Covid-19

Definitions

• SARS-Cov-2: the name of the corona virus causing the pandemic.
• COVID-19 – the name of the disease cause by the virus
• Surge capacity – the level of health system usage beyond which patient care may be compromised because of limits to availability of general medical beds, ICU beds, staffing or equipment, or a combination of these factors.

Background

Most patients who become symptomatic after SARS-Cov-2 infection do so within 7 days¹. Dyspnea, myalgia, arthralgia are present in less than one fifth and chills are rare (10%), as are gastrointestinal symptoms. About 80% have mild disease, but in the remaining 20% worsening respiratory symptoms may warrant hospital admission. Of this latter group, about one in four, predominantly older people with underlying comorbidities, develop severe disease.

Duration of infectivity is currently thought to be less than the original estimate of 14 days, so the revised figure is 10 days from symptom onset for mild disease, or 10 days from ‘resolution’ (not on oxygen, clearly improving) in those with more severe disease.

The figure above applies mainly to beta and delta – upper respiratory tract symptoms are relatively more common with omicron, and GIT symptoms probably less common

Foundation guidelines and documents

Key link: Covid-19 | Department of Health Knowledge Hub

Version 6.0 of the NICD SARS-Cov-2 document: Clinical Management of Suspected or Confirmed COVID-19 Disease | Department of Health Knowledge Hub provides a South African consensus on current issues pertaining to management. Clinicians should be familiar with this version and keep abreast of changes as they occur (they are usually highlighted in a front page synopsis).. Reviews of individual medications are updated regularly by the national EML at: COVID-19 Rapid Reviews – National Department of Health
Further useful guides on a range of topics not covered in detail here, such as face masks, infection prevention and control, screening, and quarantine can also be accessed at the KnowledgeHub site: Covid-19 | Department of Health Knowledge Hub. This portal also gives quicker access to the rapid reviews than going through the older Department of Health link.

Revised case definition.

An individual with recent onset of any one or more of cough, sore throat, shortness of breath, or fever (either on history or a measured temperature of > 38 C) should be considered as a ‘suspected case’, regardless of travel history or contacts, now that local transmission is here. The formal definition in the NICD guideline of a ‘suspected case’ (conceptually this replaces PUI , except that it includes close contacts, who are not investigated if asymptomatic) is:

“A suspected COVID-19 case includes any person presenting with an acute (≤14 days)
respiratory tract infection or other clinical illness compatible with COVID-19, or an
asymptomatic person who is a close contact to a confirmed case.”

In the context of COVID-19, the key respiratory syndrome consists of ANY of:

• Cough
• Sore throat
• Shortness of breath
• Anosmia or dysgeusia

… with or without other symptoms (which may include fever, weakness, myalgia, or diarrhoea).

Admission criteria

Suspected or confirmed COVID-19 patients should be considered for admission if there is evidence of moderate or severe disease, indicated by one or more of:

• Oxygen saturation <95% on RA
• RR ˃ 25
• HR ˃ 120
• Temp ˃ 39°
• Altered mental status

The presence of one or more co-morbidities, even if none of the above criteria are met, would also sway one towards careful consideration of admission, depending on bed availability.

Assessing severity in hospitalised patients

Aim

The aim of assessing severity is to be able to make meaningful clinical care decisions about individual patients, as well as assisting with correct placement of each patient in terms of priority setting for escalation in the context of potentially limited ventilatory resources. Documentation that this process was followed in every patient is an essential part of demonstrating equity of care, and use of these tools also aids clinicians in reaching consensus on what are often technically and emotional taxing decisions.

Process

The process has three steps: use the SOFA score to derive a placement in terms of severity of illness, then factor in the presence of comorbidities which might further influence escalation of care outcomes, and finally derive a priority of escalation category. The concept behind this last step is that it is unfair to limit access to care based on patient characteristics (e.g. age) but in situations of limited resources it is appropriate to allocate resources where they are most likely to achieve utility. Hence, when resources are freely available, all patients on a ranked list would have access to all care options; when resources are limited, they are allocated in order of potential greatest benefit.

