COVID-19 Clinical Management Guidelines

Cayuga Health System (CHS)
Cayuga Medical Center/Schuyler Hospital

COVID-19 Clinical Management Guidelines

Reviewed: 04/28/2020 Version 4
Author: Dr. de Lima

Disclaimer: This document is intended as a resource for clinicians caring for non-critically-ill as well as critically ill COVID-19 patients, based on available evidence and recommendations of governing bodies. These recommendations do not replace clinical judgment or the need for individualized patient care plans. While we attempt to keep this document up-to-date, the literature on COVID-19 is rapidly evolving, and we suggest that practitioners search for the most up-to-date literature on any specific topic.

Introduction

Transmission

Presentation

PPE

CHS PPE Guidelines COVID

Discontinuation of isolation

Testing criteria

CHS COVID-19 Testing Criteria

HCP exposure

Staff Community Exposure Protocol

CHS CHP Exposure guidelines

Laboratory

Imaging

Clinical Course

Patients at risk for poor outcomes

Indications for ICU admission/transfer

  • Usual ICU admission indications, but with lower threshold due to concern for rapid deterioration and advantages of early intubation. Examples:
    • Provider concern
    • Respiratory distress: Need O2 > 6 LPM to maintain SpO2 > 92 or PaO2 > 65, rapid escalation of oxygen requirement, significant work of breathing.
    • Hemodynamic instability after initial conservative fluid resuscitation with SBP < 90, Mean arterial pressure < 65, or Heart rate > 120.
    • Acidosis: ABG with pH < 7.3 or PCO2 > 50 or above patient’s baseline; lactate > 2.
    • Need for intensive nursing care or frequent laboratory draws requiring arterial line.
    • Severe comorbid illness / high risk for deterioration.

Management

  • Discuss code status early and regularly. CPR is unlikely to help with respiratory disease.
  • Management is largely supportive
  • Volume status: Limit fluids, balanced solutions preferred (LR). Hypokalemia may limit ability to diurese
  • NSAIDS: Reports from France indicated possible increase in mortality with ibuprofen in COVID-19 infection, but these reports have not been corroborated Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. WHO does not recommend avoiding NSAIDs (03/18/2020). Consider acetaminophen instead of NSAIDs if possible; risk / benefit should be discussed with patients
  • Acetaminophen 975mg PO q8h PRN. Preferred for symptomatic treatment of pain and fever
  • Steroids: There is no clinical evidence of net benefit from steroids in SARS-CoV, MERS-CoV or influenza infection, and observational data show increased mortality, more secondary infections, impaired viral clearance and more adverse effects in survivors Effects of early corticosteroid treatment on plasma SARS-associated Coronavirus RNA concentrations in adult patients; Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. However, a new retrospective cohort (201 patients, 84 [42%] of whom developed ARDS) demonstrated that among patients with ARDS, methylprednisolone decreased risk of death (HR, 0.38; 95% CI, 0.20-0.72) Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. May use corticosteroids if required for other indications and use the lowest dose for the shortest duration:
    • Asthma or COPD exacerbation: 40mg prednisone PO or 30mg methylprednisolone IV, once daily x 3-5 days
    • Shock with history of chronic steroid use > 10mg prednisone daily: 50mg hydrocortisone IV Q6H until improvement in shock
    • Multipressor shock without history of chronic steroid use: 50mg hydrocortisone IV Q6H until improvement in shock
    • Inhaled steroids – if asthmatic patients are already on it, they should be continued COVID-19 and Asthma: What Patients Need to Know
  • ACEI/ARB: ACC/AHA/HFSA Joint Statement (3/17/20): “The HFSA, ACC, and AHA recommend continuation of RAAS antagonists for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial, such as heart failure, hypertension, or ischemic heart disease. In the event patients with cardiovascular disease are diagnosed with COVID-19, individualized treatment decisions should be made according to each patient’s hemodynamic status and clinical presentation. Therefore, be advised not to add or remove any RAAS-related treatments, beyond actions based on standard clinical practice.” HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19
  • Bronchodilators: Insert link to CHS COVID-19 MDI guidelines
    • COVID-19 positive / PUI & non-intubated patient: Albuterol MDI – ideally with spacer
    • COVID-19 positive / PUI intubated patient: Albuterol nebulizer through Aerogen (closed circuit)
    • Non COVID-19 / non PUI patient with bronchospasm: Albuterol/Duoneb via nebulizer
    • Patients on inhalers as outpatient should be encouraged to bring their own medication.
  • OSA: Patients with OSA should continue to wear their own CPAP/BiPAP (or hospital provided) overnight and be on airborne precautions while on it
  • Statins: Continue statins if already prescribed. If no contraindication, and for those who have a guideline indication for a statin, consider starting Atorvastatin 40mg daily. Cardiovascular disease is a major risk factor for COVID-19 disease severity. Additionally, statins may help promote antiviral innate immune response.
  • Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): A Review | Clinical Pharmacy and Pharmacology | JAMA
  • Antiviral and immune-modulating therapies are investigational – we recommend hydroxychloroquine to patients with moderate or severe disease (patients with at least one Category 1 and one Category 2/3 feature admitted to the floor or any patients in ICU or with progressive disease)

