GROUP A - MILD CASES TREATMENT PRECAUTIONS: ANTIVIRAL THERAPY ‘TAB HYDROXYCHLOROQUININE(HCQ) 400MG BD FOR | DAY Followed by 200MG 1-0-1 X 4 DAY for patients in COVID CARE CENTER/HOME ISOLATION (or) Tab FAVIPIRAVIR 1800mg 1-0-1 on Day 1 M 800mg 1-0-1 for 6 days (total 7 days) for PATIENTS IN DCHC (or) If Tab HCQ/Tab FAVIPIRAVIR is. contraindicated, then combination of ‘Cap DOXYCYCLIN 100mg 1-0-1 for 5 days ‘Tab IVERMECTIN 12mg 1-0-0 for 3 days Cap Oseltamavir 75mg 1-0-1 for 5 days ANTICOAGULATION In] ENOXAPARIN 40mg S/C 1-0-0 X 7 DAYS. (OF D-DIMER IS MORE THAN 1600NG/ML (OR) X-RAY/CT THORAX SHOWING GROUND GLASS OPACITIES) SUPPORTIVE THERAPY- ‘TAB ZINC 50 MG 0-1-0 X 7 DAYS TAB VITAMIN C 500 MG 1-1-1X7 DAYS Tab N Acetylcysteine 600mg 1-1-1 If Patients Having Cough CATEGORIZATION SHOULD BE REASSESSED REGULARLY CONTRAINDICATION FOR HCQ- + QLINTERVAL > 480ms + Preexisting cardiomyopathy and cardiac rhythm disorders + History of Unexplained Syncope + Retinopathy, + Hypersensitivity to HCQ or 4- aminoquinoline compounds + GGPD deficiency + Epilepsy + Hypokalemia (k* < 3 Meq) Contraindications for Tab FAVIPIRAVIR: Hyperuricaemia, severe hepatic & renal impairment, Pregnant women and lactating mothers PREGNANCY IS NOT A CONTRAINDICATION FOR HCQ # Cop OSELTAMAVIR is advised due to possibility of HINI co infection along with COVIDIS disease with present weather condition. Its usage will be reviewed at a later date. Scanned with CamScannerGROUP B - MODERATE CASES TREATMENT PRECAUTIONS ANTIVIRAL THERAPY + Inj REMDESIVIR 200 mg TV on day 1 followed by 100 mg IV dally for 4 days (total 5 days) IF REMEDESVIR IS NOT AVAILABLE TO START TAB HYDROXYCHLOROQUININE(HCQ) 400MG BD FOR 1 DAY followed by 200MG 1-0-1 X4 DAY Co-administration of Inj REMDESIVIR with HCQ or chloroquine should be avoided © Cap Oseltamavir 75mg 1 -1 for 5 days STEROIDS Tn). Methyl Prednisolone 0.5 -1 mg/kg on) In). Dexamethasone 0.1 - .2 mg/kg for 3-5 Days ANTICOAGULATION Inj ENOXAPARIN 40MG SIC 1-0-0x7 DAYS. IV ANTIBIOTICS ACCORDING TO LOCAL, ANTIBIOGRAM AWAKE PRONING + CONVALASCENT PLASMA THERAPY: 4 to 13 ml/kg (usually 200 ml single dose given slowly over not less than 2 hours) SUPPORTIVE THERAPY = TAB ZINC 50 MG 0-1.0X 7 DAYS. «© TAB VITAMIN C 500 MG 1-1-1 X7 DAYS * TAB N-ACETYL CYSTEINE 1-1-1 IN PATIENTS WITH COUGH ‘Contraindications for Inj REMDESIVIR: © ASTIALT > 5 times Upper limit of normal (ULN) + Severe renal impairment (Le., eGFR < 30ml/min/me or need for hemodialysis) + Pregnancy or lactating females * Children (< 12 years of age) * No dose adjustment for Inj REMDESIVIR if eGFR >30ml/min ate eGER in Ac + eGFR, Male: (140 — age in years) x (welght in kg) 172 x (serum creatinine in mg/dL); + GFR, Female: (140 - age in years) x (weight in kg) x 0.85 /72 x (serum creatinine in mg/dL.) STEROIDS © tobe started preferably within 48 hours of admission (or) if oxygen requirement is Increasing and if inflammatory markers are increased. * PATIENT SHOULD BE REASSESSED EVERY 12 HRLY AND CONTINOUS MONITORING OF SATURATION. © START ON OXYGEN-NASAL PRONGS 2-5 MIN or FACE MASK SL/MIN Scanned with CamScannerGROUP C - SEVERE/CRITICAL CASES TREATMENT PRECAUTIONS ‘ANTIVIRAL THERAPY If the patient has not received Inj REMDESIVIR, such patients can be started on Inj REMDESIVIR. Inj