Protocols to follow for severe COVID-19 patients

Posted by

Salient Points

The following article focuses on the various protocols to be kept in mind when a COVID-19 patient is shifted to the ICU for further management. It includes the following:

  • Ventilator management
  • Fluid management
  • Risk of Ventricular Arrhythmia due to HCQ-Azithromycin treatment for COVID-19
  • Experimental treatment regimes
    • Systemic corticosteroids
      • =< 0.5 – 1 mg/kg/day methylprednisolone
    • In severe cases
      • Azithromycin – 500mg OD for 5 days
      • If in combination with HCQ – Monitor QTc interval
    • Antiviral
      • Lopinavir-ritonavir – 400mg/100mg PO BID for 14 days
    • IL-6 Blockers
      • Tocilizumab – single dose 400mg i.v – in sHLH (rising ferritin, cytopenias and/or an HScore > 170
    • IVIG
    • Convalescent plasma

Risk of Ventricular Arrhythmia associated with HCQ-Azithromycin treatment for COVID-19

Highest Risk associated with:

  1. >= 2 QTc prolonging drugs
  2. Sepsis
  3. HF

Moderate Risk associated with:

  1. Acute MI
  2. QTc at admission >= 450ms
  3. Serum K+ =< 3.5 mEq/L

Other Risk factors

  1. Age >= 68 y/o
  2. Female Sex
  3. Loop Diuretic

Note:

  • USA clinical trial – Two doses of Tocilizumab – 8mg/kg – maximum of 800mg per dose – interval of 12 hours.
  • Suggested to use risk score while administering HCQ along with Azithromycin in patients with pre-existing heart disease.

Risk of Ventricular Arrhythmia due to HCQ-Azithromycin treatment for COVID-19

  • Highest Risk associated with:
  1. >= 2 QTc prolonging drugs
  2. Sepsis
  3. HF
  • Moderate Risk associated with:
  1. Acute MI
  2. QTc at admission >= 450ms
  3. Serum K+ =< 3.5 mEq/L
  • Other Risk factors
  1. Age >= 68 y/o
  2. Female Sex
  3. Loop Diuretic

Detailed Summary

The following are protocols to follow for severe COVID-19 patients.

  • Careful use of NIV/HFNC – reduce risk of aerosol generation
  • Ventilator management as per ARDS protocol
  • Follow SSC guidelines for fluid management
  • Follow standard procedures for ventilated patients
  • Usage of Closed suction and HME filters
  • Prone ventilation
  • ECMO for refractory hypoxemia

If patient shows Improvement with respect to clinical or radiological findings –

  • Discharge if 2 Samples over 24 hours apart are negative

Alternate treatment plans (Based on individual)

Note – NO sufficient evidence is available for any as of date of publishing of article

  1. Systemic corticosteroids
    1. =< 0.5 – 1 mg/kg/day methylprednisolone or equivalent (< 1 week)
    2. Max dose – 2 mg/kg/day
  2. In severe cases
    1. Azithromycin – 500mg OD for 5 days
    2. If in combination with HCQ – Monitor QTc interval
  3. Antiviral
    1. Lopinavir-ritonavir – 400mg/100mg PO BID for 14 days
  4. IL-6 Blockers
    1. Tocilizumab – single dose 400mg i.v – in sHLH (rising ferritin, cytopenias and/or an HScore > 170
  5. IVIG
  6. Convalescent plasma

Note:

  • USA clinical trial – Two doses of Tocilizumab – 8mg/kg – maximum of 800mg per dose – interval of 12 hours.
  • Suggested to use risk score while administering HCQ along with Azithromycin in patients with pre-existing heart disease.

Risk of Ventricular Arrhythmia due to HCQ-Azithromycin treatment for COVID-19

  • Highest Risk associated with:
  1. >= 2 QTc prolonging drugs
  2. Sepsis
  3. HF
  • Moderate Risk associated with:
  1. Acute MI
  2. QTc at admission >= 450ms
  3. Serum K+ =< 3.5 mEq/L
  • Other Risk factors
  1. Age >= 68 y/o
  2. Female Sex
  3. Loop Diuretic

Leave a Reply

Your email address will not be published. Required fields are marked *