Coronavirus disease (covid 19)

DR.Mohammad Abdeljawad
AL-Bashir Hospital
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Definition of Healthcare Personnel (HCP) –For the purposes of this
document, HCP refers to all paid and unpaid persons serving in
healthcare settings who have the potential for direct or indirect
exposure to patients or infectious materials, including body
substances; contaminated medical supplies, devices, and equipment;
contaminated environmental surfaces; or contaminated air.

Coronaviruses (CoV) are a large family of viruses that cause
illness ranging from the common cold to more severe diseases
such as Middle East Respiratory Syndrome (MERS-CoV) and Severe
Acute Respiratory Syndrome (SARS-CoV).
 Coronavirus disease (COVID-19) is a new strain that was discovered
in 2019 and has not been previously identified in humans
Coronaviruses are zoonotic, meaning they are transmitted
between animals and people. Detailed investigations found that
SARS-CoV was transmitted from civet cats to humans and MERS-CoV
from dromedary camels to humans. Several known coronaviruses are
circulating in animals that have not yet infected humans
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Corona viruses constitute the subfamily Orthocoronavirinae, in
the family Coronaviridae , order Nidovirales , and realm Riboviria.
They are eneveloped viruses with a positive-sense single-stranded
RNA genome and a nucleocapsid of helical symmetry. The genome
size of coronaviruses ranges from approximately 27 to 34 kilobases ,
the largest among known RNA viruses .
 The name coronavirus is derived from the Latin corona, meaning
"crown" or "halo", which refers to the characteristic appearance
reminiscent of a crown or a solar corona around the virions (virus
particles) when viewed under two-dimensional transmission electron
microscopy , due to the surface covering in club-shaped protein
spikes.
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 COVID-19 appeared in Wuhan, a city in China, in December
2019. Although health officials are still tracing the exact
source of this new coronavirus, early hypotheses thought it
may be linked to a seafood market in Wuhan, China. Some
people who visited the market developed viral pneumonia
caused by the new coronavirus. A study that came out on
Jan. 25, 2020, notes that the individual with the first
reported case became ill on Dec. 1, 2019, and had no link
to the seafood market.
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The Chinese health authorities have taken prompt public health
measures including intensive surveillance, epidemiological investigations,
and closure of the market on 1 Jan 2020.
 SARS-CoV, MERS-CoV, avian influenza, influenza and other common
respiratory viruses were ruled out.
 The Chinese scientists were able to isolate a 2019-nCoV from a patient
within a short time on 7 Jan 2020 and perform genome sequencing of the
2019-nCoV.
The genetic sequence of the 2019-nCoV has become available to the
WHO on 12 Jan 2020 and this has facilitated the laboratories in different
countries to produce specific diagnostic PCR tests for detecting the novel
infection (WHO, 2020b).
The 2019-nCoV is a β CoV of group 2B with at least 70% similarity in
genetic sequence to SARS-CoV and has been named 2019-nCoV by the
WHO.

Published and early reports suggest spread from person-to-person most
frequently happens during close exposure to a person infected with COVID-
19.
 Person-to-person appears to occur similar to other respiratory viruses,
mainly via respiratory droplets produced when an infected person coughs or
sneezes. These droplets can land in the mouths, noses, or eyes of people
who are nearby or possibly be inhaled into the lungs.
 Although not likely to be the predominant mode of transmission, it
is not clear the extent to which touching a surface contaminated with
the virus and then touching the mouth, nose, or eyes contributes to
transmission.
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What is the incubation period for COVID-19?
It appears that symptoms are showing up in people within 14 days
of exposure to the virus.
A study published on medRxiv has found that the incubation period for
the virus in ion period
One rare cases is as long as 24 days compared to the previously believed 14
days. This was concluded from one patient who reported a 24-day incubat
one in a sample of 1,099 patients infected with the new coronavirus was
found to have an incubation period of as long as 24 days,
More research and comments from other doctors is needed.
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Clinical Presentation
Frequently reported signs and symptoms of patients admitted to
the hospital include fever (77–98%), cough (46%–82%), myalgia or
fatigue (11–52%), and shortness of breath (3-31%) at illness onset.
Among 1,099 hospitalized COVID-19 patients, fever was
present in 44% at hospital admission, and developed in 89%
during hospitalization
 Other less commonly reported respiratory symptoms include
sore throat, headache, cough with sputum production and/or
hemoptysis.
Some patients have experienced gastrointestinal symptoms such
as diarrhea and nausea prior to developing fever and lower
respiratory tract signs and symptoms
Risk factors for severe illness are not yet clear, although
older patients and those with chronic medical conditions may
be at higher risk for severe illness

