Revised Guidelines on COVID-19

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Government of India Ministry of Health & Family Welfare Directorate General of Health Services

(EMR Division)

Revised Guidelines on Clinical

Management of COVID – 19

This document is intended for clinicians taking care of hospitalised adult and paediatric patients of COVID – 19. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen clinical management of these patients and provide to up-to-date guidance. Best practices for COVID - 19 including IPC and optimized supportive care for severely ill patients as considered essential. This document aims to provide clinicians with updated interim guidance on timely, effective, and safe supportive management of patients with COVID - 19, particularly those with severe acute respiratory illness and critically ill.

31st    March 2020

TABLE OF CONTENTS

No.	Topic	Page No.
1	Case definitions	1
2	Clinical features	2
3	Immediate implementation of IPC measures	4
4	Laboratory diagnosis	6
5	Early supporting therapy and monitoring	8
6	Management of hypoxemic respiratory failure and ARDS	10
7	Management of septic shock	13
8	Other therapeutic measures	15
9	Prevention of complications	16
10	Specific therapy	18

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1. Case definition

When to suspect

•   All symptomatic individuals who have undertaken international travel in the last 14 days

or

•   All symptomatic contacts of laboratory confirmed cases

or

•   All symptomatic healthcare personnel (HCP)

or

•   All hospitalized patients with severe acute respiratory illness ( SARI) (fever AND

cough and/or shortness of breath)

or

•    Asymptomatic direct and high risk contacts of a confirmed case (should be tested once between day 5 and day 14 after contact)

Symptomatic refers to fever/cough/shortness of breath.

Direct and high-risk contacts include those who live in the same household with a confirmed case and HCP who examined a confirmed case.

Confirmed case

A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms

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2. Clinical features

COVID–19 may present with mild, moderate, or severe illness; the latter includes severe pneumonia, ARDS, sepsis and septic shock. Early recognition of suspected patients allows for timely initiation of IPC (see Table 1). Early identification of those with severe manifestations (see Table 1) allows for immediate optimized supportive care treatments and safe, rapid admission (or referral) to intensive care unit .

Table 1: Clinical syndromes associated with COVID - 19 infection

Uncomplicated illness	Patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache. The elderly and immunosuppressed may present with atypical symptoms.
Mild pneumonia	Patient with pneumonia and no signs of severe pneumonia. Child with non-severe pneumonia has cough or difficulty in breathing/ fast breathing: (fast breathing - in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1– 5 years, ≥40 and no signs of severe pneumonia
Severe pneumonia	Adolescent or  adult:  fever  or  suspected  respiratory infection, plus  one  of  the following; respiratory rate >30 breaths/min, severe respiratory distress, SpO2 <90% on room air Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis  or  SpO2  <90%;  severe  respiratory  distress  (e.g.  grunting,  chest  in- drawing); signs of pneumonia with any of the following danger signs: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be present: chest indrawing, fast breathing (in breaths/min): <2 months ≥60; 2–11 months ≥50; 1–5 years ≥40. The diagnosis is clinical; chest imaging can exclude complications.
Acute Respiratory Distress Syndrome	Onset: new or worsening respiratory symptoms within one week of known clinical insult. Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.

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	Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present. Oxygenation (adults): •   Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated) •     Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated) •     Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cm H2O, or non- ventilated) •     When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non- ventilated patients) Oxygenation (children; note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2) •   Bilevel NIV or CPAP ≥5 cm H2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤264 •   Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5 •   Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3 •   Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3
Sepsis	Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection, with organ dysfunction. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia. Children: suspected or proven infection and ≥2 SIRS criteria, of which one must be abnormal temperature or white blood cell count
Septic Shock	Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level < 2 mmol/L Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2- 3 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

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capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea;

mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia

3. Immediate implementation of appropriate IPC measures

Infection prevention control (IPC) is a critical and integral part of clinical management of patients and should be initiated at the point of entry of the patient to hospital (typically the Emergency Department). Standard precautions should always be routinely applied in all areas of health care facilities. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.

