Pan American Health Organization · Version 3, 2021
GRADE-based recommendations for intensive care management of COVID-19, including respiratory support, pharmacotherapy and prevention of complications.
- Issuer
- Pan American Health Organization
- Edition
- Version 3, 2021
- Audience
- Emergency medicine physicians, intensivists, pulmonologists, anaesthesiologists, infectious disease specialists, respiratory therapists, physical therapists, ICU nurses, hospital pharmacists, and decision-makers managing COVID-19 patients in the Americas
- Evidence
- GRADE-rated recommendations based on systematic literature review with quality of evidence ranging from high to very low; includes good practice statements
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This third version of PAHO’s rapid guidelines for critical COVID-19 care provides evidence-based recommendations for adult patients requiring intensive care. Using GRADE methodology, the guidelines address risk stratification, respiratory and haemodynamic support, pharmacological treatment, and prevention of complications in ICU settings across the Americas.
Key strong recommendations include low tidal volume ventilation (4–8 mL/kg predicted body weight, plateau pressure <30 cmH₂O) for mechanically ventilated patients with ARDS, maintaining SpO₂ ≤96% in hypoxaemic respiratory failure, corticosteroids for patients on supplemental oxygen or ventilation, and norepinephrine as first-line vasopressor with mean arterial pressure targets of 60–65 mmHg. Conservative fluid strategies are recommended for both resuscitation and ongoing management.
The guidelines recommend against remdesivir, lopinavir/ritonavir, hydroxychloroquine, chloroquine, colchicine and convalescent plasma (strong recommendation, moderate evidence). Tocilizumab is conditionally recommended for critically ill patients with rapid respiratory decompensation in the first 72 hours, combined with corticosteroids. Prophylactic anticoagulation with low molecular weight heparin is strongly recommended, with enoxaparin 1 mg/kg daily for high-risk patients without contraindications.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Low tidal volume ventilation 4–8 mL/kg predicted body weight with plateau pressure <30 cmH₂O for mechanically ventilated ARDS patients
- Maintain SpO₂ ≥94% initially, then ≤96% during oxygen therapy; FiO₂/PaO₂ ≤250 or oxygen saturation ≤90% with respiration rate ≥30 defines complicated case
- Low-dose corticosteroids (e.g. dexamethasone 6 mg/day for 10 days) for patients receiving supplemental oxygen or ventilation reduces mortality
- Tocilizumab 8 mg/kg (maximum 800 mg) as single IV dose within 72 hours of ICU admission for rapid respiratory decompensation, combined with corticosteroids
- Norepinephrine as first-line vasopressor targeting mean arterial pressure 60–65 mmHg; dopamine is not recommended
- Conservative fluid strategy using 250–500 mL boluses of buffered/balanced crystalloids; avoid hydroxyethyl starches, gelatins and dextrans
- Prone ventilation 12–16 hours for moderate-to-severe ARDS (PEEP >10 cmH₂O, PaO₂/FiO₂ <150)
- Prophylactic anticoagulation with low molecular weight heparin; enoxaparin 1 mg/kg/day for at least 7 days in high-risk patients without contraindications
GRADE Quality of Evidence and Strength of Recommendations
Table extracted from the guideline
| Category | Characteristic |
|---|---|
| High quality | Further research very unlikely to change confidence in estimate of effect |
| Moderate quality | Further research likely to have important impact on confidence and may change estimate |
| Low quality | Further research very likely to have important impact and likely to change estimate |
| Very low quality | Any estimate of effect very uncertain |
| Strong recommendation | Should be used; new evidence unlikely to change recommendation |
| Conditional recommendation | Could be used; new evidence may change recommendation |
| Strong against | Should not be used; new evidence unlikely to change recommendation |
| Conditional against | May not be used; new evidence may change recommendation |
Source: Pan American Health Organization, Guidelines for Care of Critically Ill Adult Patients with COVID-19 in the Americas, Summary, version 3. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Updated pharmacological recommendations now strongly recommend against remdesivir, lopinavir/ritonavir, hydroxychloroquine, chloroquine, colchicine and convalescent plasma
- Added conditional recommendation for tocilizumab (8 mg/kg up to 800 mg) within first 72 hours for critically ill patients with rapid respiratory decompensation
- Updated recommendations for respiratory support including high-flow nasal oxygen and non-invasive ventilation strategies
- Expanded guidance on thromboembolism prophylaxis with specific enoxaparin dosing (1 mg/kg/day) for high-risk patients
- Added recommendations on early rehabilitation to reduce ICU-acquired weakness
- Updated infection prevention and control recommendations including natural ventilation requirements (160 L/s/patient for airborne precaution rooms)
From the guideline
Verbatim
“For critically ill patients with COVID 19 receiving supplemental oxygen or ventilation, we recommended low-dose of corticosteroids to reduce mortality and progression to invasive mechanical ventilation.”