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Among more than 44,000 confirmed cases of COVID-19 in China as of
Feb 11, 2020:
 most occurred among patients aged 30–69 years (77.8%), and
approximately 19% were severely or critically ill .
Case-fatality proportion among cases aged ≥60 years was: 60-69
years: 3.6%; 70-79 years: 8%; ≥80 years: 14.8%.
 Patients who reported no underlying medical conditions had an
overall case fatality of 0.9%, but case fatality was higher for patients
with comorbidities: 10.5% for those with cardiovascular disease, 7%
for diabetes, and 6% each for chronic respiratory disease,
hypertension, and cancer.
Case fatality for patients who developed respiratory failure, septic
shock, or multiple organ dysfunction was 49%

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the clinical presentation, clinical course, and risk factors for
severe COVID-19 in children
Of confirmed COVID-19 patients in China as of Feb 11,
2020, only 2.1% were aged <20 years, and no deaths were
reported among those <10 years of age
From limited published reports, signs and symptoms among
children with COVID-19 may be more mild than adults,
most pediatric patients presenting with fever, cough,
congestion, and rhinorrhea , and one report of primarily
gastrointestinal symptoms (vomiting and diarrhea).

Symptoms include fever (>90% cases), malaise, dry cough (80%), shortness
of breath (20%) and respiratory distress (15%). The vital signs were stable
in most of the cases while leucopenia and lymphopenia were common
Older adults and people who have severe
underlying chronic medical conditions like
heart or lung disease or diabetes seem to
be at higher risk for developing more
serious complications from COVID-19
illness.
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Symptoms

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Clinical Course
Clinical presentation among reported cases of COVID-19 varies
in severity from asymptomatic infection to mild illness to severe
or fatal illness.
Some reports suggest the potential for clinical deterioration
during the second week of illness
Acute respiratory distress syndrome (ARDS) developed in 17–29%
of hospitalized patients, and secondary infection developed in 10%
Compared to patients not admitted to an intensive care unit,
critically ill patients were older (median age 66 years versus 51
years), and were more likely to have underlying co-morbid
conditions (72% versus 37%).
While most people with COVID-19 develop only mild or
uncomplicated illness, approximately 14% develop severe disease
that requires hospitalization and oxygen support, and 5% require
admission to an intensive care unit

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Among critically ill patients admitted to an intensive care
unit, 11–64% received high-flow oxygen therapy and 47-71%
received mechanical ventilation; some hospitalized patients
have required advanced organ support with endotracheal
intubation and mechanical ventilation (4–42%)
. In severe cases, COVID-19 can be complicated by the
acute respiratory distress syndrome (ARDS), sepsis and
septic shock, multiorgan failure, including acute kidney
injury and cardiac injury
Older age and co-morbid disease have been reported as risk factors
for death, and Interim guidance recent multivariable analysis
confirmed older age, higher Sequential Organ Failure Assessment (SOFA)
score and d-dimer > 1 µg/L on admission were associated with higher
mortality.