 

Epidemiological – Category 1 Vital Signs – Category 2 Labs – Category 3
Age >55 Respiratory rate > 24 D-dimer > 1000 ng/mL
Pre-existing pulmonary disease HR > 125 CPK > twice upper limit of normal
CKD SpO2<90% on RA CRP > 100
DM with A1c>7.6   LDH > 245 U/L
HTN   Elevated troponin
Cardiovascular disease   Admission absolute lymphocyte count < 0.8
Use of biologics   Ferritin > 300 ug/L
Transplant or other immunosuppression    
HIV CD4<200 or unknown    

  

 

Steroids

Anticoagulation

VTE prophylaxis for ICU patients

Indication CrCl CrCl AKI/HD CRRT
VTE prophylaxis ≥30 ml/min

Enoxaparin 0.5mg/kg SQ q12h

<30 ml/min and ≥10ml/min

UFH 5,000 units SQ q8h

UFH 5,000 units SQ q8h UFH 5,000 units SQ q8h
HIT or suspected HIT Fondaparinux 2.5mg SQ daily Fondaparinux 2.5mg SQ daily (requires Hematology consult) Requires Hematology consult

 

Requires Hematology consult

 

 

VTE treatment for ICU patient

Indication CrCl CrCl AKI CRRT
DVT/PE ≥30 ml/min

Enoxaparin 1mg/kg SQ q12h

UFH IV continuous infusion UFH IV continuous infusion UFH IV continuous infusion
HIT or suspected HIT Fondaparinux

>100kg 10mg SQ daily

50-100kg 7.5mg SQ daily

<50kg 5mg SQ daily

 

Argatroban infusion (Requires Hematology consult)

 

Argatroban infusion (Requires Hematology consult)

 

 

Argatroban infusion (Requires Hematology consult)

 

  

VTE prophylaxis for non-ICU patients

Indication CrCl CrCl AKI/HD CRRT
VTE prophylaxis ≥30 ml/min

Enoxaparin 0.5mg/kg SQ q12h

<30 ml/min and ≥10ml/min

UFH 5,000 units SQ q8h

UFH 5,000 units SQ q8h UFH 5,000 units SQ q8h
HIT or suspected HIT Fondaparinux 2.5mg SQ daily Fondaparinux 2.5mg SQ daily (requires Hematology consult) Requires Hematology consult

 

Requires Hematology consult

 

 

Thromboprophylaxis at discharge

VTE risk factor VTE risk score
Previous VTE 3
Known thrombophilia 2
Current limb paralysis of paresis 2
History of cancer 2
ICU/CCU stay 1
Complete immobilization ≥ 1 day 1
Age ≥ 60 1
Elevated d-dimer > 2 ULN 2

 

  • Score ≥4 or a score of 2-3 plus elevated d-dimer
  • Duration: at least 2 weeks AND until fully ambulatory
  • Options:
    • Apixaban 2.5mg PO q12h
    • Rivaroxaban 10mg PO daily
    • Rivaroxaban 10mg daily x 5 days followed by Aspirin 81mg PO daily for patients with no insurance coverage
    • If oral intake unreliable due to nausea and vomiting:
      • Enoxaparin 40mg SQ daily BMI <30
      • Enoxaparin 30mg SQ q12h BMI ≥30 and <40
      • Enoxaparin 40mg SQ q12h BMI ≥ 40

Respiratory support and intubation

 

    • Humidified nasal cannula (NC) 1 to 8 LPM for target SpO2 92-96% (88-94% in oxygen-dependent COPD)
    • If a patient requires > 8 LPM NC, initiate dry oxy mask (non-humidified to reduce aerosolization risk)
      • Start oxy mask at 9 LPM and FiO2 28%
      • Up-titrate FiO2 to goal SpO2 of 92-96% (not exceeding FiO2 35%)
      • If FiO2 > 35% then increase flow to 12 LPM
    • Change to HFNC at flow rate less than 30L

