PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGEDINFORMATION CREATED AS PART OF LPSES – LEE HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM

COVID-19 Meeting # 6ICU-ED-AnesthesiaMedical Staff Updates and Discussion

April 22, 2020

“Failing to prepare is preparing to fail”

Benjamin Franklin

Guiding Premise

“The one thing we know- We have no idea what the ideal management of these patients really is.”

We will continue to learn, modify and adapt our guidelines as more information and literature becomes known.

AGENDA

Overview: Dr Pammi

Renal Disease in COVID-19: Dr Conrey

Proning for non-intubated patients: Dr Pammi

Prone CPR: Dr Dougherty

Ventilation options in Code Blue: Dr Taillon

Extubation procedure in COVID-19: Dr Kapadia

Hydroxychloroquine: Dr Dougherty/A. Cubillos

Medication updates

NIH Guidelines

Thanks to Covid-19 Critical Care Team

Tim Dougherty Elena Gatskevich Doug Brust

Marilyn Kole Javaad Khan Sandra Simmons

Dolan Abu Aouf Shyam Kapadia Linda Odnoha

Razak Dosani Ragai Meena Amy Hiteman

Sagar Naik Jordan Taillon Renee McCauley

Ken Tolep Ashley Cubillos Sunil Pammi

Justin Burkholder Rabia Khan Keith Lafferty

Thank You

OverviewDr S. Pammi

Where are we with the projected surge?

• Where are we in the timing of the surge?

• Are we close to herd immunity?

• What are the non-Covid illness ER volumes?

• Where are the STEMI/Stroke patients?

• Will there be a Covid surge plus delayed care patient sequence?

Surge Plan: ICU beds

Surge plan is out and reviewed with PLC and MEC

CCH 3246

GCMC 72112

HPMC 3994

LMH 4668

Discussed and coordinated with ICU medical directors and will be able to mobilize and redirect from outpatient and APP in order staff.

Guiding Principles There is not much evidence based medicine available. The disease has a wide spectrum of presentation.

Different patients can come in with different presentation.

Same patient can progress to different presentation

No one size fits all protocol.

These are guidelines (advisory). Clinical context should take precedence.

1. Make recommendations and design protocols based on current available data from case reports and experiences described from other centers that have had high volumes.

2. Apply safest approach to the patient

3. Protocols take into account the safety of the entire medical staff.

Presentation

• Mild

• Indolent

• Happy Hypoxemic (L- type versus H-type)

• Hyperacute

Therapeutics• Intubations

• Ventilator utilization

• Preoxygenation

• Codes

• Proning- awake, intubated, nursing protocol

• Hydroxychloroquine: new VA study- may be harmful

• Azithromycin: combination no longer recommended)

• Steroids

• Ace inhibitors

• Remdisivir

• Tociluzimab

• Convalescent serum

• Tracheostomy

No clear guidance

• Anticoagulation

o DVT prophylaxis universally accepted

o Intermediate dose based on D-Dimer

o Full dose based on D-dimer

o Discharge on AC? DOAC?

• Post cardiac arrest hypothermia

ACC recommendations

ACC website: www. acc.org

Thrombosis

Consensus statement AMI recommendations

"[informing] the public that we can minimize exposure to the coronavirus so they can continue to call the Emergency Medical System (EMS) for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants."

Cardiomyopathy and Heart failure

Statin

Hydroxychloroquine- QT prolongation

Supportive therapeutics

• Q-life support

• Telemedicine support

Financial impact on Health System

• Universally volumes are down- Inpatient, Outpatient, Surgeries and peripheral studies.

• How will this effect your practice?

• What can we do as physician leaders to deflect the financial impact?

• We need to promote and publicize that we are capable of taking care of patients needs safely.

Thank YouNephrology Issues in COVID-19

NEPHROLOGY ISSUES IN COVID-19 DISEASE

Presented by John Conrey, MD

Associates in Nephrology

4/22/2020

RESOURCES

• American Society of Nephrology

• 4/21 COVID AKI Webinar

• Dr Michael Connor – Emory Univ.

• Dr Kia Kahani – Mayo Clinic

• Dr Stu Goldstein – Cincinnati Children’s Hosp.

