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Management Protocol for COVID-19 Patients MoHP Protocol for COVID19 November 2020

Authors:

Abstract

All patients with symptomatic COVID-19 and risk factors for severe disease should be closely monitored. The clinical course may rapidly progress in some patients. Antibiotics are not recommended to prevent bacterial infection in mild or ordinary patients. Administer empiric antibiotics if bacterial pneumonia/sepsis strongly suspected; re-evaluate daily. In non-hospitalized patients, do not initiate therapeutic anticoagulants or anti platelet unless other indications exist.
Version 1.4 / November 2020 1
Management Protocol
in Hospitals
C VID-19
Ministry of Health and Population, Egypt
Management protocol for COVID-19
Patients
Version 1.4 / November 2020
Management Protocol for
Patients
Version 1.4 / November 2020
2
Version 1.4 / November 2020 3
Table of contents
Item Page
Number
Triage Protocol 4
Management Protocol 6
Gastrointestinal Manifestations
of COVID-19 15
Anticoagulation of COVID-19
Patients 16
High-Velocity Nasal Insuation 17
Post-acute COVID Syndrome 18
Prevention and Control of COVID-19 Inside
Health Care Facilities 20
Antibiotics in Covid-19 25
List of Editors 26
Version 1.4 / November 2020
4
1st Step: Triage
Case denition + severity assessment
Suspect Case Denition
A) Clinical AND epidemiological criteria: OR: B
Patient with severe acute
respiratory illness (SARI: acute
respiratory infection with history
of fever or measured fever ≥ 38°C
and a cough; onset within last 10
days; requires hospitalization)
-Acute onset of fever and cough OR
-≥ 3 of the followings: fever, cough, sore
throat, coryza, general weakness/fatigue,
headache, myalgia, dyspnea, anorexia/nausea/
vomiting, diarrhea, altered mental status
And 1 of the followings within 14 days of
symptom onset:
Residing or
working in an
area with high
risk of
transmission*
Working in
a healthcare
seing
Residing or
travel to an area
with community
transmission
*Closed residential seings, humanitarian seings such as camp and camp-like seings for displaced persons.
NB: Minimal role for the epidemiological criteria during the period of community spread
Probable Case
A patient who meets clinical criteria AND is a contact of a probable or conrmed case,
or epidemiologically linked to a cluster with at least one conrmed case.
OR
Suspect case with chest imaging showing ndings suggestive of COVID-19 disease*
OR
Recent onset of loss of smell or taste in the absence of any other identied cause
OR
Unexplained death in an adult with respiratory distress who was a contact of a probable
or conrmed case or epidemiologically linked to a cluster with at least 1 conrmed case
*Hazy opacities with peripheral and lower lung distribution on chest radiography; multiple bilateral ground
glass opacities with peripheral and lower lung distribution on chest CT; or thickened pleural lines, B lines, or
consolidative paerns on lung ultrasound.
Conrmed Case
A person with laboratory conrmation* of COVID-19 infection, irrespective of clinical signs
and symptoms
*Molecular testing(PCR) with deep nasal swab is the current test of choice for the diagnosis of acute COVID-19
infection
During seasonal u period, clinical dierentiation between inuenza and COVID 19 is dicult.
Swab for inuenza A &B may help in early dierentiation.
Triage Protocol
Version 1.4 / November 2020 5
OR: B
Severity assessment
Suspected case
-PCR to conrm the diagnosis *
-Assess disease severity
(clinical, lab & imaging)
-Mild symptoms
-Normal imaging
Imaging: +ve
SpO2 ≥ 92%
SpO2 < 92%, PaO2/FiO2 <
300,
respiratory rate > 30
breaths/min, or
lung inltrates > 50%
Respiratory failure,
septic shock, and/or
multiorgan
dysfunction
Admit to
Intensive care
Admit to
Intermediate Care
Hospitals admission
COVID area
Home isolation &
close follow up
If possible, < 65 years
old & no uncontrolled
comorbidity
Critical illnessSevere
Moderate
Mild Risk Factor
Yes
No
In severe and critically ill patients, if-ve 1st PCR, repeat within 48 hours, negative case is considered after 2 –ve
consecutive RT-PCR results from respiratory samples tested at least 1 day apart.
