COVID-19 MANAGEMENT PROTOCOL FOR HOSPITALIZED PATIENTS

Version-4

December 2021

COVID-19

MANAGEMENT PROTOCOL FOR HOSPITALIZED PATIENTS

ACME

AsiaED Collegium of Medical Education

DCCET

COVID 19 RT-PCR POSITIVE SYMPTOMATIC PATIENT

1) Management of any COVID 19 patient mandates the Health Care Personnel (HCP) to be in full Personal Protection Equipment (PPE)

2) Asymptomatic COVID 19 patient management involves strict containment, isolation and observation for any symptoms.

SYMPTOMS

Respiratory symptoms ( Cough & Shortness of breath) with or without Fever, Sore Throat, Myalgia, Diarrhea, Headache, Fatigue,

Nausea and Vomiting, Anosmia & Loss of taste

Disclaimer : There is no conclusive evidence of outcome benefit with the use of antiviral drugs and novel therapies listed below. However the suggestions made are derived from the prevailing trials published so far & collation of literature

that has come out so far. These recommendations would change with the evolving evidence.

COVID 19 SYMPTOMATIC

Mild disease SpO2 ≥ 94%

[ Symptoms of fever,

sore throat, bodyache, fatigue running nose, cough, anosmia ]

Home Isolation

Monitor SpO2 4hrly Do 6min walk test 4hrly if SpO2 drops ≥ 4%

consult doctor

T. Paracetamol 650 mg SOS Budesonide inhaler 200mcg 2 puffs 6 hourly.

Breathing exrcises (refer video)

Moderate disease

Symptoms with SpO2 ≥ 94%

Hospitalization

O2 Supplementation Target SpO2 92 – 94%

Encourage Awake Proning (Refer Picture)

COVID-19 MANAGEMENT PROTOCOL

If any one of them ~ Age > 60yrs, Obese (BMI > 30) or other Comorbidities like DM, Heart Failure CKD etc…

start T.Molnupiravir 800mg BD X 5days

(preferably with in symptom onset of 5 days) Or T.Paxlovid (currently not available in India)

Consider Antibody Cocktail Regeneron 1.2gms IV as infusion over one hour

(to be administered within 7 days

of symptom onset)

If fever persisting at Day 6 with worsening cough get C-RP, TC, DC, LDH, C-RP, Ferritin, d-dimer & CT Chest

if C-RP > 5 times baseline

or CT Severity Score >12/25

or LDH > 450

or D-dimer > 5 Times baseline & persisting fever

Follow moderate disease protocol”

Antiviral : Inj Remdesivir 200mg IV STAT followed by 100 mg IV OD X 5 Days

[Benefit of Remdesivir if administered within 10 of Symptom onset]

Anti-inflamatory : Inj.Dexamethasone 6mg IV OD X 10days

or Equivalent dose of Inj.Methyl- prednisolone (40mg once a day)

Anticoagulation :

Inj Enoxaprine 40mg s/c OD or

Inj Dalteparin 5000U s/c OD

Miscellaneous :

Budesonide inhaler 200mg 2 puff @ 6 hourly

COVID-19 MANAGEMENT PROTOCOL

SEVERE DISEASE (NEEDING HFNC/NIV)

( Send TC, DC, Blood C/S X 2 sets, urine rout and micro, Urine C/S, sputum gram stain and culture)

Antiviral :

Inj.Remdesivir 200mg IV stat followed by 100mg OD X 5 days Only if symptom onset is < 10days

Anti-inflammatory :

Inj Dexamethasone 6mg/ Inj Methylprednisolone 36mg Inj. Tocilizumab 8mg/kg as infusion (over 2 – 4 hrs) Tab. Tofacitinib 10mg BD X 5days

Tab. Baricitinib 2mg BD X 14days

Anti-Coagulation :

Tab. Enoxaprin 40mg s/c OD

ONLY IN PROVEN CASE OR HIGH SUSPICION OF VTE

If d-dimer > 10 times baseline, Age < 65 yrs in context of worsening hypoxemia & clinical deterioration consider IV thrombolysis :

Inj. Alteplase 25mg over 2hrs followed by 25mg over next 22hrs

(after discussion with subject expert)

AWAKE PRONING 1 1. 30 minutes – 2 hours :

laying on on belly

22. 30 minutes – 2 hours : laying on on your right side

33. 30 minutes – 2 hours : sitting up

5Then back to position 1 : laying on on belly

4. 30 minutes – 2 hours : laying on on your left side

COVID-19 MANAGEMENT PROTOCOL

RESPIRATORY SUPPORT

SpO2 ≤ 94%

Face mask 5L/min Nasal prong 2-5 L/min

Oxygen

Check – SpO2 SpO2

≥ 94%

< 94%

(send blood cultures,

sputum gram stain and culture)

(in lieu of defecit in oxygen supply it is preferrable to avoid HFNO)

Oxygen on Non Rebreathing Mask @ 10 -15 L/min (NRB)

HFNC

(High Frequency Nasal Cannula)

NIV

(non-invasive ventilation)

[two limbed circuit Expiratory HME filter]

