Covid -19 Management Protocol - Narayana Health

For a patient with RT-PCR or Trunat confirmed Covid-19 infection or strong clinical suspi-
cion with CT of Corads 4 or 5 at least in absence of a positive RT-PCR or Trunat.
Step 1:
First determine the severity of the illness using the following table.
MILD MODERATE SEVERE

Clinical Criteria
SpO2 > 94 % on Room Air 90 - 94 % on Room Air < 90 % on Room Air
RR (/min) < 24 24 – 30 > 30

Symptoms Fever +/- Fever plus breathing difficultyFever with respiratory distress

Pneumonia involving 1 or Pneumonia involving more

Chest Xray (evaluate
Normal
3 zones in each lung upper, mid and lower zones)
two zones than 2 zones

CT Chest Criteria

Average of the % involvement

Normalof
oreach
< 25 lobe
% < 50% > 50%

Laboratory Findings

< 3.2 > 3.2 >17

NLR
CRP < 20 > 40 >40

Ferritin <500 > 500 > 800

D-dimer <0.5 0.5-1.0 > 1.0

LDH < 300 300 – 400 > 400

IL6 < 5.0 5 – 50 > 50, or rising

LFT Normal Slight Derangement Moderate Derangement

 SE-
MILD MODERATE
VERE

Treatment

T. Paracetamol 500 mg QID; in high fever not settling can give 1 gm Q8H; DO
NOT exceed 3 g/day. NB: Caution in persons with liver dysfunction
Anti-tussives SOS Anti-tussives SOS Anti-tussives SOS
T. Vitamin C 500 mg
Symptomatic T. Vitamin C 500 mg BD Inj Vit C 1.5 G q8h in ICU
OD
and supportive
care T. Zinc 50 mg BD T. Zinc 50 mg BD T. Zinc 50 mg BD
Inj. Pantoprazole 40 mg IV
Consider Sucralfate OD; titrate up or down de-
C. Esomeprazole 40 mg OD, if symptomatic pending on symptoms and
response
Adequate but conservative hydration - oral or
Fluids Conservative Fluids
parenteral

DOXYCYCLINE
• COLCHICINE
100mg BD for 5 days
• Loading dose: 1.5 mg followed by 0.5 mg of
+
colchicine 60 minutes later if no adverse gastroin-
IVERMECTIN
testinal effects
Antiviral 12mg OD for 5 days
• Maintenance dosage: 0.5 mg BD until discharge
and/or or a maximum of 21 days (reduce to OD if body
OR
Anti-inflamma- weight <60 kg)
tory • Contra indicated if eGFR <30 ml/min/1.73m2
FAVIPIRAVIR 1800mg
• Inj REMDESIVIR
1-0-1 on Day 1
• 200 mg IV on day 1 followed, by 100 mg IV daily
then 800mg 1-0-1 for
for 4 days (total 5 days)
6 days (total 7 days;
• Consider CONVALESCENT PLASMA
can be extended to 14
days on expert ad-
vice)
Inj. Piperacillin-
Tazobactam 4.5 G IV
infusion over 4 hours,
Inj Co-amoxiclav 1.2 G q6h for 7 days.
Not indicated; can be infusion q8h Escalate/deescalate /
Antibiotics prescribed with ex- or change if indicated by
pert consultation Inj Ceftriaxone 2 G iv in- infection biomarkers or
fusion OD by C/S
Seek expert opinion if
allergic to PipTazo or
resistant on culture
Anticoagula-
tion
Inj. Enoxaparin 40 Inj. Enoxaparin 40 mg SC
Inj. Enoxaparin 1 mg/ BD x 5 Days (can be started
Contraindicated mg SC OD x 5 Days kg SC OD x 5 Days as prophylactic without D
in ESRD, active if D-dimer elevated
bleeding, or DIMER)
emergency Inj. Dalteparin 2500 IU Inj. Dalteparin 5000 IU SC
surgery, SC OD ×5 days OD × 5 day
platelets < Alternatively, Tab
3 Dabigatran 110 mg In ESRD, Unfractionated
In ESRD, Unfractionated
BD Heparin – 5000U SC BD
Heparin – 5000U SC BD
20,000/mm ,
BP > 200/120