NB: Unstable patient who don’t meet the suspected criteria should receive 1st aid therapy in non-COVID area
before referral to general hospital.+ Risk factors include, old age > 60 years, uncontrolled comorbidity as hyperten-
sion, DM, ……. or Social un applicable to home isolation.
All persons with suspected, probable or conrmed COVID-19 should be immediately
isolated to contain the virus transmission.
Triage Protocol
Version 1.4 / November 2020
6
Time is an important issue Time is an important issue in management of COVID-19. Before day 12( stage of viral
load), Antiviral drug is essential. After day 12, the role of antiviral declines with
augmentation for the role of anti-inammatory, immune-modulators and Supportive drugs
(stage of hyper-immune state).
Potential antiviral drugs under evaluation for the treatment of COVID-19 include:Potential antiviral drugs under evaluation for the treatment of COVID-19 include:
- Hydroxy ChloroquineHydroxy Chloroquine 400mg/ 12 hours 1st day followed by 200 mg/12 hours for 6 days,
- IvermectinIvermectin 6 mg (36 mg on day 0 -3-6),
- FavipiravirFavipiravir 1600 twice daily rst day then 600 mg twice daily,
- RemdesivirRemdesivir 200 mg IV on day 1, followed by 100 mg IV daily for high risk population for 5
days that could be extended to 10 days if the response is unsatisfactory or
- Lopinavir/Ritonavir Lopinavir/Ritonavir 200/ 50 mg 2 tablets PO BID
- Monoclonal antibodiesMonoclonal antibodies: early testing in blocking SARS-CoV-2.
- Convalescent plasmaConvalescent plasma: for impending severely ill after counseling the scientic commiee
2nd Step: Management
Home isolation and symptomatic treatment symptomatic treatment (eg, antipyretics for fever, adequate nutrition,
appropriate rehydration).
Educate the patientsEducate the patients on signs/symptoms of complications that, if developed, should prompt
pursuit of urgent care.
There are insucient data to recommend either with or against any antiviral or im-
mune-based therapy in patients with COVID-19 who have mild illness.
Mild illness
All patients with symptomatic COVID-19 and
risk factors for severe disease should be closely
monitored. The clinical course may rapidly
progress in some patients.
Antibiotics are not recommended to prevent
bacterial infection in mild patients. Administer
empiric antibiotics if bacterial
pneumonia/sepsis strongly suspected; re-evaluate
daily.
In non-hospitalized patients, do not initiate
therapeutic anticoagulants or antiplatelet
unless other indications exist.
No harmful eect for administration of vitamin
C or D or Zinc or Lactoferrin within the required
daily dose.
Check Every Patient For Risk
Factors
. Age 65 years
. SpO2 < 92%
. Heart Rate ≥110
. Respiratory Rate ≥ 25 /min.
. Neutrophil / lymphocyte ratio on
CBC ≥ 3.1
. Uncontrolled Comorbidities
. On Immunosuppressive or
chemotherapy drug
. Pregnancy
. Active Malignancy
. Obesity (BM>40)
Management Protocol
Version 1.4 / November 2020 7
All patients with symptomatic COVID-19 and risk factors for severe disease should
be closely monitored. In some patients, the clinical course may rapidly progress.
Flu or COVID-19
IS IT A FLU OR COVID-19?IS IT A FLU OR COVID-19?
