RECOMMENDATIONS FOR THE MANAGEMENT OF COVID-19 PATIENTS

        Classification of COVID-19 patients on clinical features

  

Asymptomatic	COVID nucleic acid test positive. Without any clinical symptoms and signs and the chest imaging is normal
Mild	Symptoms of acute upper respiratory tract infection (fever, fatigue, myalgia, cough, sore throat, runny nose, sneezing) or digestive symptoms (nausea, vomiting, abdominal pain, diarrhea)
Moderate	Pneumonia (frequent fever, cough) with no obvious hypoxemia, chest CT with lesions.
Severe	Pneumonia with hypoxemia (SpO2 < 92%)
Critical	Acute respiratory distress syndrome (ARDS), may have shock, encephalopathy,    myocardial   injury,   heart  failure,          coagulation   dysfunction and acute kidney injury.

Proposed Clinical Staging System

• Stage I: Mild (Early Infection)           ---     Groups A B & C
• Stage IIa: Moderate (Pulmonary Involvement Without Hypoxia) --- Group D
• Stage IIb: Moderate (Pulmonary Involvement With Hypoxia) --- Group E
• Stage III: Severe (Pulmonary Involvement With Hypoxia with sepsis/ septic shock/ multi organ dysfunction syndrome)   --- Group F

Stage & Group		Criteria	Investigatio ns	Site of Admission	Treatment	Remarks
	Group A	Asymptomatic but positive for COVID-19	CBC, RFT, RBS, LFT, ECG	Isolation ward / Home Isolation (as per availability)	T. Vit C 1000 mg per day + T. Zinc 50 mg per day +	Monitor symptoms and body temperature 12 hourly and Oxygen Saturation
					Vitamin D	every 12 hours
					60000 IU stat	with walk test
STAGE I (Mild)	Group B	Symptomatic/URTI without comorbidity   ·        Anosmia ·        Fever ·        Dry cough ·        Shortness of breath ·        Myalgia ·        Diarrhea ·        Loss of taste   RED FLAG SIGNS 1.     Resting tachycardia   2.     Spo2 below 94% on rom air	CBC, RFT, RBS, LFT, CXR, ECG SpO2 monitoring	Isolation ward	{T. Favipiravir* 200 mg 9 tablets twice daily on Day 1 followed by 4 tablets twice daily for 13 days.(works best in first 72 hours and unlikely to work after 7 to 10 days * EUA)} Or (Off Label Doxy 100 mg bid + Ivermectin 12mg od ,5 days ;no RCT data available)	Baseline ECG for QTc Monitor symptoms and body temperature 12 hourly and Oxygen Saturation every 12 hours with walk test

					+
		3. 6 min exercise			T. Vit C 1000
		induced dexoygenation			mg per day
		(see below)			+
					T. Zinc 50 mg
		4. Neutrophil			per day
		Lymphocyte			+
		ratio > 3.5			Vitamin D
		5. P:F ratio less			60000 IU stat
		than 300
		Symptomatic/URTI with	CBC , LFT, RFT, RBS, CXR, ABG ECG ESR, CRP, S. Ferritin, D-dimer, LDH, S.Triglycerides     If QTc prolongation then Daily S. electrolytes, ionic calcium & magnesium		{T. Favipiravir 200 mg 9 tablets twice daily on Day 1 followed by 4 tablets twice daily for 14 days,EUA} +   T. Vit C 1000 mg per day + T. Zinc 50 mg per day + Vitamin D 60000 IU stat   If raised D-dimer / Ferritin then add Inj. LMWH 40 mg SC OD
		comorbidity
		·        > 60 yrs
		·        DM
		·        HTN /IHD				T. Cefixime
		·        COPD/Chronic lung				200 mg BD or
		disease				T.
		·        Immunocompromised				Coamxoyclav
		state				625mg TDS
		·        Immunosuppressive				(as per local
		drugs				antibiotic
	Group C	·       CKD ·       Obesity		Isolation ward		policy)
		RED FLAG SIGNS
		1. Neutrophil Lymphocyte ratio > 3.5				ECG- Baseline & daily to look
		2. P:F ratio less than				for QTc
		300 3. 6 min exercise				prolongation
		induced
		dexoygenation (see
		below)
		4. Resting tachycardia
		5.  Raised CRP /
		Ferritin / D-dimer
		/LDH /
		Triglycerides