    • Awake proning:
      • This involves a non-intubated patient on nasal cannula who prone themselves by lying on their belly.
      • Can be combined with simultaneous use of any other noninvasive support device (e.g. low-flow nasal cannula, high-flow nasal cannula, BiPAP, or CPAP).
      • Requires cooperative patients with intact mentation.
      • Could be useful especially in situations where access to invasive ventilation is limited.
      • Encourage proning as much as is tolerated (ideally ~12-18 hours/day, but this may be difficult for some patients).
      • Follow oxygenation and FiO2 requirements. Ideally an improvement in oxygenation should be seen within a few hours.  If no change in oxygenation is observed, ongoing pronation may have less merit.
    • Non invasive ventilation:
    • Intubation:
  • Case reports from China suggest high failure rates for non-invasive ventilation, including high-flow nasal oxygen (Zuo et al., Chin Med Sci J, 2020)
  • For patients on NC 6 liters and SpO2<92% – initiate arrangements for “elective” intubation
  • For patients maintained on oxy mask, once FiO2=60% and SpO2 < 92%, or RR>30, AMS, paradoxical respiration, or increasing WOB, call for intubation if patient is a candidate for mechanical ventilation
  • Standard, contact, airborne precautions: N95 or PAPR, gown, eye protection, gloves. PPE Guidelines COVID
  • All ABC alerts will be attended by essential personnel only (one provider, two BLS trained compressor, respiratory therapist, ICU RN, ED RN, 4S RN [recorder]). House supervisor and pharmacist will attend but not enter room.  House supervisor will call additional resources if needed. Back up support personnel outside only (see picture below). ABC FLYER

Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group

  • “Closed” pre oxygenation with oxymask and viral filter on BMV before start. Apneic Oxygenation with NC with flush flow
  • Avoid bag-masks due to risk of aerosolization, always use a viral filter. If absolutely needed, use small tidal volumes + 2 person technique to ensure tight seal
  • Most skilled non trainee operator available. First pass success keeps the team safe
  • True RSI (succinylcholine and etomidate), no BMV, with paralytic (Rocuronium) + VL (Glidescope)
  • Backup supplies kept outside of room with personnel outside to provide supplies
  • Proning: Good clinical response per reports from China and Italy. Resource burden recognized Proning guidelines
  • Avoid the following unless absolutely necessary:
    • Nebulizer treatments (Bronchodilators, Hypertonic saline), chest PT of any kind; induced sputum samples
    • Bronchoscopy: Very limited role, to be essentially avoided. Need ICU attending approval.

Mechanical ventilation

CHS Guidelines for management of ARDS and COVID

Guidelines for discharge

Guidlines for Discharging Inpatients with COVID 19.docx

Complication/Prognosis

  • Hypokalemia: can be severe/refractory, use IV + oral supps. Especially life threatening if NICM. Consider spironolactone/eplerenone if BP/GFR stable.
  • Hypoalbuminemia can be severe and require supplementation
  • Median hospital LOS in severe patients 13 days (11.5 – 17.0). Mortality rate unclear, likely <1 – 2%
  • Cardiac:
  • Septic shock
    • Goal MAP > 65mmHg
    • Start Norepinephrine while determining the etiology of undifferentiated shock
    • We do not recommend conventional 30cc/kg resuscitation: Give 250-500cc IVF and assess in 15-30 minutes for increase > 2 in CVP, increase in MAP or decrease in pressor requirement. Use isotonic crystalloids; Lactated Ringer’s solution is preferred where possible. Avoid hypotonic fluids, starches, or colloids
    • Unless new evidence emerges, standard choices for distributive shock (e., norepinephrine then vasopressin) are recommended.
  • Cardiogenic shock
    • May present late in the course of illness even after improvement of respiratory symptoms, and manifest as a precipitous clinical deterioration in the setting of an acute decline in LVEF
    • Norepinephrine gtt for goal MAP 65-75
    • Diuretic therapy for CVP > 14, PCWP >18, PAD > 25
    • Inotropic support with Dobutamine gtt for SCvO2 < 60%, CI < 2.2 and MAP > 65. Start at 2mcg/kg/min. Up-titrate by 1-2mcg/kg/min every 30-60 minutes for goal parameters. Alternative strategies should be considered once dose exceeds 5mcg/kg/min.  Maximum dose is 10mcg/kg/min.
    • Ensure negative inotropes such as beta blockers, calcium channel blockers and antihypertensives are discontinued.
  • Cytokine Activation Syndrome
    • Subgroup of patients with severe COVID-19 may have cytokine storm syndrome and secondary HLH. Patients who had cytokine storm developed rapid progression to ARDS, shock, and multiorgan failure COVID-19: consider cytokine storm syndromes and immunosuppression
    • IVIG, steroids, cytokine blockade (IL-6 and IL-1)may be useful. While steroids have been implicated with worse lung injury and outcomes, they may be beneficial in the hyperinflammatory state.

Causes of death

Discharge education

 

Other Sources:

EMCrit – COVID-19

UW Medicine COVID-19 Resource Site

Crouse Critical Care Services COVID-19 Resource copy.pdf

SCCM COVID19 guidelines.docx

BWH Covid-19 Protocol

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