SYMPTOM FLU COVID-19
FEVER
FATIGUE
COUGH
SORE THROAT
HEADACHES
RUNNY NOSE
SHORTNESS OF BREATH
BODY ACHES
DIARRHEA AND/OR
VOMITING
ONSET 1-4 days after infection About 5 days after infection but can range
from 2-14 days
LOSS OF TASTE AND/OR
SMELL
RED, SWOLLEN EYES
SKIN RASHES
Version 1.4 / November 2020
8
Mild Case
Symptomatic case
with lymphopenia or leucopenia
with no radiological signs for pneumonia
1. Age 65
2. Temperature > 38
3. SaO2 ≤ 92%
4. Heart Rate ≥ 110
5. Respiratory Rate ≥ 25 /min.
6. Neutrophil / lymphocyte ratio
on CBC ≥ 3.1
7. Uncontrolled Comorbidities
8. Immunosuppressive Drug
9. Pregnancy
10. Active Malignancy
11. On Chemotherapy
12. Obesity (BMI>40)
Check for
Any YES
All No
Age ≥ 65
OR
Age < 65
AND
• Strict Home Isolation (Symptomatic
Treatment)
• Follow and use personal protective guide
equipment
• If any deterioration occurs, back to
hospital
NB: Paracetamol is the preferred antipyretic
If more than 3
symptoms admit
Treatment
- Hydroxychloroquine (400 mg twice in
rst day then 200 mg twice for 6 days)
- Zinc 50mg daily
- Acelylcysteine 200 mg t.d.s.
- lactoferrin one sachet twice daily
- Vitamin C 1 gm daily
OR Ivermectin 6 mg (36 mg on day 0
-3-6)
OR Favipiravir 1600 TWICE daily rst
day then 600 mg twice daily
+
Version 1.4 / November 2020 9
Anti-virals
Hydroxychloroquine +
Ivermectin or
Lopinavir/Ritonavir
or
Remdesivir for high
risk population with
SaO2 < 92
Immune-modulators
Anti-inammatory Anti-coagulation
Steroids
(if patient has severe
dyspnea) RR>24 or CT
scan showing rapid
deterioration
Dexamethasone 6 mg
or its oral equivalent
Prophylactic
anticoagulation if
D-Dimer between
500 -1000
Therapeutic
anti-coagulation if
D-dimer > 1000
Patient has pneumonia manifestations on radiology associated with symptoms &/Or
leucopenia or lymphopenia.
Moderate Case
Anti-virals
anticoagulation if
D-Dimer between
500 -1000
Therapeutic
anti-coagulation if
D-dimer > 1000
Or if severe
hypoxia
Anti-inammatory Convalescent
plasma
Steroids
(Dexamethasone 6
mg or methyl
prednisolone (1 mg /
kg /24 hours)
Tocilizumab
4-8 mg/kg/day for 2
doses 12 to 24 hours
apart after failure of
steroid therapy to
improve the case for
24 hours
Before day 12
(under clinical trial)
(after scientic
commiee
approval)
RR > 30, SaO2 < 92 at room air, PaO2/FiO2 ratio < 300, Chest radiology showing more than
50% lesion or progressive lesion within 24 to 48 hrs.
Severe cases
Remdesivir
or
Lopinavir/
Ritonavir
Anti-coagulant
Prophylactic
Admit to Intermediate Care
Version 1.4 / November 2020
10
RR > 30, Sa02 < 92 at room air, PaO2/FiO2 ratio < 300, Chest radiology showing more than
50% lesion or progressive lesion within 24 to 48 hrs. Critically ill if SaO2 <92, or RR>30, or
PaO2/FiO2 ratio < 200 despite Oxygen Therapy.
Critically ill patients
Admit to Intensive care
Anti-virals
Remdesivir
or
Lopinavir/
Ritonavir
Anti-coagulant Anti-inammatory
Therapeutic
anti-coagulation
Steroids
(Methyl prednisolone 2mg /kg or its
equivalent)
Tocilizumab
4-8 mg/kg/day for 2 doses 12 to 24 hours
apart after failure of steroid therapy to
improve the case for 24 hours
Tocilizumab
4-8mg/kg/dose
2 doses
Early Block
the storm
if steroids
failed
Antiviral
Drugs As is In
Severe case
Steroids
Methylpred-
nisolone
1-2 mg/kg/d
Anti-
Coagulation
Enoxaparine
1 mg/kg BID
Prone
Awake or
ventilated
Avoid
Hypoxia
O2/ NIV/
HFNC/IMV
Add
Antibiotics
As per
protocol
1 mg for non
ventilated
and 2 mg for
ventilated
Consider
D-dimer level
as a guide
Improves
V/Q matching
and survival
Don’t wait
too much for
any type of
support Keep
plateau<30
High ow nasal oxygen is an important modality in the early management of critically ill patients.