STAGE IIA   (Modera te)	Group D	Pneumonia (LRTI) without respiratory failure   (Fever/cough/dyspnea however SpO2 >93% on rom air, PaO2 > 60 mmHg & RR < 24/min)   RED FLAG SIGNS 1.     Neutrophil Lymphocyte ratio > 3.5 2.     P:F ratio less than 300 3.     Raised CRP / Ferritin / D-dimer /LDH / Triglycerides	CBC , LFT, RFT, RBS, CXR, ECG ABG ESR, CRP, S. Ferritin, D-dimer, LDH, S.Triglycerides     If QTc prolongation then Daily S. electrolytes, ionic calcium & magnesium	Isolation ward/SOS ICU	{T. Favipiravir 200 mg 9 tablets twice daily on Day 1 followed by 4 tablets twice daily for 14 days,EUA}   +     If raised D-dimer / Ferritin then add Inj. LMWH 40 mg SC OD   + T. Vit C 1000 mg per day +   T. Zinc 50 mg per day + Vitamin D 60000 IU stat	Inj. Ceftriaxone 1g IV OD for 5- 10 days (as per local antibiotic policy)     ECG- Baseline & daily to look for QTc
STAGE IIB (Modera te)	Group E	Pneumonia (LRTI) with respiratory failure	CBC , LFT, RFT, RBS, CXR, ECG	ICU	Appropriate Oxygen therapy (Nasal cannula / Hudson mask /	Inj. Piperacillin- tazobactam 4.5 g IV TDS extended

(RR> 24 /min, SpO2 < 94% on room air, PaO2 < 60 mmHg)         RED FLAG SIGNS 1.     Neutrophil Lymphocyte ratio > 3.5   2.     Raised CRP / Ferritin / D-dimer /LDH / Triglycerides / Troponin I / CPK- MB   3.     Raised IL-6 levels

ABG, ESR, CRP, S. Ferritin, D-dimer, LDH, S.Triglycerides Troponin I CPK-MB, IL-6 levels

Non-rebreather mask/ HFNC / CPAP/ Mechanical ventilation)   +     CARP Protocol     +     Inj. Remdesivir 200 mg IV OD on Day1 followed by 100 mg IV OD for 4 days (EUA)   +     Inj. MPS 40 mg IV BD. If MPS is unavailable may use Inj. Dexamethasone 6 mg IV OD x 10 days   +     If raised IL-6, D-dimers & Ferritin then Add Inj. Tocilizumab 8mg/kg ( ~400 mg , max 800 mg) IV in 100 cc NS over 60 min

infusion over 4 hours (as per local antibiotic policy)

					(Itolizumab may be used if Toclizumab is not available and is cheaper but lacks robust data ,Both are off label,EUA on compassionate grounds)     +     If raised D-dimer / Ferritin then add Inj. LMWH 40 mg SC OD     +     T. Vit C 1000 mg per day +   T. Zinc 50 mg per day
STAGE III	Group F	Pneumonia (LRTI) with respiratory failure with sepsis/ septic shock/ multi organ dysfunction syndrome         RED FLAG SIGNS	CBC , LFT, RFT, RBS, CXR, ECG     ABG, ESR, CRP,  S. Ferritin,  D-dimer, LDH,	ICU	Appropriate Oxygen therapy (Nasal cannula / Hudson mask / Non-rebreather mask/ HFNC / CPAP/ Mechanical ventilation)   +	Inj. Meropenem 1g IV TDS extended infusion over 3 hours (as per local antibiotic policy)

1.     Neutrophil Lymphocyte ratio > 3.5   2.      Raised CRP / Ferritin / D-dimer /LDH / Triglycerides / Troponin I/ CPK-MB

S.Triglycerides Troponin I CPK-MB     Blood culture & sensitivity

CARP Protocol     +     Inj. Remdesivir 200 mg IV OD on Day1 followed by 100 mg IV OD x 4days (EUA)   +     Inj. MPS 40 mg IV BD. I Or Inj. Dexamethasone 6 mg IV OD x 10 days     +     If raised IL-6, D-dimers & Ferritin then Add Inj. Tocilizumab 8mg/kg ( ~400 mg , max 800 mg) IV in 100 cc NS over 60 min (Itolizumab may be used if Toclizumab is not available and is

cheaper but lacks robust data ,Both are off label,EUA on compassionate grounds)   + If raised D-dimer / Ferritin then add Inj. LMWH 60 mg SC BD as per phsycians choice     +     T. Vit C 1000 mg per day +   T. Zinc 50 mg per day + Vitamin D 60000 IU stat

* All therapies above except Steroids have not shown any benefit in RCTs on mortality but have shown some benefits either on viral clearance or recovery time or length of stay in ICU or hospital. The other end points of covid 19 therapy. All therapies are experimental.

SIX Minute Walk Test

1. A 6-minute walk test is an established clinical test to look for cardio pulmonary exercise tolerance.
2. American Thoracic Society recommends its use for prediction for mortality and morbidity in Heart Failure, COPD and Primary Pulmonary Hypertension.
3. Patient with pulse oximeter attached to his finger is asked to walk in confines of his room.
4. Any drop in saturation below 93%, or an absolute drop of more than 3%, or feeling unwell (light headed, short of breath) while performing the test are significant findings.
5. This test is used to unmask hypoxia.
6. Patients with positive 6 minute walk test may progress to become hypoxic and hence early intervention in form of admission to hospital, or shifting to ICU and giving oxygen and +/- Steroids is recommended.
7. The 6 minutes may be cut short for 3 minutes in patients above 60 years of age.