• 4/2 COVID Update Webinar

• Dr Michelle Mokrzycki – Albert Einstein Medical Center

MECHANISMS OF RENAL INJURY

• Direct viral invasion may be a factor via ACE2r

• Viral clusters seen in podocytes and tubules on EM

• Volume depletion

• initial presentation, later diuretic related

• Hypercoagulable

• Glomerular injury, fibrin thrombosis

• ATN

• oxidative stress model, brush boarder loss, vacuolization

• Shock – unusual at initial presentation

• Cardiogenic – myositis

• Distributive/vasoplegic – cytokine surge

• Sepsis – super infection

EPIDEMIOLOGY OF AKI

• BC (before COVID)

• ICU AKI = 57.3%

• Stage 1: 18.4%

• Stage 2: 8.9%

• Stage 3: 30%

• AKI-D:13.5%

AKI-EPI study Intensive Care Med

(2015)

• DC (during COVID)

• 6-10% requiring ICU

• ICU AKI = 40-60%

• AKI-D: 20-30%

Unpublished observations

• AKI is now felt to be common in hospitalized COVID-19 patients.

• Early reports from China suggested little to no AKI

• Italy subsequently reported 40% in ICU cases, 20% RRT

• US unpublished reports from hot spots describe AKI 20%-50% in ICU and

20-30% needing RRT

VERY FEW AKI-D REMAIN DIALYSIS DEPENDENT AT DISCHARGE

AKI DIAGNOSIS

• Standard AKI criteria on creatinine and uop

• Urine sediments have been highly variable suggesting

multiple mechanisms.

COVID-19 ICU MANAGEMENT

• Optimize critical care targets: Timing of ventilation, protective

ventilation, euvolemia, nutritional support, minimize sedation

• Recognize atypical ARDS: Caution with high PEEP, Expect high FiO2,

secretion clearance.

• VTE/PE: Low threshold for systemic anticoagulation (D-dimer,

proteinuria)

AKI – EARLY MANAGEMENT

• Determine cause with consideration for each potential mechanism

• Determine true volume status

oExam, passive leg raise, NICOM, IVC/ ECHO, pulse wave analysis

• Furosemide stress test

• Renal specific biomarkers have not been useful

COVID-AKI: ACUTE RRT

• Timing of RRT initiation: classic absolute indications, volume control

most common

• Failed FST correlates with progression to RRT

• RRT circuit thrombosis is major challenge (all modalities)

• CRRT: regional citrate-> systemic heparin-> argatroban

• Suitable length and placement of CVC is paramount

• Temporary CVC over tunneled with near term recovery potential

RENAL MARKERS FOR MORTALITY IN COVID-19

• N=710

• Proteinuria 44% Hazard Ratio 2.5-6.8

• Hematuria 26.9% HR 3.0-8.9

• BUN elevation 14% HR 4.2

• Cr elevation 15.5% HR 2-3

• Relative risk AKI = 3.2

• AKI-1 HR 1.9

• AKI-2 HR 3.5

• AKI-3 HR 4.7

• Cheng, Kidney International, 2020

CRRT/ PIRRT

• Consideration for removal of inflammatory markers in cytokine storm though

historically this has not been proven efficacious in sepsis studies.

• Prolonged Intermittent Renal Replacement Therapy

DIALYSIS SURGE PLANNING

• RRT is a finite resource

(machines, supplies, personnel).

• Spectrum of modalities (PD,

IHD, PIRRT, CRRT).

• Limiting initiation of dialysis to

absolute indications

• Reasonable distribution may

include reduced treatment

time/ frequency.

• Full staffing Sunday

• Increase use of potassium

binders, alkali therapy,

diuretics.

INPATIENT DIALYSIS PROCEDURES

• COVID19 and PUI with

fever/symptoms

• Bedside HD in their room

• No splash efflux

• Bleach disinfect machine

• Requires 1:1 HD RN

• When asymptomatic and 72 hrs

afebrile

• Return to dialysis ward setting

• Cohort on last shift

• End of day disinfect

• Safe transport

• 2:1 or 3:1 HD RN

FUROSEMIDE STRESS TEST

Thank You

Proning for non intubated patientsDr S. Pammi

Non-Intubated Patient Proning Order set

Thank You

CPR in the Proned PatientDr T. Dougherty

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19

Proned patients at the time of arrest

For suspected or confirmed COVID-19 patients who are in a prone position without an advanced airway, attempt to place in the supine position for continued resuscitation.

