Pan American Health Organization · 1st edition, March 2020
Evidence-based list of medicines for ICU management of COVID-19 patients with respiratory failure, shock and complications (March 2020)
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, March 2020
- Audience
- ICU physicians, intensivists, pharmacists, hospital administrators in the Americas
- Evidence
- Based on WHO and Surviving Sepsis Campaign guidelines, systematic reviews, meta-analyses and RCTs from the past 10 years; expert panel recommendations
- Reviewed
- 21 Oct 2026 · GMJ
What this guideline says
GMJ summary
This essential medicines list (EML-ICU-COVID-19) was developed by PAHO in March 2020 to guide ICU management of critically ill COVID-19 patients. It focuses on medicines for the most common complications: hypoxemic respiratory failure and ARDS, hemodynamic deterioration and septic shock, and associated critical care needs including sedation, analgesia, and ventilator management.
The list is based on WHO and Surviving Sepsis Campaign guidelines and emphasizes that no specific anti-COVID-19 drugs had proven efficacy at the time. It recommends first-line sedation with propofol over benzodiazepines, neuromuscular blockade with atracurium or vecuronium for severe ARDS, norepinephrine as first-choice vasopressor for shock, conservative fluid resuscitation with balanced crystalloids (Ringer’s lactate), and empiric broad-spectrum antibiotics for bacterial superinfection.
For corticosteroids in COVID-19 ARDS, the guidance notes conflicting evidence and includes hydrocortisone conditionally without a firm recommendation, pending additional data. The document stresses that antimicrobial choices must be adapted to local resistance patterns and that all recommendations are extrapolated from management of similar critically ill patients, as COVID-19-specific trial data were not yet available in March 2020.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Sedation: propofol or dexmedetomidine preferred over benzodiazepines (midazolam, lorazepam) for mechanically ventilated adults; haloperidol for delirium in select patients only
- Analgesia: morphine and fentanyl are the cornerstone opioids for pain management and sedation in mechanically ventilated patients
- Neuromuscular blockade: atracurium or vecuronium for ARDS patients with persistent ventilator dyssynchrony, deep sedation needs, prone positioning, or high plateau pressure; limit continuous infusion to <48 hours; succinylcholine for emergency intubation
- Fluid resuscitation: conservative approach with balanced crystalloid solutions (Ringer's lactate) or 0.9% saline; avoid large-volume infusions, colloids, and hypotonic solutions
- Vasopressors: norepinephrine as first choice for shock; vasopressin or epinephrine if norepinephrine unavailable; add dobutamine for cardiac dysfunction and persistent hypoperfusion without increasing norepinephrine dose
- Corticosteroids: evidence conflicting; hydrocortisone included conditionally in adults with ARDS without firm recommendation; not recommended for COVID-19 respiratory failure without ARDS
- Antimicrobials: empiric broad-spectrum therapy for bacterial superinfection (meropenem/imipenem-cilastatin or piperacillin-tazobactam; vancomycin; consider antifungal amphotericin B for Candida risk; oseltamivir for influenza coinfection); adapt to local resistance patterns
- Paediatric shock: epinephrine or norepinephrine based on pathophysiology (epinephrine for myocardial dysfunction/low cardiac output, norepinephrine for low vascular resistance); hydrocortisone only for children with prior corticosteroid exposure or adrenal disorders
Essential Medicines List for ICU-COVID-19 by Therapeutic Category
Table extracted from the guideline
| Medicine | Dosage Form and Concentration |
|---|---|
| Paracetamol (fever) | Injection: 10 mg/ml in 10 ml ampoule or 50-100 ml vial |
| Fentanyl (analgesia) | Injectable: 50 µg/ml in 5 ml ampoule |
| Morphine (analgesia) | Injection: 10 mg in 1 ml ampoule |
| Propofol (sedation) | Injection: 10 mg/ml in 20 ml ampoule |
| Midazolam (sedation) | Injection: 1 mg/ml and 5 mg/ml |
| Lorazepam (sedation) | Parenteral: 2 mg/ml or 4 mg/ml in 1 ml ampoule |
| Haloperidol (delirium) | Injection: 5 mg in 1 ml ampoule |
| Atracurium (muscle relaxant)* | Injection: 10 mg/ml in 5 ml ampoule |
| Succinylcholine (emergency intubation) | Injection: 50 mg/ml in 2 ml ampoule |
| Norepinephrine (vasopressor)* | Injection: 1 mg/ml in 4 ml ampoule |
| Epinephrine (vasopressor) | Injection: 1 mg in 1 ml or 100 µg/ml in 10 ml ampoule |
| Dobutamine (inotrope) | Injection: 5-100 mg in 20 ml ampoule |
| Ringer's lactate (volume) | Injectable solution |
| Normal saline (volume) | Injectable solution: 0.9% isotonic |
| Meropenem (antibiotic)* | Powder for injection: 500 mg or 1 g in vial |
| Piperacillin-tazobactam | Powder: 2 g + 250 mg or 4 g + 500 mg in vial |
| Vancomycin | Powder for injection: 250 mg in vial |
| Hydrocortisone (conditional)* | Powder for injection: 100 mg, 500 mg in vial |
Source: Pan American Health Organization, Essential Medicines List for Management of Patients Admitted to Intensive Care Units with Suspected or Confirmed COVID-19 Diagnosis. Reproduced in summary form.
