Covid-19 Management. Stand 30.03.

2020
19 – 30/03/2020
Clinical aspect Management Treatment
Uncomplicated course HIGH DIAGNOSIS
- Possible COVID
A
• Fever, myalgia, upper respiratory M • Non-analytical
symptoms • HIGH without PCR COVID-19 Discharge treatment
B -symptomatic treatment
• No bilateral crackles • Home isolation with
U
• Rx normal chest recommendations +
• NO hypoxemia: Sat. > 93% L
-recommendations + tips
• No risk factors1 A
T
Patients without Pneumonia O
• Emergency analytics 3 (factors Discharge treatment
R
•Fever and respiratory symptoms of bad prognosis) + Rx thorax (make prescription and ask the
Y
•Risk factors1 pharmacy to deliver it to the
•No bad prognosis factors 2 • Consider Blood cultuer as well as patient):
P atypical Pneumonia • Verbal consent for tto
A (Pneumococcus & Legionella) • Deliver treatment in the ER:
Mild Pneumonia
T - Chloroquine 500mg / 12 h or
• Home isolation with - Hydroxychloroquine 400 mg / 12h 1st
• No risk factors 1 or por prognostic I
recommendations day and then 200 mg / 12h (5 days)
factors2 E
+
• CURB-65 < 2 N - Doxycycline 100 mg / 12h or
• Rx thorax: bilateral infiltration T - Azithromycin 500 mg / 24h or
S - Levofloxacin 500 mg / 24h (5 days)

Serious to moderate • Emergency Analytics3 + TREATMENT: -

respiratory symptomas Rx portable chest Specific therapy (see Table A1 for
• Blood cultures. Antigens hospitalization)
- CURB-65 >2 or FINE >II (rule out bacterial co- +
- Sat.O2 < 93% or FResp> 20 rpm infection) Cyclosporin A (verbal IC)
or PaO2 < 65mmHg • Organise isolation +
- Bilateral crepitations A • Add procalcitonin, Evaluate antimicrobial association
- Rx thorax: bilateral infiltration hepatitis B and HIV based on patient risk factors and
D
M serology, coagulation and superinfection data (Ceftriaxone 2g
ferritin to the emergency / 24h or Ceftazidime or Cefepime)
I
analysis3 if not already
S done.
S • ECG.
I
O
SERIOUS RESPIRATORY
N
DISTRESS (PaO2 / FiO2 <150)
AVISAR UCI (Busca 860014)
without
SEPTIC SHOCK
1 RISK FACTORS: Age> 50 years, COPD, severe asthma, DM, HT, obesity, ischemic heart disease, malignancy, chronic liver disease and
immunosuppression
2 ymphopenia (<800 cells), ferritin> 500 ug / L, elevation of LDH, DD, CPK or troponin (not in early stages, but its elevation confers poor

prognosis), hyperbilirubinemia, hypertransaminasemia, poor glycemic control / hyperglycemic decompensation

3 URGENT REQUESTS: blood count, glucose, urea, creatinine, ions, GOT, GPT, GGT, FALC, LDH, CK, CK-MB, PCR, Troponin Tc, D-dimer,

ac. lactic +/- ferritin). If dyspnea or basal Sat.O2 <93% arterial arterial blood gas.
Portable chest x-ray .

CURB-65 Score
C-Confusion 1 point
U-Bood Urea > 19 mg/dL 1 point
R-Respiratory rate>30 1 point
B-Blood pressureTA (S<90 or D≤60) 1 point
Age ≥ 65 Years 1 point

30 March 202
1
Covid-19 Management. Stand 30.03.2020
19 – 30/03/2020
MEDICAL TREATMENT OF Respiratory Failure AT admission
IN HOSPITALIZATION (according to respiratory functional situation: day 1)
Admission Severity level Medical Treatment
(According to Respiratory parameters)
Antimicrobial therapy
+
Required FiO2 at 35% to Specific therapy:
reach a saturaion of • Combined antiviral therapy according to guidelines (See
A1 page 3)
SO2>90%
+
• Antimalarials (See page 3)
+
• Cyclosporine A (See page 3)

required FIO2 35-60% to Scheme A1

+
reach a saturation of A2 • Methylprednisolone (MP) 250 mg i.v. 1st day, followed
SO2>90% by 40-80 mg / day i.v. 3-5 days (See page 4)

Scheme A2
+
Severity • Tocilizumab 400 mg, 1-2 doses i.v. separated on the 2nd day.
Required FIO2 ≥60% to (See page 4)

reach a saturation of A3 • Note: Advance Tocilizumab for A2 patients could be

considered if radiological progression and very high or rising
SO2 >90% inflammatory reactants, even if they do not yet have severe
respiratory distress, individualize and agree with the medical
team.

Valorar en todo paciente que no responde a los esquemas

anteriores de manera individualizada
(confirmar con el equipo)
ICU

BUSCA DE UCI (860014)

Covid-19 Management. Stand 30.03.2020
19 – 30/03/2020
After day 1 of admission
Cyclosporine A scale according to +/- tolerance response
According to GRAVITY LEVEL PROGRESSION, add sequentially the measures NOT previously adopted

qSOFA (quick SOFA): Antimicrobial therapy:

- Glasgow ≤14 - Doxycycline 100 mg / 12 hours 5 days (preferred option)
- Systolic blood pressure ≤100 mm Hg - Azithromycin 500 mg / day 3 days or levofloxacin 500 mg / day 5 days
- Respiratory rate ≥22 r.p.m.

Combined antiviral therapy according to Antimalarials (p.o.):

guidelines (up to 7 days): - Chloroquine 500 mg / 12 hours for 5 days or
- Lopinavir / ritonavir 200 / 50mg, 2 pcs / 12 h - Hydroxychloroquine 400 mg / 12 h on the 1st day followed by
200 mg / 12 h for 5 days.

Cyclosporin A: Start and Climb

- Patients with renal insufficiency are excluded (stages 4 and 5: GFR <30 mL / min according to the Cockroft-Gault formula)
- It will not start in patients with uncontrolled hypertension until an acceptable control is achieved
- Preferred route of administration: oral.
- 50 mg and 100 mg capsules, or
- Oral solution: 1 mL = 100 mg

I.v.management option in necessary case

> 80 Kg. 125 mg 1st dose and then 50 mg / 12h Dilute 250 cc SG 5% and administer in 2h
<80 Kg. 50 mg / 12h from the first day

- Reduce the dose to the immediately lower regimen in the event of a> 30% increase in the baseline creatinine level or poor BP control.
- CAUTION: Both antiviral therapy and tocilizumab INCREASE plasma levels of cyclosporine
- If tocilizumab is administered, de-escalate cyclosporine at the initial dose and re-escalate after 48 hours.
- - In case of dosage doubts, determine plasma levels (therapeutic range of 100 to 250 ng / mL)

Cyclosporin A v. oral (starting dose and escalation every 48 h): Cyclosporin A (minimum dose if necessary
starting dose reduction)
<60 kg: 100 mg / day (50-0-50) or (0.5 mL-0-0.5 mL)
60-80 kg: 150 mg / day (100-0-50) or (1 mL-0-0.5 mL)
> 80 kg: 200 mg / day (100-0-100) or (1 mL-0-1 mL) <80 kg: 50 mg/day (50-0-0) ó (1 mL-0-0)
≥80 kg: 100 mg/day (50-0-50) ó (0,5 mL-0-0,5
- If good tolerance: mL)

<60 kg: 150 mg / day (100-0-50) or (1 mL-0-0.5 mL)

60-80 kg: 200 mg / day (100-0-100) or (1 mL-0-1 mL)
> 80 kg: 300 mg / day (150-0-150) or (1.5 mL-0-1.5 mL)

- Keep climbing in a personalized way according to tolerance and

requirements up to 5 mg / Kg / day divided into 2 to 4 doses. dilute in
solution if necessary.

- Cyclosporin A: Maintenance and suspension of treatment:

- This medication will not be withdrawn during admission if the medical team considers that the patient is benefiting from
its use.
- In case of clinical improvement, reduce to starting dose until withdrawal.
- At discharge:
- Non-serious patients: Complete 1 week of treatment (2 weeks from the onset of symptoms).
- Serious patients: Complete 15 days (3 weeks from the onset of symptoms)
Covid-19 Management. Stand 30.03.2020
19 – 30/03/2020
Corticotherapy i.v .:
- Individually in patients with chronic bronchopulmonary processes
- We will comply with the sepsis and septic shock treatment guidelines that include the daily administration of Hydrocortisone 200 mg
(or its equivalent: Methylprednisolone 40 mg) i.v. every 12 hours to 24 hours
- Administration of IV boluses (Methylprednisone 250 mg. Iv first day followed by 40 mg / day iv x 3-5 days) in the following
circumstances:
a) Failure to treatments including rescue with Tocilizumab
b) Stage A1, with the intention of preventing progression to ventilatory support (prior to Tocilizumab)
c) Patient not a candidate for Tocilizumab or extraordinary life support measures

Tocilizumab at a dose of 400 mg i.v.

A maximum of 2 infusions must be given
After the 1st infusion, reassess in each patient whether or not a 2nd infusion is required.

Tocilizumab, administration criteria: Tocilizumab, is contraindicated or not

recommended in:
- Patient who progresses resistant to cyclosporine A during admission
- Evidence of bacterial coinfection
- Interstitial pneumonia with severe respiratory failure (A3)
(clinical, elevated procalcitonin, ...) and
- Rapid respiratory worsening requiring non-invasive or invasive ventilation / or sepsis by other pathogens other
(N or R) than COVID-19.
- Presence of extrapulmonary organic failure - AST / ALT> 10 times reference value
- Criteria for severe systemic inflammatory response. - Neutrophils <500
- In adults: elevated CRP levels> 20 mg / L or increasing and / or levels of
- Platelets <50,000
D-dimer (> 400 ng / mL) or progressively increasing D-dimer.
- Pregnancy
- History of diverticulitis
- - Low survival expectancy according to
critically ill criteria.

Other measure in ambulatory and in-hospital patients

Upon admission:
- Assess withdrawal of non-essential medication.
- Do not use mists (risk of aerosols). In case of need for being patients with
chronic respiratory disease, assess administration in a pressurized
cartridge associated with a spacer chamber.
- Assess prophylactic anticoagulation with low molecular weight heparin
(Bemiparin 3500 units / 24h) in bedridden and without risk of bleeding.
- High:
-Conservative management of fluid therapy in patients with respiratory - If the clinical situation allows it, even if the
failure without evidence of shock. Valorar
virus PCRy anotar diariamente:
is positive.
-Assess hydration status and kidney function. - Estado general,
Treatment: nivel detoconciencia
According treatment table
-In A1 and A2 patients who can collaborate, assess Interconsultation to -(above)
Preguntar por efectos adversos GI (diarrea,
Rehabilitation for respiratory physiotherapy. náuseas,.. por antirretrovirales)
- Home isolation with follow-up by AP at
-Consult Cardiology. -least
Temperatura, FC, tension
14 days after dischargearterial, FR, SO2/FIO2,
or negative
-laboratory
Auscultación pulmonar
result.
- Vigilar glucemias
Hospital en pacientes
management con corticoterapia
recommendations
will be attached.

Chest x-ray:
- Pre-admission or
- If clinical worsening