Outcome

The outcome of the process is a record of decision documented in the all patients’ notes which provides a risk level – high risk patients warrant strong attempts at escalation of care in the event of deterioration or failure to improve, intermediate risk less so, and low risk would only warrant escalation when resources are adequate and all patients in the two higher risk groups had been catered for.

Clinical circumstances may change, and thus it is important to recognise that escalation priority can either improve or fall. Judicious re-scoring and revising the SOFA score/priority status is thus important if felt to be clinically meaningful in an individual patient.

SOFA score

There are several modifications of this, with the aim of reducing complexity and reliance on less readily accessible measures. The version below has been further modified to use oxygen saturation graded by device use, rather than expecting calculation of FiO₂ . Note that saturations of 86% should not necessarily be seen as clinically useful ‘thresholds’ for guiding care; they are used simply to adhere to mSOFA S/F ratios.

Meaning: patients with SOFA scores of more than 11 have high mortality (> 60%), reflecting impact on several organ systems; scores below 7 usually indicate excellent prognosis. Validation in COVID-19 is still preliminary²
, but values of more than 3 had 50% positive predictive value, and values above 8 had PPV of 100%.

Co-morbidities

Numerous cohort studies have now provided increased odds of mortality for a range of co-morbidities. Commonly mentioned are: Obesity, diabetes, COPD, CMO, CKD, immunosuppression, cirrhosis, uncontrolled malignancy and dementia.

Risk rating

Patients can then be grouped as follows:

SOFA score		Comorbidities		Risk rating	Escalation Priority
Low		Few or none		Low	Highest
Higher		Some		Intermediate	Intermediate
Highest		More		High	Lowest

Diagnostic testing

Patients admitted with COVID-19 are often severely ill. Key complications and co-morbidities include kidney injury, DKA, dehydration, anaemia. Rarer complications are hepatitis, pancreatitis, coagulopathy, and cardiac injury. A number of tests (e.g. d-Dimer, IL-6, ferritin) are touted as being of prognostic value in COVID-19, however they are unhelpful in the local situation where most management decisions are based on clinical status (specifically respiratory compromise) and the presence of comorbidities.

The D-dimer was popular in 2020 as a way of identifying patients who might be potential candidates for higher than standard dose heparin prophylaxis. The evidence around this is still uncertain – we now have some evidence that so-called ‘intermediate dose’ heparin is not of benefit to ICU patients, but the role of this dose of heparin in less severely ill patients is still undefined. In the absence of therapeutic certainty, the value of the D-Dimer is moot.

Standard investigations

Oxygen therapy in COVID-19

Distressed or critically hypoxaemic patients should be started on 40% to 60% oxygen. In patients where there appears to be more time, adopt an incremental approach – nasal prongs at 3-5 l/min, to keep saturation above 90% to 92%; if this fails, 40% face mask, then 60% rebreather, then 60% non-rebreather. If there is little doubt that they will require higher flows, skip steps and save masks by not stepping up through all of the options.

Venturi masks

Run Venturi masks at the flow rate printed on the coloured Venturi device at the end of the tubing; running higher flow rates gives very unpredictable (and not necessarily better) FiO2. If available, replace just the Venturi device and not the whole mask. Unless visibly damaged, the coloured venturi devices can be removed after use, chemically sterilised, and re-used on another mask. Do not re-cycle the actual masks, and especially not the rebreather masks with bags.

Difference between rebreather and non-rebreather masks.

The latter has flap valves on the sides of the masks as well as on the bag, and if fitted tightly, reduces mixing of exhaled and ‘new’ gas, theoretically somewhat further increasing Fi02 (60-80% for the former, 80%+ with the latter.) The former can easily be converted to the latter by adding the valves, which are available (3-D printed versions, or from other masks.)

