What are the initial management orders for a Covid-19 patient?

Initial Management Orders for COVID-19 Patients

For COVID-19 patients, initial management should include oxygen therapy for those with respiratory distress or hypoxemia (target SpO2 ≥93%), dexamethasone 6 mg daily for hospitalized patients requiring oxygen, and remdesivir for those requiring oxygen but not invasive mechanical ventilation. 1

Initial Assessment and Monitoring

• Vital signs monitoring: heart rate, oxygen saturation, respiratory rate, blood pressure
• Laboratory tests:
  • Complete blood count
  • C-reactive protein (CRP)
  • Procalcitonin (PCT)
  • Liver enzymes
  • Renal function
  • Coagulation parameters (including prothrombin time) 1, 2
• Chest imaging (X-ray or CT scan) 1

Respiratory Support

1. Oxygen therapy:

   • Initial flow rate of 5 L/min, titrated to reach target SpO2 ≥93% 1
   • For patients with respiratory distress or hypoxemia

2. Escalation of respiratory support:

   • High-Flow Nasal Oxygen (HFNO) or Non-Invasive Ventilation (NIV) if standard oxygen therapy fails
   • If no improvement or worsening within 1-2 hours, proceed to intubation and invasive mechanical ventilation 3

3. For patients requiring mechanical ventilation:

   • Use lung-protective ventilation strategy:
     • Low tidal volume (4-6 ml/kg)
     • Low plateau pressure (<30 cmH2O)
     • Appropriate PEEP
   • For moderate to severe ARDS (PaO2/FiO2 <150 mmHg):
     • Higher PEEP
     • Prone positioning for >12 hours daily
     • Deep sedative analgesia in first 48 hours 3

Pharmacological Management

1. Antiviral therapy:

   • Remdesivir for patients requiring oxygen but not invasive mechanical ventilation:
     • Loading dose: 200 mg IV on Day 1
     • Maintenance dose: 100 mg IV daily from Day 2
     • Duration: 5 days (can extend to 10 days if no clinical improvement) 1, 2

2. Corticosteroids:

   • Dexamethasone 6 mg daily (IV or oral) for up to 10 days for hospitalized patients requiring oxygen 1

3. Immunomodulators (for worsening respiratory status with elevated inflammatory markers):

   • Consider adding tocilizumab (IL-6 inhibitor) to dexamethasone 1

4. Anticoagulation:

   • All hospitalized COVID-19 patients should receive thromboprophylaxis
   • Low-molecular-weight heparin (LMWH) preferred for inpatient setting
   • Consider therapeutic-dose anticoagulation for patients with deteriorating pulmonary status or ARDS 1

Special Considerations

1. For non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression:

   • Consider nirmatrelvir-ritonavir (Paxlovid) if within 5 days of symptom onset 1
   • Remdesivir for 3 days if within 7 days of symptom onset 1, 2

2. For immunocompromised patients:

   • Consider early initiation of antiviral therapy regardless of symptom severity 1

Treatments to Avoid

• Hydroxychloroquine
• Azithromycin (unless bacterial infection is present)
• Lopinavir-ritonavir
• Interferon-β
• Colchicine 1

Discharge Criteria

Patients can be discharged when meeting all the following criteria:

1. Temperature returned to normal for more than 3 days
2. Respiratory symptoms significantly improved
3. Significant absorption of pulmonary chest lesions on CT imaging
4. Two consecutive negative nucleic acid tests from respiratory tract samples (at least 24 hours between samples) 3

Important Clinical Pitfalls

1. Delayed recognition of deterioration: Monitor for signs of worsening respiratory status and initiate appropriate escalation of care promptly.

2. Overlooking thrombotic complications: Actively monitor for signs of thromboembolism (stroke, deep vein thrombosis, pulmonary embolism, acute coronary syndrome) 1.

3. Inappropriate antibiotic use: Antibiotics should not be routinely administered for COVID-19 patients unless there is clinical suspicion of bacterial infection 3.

4. Inadequate liver monitoring: Perform hepatic laboratory testing before starting remdesivir and monitor during treatment, as liver injury has been reported 2.

5. Neglecting comorbidities: Continue appropriate management of underlying conditions while treating COVID-19 1.