Editing COVID

Risk factors for severe disease

* Epidemiological
** Age >65
** Hx chronic lung disease
** Hx CVD
** Diabetes, CKD, CLD
** Transplant/cancer/immunosppuression
** NH or long-term care facility
** BMI > 40
* Clinical
** RR > 244
** HR > 125
** Sats < 94% RA
* Labs
** Elevated D-dimer, CK, LDH, ferriting, troponin, CRP > 100, low lymphocytes


Admission:

* Mild/moderate COVID patients with no no risk factors for deterioration could be considered for home management
** Supportive care
** Daily telehealth, back to fever clinic if worse
** COVID-CARE monitoring
* Severity
** Asymptomatic
** Mild - no SOB/dyspnoea/abnormal chest imaging
** Mod - evidence of LRT involvement and O2 sat >94% on RA
** Severe - any of
*** Sats<94% RA
*** RR > 30
*** Lung infiltrates >50%
*** Pa02/Fi02 < 300mmHg
** Critical
*** Respiratory failure
*** Septic shock
*** MODS
* Bloods
** FBE, UEC, LFT
** Ferritin, CRP, D-dimer
** aPTT/PT, fibrinogen
** LDH
** CK/Trop
** bHCG?
* Imaging
** CXR
** CT if empyema/lung abscess suspected
* Medications
** Continue statins, anticoagulants, antiplatelets, ACE/ARB
** Prefer MDI via spacer
** Clexane for hospitalised nonpregnant adults - prophylactic


Handover

* Symptoms
* Severity
* Epidemiological exposure
* Vaccines and dates
* Date of first positive swab
* Day of illness
* RFs
* Clinical parameters
* Bloods indicating severe disease
* GOC


Inpatient:

* Bloods
** Mod/severe - 3x weekly
** Escalating O2 requirement
* Awake proning if
** GCS 15
** BMI < 30 and <95kg total body weight
** Independently mobile
** Patient happy to do it
** Sats <92% on 4L via NP
** Consultant should be aware
** Do it for 12-16 hours
* Avoid IVF if possible


Management

* Mild
** Sotrovimab unless fully vaccinated, also if immunosuppressed regardless vaccination status
*** Must be <5 days since onset
*** Must have no O2 requirement
*** Must have one of 
**** Diabetes requiring meds
**** BMI > 30
**** CKD eGFR<60
**** CCF NYHA class II or greater
**** Asthma requiring some sort of steroids in past year
**** Age > 55
**** COPD
** No steroids
* Moderate
** Supportive care
** Consider clinical trials
* Severe
** Dexamethasone or dexamethasone + remdesivir
*** Only in patients with Sp02 < 92% RA
*** Remdesivir should ideally be used within 7 days of onset
** Tocilizumab or baricitinib
*** If deteriorating within 3/7 of admission AND CRP > 75
*** Requires high-flow device or NIV
*** Approval required from on-call COVID-ID consultant - may need clinical trial
*** Monitor serum procalcitonin prior to tocilizumab, daily after the dose and prior to any subsequent dose
*** Prophylactic ivermectin may be required - discuss with ID - depends whether patient comes from area endemic with strongyloides?
* Critical
** Dexamethasone
** +/- tocilizumab
** Can't tell what the guideline is saying - I think if patient goes to ICU on ECMO or mechanical ventilation they need tocilizumab as well



[[Category:Respiratory]]