What is the management plan for a Covid-19 positive patient?

Management of COVID-19 Positive Patient

For hospitalized COVID-19 patients, immediately isolate the patient, initiate prophylactic anticoagulation with LMWH, start remdesivir if requiring oxygen (with dexamethasone 6 mg daily for 10 days), and avoid routine antibiotics unless bacterial superinfection is clinically evident. 1

Initial Assessment and Risk Stratification

Severity classification is the critical first step that determines your entire management pathway 1:

• Moderate disease: SpO2 ≥94% on room air with evidence of lower respiratory disease 1
• Severe disease: SpO2 <94% on room air 1
• Critical disease: Requires ICU admission, mechanical ventilation, ARDS, or septic shock 1

Obtain chest imaging (CT preferred over X-ray) during initial assessment to evaluate pneumonia severity and rule out complications like pulmonary embolism 2, 3

Immediate Isolation and Infection Control

Isolate confirmed COVID-19 patients immediately from negative patients to prevent nosocomial transmission 2, 1

Healthcare workers must use complete PPE including N95 masks, goggles, double gloves, face shields, and protective gowns when caring for COVID-19 patients 2

For hospitalized patients, maintain isolation for at least 2 weeks from first positive test and until negative RT-PCR is obtained 2

Pharmacological Management by Severity

For Moderate Disease (SpO2 ≥94% on Room Air)

Start remdesivir 200 mg IV loading dose on Day 1, then 100 mg IV daily for 5 days 1, 4

• May extend to 10 days if no clinical improvement 4
• Perform hepatic laboratory testing before starting and monitor during treatment 4
• Determine prothrombin time before starting and monitor as clinically appropriate 4

Do NOT give corticosteroids to patients not requiring oxygen - this can be harmful 1

For Severe Disease (SpO2 <94% on Room Air)

Administer dexamethasone 6 mg daily for 10 days in addition to remdesivir 1

Provide supplemental oxygen to maintain SpO2 above 90-96% 3

Position patient upright to improve ventilatory capacity 3

For Critical Disease (ICU/Mechanical Ventilation/ECMO)

Continue remdesivir for 10 days total duration 4

Continue dexamethasone 6 mg daily for 10 days 1

Monitor for common complications including ARDS, shock, myocardial dysfunction, acute kidney injury, arrhythmia, and secondary infections 1

Universal Inpatient Interventions

Anticoagulation (Critical - Do Not Delay)

Start prophylactic LMWH for all hospitalized COVID-19 patients as soon as possible 1

Dose based on renal function, bleeding risk, and weight 1

Antibiotic Stewardship

Do NOT routinely prescribe antibiotics 1

Only initiate antibiotics when clinically justified based on:

• Disease manifestations suggesting bacterial superinfection 1
• Imaging findings consistent with bacterial pneumonia 1
• Laboratory data supporting bacterial infection 1

If empirical antibiotics are started, target to culture results and de-escalate as soon as possible 2

Common pitfall: Using biomarkers alone to decide antibiotic initiation - this should be avoided 1

Respiratory Support Considerations

For patients requiring high-flow nasal cannula: patient should wear mask during treatment 5

Use dual-limb ventilators with filters at outlets for mechanically ventilated patients 5

Avoid T-piece for spontaneous breathing trials; use PSV mode instead 5

Monitoring and Follow-up

Monitor continuously for:

• Oxygen saturation and respiratory rate 3
• Signs of respiratory failure requiring advanced support 3
• Hepatic function while on remdesivir 1, 4
• Thromboembolic complications 3
• Secondary bacterial or fungal infections 1

Serial chest imaging to monitor disease progression 3

Special Populations and Considerations

Non-Hospitalized High-Risk Patients

For outpatients with mild-to-moderate COVID-19 at high risk for progression:

• Remdesivir 200 mg IV Day 1, then 100 mg IV daily for 3 days total 4
• Must be initiated within 7 days of symptom onset 4
• Requires setting with immediate access to treat anaphylaxis and activate EMS 4

Surgical Patients with COVID-19

Require multidisciplinary management approach 2

After emergency surgery, re-admit severe pneumonia patients to COVID-ICU 2

Stable asymptomatic/mild symptomatic patients should go to dedicated COVID surgical ward 2

Critical Pitfalls to Avoid

1. Delaying anticoagulation - start LMWH immediately 1
2. Giving corticosteroids to patients not requiring oxygen - harmful 1
3. Routinely prescribing antibiotics - increases resistance 1
4. Using biomarkers alone for antibiotic decisions - requires clinical correlation 1
5. Forgetting hepatic monitoring with remdesivir - mandatory 1, 4
6. Inadequate PPE for healthcare workers - complete protection required 2, 1