Table 2: How to implement infection prevention and control measures for patients with suspected or confirmed COVID - 19 infection

At triage

•    Give suspect patient a triple layer surgical mask and direct patient to separate area, an isolation room if available. Keep at least 1meter distance between suspected patients and other patients. Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for others. Perform hand hygiene after contact with respiratory secretions

Apply droplet precautions

•   Droplet precautions prevent large droplet transmission of respiratory viruses. Use a triple layer surgical mask if working within 1-2 metres of the patient. Place patients in single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatial separation. When providing care in close contact with a patient with respiratory symptoms (e.g.  coughing or  sneezing), use  eye  protection (face-mask or goggles), because sprays of secretions may occur. Limit patient movement within the institution and ensure that patients wear triple layer surgical masks when outside their rooms

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Apply contact precautions

•    Droplet and contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). Use PPE (triple layer surgical mask, eye protection, gloves and gown) when entering room and remove PPE when leaving. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect between each patient use. Ensure that health care workers refrain from touching their eyes, nose, and mouth with potentially  contaminated gloved or  ungloved hands. Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Ensure adequate room ventilation. Avoid movement of patients or transport. Perform hand hygiene.

Apply airborne precautions when performing an aerosol generating procedure

•    Ensure that healthcare workers performing aerosol-generating procedures (i.e. open suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation) use PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95). (The scheduled fit test should not be confused with user seal check before each use.) Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary individuals in the room. Care for the patient in the same type of room after mechanical ventilation commences

Abbreviations: ARI, acute respiratory infection; PPE, personal protective equipment

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4. Laboratory diagnosis

Guidance on specimen collection, processing, transportation, including related biosafety procedures, is available on  https://mohfw.gov.in/media/disease-alerts.

As per directive from MoHFW, Government of India, all suspected cases are to be reported to district and state surveillance officers.

Figure 1: Helpline for COVID-19 (MOHFW, GOI) Sample collection:

Preferred sample: Throat and nasal swab in viral transport media (VTM) and transported on ice Alternate: Nasopharyngeal swab, BAL or endotracheal aspirate which has to be mixed with the viral transport medium and transported on ice

General guidelines:

•     Trained health care professionals to wear appropriate PPE with latex free purple nitrile gloves while collecting   the   sample   from   the   patient.   Maintain proper   infection control when collecting specimens

•   Restricted entry to visitors or attendants during sample collection

•   Complete the requisition form for each specimen submitted

•   Proper disposal of all waste generated

Respiratory specimen collection methods:

A.  Lower respiratory tract

•   Bronchoalveolar lavage, tracheal aspirate, sputum

•     Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container.

B.  Upper respiratory tract

•   Nasopharyngeal swab AND oropharyngeal swab

Oropharyngeal swab (e.g. throat swab): Tilt patient’s head back 70 degrees. Rub swab over both tonsillar pillars and posterior oropharynx and avoid touching the tongue, teeth, and gums. Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media.

Combined nasal & throat swab: Tilt patient’s head back 70 degrees. While gently rotating the swab, insert swab less than one inch into nostril (until resistance is met at turbinates). Rotate the swab several times against nasal wall and repeat in other nostril using the same swab. Place tip of the swab into sterile viral transport media tube and cut off the applicator stick. For throat swab, take a second dry polyester swab, insert into mouth, and swab the posterior pharynx and tonsillar areas (avoid the tongue). Place tip of swab into the same tube and cut off the applicator tip.

Nasopharyngeal swab: Tilt patient’s head back 70 degrees. Insert flexible swab through the nares parallel to the palate (not upwards) until resistance is encountered or the distance is equivalent to that from the ear to the nostril of the patient. Gently, rub and roll the swab. Leave the swab in place for several seconds to absorb secretions before removing.