From the guideline
Verbatim
“In adults with COVID-19 and shock, norepinephrine is recommended as the first choice.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked with WHO on health systems strengthening, I recognize this document as a critical early-pandemic tool that helped standardize ICU care when evidence was scarce. For Georgian clinicians, the most important take-home is the systematic approach to shock management—norepinephrine first, conservative fluid resuscitation with balanced crystalloids—and the recognition that antimicrobial choices must reflect local resistance patterns, something our national AMR surveillance programme at the Public Health Institute has been building capacity for since 2017. Georgian ICUs should note that the conditional inclusion of corticosteroids here was superseded within months by the RECOVERY trial showing clear mortality benefit of dexamethasone, highlighting why we must continuously update practice as evidence evolves. The challenge for Georgia remains ensuring consistent availability of the full range of ICU medicines listed here across all regions, not just in Tbilisi tertiary centres, particularly neuromuscular blockers and balanced crystalloid solutions.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this March 2020 guidance represents the early pandemic evidence base for ICU COVID-19 management. Georgian ICUs should note that the document predates steroid trials (RECOVERY, 2020) that established dexamethasone 6 mg daily for 10 days as standard for COVID-19 requiring oxygen. The antimicrobial recommendations require adaptation to regional resistance patterns; Georgia’s national antimicrobial resistance surveillance data should guide empiric choices for ventilator-associated pneumonia and sepsis. The preference for propofol and atracurium aligns with typical ICU formularies in the region, though availability of balanced crystalloids (Ringer’s lactate) versus normal saline may vary. Georgian ICUs implementing these recommendations should integrate them with current national COVID-19 protocols and WHO living guidance updates, particularly regarding corticosteroids, anticoagulation, and respiratory support strategies that have evolved substantially since March 2020.
Questions this guideline answers
Quick answers
What is the first-choice vasopressor for COVID-19 patients with shock?
Norepinephrine is the first-choice vasopressor. If unavailable, vasopressin or epinephrine can be used. For children with septic shock, choose between epinephrine (for myocardial dysfunction and low cardiac output) or norepinephrine (to increase vascular resistance) based on the patient's pathophysiology.
Should all COVID-19 ARDS patients receive neuromuscular blockade?
No. For mild to moderate ARDS, use boluses on demand rather than continuous infusion. Limit IV infusion to <48 hours for patients with persistent ventilator dyssynchrony, those requiring very deep sedation, those ventilated prone, or those with persistently high plateau airway pressure. Atracurium or vecuronium are the recommended agents.
What type of IV fluids should be used for resuscitation in COVID-19 shock?
Use balanced crystalloid solutions such as Ringer's lactate, or if unavailable, 0.9% saline, with a conservative (restrictive) fluid administration approach. Avoid hypotonic solutions, large-volume infusions, and colloids. Evidence suggests potential benefit of balanced crystalloids over normal saline.
Are corticosteroids recommended for all COVID-19 patients with respiratory failure?
No. For respiratory failure without ARDS, systemic glucocorticoids are not recommended. For ARDS, the guidelines suggest their use but note the evidence is conflicting. Hydrocortisone is included conditionally in this list pending additional evidence. The document predates trials establishing clear benefit.
Related on GMJ
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GMJ News coverage
- UK flu and COVID-19 surveillance data to May 2027 shows continued monitoring amid seasonal trendsOct 2026
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- Cambridge researchers identify three distinct severe pneumonia subtypes, opening path to personalised treatmentSep 2026
- Five-year survival gap persists after septic shock discharge, study findsAug 2026
- Early Vasopressors Versus Fluid Resuscitation in Septic Shock: Major Trial Challenges Standard PracticeJul 2026
Quality & accreditation
Other guidelines on this topic
- Considerations for Regulatory Oversight of Clinical Trials in the COVID-19 Pandemic
- Recommendations for medical surge capacity and deployment of emergency medical teams
- Guidelines for care of critically ill adult patients with COVID-19 in the Americas
- Adapting the First Level of Care in the Context of the COVID-19 Pandemic: Interventions, Modalities, and Scope
- Safety of COVID-19 Patients and Use of Medicines without Scientific Evidence of Their Benefit
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, March 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English, Spanish (implied from PAHO context)
- Scope
- Essential medicines for ICU management of suspected or confirmed COVID-19
- Audience
- ICU physicians, intensivists, pharmacists, hospital administrators in the Americas
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Based on WHO and Surviving Sepsis Campaign guidelines, systematic reviews, meta-analyses and RCTs from the past 10 years; expert panel recommendations
- Next review
- Document states it will be updated based on new evidence (March 2020 version)
- Record history
- Created 21 Oct 2026 · updated 21 Oct 2026 · next check Apr 2027
Pan American Health Organization. Essential Medicines List for Management of Patients Admitted to Intensive Care Units with Suspected or Confirmed COVID-19 Diagnosis (EML-ICU-COVID-19). Washington, D.C.: PAHO; 2020. (PAHO/HSS/MT/COVID-19/20-0019).GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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