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Diagnostic Testing
Clinicians should use their judgment to determine if a patient has signs and
symptoms compatible with COVID-19 and whether the patient should be
tested.
Acceptable Specimens:
Respiratory specimens including: nasopharyngeal or oropharyngeal
aspirates or washes, nasopharyngeal or oropharyngeal swabs,
broncheoalveolar lavage, tracheal aspirates, and sputum.
Swab specimens should be collected only on swabs with a
synthetic tip (such as polyester or Dacron®) with aluminum or
plastic shafts. Swabs with calcium alginate or cotton tips with
wooden shafts are not acceptable.

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Recommendations for laboratory testing “
Any suspected case should be tested for infection with the COVID-19
virus using a molecular test. However, it is possible to test only a subset
of suspected cases, depending on the intensity of the transmission, the
number of cases and laboratory capacity.
If resources allow, testing may be done more broadly (for
instance, through sentinel surveillance) to better assess the full
extent of the circulation of the virus.
Based on clinical judgment, clinicians may opt to order a test for
the COVID-19 virus in a patient who does not strictly meet the
case definition, for example, if there is acute respiratory illness
among a cluster of health care workers or severe acute
respiratory infection or pneumonia in families, workplaces or
social networks.

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Diagnostic Testing
For initial diagnostic testing for COVID-19, CDC recommends
collecting and testing an upper respiratory nasopharyngeal swab
(NP).
Collection of oropharyngeal swabs (OP) is a lower priority and if
collected should be combined in the same tube as the NP
Collection of sputum should only be done for those patients
with productive coughs. Induction of sputum is not
recommended.
Specimens should be collected as soon as possible once a Persons
Under Investigation is identified, regardless of the time of symptom
onset.

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Recommendations for specimen collection :
Specimens from the lower respiratory tract likely have a higher
diagnostic value for detecting COVID-19 infection than those from
the upper respiratory tract
WHO recommends that specimens from the lower respiratory
tract, such as sputum, endotracheal aspirate, or from
bronchoalveolar lavage, be collected for testing when possible.
If patients do not have signs or symptoms of lower respiratory tract
disease or if specimen collection for lower respiratory tract disease is
clinically indicated but collection is not possible, upper respiratory
tract specimens, such as a nasopharyngeal aspirate or combined
nasopharyngeal and oropharyngeal swabs, should be collected.
If initial testing is negative in a patient who is strongly suspected to have
COVID-19 infection, specimens should be collected again from multiple
respiratory tract sites (such as the nose) and should also include sputum
and endotracheal aspirate. Additional specimens may be collected, such
as blood, urine and stool, to monitor the presence of virus and shedding
of virus from different body compartments.

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Laboratory and Radiographic Findings
the most common laboratory abnormalities reported among
hospitalized patients with pneumonia on admission included
leukopenia (9–25%), leukocytosis (24–30%), lymphopenia (63%), and
elevated alanine aminotransferase and aspartate aminotransferase
levels (37%).
Among 1,099 COVID-19 patients, lymphocytopenia was
present in 83%; 36% had thrombocytopenia, and 34% had
leukopenia. [6] Most patients had normal serum levels of
procalcitonin on admission
Chest CT images have shown bilateral involvement in most
patients. Multiple areas of consolidation and ground glass opacities
are typical findings reported to date.
one study that evaluated the time from symptom onset to
initial CT scan found that 56% of patients who presented
within 2 days had a normal CT.

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information regarding infection prevention

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Recommendations :
1. Minimize Chance for Exposures:
Measures should be implemented before patient arrival, upon arrival,
throughout the duration of the patient’s visit, and until the patient’s
room is cleaned and disinfected.
Before Arrival
When scheduling appointments for routine medical care (e.g., annual
physical, elective surgery), instruct patients to call ahead and discuss
the need to reschedule their appointment if they develop symptoms of
a respiratory infection (e.g., cough, sore throat, fever1) on the day
they are scheduled to be seen.
When scheduling appointments for patients requesting evaluation
for a respiratory infection, use nurse-directed triage protocols to
determine if an appointment is necessary or if the patient can be
managed from home.

