Recommendations for the treatment of coronavirus patients
In the past few days, infections with the novel coronavirus SARS-CoV-2 have risen rapidly in Germany. In the meantime, more than 3,600 people (as of March 14, 2020) have been infected with the pathogen in this country. Experts have now published recommendations on how to treat patients.
The German Society for Internal Intensive Care Medicine and Emergency Medicine (DGIIN), in collaboration with other specialist societies, has issued recommendations for doctors in intensive care units who care for patients with the disease COVID-19 caused by the SARS-CoV-2 coronavirus.
Spread of the virus is developing very dynamically
The German Society for Internal Intensive Care Medicine and Emergency Medicine (DGIIN) expects a further increase in intensive care patients as part of the COVID-19 epidemic.
There are special aspects to consider when treating these sufferers. Under the leadership of the DGIIN, experts from several specialist societies have published current recommendations for intensive care therapy for patients with COVID-19.
“The spread of the SARS-CoV-2 virus is currently developing very dynamically. We firmly believe that this will lead to a further increase in intensive care patients, ”explains Professor Dr. med. Stefan Kluge, board member of DGIIN and director of the intensive care clinic at the University Medical Center Hamburg-Eppendorf in a message.
"It is important to us to provide local clinics with recommendations on how to deal with COVID-19 patients in need of intensive medical treatment in a compact paper."
Current state of knowledge
In the recommendations, the experts provide an overview of the current state of knowledge of diagnostics, the possible clinical picture and what special attention should be paid to the protective measures for the staff.
According to the recommendations, only trained personnel should definitely have access to those affected and these personnel should be released from the care of other patients if possible.
Specific recommendations on therapeutic aspects such as medication, ventilation and adjuvant measures are also given. With regard to the exact hygiene measures and protective equipment, the experts refer to the recommendations of the Robert Koch Institute (RKI).
Consistent implementation of basic hygiene
According to the DGIIN, the current state of intensive medical knowledge mainly relates to observations from China and Italy. Information about this can be found in the specialist magazine "Intensive Care Medicine".
It is generally recommended that a multidisciplinary team of intensive care physicians, nurses, infectiologists and hospital hygienists should deal with the issue in the hospital.
Since infection is usually transmitted by infected people via droplet infection and in close contact, consistent implementation of basic hygiene (including hand hygiene) and personnel protection measures are essential.
Diagnosis using a throat swab or using PCR
According to the information, the detection of SARS-CoV-2 is carried out from a deep throat swab or from throat rinsing water using PCR. This abbreviation stands for the polymerase chain reaction.
If the test result is negative and there is urgent clinical suspicion, a second sample should be tested according to the DGIIN.
In the later course of the disease (pneumonia, acute lung failure), the throat swab can already be virus-free while there is still infectious viral load in the lower airways, so that the extraction of tracheobronchial secretion is helpful.
Clinical picture COVID-19
The disease COVID-19 manifests itself as an infection of the respiratory tract with the main symptoms fever and cough. The course is mild in 81 percent of those infected, severe in 14 percent and critically ill in five percent of the patients.
As a rule, admission to the intensive care unit leads to dyspnea (shortness of breath) with increased respiratory rate, with hypoxemia (lack of oxygen in the blood) in the foreground.
Possible forms of course are the development of acute lung failure (ARDS) and, to date, bacterial co-infection with septic shock. Other complications described include rhythm disturbances, myocardial damage and the occurrence of acute kidney failure.
The time from the onset of symptoms to admission to the intensive care unit is approximately ten days.
The recommendations also point out what doctors should consider in laboratory chemistry and imaging (X-ray or CT).
Accommodation of the patients
The patients are preferably accommodated individually in an isolation room, ideally with a lock / anteroom.
Access to the sick is only possible through staff trained for the care of COVID-19 patients, who are exempted from the care of other patients if possible.
The number of people entering the room must always be reduced to a minimum (ban on visits).
The DGIIN points out that when caring for those affected, it is essential to ensure consistent implementation of basic hygiene (including hand hygiene) and the correct use of personal protective equipment (PPE).
According to the recommendations of the RKI, personal protective equipment consists of protective gowns, disposable gloves, a close-fitting breathing mask and protective goggles.
To date, insufficient data are available for specific antiviral therapy. There are various therapy attempts with a number of substances (hydroxychloroquine, lopinavir / ritonavir, camostat, remdesivir etc.).
Under certain circumstances, after a benefit-risk assessment, use as an individual decision can be considered. According to the DGIIN, therapy attempts should, if possible, be carried out as part of “compassionate use” programs or study protocols.
The University of Liverpool has published a list of probable PK interactions with experimental therapies from COVID-19.
In ARDS, steroids should never be given routinely; administration appears to delay viral clearance and promote fungal growth. Studies in SARS and influenza showed adverse effects.
The exception is low-dose hydrocortisone therapy for septic shock without response to fluid and vasopressor therapy for more than an hour.
Basically, at least two blood culture sets (both aerobic and anaerobic) should be taken at the beginning of treatment in the intensive care unit and if the patient worsens over the course of time.
In patients with suspected co-infection, calculated antibiotic therapy should be initiated at an early stage. Prophylactic antibiotics are not recommended.
In addition, the DGIIN explains in the recommendations which measures should be taken into account for acute hypoxemic respiratory insufficiency and for intubation and invasive ventilation. (ad)
Author and source information
This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
- German Society for Internal Intensive Care Medicine and Emergency Medicine (DGIIN): Intensive care physicians publish recommendations for intensive care therapy of COVID-19 patients, (accessed: March 14, 2020), German Society for Internal Intensive Care Medicine and Emergency Medicine (DGIIN)
- Stefan Kluge, Uwe Janssens, Tobias Welte, Steffen Weber-Carstens, Gernot Marx & Christian Karagiannidis: Recommendations for intensive medical therapy for patients with COVID-19; in: Medical Clinic - Intensive Care Medicine and Emergency Medicine, (published: 12.03.2020), Medical Clinic - Intensive Care Medicine and Emergency Medicine
- Robert Koch Institute (RKI): Novel Corona Virus in Germany, (accessed: March 14, 2020), Robert Koch Institute (RKI)
- Jianfeng Xie, Zhaohui Tong, Xiangdong Guan, Bin Du, Haibo Qiu & Arthur S. Slutsky: Critical care crisis and some recommendations during the COVID-19 epidemic in China; in: Intensive Care Medicine, (published: 02.03.2020), Intensive Care Medicine
- University of Liverpool: COVID-19 Drug Interactions, (accessed: March 14, 2020), University of Liverpool