COVID19 Management Protocol

School of Excellence in Pulmonary Medicine,
Netaji Subhash Chandra Bose Medical College (NSCB Medical College) Jabalpur (Madhya Pradesh)

Based on COVID19 Management Guidelines Issued by-

MoHFW, Govt of India
AIIMS, New Delhi
Ministry of Health, Govt of Madhya Pradesh Authors

Prof.Dr. Jitendra Bhargava,

Director,

School of Excellence in Pulmonary Medicine (SEPM), Netaji Subhash Chandra Bose Medical College, Jabalpur Inputs from:

Dr. Sanjay Bharti, Associate Professor, SEPM Dr Brahmaprakash Associate Professor, SEPM Dr Vikas Patel Assistant Professor, SEPM
Dr Avinash Jain Assistant Professor, SEPM

Dr, Veerendra Arya, Assistant Professor, SEPM Dr. Amrendra Shukla, Assistant Professor, SEPM

Forwarded By:

Mr B Chandrashekhar Commissioner, Jabalpur Division Madhya Pradesh Government

Dr. Pawan Tiwari, DM ( Pulmo. Med) Associate Professor, SEPM,
Netaji Subhash Chandra Bose Medical College, Jabalpur

Foreword



This booklet aims at providing some guidelines for the doctors involved in the



treatment and overall management of Covid-19 patients in the hospital setting.

After more than a year, we are still learning to treat Covid-19 disease. In the absence

of any evidence-based treatment of Covid-19, doctors have been able to evolve

ways of treating patients with varying degree of severity. Despite a wide spectrum in

which the disease exhibits itself in different patients, we have been able to arrive at

some standard line of treatment which would be applicable in more than ninety

percent cases. This booklet attempts to provide such standard line of treatment.



It covers almost all aspect related to management of Covid-19 patients, starting from



triage to discharge. Inter alia, it covers management of patients, rational use of



Remdesivir and oxygen, investigations, drugs, step down criteria, etc.



It is meant to serve as a guide and will be of great use particularly in hospitals where



specialist doctors required for the treatment of Covid-19 are either not available or



are in very few numbers.

I thank Dr Jitendra Bhargava, Dr Pawan Tiwari and others who have taken extra

efforts to come up with this booklet in the midst of heavy load of patients in the

Medical College Jabalpur. I hope it will help doctors in Jabalpur Division to improve

treatment of Covid-19 patients, thereby saving more lives.

B ChandraShekhar, IAS

Commissioner, Jabalpur Division

Contents

1. Triage

a. Decision on Admission: Whom to Admit?

b. Where to admit: COVID Care Center, General Ward or HDU/ICU

c. If admission not required: Guidelines for Management of patients during Home
Isolation

2. COVID19 Management Protocol (for admitted patients)

a. For mild patients

b. For moderate and severe patients

3. Rational Use of Remdesivir

4. Rational Use of Immunomodulators (Tocilizumab and Itolizumab)

5. Rational Use of Oxygen

6. Important Investigations with Reference Values in COVID19

7. Overview of important drugs used in COVID19 management

8. Step Down Criteria (From HDU/ICU→ General Wards→ Discharge/ Home isolation)

9. Criteria for Discharge or Home Isolation

10. Appendix:

a. Important websites and links to documents

b. MoHFW protocol flowchart

c. AIIMS (ND) Patient management protocol

d. MP Govt Reference Documents

e. SEPM Discharge and Advice Template

Triage Flow

The following flow chart outlines evaluation and triage of patients with suspected COVID19, to decide regarding requirement and site of hospital admission.

Figure 1. Triage flow of COVID19 patients

These are general guiding principles to decide which patients should be admitted. However, the treating physician should take the final call on admission, after careful clinical evaluation.





COVID 19 Management Protocol for Admitted patients with COVID19

All admitted patients shall be closely monitored with:

   

heart rate, blood pressure,

respiratory rate, and
oxygen saturation (pulse oximetry).



Investigations to be done in Admitted Patients: These investigations should be done in all admitted patients with

• Mild disease with risk factors for development of severe disease

• According to clinical judgement of treating physician for all other patients`

• The essential investigations include:

• CBC, LFT, KFT, Chest X Ray, ECG, HbA1C, Blood sugars

• LDH, CRP (preferably quantitative)

• D-DIMER

• PT/INR

• Ferritin and

• IL6 (subject to availability and if indicated)

• CT Chest: Not usually required. It should only be done in cases of:

• Diagnostic dilemma ( when Xray chest inconclusive, RTPCR negative but clinical condition highly suspicious of Covid 19 infection)

• Suspected pulmonary embolism, any alternate diagnosis or complications (pneumomediastinum)

Management of admitted COVID19 patients with mild COVID19

Most of these patients require symptomatic treatment along with management of their pre-existing diseases or comorbidities.

