Guidelines
Treatment

Treatment

Clinical Management and Treatment

  • Hospitalization is not required for mild presentations

  • Indication for hospitalization follows typical rules as for any other respiratory infection e.g. requirement for oxygen, SOB at rest, or clinical gestalt.

  • If your site does not have the ability to manage a ventilated patient, or other complications such as dialysis requirement, consult with your usual tertiary critical care site physician via the Patient Transfer Network

  • Detailed goals of care discussion is essential: please see Palliative Care, Goals Discussion & Ethical Framework from "Guidelines" mainpage

  • Encourage patient to trial self-positioning proning- example protocol
    • 30min - 2h prone
    • 30min - 2h on right side
    • 30min - 2h sitting up (as close to 90 degrees as possible)
    • 30min - 2h on left side
    • Back to first position

  • A risk assessment needs to be considered prior to initiating BiPAP even if COVID-19 is not strongly suspected

  • COVID swab will likely be recommended for all patients requiring BiPAP regardless of clinical suspicion

  • Consider discussion with Critical Care physician or intubation team on call if initiating BiPAP

  • Until COVID swab negative, negative pressure room with staff using AGMP PPE should be considered - discuss with Infection Control

  • CPAP approach may be different and may not require a test; consult with Infection Prevention & Control staff

  • See BC COVID Therapeutics Committee Recommendations on Antimicrobial and Immunomodulatory Therapies for the most up-to-date treatment recommendations from the BC COVID Therapeutics Committee

  • Dexamethasone 6mg IV/PO q24h for up to 10days for any patient requiring supplemental oxygen.

  • Do not routinely give dexamethasone for mildly ill COVID-19 patients (e.g. outpatients not requiring supplemental oxygen), unless other indications are present or in context of a clinical trial

  • See BC COVID Therapeutics Committee Recommendations on Antimicrobial and Immunomodulatory Therapies for the most up-to-date treatment recommendations from the BC COVID Therapeutics Committee

  • Tocilizumab 400mg IV single dose is recommended for patients requiring life support due to confirmed COVID-19.

  • This includes high-flow oxygen support (e.g., Optiflow) if flow rate > 30 L/min and FiO2 > 0.4 OR invasive or non-invasive ventilation OR vasopressor or inotropic support.

  • Tocilizumab must be administered within 24 hours of the initiation of life support measures.

  • Patients admitted to hospital for more than 14 days with symptoms of COVID-19 should not receive tocilizumab for this indication.

  • Tocilizumab should only be initiated when life support is required because of COVID-19 rather than other causes (such as bacterial infection, pulmonary embolism, etc).

  • See BC COVID Therapeutics Committee Recommendations on Antimicrobial and Immunomodulatory Therapies for the most up-to-date treatment recommendations from the BC COVID Therapeutics Committee

  • Therapeutic anticoagulation (LMWH preferred) should be considered for severe patients (requiring oxygen, but not requiring high flow nasal cannula or other organ support) without high-risk for bleeding.

    • Bleeding risk factors include: age 75 or greater, eGFR less than 30 mL/min, any coagulopathy, platelet count less than 50x109/L, use of dual antiplatelet therapy, recent history of serious GI bleed or recent intracranial condition (stroke, neurosurgery, aneurysm, cancer), epidural or spinal catheter.
  • Anticoagulation for COVID-19 should start within 72 hours of admission and be continued for 14 days or until hospital discharge, whichever is sooner. Therapeutic anticoagulation should be continued even if there is deterioration requiring organ support during this period.

  • For patients requiring organ support at initial presentation (critically ill including high flow nasal cannula) therapeutic anticoagulation IS NOT RECOMMENDED due to lack of benefit and potential for increased harm.

  • For hospitalized patients not receiving therapeutic anticoagulation, recommended DVT prophylaxis is Enoxaparin 30mg SQ BID

    • higher doses recommended for patients weighing >100kg - please discuss with pharmacy in obese patients
    • Heparin 5000U sc BID to TID (based on weight) for renal dysfunction as per usual