Version 1.4 / November 2020 11
(HFNC):
Conscious patients with minimal secretions.
Hypoxia SpO2 < 90% on oxygen. Or PaCO2 >40 mmHg provided pH 7.3 and above.
NIV trial shall be short with ABG 30 minutes apart.
Any deterioration in blood gases from baseline or oxygen saturation or consciousness
level shift to IMV.
CPAP gradually increased from 5-10 cmH2O.
Pressure support from 10-15 cm H2O.
HFNC can be alternative to NIV.
Use PPE specially goggles during intubation and avoid bagging.
Indications:
Failed NIV or not available or not practical.
PaO2 < 60 mmhg despite oxygen supplementation.
Progressive Hypercapnia.
Respiratory acidosis (PH < 7.30).
Progressive or refractory septic shock.
Disturbed consciousness level (GCS ≤ 8) or deterioration in consciousness level from
baseline
Non Invasive Ventilation or High Flow Nasal Cannula
Invasive Mechanical Ventilation:
Version 1.4 / November 2020
12
COVID-19 PNEUMONIA (type L & type H)
Type LType H
Type L
Low elastance
Low VA/Q mismatch
Low lung weight
Low recruitability High elastance
High RL shunt
High lung weight
High recruitability
Type H
Non invasive
support Early intubation Late intubation
HFNC
CPAP
NIV
PEEP (5-10 cmH2O)
Sedation
NMBA
Higher PEEP(10-15
cmH2O)
Prone
(ECMO)
STOP STOP STOP
Lung Damage Progression
(Virus + P-SILI)
Inspiratory eort - edema
Type L and Type H patients are best identied by CT scan and are aected by dierent
Pathophysiological mechanisms. If CT not available, denition could be used as surrogates:
Respiratory system elastance and recruitability.
Understanding the correct pathophysiology is crucial to establishing the basis for appropriate
treatment.
Version 1.4 / November 2020 13
Plateau
P<30 cmH2O
Incremental
PEEP
Shift to ARDSNet protocol if needed
Step 2:
- ARDSNet protocol:
LOW TV
6-4 ml/kg Driving
P<15 cmH2O
Initiation of Invasive Mechanical Ventilation
Step 1:
VCV
TV 8 ml/kg
PEEP 5 cmH2O
Plateau
Pressure
Less than 30
cmH2O
Sat >93
Keep and Watch
Less than 30
Sat<93
Increase PEEP
to 10
More than 30
ARDSnet
protocol
Inspiratory Pause for 1 second
IF PLATEAU ABOVE 30 CMH2O
Version 1.4 / November 2020
14
Assessment of respiratory support outcome
Step 3:
Improved
Weaning of
respiratory
support
Assess
ABGs, Clinical
Radiological
Stationary
Continue
respiratory
support as
needed
*Criteria for VV ECMO: Age below 55, mechanical ventilation duration
less than 7 days, no comorbidities, preserved conscious level,
PaO2/FiO2 <100 despite prone RESPscore >0.
Expert opinion is needed and depends on availability.
Deteriorating
Criteria for
ECMO*
Start with tidal volume of 6 ml/Kg to keep plateau pressure on volume controlled
ventilation (VCV) below 30 cmH2O, decrease to 4 ml/kg if the plateau remain higher
than 30 allow permissive hypercapnia so long the pH is above 7.3
compensate by increasing respiratory rate up to 30 breath/ minute. Consider heavy
sedation and paralysis. If pressures are high or any evidence of barotrauma shift to
pressure controlled ventilation and be cautious about low tidal volume alarms for
fear of unnoticed endotracheal tube obstruction. Consider ECMO
early if eligible. Increase PEEP gradually if the patient remains hypoxic
according to FIO2 level to keep driving pressure < 15cmH2O. NEVER FORGET
PRONE POSITION.
Version 1.4 / November 2020 15
- Gastrointestinal (GI) symptoms are seen in patients with COVID-19. The preva-
lence could be as high as 50%, but most studies show ranges from 16% to 33%
- Some patients with COVID-19 have presented with isolated GI symptoms that may
precede the development of respiratory symptoms
- It is important to note that medications used for COVID-19 may be associated with
GI symptoms as well.
- Approximately 50% of patients with coronavirus disease 2019 (COVID-19) have
detectable viral RNA in the stool
- Loss of appetite or anorexia is the most commonly reported symptom.
- Diarrhea was the second most common symptom.
- Other digestive manifestations include nausea or vomiting and abdominal pain.
- Dysgeusia has also been reported, often in conjunction with anosmia.
- Currently, management of GI symptoms in patients with COVID-19 is mainly sup-
portive.
- Treatment should be individualized according to the patient’s symptoms, underly-
ing comorbidities and COVID-19–associated complications.
- Oral or intravenous hydration
- The antidiarrheal agent loperamide can be used in an initial dose of 4 mg and with
a maximum daily dose of 16 mg in patients without fever, bloody stools, or risk fac-
tors for C. dicile infection
- Antiemetic drugs can often help relieve symptoms.
Gastrointestinal Manifestations of COVID-19
Gastrointestinal Manifestations
of COVID-19
Version 1.4 / November 2020
16
Yes No
Anticoagulation in COVID-19 Patients
the patient clinically indicated
for hospitalization
Is he/she critically ill
No Yes
Prophylactic dose
Higher than standard
dose
0.5 mg/kg/m
Therapeutic dose
Consider also therapeutic
anticoagulation for
patients with high
clinical susceptibility
of VTE and those with
Severe hypoxia not
explained by the chest CT
ndings
The preferred agents
are LMWH and
Fondaparinux unless
contraindicated
In renal patients, heparin
is the preferred agent.
If the dose of LMWH
exceeds 150 twice daily
use heparin instead.
Anticoagulation in COVID-19
Patients
Version 1.4 / November 2020 17
High Velocity Nasal Insuation
(Hi-VNI)
Hi-VNI is a rst-line therapy for COVID-19 patients who are struggling to
breathe.
Hi-VNI Technology and WOB reduction: The fact that small-bore
cannulas reduce the time required to fully purge the upper airway dead space3 is
signicant because as the respiratory rate of a patient in respiratory distress
increases, the time between breaths decreases. By quickly clearing the upper
airway dead space of end-expiratory gas rich in CO2, Hi-VNI Technology helps
patients breathe directly from a fresh gas reservoir and thereby reduces their
WOB.
0
70
60
50
40
30
20
10
10 20 30 40 50 60
HVNI
HFNC
Volumetric Flow (L.min-1)
Velocity (m.sec-1)
High-Velocity Nasal Insuation
Version 1.4 / November 2020
18
Post- acute COVID syndrome
(long COVID)
Denition & incidence:
In the absence of agreed denition, it may be dened as “patients not
recovering for several weeks or months following the start of symptoms that
were suggestive of COVID, whether patients were tested or not.” It may
extend beyond 3 weeks from the onset of rst symptoms up to 3 months,
sometimes occurring after a relatively mild acute illness. If symptoms are
extending beyond 3 months, it is termed Chronic COVID.
In short, “Despite their illness being ‘over,’ they are having a lot of
trouble returning to normal life.” It occurs in around 10% of patients.
Patients can be divided into those who may have serious sequelae (such as
thromboembolic complications) and those with a non-specic clinical pic-
ture, often dominated by fatigue and breathlessness. One last group of
covid-19 patients whose acute illness required intensive care management.
Management:
Specialist referral may be indicated based on clinical nding, for example:
Respiratory: if suspected pulmonary embolism, severe pneumonia.
Cardiology: if suspected myocardi-
al infarction, pericarditis, myocarditis or new heart failure.