Options beyond 60% non-rebreather are more limited

• Adding nasal prongs to the 60% mask – unproven if truly adds extra efficacy, although sometimes seems to increase saturation and thus worth a try – to some extent dependent on mask fit and ability to add the nasal prongs without excessive mask leakage.
• Consider either CPAP mask or high flow nasal oxygen. Both modalities are limited in availability; the mask is less effective in confused and less motivated patients, but the pressure support can be strikingly effective in other patients.
• For patients found unable to tolerate the one modality, or in whom it is ineffective, consider trying the other.
• If otherwise good prognostic features, consider for elective intubation (discuss with a senior and/or the ICU.)
• Some clinicians even have added re-breather masks to high-flow nasal cannulae in patients who predominantly mouth breath and cannot tolerate a CPAP mask. This definitely drains a a massive amount of oxygen and is of unclear if any value.

Oxygen availability.

As well as overall issues of availability as the epidemic increases, there are important local issues – piped oxygen flow is dependent on pressure (4 bar) but also limited by pipe calibre. If too many devices are run from the same wall line, or if another oxygen-hungry set-up is added in a cubicle, it may drop flow to all the other patients, with potentially catastrophic consequences. When adding such devices, check the impact on nearby devices rather than simply assuming there is capacity; it may be necessary to move around patients to limit the demand on a single line.

Using a Y-connector for two devices on a single flow meter is only feasible for devices drawing less than 8l/min (40% mask or nasal prongs) – you cannot connect a 60% rebreather mask at 15l/min and nasal prongs at 6l/min to the same flow meter and expect to get adequate flow through both.

Target oxygen saturation

• There is no clarity on this; most guidelines give figures of at least 90% (92% in pregnancy) without much science behind the recommendations. Clearly these are aspirational targets, and in many patients where escalation strategies are limited by multiple co-morbidities and lack of next level oxygen devices, these targets may not be met. There are suggestions that targets should actually be higher³, based on reservations with the NIH reliance on a systematic review⁴ and the LOCO-2 trial⁵. The HOT-COVID trial may give us some answers in 2022…
• Patients vary considerably in their tolerance of lower saturations – the ‘happy hypoxic’ may have saturations of considerably less than the target and seem clinically comfortable. Remember that our clinical recognition of respiratory ‘distress’ is skewed by patients presenting with obstructive pulmonary conditions and acute bacterial pneumonia, where use of accessory muscle is often more prominent (particularly in COPD). Take care to look for cyanosis (or do oximetry) and check for confusion and actually measure the respiratory rate.
• Aim for what you can get in terms of saturation and escalate with stricter thresholds in patients with fewer co-morbidities who are ‘high risk’ (i.e. clearly candidates for prompt escalation and even consideration for invasive ventilation.)

Indications for ventilation

Patients who are failing on 60% rebreather (saturations less than 90% or respiratory rate greater than 40, or both) should be considered for non-invasive ventilation (NIV) or even intubation and full ventilation if they are suitable ICU candidates. Discuss with a senior/ ICU staff early rather than when there is little time to make reasoned decisions.

Medications in COVID-19

There are still very few therapeutic options of proven benefit in the treatment of COVID-19, and a large amount of research activity (over 6000 articles published this year already) is underway to determine what may be helpful. The argument for using medications which may help before we have information on this, on the assumption that ‘we don’t know and it can’t do any harm to try’ only works if you know the treatment is without harms. Because the trials have not yet been done, we clearly cannot determine this either. A case in point is chloroquine, initially touted as harmless, but which in severely ill patients with myocardial injury, may be doing more harm than good. Most of the planned major trials on this agent have now been stopped because of perceived futility.