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 helped coordinate Georgia's COVID-19 response, I recognise how these PAHO guidelines provide the evidence base our ICUs urgently needed during the pandemic's most challenging phases. The strong recommendation for corticosteroids and against several expensive antivirals helps resource-constrained settings like Georgia focus investment where evidence supports benefit. I would particularly stress to Georgian intensivists the importance of protective ventilation strategies and conservative fluid management, which require protocol change rather than procurement, alongside ensuring reliable access to low molecular weight heparin for prophylaxis given the high thrombotic risk. The realistic challenge for Georgian hospitals remains ensuring adequate staffing to safely implement prone positioning for 12–16 hours and to maintain the recommended natural ventilation rates of 160 L/s per patient where negative pressure isolation is unavailable.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s intensive care capacity faced significant strain during COVID-19 surges, making these evidence-based protocols directly applicable for standardising critical care across Georgian hospitals. The recommendations for conservative oxygen targets, corticosteroids and thromboprophylaxis align with resource-appropriate care. Key implementation considerations for Georgia include ensuring availability of low molecular weight heparin for prophylaxis, procurement of balanced crystalloid solutions, and training ICU staff in protective ventilation strategies. The strong recommendation against several expensive antivirals (remdesivir, convalescent plasma) supports rational resource allocation. Georgian facilities should prioritise establishing natural ventilation systems (160 L/s/patient) where negative pressure rooms are unavailable, and develop institutional protocols for prone positioning and early mobilisation that can be sustained with existing staffing levels.
Questions this guideline answers
Quick answers
What oxygen saturation targets should be maintained in critically ill COVID-19 patients?
Initially administer supplemental oxygen to achieve SpO₂ ≥94%. Once stabilised on oxygen therapy, maintain SpO₂ at no higher than 96% to avoid hyperoxia. A complicated case is defined by oxygen saturation ≤90% or FiO₂/PaO₂ ratio ≤250.
Which medications are strongly recommended against for COVID-19 treatment?
Remdesivir, lopinavir/ritonavir, chloroquine, hydroxychloroquine (with or without azithromycin), colchicine and convalescent plasma are not recommended for patient management or clinical trials (strong recommendation, moderate quality evidence).
When should tocilizumab be considered in ICU patients?
Tocilizumab is conditionally recommended for critically ill patients with rapid respiratory decompensation: single IV dose of 8 mg/kg (maximum 800 mg) within the first 72 hours of hospitalisation or ICU admission, combined with corticosteroids such as dexamethasone 6 mg/day for 10 days, based on presence of inflammation markers.
What thromboprophylaxis regimen is recommended?
Low molecular weight heparin is strongly recommended for prophylaxis. For high-risk patients without kidney complications and low bleeding risk, give enoxaparin 1 mg/kg daily for at least 7 days or duration of hospital stay, initiated within 14 hours of admission. High risk is identified by elevated C-reactive protein, fibrinogen and D-dimer.
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Quality & accreditation
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
- ASF Medical Transport — Standard 5 — Infection Prevention & Control
- ASF Laboratory — Standard 7 — Examination: Process & Safety
Other guidelines on this topic
- Guideline for Preventive Chemotherapy for the Control of Taenia solium Taeniasis
- Guidelines for Prophylaxis and Management of Patients with Mild and Moderate COVID-19 in Latin America and the Caribbean
- Management of Inter-Hospital Transfer of Patients with COVID-19
- Recommendations for the adoption and procurement of pressure swing adsorption oxygen generator plants
- Guideline for the Treatment of Leishmaniasis in the Americas
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- Version 3, 2021
- Replaces
- Guidelines for Care of Critically Ill Adult Patients with COVID-19 in the Americas, Version 2
- Status
- Current
- Published
- 2021-01-01
- Languages
- English, Spanish
- Scope
- Identification of risk factors, infection control, respiratory and haemodynamic support, pharmacological treatment, prevention of complications, early rehabilitation, and discharge criteria for critically ill adult COVID-19 patients in ICU settings
- Audience
- Emergency medicine physicians, intensivists, pulmonologists, anaesthesiologists, infectious disease specialists, respiratory therapists, physical therapists, ICU nurses, hospital pharmacists, and decision-makers managing COVID-19 patients in the Americas
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE-rated recommendations based on systematic literature review with quality of evidence ranging from high to very low; includes good practice statements
- Next review
- Continuous updating process (living guideline)
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guidelines for Care of Critically Ill Adult Patients with COVID-19 in the Americas. Summary, version 3. Washington, D.C.: PAHO; 2021. (PAHO/IMS/EIH/COVID-19/21-010).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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