While the effectiveness of CPR in the prone position is not completely known, for those patients who are in the prone position with an advanced airway, avoid turning the patient to the supine position unless able to do so without risk of equipment disconnections and aerosolization.

Instead, consider placing defibrillator pads in the anterior-posterior position and provide CPR with the patient remaining prone with hands in the standard position over the T7/10 vertebral bodies.

Prone CPR: Historical Background

1st proposed in 1989, by McNeil

(Resuscitation; 1989, 18:1-5)

In 2001, Brown et al10 published the first systematic review on CPR in the prone position. It was reported that 22 intubated inpatients received CPR in the prone position and 10 of those 22 cases could be discharged from the hospital.

(Resuscitation; 2001, 50:233-8)

A pilot study showed that CPR performed in the prone position generated higher systolic and mean arterial pressure during circulatory arrest compared to standard CPR.

(Resuscitation; 2003, 57:279-85)

Theoretical Benefits

Studies suggest that as CPR in the prone position generates higher blood pressures than in the supine position, it is more advantageous compared to classical Crp

Abdomen is in contact with a solid surface and movement of abdominal structures is restricted. In this way, compressions become more effective

As shunting is decrease in the prone position, better oxygenation can be achieved.

CPR in prone position, minimum risk of aspiration.

As the posterior chest is more rigid, there is lower risk for development of traumatic injury as a result of spread of the applied power, thus, stronger compressions may be applied in the prone position with minimal risks yet without significant reductions in heart compressions

2010 AHA Guidelines for CPR & Emergency Cardiovascular Care

Prone CPR When the patient cannot be placed in the supine position, it may be reasonable for rescuers to

provide CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place (Class IIb, LOE C).

Chest compression in the prone position can be achieved with or without sternal counter-pressure.

Proper Hand Placement

Both one- handed and two-handed techniques and two handed techniques of prone CPR have been described.

Defibrillator Pads

Defibrillation pads can be attached in 3 different ways:

Anterior‐lateral, Anterior‐posterior, and Apex posterior.

The success rate of defibrillation is comparable in all these three locations.

In the apex posterior position, which is most convenient for a prone patient, one of the pads is placed at the left 5th ICS just posterior to midaxillary line and the other between the tip of right scapula and the spine.

CPR Rescuing the Patient from Roto Prone Bed

https://www.youtube.com/watch?v=JH5VzJDwEFk

Thank You

Ventilator settings in Code BlueDr J. Taillon

10.1161/CIRCULATIONAHA.I120.047463

Intubated patients at the time of cardiac arrest• Consider leaving the patient on a mechanical ventilator with HEPA filter to

maintain a closed circuit and reduce aerosolization.• Adjust the ventilator settings to allow for asynchronous ventilation (time

chest compressions with ventilation in newborns). Consider the following suggestions:o Increase the FIO2 to 1.0o Change mode to Pressure Control Ventilation (Assist Control) and limit

pressure as needed to generate adequate chest rise (6mL/kg ideal body weight is often targeted, 4-6 mL/kg for neonates).

o Adjust the trigger to Off to prevent the ventilator from auto-triggering with chest compressions and possibly prevent hyperventilation and air trapping.

o Adjust respiratory rate to 10/min for adults and pediatrics and 30/min for neonates.

o Assess the need to adjust positive end-expiratory pressure level to balance lung volumes and venous return.

o Adjust alarms to prevent alarm fatigue.o Ensure endotracheal tube/tracheostomy and ventilator circuit security

to prevent unplanned extubation.If return of spontaneous circulation is achieved, set ventilator settings as appropriate to patients’ clinical condition.

Maintaining patients on Ventilator during code

Pressure Ventilation: Alternative option reviewedVolume Ventilation: Current process

Thank YouExtubation Procedure in COVID 19

Dr S. Kapadia

Extubation in COVID-19 patients: Mask over Tube

-Position the patient 30o head up.

-Anesthetist and assistant positioned behind the patient’s head, attempting to avoid exposure to any coughing.

