›Tidal volume 6 mL/kg ideal body weight
›Plateau pressure target <30 cmH2O
›PEEP titration per ARDSNet table or esophageal pressure
›Prone positioning
›Initiate for PaO2/FiO2 <150 mmHg despite optimized ventilation
›16 hours prone per 24-hour cycle
›Class I evidence from PROSEVA trial (non-SARS context, applicable by extension)
›ECMO
›VV-ECMO for refractory hypoxemia PaO2/FiO2 <80 mmHg
›Consider at ECMO center: used in approximately 6% of MERS ICU patients
›VA-ECMO for cardiogenic shock complicating respiratory failure
Antiviral and investigational therapies
›No approved specific antiviral therapy for MERS-CoV
›All antiviral use is investigational or compassionate access
›Enrollment in clinical trial preferred when available
›Infectious disease consultation mandatory before initiation
›Interferon beta-1b plus lopinavir-ritonavir
›MIRACLE trial regimen
›Interferon beta-1b 8 million IU subcutaneous every other day for 14 doses
›Lopinavir 400 mg / ritonavir 100 mg orally twice daily for 14 days
›Initiate within 7 days of symptom onset for mortality benefit
›MIRACLE trial findings
›Improved 28-day survival when initiated early
›No benefit demonstrated when initiated after 7 days
›Class IIb evidence; investigational use only
›Ribavirin plus interferon alfa-2a
›Ribavirin dosing
›Loading dose 2000 mg orally followed by 1000-1200 mg twice daily for 10 days
›Renal dose adjustment required for eGFR <50 mL/min
›Interferon alfa-2a
›180 micrograms subcutaneous weekly for 2 doses
›Associated with 14-day survival benefit in retrospective cohort; no 28-day benefit
›Larger observational study found no 90-day mortality reduction
›Remdesivir
›Preclinical data only for MERS-CoV
›Efficacy demonstrated in rhesus macaque model
›No completed human MERS-CoV trials published
›May be considered compassionate use given COVID-19 safety profile data
›Empirical antibiotics for co-infection
›Community-acquired pneumonia coverage pending MERS confirmation
›Beta-lactam plus macrolide or respiratory fluoroquinolone
›Ceftriaxone 1-2 g IV every 24 hours plus azithromycin 500 mg IV every 24 hours
›Alternative: levofloxacin 750 mg IV every 24 hours
›Hospital-acquired coverage if nosocomial presentation
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›Add vancomycin 25-30 mg/kg/day if MRSA risk
›De-escalate antibiotics based on cultures and clinical response at 48-72 hours
›Vasopressor therapy
›Norepinephrine first-line
›Start at 0.01-0.1 mcg/kg/min IV continuous infusion
›Titrate to MAP >=65 mmHg
›Maximum 0.5 mcg/kg/min before adding second agent
›Vasopressin second agent
›Vasopressin 0.03-0.04 units/min fixed dose added to norepinephrine
›Reduces norepinephrine requirements; no titration
›Corticosteroids for refractory shock
›Hydrocortisone 200 mg/day IV continuous or divided doses
›Only for vasopressor-refractory shock; evidence remains limited for MERS
›Renal replacement therapy
›Continuous RRT preferred in hemodynamically unstable patients
›CVVHDF for combined solute clearance and fluid management
›Anticoagulation with regional citrate preferred
›Intermittent hemodialysis when hemodynamically stable
›Required in approximately 49% of MERS ICU patients
Fever and symptomatic management
›Antipyretics
›Acetaminophen 650-1000 mg orally or IV every 6 hours
›Preferred over NSAIDs in AKI risk
›Maximum 3 g/day in hepatic dysfunction
›Avoid NSAIDs in setting of AKI or renal impairment