Re-assess every hour, monitor & observe

ABG 4-6hrly

Re-assess every hour

Not improving Signs of fatigue Worsening Oxygenation Rising PaCo2

Obtundation SpO2 < 88% RR > 30/min HR > 120/min ROX index < 2.85

Intubation with full PPE

Expert in Airway to intubate

Follow post – intubation Mechanical ventilation protocol

watch for accessory muscles of breathing

Flow rate FiO2

Nasal prongs 3-4L/min 30-40%

Oxygen mask 6-10L/min 50-60%

NRB mask 10-15L/min 60-90%

COVID-19 MANAGEMENT PROTOCOL FOR HOSPITALIZED PATIENTS

Reassess ROX index every 4th hourly in NIV patients. ROX INDEX = SPO2/FIO2/RR

Experimental or Novel therapies (as part of clinical trial):

If d-dimer > 10 times baseline, Age < 65 yrs in context of worsening hypoxemia & clinical deterioration consider IV thrombolysis :

Inj. Alteplase 25mg over 2hrs followed by 25mg over next 22hrs

Criteria for discharge:

In consensus with subject Expert

Resolution of clinical symptoms ~ patient remaining asymptomatic for 3 days No need for RT-PCR/CBNAAT/True-NAT before discharge

Post discharge ~ home quarantine X 10 days

Encourage proning whilst on any forms of oxygen supplementation including HFNC/NIV

Ancillary measures

Normal Feeding, no dietary restrictions

No role of maintenance IV fluids

Maintain blood glucose levels < 180 mg/ dl

Patients on oxygen should always remain in propped up & prone position Mandatory incentive Spirometry every hour for 35 – 35 breaths

Maintain net-neutral fluid balance in patients on supplemental oxygen

COVID-19 MANAGEMENT PROTOCOL FOR HOSPITALIZED PATIENTS

References:

For steroids:

1) Horby P, Landray M et.al. Recovery Trial (interim report), 16 June 2020

2) Villar J et.al. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomized controlled trial, Lancet 2020;8:267-276

3) Steinberg et.al. NEJM 2006;354:1671-1684

4) Meduri U et.al. Chest 2007;131(4):954-63

5) Tang BM et.al. Crit Care Med 2009;37(5):1594-603

6)The COVID STEROID 2 Randomized Trial. JAMA. 2021;326(18):1807–1817. doi:10.1001/jama.2021.18295

1) Thompson AE et.al. JAMA Int.Med 17 June 2020

2) Sarma et.al. JAMA Int.Med 17 Jan 2020

3) Tellas et.al. JAMA, 15 May 2020

4) Guerin et.al. Prone Position in Severe Acute Respiratory Distress Syndrome, NEJM 2013;368(23)

5) Caputo et al. Early self-proning in awake, non-intubated patients in the emergency department. Academic Emergency Medicine 2020; 27:375–378

6) Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-centre prospective cohort study. Critical care (London, England). 2020;24(1):28.

7) Xavier Elharrar et al. Use of Prone Positioning in Non-intubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure.

JAMA. 2020;323(22):2336-2338

1) Wang et.al. Lancet 16 May 2020;395:1569-78 2) Grein J et.al. NEJM 10 Apr 2020

3) Goldman et.al NEJM 27 May 2020

4) ACTT-I Study Group, NEJM, 5 Nov 2020

1) Selvaraj et.al. Tocilizumab in hospitalized patients with COVID-19: A meta-analysis of randomized controlled trials.

doi: https://doi.org/10.1101/2021.03.23.21254054

2) EMPACTA trial

3) COVACTA trial

4) Parr JB et.al. JAMA Int.Med 20 Oct 2020 5) Gordon A.C et.al. NEJM 25 Feb 2021

For Proning:

For Remdesivir:

For Tocilizumab:

COVID-19 MANAGEMENT PROTOCOL FOR HOSPITALIZED PATIENTS

For Tofacitinib

1) Hayek ME et. al. Anti-Inflammatory treatment of COVID-19 pneumonia with tofacitinib alone or in combination with dexamethasone is safe and possibly superior to dexamethasone as a single agent in a predominantly African American cohort. doi: https://doi.org/10.1016/j.mayocpiqo.2021.03.007.

For Baricitinib

1) Kalil AC et. al. Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19. N Engl J Med 2021; 384:795-807. DOI: 10.1056/NEJMoa2031994

For Thrombolysis

1) Poor HD et.al. MedRxiv 21 April 2020

2) Wang J et.al. J.Thrombosis Haemostasis 2 April 2020

For Budesonide:

1) Ramakrishnan et.al (STOIC study), Lancet Resp.Med. 9 April 2021

For Molnupiravir :

Painter WP, Holman W, Bush JA, et al. Human Safety, Tolerability, and Pharmacokinetics of Molnupiravir, a Novel Broad-Spectrum Oral Antiviral Agent with Activity Against SARS-CoV2. Antimicrob Agents Chemother. 2021;65(5):e02428-20. doi:10.1128/AAC.02428-20

MOVE OUT STUDY , NEJM 16 DEC 2021

For Paxlovid :

Mahase E. Covid-19: Pfizer’s paxlovid is 89% effective in patients at risk of serious illness, company reports BMJ 2021; 375 :n2713 doi:10.1136/bmj.n2713

COVID 19 MANAGEMENT PROTOCOL FOR HOSPITALIZED PATIENTS

Prepared by

Dr. Pradeep Rangappa

Manipal Hospital Yeshwantpur

Dr. Karthik Rao

Manipal Hospital Yeshwantpur

Dr. Prathibha G.A & Dr. Raghavendra Kotal

Manipal Hospital Yeshwantpur

ICU TEAM

Manipal Hospital Yeshwantpur

COVID-19 MANAGEMENT PROTOCOL