REMDESIVIR 200 mg IV on day 1 followed by 100 mg IV daily for 4 days (total 5 days) Inj. TOCILUZUMAB 8mg/kg (maximum 800 ‘mg at one time) given slowly in 100 ml NS over 1 hour; dose can be repeated once after 12 to 24 hours if needed (Or) Inj ITOLIZUMAB: 1st dose — 1.6mg/kg dose iv infusion. Subsequent dose: weekly O.8mg/kg dase infusion over 4hours if required Cap Oseltamavir 75mg 1-0-1 for 5 days STEROIDS + Inj, Methyl Prednisolone 1-2 mg/kg (or) Inj. Dexamethasone 0.2 — 0.4 mg /kg for 5-7 Days ANTICOAGULATION + Inj ENOXAPARIN Img/kg body wt s/c 1-0-1 X TDAYS PRONE VENTILLATION Inj CEFTRIAXONE Igm IV 1-0-1 AND CAN BE ESCALATED ACCORDING TO LOCAL ANTIBIOGRAM OR TREATING PHYSICIAN CONSIDER SEPSIVAC (IF AVAILABLE) 0.3ml INTRADERMAL ONCE A DAY FOR 3 DAYS IN CASE OF SEPTIC SHOCK IV Diuretics in case of evidence of Heart Failure secondary to Myocarditis SUPPORTIVE THERAPY. © TAB ZINC 50 MG 0-1.0X 7 DAYS # INJ. VITAMIN C 1.5GM IV 6 HOURLY X SDAYS * TABN-ACETYL CYSTEINE 1-1-1 Tidication for TOCILUZUMAB/TOLIZUMAB:- 1, TL-6 levels 50-100 fold higher than normal (Normal range 0 -9.5pp/ml 2. Worsening trend of the inflammatory ‘markers (Ferritin, LDH, CRP) 3. Deteriorating clinical condition with ‘worsening of PaQ2/Fio? ratio (more than 25% deterioration [rom the immediate previous value). Contraindicattons for In TOCILIZUMABTTOLIZUMAB PLHTV, those with active Infections (systemic Dacterial/fungal), High Serum. Procaleltontn, ‘Tuberculosis, active hepatitis, Absolute ‘Neutrophil Count < 2000/mm3 and Platelet count < 1,00,000/mm3, hepatic and renal impairment; patients on chronic steroid therapy, Paediatric patients <18 years old; Pregnancy and, Nursing mothers © PATIENT SHOULD BE CONTINOUSLY MONITORED © TOSTARTON OXYGEN WITH FACE, MASK WITH NON REBREATHING BAG @ 8.10lvm ‘+ BASED ON PaO2/FiO2 ratio, HIGH FLOW NASAL OXYGEN (HFNC)/NIV SHOULD BE GIVEN AND IF PATIENT DETERIORATES INTUBATION SHOULD BE CONSIDERED AND LUNG PROTECTIVE VENTILATION TO BE FOLLOWED AS PER ARDSnet PROTOCOL © ABG TO BE DONE REGULARLY FOR MONITORING OF ACIDOSIS AND HYPOXEMIA ¢ INOTROPHIC SUPPORT (NORADRENALINE, = TITRATE ACCORDING TO THE MEAN ARTERIAL PRESSURE) © CORRECTION OF ACIDOSIS * MAINTAIN Hb% GREATER THAN Bgmi% Scanned with CamScanneri” Inj REMDESVIR 200 mg IV on cay In. TOCILUZUMAB &mg/kg ‘followed by 100 mg IV dally for 4 (maximum 800 mg at one time) days ‘lven slowty in 100 miNS over 1 (or) nour; dose can be repeated once after 12 024 hours noaded IF REMEDESVIRIS NOT ‘AVAILABLE TO START 9 Tab! Hydro {nj TOLIZUMAB: 1% dose - 1.6mg/iep LEDC taEDeea ddosel infusion. Subsequent dose: ate ‘weekly 0.8mg/kg dose Infusion over Co-administration of In} eee REMDESVIR with HCQ or STEROIDS ‘ehloroquine shouldbe avoided Inj. Methy!Prednisotone 1-2 mg/kg, STEROIDS rage [Devs con) {nj. Methy Prodnisolone 0.5-1 Inj. Dexamethasone 2 - 0.4 mg "xg ig (or) In}. Dexamethasone for 5-7 Days '1=0.2 mg/ag or 35 Days ANTICOAGULATION tn Enoxaparin 1 Mg/kg $101.04 Taays Inj Cortriaxone 1 Gm 1-0-1 And CanBo Escalated According To Local ‘Antibiogram Or Treating Physician Starton orygen with tace ‘mask+NRM and change over to HFNC/NIV (based on Pa02/F102) ‘5/minor face mask 5i/min. eee Geet hee ene hes jot 4 10 13 mi/kg (usually ponation) nen EATLY Bor sri cose soy TION SHOULD BE |. Continous monitoring of eee, ae CONSIDERED AND LUN( Supportive Therapy PROTECTIVE VENTILATION TO BE ‘oxygen saturation by pulse rai FOLLOWEDAS PER ARDSnet oximeter and early diagnosis ee cine OMe OO De PROTOCOL cof hypoxemia is essential in tba aco rors Vemtitation all group of patients Tob N Acad aaa ‘SEPSIVAC 0.3m INTRADERMAL Indications and Patlonts Having Cough ONCE ADAY FOR DAYS contraindications of the ‘Supportive Therapy drugs are to be considered Beene aaa ee rened tr dete beloer Special Note: ‘Tob Zinc 50 Mg 0-1-0x 7 Days renvenee vation } "Cap Oseltamavir 75mg 1-0-1 for || IMB Aceivestone Tifa 5 days to be added to patients of ing Cougr between the clinical all categories ‘categories is based on Sp02, All the investigational therapies RR & Pa02/Fi02 ratio and drugs approved recently by Treatment of all co morbid DGCI should be used with caution ilthess to continue and afler informed consent from the patient {Se Scanned with CamScannerINVESTIGATIONS Timing Mild Moderate ‘Severe/Critical At CBC + Complete Blood Count ~Complete Blood Count admission | RBS (with N/L RATIO) (with N/L RATIO) ECG + LET, RFT, RBS “LET, RFT, RBS HDAIC (if Diabetic) | + S.Electrolytes +S. Electrolytes D-Dimer + 12 lead ECG +12 lead ECG + CHEST X Ray-PA view | *CHEST X Ray -PA view (ifstarting on Tab + CRP, D-DIMER *CRP, D-DIMER Favipiravir) + S. FERRITIN, S.LDH +S. FERRITIN, S.LDH RFT + PROCALCITONIN -PROCALCITONIN S.Electrolyte + TROP -1&T *TROP-1&'T S. Uric Acid + PT/INR *PT/INR + ABG *ABG + CT Thorax (if Available) *CT Thorax (if Available) + Blood culture (if total “Blood culture (if total count is high) count is high) + IL-6 “IL-6 + S. Cortisol +S. Cortisol + 2D *+S.Mgr", S.Ca®* ECHOCARDIOGRAP| — «2D HY ECHOCARDIOGRA + COVID Antibody PHY IgM/IgGTests -NTproBNP *HsCRP +S. Lactate “COVID Antibody IgM/IgGTests Repeat ‘Complete Blood Count, LFT, | Complete Blood Count, LFT, Daily - RET RET ABG ABC Repeat CRP, D-DIMER CRP, D-DIMER Every 72hrs | Ifinitial D-Dimer is | S. FERRITIN, S.LDH S. FERRITIN, S.LDH high Chest X ray Chest X ray ‘Atthe time CRP, D-DIMER CRP, D-DIMER of discharge - S. FERRITIN, S.LDH S. FERRITIN, S.LDH (Chest X ray Chest X ray RT-PCR — Nasal & Throat swab Scanned with CamScannerRevised Di Policy for COVID-19 ‘The revised discharge policy is aligned with the guidelines on the 3 tier COVID facilities and the categorization of the patients based on clinical severity (Available at: hups://www.mohfw.gov.in/pdf/FinalGt lanceonMangaementofCovideasesversion?.pdi 1, Mild/very mild/pre-symptomatic cases Mild/very mild/pre-symptomatic cases admitted to a COVID Care Fac ity will undergo regular temperature and pulse oximetry monitoring. The patient can be discharged after 10 days of symptom onset and no fever for 3 days. There will be no need for testing prior to discharge. At the time of discharge, the patient will be advised to isolate himself at home and self-monitor their health for further 7 days. At any point of time, prior to discharge from CCC, if the oxygen saturation dips below 95%, patient is moved to Dedicated COVID Health Centre (DCHC). After discharge from the facility, if he/she again develops symptoms of fever, cough or breathing difficulty he will contact the COVID Care Centre or State helpline or 1075. His/her