Neurology: if suspected neurovascular or acute neurological event.
Pulmonary rehabilitation may be indicated if patient has persistent
breathlessness.
Post-acute COVID syndrome
Version 1.4 / November 2020 19
Medical management:
Symptomatic: treating fever by paracetamol & NSAIDs
Management of co-morbidities including diabetes, hypertension, kidney
diseases & ischemic heart diseases
Listening and empathy
Consider antibiotics for secondary infection
Treat specic complication as indicated
Self-management:
Daily pulse oximetry.
Aention to general health like:
Good diet
Good sleep hygiene
Quiing smoking
Limiting alcohol
limiting caeine
Rest and relaxation.
Self-pacing and gradual increase exercise.
Set achievable targets.
Post-acute COVID syndrome
Version 1.4 / November 2020
20
Prevention and Control of Transmission
of COVID-19 inside
Health Care Facilities
Version 1.4 / November 2020 21
General Recommendations for
Prevention and Control of Transmission of COVID-19
inside Health Care Facilities
1-Daily screening of health care workers and patients before entering the
health care facility (HCF) based on clinical signs (fever, respiratory symp-
toms…….).
2- Any health care worker appears/reports to be diseased should be segregated
until proper examination/management.
3- All health care workers are required to wear surgical masks during work
hours (during existence in HCFs).
4- Minimal number of health care workers should be present at the same time
in patient’s units to keep social distancing
5- Restrict unneeded movements between departments.
6- Suspected or conrmed cases should take a separate route from other pa-
tients beginning from the facility entrance (Triage area), and all facility sec-
tions should follow the same separation.
7- Suspected or conrmed cases should be isolated in a well- ventilated isola-
tion room.
8- Standard precaution should be applied :
• Hand hygiene
• Cough etiquee.
• Personal protective equipment.
• Clean and disinfected Environmental surfaces.
• Sterile instrument and devices
• Sharp safety.
• Isolation transmied precaution.
• Safe injection practices.
General Recommendations
Version 1.4 / November 2020
22
Recommendations
According To The Type Of Procedure
1) Non Aerosol Generating Procedures (AGPs)
• Standard precautions.
• Isolation precautions taken to prevent the spread of infection by spray and
contact.
• The need to adhere to washing hands before donning personal protective
equipment and immediately upon dong.
• The necessity to adhere to donning personal protective equipment as
follows:
1- Surgical mask.
2- Protect your eyes by wearing goggles or face shield.
3- Long-sleeve medical gowns (gown) clean, non-sterile or sterile, according to
type of technique.
4- Clean or sterile gloves depending on type of technique.
5- Health care worker are not required to wear protective boots and protective
suits during routine care of cases.
6- Extended use of surgical masks, gowns, eye protectors, and face shields can
be applied while caring for COVID-19 patients in the event of a shortage of
personal 2 protective equipment for the length of the work shift (preferably
not more than six hours).
7- Always remember not to touch the eyes, mouth or nose with contaminated
hands or used gloves (wash your hands or rub using alcohol when touch any
environmental surface).
8- Always clean and disinfect surfaces .
Medical Recommendations
Version 1.4 / November 2020 23
2) Procedures that include (AGPs):
• Tracheal intubation .
• Non-invasive ventilation e.g. BiPAP, CPAP.
• Tracheotomy.
• Cardiopulmonary resuscitation.
• Manual ventilation before intubation or bronchoscopy.
• Sputum induction by using nebulizer hypertonic saline.
The health care workers must adhere to the following:
• Standard precautions.
• Perform procedures inside a well-ventilated room.
• Follow the isolation precautions taken to prevent the spread of infection
through air and contact.
• The need to adhere to washing hands before donning personal protective
equipment and immediately upon dong them.
Medical Recommendations
Version 1.4 / November 2020
24
Donning personal protective equipment as follows:
- A high-performance respiratory masks such as N95 or FFP2 or equivalent,
with the need to conduct a tightness test to ensure that there is no leakage.