Clinicians may also collect lower respiratory tract samples when these are readily available (for example, in mechanically ventilated patients). In hospitalized patients with confirmed COVID - 19 infection, repeat upper respiratory tract samples should be collected to demonstrate viral clearance.

5.  Early supportive therapy and monitoring

a.    Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia, or shock: Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-95 % in pregnant patients. Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions) should receive oxygen therapy during resuscitation to target SpO2

≥94%; otherwise, the target SpO2 is ≥90%. All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning oxygen systems and disposable, single- use, oxygen-delivering interfaces (nasal cannula, simple face mask, and mask with reservoir bag). Use contact precautions when handling contaminated oxygen interfaces of patients with COVID – 19.

b.    Use conservative fluid management in patients with SARI when there is no evidence of shock: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation may worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation.

c.    Give empiric antimicrobials to treat all likely pathogens causing SARI. Give antimicrobials within one hour of initial patient assessment for patients with sepsis: Although the patient may be suspected to have COVID - 19, Administer appropriate empiric antimicrobials within ONE hour of identification of sepsis. Empirical antibiotic treatment should be based on the clinical diagnosis (community-acquired pneumonia, health care-associated pneumonia [if infection was acquired in healthcare setting], or sepsis), local epidemiology and susceptibility data, and treatment guidelines. Empirical therapy includes a neuraminidase inhibitor for treatment of influenza when there is local circulation or other risk factors, including travel history or exposure to animal influenza viruses. Empirical therapy should be de-escalated on the basis of microbiology results and clinical judgment

d.   Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of clinical trials unless they are indicated for another reason: A systematic review of observational studies of corticosteroids administered to patients with SARS reported no survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance). A systematic review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the evidence was judged as very low

to low quality due to confounding by indication. A subsequent study that addressed this limitation by adjusting for time-varying confounders found no effect on mortality. Finally, a recent study of patients receiving corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but delayed lower respiratory tract (LRT) clearance of MERS-CoV. Given lack of effectiveness and possible harm, routine corticosteroids should be avoided unless they are indicated for another reason. See section F for the use of corticosteroids in sepsis.

e.    Closely  monitor  patients  with  SARI  for  signs  of  clinical  deterioration,  such  as  rapidly progressive respiratory failure and sepsis, and apply supportive care interventions immediately: Application of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of COVID – 19.

f.    Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the prognosis: During intensive care management of SARI, determine which chronic therapies should be continued and which therapies should be stopped temporarily.

g.    Communicate early with patient and family: Communicate pro-actively with patients and families and provide support and prognostic information. Understand the patient’s values and preferences regarding life-sustaining interventions.

6.  Management of hypoxemic respiratory failure and ARDS

•     Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy. Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face mask with reservoir bag (flow rates of

10-15 L/min, which is typically the minimum flow required to maintain bag inflation; FiO2

0.60-0.95). Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation-perfusion mismatch or shunt and usually requires mechanical ventilation.

•     High – flow nasal catheter oxygenation or non – invasive mechanical ventilation: When respiratory distress and/or hypoxemia of the patient cannot be alleviated after receiving standard oxygen therapy, high – flow nasal cannula oxygen therapy or non – invasive ventilation can be considered. If conditions do not improve or even get worse within a short time (1 – 2 hours), tracheal intubation and invasive mechanical ventilation should be used in a timely manner. Compared to standard oxygen therapy, HFNO reduces the need for intubation. Patients with hypercapnia (exacerbation of obstructive lung disease, cardiogenic pulmonary oedema), hemodynamic instability, multi-organ failure, or abnormal mental status should generally not receive HFNO, although emerging data suggest that HFNO may be safe in patients with mild-moderate and non-worsening hypercapnia25. Patients receiving HFNO should be in a monitored setting and cared for by experienced personnel capable of endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about 1 hr).