Corticosteroids

Corticosteroid use is now a promising option in hypoxaemic patients. The single high quality completed RCT of this agent in COVID-19 found that use decreased mortality in mechanically ventilated patients from 41% to 29% (12% ARR, NNT 8) which is clearly very impressive, but will be more convincing when reproduced in other trials. In hypoxaemic patients not on ventilation it reduced mortality by 3,5% (from 25% to 21.5%, NNT = 29). The dose used in the trial was dexamethasone 6 mg IV daily if severely ill, or the same dose orally in less ill patients. Oral dexamethasone is not registered in South Africa; suitable alternatives include hydrocortisone 100mg IV 12 hourly or prednisone 40 mg daily orally. The medication was given for either 10 days or until well enough for discharge, whichever happens first.

In COVID-19 patients who were not hypoxaemic, there was an impression of increased mortality, although this was not statistically significant. Sending patients who are not hypoxaemic home on corticosteroids is definitely not supported by any evidence, and may be harmful.

Corticosteroid effects

Leukocytosis. Use of corticosteroids is well known to increase the white cell count, by on average 4000/mm3. This can start as early as the day after administration and can persist for several weeks⁶. Levels as high as 20 000 have been reported. In the setting of COVID-19 patients started on dexamethasone, and this effect should be considered when evaluating patients for secondary infection.
Hyperglycaemia. Consider not only poorer control in non-diabetics, but also new onset diabetes precipitated in the case of recognised COVID-19 associated worsening of sugar control.
Masking of infection. Steroids are being given to ameliorate the hyper-inflammatory response; in some situations they may mask the fever and tachycardia which would otherwise be signs of a secondary infection. Consider this in patients who worsen some days into their steroid course.
Acute steroid myopathy.⁷
This is a rare and incompletely characterised condition more common in individuals with underlying muscle disorders but can present after only one or two doses of corticosteroids and may not always be associated with marked CK rises. Consider it in ill COVID-19 patients whose weakness seems disproportionate to illness severity. COVID-19 causes myopathy in its own right, further complicating its recognition, although this latter tends to occur earlier in the illness.

Heparin

There is no high quality evidence on the use of therapeutic dose anticoagulation in COVID-19; prophylactic doses are sensible in most bed-ridden patients. There is some appetite for ‘intermediate’ dose heparin, but also no controlled trial evidence yet. In ICU-severity patients, there was clearly no benefit REMAP-CAP pre-print (https://doi.org/10.1101/2021.03.10.21252749))

Prophylaxis

DVT/PE prophylaxis with enoxaparin 40 mg daily is appropriate for bedridden patients.

Antibiotics

In a recent systematic review, bacterial superinfection was identified in only 7% overall of hospitalised COVID-19 patients (unlike the 25% in influenza studies). The figure was 14% for ventilated patients and 4% for the rest. Of the identified infections, 40% were due to mycoplasma, and only 10% to 30% were due to organisms conventionally susceptible to ceftriaxone. Thus, in non-ventilated COVID-19 patients, ceftriaxone would be likely to benefit about 1% of patients, and azithromycin 1.5%. The corollary is that 97.5% are unlikely to benefit from the combination.
Following standard stewardship principles, the combination should thus be reserved for:

• Patients with severe pneumonia but unknown Covid status
• Patients with a clear clinical and radiological lobar pneumonia
• Patients with later deterioration associated with purulent sputum or recurrence of fever and/or leukocytosis of >12 000.
• Severely immunosuppressed patients (e.g. CD4 count less than 200) where standard clinical features of bacterial pneumonia may be lacking.

Also remember that even if azithromycin is prescribed, it is only needed for three days – after three doses tissue concentrations remain therapeutic for about three weeks. Also remember this when prescribing other medications with potential to prolong the QT interval in the three weeks after giving the agent.

