What is the recommended management approach for a hospitalized patient with Covid-19 (Coronavirus disease 2019)?

Hospital Management of COVID-19

Core Treatment Strategy: Oxygen-Guided Approach

All hospitalized COVID-19 patients should receive prophylactic anticoagulation, and those requiring supplemental oxygen or ventilatory support should receive corticosteroids—these are the only interventions proven to reduce mortality. 1

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Treatment Algorithm Based on Oxygen Requirements

Patients NOT Requiring Supplemental Oxygen (SpO2 ≥94% on room air)

• Provide supportive care only—do NOT use corticosteroids as there is no mortality benefit and potential for harm 1, 2
• Initiate prophylactic-dose anticoagulation with low molecular weight heparin (LMWH) preferred over unfractionated heparin 1, 2
• Monitor oxygen saturation, respiratory rate, and clinical status closely for deterioration 2

Patients Requiring Supplemental Oxygen (SpO2 <94% on room air)

Initiate the following immediately:

• Dexamethasone 6 mg daily for 10 days—this reduces mortality by 3% 1, 2
• Prophylactic-dose anticoagulation with LMWH as soon as possible 1, 2
• Target oxygen saturation of 92-96% (no higher than 96%) 1, 3

For escalating oxygen needs:

• Start with conventional oxygen therapy up to 5 L/min 3
• If hypoxemia persists despite conventional oxygen, use high-flow nasal cannula (HFNC) or continuous positive airway pressure (CPAP) 1, 3
• Avoid nebulized medications; use spacers instead to minimize aerosolization 3

Patients with Increasing Oxygen Requirements AND Systemic Inflammation

Add IL-6 receptor antagonist if:

• C-reactive protein (CRP) ≥75 mg/L or other markers of systemic inflammation are present 1
• Patient is receiving systemic corticosteroids and requires supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO 4

Tocilizumab dosing:

• Single IV infusion of 8 mg/kg (actual body weight), maximum 800 mg 4
• Reduces the combined endpoint of mechanical ventilation or death 1
• Do NOT initiate if: ANC <1000/mm³, platelets <50,000/mm³, or ALT/AST >10× ULN 4

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Mechanical Ventilation Considerations

Indications for Intubation

• Intubate based on signs of respiratory distress (increased work of breathing, accessory muscle use, inability to speak in full sentences) more than refractory hypoxemia alone 5
• Do not delay intubation if patients fail to respond to HFNC or CPAP within 1-2 hours 1
• Recommend ICU admission for any patient with SpO2 <90% despite oxygen, severe dyspnea, or high respiratory rate 6

Ventilation Strategy

• Use low tidal volume ventilation (6 mL/kg predicted body weight) 5
• Manage FiO2 and PEEP based on high FiO2/low PEEP table 5
• Prone positioning for 12-16 hours if PaO2/FiO2 <150 mmHg, FiO2 ≥0.6, and PEEP ≥10 cmH2O—this reduces mortality 1, 5

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Anticoagulation Management

Standard Prophylactic Dosing

• All hospitalized COVID-19 patients should receive prophylactic-dose anticoagulation 1, 2
• LMWH is preferred over unfractionated heparin 1
• Adjust dosing based on renal function, bleeding risk, and weight 2

Monitoring

• Check platelet count, coagulation parameters, and renal/hepatic function before starting 7
• Do NOT change anticoagulation based solely on D-dimer levels 1

Special Considerations

• For patients with new-onset atrial fibrillation in hospital: start therapeutic-dose parenteral anticoagulation regardless of CHA2DS2-VASc score 7
• For patients on chronic antiplatelet or anticoagulation therapy: continue unless significant bleeding or contraindications develop 7

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Remdesivir: Limited Role

The European Respiratory Society does NOT recommend routine remdesivir use 1

• Strongly recommend AGAINST use in patients requiring invasive mechanical ventilation—no survival benefit demonstrated 1, 2
• If used in moderate disease (SpO2 ≥94% with lower respiratory disease evidence): 200 mg IV loading dose on Day 1, then 100 mg IV daily for 5 days (may extend to 10 days if no improvement) 2
• Monitor hepatic function during therapy 2

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Treatments to AVOID

Strong recommendations AGAINST the following:

• Hydroxychloroquine—no benefit, potential harm 1
• Lopinavir-ritonavir—no benefit, potential harm 1
• Azithromycin (unless bacterial coinfection documented)—no benefit 1
• Routine antibiotics—only prescribe when clinically justified based on imaging, laboratory data, and severity suggesting bacterial coinfection 2

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Critical Monitoring Parameters

Laboratory Monitoring

• Complete blood count (CBC) with differential 2
• Liver function tests (ALT, AST) 2
• Renal function (creatinine, eGFR) 2
• Coagulation parameters (PT/INR, aPTT, platelets) 7

Clinical Monitoring

• Oxygen saturation continuously or frequently 3
• Respiratory rate and work of breathing 2
• Signs of complications: ARDS, shock, myocardial dysfunction, acute kidney injury, arrhythmias, secondary infections 2

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Infection Control and Supportive Care

Isolation and PPE

• Isolate confirmed COVID-19 patients from negative patients 2
• Healthcare workers require trained use of complete personal protective equipment (PPE) 2
• Use FFP2-3 masks when providing humidified oxygen therapy 3

Adjunctive Measures

• Awake prone positioning for non-intubated hypoxemic patients—requires close monitoring with clear failure criteria 5
• Provide psychological support for patients and families experiencing anxiety, fear, or depression 1
• Initiate rehabilitation care as soon as clinically appropriate 1

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Common Pitfalls to Avoid

1. Giving corticosteroids to patients not requiring oxygen—causes harm without benefit 1, 2
2. Delaying anticoagulation initiation 2
3. Using remdesivir in mechanically ventilated patients—no survival benefit 1, 2
4. Routinely prescribing antibiotics without evidence of bacterial infection 2
5. Delaying intubation in patients failing non-invasive support 1
6. Using biomarkers alone (like D-dimer) to guide anticoagulation changes 1