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 If the patient must come in for an appointment, instruct them
to call beforehand to inform triage personnel that they have
symptoms of a respiratory infection (e.g., cough, sore throat,
fever1) and to take appropriate preventive actions (e.g., follow
triage procedures, wear a facemask upon entry and throughout
their visit or, if a facemask cannot be tolerated, use a tissue to
contain respiratory secretions).
If a patient is arriving via transport by emergency medical services
(EMS) , EMS personnel should contact the receiving emergency
department (ED) or healthcare facility and follow previously agreed
upon local or regional transport protocols. This will allow the
healthcare facility to prepare for receipt of the patient.

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Upon Arrival and During the Visit
Consider limiting points of entry to the facility
Take steps to ensure all persons with symptoms of COVID-19 or
other respiratory infection (e.g., fever, cough) adhere to
respiratory hygiene and cough etiquette , hand hygiene, and
triage procedures throughout the duration of the visit.
Ensure rapid safe triage and isolation of patients with symptoms of
suspected COVID-19 or other respiratory infection (e.g., fever,
cough).
Incorporate questions about new onset of respiratory symptoms
into daily assessments of all admitted patients. Monitor for and
evaluate all new fevers and respiratory illnesses among patients
Place any patient with unexplained fever or respiratory symptoms
on appropriate Transmission-Based Precautions and evaluate.

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2. Adhere to Standard and Transmission-Based Precautions:
HCP who enter the room of a patient with known or suspected
COVID-19 should adhere to Standard Precautions and use a respirator
or facemask, gown, gloves, and eye protection. When available,
respirators (instead of facemasks) are preferred;
Hand Hygiene
HCP should perform hand hygiene before and after all patient contact,
contact with potentially infectious material, and before putting on and
after removing PPE, including gloves. Hand hygiene after removing PPE is
particularly important to remove any pathogens that might have been
transferred to bare hands during the removal process.
HCP should perform hand hygiene by using ABHR with 60-95%
alcohol or washing hands with soap and water for at least 20 seconds.
If hands are visibly soiled, use soap and water before returning to
ABHR.
Healthcare facilities should ensure that hand hygiene supplies are
readily available to all personnel in every care location.

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Personal Protective Equipment
Any reusable PPE must be properly cleaned, decontaminated, and
maintained after and between uses. Facilities should have policies
and procedures describing a recommended sequence for safely
donning and doffing PPE.
Respirator or Facemask
The PPE recommended when caring for a patient with known or
suspected COVID-19 includes:
Put on a respirator or facemask (if a respirator is not available)
before entry into the patient room or care area.
N95 respirators or respirators that offer a higher level of
protection should be used instead of a facemask when performing
or present for an aerosol-generating procedure
Disposable respirators and facemasks should be removed and
discarded after exiting the patient’s room or care area and closing
the door.
Perform hand hygiene after discarding the respirator or facemask

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Eye Protection
Put on eye protection (i.e., goggles or a disposable face shield that
covers the front and sides of the face) upon entry to the patient room
or care area. Personal eyeglasses and contact lenses are NOT
considered adequate eye protection.
Reusable eye protection (e.g., goggles) must be cleaned and
disinfected according to manufacturer’s reprocessing instructions
prior to re-use. Disposable eye protection should be discarded after
use.
Gloves
Put on clean, non-sterile gloves upon entry into the patient room
or care area.Change gloves if they become torn or heavily
contaminated.
Remove and discard gloves when leaving the patient room or
care area, and immediately perform hand hygiene.

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Gowns
Put on a clean isolation gown upon entry into the patient room or
area.
Change the gown if it becomes soiled.
Remove and discard the gown in a dedicated container for waste or
linen before leaving the patient room or care area.
 Disposable gowns should be discarded after use.
 Cloth gowns should be laundered after each use.

