Critical Care COVID-19 Management Protocol. (updated 9-02-2020)

Critical Care COVID-19 Management Protocol (updated 9-02-2020)

Prophylaxis

While there is very limited data (and none specific for COVID-19), the following “cocktail” may

have a role in the prevention/mitigation of COVID-19 disease.

■ Vitamin C 500 mg BID and Quercetin 250-500 mg BID

■ Zinc 75-100 mg/day

■ Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 2 mg

at night

■ Vitamin D3 1000-4000 u/day

■ Optional: Famotidine 20-40mg/day

Mildly Symptomatic patients (at home):

■ Vitamin C 500mg BID and Quercetin 250-500 mg BID

■ Zinc 75-100 mg/day

■ Melatonin 6-12 mg at night (the optimal dose is unknown)

■ Vitamin D3 2000-4000 u/day

■ Optional: Ivermectin 150-200ug/kg (single dose)

■ Optional: ASA 81/325mg/day

■ Optional: Famotidine 20-40mg/day

In symptomatic patients, monitoring with home pulse oximetry is recommended.

Ambulatory desaturation below 94% should prompt hospital admission

Mildly Symptomatic patients (on floor):

■ Vitamin C 500 mg PO q 6 hourly and Quercetin 250-500 mg BID (if available)

■ Zinc 75-100 mg/day

■ Melatonin 6-12 mg at night (the optimal dose is unknown)

■ Vitamin D3 2000-4000 u/day

■ Enoxaparin 60 mg daily

■ Famotidine 40mg daily (20mg in renal impairment)

■ Methylprednisolone 40 mg q 12 hourly; increase to 80 mg q 12 if poor response

■ Optional: Remdesivir 200mg D1 then 100mg daily for 9 days.

■ Optional: Ivermectin 150-200 ug/kg (single dose)

■ N/C 2L /min if required (max 4 L/min; consider early t/f to ICU for escalation of care).

■ T/f EARLY to the ICU for increasing respiratory signs/symptoms and arterial

desaturations.

General schema for respiratory support in patients with COVID-19

TRY TO AVOID INTUBATION IF POSSIBLE

Low-Flow Nasal Cannula

■ Typically set at 1-6 Liters/Min

High Flow Nasal Cannula

■ Accept permissive hypoxemia (O2 Saturation > 86%)

■ Titrate FiO2 based on patient’s saturation

■ Accept flow rates of 60 to 80 L/min

■ Trial of inhaled Flolan (epoprostenol)

■ Attempt proning (cooperative proning)

Invasive Mechanical Ventilation

■ Target tidal volumes of ~6 cc/kg

■ Lowest driving pressure and PEEP

■ Sedation to avoid self-extubation

■ Trial of inhaled Flolan

Prone Positioning

■ Exact indication for prone ventilation is unclear

■ Consider in patients with PaO2/FiO2 ratio < 150

SALVAGE THERAPIES

■ High dose corticosteroids; 120 -250 mg methylprednisolone q 6-8 hourly

■ Plasma exchange

■ “Half-dose” rTPA

■ Siltuximab and Tocilizumab (IL-6 inhibitors)

■ ?? ECMO < 60 yrs. and no severe comorbidities/organ failure

Deterioration

Recovery

continued on next page

Find the latest version at evms.edu/covidcare

Critical Care COVID-19 Management Protocol

(updated 6-17-2020)

Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min:

admit to ICU):

Essential Treatment (dampening the STORM)

1. Methylprednisolone 80 mg loading dose then 40 mg q 12 hourly for at

least 7 days and until transferred out of ICU. In patients with poor response,

increase to 80 mg q 12 hourly.

2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until

transferred out of ICU. Note caution with POC glucose testing.

3. Full anticoagulation: Unless contraindicated we suggest FULL

anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c

q 12 hourly (dose adjust with Cr Cl < 30mls/min). Heparin is suggested with

CrCl < 15 ml/min.

Note: Early termination of ascorbic acid and corticosteroids will likely result in a

rebound effect.

Additional Treatment Components (the Full Monty)

4. Melatonin 6-12 mg at night (the optimal dose is unknown).

5. Famotidine 40mg daily (20mg in renal impairment)

6. Vitamin D 2000-4000 u/day

7. Thiamine 200mg IV q 12 hourly

8. Simvastatin 80 mg/day (caution drug-drug interactions) or Atorvastatin

80mg/day

9. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent

hypomagnesemia (which increases the cytokine storm and prolongs Qtc).

10. Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days

11. Optional: Remdesivir, 200 mg IV loading dose D1, followed by 100mg day IV

for 9 days

12. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected

based on procalcitonin levels and resp. culture (no bronchoscopy).

13. Maintain EUVOLEMIA

14. Early norepinephrine for hypotension.

15. Escalation of respiratory support; See General Schema for Respiratory

Support in Patients with COVID-19.

Salvage Treatments

■ Plasma exchange. Should be considered in patients with progressive

oxygenation failure despite corticosteroid therapy. Patients may require

up to 5 exchanges.

■ High dose corticosteroids; 120 mg methylprednisolone q 6-8 hourly

■ Siltuximab and Tocilizumab (IL-6 inhibitors)

■ Convalescent serum; the role and timing of convalescent serum are

uncertain.

Treatment of Macrophage Activation Syndrome (MAS)

■ A sub-group of patients will develop MAS. A ferritin > 4400 ng/ml

is considered diagnostic of MAS. Other diagnostic features include

increasing AST/ALT and increasing CRP.

■ Methylprednisolone 120 mg q 6-8 hourly for at least 3 days, then wean

according to Ferritin, CRP, AST/ALT. Ferritin should decrease by at least

15% before weaning corticosteroids.

Monitoring:

■ On admission: PCT, CRP, IL-6, BNP, Troponins, Ferritin, NeutrophilLymphocyte ratio, D-dimer and Mg.

■ Daily: CRP, Ferritin, D-Dimer and PCT. CRP and Ferritin track disease

severity closely (although ferritin tends to lag behind CRP).

■ Thromboelastogram (TEG) in patients with high D-dimer and repeated as

indicated.

■ In patients receiving IV vitamin C, the Accu-Chek™ POC glucose monitor

will result in spuriously high blood glucose values. Therefore, a laboratory

glucose is recommended to confirm the blood glucose levels

Post ICU management

Find the latest version at evms.edu/covidcare Developed and updated by Paul Marik, MD, Chief of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA

Marik-Covid-Protocol-Summary