Covid 19 Treatment Options for our HDU/ICU

Mild cases: sats > 90, < 95% at room air.

✓ Tab Azomax 500mg 1st day then 250 mg for four days.
✓ Tab ivermectin 12 mg for 2 days.
✓ Tab loprin 75 mg B.D
✓ Tab Cac1000 B.D
✓ 2 tab panadol TDS
✓ (If cough) syp pulmonol 2TSF in half cup warm water TDS
✓ Tab supravit M OD
✓ Frequent position change.
Moderate Cases: sats less than 80 at room air but >88%
with O2.
Same as above plus
✓ Inj Tanzo/meronem iv
✓ Inj solumedrol 40 mg B.D
✓ Inhaler xaltide 2 puffs 6 hrsly.
✓ Tab xarelto 10 mg OD. Or inj clexane 40I.U s/c B.D
✓ Cap risek 40 mg OD before breakfast
✓ Consider tocilizumab.. by fulfilling the criteria.
✓ Iv fluids if require.

Sever cases:
Same as above.
But mostly in iv form.
General ICU care
And follow bundles.

COVID ICU JHL

 DNR (Covid ICU)

Date:
Patient Name:______________________________________ Age/Gender:___________________

Covid Status Positive: Negative: Awaited:

COVID ICU JHL

 Receiving Notes – Anesthesia (COVID-ICU)

Date: Time: HIV/HBV/HCV Status:

Patient Name: Age/Gender:

Covid Status: PCR # :

Shifted From: With O2/Without O2 @_______L/Min
Condition at Shifting:

BP: Pulse: SpO2: RR:

GCS: Temp: BSR:
Comorbidities:

Presenting Complaint: (# of days)

Chest X-Ray:
Labs:

Hb: TLC: PLT: Lymphocytes:

PT/APTT: LFTs: RFTs: LDH:
CRP: S/Ferritin: Na+ K+:

Others:

Plan:

Signature.

COVID ICU JHL

 SOPs FOR TOCILIZUMAB IN COVID-19

JHL/AIMC Anesthesia Department Lahore.

Introduction: Tocilizumab (or Actemra) is a monoclonal antibody that binds to IL-6 receptor and inhibits IL-6
mediated cytokine storm associated with COVID-19
Mechanism of action: Tocilizumab binds to both soluble and membrane-bound IL-6 receptors and inhibits IL-6
mediated signaling. IL-6 is a pro-inflammatory cytokine that is elevated in the CRS.
INCLUSION CRITERIA
All of the following should be fulfilled
S# CRITERIA YES/NO

1 COVID-19 positive

2 Evidence of prolonged severe hypoxic respiratory failure defined as the presence of:

i. Ventilator Dependent Severe Hypoxic Respiratory failure and/OR

ii.P/F ratio < 200 despite at least 16 hours of prone ventilation

3 At least 72 hours of up trending and abnormal inflammatory markers (any 2 (two) of the
markers below):
a.CRP >100 or >50 but doubled in past 48 hours

b.LDH >250

c.Ferritin >500ng/ml

d.D-dimer > 1 mcg/mL

e.Lymphocyte count <0.6x109/L.

LYMPH COUNT = (%𝐿𝑌𝑀𝑃𝐻 × 𝑇𝐿𝐶) ÷ 100

I4 Absence of bacterial super/co-infection

5 Absence of Tb

6 Absence of fungal infection

7 Completed the first 24-hours of steroid therapy given as:

Methylprednisolone 1 mg/kg daily IV for 5 days followed by 40 mg daily x 3 days, followed by 10mg
daily x 2 day

COVID ICU JHL

The use of steroids is mandatory if tocilizumab is used:
●Methylprednisolone 1 mg/kg daily IV for 5 days followed by 40 mg daily x 3 days, followed by 10 mg dailyx 2
days

After patient receives Tocilizumab

Repeat inflammatory markers at 12-hours and 24-hours

Consider re-dosing Tocilizumab in 24 hours if

1) CRP at 24 hours does not drop 50% or greater than baseline pre-dosing CRP level
AND
2) Patient has persistent respiratory failure with no improvement in the clinical parameters for which
initial dose was given. These clinical parameters include:
a) P/F Ratio
b) Hemodynamics
c) Persistent fever

Dose Recommendations:
Proposed Dosing (after discussions with consultant, based on limited supply)
●> 30kg: 8mg/Kg IV x 1 dose (Maximum single dose is 800mg)
Dose can be repeated 8 to 12 hours after preceding dose 2 additional times for a total of 3 doses.
●< 30Kg: 12mg/Kg IV x 1 dose (Maximum single dose is 800mg)

