Critical Care COVID-19 Management Protocol General schema for respiratory support in patients with COVID-19

(updated 6-17-2020) TRY TO AVOID INTUBATION IF POSSIBLE

Low-Flow Nasal Cannula
Prophylaxis
■ Typically set at 1-6 Liters/Min
While there is very limited data (and none specific for COVID-19), the following “cocktail” may
have a role in the prevention/mitigation of COVID-19 disease.
■ Vitamin C 500 mg BID and Quercetin 250-500 mg BID High Flow Nasal Cannula
■ Accept permissive hypoxemia (O2 Saturation > 86%)
■ Zinc 75-100 mg/day
■ Titrate FiO2 based on patient’s saturation
■ Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 2 mg ■ Accept flow rates of 60 to 80 L/min
at night
■ Trial of inhaled Flolan (epoprostenol)
■ Vitamin D3 1000-4000 u/day Attempt proning (cooperative proning)

Deterioration
■

■ Optional: Famotidine 20-40mg/day

Recovery
Mildly Symptomatic patients (at home): Invasive Mechanical Ventilation
■ Vitamin C 500mg BID and Quercetin 250-500 mg BID ■ Target tidal volumes of ~6 cc/kg
■ Zinc 75-100 mg/day ■ Lowest driving pressure and PEEP
■ Melatonin 6-12 mg at night (the optimal dose is unknown) ■ Sedation to avoid self-extubation
Trial of inhaled Flolan
Vitamin D3 2000-4000 u/day
■
■

■ Optional: Ivermectin 150-200ug/kg (single dose)

Prone Positioning
■ Optional: ASA 81/325mg/day ■ Exact indication for prone ventilation is unclear
■ Optional: Famotidine 20-40mg/day ■ Consider in patients with PaO2/FiO2 ratio < 150
In symptomatic patients, monitoring with home pulse oximetry is recommended.
Ambulatory desaturation below 94% should prompt hospital admission
VV-ECMO
Mildly Symptomatic patients (on floor):
■ Indications remain unclear
■ Vitamin C 500 mg PO q 6 hourly and Quercetin 250-500 mg BID (if available) ■ Early discussion with ECMO center or team may be advisable
■ Zinc 75-100 mg/day
■ Melatonin 6-12 mg at night (the optimal dose is unknown)
■ Vitamin D3 2000-4000 u/day ■ Optional: Ivermectin 150-200 ug/kg (single dose)
■ Enoxaparin 60 mg daily ■ N/C 2L /min if required (max 4 L/min; consider early t/f to ICU for escalation of care).
■ Famotidine 40mg daily (20mg in renal impairment) ■ T/f EARLY to the ICU for increasing respiratory signs/symptoms and arterial
■ Methylprednisolone 40 mg q 12 hourly; increase to 80 mg q 12 if poor response desaturations.
■ Optional: Remdesivir 200mg D1 then 100mg daily for 9 days.
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Find the latest version at evms.edu/covidcare

Critical Care COVID-19 Management Protocol
(updated 6-17-2020)
Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min:
admit to ICU): 15. Escalation of respiratory support; See General Schema for Respiratory
Support in Patients with COVID-19.
Essential Treatment (dampening the STORM)
Salvage Treatments
1. Methylprednisolone 80 mg loading dose then 40 mg q 12 hourly for at
least 7 days and until transferred out of ICU. In patients with poor response,
■ Plasma exchange. Should be considered in patients with progressive
increase to 80 mg q 12 hourly. oxygenation failure despite corticosteroid therapy. Patients may require
up to 5 exchanges.
2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until
transferred out of ICU. Note caution with POC glucose testing.
■ High dose corticosteroids; 120 mg methylprednisolone q 6-8 hourly
3. Full anticoagulation: Unless contraindicated we suggest FULL
■ Siltuximab and Tocilizumab (IL-6 inhibitors)
anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c ■ Convalescent serum; the role and timing of convalescent serum are
q 12 hourly (dose adjust with Cr Cl < 30mls/min). Heparin is suggested with uncertain.
CrCl < 15 ml/min. Treatment of Macrophage Activation Syndrome (MAS)
Note: Early termination of ascorbic acid and corticosteroids will likely result in a ■ A sub-group of patients will develop MAS. A ferritin > 4400 ng/ml
rebound effect.
is considered diagnostic of MAS. Other diagnostic features include
Additional Treatment Components (the Full Monty) increasing AST/ALT and increasing CRP.
4. Melatonin 6-12 mg at night (the optimal dose is unknown). ■ Methylprednisolone 120 mg q 6-8 hourly for at least 3 days, then wean
5. Famotidine 40mg daily (20mg in renal impairment) according to Ferritin, CRP, AST/ALT. Ferritin should decrease by at least
6. Vitamin D 2000-4000 u/day 15% before weaning corticosteroids.
7. Thiamine 200mg IV q 12 hourly Monitoring:
8. Simvastatin 80 mg/day (caution drug-drug interactions) or Atorvastatin ■ On admission: PCT, CRP, IL-6, BNP, Troponins, Ferritin, Neutrophil-
80mg/day Lymphocyte ratio, D-dimer and Mg.
9. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent ■ Daily: CRP, Ferritin, D-Dimer and PCT. CRP and Ferritin track disease
hypomagnesemia (which increases the cytokine storm and prolongs Qtc). severity closely (although ferritin tends to lag behind CRP).
10. Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days ■ Thromboelastogram (TEG) in patients with high D-dimer and repeated as
indicated.
11. Optional: Remdesivir, 200 mg IV loading dose D1, followed by 100mg day IV
for 9 days ■ In patients receiving IV vitamin C, the Accu-Chek™ POC glucose monitor
will result in spuriously high blood glucose values. Therefore, a laboratory
12. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected
glucose is recommended to confirm the blood glucose levels
based on procalcitonin levels and resp. culture (no bronchoscopy).
Post ICU management
13. Maintain EUVOLEMIA
a. Enoxaparin 40-60 mg s/c daily c. Vitamin C 500 mg PO BID
14. Early norepinephrine for hypotension.
b. Methylprednisone 40 mg day, d. Melatonin 3-6 mg at night
then wean slowly

Find the latest version at evms.edu/covidcare Developed and updated by Paul Marik, MD, Chief of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA