AIIMS Releases new Clinical Guidance for Management of Covid-19

The guidelines specify the management protocol for COVID patients with mild, moderate and severe disease.

1. Mild disease

Upper respiratory tract symptoms (&/or fever) WITHOUT shortness of breath or hypoxia

Home Isolation

✓ Contact & droplet precautions; strict hand hygiene

✓ Symptomatic management(hydration, anti- pyretics, anti-tussive)

✓ Stay in contact with the treating physician

• Seek immediate medical attention if:

o Difficulty in breathing/RR >= 24/min/ SpO2<94%

o High-grade fever/ severe cough particularly beyond 5 days of symptoms onset

o A low threshold should be kept for those with any of the high-risk features*

➢ Tab Ivermectin (200 mcg/kg once a day for 3 to 5 days) to be considered.

(Avoid in pregnant/ lactating).

➢ If fever is not controlled with a maximum dose of Tab. Paracetamol 650 mg QID, may consider the use of NSAID like Tab. Naproxen 250 mg BD

➢ Inhalational Budesonide (given via DPI, MDI with Spacer at a dose of 800 mcg BD for 5 to 7 days to be given if symptoms(fever and/ or cough) are persistent beyond 5 days of disease onset.

➢ Systemic Steroids NOT indicated in mild disease; however, may be considered in cases with high-grade fever and worsening cough beyond 7 days only in consultation with the treating physician for a duration of 3-5 days.

Tab Dexamethasone 0.1 to 0.2 mg /kg OD or

Tab Methylprednisolone 0.5-1 mg/kg in 2 divided doses

2. Moderate disease

Any one of:

1. Respiratory rate >=24/min

2. SpO2 < =93% on room air

Admit in ward

Oxygen Support:

➢ Target SpO2: 92-96% (88-92% in patients with COPD)

➢ Preferred devices for oxygenation: non-rebreathing face mask

➢ Awake proning should be encouraged in all patients who are requiring supplemental oxygen therapy( sequential position changes every 1-2 hours)

Anti-inflammatory or immunomodulatory therapy

➢ Inj. Methylprednisolone 0.5 to 1 mg/kg in 2 divided doses ( or an equivalent dose of dexamethasone -0.1 to 0.2 mg/ kg per day) usually for a duration of 5 to 10 days.

➢ Patients may be initiated or switched to the oral route if stable and/ or improving

Anticoagulation

➢Conventional dose prophylactic UFH or LMWH (weight-based e.g., enoxaparin 0.5mg/kg per day SC OD)

Monitoring

➢ Clinical Monitoring: Work of breathing, Hemodynamic instability, Change in oxygen requirement

➢ Serial CXR, HRCT Chest to be done only if there is worsening.

➢ Lab monitoring: CRP, D-dimer every 48 to 72 hrly; CBC, KFT, LFT 24 to 48 hrly; IL-6 levels to be done if deteriorating (subject to availability)

3. Severe disease

Any one of:

1. Respiratory rate > 30 /min

2. SpO2 < 90% on room air

ADMIT IN ICU

Respiratory support

• Consider the use of NIV/(Helmet or face mask interface depending on availability)/ HFNC in patients with increasing oxygen requirement, if work of breathing is LOW

• Intubation should be prioritized in patients with high work of breathing /if NIV is not tolerated

• Use Conventional ARDSnet protocol for the ventilatory management

Anti-inflammatory or immunomodulatory therapy

• Inj Methylprednisolone 1 to 2mg/kg IV in 2 divided doses( or an equivalent dose of dexamethasone - 0.2 to 0.4 mg/kg per day) usually for duration 5 to 10 days.

Anticoagulation

• Weight based Intermediate dose prophylactic UFH or LMWH (e.g., Enoxaparin 0.5mg/kg per dose SC BD)

Supportive measures

• Maintain euvolemia(if available, use dynamic measures for assessing fluid responsiveness)

• If sepsis/septic shock: manage as per existing protocol and local antibiogram

Monitoring

➢ Serial CXR, HRCT Chest to be done ONLY if deteriorating

➢ Lab monitoring: CRP and D-dimer 24-48 hourly; CBC, KFT, LFT daily; IL-6 levels to be done if deteriorating (subject to availability)

After clinical Improvement discharge as per revised discharge criteria