Clinical management of severe acute respiratory infection when Coronavirus is suspected
Interim Guidance by World Health Organization (WHO)
This is the first edition of this document for novel coronavirus, an adaption of WHO Clinical management of severe acute respiratory infection when MERS-CoV infection is suspected (2019). This document is intended for clinicians taking care of hospitalised adult and paediatric patients with severe acute respiratory infection (SARI) when coronavirus disease is suspected. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen clinical management of these patients and provide to up-to-date guidance. Best practices for SARI including IPC and optimized supportive care for severely ill patients are essential.
1) Triage: recognize and sort patients with SARI
Recognize and sort all patients with SARI at first point of contact with health care system (such as the emergency department). Triage patients and start emergency treatments based based on disease severity.
2. Immediate implementation of appropriate infection prevention and control (IPC) measures
IPC is a critical and integral part of clinical management of patients and should be initiated at the point of entry of the patient to hospital (typically the Emergency Department). Standard precautions should always be routinely applied in all areas of health care facilities. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.
3. Early supportive therapy and monitoring
- Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia, or shock
- Use conservative fluid management in patients with SARI when there is no evidence of shock.
- Give empiric antimicrobials to treat all likely pathogens causing SARI.
- Give antimicrobials within one hour of initial patient assessment for patients with sepsis.
- Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of clinical trials unless they are indicated for another reason.
- Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis,
and apply supportive care interventions immediately.
- Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the prognosis.
- Communicate early with patient and family
4. Collection of specimens for laboratory diagnosis
- Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy.
- DO NOT delay antimicrobial therapy to collect blood cultures.
- Collect specimens from BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) & lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage) for coronavirus disease testing by RT-PCR.
- Clinicians may elect to collect only LRT samples when these are readily available (for example, in mechanically ventilated patients).
- Serology for diagnostic purposes is recommended only when RT-PCR is not available.
5. Management of hypoxemic respiratory failure and ARDS
- Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy
- High-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) should only be used in selected patients with hypoxemic respiratory failure.
- The risk of treatment failure is high in patients with MERS treated with NIV, and patients treated with either HFNO or NIV should be closely monitored for clinical deterioration.
- Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.
- Implement mechanical ventilation using lower tidal volumes (4–8 ml/kg predicted body weight, PBW) and lower inspiratory pressures (plateau pressure <30 cmH2O).
- In patients with severe ARDS, prone ventilation for >12 hours per day is recommended.
- Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion
- In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested
- In patients with moderate-severe ARDS (PaO2/FiO2 <150), neuromuscular blockade by continuous infusion should not be routinely used.
- In settings with access to expertise in extracorporeal life support (ECLS), consider referral of patients with refractory hypoxemia despite lung protective ventilation.
- Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis.
- Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection is required (for example, transfer to a transport ventilator).
6. Management of septic shock
- Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) ≥65 mmHg AND lactate is ≥2 mmol/L, in absence of hypovolemia.
- Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.
- In resuscitation from septic shock in adults, give at least 30 ml/kg of isotonic crystalloid in adults in the first 3 hours.
- In resuscitation from septic shock in children in well-resourced settings, give 20 ml/kg as a rapid bolus and up to 40-60 ml/kg in the first 1 hr.
- Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.
- Fluid resuscitation may lead to volume overload, including respiratory failure.
- If there is no response to fluid loading and signs of volume overload appear (for example, jugular venous distension, crackles on lung auscultation, pulmonary oedema on imaging, or hepatomegaly in children), then reduce or discontinue fluid administration.
- This step is particularly important where mechanical ventilation is not available.
- Alternate fluid regimens are suggested when caring for children in resource-limited settings
- Administer vasopressors when shock persists during or after fluid resuscitation.
- The initial blood pressure target is MAP ≥65 mmHg in adults and age-appropriate targets in children.
- If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein and closely monitor for signs of extravasation and local tissue necrosis.
- If extravasation occurs, stop infusion.
- Vasopressors can also be administered through intraosseous needles.
- If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors, consider an inotrope such as dobutamine
7. Prevention of Complications
Implement the following interventions to prevent complications associated with critical illness
8. Specific anti-Novel-CoV treatments and clinical research
There is no current evidence from RCTs to recommend any specific anti-nCoV treatment for patients with suspected or confirmed 2019-nCoV infection.
9. Special considerations for pregnant patients
Emergency delivery and pregnancy termination decisions are challenging and based on many factors: gestational age, maternal condition, and fetal stability. Consultations with obstetric, neonatal, and intensive care specialists (depending on the condition of the mother) are essential.
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