•     NIV guidelines make no recommendation on use in hypoxemic respiratory failure (apart from cardiogenic pulmonary oedema and post-operative respiratory failure) or pandemic viral illness (referring to studies of SARS and pandemic influenza). Risks include delayed intubation, large tidal volumes, and injurious transpulmonary pressures. Limited data suggest a high failure rate when MERS patients received NIV. Patients receiving a trial of NIV should be in a monitored setting and cared for by experienced personnel capable of endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about

1 hr). Patients with hemodynamic instability, multiorgan failure, or abnormal mental status should not receive NIV.

•     Recent publications suggest that newer HFNO and NIV systems with good interface fitting do not create widespread dispersion of exhaled air and therefore should be associated with low risk of airborne transmission.

•     Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions. Patients with ARDS, especially young children or those who are obese or pregnant, may de-saturate quickly during intubation. Pre-oxygenate with 100% FiO2 for 5 minutes, via a face mask with reservoir bag, bag-valve mask, HFNO, or NIV. Rapid sequence intubation is appropriate after an airway  assessment  that identifies no  signs  of difficult intubation.

•     Implement mechanical ventilation using lower tidal volumes (4–8 ml/kg predicted body weight, PBW) and lower inspiratory pressures (plateau pressure <30 cmH2O). This is a strong recommendation from a clinical guideline for patients with ARDS, and is suggested for patients with sepsis-induced respiratory failure. The initial tidal volume is 6 ml/kg PBW; tidal volume up to 8 ml/kg PBW is allowed if undesirable side effects occur (e.g. dyssynchrony, pH

<7.15). Hypercapnia is permitted if meeting the pH goal of 7.30-7.45. Ventilator protocols are available. The use of deep sedation may be required to control respiratory drive and achieve tidal volume targets.

•   In patients with severe ARDS, prone ventilation for >12 hours per day is recommended.

Application of prone ventilation is strongly recommended for adult and paediatric patients with severe ARDS but requires sufficient human resources and expertise to be performed safely.

•     Use   a   conservative   fluid   management   strategy   for   ARDS   patients   without   tissue hypoperfusion.

•     In  patients  with  moderate  or  severe  ARDS,  higher  PEEP  instead  of  lower  PEEP  is suggested.PEEP titration requires consideration of benefits (reducing atelectrauma and improving alveolar recruitment) vs. risks (end-inspiratory overdistension leading to lung injury and higher pulmonary vascular resistance). Tables are available to guide PEEP titration based on the FiO2 required to maintain SpO2. A related intervention of recruitment manoeuvres (RMs) is delivered as episodic periods of high continuous positive airway pressure [30–40 cm H2O], progressive incremental increases in PEEP with constant driving pressure, or high driving pressure; considerations of benefits vs. risks are similar. Higher PEEP and RMs were both conditionally recommended in a clinical practice guideline. In patients with moderate-

severe ARDS (PaO2/FiO2<150), neuromuscular blockade by continuous infusion should not be routinely used.

•     In settings with access to expertise in extracorporeal life support (ECLS), consider referral of patients with refractory hypoxemia despite lung protective ventilation. ECLS should only be offered in expert centres with a sufficient case volume to maintain expertise and that can apply the IPC measures required for COVID – 19 patients

•     Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis. Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection is required (for example, transfer to a transport ventilator)

7.  Management of 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 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR

<70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.

•     In the absence of a lactate measurement, use MAP and clinical signs of perfusion to define shock. Standard care includes early recognition and the following treatments within 1 hour of recognition: antimicrobial therapy and fluid loading and vasopressors for hypotension. The use of central venous and arterial catheters should be based on resource availability and individual patient needs. Detailed guidelines are available for the management of septic shock in adults and children.

•     In resuscitation from septic shock in adults, give at least 30 ml/kg of isotonic crystalloid in adults in the first 3 hours. In resuscitation from septic shock in children in well-resourced settings, give 20 ml/kg as a rapid bolus and up to 40-60 ml/kg in the first 1 hr. Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.

•     Fluid resuscitation may lead to volume overload, including respiratory failure. If there is no response to fluid loading and signs of volume overload appear (for example, 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 important where mechanical ventilation is not available. Alternate fluid regimens are suggested when caring for children in resource-limited settings.

•     Crystalloids include normal saline and Ringer’s lactate. Determine need for additional fluid boluses (250-1000 ml in adults or 10-20 ml/kg in children) based on clinical response and improvement of perfusion targets. Perfusion targets include MAP (>65 mmHg or age- appropriate targets in children), urine output (>0.5 ml/kg/hr in adults, 1 ml/kg/hr in children), and improvement of skin mottling, capillary refill, level of consciousness, and lactate. Consider

dynamic indices of volume responsiveness to guide volume administration beyond initial resuscitation based on local resources and experience. These indices include passive leg raises, fluid challenges with serial stroke volume measurements, or variations in systolic pressure, pulse pressure, inferior vena cava size, or stroke volume in response to changes in intrathoracic pressure during mechanical ventilation.

•     Administer vasopressors when shock persists during or after fluid resuscitation. The initial blood pressure target is MAP ≥65 mmHg in adults and age-appropriate targets in children.

•     If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein and closely monitor for signs of extravasation and local tissue necrosis. If extravasation occurs, stop infusion. Vasopressors can also be administered through intraosseous needles.

•     If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors, consider an inotrope such as dobutamine

8.  Other therapeutic measures:

For patients with progressive deterioration of oxygenation indicators, rapid worsening on imaging and excessive activation of the body’s inflammatory response, glucocorticoids can be used for a short period of time (3 to 5 days). It is recommended that dose should not exceed the equivalent of methylprednisolone 1 – 2mg/kg/day. Note that a larger dose of glucocorticoid will delay the removal of coronavirus due to immunosuppressive effects. For pregnant severe and critical cases, pregnancy should be preferably terminated. Consultations with obstetric, neonatal, and intensive care specialists (depending on the condition of the mother) are essential. Patients often suffer from anxiety and fear and they should be supported by psychological counseling.

9.  Prevention of complications

Implement the following interventions (Table 3) to prevent complications associated with critical illness. These interventions are based on Surviving Sepsis or other guidelines, and are generally limited to feasible recommendations based on high quality evidence.

Table 3: Prevention of complications

Anticipated Outcome	Interventions
Reduce days of invasive mechanical ventilation	•     Use weaning protocols that include daily assessment for readiness to breathe spontaneously •     Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless contraindicated) or with daily interruption of continuous sedative infusions
Reduce incidence of ventilator associated 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 in tubing •     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	•   Turn patient every two hours

Ulcers
Reduce incidence of stress ulcers and gastrointestinal 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 gastrointestinal bleeding include mechanical ventilation for ≥48 hours, coagulopathy, renal replacement therapy, liver disease, multiple co-morbidities, 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

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10.        Specific therapy

NO SPECIFIC ANTIVIRALS have been proven to be effective as per currently available data. However, based on the available information (uncontrolled clinical trials), the following drugs may be considered as an off – label indication in patients with severe disease and requiring   ICU management:

•   Hydroxychloroquine  (Dose 400mg BD  – for 1 day followed by 200mg BD for 4 days)

In combination with

•   Azithromycin (500 mg OD for 5 days)

These drugs should be administered under close medical supervision, with monitoring for side effects including QTc interval.

The above medication is presently not recommended for children less than 12 years, pregnant and lactating women.

These guidelines are based on currently available information and would be reviewed from time to time as new evidence emerges.

Support to Treating Physicians: AIIMS, New Delhi is running a 24x7 helpline to provide support  to  the  treating  physicians  on  clinical  management.  The  helpline  number  is

9971876591. The identified nodal doctor of the State, appointed for clinical management of

COVID – 19 should only contact AIIMS Call Centre.

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