The commonly prescribed treatment in this group includes:

  Antipyretics: Paracetamol in case of fever, as required

  Antibiotics: (Azithromycin/Doxycycline + Amoxycillin-Clavulanate), if clinically indicated

  Other therapies

o Favipiravir approved by DGCI: Very high doses (3600 mg on Day 1, followed by 1600 mg from D2-14), efficacy unclear

o Ivermectin: 12 mg once a day for 3 to 5 days; commonly prescribed but unclear efficacy

o Vitamin C: 500 mg twice to thrice a day

o Other vitamin supplementations: Zinc, Vitamin D

 Treatment of Comorbidities: All patients should continue taking medications for co- morbidities like hypertension, coronary artery disease, hypothyroidism and others. For example:

o Patients receiving angiotensin converting enzyme (ACE) inhibitors or Angiotensin II receptor Blockers (ARBs) should continue the same.

o In patients with immunologic disorders and post transplantation receiving immunomodulatory agents, treatment shall be modified after discussion with decision to discontinue prednisone, biologics, or other immunosuppressive drugs be determined on a case-by-case basis

  In patients at risk of severe disease: Inj. Enoxaparin 0.6 subcutaneously once a day (Twice a day if D-DIMER is greater than 500 ng/ml)

  Special Considerations for patients with pre-existing Diabetes Mellitus

o Monitor HbA1C and blood glucose at baseline
o If controlled, can continue metformin
o Monitor blood glucose 6 hourly or as indicated; target a finger prick blood glucose of

180-200 mg/dl
o Keep close watch in patients on methylprednisolone/dexamethasone

 Non-Pharmacologic Interventions:

o Regular physical activity: Patients should be encouraged to be active, and walk around in their rooms or ward, for at least a total duration of 30 to 45 minutes daily.

o Awake proning: Awake proning improved oxygen saturation, due to improved ventilation perfusion ratio. Therefore, patients should be encouraged to do awake proning, that is, lying on their tummy, and in lateral positions, and to avoid supine posture.

o Physiotherapy: Subject to availability, patients should undergo supervised

physiotherapy sessions, during their hospitalisation.



COVID 19 Management Protocol for Admitted patients with Moderate COVID19



In addition to the investigations (as above), patients with moderate disease (Spo2 90%-94%) should include:

 Supplemental Oxygen Therapy: Initiate @ 5L/min,; Target SpO2 > 92-96%  Remdesivir:

o Emergency approval/DGCI approval
o 200 mg IV as a single dose on day 1, followed by 100 mg once daily for a total duration

of 5 days
o Indicated in moderate to severe disease
o Other indications (subjective), with no clearly known benefit: CT Score more than 9/25;

nonresolution of fever despite antipyretics >48 hrs

o See baseline Liver and renal function tests; don’t give if baseline transaminases (AST/ALT) >5 times of upper limit of normal) or chronic renal failure with Creatinine Clearance of <30 ml/ min

 Low Dose Systemic Steroids

o Have been shown to be beneficial and have mortality benefit in patients with moderate to severe disease

o Should be initiated along with Remdesivir
o Methylprednisolone 40 mg twice a day or Dexamethasone 6 mg once a day can be

given for a period of 7 to 10 days
o Blood sugars should be frequently monitored (6-8 hourly) in patients receiving

systemic steroids. Finger prick blood glucose monitoring should be preferred, to

venous sampling. Insulin should be used for blood sugar control o May be stopped once patients improve, and are off oxygen

  Thromboprophylaxis: Inj. Enoxaparin 0.6 subcutaneously once a day (Twice a day if D-DIMER is greater than 500 ng/ml)

  Symptomatic treatment: as above

  Management of Comorbidities: as above

  Monitoring: These patients should be kept under close monitoring for development of
hypoxemia, hemodynamic instability or other complications. This should include monitoring of SpO2, heart rate and blood pressure, and for other signs of respiratory failure. If patients deteriorate, management should be modified as for severe or critical COVID19.

  Rational use of oxygen, Remdesivir and systemic steroids is outlined in appendix.

