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