MILD MODERATE
Inj. Dexamethasone 0.1
– Inj. Dexamethasone 0.2 –
0.2 mg /kg ≈ 6 mg IV
OD x 5 Days
Steroids Not recommended or
inj. Methyl Prednisolone
0.5
-1 mg/kg ≈ 60mg OD x 5
Days
Oxygen Sup-
Not Required Maintain Target sPO2 of
port
92 to 96 %
Nasal Prongs (4 lit / min)
↓ ↓
Face Mask (5-10 lit / min)
↓ ↓
NRM (10 -15 lit / min)
↓
HFNC (10 - 40 lit / min)
↓ MV (ARDS Protocol)
NIV
Awake Proning
- 30 to 120 mins prone
- 30 to 120 mins left lat-
eral
- 30 to 120 mins right lat-
Encourage early
Proning eral
awake proning
- 30 to 120 mins upright
– Caution in altered
mental status and he-
modynamic instability,
pregnancy
Inj. Itolizumab- Start at
1.6 mg/kg dose iv infu-
sion, if well tolerated
and improvement in
Cytokine patient observed, clini-
Storm* cian has the discretion
(Criteria for use to continue with 1.6 mg/
and contraindi- kg dose every 2 weeks
cations listed at or 0.8 mg/kg weekly
-
the bottom of or
the table) Inj. Toculizumab 400
If in doubt, mg (max 800 mg) slow
please seek IV in 100 ml NS over 1
expert opinion. Hour
Repeat Dose after 12
hours if needed
Informed consent is
needed
SE-
VERE
0.4 mg
/kg ≈ 6 mg IV BD x 10
Days or
Inj. Methyl Prednisolone 1.0
-2.0 mg/kg ≈ 80 mg OD x
10 Days
Maintain Target SPo2
> 90 %
NRM (10 -15 lit / min)
HFNC (10 - 60 lit / min)
NIV
↓
Prone Ventila-
tion 16 to 18
hrs / Day
– Caution in altered mental
status and hemodynamic
instability, pregnancy
Inj. Itolizumab- Start at 1.6
mg/kg dose iv infusion, if
well tolerated and im-
provement in patient ob-
served, clinician has the
discretion to continue with
1.6 mg/kg dose every 2
weeks or 0.8 mg/kg weekly
or
Inj. Toculizumab 400 mg
(max 800 mg) slow IV in
100 ml NS over 1 Hour
Repeat Dose after 12
hours if needed
-Informed consent is need-
ed
 COMORBIDITIES AND COMPLICATIONS

Comorbidi6es
and Complica- Treat Appropriately; seek expert opinion where needed
6ons

MONITORING
BP / HR Daily 6th Hourly 4th Hourly

RR / WOB /spO2 6th Hourly 2nd Hourly ConAnuously

CBC / NLR / RFT / Baseline Every 2 Days Daily

LFT
COVID Profile Baseline Once every 4 days Once every 2 days

D Dimer Repeat every 4 days Once every 4 days Once every 2 days

Troponin / CK Repeated 24 hours & Once every 2 days Once everyday

MB 36 hours
ECG Baseline Once every 2 days Daily
ABG - - Daily
X Ray - If Clinical DeterioraAon

DISCHARGE POLICY

MILD MODERATE SEVERE

DISCHARGE CRITERIA
Afebrile > 3 Days without anApyreAcs + No Breathlessness

10 Days from Symptom 10 Days from Symp- Clinical Recovery

Onset tom Onset
- No O2 Requirement
for 3 Days
RT-PCR not Required RT-PCR not Required Repeat RT-PCR if Swab NegaAve
Transfer to Non Covid Care
Ward – if clinical recovery is de-
layed
 DISCHARGE POLICY

DISCHARGE ADVICE

MILD MODERATE SEVERE

Tab Dabigatran 150 mg twice daily

AnAcoagula- Tab Dabigatran 110 mg twice daily for 15-30 days or for 15-30 days
Aon Tab Apixaban 2.5 mg BD for 15-20 days Tab Apixaban 5 mg BD for 15-20
days

Supportive ther-
• Tab Zinc 50 mg 1-0-1 X 7 DAYS
apy ( unevi-
• Tab Vitamin C 500 mg 1-0-1 X 7 DAYS
denced)
• Tab N Acetylcysteine 600mg 1-1-1 If Patient has cough with thick sputum

Isola6on + Self Monitoring for 7 Days

Take all necessary precauAons (e.g. single room with good venAlaAon, face-mask
wear, reduced close contact with family members, separate meals, good hand sani-
taAon, no outdoor acAviAes, personal hygiene) in order to protect family members
and the community from infecAon and further spread of SARS-CoV-2.

Discuss blood donaAon acer full recovery for convalescent plasma collecAon
* Indications for the onset of the cytokine storm and for use of itolizumab or tocilizumab
are:
• Male or non-pregnant female, ≥60 years of age
OR
• ≥30 years of age with at least one known risk factor (arterial hypertension, diabetes
mellitus, coronary heart disease, heart failure, pre-existing chronic pulmonary disease)
• Signed Informed Consent Form
• CRP ≥50mg/L PLUS 3 out of the following 5 criteria need to be fulfilled:
• Respiration Rate ≥25
• SpO2 ≤ 93% (on ambient air)
• PaO2 <65 mmHg
• Persistent or increasing dyspnoea as defined by a one point increase on the mMRC
dyspnoea scale (over 1 hour)
• Persistent or increasing oxygen demand (over 1 hour)

Exclusion Criteria:
• Patients >80 years of age
• Treatment with tocilizumab or itolizumab in previous 4 weeks
• Uncontrolled bacterial superinfection according to treating clinician
• History of severe allergic reaction to monoclonal antibodie
• History of diverticulitis requiring antibiotic treatment or history of colon perforation
• History of primary immunodeficiency (e.g. CVID) or progressing malignancy
• History of chronic liver disease (>Child-Pugh A)
• ALT/AST >5 X ULN
• Hemoglobin <8.0 g/dL
• Leukocytes <2000/mL
• Absolute neutrophil count <1000
• Platelets < 50000