 

COVID 19 Management Protocol for Admitted patients with Severe or Critical COVID19

• Recognize hypoxemic respiratory failure –



In addition to management for admitted patients with moderate COVI19, treating physicians should consider the following:

• Hypoxemia/increased work of breathing despite O2 @ 10-15 L/min

• Consider HFNC/NIV in selected patients with monitoring for clinical deterioration

• Intubation with aerosol precautions by trained and experienced provider

• Mechanical ventilation using ARDS protocol

• Recognize and treat septic shock – hemodynamic monitoring and early initiation of optimal antibiotics as per clinical scenario

• Prevention of complications/supportive care

• DVT prophylaxis (using prophylactic or therapeutic doses of enoxaparin as above)

• Stress ulcer prophylaxis (Inj. Pantoprazole 40 mg iv once a day, or Inj. ranitidine 150
mg iv twice a day)

• Early mobilization (using passive and active physiotherapy)

• Pharmacologic management: Remdesivir and systemic steroids as in patients with moderate disease

• Immunomodulation: In patients with increasing oxygen requirements or worsening respiratory failure, and increasing inflammatory markers like CRP greater than 100 mg/dl or Interleukin 6 levels greater than 40 pg/ml, consider:



• Tocilizumab 4-8 mg/kg single dose, usual dose400 mg iv, OR

• Itolizumab 1.6 mg/kg single dose, usual dose 100 mg iv

 

A brief overview of Mechanical Ventilation in patients with critical COVID19

Strategies for mechanically ventilated patients is as per ARDS NET protocol. A brief overview of initial ventilatory settings and target parameters is shown below:



Initial ventilatory settings and target parameters in COVID19 patients requiring invasive mechanical ventilation

ARDS Net Protocol is provided in appendix.

Rational Use of Remdesivir

Remdesivir has been approved under emergency usage in India in patients with moderate to severe disease. There is no clear evidence of its benefit in COVID19 as per recent meta-analysis by World Health Organisation. However, it continues to be used in admitted patients with moderate to severe disease, in accordance with Indian guidelines. Following are important points to be considered when using remdesivir:

 Indications:

o Admitted COVID19 patients with moderate to severe disease
o Other criteria (subjective): no clearly known benefit: CT Score more than 9/25;

nonresolution of fever despite antipyretics >48 hrs

 Dosing: 200 mg IV as a single dose on day 1, followed by 100 mg once daily for a total duration

of 5 to 10 days
 See baseline LFT/RFT; don’t give if elevated liver enzymes (AST/ALT >5 Upper limit of normal

values) or CKD with creatinine clearance of <30 ml/min or on hemodialysis



Rational Use of Systemic Steroids

Low dose systemic steroids have shown to provide mortality benefit in patients with moderate to severe COVID19, i.e., patients requiring oxygen supplementation or ventilatory support. However, there is some indication of harm, if given alone, in non-severe disease, especially in early period of illness. Therefore, systemic steroids should be given only when indicated. The following points should be considered while administering systemic steroids:

  Indications: Moderate, severe or critical COVID19 (patients on oxygen or ventilatory support)

  Commonly used steroids are methylprednisolone and dexamethasone.

  Methylprednisolone 40 mg twice daily or dexamethasone 6 mg once daily should be
prescribed for a period of 7 to 10 days.

  Patients should be monitored for impaired blood sugars, and short acting insulin should
be used accordingly.

Rational Use of Oxygen

All patients should be monitored for hypoxemia, i.e., saturation of 94% or less on room air.

Patients with SpO2 94% or less, should be initiated on oxygen supplementation. Target oxygen saturation is 92 to 96%. All patients do not require high flow of oxygen to maintain target saturation.

There are grossly two types of oxygen delivery systems. These are:

  Low flow systems: These provide low flow oxygen, and are not suitable for patients with increased respiratory rate or work of breathing. Examples are nasal prongs.

  High flow systems: These can provide high flows, and have capability to meet the high respiratory demands of patients. Examples are non rebreathing mask ( NRM) with reservoir, and high flow nasal cannulae.
Table. How to choose the correct oxygen delivery device for COVID19 patients

Modality



Type of Delivery System



Flow rates



Oxygen delivery

Remarks



Nasal prongs

Low flow

Upto 5 litre/min

Upto 40% FiO2

Suitable for patients with less oxygen requirement
No need to remove while eating and drinking

Cannot deliver higher FiO2

Face Masks



Low/variable flow



Should be higher than 5 litres/min



Can deliver upto 60% Fio2 at 10 litres/min

May be used for patients requiring 5 to 10 litres/min oxygen
In tachypneic patients, nonrebreathing masks preferred

Venturi Masks



Low/variable flow





Upto 15 litres/min





Upto 60%



May be used for patients requiring 5 to 15 litres/min oxygen
Better titration of FiO2

Non rebreathing masks with reservoir

High flow

14-16 litres/min

Upto 90%

Best used in patients requiring high flows and with high ventilatory demand

High Flow nasal cannula

High flow

Upto 60 litres per minute

Upto 100%

High aerosol generating
Health care workers should take adequate precautions Consumes maximum oxygen Use only when indicated

