COVID-19: general template for hypoxemic, non-intubated patients

daily examination:  focus on

• Physical exam probably doesn't add much for most patients who are mentating normally and able to report symptoms accurately.
• Do not use a stethescope (this is a fomite that poses risk of disease transmission).
• Cardiac and lung ultrasonography may be performed as indicated for changes in clinical status.
• Lung ultrasonography (not ascultation) is the preferred modality for evaluating pulmonary status.

labs

• Daily labs
  • Electrolytes, Creatinine, Magnesium, Phosphate
  • CBC with differential
• Periodic labs (q48 hr)
  • D-dimer
  • C-reactive protein
  • Ferritin, LDH
  • Troponin (B&W guidelines)
• Admission labs: all of the above plus:
  • Urine pregnancy test in reproductive-age women
  • Blood culture x2
  • Tracheal aspirate for gram stain & culture
  • Urine legionella & pneumococcal antigens)
  • Liver function tests
  • Coagulation tests including INR, PTT, fibrinogen

cardiovascular

• Target even or negative fluid balance.
  • Avoid fluid boluses (more on this here and here).
  • Avoid maintenance fluid infusions (ANZICS guidelines).
• Consider discontinuation of home antihypertensive agents (especially ACE-inhibitors or ARBs).

pulmonary

• Oxygen supplementation
  • Institutional strategies vary considerably.
  • Currently, most guidelines are recommending HFNC as a preferred modality for patients failing low-flow cannula (e.g. SSC campaign, ANZICS).  This should be instituted with close monitoring and airborne precautions.
  • The threshold for intubation should be lower than for the average patient in respiratory failure.  Early consultation with the ICU is important for patients with rising oxygen requirement.
  • The approach to respiratory support is discussed further below.
• Check portable chest X-ray only as clinically indicated.
• Target oxygen saturation for most patients is ~92-96% (excess oxygen may be harmful & drain hospital's supply)(SSC guidelines).
• Avoid nebulized bronchodilators
  • Only use bronchodilators if truly indicated.
  • Instead of nebulizers, use a metered dose inhaler (4-8 puffs may be roughly equivalent to one nebulizer treatment).

renal

• Avoid nephrotoxins (especially NSAIDs).
• Aggressive repletion of K and Mg in patients on QT-prolonging medications (e.g. chloroquine, hydroxychloroquine).

infectious diseases

• Initially most patients will be on empiric antibiotics for bacterial pneumonia (e.g. azithromycin plus ceftriaxone).
• Consider anti-viral therapy if available (e.g. hydroxychloroquine or remdesivir).
• Follow microbiologic studies.

heme

• DVT prophylaxis (continue unless platelets <30, as COVID-19 may cause a pro-coagulable form of DIC despite low platelet count)(B&W guidelines).
• Conservative transfusion strategy (generally avoid transfusion unless HgB <7 mg/dL, or <8 mg/dL with active myocardial ischemia).  Consider diuretic with transfusion to achieve even fluid balance.

neurology

• May use acetaminophen 1 gram enterally q6hr for antipyretic and analgesic effects.
• Melatonin 5 mg QHS for sleep (Zhang et al 2020, Zhou et al. 2020).
• Avoid NSAIDs (may cause nephrotoxicity and possibly up-regulate the ACE2 receptor, thereby worsening infection)

source: emcrit.org