The key points in treatment of the critical coronavirus disease 2019 patients

Original Article: X Y Li, D Du, YS Wang, H Y J Kang, F Wang, B Sun, H B Qiu, Z H Tong.  The key points in treatment of the critical coronavirus disease 2019 patients. Zhong Hua Jie He He Hu Xi Za Zhi. Feb.29, 2020 (online ahead of print).

Translation from Chinese: Haitong Hoi and Xiang-Ning Li; Edits, Summary and Translation to Italian: Federica La Russa

Original Article Published on February 29th, 2020

A group of front-line medical doctors at Beijing Chaoyang Hospital share their experiences with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), thus defining key points for evaluation, treatment and management of critically ill patients.

  • Background

COVID-19 critically ill patients often require invasive mechanical ventilation and are prone to hypovolemic, septic or cardiogenic shock. Key parameters to prioritize are listed below.

  • Hemodynamic

Hemodynamic parameters in COVID-19 critically ill patients are often altered, thus requiring monitoring, especially in patients requiring mechanical ventilation or sedation. A top priority is to differentiate the underlying causes of unstable hemodynamics. These include:

  1. Dehydration: caused by prolonged anorexia and fever, should be treated referring to cluster therapy for septic shock [fluid infusion 30ml/kg for 3 hours].
  2. Use of sedatives and analgesic: these can inhibit the sympathetic nervous system, causing low blood pressure, and therefore require constant dosing adjustment.
  3. Cardiac function alteration: needs to be closely monitored to avoid cardiac shock since severe patients often show elevated myocardial enzymes (especially troponin).
  4. Septic shock: requires evaluation by measurement of blood lactic acid level and check for pathogen growth. If positive, administration of broad-spectrum antibiotics is recommended.

If these interventions do not revert hemodynamic alterations, vasopressors might be used. Yet, choice of the appropriate medication and potential adverse reaction – especially renal insufficiency and failure – must be taken under careful consideration. Vein catheter pump administration of norepinephrine is the top choice.

  • Prevention of venous thromboembolism

COVID-19 critically ill patients remain bed-bound for long period of time, and 20% of them are reported to present coagulation abnormalities. For this reason, attention should be paid to prevent venous thromboembolism, especially since risk and occurrence might change dynamically, and even suddenly, during the disease. D-dimers levels result often elevated in critically ill patients with negative prognosis, thus suggesting it may be a potential marker.

  • Nutritional support

Nutritional support is pivotal in managing critically ill patients. Most of the available guidelines recommend establishment of enteral nutritional support within 48 hours following admission to the ICU. Specifically, post-pyloric feeding should be the first choice. Following fluid resuscitation, energy supply should be maintained to 20~30 kcal.kg-1.d-1 alongside protein supply within a range of 1.2~2.0 g/kg.

  • Convalescent plasma as a potential treatment

Convalescent plasma therapy is a passive immunotherapy consisting in plasma transfusion from patients who have recovered to ill patients. Convalescent plasma therapy has been reported to reduce viral load and mortality in both influenza and SARS-induced pneumonia with limited benefit in treatment of severe influenza. To date, WHO has not published any guidelines on convalescent plasma therapy in COVID-19 patients, and therefore the authors could only postulate on such strategy empirically.

The following criteria for convalescent plasma donors are inferred: 1. Fully recovered patient with no detectable viral load; 2. Physical conditions should meet standard criteria for blood donors; 3. Donation must be voluntary and informed consent must be signed; 4. Donors must have adequate specific antibodies titer.

With regards to the recipient, at present, convalescent plasma therapy should be used in patients with rapid disease progression or with preexisting conditions, because of the limited availability of donors and technical difficulties in the preparation and standardization of plasma. A total volume of 500ml of blood is recommended over the course of two transfusions with an interval of at least 15 minutes, and each transfusion must be adjusted to the patient’s conditions.

  • Conclusions

Overall, as specific anti-viral drugs for COVID-19 treatment are lacking, the current focus is on symptomatic treatment and supportive care, relying on comprehensive and systematic considerations of respiratory, circulatory, and nutritional supports to provide best patient outcome.

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