Noninvasive or invasive mechanical Ventilation

High flow

As per specifications and demand

Upto 100% (via critical care ventilator)

Can deliver high oxygen, and can also provide positive pressure. To be used if all other modalities not working

Important Investigations with Reference Values in COVID19



A list of various drugs commonly used in the management of COVID19

Drug

Route of administratio n

Dosing

Durati on

Contra indicat ions

Advers e Effects

Monitorin g

Remark s

Paracetamol

Oral or intravenous

500 mg (oral) or upto 1000 mg (intravenous)

As neede d

Try not to exceed 2 grams per day

Vitamin C

Oral or intravenous

500 mg to 1 gram

7-10 days

–

Hypero xaluria (with large doses)

–

–

Zinc

oral

50 mg once a day

 

7-10 days

 

–



–



–

–

Azithromycin

Oral or intravenous

500 mg

5 days

 

Prolon ged QTc Hypers ensitivi ty

Cardiac arrhyth mias



ECG if given concomita ntly with QTc prolonging drugs

To be given only if suspect ed seconda ry infectio n

Doxycycline

oral

100 mg twice a day

7 days

childre n <8 years , second and third trimest er of pregna ncy, breastf eeding



Dysglyc emia Elevate d LDH

–

To be given only if suspect ed seconda ry infectio n

Favipiravir

oral

1800 mg twice a day on Day 1 Followed by 800 mg twice a day

Upto 14 days

Hypers ensitivi ty to favipir avir or any compo nent of the formul ation; severe renal or hepati c

hyperu ricemia

–

? Efficacy Not studied in modera te to severe disease

impair ment; pregna ncy; breastf eeding

Remdesivir

intravenous

200 mg on day 1, followed by
100 mg once a day from day 2 to day 5

5 days

Hypers ensitivi ty to drug Use with cautio n if GFR < 30 ml/mi n or elevat e transa minase s (> 5 times upper limit of normal )



Hypote nsion Bradyc ardia

Liver and kidney function tests Discontinu e if worsening renal function, or liver enzyme elevation > 5-10 times

Only in modera te to severe disease

Ivermectin

oral

12 mg

3 to 5 days

Avoid use in patient with weight <15 kg Pregna ncy

Allergic or immun ologic reactio ns (uncom mon in COVID1 9) Tachyc ardia periphe ral edema Dizzine ss Diarrhe a, nausea Transa minitis

Liver function tests

No clear evidenc e of benefit

Methylprednisol one

Oral or intravenous

40 mg twice a day

7-10 days

hypers ensitivi ty to compo nents



dysglyc -emia second ary



blood sugars secondary infections

only in modera te to severe disease



Dexamethasone

Oral or intravenous

6 mg once a day

7-10 days

infectio ns

Tocilizumab

intravenous

4-8 mg/kg

Single dose

Hypers ensitivi ty Sepsis/ septic shock Invasiv e fungal infecti on

Second ary infectio ns Hypers ensitivi ty

–

Only in patients with worseni ng oxygen require ments and increasi ng inflamm atory markers , after ruling out seconda ry infectio n

Itolizumab

intravenous

1.6mg/kg

Single dose

–

Enoxaparin

subcutaneous

40-60 mg

 

Once or twice a day

Bleedi ng diathe sis throm bocyto penia





Bleedin g

Platelet count Clinical evidence of bleeding

IF normal D Dimer give once a day. Twice a day if elevate D Dimer (>500 ug/ml)

Step Down Criteria (From HDU/ICU→ General Wards→ Discharge/ Home isolation)

Once patient is hemodynamically stable, with decreased oxygen requirements and shifted to nonrebreathing masks or face masks, he/she can be shifted to high dependency units. Patients requiring low flow oxygen or maintaining saturation on room air can be shifted to general wards.

All patients should be closely monitored for hemodynamic stability, development of secondary infections, increase in oxygen requirement and blood glucose control.

Once a patient is on room air, and co-morbidities are well controlled, treating team should start counselling them for discharge. Investigations that were abnormal earlier, shall be repeated to document improvement or normalisation, or to plan continuation of treatment on discharge.

Criteria for Discharge or Home Isolation



The following patients can be discharged to home isolation:

  No fever (without antipyretics) for last 3 days

  Maintaining acceptable oxygen saturation (SpO2>94%) on room air for last 3 days

  Comorbidities are well-controlled



All patients discharged to home isolation should be instructed to return to hospital if they develop worsening of illness. Duration of home isolation should be a total of 17 days from onset of symptoms.