-Optimize anesthetic facemask seal (prior to induction of general anesthesia the anesthetist will have ensured correct facemask size, adjusted inflation of mask cuff, shaved any facial hair).

-Attach a second airway filter to the facemask. The CO2 sampling port should be capped.

-Position the tracheal tube (TT) to one side of the mouth, closest to the anesthetic assistant’s position for extubation.

-Position the facemask with second airway filter, using a two-handed technique to ensure a seal over the mouth and nose with the TT exiting under the facemask.

-No positive airway pressure during extubation: ventilator off with no or low fresh gas flow. Consider attempting to extubate at end-expiration.

-Deflate TT cuff and extubate while maintaining facemask seal.

-Discard TT and connect circuit to the second airway filter facemask to the anesthetic circuit (in the operating theatre) or the non-rebreather valve of a self-expanding bag (in the intensive care unit).

-Maintain a two-handed mask seal until regular breathing via the circuit and any immediate post-extubation coughing has subsided.

Post-Extubation

Extubation options in COVID-19: UP TO DATE

Tracheal extubation — In some cases (eg, after general anesthesia in patients with documented or suspected COVID-19-positive

status), tracheal extubation is planned.

●High-level PPE is worn by clinicians performing extubation. Similar to endotracheal intubation, non-anesthesia personnel should

leave the room during extubation, and should allow a number of air exchanges before reentry into a positive pressure room.

●Some experts suggest administration of prophylactic lidocaine to reduce risk of coughing before tracheal extubation in a COVID-

19-positive [5]. If general anesthesia was employed, prophylactic antiemetics should be administered near the end of the

procedure to reduce risk of vomiting and consequent viral spread.

●Some experts suggest placement of wet gauze over the patients mouth and nose just prior to extubation if the patient starts to

cough

●After extubation, a surgical mask is placed over the patient's airway, with supplemental oxygen administered via a plastic mask

applied over the surgical mask or nasal prongs under the mask.

●Perform routine visual and manual maneuvers to ensure an adequate airway post extubation while wearing double gloves.

Posted on March 28, 2020 by INTENSIVEExtubation of Suspected or Confirmed

COVID-19 Patients in Isolation

Precautions | Alfred ICU Guideline

Alfred ICU is a university attached

quaternary referral centre, providing State

Services for heart & lung transplantation

(including pediatric lung transplantation),

artificial heart technology, extra-corporeal

membrane oxygenation (ECMO), burns and

hyperbaric medicine. It also provides

Victoria's Adult Cystic Fibrosis and Pulmonary Hypertension services.

INTENSIVE is an educational website for doctors and other health professionals training in and practicing intensive care medicine.INTENSIVE is provided by intensivists and trainees from The Alfred ICU in Melbourne, Australia

Thank You

Hydroxycholoroquine Review of Recent COVID 19 Clinical Data

Dr T. DoughertyAshely Cubillos, Pharm.D., BCPS, BCIDP

Recent Studies (April 14th – 21st)

Tang et al (multicenter open-label randomized, N=150, pre-print)

• HCQ (n=75) vs. control (n=75)• 99% of patients mild-moderate disease

Outcomes:

• 28 day negative PCR: HCQ 85.4%, control 81.3%, P=0.341• No difference in time to symptom resolution or resolution at

28 days

Conclusion: no overall benefit to HCQ in viral PCR negativity or symptom resolution

• Did not meet power

• Post hoc analysis: shorter time to symptom resolution in those receiving no other antivirals

49

Tang W et al. 14 Apr 2020. https://www.medrxiv.org/content/10.1101/2020.04.10.20060558v1

Recent Studies (April 14th – 21st)

Mahevas et al (retrospective, N=181, pre-print)

• HCQ (n=84) vs. control (n=97)• Pneumonia with supplemental O2 (non-ICU)

Outcomes:

• Transfer to ICU within 7 days or death: • HCQ 20.5%, control 22.1% (weighted RR 0.98, 95% CI

0.48-1.81)

• No difference in rate of ARDS development or day 7 mortality

• 8 patients required HCQ discontinuation (ECG abnormalities)

Conclusion: no benefit noted in clinical outcomes (raw data or weighted analysis)

50

Mahevas M et al. 14 Apr 2020. https://www.medrxiv.org/content/10.1101/2020.04.10.20060699v1

