COVID-19 disease severity
Mild disease Symptomatic patients (fever, cough, fatigue, anorexia,
shortness of breath, myalgias, sore throat, nasal congestion,
headache, diarrhoea, nausea and vomiting, Loss of smell
(anosmia) or loss of taste) without evidence of viral
pneumonia or hypoxia.
Moderate Pneumonia clinical signs of pneumonia (fever, cough, dyspnoea,
disease tachypnea) but no signs of severe pneumonia, (e.g. SpO2 ≥
90% on room air, and respiratory rate < 30 breaths/min)
Severe disease Severe clinical signs of pneumonia (fever, cough, dyspnoea,
pneumonia tachypnea) plus one of the following: respiratory rate > 30
breaths/min; severe respiratory distress; or SpO2 < 90% on
room air
Critical disease Acute Onset: within 1 week of a known clinical insult (i.e.
respiratory pneumonia) or new or worsening respiratory symptoms.
distress Chest imaging: (radiograph, CT scan, or lung ultrasound):
syndrome bilateral opacities, not fully explained by volume overload,
(ARDS) lobar or lung collapse, or nodules.
Origin of pulmonary infiltrates: respiratory failure not
fully explained by cardiac failure or fluid overload. Need
objective assessment (e.g. echocardiography) to exclude
hydrostatic cause of infiltrates/oedema if no risk factor
present.
Oxygenation impairment:
• Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with
PEEP or CPAP ≥ 5 cmH2O).
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg
(with PEEP ≥ 5 cmH2O).
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5
cmH2O).
Sepsis acute life-threatening organ dysfunction (Signs of organ
dysfunction include: altered mental status, tachypnea, low
oxygen saturation, reduced urine output , tachycardia, weak
pulse, cold extremities or hypotension, skin mottling,
laboratory evidence of coagulopathy, thrombocytopenia,
acidosis, high lactate, or hyperbilirubinemia).
Septic shock persistent hypotension despite volume resuscitation,
requiring vasopressors to maintain MAP ≥ 65 mmHg and
serum lactate level > 2 mmol/L.
Risk factors for severe disease Age more than 60 years.
Comorbidities: diabetes, hypertension,
cardiac disease, chronic lung disease,
cerebrovascular disease, chronic kidney
disease, immunosuppression and cancer
have been associated with higher
mortality.
Smoking.
Treatment Algorithm
Asymptomatic No treatment is
patients recommended
Symptomatic
patients
Moderate
Mild disease Severe disease Critical disease
disease
1. Symptomatic 1. Dexamethasone 1. Dexamethasone
Symptomatic treatment
treatment 2. Antibiotics if 2. Antibiotics If
2. Antibiotics if evidence of evidence of
evidence of bacterial infection bacterial infection
bacterial 3. Remdesivir
infection 3. Remdesivir
4. Tocilizumab (if 4. Tocilizumab (if
3. consider evidence of
anticoagulation evidence of
cytokine storm & cytokine storm &
4. Favipiravir no C.I.) no C.I.)
5. Convalescent 5. Anticoagulation
plasma
6. O2 therapy
6. O2 therapy
7. consider
7. Anticoagulation Convalescent
plasma
8. I.V. fluid &
vasopressors if
septic shock
Markers of cytokine storm:
1. Ferritin > 1000ng/ml
2. CRP > 125 mg/dl
3. D- dimer > 1000 ng/ml
4. LDH > 300 U/L
5. Absolute Lymphocyte count < 0.8 * 109/L
O2 therapy:
Target SpO2: in stable patient > 90% in non-pregnant adults
≥ 92–95% in pregnant women
during resuscitation ≥ 94%
Oxygen delivery devices:
o nasal cannula for rates up to 5 L/min
o Venturi mask for flow rates 6–10 L/min
o face mask with reservoir bag for flow rates 10–15 L/min
o CPAP (or BiPAP for more complex respiratory disease e.g. COPD):
titrate up as tolerated ( in severe hypoxemia may target 15cm H2O)
o Awake prone position plus CPAP (or BiPAP)
o Invasive mechanical ventilation: target tidal volume 4–8 ml/kg,
plateau pressure < 30 cmH2O
o ECMO
Drug consideration:
Dexamethasone: 6 mg Daily for 10 days I.V.
