AIIMS issues new guidelines for treatment of Covid-19 cases

Treatment for mild Covid-19 cases:

Identification: A patient is considered to be having mild Covid-19 is they have upper respiratory tract symptoms and/or fever WITHOUT shortness of breath or hypoxia. Recommendation: Home isolation and care MUST DOs: Physical distancing, indoor mask use, strict hand hygiene. Symptomatic management (hydration, anti-pyretics, antitussive, multivitamins). Stay in contact with treating physician. Monitor temperature and oxygen saturation (by applying a SpO2 probe to fingers). Seek immediate medical attention if: Difficulty in breathing High grade fever/severe cough, particularly if lasting for more than five days A low threshold to be kept for those with any of the high-risk features. MAY DOs Therapies based on low certainty of evidence Tab Ivermectin (200 mcg/kg once a day for 3 days). Avoid in pregnant and lactating women. Tab HCQ (400 mg BD for 1day f/b 400 mg OD for 4 days) unless contraindicated. Inhalational Budesonide (given via Metered dose inhaler/ Dry powder inhaler) at a dose of 800 mcg BD for five days) to be given if symptoms (fever and/or cough) are persistent beyond five days of disease onset.

Treatment for moderate Covid-19 cases:

Identification: The patient's respiratory rate is more than 24/min, there is breathlessness and the SpO2 is 90 per cent to less than or equal to 93 per cent on room air. Recommendation: Admit in ward Oxygen Support: Target SpO2: 92-96% (88-92% in patients with COPD). Preferred devices for oxygenation: non-rebreathing face mask. Awake proning encouraged in all patients requiring supplemental oxygen therapy (sequential position changes every 2 hours). Anti-inflammatory or immunomodulatory therapy Injection Methylprednisolone 0.5 to 1 mg/kg in 2 divided doses (or an equivalent dose of dexamethasone) usually for a duration of 5 to 10 days. Patients may be initiated or switched to oral route if stable and/or improving. Anticoagulation Conventional dose prophylactic unfractionated heparin or Low Molecular Weight Heparin (weight based e.g., enoxaparin 0.5mg/kg per day SC). There should be no contraindication or high risk of bleeding. Monitoring Clinical Monitoring: Work of breathing, hemodynamic instability, change in oxygen requirement. Serial CXR; HRCT chest to be done ONLY if there is worsening. Lab monitoring: CRP and D-dimer 48 to 72 hourly.

Treatment for severe disease:

Identification: Any one of these--Respiratory rate more than 30/min, breathlessness orSpO2 less than 90 per cent on room air

Recommendation: Admit in ICU Respiratory support Consider use of NIV (Helmet or face mask interface depending on availability) in patients with increasing oxygen requirement, if work of breathing is low. Consider use of HFNC in patients with increasing oxygen requirement. Intubation should be prioritised in patients with high work of breathing /if NIV is not tolerated. Use conventional ARDSnet protocol for ventilator management. Anti-inflammatory or immunomodulatory therapy Injection Methylprednisolone 1 to 2mg/kg IV in 2 divided doses (or an equivalent dose of dexamethasone) usually for a duration 5 to 10 days. Anticoagulation Weight-based intermediate dose prophylactic unfractionated heparin or Low Molecular Weight Heparin (e.g., Enoxaparin 0.5mg/kg per dose SC BD). There should be no contraindication or high risk of bleeding. Supportive measures Maintain euvolemia (if available, use dynamic measures for assessing fluid responsiveness). If sepsis/septic shock: manage as per existing protocol and local antibiogram. Monitoring Serial CXR; HRCT chest to be done only if there is worsening.