- Protect your eyes by wearing goggles or face shield.
- Long-sleeve medical gowns (gown) clean, non-sterile or sterile according to
the procedure.
- Clean or sterile gloves depending on type of technique.
- The extended use of a mask, medical gown, eye goggles, or face shield
(Extended use) can be applied while caring for patients with COVID-19 in the
event of a lack of personal protective equipment and for the length of the work
shift (preferably no more than six hours).
- Care must be taken not to touch the eyes, mouth or nose with contaminated
bare hands or using gloves (wash your hands or rub using alcohol when touch
any environmental surface).
- Always clean and disinfect surfaces regularly.
Personal Recommendations
Version 1.4 / November 2020 25
Indications:
- Rapid development of consolidation paern.
- Development of lobar consolidation.
- Leukocytosis with absolute neutrophilia.
- Reappearance of fever after afebrile days.
- Increased CRP with improved other markers as ferritin.
- Procalcitonin is highly specic.
ANTIBIOTICS IN COVID-19
Low-risk inpatients:
- Combination therapy:
β-lactam (eg, ceftriaxone, or cefotaxime) plus either a macrolide
(eg, azithromycin or clarithromycin) or doxycycline.
- Monotherapy:
Respiratory uoroquinolone (eg, levooxacin or moxioxacin)
High-risk inpatients:
- β-lactam plus a macrolide or uoroquinolone is recommended.
ANTIBIOTICS IN COVID-19
Version 1.4 / November 2020
26
Treatment Protocol
Revised By:
NAME AFFILIATION
Hossam Hosny Masoud
Professor of Chest Diseases. Head of
Pulmonary Hypertension Unit, Faculty of
Medicine, Cairo University
Gehan Elassal Professor of Chest Diseases, faculty of
Medicine , Ain Shams University
Dr. Mohamed Hassany
Fellow of Infectious Diseases and Endemic
Hepatogastroentrology , National Hepatology
and Tropical Medicine Research Institute
Dr. Ahmed Shawky Professor of Chest Diseases, faculty of
Medicine , Tanta University
Dr. Mohamed Abdel Hakim Professor of Chest Diseases, faculty of
Medicine , Cairo University
Dr. Samy Zaky
Professor of Hepatogastroentrology and
Infectious Diseases, faculty of Medicine ,
Al Azhar University
Dr. Amin Abdel Baki
Consultant and Head of Hepatology ,
Gastroentrology and Infectious Diseases
Department. National Hepatology and Tropical
Medicine Research Institute
Dr. Akram Abdelbary
Professor of Critical care Medicine , Cairo
University
Chairman elect of ELSO SWAAC chapter
Dr. Ahmed Said Lecturer of Critical care Medicine , faculty of
Medicine, Cairo University
Dr. Khaled Taema Assistant Professor of Critical care Medicine ,
faculty of Medicine, Cairo University
Dr. Noha Asem
Minister”s Counselor for Research and Health
Development
Chairman of Research Ethics Commiee
MOHP, Lecturer of Public Health , Cairo
University
Version 1.4 / November 2020 27
NAME AFFILIATION
Dr. Ehab Kamal
Minister of Health Assistant for Continuous
Medical Education
General Director of Fever hospitals Directorate
Dr. Wagdy Amin Director General for Chest Diseases , MOHP
Dr. Ehab Aia General Director of IPC Department , MOHP
Dr. Hamdy Ibrahim
Infectious Diseases Consultant , National
Hepatology and Tropical Medicine Research
Institute
Dr. Alaa Eid Head of Preventive Medical Sector MOHP
Treatment Protocol
Revised By:
Version 1.4 / November 2020
28
Ministry of Health and Population
Egypt / November 2020
... This was a retrospective observational cohort study conducted on COVID-19 patients admitted to Assiut and Aswan University Hospitals as tertiary hospitals in the period between the 1st of June and the 31st of July 2020. All participants were diagnosed with COVID-19 according to the WHO and Egyptian Ministry of Health and Population (MOHP) definitions [11,12]. Diagnosis of the cases was confirmed using RT-PCR for detection of the viral RNA by TaqMan™ 2019-nCoV Control Kit v1 (Cat. ...