Other medications

The following medications, in the absence of any adequately powered controlled trial evidence of efficacy, should not be used at all or only be used in the context of an ongoing trial:

• Chloroquine (ineffective)
• Cochicine – some benefit but clinical importance less clear
• Lopinivir/ritonavir Doesn’t work(unless already on it for HIV)
• BCG
• Oseltamivir
• Intravenous immunoglobulin (too much variation in preparations to know what is being given)
• Interferons (probably ineffective)
• Remdesivir (some evidence of benefit in reducing duration of hospitalisation, but very high cost, and the recently completed Solidarity trial does not provide convincing evidence of benefit)
• Tocilizumab is effective in reducing mortality – about 2-3% ARR, but very expensive
• Femdesivir

Other medications whose use is discouraged because of unlikely clinical benefit in COVID-19 (and unnecessary nursing dispensing load), include:

• Zinc (a definitive trial on the combination of this agent with Vit C will be completed in December…)
• Vitamin D (recent NICE review could find no evidence of benefit)
• Vitamin C (no direct evidence in COVID-19; Cochrane review found it did not prevent common cold except possibly in a subgroup of highly physically stressed individuals)
• Azithromycin (increased risk of CVS death relative to other antibiotics⁸
• Simvastatin (like many other agents, might help in theory, but no high quality evidence of real-world benefit.)
• Enalapril can be continued in a patient who is on it for an appropriate indication, and who is not hypotensive. It can be commenced in a PUI with another appropriate indication such as cardiac failure on protein-losing nephropathy.
• The use of non-steroidal anti-inflammatory agents should follow standard medical indications and cautions – avoid in patients with renal disease, heart failure, peptic ulcer disease or bleeding disorders, but not contra-indicated in COVID-19 if myalgic symptoms not responding to paracetamol.

Special issues in clinical management

This section describes several case scenarios which may be encountered, and reviews appropriate management approaches for each scenario.

PUI with negative SARS-Cov-2 PCR but remaining high index of suspicion.

The key issue is whether there is an adequate better explanation for all of the patient’s symptoms. The sensitivity of the PCR is dependent on how well the sample was collected as well as issues around lab processing. It is variously described as between 70% and 95%, or even higher, but the point being that some false negatives will occur. If a high index of suspicion remains, please discuss with a senior, and consider keeping the PUI in G2 and repeating the PCR.

COVID-19/PUI requiring admission because of clinical severity (too ill for home care.)

This is based on the severity score (one or more of pulse > 120, respiratory rate > 25, temp > 39, or sats < 92%.) Investigation. Appropriate investigations include a FBC (looking for absolute lymphopenia on the diff), a serum creatinine and urea, and in an afebrile patient, a CRP. Other investigations as appropriate for other underlying conditions.

Diagnostic issues.

The first step is to consider other underlying causes such as heart failure, renal failure or severe anaemia. If the clinical picture looks like COVID-19, and particularly if the CXR shows the typical ground-glass or patchy bibasal appearance, then a deteriorating viral pneumonia is the most likely. (Initial CXR may be normal or show unilateral changes, or be very atypical in the presence of underlying lung disease/TB).

In the HIV positive patient the differential is clearly broader (see next section). Further testing is unlikely to be helpful unless indicated by underlying co-morbidities or very appropriate differential diagnoses.

HIV positive PUI with undifferentiated pneumonia. Look hard for a lymph node to FNAB. The core differentials include pneumocystis and tuberculosis. The former is less likely with a CD4 of >200, and both are less likely in a patient on treatment with suppressed viral load and a normal CD4.

Investigations

• CXR may help if there is adenopathy or an effusion (both pointing to either tuberculosis or Kaposi’s sarcoma, and uncommon in pneumocystis or COVID-19.)
• CRP can be markedly elevated in all of these conditions, and a ferritin behaves like another acute phase reactant, so neither is a useful differentiator (although this may change as more local information becomes available.)
• Sputum/FNA for TB PCR (Xpert MTB-Rif)
• Urinary LAM is rapid and point of care, so should be done promptly as it may impact the decision about PUI status (ie. if positive, and presentation more typical for TB, unlikely to warrant COVID testing).
• Abdominal ultrasound. Limit the use of this test for abdominal TB in PUI’s due to the risks to radiology staff. Should be reserved for those with a strong indication, always discuss with a senior.
• A serum beta-D-glucan may be of value if considering PCP, although results often take some time, and frequently come back indeterminate. A very low titre has a negative predictive value in these circumstances of about 70% (considerably higher if the probability of pneumocystis is low).

