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composite outcome of mortality and crossover to ECMO (47), and a post hoc Bayesian analysis of this RCT showed that ECMO is very likely to reduce mortality across a range of prior assumptions (48). In patients with MERS, ECMO vs conventional treatment was associated with reduced mortality in a cohort study (49). ECMO should be offered only in expert centres with a sufficient case volume to maintain expertise and that can apply the IPC measures required for adult and paediatric COVID-19 patients (50, 51). 8. Management of critical illness and COVID-19: prevention of complications Implement the following interventions (Table 4) to prevent complications associated with critical illness. These interventions are based on Surviving Sepsis (5) or other guidelines (52-55), and are generally limited to feasible recommendations based on highquality evidence. Table 4. Prevention of complications Anticipated outcome Interventions Reduce days of invasive mechanical ventilation • Use weaning protocols that include daily assessment for readiness to breathespontaneously • Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless contraindicated) or with daily interruption of continuous sedative infusions Reduce incidence of ventilatorassociated pneumonia • Oral intubation is preferable to nasal intubation in adolescents and adults • Keep patient in semi-recumbent position (head of bed elevation 30–45º) • Use a closed suctioning system; periodically drain and discard condensate intubing • Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or damaged, but not routinely • Change heat moisture exchanger when it malfunctions, when soiled, or every 5–7 days Reduce incidence of venous thromboembolism • Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000 units subcutaneously twice daily) in adolescents and adults without contraindications. For those with contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices) Reduce incidence of catheter-related bloodstream infection • Use a checklist with completion verified by a real-time observer as reminder of each step needed for sterile insertion and as a daily reminder to remove catheter if no longer needed Reduce incidence of pressure ulcers • Turn patient every 2 hours Reduce incidence of stress ulcers and gastrointestinal (GI) bleeding • Give early enteral nutrition (within 24–48 hours of admission) • Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI bleeding. Risk factors for GI bleeding include mechanical ventilation for ≥ 48 hours, coagulopathy, renal replacement therapy, liver disease, multiple comorbidities, and higher organ failure score Reduce incidence of ICU-related weakness • Actively mobilize the patient early in the course of illness when safe to do so 9 Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance 9. Management of critical illness and COVID-19: septic shock Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) ≥ 65 mmHg AND lactate is ≥ 2 mmol/L, in absence of hypovolemia. Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] < 5th centile or > 2 SD below normal for age) or two or more of the following: altered mental state; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulses; tachypnea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia. Remark 1: In the absence of a lactate measurement, use blood pressure (i.e. MAP) and clinical signs of perfusion to define shock. Remark 2: Standard care includes early recognition and the following treatments within 1 hour of recognition: antimicrobial therapy, and initiation of fluid bolus and vasopressors for hypotension (5). The use of central venous and arterial catheters should be based on resource availability and individual patient needs. Detailed guidelines from the Surviving Sepsis Campaign and WHO are available for the management of septic shock in adults(5) and children (6, 16). Alternate fluid regimens are suggested when caring for adults and children in resource-limited settings (56, 57). The following recommendations pertain to resuscitation strategies for adult and paediatric patients with septic shock. In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid as rapid bolus in first 15–30 minutes and reassess for signs of fluid overload after each bolus. In resuscitation from septic shock in children, give 10–20 mL/kg crystalloid fluid as a bolus in the first 30–60 minutes and reassess for signs of fluid after each bolus. Fluid resuscitation may lead to volume overload, including respiratory failure, particularly with ARDS. If there is no response to fluid loading or signs of volume overload appear (e.g. jugular venous distension, crackles on lung auscultation, pulmonary oedema on imaging, or hepatomegaly in children), then reduce or discontinue fluid administration. This step is particularly