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3. Patient Placement:
For patients with COVID-19 or other respiratory infections,
evaluate need for hospitalization. If hospitalization is not
medically necessary, home care is preferable if the
individual’s situation allows.
If admitted, place a patient with known or suspected COVID-19 in a
single-person room with the door closed. The patient should have a
dedicated bathroom.
Airborne Infection Isolation Rooms (AIIRs) should be reserved
for patients who will be undergoing aerosol-generating
procedures
As a measure to limit HCP exposure and conserve PPE, facilities
could consider designating entire units within the facility, with
dedicated HCP, to care for known or suspected COVID-19 patients.
Dedicated means that HCP are assigned to care only for these
patients during their shift.

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Limit transport and movement of the patient outside of the room to
medically essential purposes.
To the extent possible, patients with known or suspected COVID-19
should be housed in the same room for the duration of their stay in
the facility (e.g., minimize room transfers).
Patients should wear a facemask to contain secretions
during transport. If patients cannot tolerate a facemask or
one is not available, they should use tissues to cover their
mouth and nose
Once the patient has been discharged or transferred, HCP, including
environmental services personnel, should refrain from entering the
vacated room until sufficient time has elapsed for enough air changes
to remove potentially infectious particles .After this time has elapsed,
the room should undergo appropriate cleaning and surface disinfection
before it is returned to routine use .

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4. Take Precautions When Performing Aerosol-Generating
Procedures (AGPs):
Some procedures performed on patient with known or suspected
COVID-19 could generate infectious aerosols. In particular,
procedures that are likely to induce coughing (e.g., sputum
induction, open suctioning of airways) should be performed
cautiously and avoided if possible.
If performed, the following should occur:
HCP in the room should wear an N95 or higher-level respirator,
eye protection, gloves, and a gown.
The number of HCP present during the procedure should be
limited to only those essential for patient care and procedure
support.
 Visitors should not be present for the procedure.
AGPs should ideally take place in an AIIR.

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5. Collection of Diagnostic Respiratory Specimens:
When collecting diagnostic respiratory specimens (e.g.,
nasopharyngeal swab) from a possible COVID-19 patient, the
following should occur:
HCP in the room should wear an N-95 or higher-level respirator
(or facemask if a respirator is not available), eye protection,
gloves, and a gown.
The number of HCP present during the procedure should be
limited to only those essential for patient care and procedure
support.
Visitors should not be present for specimen collection.
Specimen collection should be performed in a normal examination
room with the door closed.

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6. Manage Visitor Access and Movement Within the Facility:
Establish procedures for monitoring, managing and training all visitors,
which should include:
All visitors should perform frequent hand hygiene and follow
respiratory hygiene and cough etiquette precautions while in the facility,
especially common areas.
Passively screen visitors for symptoms of acute respiratory illness
before entering the healthcare facility
Informing visitors about appropriate PPE use according to
current facility visitor policy
Visitors to the most vulnerable patients (e.g., oncology and
transplant wards) should be limited; visitors should be screened
for symptoms prior to entry to the unit.
limit visitors to patients with known or suspected COVID-19.
Encourage use of alternative mechanisms for patient and visitor
interactions such as video-call applications on cell phones or
tablets. I

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Clinical Management and Treatment:
Patients with a mild clinical presentation may not initially require
hospitalization.
However, clinical signs and symptoms may worsen with progression
to lower respiratory tract disease in the second week of illness; all
patients should be monitored closely.
Possible risk factors for progressing to severe illness may
include, but are not limited to, older age, and underlying
chronic medical conditions such as lung disease, cancer, heart
failure, cerebrovascular disease, renal disease, liver disease,
diabetes, immunocompromising conditions, and pregnancy.
The decision to monitor a patient in the inpatient or outpatient
setting should be made on a case-by-case basis. This decision will
depend not only on the clinical presentation, but also on the
patient’s ability to engage in monitoring, home isolation, and the
risk of transmission in the patient’s home environment.

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No specific treatment for COVID-19 is currently available
Clinical management includes prompt implementation of
recommended infection prevention and control measures and
supportive management of complications, including advanced organ
support if indicated.