Management

This consists of attending to conventional underlying medical conditions, then supportive care with simple analgesia. If the patient could reasonably have a community acquired bacterial pneumonia, then cover with ceftriaxone 1 g IV daily and possibly azithromycin 500mg daily orally (if CURB-65 score 3) (or the same dose IV if unable to take orally). COVID-19 negative cases can be moved to a general medical ward once test results are available.

Discharge criteria in COVID-19

It is usually clear when patients with COVID-19 are improving – improving saturation, reduced respiratory rate, and lower pulse rate. As a general rule, patients are suitable for discharge when they fit the criteria used to send a patient home as ‘mild disease’ rather than admitting them, but this will be nuanced by the clinical course of individual patients, some of whom remain significantly unwell even after recovery of oxygen saturation and respiratory rate. In general, patients who were sicker longer require longer to recover. Those with short trajectories may be well enough to go home while potentially still infectious; in this case they should self-isolate for 10 days after resolution of key symptoms (typically once no longer requiring oxygen.)
A small number of patients suffer sudden thrombo-embolic events even when clearly well on the road to pulmonary recovery; these are difficult to predict, and prophylaxis type and duration is not clarified. In high risk patients (prolonged illness, obesity) consider repeat D-dimer – if still elevated discuss with a senior the options which may include low dose aspirin, ongoing self-administered heparin (best theoretical evidence, no empiric support) or oral anticoagulation.

Other COVID-19 presentations

As more information becomes available, protean presentations and complications have been described. These include:
Dermatological.
Petechial rashes, small vessel vasculitis, urticaria, chicken-pox like blisters, digital ischaemia with a ‘pseudo-chillblain’ picture, and an erythematous exanthem.
Cardiovascular.
It is still unclear which of the various cardiac presentations are primarily due to direct viral effects and which are secondary to cardiovascular complications in predisposed individuals experiencing a ‘cytokine storm’. Various non-specific ECH changes, or specific changes associated with coronary disease are described, along with biochemical markers of sometimes very severe myocardial damage.
Neurological.
Apart from drowsiness and confusion, seizures and other features of encephalitis have rarely been described.
Gastrointestinal.
Nausea, vomiting, diarrhoea, and mild liver injury are increasingly being described.
Haematological.
The prevalence of lymphopenia varies considerably, and is by no means universal (as infrequent as 25% on admission in some studies), but other findings include thrombocytopenia, leucoerythroblastic anaemia, and coagulopathies, with some recent proposals that a hypercoagulable state may be central to the pathophysiology of severe disease.
Renal.
There are multiple potential mechanisms for the rare but well-described acute kidney injury described. These include medullary hypoxia, rhabdomyolysis, direct cytokine effects, hypotension and ATN, and renal compartment syndrome. Of concern also is the vulnerability to COVID-19 of renal transplant patients and other individuals taking immune-modulating medication.

Patients who develop potential COVID-19 symptoms while admitted

• Admitted medical (or surgical/obstetric and gynae) patients do develop hospital acquired fevers, pneumonia or diarrhoea, which raises management issues in the COVID-19 pandemic. The attending clinician will need to do a clinical and risk assessment on the probability of COVID:
• COVID-19 has an incubation period of up to 14 days, hence if symptoms start within this time frame, it is possible the patient was infected in the community. Ask the family about any known COVID contacts.
• Patients who have been in hospital for >14 days may have been infected by other patients or staff. Find out if they came through a PUI ward, or had close contact with infected staff or patients.
• If there is an adequate alternative explanation for the symptoms e.g. catheter associated UTI, do not label as a PUI, and managed appropriately.
• If there are potential viral symptoms and signs, and/or risk for exposure/contact, the patient should be managed as a PUI, moved to C11 or C11 or isolation in another department if such facility is available in the department, with appropriate PPE, and swabbed for SARS-CoV-2.