Recent Studies (April 14th – 21st)

Magagnoli et al (VA patients, N=368, retrospective, pre-print)

• HCQ (n=97) vs. HCQ plus AZ (n=113) vs. no HCQ (n=158)

Outcomes:

• Mortality:

• HCQ 28%, HCQ/AZ 22.1%, no HCQ 11.4%

• HR (propensity-score analysis) for mortality with HCQ: 2.61 (95%CI 1.10-6.17, P=0.03)

• Nonsignificant with HCQ/AZ

• Mechanical ventilation:

• HCQ: 13.3%, HCQ/AZ: 6.9%, no HCQ: 14.1%

• HR nonsignificant

Conclusion: no improvement in mortality or progression to mechanical ventilation with HCQ

• Higher baseline severity of illness (SpO2, labs) HCQ and HCQ/AZ

• Residual confounding?

51

Magagnoli M et al. 21 Apr 2020. . https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v1

Guideline Recommendations

52

NIH IDSA ATS SCCM

No recommendation for or against HCQ use

Recommend HCQ for hospitalized patients in context of clinical trial

Suggest HCQ for hospitalized patients with pneumonia, with shared clinical decision making, data collection for study, severe patient condition, and no drug shortage

Insufficient evidence to issue recommendation on HCQ for critically ill patients

Wilson KC et al. ATS Covid-19 Resource Center. Accessed 14 Apr 2020.Alhazzani W et al. Crit Care Med. 2020 Mar 27.IDSA COVID-19 Resource Center. Accessed 14 Apr 2020.NIH COVID-19 Guideline. Accessed 22 Apr 2020.

Thank YouPharmacy: Medication Update

Medication Availability

Thank You

SUPPLEMENT NIH Recommendation (4/21)

Dr T. Dougherty

NIH COVID Treatment Guidelines

American College of Chest Physicians

American College of Emergency Physicians

American Thoracic Society

Biomedical Advanced Research and Development Authority

Centers for Disease Control and Prevention

Department of Defense

Department of Veterans Affairs

Food and Drug Administration

Infectious Diseases Society of America

National Institutes of Health

Pediatric Infectious Diseases Society

Society of Critical Care Medicine

Society of Infectious Diseases Pharmacists.

NIH Recommendations

Currently there are no Food and Drug Administration (FDA)-approved drugs for COVID-19

To date 801 studies under way.( https://clinicaltrials.gov/)

Rated treatment recommendations in these Guidelines should not be considered mandates.

The choice of what to do or not to do for an individual patient is ultimately decided by the patient together with their provider.

NIH Summary

Summary Recommendations

•The COVID-19 Treatment Guidelines Panel (the Panel) does not recommend the use of any agents for pre-exposure prophylaxis (PrEP) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outside of the setting of a clinical trial (AIII).

•The Panel does not recommend the use of any agents for post-exposure prophylaxis (PEP) against SARS-CoV-2 infection outside of the setting of a clinical trial (AIII).

•The Panel recommends no additional laboratory testing and no specific treatment for persons with suspected or confirmed asymptomatic or presymptomatic SARS-CoV-2 infection (AIII).

•At present, no drug has been proven to be safe and effective for treating COVID-19. There are insufficient data to recommend either for or against the use of any antiviral or immunomodulatory therapy in patients with COVID-19 who have mild, moderate, severe, or critical illness (AIII).

NIH Vent Support

For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, the Panel recommends high-flow nasal cannula (HFNC) oxygen over noninvasive positive pressure ventilation (NIPPV) (BI).

In the absence of an indication for endotracheal intubation, the Panel recommends a closely monitored trial of NIPPV for adults with COVID-19 and acute hypoxemic respiratory failure for whom HFNC is not available (BIII).

For adults with COVID-19 who are receiving supplemental oxygen, the Panel recommends close monitoring for worsening of respiratory status and recommends early intubation by an experienced practitioner in a controlled setting (AII).

For mechanically ventilated adults with COVID-19 and acute respiratory distress syndrome (ARDS), the Panel recommends using low tidal volume (Vt) ventilation (Vt 4–8 mL/kg of predicted body weight) over higher tidal volumes (Vt >8 mL/kg) (AI).

For mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimized ventilation, the Panel recommends prone ventilation for 12 to 16 hours per day over no prone ventilation (BII).

For mechanically ventilated adults with COVID-19, severe ARDS, and hypoxemia despite optimized ventilation and other rescue strategies, the Panel recommends a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the patient should be tapered off treatment (CIII).

There are insufficient data to recommend either for or against the routine use of extracorporeal membrane oxygenation(ECMO) for patients with COVID-19 and refractory hypoxemia (BIII).

Vent Recommendations

For mechanically ventilated adults with COVID-19 and ARDS:

The Panel recommends using low tidal volume (Vt) ventilation (Vt 4–8 mL/kg of predicted body weight) over higher tidal volumes (Vt >8 mL/kg) (AI).

The Panel recommends targeting plateau pressures of <30 cm H2O (AII).

The Panel recommends using a conservative fluid strategy over a liberal fluid strategy (BII).

The Panel recommends against the routine use of inhaled nitric oxide (AI).

For mechanically ventilated adults with COVID-19 and moderate-to-severe ARDS:

The Panel recommends using a higher positive end-expiratory pressure (PEEP) strategy over a lower PEEP strategy (BII).

For mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimizing ventilation, the Panel recommends prone ventilation for 12 to 16 hours per day over no prone ventilation (BII).

Aerosol Generating Procedure

Include:

Endotracheal intubation and extubation; bronchoscopy; open suctioning; high-flow nasal cannula (HFNC) or face mask; nebulizer treatment; manual ventilation; physical proning of the patient; disconnecting a patient from a ventilator; mini-bronchoalveolar lavage; noninvasive positive pressure ventilation (NIPPV); tracheostomy; or cardiopulmonary resuscitation.

For health care workers who are performing aerosol-generating procedures on patients with COVID-19:

Recommend using fit-tested respirators (N95 respirators) or powered air-purifying respirators rather than surgical masks, in addition to other personal protective equipment (PPE) (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles) (AIII).

Hemodynamics Recommendations

For adults with COVID-19 and shock:

Recommend using dynamic parameters, skin temperature, capillary refilling time, and/or lactate over static parameters to assess fluid responsiveness (BII).

Recommend using buffered/balanced crystalloids over unbalanced crystalloids (BII).

Recommends against the initial use of albumin for resuscitation (BI).

Additional Recommendations

Recommend against using hydroxyethyl starches for intravascular volume replacement in patients with sepsis or septic shock (AI).

Recommend norepinephrine as the first-choice vasopressor (AII). The Panel recommends adding either vasopressin (up to 0.03 U/min)(BII) or epinephrine (CII) to norepinephrine to raise mean arterial pressure to target, or adding vasopressin (up to 0.03 U/min) (CII) to decrease norepinephrine dosage.

Recommend using dopamine as an alternative vasopressor agent to norepinephrine only in certain patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (BII).

Recommends against using low-dose dopamine for renal protection (BII)

Recommend using dobutamine in patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents (BII).

Recommends that all patients who require vasopressors have an arterial catheter placed as soon as practical, if resources are available (BIII).

For adults with COVID-19 and refractory shock, the Panel recommends using low-dose corticosteroid therapy (“shock-reversal”) over no corticosteroid (BII).

A typical corticosteroid regimen in septic shock is intravenous hydrocortisone 200 mg per day administered either as an infusion or intermittent doses. The duration of hydrocortisone therapy is usually a clinical decision.

Proposed Drug Therapy

Chloroquine or Hydroxychloroquine

There are insufficient clinical data to recommend either for or against using chloroquine or hydroxychloroquine for the treatment of COVID-19 (AIII).

When chloroquine or hydroxychloroquine is used, clinicians should monitor the patient for adverse effects (AEs), especially prolonged QTc interval (AIII).

Hydroxychloroquine plus Azithromycin

The COVID-19 Treatment Guidelines Panel (the Panel) recommends against the use of hydroxychloroquine plus azithromycin for the treatment of COVID-19, except in the context of a clinical trial (AIII).

Proposed Drug Therapies

Lopinavir/Ritonavir and Other HIV Protease Inhibitors

The Panel recommends against the use of lopinavir/ritonavir (AI) or other HIV protease inhibitors (AIII) for the treatment of COVID-19, except in the context of a clinical trial.