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Clinical management of severe acute respiratory infection
when novel coronavirus (nCoV) infection is suspected.
1. Screening and triage: early recognition of patients with SARI
associated with COVID-19
Screening and triage:
 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/clinic).
Consider COVID-19 as a possible etiology of patients with acute
respiratory illness under certain conditions (see below). Triage
patients using standardized triage tools and start first-line
treatments.

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Case definitions for surveillance :
Suspected case
A. a patient with acute respiratory illness (that is, fever and at least
one sign or symptom of respiratory disease, for example, cough or
shortness of breath) AND with no other etiology that fully explains
the clinical presentation AND a history of travel to or residence in a
country, area or territory that has reported local transmission of
COVID-19 disease during the 14 days prior to symptom onset
B. a patient with any acute respiratory illness AND who has been a
contact of a confirmed or probable case of COVID-19 disease during
the 14 days prior to the onset of symptoms
OR
OR
C. a patient with severe acute respiratory infection (that is, fever
and at least one sign or symptom of respiratory disease, for
example, cough or shortness breath) AND who requires
hospitalization AND who has no other etiology that fully explains the
clinical presentation.

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Probable case
A probable case is a suspected case for whom the report from
laboratory testing for the COVID-19 virus is inconclusive.
Confirmed case
 A confirmed case is a person with laboratory confirmation of
infection with the COVID-19 virus, irrespective of clinical signs and
symptoms.

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Remark 1: Although the majority of people with COVID-19 have
uncomplicated or mild illness (81%), some will develop severe illness
requiring oxygen therapy (14%) and approximately 5% will require
intensive care unit treatment. Of those critically ill, most will require
mechanical ventilation (2, 10). The most common diagnosis in severe
COVID-19 patients is severe pneumonia.
Remark 2: Early recognition of suspected patients allows for timely
initiation of appropriate IPC measures . Early identification of those with
severe illness, such as severe pneumonia (see Table 2), allows for
optimized supportive care treatments and safe, rapid referral and
admission to a designated hospital ward or intensive care unit according
to institutional or national protocols.
Remark 3: Older patients and those with comorbidities, such as
cardiovascular disease and diabetes mellitus, have increased risk of
severe disease and mortality. They may present with mild symptoms but
have high risk of deterioration and should be admitted to a designated
unit for close monitoring.
Remark 4: For those with mild illness, hospitalization may not be required
unless there is concern about rapid deterioration or an inability to promptly
return to hospital, but isolation to contain/mitigate virus transmission should be
prioritized. All patients cared for outside hospital (i.e. at home or non-
traditional settings) should be instructed to manage themselves appropriately
according to local/regional public health protocols for home isolation and return
to a designated COVID-19 hospital if they get worse

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2. Immediate implementation of appropriate IPC measures
Initiate IPC at the point of entry of the patient to hospital. Screening
should be done at first point of contact at the emergency department or
outpatient department/clinics. Suspected COVID-19 patients should be
given a mask and directed to separate area. Keep at least 1 m distance
between suspected patients.
Standard precautions should always be applied in all areas of health care
facilities. Standard precautions include hand hygiene and the use of
personal protective equipment (PPE) when in indirect and 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.
In addition to standard precautions, health care workers should
do a point-of-care risk assessment at every patient contact to
determine whether additional precautions (e.g. droplet, contact,
or airborne) are required.

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3. Collection of specimens for laboratory diagnosis

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4. Management of mild COVID-19: symptomatic treatment and
monitoring

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5. Management of severe COVID-19: oxygen therapy and
monitoring
Give supplemental oxygen therapy immediately to patients with
SARI and respiratory distress, hypoxaemia or shock and target
SpO2 > 94%.
Closely monitor patients with COVID-19 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) to tailor the
management of critical illness.
Remark 1: Determine which chronic therapies should be continued and
which therapies should be stopped temporarily. Monitor for drug-drug
interactions.
Use conservative fluid management in patients with SARI when there
is no evidence of shock.
Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because
aggressive fluid resuscitation may worsen oxygenation, especially in settings where there
is limited availability of mechanical ventilation (27). This applies for care of children and
adults.