... 4-Clinical outcomes: the primary outcome of the study was intensive care unit admission. Patients admitted to ICU if they had one or more of the following [12]: Respiratory rate more than 30 cycles/min. Arterial partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) less than 300 mmHg or respiratory failure requires mechanical ventilation. ...
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Background Being highly infectious disease, COVID-19 exhausts most of efficient healthcare systems worldwide. Simple and rapid risk stratification methods are mandatory to recognize severe patients. This study aims to highlight the simple available laboratory biomarkers of good predictive value for COVID-19 severity. Results Three hundred fifty-one COVID-19 positive patients admitted to two University Hospitals between the 1st of June and the 31st of July 2020 were retrospectively collected and classified to severe and non-severe COVID-19 patients according to need for ICU admission. All basic laboratory biomarkers at time of admission were recorded. Of included patients, 145 (41.3%) needed ICU admission. Anemia, leukocytosis, lymphopenia, NLR, and PLR together with liver enzymes, INR, ferritin, CRP, and D-dimer were significantly higher in patients needed ICU admission ( p < 0.001). However, by applying multivariate logistic regression, only anemia, high NLR, high PLR, and high D-dimer levels showed significant risk for ICU admission with OR equal 3.6 (95% CI 1.8–7.0), 9.0 (95% CI 3.6–22.6), 3.0 (95% CI 1.3–7.1), and 2.5 (95% CI 1.3–4.7), respectively. Conclusion Anemia, increased neutrophil-to-lymphocyte ratio (> 8), platelet-to-lymphocyte ratio (> 192), and D-dimer level (> 0.9 mg\L) at time of admission could be simple available predictors for severe COVID-19 infection requiring ICU admission.
... Patients with refractory septic shock were excluded. Patients were treated according to the COVID 19 management protocol of the Egyptian ministry of health [10]. The study protocol was approved by the medical ethics committee in our hospital. ...
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Background and Objective Low-dose acetylsalicylic acid (ASA, aspirin) is a well-known and frequently studied drug for primary and secondary prevention of disease due to its anti-inflammatory and coagulopathic effects. COVID-19 complications are attributed to the role of thrombo-inflammation. Studies regarding the use of low-dose ASA in COVID-19 are limited. For this reason, we propose that the use of low-dose ASA may have protective effects in COVID-19–related thromboembolism and lung injury. This study was conducted to assess the efficacy of low-dose ASA compared with enoxaparin, an anticoagulant, for the prevention of thrombosis and mechanical ventilation.Methods We conducted a retrospective cohort study on COVID-19-confirmed hospitalized patients at the Mansoura University Quarantine Hospital, outpatients, and home-isolated patients from September to December 2020 in Mansoura governorate, Egypt. Binary logistic regression analysis was used to assess the effect of ASA compared with enoxaparin on thromboembolism, and mechanical ventilation needs.ResultsThis study included 225 COVID-19 patients. Use of ASA-only (81–162 mg orally daily) was significantly associated with reduced thromboembolism (OR 0.163, p = 0.020), but both low-dose ASA and enoxaparin, and enoxaparin-only (0.5 mg/kg subcutaneously (SC) daily as prophylactic dose or 1 mg/kg SC every 12 hours as therapeutic dose) were more protective (odds ratio [OR] 0.010, OR 0.071, respectively, p < 0.001). Neither ASA-only nor enoxaparin-only were associated with a reduction in mechanical ventilation needs. Concomitant use of low-dose ASA and enoxaparin was associated with reduced mechanical ventilation (OR 0.032, 95% CI 0.004–0.226, p = 0.001).Conclusions Low-dose ASA-only use may reduce the incidence of COVID-19-associated thromboembolism, but the reduction may be less than that of enoxaparin-only, and both ASA and enoxaparin. Concomitant use of ASA and enoxaparin demonstrates promising results with regard to the reduction of thrombotic events, and mechanical ventilation needs.
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