Remdesivir

There are insufficient clinical data to recommend either for or against the use of the investigational antiviral agent remdesivir for the treatment of COVID-19 (AIII).

Convalescent Plasma and Specific Immune Globulins

There are insufficient data to recommend either for or against the use of convalescent plasma or hyperimmune immunoglobulin for the treatment of COVID-19 (AIII).

Proposed Drug Therapies

IL-1 Inhibitors (e.g., Anakinra)

There are insufficient data to recommend either for or against the use of IL-1 inhibitors, such as anakinra, for the treatment of COVID-19 (AIII).

IL-6 Inhibitors (Sarilumab, Siltuximab, Tocilizumab)

There are insufficient data to recommend either for or against the use of IL-6 inhibitors (e.g., sarilumab, siltuximab, or tocilizumab) for the treatment of COVID-19 (AIII)

Interferons

The Panel recommends against the use of interferons for the treatment of COVID-19, except in the context of a clinical trial (AIII).

Janus Kinase Inhibitors (e.g., Baricitinib)

The Panel recommends against the use of Janus kinase (JAK) inhibitors(e.g., baricitinib) for the treatment of COVID-19, except in the context of a clinical trial (AIII).

Corticosteroids

For Critically Ill Patients with COVID-19: The Panel recommends against the routine use of systemic corticosteroids for the treatment of

mechanically ventilated patients with COVID-19 without acute respiratory distress syndrome (ARDS)(AIII).

For mechanically ventilated patients with ARDS, there is insufficient evidence to recommend for or against the use of systemic corticosteroids (CI).

For adults with COVID-19 and refractory shock, the Panel recommends using low-dose corticosteroid therapy (i.e., shock reversal) over no corticosteroids (BII).

For Hospitalized, Non-Critically Ill Patients with COVID-19:

The Panel recommends against the routine use of systemic corticosteroids for the treatment of COVID-19 in hospitalized patients, unless they are in the intensive care unit (AIII).

For Patients on Chronic Corticosteroids:

Oral corticosteroid therapy used prior to COVID-19 diagnosis for another underlying condition (e.g., primary or secondary adrenal insufficiency, rheumatological diseases) should not be discontinued (AIII). On a case-by-case basis, supplemental or stress-dose steroids may be indicated(AIII).

Inhaled corticosteroids used daily for patients with asthma and chronic obstructive pulmonary disease for control of airway inflammation should not be discontinued in patients with COVID-19 (AIII).

Drug Therapy Summary Statement

There are insufficient data to recommend either for or against any antiviral or immunomodulatory therapy in patients with severe COVID-19 disease (AIII).

In patients with COVID-19 and severe or critical illness, there are insufficient data to recommend empiric broad-spectrum antimicrobial therapy in the absence of another indication (BIII).

The Panel recommends against the routine use of systemic corticosteroids for the treatment of mechanically ventilated patients with COVID-19 without ARDS (BIII).

In mechanically ventilated adults with COVID-19 and ARDS, there are insufficient data to recommend either for or against corticosteroid therapy in the absence of another indication (CI).

In COVID-19 patients with refractory shock, low-dose corticosteroid therapy is preferred over no corticosteroid therapy (BII).

Other Drugs…

HMG-CoA Reductase Inhibitors (Statins):

Persons with COVID-19 who are prescribed statin therapy for the treatment or prevention of cardiovascular disease should continue these medications (AIII).

The Panel recommends against the use of statins for the treatment of COVID-19 outside of the setting of a clinical trial (AIII).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):

Persons with COVID-19 who are taking NSAIDs for a co-morbid condition should continue therapy as previously directed by their physician (AIII).

The Panel recommends that there be no difference in the use of antipyretic strategies (e.g., with acetaminophen or NSAIDs) between patients with or without COVID-19 (AIII)

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs):

Persons with COVID-19 who are prescribed ACE inhibitors or ARBs for cardiovascular disease (or other indications) should continue these medications (AIII).

The COVID-19 Treatment Guidelines Panel (the Panel) recommends against the use of ACE inhibitors or ARBs for the treatment of COVID-19 outside of the setting of a clinical trial (AIII).

Thank You