Monitor blood sugar
Remdesivir:
Dosage (weight 40 kg or more)
Requires mechanical ventilation and/or ECMO
o Day 1 loading dose: 200 mg IV infused over 30-120 min, then
o Days 2-10 maintenance dose: 100 mg IV daily
Does not require mechanical ventilation and/or ECMO
o Day 1 loading dose: 200 mg IV infused over 30-120 min, then
o Days 2-5 maintenance dose: 100 mg IV daily
o If clinical improvement not demonstrated, treatment may be extended
for up to 5 additional days (ie, up to 10 days total)
Favipiravir:
Loading dose: 1600 mg/dose twice on day 1
Maintainance: 600 mg twice daily on day 2-7 for moderate disease ( up to 10
days for severe disease)
Convalescent plasma:
2 units of Convalescent plasma. Each unit of plasma (200 -250 ml) will be given
over 2 h with an interval of 1 h between the two units.
Tocilizumab:
o dose: 8 mg per kg Alone or in combination with corticosteroids.
o dilute to 100 mL in 0.9% or 0.45% NaCl for intravenous infusion over
1 hour,
o Doses exceeding 800 mg per infusion are not recommended
o If no clinical improvement occurs after the first dose, up to 3
additional doses of ACTEMRA may be administered. The interval
between consecutive doses should be at least 8 hours.
Contraindications:
❖ Active TB
❖ AST / ALT values higher than 5 times the normal levels.
❖ Neutrophil value lower than 500 cells / mm3
❖ Platelets value lower than 50,000 cells /mm3
❖ Complicated diverticulitis or intestinal perforation
❖ Skin infection in progress (e.g. dermohypodermatitis not controlled by
antibiotic therapy)
❖ Immunosuppressive anti-rejection therapy
❖ Confirmed systemic bacterial & or fungal infection (i.e. Bacteremia with
pathogenic bacteria, fungemia)
Laboratory monitoring—recommended due to potential consequences of
treatment-related changes in neutrophils, platelets, lipids, and liver function tests.
Anticoagulation:
1. If patient indicated for anticoagulation (e.g. Acute MI, acute ischemic
stroke, PE, DVT, arterial thrombosis with threatened ischemia) give full
dose anticoagulant.
2. If already taking anticoagulant (e.g. AF, VTE) continue anticoagulant ( may
switch to short acting parenteral agents in acutely ill or hospitalized patient).
3. If hospitalized patient with mild disease with high risk( prior VTE, recent
surgery or trauma, immobility, obesity), moderate disease, Severe disease or
critical disease give anticoagulant according to D-dimer:
<2000 give enoxaparin 4000 I.U. once daily or UFH 5000 I.U. twice
daily
>2000 give enoxaparin 4000 I.U. twice daily or UFH 8 I.U./kg/hr
4. If CrCl <15 ml/min or ESRD switch to UFH.
5. Hold anticoagulation if PLT count <50000, INR > 1.5 or high risk of
bleeding.
NOTES:
In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid
(normal saline and Ringer’s lactate) as rapid bolus in first 15–30 minutes.
Administer vasopressors (i.e. norepinephrine, epinephrine, vasopressin and
dopamine) when shock persists during or after fluid resuscitation The initial
blood pressure target is MAP ≥ 65 mmHg.
References
1. WHO interim guidance 27 may 2020.
2. https://wfsj-briefing.org/external/the-internet-book-of-critical-care-covid-
19/view/
3. The RECOVERY Trial is registered at ISRCTN50189673 ,EU Clinical
Trials Register: EudraCT 2020-001113-21 Clinical Trials.gov:
NCT04381936
4. US Food and Drug Administration. ACTEMRA (Tocilizumab) Injection, for
Intravenous or Subcutaneous Use. US Food and Drug Administration; 2017.
5. https://www.covid19treatmentguidelines.nih.gov/antiviral-therapy/
6. https://www.uptodate.com/contents/image?imageKey=HEME
%2F128045&topicKey=ID%2F127429&source=see_link
7. Protocol of MOH of Iraq.