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6. Management of severe COVID-19: treatment of co-infections:
Give empiric antimicrobials to treat all likely pathogens causing
SARI and sepsis as soon as possible, within 1 hour of initial
assessment for patients with sepsis.
Empiric therapy should be de-escalated on the basis of
microbiology results and clinical judgment
7. Management of critical COVID-19: acute respiratory distress
syndrome (ARDS :(
Recognize severe hypoxemic respiratory failure when a patient
with respiratory distress is failing to respond to standard oxygen
therapy and prepare to provide advanced oxygen/ventilatory
support.
Endotracheal intubation should be performed by a trained and
experienced provider using airborne precautions

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The following recommendations pertain to mechanically
ventilated adults and paediatric patients with ARDS :
Implement mechanical ventilation using lower tidal volumes (4–8
mL/kg predicted body weight, PBW) and lower inspiratory
pressures (plateau pressure < 30 cmH2O).
In adult patients with severe ARDS, prone ventilation for 12–16
hours per day is recommended.
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.
Avoid disconnecting the patient from the ventilator, which
results in loss of PEEP and atelectasis.

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Use in-line catheters for airway suctioning and clamp
endotracheal tube when disconnection is required (for
example, transfer to a transport ventilator
The following recommendations pertain to adult and paediatric
patients with ARDS in whom lung protective ventilation strategy
fails.
In settings with access to expertise in extracorporeal membrane
oxygenation (ECMO), consider referral of patients who have
refractory hypoxemia despite lung protective ventilation.
The following recommendations pertain to adult and paediatric
patients with ARDS who are treated with non-invasive or high-flow
oxygen systems.
High-flow nasal oxygen (HFNO) should be used only in selected
patients with hypoxemic respiratory failure.
Non-invasive ventilation (NIV) should be used only in selected
patients with hypoxemic respiratory failure.
Patients treated with either HFNO or NIV should be closely monitored
for clinical deterioration.

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8. Management of critical illness and COVID-19: prevention of
complications

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9. Management of critical illness and COVID-19: 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 two or more of the following: altered mental state; bradycardia
or tachycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70
bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or
feeble pulses; tachypnea; mottled or cold skin or petechial or
purpuric rash; increased lactate; oliguria; hyperthermia or
hypothermia.

3/17/2020 56
The following recommendations pertain to resuscitation
strategies for adult and paediatric patients with septic shock.
In resuscitation for septic shock in adults, give 250–500 mL
crystalloid fluid as rapid bolus in first 15–30 minutes and reassess
for signs of fluid overload after each bolus.
In resuscitation from septic shock 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.
Fluid resuscitation may lead to volume overload, including
respiratory failure, particularly with ARDS.
If there is no response to fluid loading or signs of volume
overload appear (e.g. 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 in patients with hypoxemic
respiratory failure

3/17/2020 57
Do not use hypotonic crystalloids, starches, or gelatins for
resuscitation.
In adults, administer vasopressors when shock persists during or after
fluid resuscitation. The initial blood pressure target is MAP ≥ 65 mmHg in
adults and improvement of markers of perfusion.
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.

3/17/2020 58
10. Adjunctive therapies for COVID-19: corticosteroids:
Do not routinely give systemic corticosteroids for treatment of
viral pneumonia outside clinical trials.
11. Caring for pregnant women with COVID-1:9

3/17/2020 59
12. Caring for infants and mothers with COVID-19: IPC and
breastfeeding :

3/17/2020 60
13. Caring for older persons with COVID-19:

3/17/2020 61
14. Clinical research and specific anti-COVID-19 treatments
There is no current evidence to recommend any specific anti-
COVID-19 treatment for patients with confirmed COVID-19. There
are many ongoing clinical trials testing various potential antivirals.

Coronavirus disease (covid 19)

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