Escalated care in COVID-19

Background

COVID-19 lung injury (CARDS)⁹ is a condition with serious outcome implications. Management is largely empiric and extrapolated from other illnesses, and such extrapolation may not always travel well. Higher quality reviews are more nuanced in their recommendations, and there is no single modality for which there is definitive evidence of benefit apart from corticosteroids (and tociliziumab, and even the latter is based on relative slim data)¹⁰

There has been peculation¹¹ that there are two distinct stages of lung pathology in COVID-19. Type L is characterised by low elastance (still compliant) and low lung weight and Type H by high elastance and high lung weight (more in keeping with typical ARDS). The transition may be associated with patient self-inflicted lung injury (P-SILI) where hypoxaemia causes increased depth of breathing with stretch associated cytokine release, inflammation, and interstitial oedema. This stage has also been associated with a so-called ‘cytokine storm’. The clinical implications of this is that recruitment strategies may be less helpful in the early stages, and higher tidal volumes may be better tolerated in the earlier less stiff lung.

Prognostic criteria

Patients with multiple co-morbidities have a worse prognosis than those who have no other illness than COVID-19, and this needs consideration when balancing optimal use of scarce resources. In the absence of information on HIV as a co-morbidity, we can only assume that severely immunocompromised patients are likely to do less well.

Admission criteria

Admission to HCW/ICU s based on a priority setting strategy which combines clinical severity at the time of consideration with consideration of comorbidities, and uses this to ‘rank’ patients in terms of their likelihood of being offered the next available bed. This process is imperfect, and particularly fraught in the early stages of the epidemic when beds are not yet at a premium, but admission duration may be up to three weeks.

Respiratory support options

The data on whether high flow nasal oxygen or non-invasive ventilation with some form of pressure support reduces important outcomes such as requirement for invasive ventilation or mortality in COVID-19 is unknown, as is the risk of transmission of aerosol to staff; if these modalities are considered, patients should ideally be nursed in single bed units and with staff wearing full PPE on entry.

Current recommendations for ventilation once established ARDS with stiff lungs revolve around lower tidal volumes of 5ml/kg and plateau pressures of less than 30 cm water¹²

Patient positioning

Although most guidelines are enthusiastic about the value of prone positioning, even extrapolating back from the data in ventilated patients to make recommendations about patients who are not intubated¹³, the underlying evidence is less robust than often accepted. A 2015 Cochrane review¹⁴ did not find an overall mortality benefit and noted that the quality of the evidence was weak; a subsequent 2017 systematic review¹⁵also failed to identify an overall survival advantage but found it in a pre-specified subgroup where positioning happened for more than 12 hours per day. The same group found the procedure increased the risk of endotracheal tube obstruction (RR 1.76 95%CI 1.24 to 2.5). On balance then, the weak evidence of benefit needs to be weighed against the implications for optimising staff resources.

Managing hypotension

Capillary refill time will give some indication of tissue perfusion and is easy to assess. A mean arterial pressure of 60 to 65 mmHg is adequate, using adrenalin as the agent of choice. Avoid overhydrating patients but consider initial bolus of normal saline as hyperventilating patients from the wards may be behind on fluids.

Dialysis

Severe COVID-19 is often associated with renal impairment; as part of supportive care of severally septic patients, this modality needs to be considered, but again needs to be weighed against alternative uses of scarce staff resources and the technical issues around reserving machines for Covid positive patients. Discuss with a senior.

Palliative care

In patients with multiple co-morbidities, frailty and advanced age, or other conditions (e.g. advanced malignancy) rendering escalated care medically futile, it is appropriate to consider patients (ideally in telephonic discussion with the family) as appropriate for palliative care. If such decisions are made, they need to be clearly communicated to all members of the team caring for the patient, and stated clearly in the folder, with the underlying justification also in writing. Two key symptoms warrant attention:
Dyspnoea.
This will usually respond to appropriately titrated low-dose morphine – e.g. 5mg morphine 6 hourly orally. If there is breakthrough dyspoea consider decreasing the dose interval to 4 hourly. Add lactulose 10ml daily for constipation.
Confusion/agitation
This may be due to the underlying diseases, dehydration and/or hypernatraemia, COVID-19 itself, hypoxaemia, or a combination of all of these. The palliative care literature does not contain strong evidence for any therapy, but it is appropriate to try either low dose haloperidol (e.g 0.5 mg daily, either orally or IM, escalating as needed), or clonazepam 0.5 mg daily PO/IM.