Note Round dose to nearest vial size (80 mg)

HOW TO ADMINISTER
The required amount of Tocilizumab should be withdrawn from the vial and place in the 100 mL
microburrette. Add normal saline 0.9% to make final volume of 100 mL. To mix the solution, gently invert the
microburrette to avoid foaming. Administer by intravenous (I.V.) infusion over 60 minutes.IV line should not
be used for other drugs.
After finishing the dose, 10-15 ml Normal saline should be added in microbeurette and finish in 10-15 mins
for flush.
Donot give stat push or bolus dose.

MONITOR ECG ,HEART RATE,SpO2 AND RESPIRATORY RATE

References:
1.FDA Approves Phase III Clinical Trial of Tocilizumab for COVID-19 Pneumonia
2.Tocilizumab in COVID-19 Pneumonia (TOCIVID-19)_Clinicaltrials.gov/NCT04317092
3.Xu X et al. Effective Treatment of Severe COVID-19 Patients with Tocilizumab. Unpublished study. 2020[http://chinaxiv.org…]
4.National Health Commission & State Administration of Traditional Chinese Medicine, Diagnosis andTreatment Protocol for Novel Coronavirus Pneumonia [Trial
Version 7], March 2020

COVID ICU JHL

 CONSENT FORM For Tocilizumab
Dose : 4-8mg/kg max 800mg

Injection Administration: injection Tocilizumab 400mg I/V in 100ml N/S in 60 minutes.

Patient Name:
Age:
P/F Ratio: < 200

LDH > 250 CRP > 100 Ferritin > 500ng/ml D-Dimers >
1mcg/ml

Chest X-Ray: Bilateral Infiltrates / Bilateral haziness

Contraindications: HIV, TB, HBV, Organ Transplant, Allergy, Fungal Infection, Neutropenia.

BP PULSE SpO2 Skin

Pre Injection Vitals
During Injection Vitals
Post Injection Vitals
Time of Start of Injection:
Time of End of Injection:

Signature.

COVID ICU JHL

 Use of Convalescent plasma In Covid 19 pts
Patient name: COVID status:
Age/S:. Donor name:
Blood group:. Blood bag no.: Date:
Inclusion criteria: Yes/No Exclusion criteria Yes/No
Age > 18 years >10 days covid +ve

COVID +ve Active Bacterial infection

Pulmonary infiltrates Recent bleeding/ High risk of

bleeding
Moderate stage requiring D dimer > 5mg/L
O2 Evidence of thorombosis
NRM/HFNC/Vent
PF ratio < 200 Known Sever IgA deficiency

Critical stage: Active Fungal Infection

Resp failure
Septic shock
MODs
‫اجازت نامہ‬
‫ منتقلی بند‬، ‫ہم اپنے مریض کو پالزما منتقل کرنے کی اجازت دیتے ہیں۔ کسی بھی الرجک رد عمل کی صورت میں‬
‫ اسپتال کا عملہ یا ڈاکٹر ذمہ دار نہیں ہوں گے۔‬، ‫کردی جائے گی۔ کسی بھی پریشانی کی صورت میں‬
Sign:…………………….
Time BP PULSE SpO2 Skin
Pre transfusion Vitals
During transfusion Vitals
Post transfusion Vitals

Doctor Name:. Sign:. Date:.

COVID ICU JHL

Date: COVID-ICU
Patient Name:____________________________ Age/Gender:________________
Covid Status:_______________________ PCR # :______________
Comorbidities:_______________________________________________
H/O Drug Intake:_____________________________________________

Date Pre-injection 8 hours Past 8 hours Past After 24 hours After 3 days
Parameters 1st dose 2nd dose parameters of 1st dose
parameters parameters parameters
Days of
presentation
SpO2

Oxygen
Demand
Chest X-Ray

D-Dimers

CRP

S/Ferritin

LDH

COVID ICU JHL

 Laboratory findings covid ICU
Dates
Hb
TLC
PLT
Hematocrit
Lymphocytes
ESR
CRP
Calcitonin
Procalcotinin
LDH
D Dimers
Urea
Creatinine
Bun
Ast
Alt
Albumin
Bilirubin
Pt
Aptt
Inr
Ph
Pc02
Hco
Po2
Pf ratio
Na
K
Cl
Calcium
Magnesium
Phosphate

COVID ICU JHL