为 4 个领域下的 50 多条建议. 预期目标是减少不必要的实践变化，并以一种对世界各地的临床医生实用且易于使用的方式对现有证据进行集中和知情的提炼。由于 COVID-19 是一种新疾病，SSC 工作组在提出建议时依赖于专家对来自类似疾病（例如败血症）的现有证据的解释。指南委员会的目的是在出现针对 COVID-19 患者护理的特定证据时更新指南。COVID-19 指南可能会被已经熟悉 SSC 的临床医生所接受，尤其是在重症监护需求不超过容量的高收入国家。以以前的指南为基础，无疑有助于快速制定 SSC 指南。一个权衡是，这些建议通常是对更广泛的脓毒症指南的裁剪和修改。较少强调其他一些护理领域，这些领域是传染病暴发的重症监护管理的特殊特征。例如，关于如何从整体上管理疫情（包括对正常医疗服务的严重干扰）以及如何解决诸如强制隔离以管理传染会如何影响患者的心理和结局等问题的建议较少受到关注。 -终生护理。据推测，其中一些主题将在后续指南或更新中得到解决。目前，指南强调支持常规使用许多干预措施的证据不足，例如体外生命支持和吸入血管扩张剂。然而，许多建议表明，可以尝试将此类疗法作为重病患者的抢救疗法。这种在极端情况下救援治疗的警告可能被解释为在过渡到临终关怀之前尝试任何事情的义务。然而，这种方法在大流行期间可能并不理想或不切实际，尤其是在资源稀缺或干预可能弊大于利时。 4 另一个问题是，很难制定一套适用于所有设置。相反，许多建议可能需要仔细分析并适应每个当地环境。使用高流量鼻插管 (HFNC) 和无创正压通气 (NIPPV) 的建议就是一个很好的例子。对于 HFNC 和 NIPPV，专家组高度重视避免插管的可能性。NIPPV 的空气传播风险已被确认，但根据一项评估 HFNC 与氧气面罩对环境细菌污染的研究，HFNC 的风险很小。 5 考虑到使用高流量开放式回路（如 HFNC）无意间病毒雾化的潜在风险，可能需要对这种潜在的疾病传播来源进行更彻底的检查。目前，试图控制疫情的临床医生和决策者可能会对 HFNC 和 NIPPV 的大量使用感到不安，尤其是在拥挤的急诊室或医院病房中使用时间过长的情况。因此，至少可以考虑当地的流行病学背景来解释 HFNC 的建议。例如，当临床医生有足够的个人防护设备并且为接受 HFNC 治疗的低氧血症患者提供足够的负压室时，收益几乎肯定会超过风险。同样，当病例激增且大量确诊病例集中在一起但呼吸机无法获得时，则需要使用 HFNC 和 NIPPV。然而，在中间情况下（例如，受感染和未受感染的患者可能在一起），临床医生可能会得出结论，使用 HFNC 的风险大于收益。COVID-19 指南的众多优势之一是它们强调提供最佳支持性护理的重要性。该小组明确指出需要为需要有创机械通气的患者插管。尽管这一点看起来很明显，尽管如此，强调还是很重要的。否则，任何基于预后不良而限制 COVID-19 重症患者护理的趋势都可能很快成为自我实现的预言。6 该指南还解决了资源稀缺（例如 N95 口罩）和对临床护理的影响. 这很重要，因为在出​​现大量病例的低收入和中等收入国家以及高收入国家，员工、呼吸机、负压室和个人防护设备的短缺可能是一个关键问题 相关文章 意见 N95 口罩）和对临床护理的影响。这很重要，因为在出​​现大量病例的低收入和中等收入国家以及高收入国家，员工、呼吸机、负压室和个人防护设备的短缺可能是一个关键问题 相关文章 意见 N95 口罩）和对临床护理的影响。这很重要，因为在出​​现大量病例的低收入和中等收入国家以及高收入国家，员工、呼吸机、负压室和个人防护设备的短缺可能是一个关键问题 相关文章 意见