Marik Covid Protocol Summary

Critical Care COVID-19 Management Protocol General schema for respiratory support in patients with COVID-19
Please refer to the full protocol for optional treatments and explanations. TRY TO AVOID INTUBATION IF POSSIBLE
(updated 10-29-2020)
Low-Flow Nasal Cannula
Prophylaxis ■ Typically set at 1-6 Liters/Min
■ Vitamin C 500 mg BID and Quercetin 250 mg daily
B complex vitamins
High Flow Nasal Cannula
■
■ Zinc 30-50 mg/day ■ Accept permissive hypoxemia (O2 Saturation > 86%)
■ Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 2 mg ■ Titrate FiO2 based on patient’s saturation
at night
■ Accept flow rates of 60 to 80 L/min
■ Vitamin D3 1000-3000 u/day
■ Trial of inhaled Flolan (epoprostenol)
■ Ivermectin for postexposure prophylaxis and weekly prophylaxis in high risk groups
(150-200 ug/kg) ■ Attempt proning (cooperative proning)
Deterioration
Mildly Symptomatic patients (at home):
Invasive Mechanical Ventilation
Recovery
■ Ivermectin 150-200 ug/kg daily for two doses
■ Target tidal volumes of ~6 cc/kg
■ Vitamin C 500mg BID and Quercetin 250-500 mg BID
■ Lowest driving pressure and PEEP
■ Vitamin D3 2000 - 4000 u/day
■ Sedation to avoid self-extubation
■ B Complex vitamins
■ Trial of inhaled Flolan
■ Zinc 75-100 mg/day
■ Melatonin 6-10 mg at night (the optimal dose is unknown)
■ ASA aspirin 81-325 mg/day (unless contraindicated)
Prone Positioning
■ Exact indication for prone ventilation is unclear
In symptomatic patients, monitoring with home pulse oximetry is recommended.
Ambulatory desaturation below 94% should prompt hospital admission
■ Consider in patients with PaO2/FiO2 ratio < 150
Mildly Symptomatic patients (on floor):

SALVAGE THERAPIES
■ Ivermectin 150-200 ug/kg daily for two doses
■ High dose corticosteroids; 120 -250 mg
■ Vitamin C 500 mg PO q 6 hourly and Quercetin 250-500 mg BID (if available) methylprednisolone q 6-8 hourly
■ Vitamin D3 20 000 – 60 000 iu single oral dose. Calcifediol 200 -500 μg is an alternative. ■ Plasma exchange
Then 20 000 iu D3 (or 200 μg calcifediol) weekly until discharged from hospital.
■ “Half-dose” rTPA
■ B complex vitamins
■ Zinc 75-100 mg/day
■ Melatonin 10 mg at night (the optimal dose is unknown) ■ Methylprednisolone 40 mg q 12 hourly; increase to 80 mg q 12 if poor response
■ Enoxaparin 60 mg daily ■ T/f EARLY to the ICU for increasing respiratory signs/symptoms and arterial
desaturations.
Find the latest version at evms.edu/covidcare continued on next page

Critical Care COVID-19 Management Protocol
(updated 10-29-2020)
Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: Salvage Treatments

admit to ICU): ■ Plasma exchange. Should be considered in patients with progressive
Essential Treatment (dampening the STORM) oxygenation failure despite corticosteroid therapy. Patients may require up
to 5 exchanges.
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, increase to 80-125 ■ High dose corticosteroids; Bolus 250- 500mg/ day methylprednisolone
mg q 12 hourly. ■ Half-dose rTPA
2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until ■ ECMO
transferred out of ICU. Note caution with POC glucose testing. Monitoring:
3. Full anticoagulation: Unless contraindicated we suggest FULL ■ On admission: PCT, CRP, BNP, Troponins, Ferritin, Neutrophil-Lymphocyte
anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c ratio, D-dimer and Mg.
q 12 hourly (dose adjust with Cr Cl < 30mls/min). Heparin is suggested with ■ Daily: CRP, Ferritin, D-Dimer and PCT. CRP and Ferritin track disease severity
CrCl < 15 ml/min. closely (although ferritin tends to lag behind CRP).
Note: Early termination of ascorbic acid and corticosteroids will likely result in a ■ In patients receiving IV vitamin C, the Accu-Chek™ POC glucose monitor
rebound effect.
will result in spuriously high blood glucose values. Therefore, a laboratory
Additional Treatment Components (the Full Monty) glucose is recommended to confirm the blood glucose levels
4. Ivermectin 150-200 ug/kg daily for two doses Post ICU management
5. Vitamin D3 20 000 – 60 000 iu single oral dose. Calcifediol 200 -500 μg ■ Enoxaparin 40-60 mg s/c daily
is an alternative. Then 20 000 iu D3 (or 200 μg calcifediol) weekly until ■ Methylprednisone 40 mg day, then wean slowly
discharged from hospital. ■ Vitamin C 500 mg PO BID
6. Thiamine 200 mg IV q 12 hourly ■ Melatonin 3-6 mg at night
7. B complex vitamins
Post hospital discharge
8. Zinc 75-100 mg/day
1. Consider extended DVT prophylaxis in high risk patients.
9. Melatonin 10 mg at night (the optimal dose is unknown).
2. Consider tapering course of corticosteroids (guided by CRP)
10. Atorvastatin 80mg/day 3. Omega-3 fatty acids
11. Escalation of respiratory support; See General Schema for Respiratory 4. Atorvastatin 40mg daily
Support in Patients with COVID-19.
5. Melatonin
6. Multivitamins including B complex and Vitamin D
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

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

Mildly Symptomatic patients (on floor):

Find the latest version at evms.edu/covidcare continued on next page

Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: Salvage Treatments

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