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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
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No.
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Topic
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Page No.
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1
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Case definitions
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1
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2
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Clinical features
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2
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3
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Immediate implementation of IPC
measures
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4
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4
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Laboratory diagnosis
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6
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5
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Early supporting therapy
and monitoring
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8
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6
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Management of hypoxemic
respiratory failure
and ARDS
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10
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7
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Management of septic
shock
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13
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8
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Other therapeutic measures
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15
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9
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Prevention of complications
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16
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10
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Specific therapy
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18
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2
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
1
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
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Uncomplicated illness
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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.
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Mild
pneumonia
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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
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Severe
pneumonia
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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.
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Acute
Respiratory Distress Syndrome
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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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2
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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
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Sepsis
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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
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Septic
Shock
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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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3
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
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At triage
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• 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
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Apply droplet
precautions
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• 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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4
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Apply contact precautions
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• 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.
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Apply airborne precautions
when
performing an
aerosol generating procedure
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• 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
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Abbreviations: ARI, acute respiratory infection; PPE, personal protective equipment
5
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.
|
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
|
17
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.
18
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