Staff care

PPE stewardship versus staff safety.

Clinicians need to balance maximising current versus future safety with the use of personal protective equipment. Most other countries, even those which are affluent with well-functioning health systems, have faced severe PPE constraints during epidemic peaks. Advice on PPE use thus needs to consider both safety now and in the future.

Issues around PPE quality

Not all PPE is of equal quality. There is are international constraints on supply, and some is donated, with perhaps less stringent quality controls. Where there are clearly identified quality concerns, report these promptly to consultants who will then escalate to HoD. Such reports gain major credibility if accompanied by a brief report of a particular incident ( e.g. mask strings broke during donning, mask tore in use, etc), rather than generic statements about poor quality. When an item is clearly unusable, attempt to access a similar item from another manufacturer; however this is not always possible, and attempting to use with more care may be a short-term compromise.

Recommendations for personal protection during routine patient care of COVID-19.

The main barrier to nosocomial infection of staff and other patients is regular and thorough hand washing with soap and water. Alcohol hand sanitiser needs to be used properly to clean all of both hands – not just a ritual palmar dab. As a predominantly droplet spread infection, current NICD and WHO recommendations endorse the wearing of a surgical mask by all staff with patient contact. Gloves makes some sense but need to be changed regularly. When there are situations of glove shortages, changing gloves between patients may not be appropriate. Eye protection is advised, although there is little direct evidence that this is a likely route of infection.
An apron serves as clothing protection from droplets. Careful removal (doffing) of used PPE in a designated area followed by thorough hand hygiene is essential to prevent inadvertent cross-contamination.

Recommendations for potential high-contamination processes.

In this situation a well-fitting N95 (or HPP2) mask, gloves, eye protection (face shield or goggles) and a gown are appropriate. These should be donned and doffed with due consideration of the potential for contamination at the time of doffing. Caps and shoe covers are of unclear value but the former may make sense.

Clothing and fomites.

There are concerns that clothing, shoes, hair, pens, cell phones and patient folders can be a source of infection. SARS-Cov-2 does survive for hours to days on surfaces, but evidence of human infection from such sources is not clear. The main defence against this potential is regular hand sanitisation/washing before your hands reach your eyes, face or mouth after touching potentially contaminated objects. For clothes washing advice (soap, >60 C) see the NICD guidelines in the section on self-isolation at home.

Aerosol versus droplet.

There have been recent suggestions of viral persistence in cough/sneeze jets in what is regarded as aerosol (< 5 micrometres diameter) sized particles. At this stage there is scanty evidence, if any, that these particles cause infection, but this is a closely watched subject¹⁶.

Staff wellness

Team care.

All clinical staff are going to be both mental and physically stressed if the expected epidemic evolves. Please keep an eye on colleagues and offer support, encouragement, and help to those who are over-worked on the day. Ensure, before going off, that there are no stressed parts of the system where you could be of assistance – helping others today will lead to help for yourself in a day or two. Communicate.

Vulnerable staff.

Underlying co-morbidities, pregnancy, and other factors may make it inadvisable to expose certain members of the team to high-risk SARS-Cov-2 situations. Please help identify this and facilitate such movement – we will all be needed!

Flexibility of work patterns.

In a time of potentially changing workloads, expect alterations in the routine of work – assuming this is likely to happen makes it easier to handle change. We will try and provide plenty of advance notice of needed alterations, but sometimes administrative contingencies do force our hands. Keep alert for ways you think we could do things better, and pass on any such suggestions.

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