严重COVID-19病例的激增导致临床医生在需求超出容量的地方对重症监护病房(ICU)的入院进行分类。为了帮助做出困难的分诊决定,临床医生需要关于如何优先考虑患者的明确指南.现有的指导方针在其发展中显示出显著的可变性,解释,实施,迫切需要对已发布的指南进行强有力的综合。为了了解如何管理哪些患者入住ICU,接受机械通气支持,在COVID-19大流行期间的高需求时期,进行了系统评价.索引文献数据库(Medline,Embase,WebofScience,和全球健康)和灰色文献(Google.com和MedRxiv),从2020年1月1日至4月2日发布,进行了搜索。搜索词包括COVID-19、ICU、通风,和分诊。仅包括正式的书面指南。没有基于地理位置或出版物语言的排除标准。准则的质量评估是使用评估指南II(AGREEII)和评估指南的研究和评估工具推荐证明(AGREEREX)评估工具进行的,使用叙事综合提取与分诊相关的关键主题。在1902年确定的独特记录中,包括9项相关指南。六项准则是国家或跨国层面的指导(英国,瑞士,比利时,澳大利亚和新西兰,意大利,和斯里兰卡),一个州一级(堪萨斯州,美国),一个国际(体外生命支持组织)和一个专门针对军事医院(国防部,美国)。准则涵盖了几个广泛的主题:使用道德框架,ICU入院和出院标准,随着需求的变化而调整标准,卫生条件和医疗系统之间的平等,决策过程,沟通决策,和指导方针的发展过程。我们综合了当前的指南,并确定了在COVID-19大流行期间全球采取的不同方法来管理重症监护资源的分诊。关于如何分配ICU病床和呼吸机的有限资源的共识有限,以及缺乏关于大流行期间资源分配的高质量证据和指导方针。我们制定了一套在制定重症监护入院管理指南时要考虑的因素,并概述了对临床线索和当地实施的影响。
The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic
review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.