health will again be followed up through tele-conference on 14 day. 2 Moderate cases admitted to Dedicated COVID Health Centre (Oxygen beds) 2.1.Patients whose symptoms resolve within 3 days and maintains saturation above 95% for the next 4 days Cases clinically classified as “moderate cases” will undergo monitoring of body temperature and oxygen saturation. If the fever resolve within 3 days and the patient maintains saturation above 95% for the next 4 days (without oxygen support), such patient will be discharged after 10 days of symptom onset in case of: ‘© Absence of fever without antipyretics ‘* Resolution of breathlessness © No oxygen requirement ‘There will be no need for te: At the time of discharge, the patient will be advised to isolate himself at home and self-monitor their health for further 7 days. Scanned with CamScanner2.2.Patient on Oxygenation whose fever does not resolve within 3 days and demand of oxygen therapy continues Such patients will be discharged only after ‘* resolution of clinical symptoms ‘ability to maintain oxygen saturation for 3 consecutive days 3. Severe Cases including immunocompromised (HIV patients, transplant recipients, malignancy) Discharge criteria for severe cases will be based on. © Clinical recovery © Patient tested negative once by RT-PCR (after resolution of symptoms) Revised Discharge Policy for COVID.19 Confirmed COWID-TaCae E =z Severe Teverreavedwitin | [ Symptonanat [Dechrge ony afer Baca ot Sdn tesovedand demand > Cinescore simptomonsetandre | | sngonygensatiratin | } "ot oneentherpy I Patentesed negative feverfor3 cov imataned thot continue nce by RT-PCR ster spor i resotionat SSE [Petar oni ater spins) veces | | ctnionef deal + antmectinranim | | Symptoms rein + Sy toma roe, ‘gen stration or3 |. Sccnterwrenen_| [_consecsivedye Fa = re Saaceaetaa a eae ero es a mn Scanned with CamScannerCLINICAL CATEGORIES a Description Parameters SpO2: 394% in room alr Asymptomatic | No Symptoms 2 <24/m No evidence of hypoxemia or breathlessness Patients with + . sag | socompleated upper S02: 254% fnroom respitatory tact No evidence of hypoxemia or breathlessness Kisterae |! ene p02: 94%-90% in room air sar RR: 24-30/m disease ; SpO2: < 90% room alr Severe Severe Pneumonia RR: >30/m ‘Onset: new or worsening respiratory symptoms within one week of known clinical insult. Chest imaging (Chest X ray and portable bed side Jung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules. Origin of Pulmonary infiltrates: respiratory failure not fully explained by cardiac failure or fuid overload. Need objective assessment (c.g. echocardiography) to exclude hydrostatic cause of Acute Respiratory infiltrates! vedema if no risk factor present. Critical | Distress Syndrome femetine pin (ARDS) Oxygenation impairment in adults: Mild ARDS: 200 mmHg < PaO2/Fi02 < 300 mmHg (with PEEP or CPAP >5 em H20) Moderate ARDS: 100 mmHg < Pa02/Fi02 <200 mmHg with PEEP >5 em H20) Severe ARDS: PaO2/FiO2 < 100 mmHg with PEEP >5 em H20) When Pa02 is not available, SpO2/FI02 315 suggests ARDS (including in non- ventilated patients) ‘Adults: persisting hypotension despite volume Critical Septic Shock resuscitation, requiring vasopressors to maintain MAP 265 mmHg and serum lactate level > 2 mmol/L Scanned with CamScanner