Clinical Management of COVID-19 Patients

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 About COVID-19

• Novel Corona virus disease 2019 (COVID-19) is a respiratory tract infection

caused by a newly emergent corona virus.
• COVID–19 may present with mild, moderate, or severe illness.
• In severe cases, COVID-19 can be complicated by the acute respiratory
distress syndrome (ARDS), sepsis and septic shock, multi-organ failure,
including acute kidney injury and cardiac injury.

• Pic: https://ecancer.org/en/news/17519-how-to-manage-cancer-care-during-covid-19-pandemic
Management of Suspected /
Confirmed COVID-19
Triage & Screening
Screen and isolate all patients with suspected COVID-19 at the first
point of contact with the health care system (such as the emergency
department or outpatient department).
Laboratory Diagnosis
Preferred samples: Throat and nasal swabs
Alternatively: Nasopharyngeal swab, Broncho Alveolar Lavage (BAL)
or Endo Tracheal spirate
Clinical Syndromes of COVID-19
Infection
Uncomplicated Illness
Mild pneumonia
Severe pneumonia
Acute Respiratory Distress Syndrome
Sepsis
Septic shock
Infection Prevention & Control
(IPC) Measures: For Patients

 Give suspect patient a triple layer surgical mask and direct patient to an isolation
room.
 Keep at least 1 (one) metre distance between suspected patients and other patients.
 Instruct all patients to cover nose and mouth during coughing or sneezing with
tissue or flexed elbow for others and hand hygiene after contact with respiratory
secretions

 Pic: https://www.indiatoday.in/information/story/coronavirus-death-india-how-handle-covid-19-dead-bodies-1657799-2020-03-20
 Infection Prevention & Control (IPC)
Measures: Droplet Precautions

o Use a medical mask if working within 1 metre of the patient.

o Place patients in single rooms, or group together those with the same etiological
diagnosis.
o When providing care to a patient with respiratory symptoms (e.g. coughing or
sneezing), use eye protection (face mask or goggles).
o Limit patient movement within the institution and ensure that patients wear medical
masks when outside their rooms.
Infection Prevention & Control (IPC)
Measures: Contact Precautions
o Use PPE (medical mask, eye protection, gloves and gown) when entering room and
remove PPE when leaving and practise hand hygiene after PPE removal.
o If equipment (e.g. stethoscopes, blood pressure cuffs, pulse oximeters and
thermometers) needs to be shared among patients, clean and disinfect between each
patient use.
o Refrain from touching eyes, nose, and mouth with potentially contaminated gloved or
un-gloved hands.
o Perform hand hygiene.
Infection Prevention & Control
Measures: Airborne Precautions

o When performing procedures like respiratory tract suctioning, intubation,

bronchoscopy or CPR.,
o Wear appropriate PPE (gloves, long-sleeved gowns, eye protection, and fit-
tested particulate respirators (N95).
o Use adequately ventilated single rooms.
o Avoid the presence of unnecessary persons individuals in the room.
Management of Mild COVID-19

• Mild cases (with fever, cough, sore throat, nasal congestion, malaise,
headache) usually do not require hospitalization but to contain the virus
isolation is necessary.
• Symptomatic treatment like antipyretics, anti histamines.
• Counsel patients about signs and symptoms of severe disease.
Pic: https://www.livescience.com/covid-19-treatments-might-exist.html
Management of Severe COVID-19

 Provide airway management and supplemental oxygen therapy immediately to patients

with severe infection with respiratory distress, hypoxaemia or shock and target SpO2 >
90% in non-pregnant adults and >92-95% in pregnant women.
 Closely monitor patients for signs of clinical deterioration, such as rapidly progressive
respiratory failure and sepsis and respond immediately with supportive care
interventions.
 Understand the patient’s co-morbid condition(s) (like DM/HTN/Renal disease) to tailor
the management of critical illness.
 Treat cautiously with intravenous fluids.
Management of Critical COVID-19

Treat co-infections:
o Give antimicrobials within one hour of assessment of sepsis.
Acute Respiratory Distress Syndrome (ARDS):
o Perform endotracheal intubation.
o Start mechanical ventilation with low tidal volumes and pressures.
o In severe ARDS prone ventilation for 12-16 hours per day. (In pregnant
women prone ventilation is not recommended.)
o Conservative fluid management.
Management of Critical COVID-19

Prevention of complications:
o Reduce days of invasive mechanical ventilation.
o Reduce incidence of ventilator- associated pneumonia.
o Reduce incidence of venous thrombo embolism.
o Reduce incidence of catheter-related bloodstream infection.
o Reduce incidence of pressure ulcers.
o Reduce incidence of stress ulcers and gastrointestinal (GI) bleeding.
o Routinely do not administer steroids.
Management of Critical COVID-19

Treat Septic Shock:

o in adults, give 250–500 ml crystalloid (NS/RL) fluid as rapid bolus in first 15–30
minutes and reassess for signs of fluid overload after each bolus.
o in children, give 10–20 ml/kg crystalloid fluid as a bolus in the first 30–60 minutes
and reassess for signs of fluid after each bolus.
o administer vasopressors when shock persists during or after fluid resuscitation.
COVID-19 and Pregnant / Lactating
Women
• Pregnant women with suspected, probable, or confirmed COVID-19, should
have access to respectful skilled care, including obstetric, neonatal care, as
well as mental health and psychosocial support, with readiness to care for
maternal and neonatal complications.
• All pregnant women with COVID-19 or who have recovered from COVID-19
should be provided with information and counselling on safe infant feeding
and appropriate IPC measures to prevent COVID-19 virus transmission.
• Pic: https://www.thewellnesscorner.com/article/eatright/pregnancy-and-lactation
COVID-19 and Pregnant / Lactating
Women
• Infants born to mothers with suspected, probable, or confirmed COVID-19
should be fed according to standard infant feeding guidelines, while
applying necessary precautions for IPC.
• When severe illness in a mother with COVID-19 or other complications
prevents her from continuing direct breastfeeding, mothers should be
encouraged and supported to express milk, and safely provide breast milk to
the infant, while applying appropriate IPC measures.
Specific Therapy

In patients with severe disease and requiring ICU management:

o Hydroxychloroquine (Dose 400mg BD – for 1 day followed by 200mg BD for 4
days)
o Azithromycin (500 mg OD for 5 days)
These drugs are presently not recommended for children less than 12
years, pregnant and lactating women.
References

https://www.mohfw.gov.in/pdf/RevisedNationalClinicalManagementGuidelinef
orCOVID1931032020.pdf
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-g
uidance/patient-management
Thank you