Negative RTPCR reports are not pre-requisite for discharge. Only following patients should undergo repeat nasopharyngeal/ oropharyngeal swab RTPCR testing, and should be negative prior to discharge:

  Severe COVID19 infection

  Immunocompromised status

  Active malignancy

 

Appendix

Websites for relevant information

1. Up to date, all resources and information on COVID19 management in hospitalised adults

COVID-19: Management in hospitalized adults – UpToDate

2. MP Government Resources on COVID19: CORONA VIRUS | Directorate of Health Services, Government of Madhya Pradesh,India (mp.gov.in)

3. Rational Use of Remdesivir (Guidance from Govt of MP): L.No_.508-11-04-2021.pdf (mp.gov.in)

4. ARDS NET Protocol link for mechanically ventilated patients: Microsoft Word – 6mlcardsmall_2008update_final_JULY2008.doc (ardsnet.org)

5. Awake Proning: Guidance and Patient Instructions for Proning and Repositioning of Awake, Nonintubated COVID‐19 Patients – Bentley – 2020 – Academic Emergency Medicine – Wiley Online Library

6. Clinical Management MoHFW Govt of India Guideline: NATIONAL CLINICAL MANAGEMENT PROTOCOL COVID-19 (mohfw.gov.in)

7. Management of Diabetes in COVID19, Indian Guideline:
ClinicalGuidanceonDiabetesManagementatCOVID19PatientManagementFacility.pdf
(mohfw.gov.in)

8. WHO Therapeutics Guideline for COVID19: Therapeutics and COVID-19: living guideline
(who.int)

               

 

 









   

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Name of The Hospital ………………………………………

कोविड िाडड———— वि ड ग———— ोर/िाडड——————

डि चा ज/होम आईसोलेशन के संबंध म िॉ टरी सलाह

1. विना क——————– तक घर पर आइसोलेट रह ।

2. आइसोलेशन की अिवि म एक ही कमरे म रह विसका उपयोग अ य पररिारिन न कर ।

3. केयरटेकर यूनतमछ:फीटकीिूरीरख ।

4. के यर टेकर मरीि की िेखभाल के समय वटिपल लेयर मा क अि य लगाये रख ।

5. मरीि ारा उपयोग वकये ितडनो को ल स पहनकर अ छी तरह सािुन पानी से िोय । इसके िाि
पुन: अपने हाथ सािुन पानी से िोय ।

6. हर िो-तीन घ टे म थमाडमीटर से िुखार नाप ।

7. हरतीनघ टेम प सऑ सीमीटरसेऑ सीिनलेिलनाप ।94 वतशतसेकमहोनेपरडॉ टरया
वनकट के अ पताल/ कोरोना क टिोल म म स पकड कर ।

8. ितायी गयी ििाय वनयवमत लेते रह ।

9. होम आइसोलेशन की वनिाडररत अिवि पू ड होने के िाि िोिारा कोविड िा च (RTPCR) कराना



आि यक नही है।
10. समय पर भोिन कर ।
11. पानी विन भर म कम से कम 2.5 से 03 लीटर वपय । 12. यथास भि मौसमी फल खाय ।
13. िय को य त रख ।
14. सकारा मता िनाये रख ।
15. वकसी भी सहायता के

07612679007
16. वन न ििाओ का सेिन कर ।

स पकड कर ।

वलये हे प डे क न िर पर

07612637500-505,

1. Tab. Vitamin C 500mg BD 10 विन

2. Tab. Zinc 50 mg BD 10 विन

3. Tab. Paracetamol 500mg (िुखार आने पर) 10 विन

4. Tab. Multivitamin/Calcium 1 Tab OD 10 विन

5. ……………………………………………………..

6. ………………………………………………………

7. ……………………………………………………..

8. ……………………………………………………….

9. ………………………………………………………

10. …………………………………………………………..

     

(SIGNATURE OF DOCTOR ON DUTY )

डि चा ज / ेप िाउन मापदंि

1. तीन विन से कोई िुखार नही।

2. तीन विन से कोई ऑ ीिन वडमा ड नही।

3. को-मोविडवडटी, यथा उ र चाप, डायविटीि अ ग भीर िीमाररया वनय वित हो।

4. ूमोवनया वनय वित हो।

5. ग भीर मरीिो म RT-PCR (Repeat) नेगेवटि हो अ मरीिो म Repeat RT-
PCRकीआि कतानही है।17वििसके पूिडवड चािडवकएिानेकी थवतम उ 17 वििस के वलए होम आइसोलेशन स ि िी सलाह भी िे
(SIGNATURE OF DOCTOR ON DUTY )