Treatment plan
(A) antiviral treatment
You can try hydroxychloroquine sulfate or chloroquine phosphate, or Abidol for oral
administration, interferon nebulization and inhalation, interferon κ is preferred, and interferon α
recommended by the national scheme can also be applied. It is not recommended to use 3 or
more antivirals at the same time. The viral nucleic acid should be stopped in time after it becomes
negative. The efficacy of all antiviral drugs remains to be evaluated in further clinical studies.
For patients with severe and critical viral nucleic acid positives, recovery patients can be tested for
recovery plasma. For detailed operation and management of adverse reactions, please refer to the
"Clinical Treatment Program for Recovery of New Coronary Pneumonia Patients During Recovery
Period" (trial version 1). Infusion within 14 days of the onset may be more effective. If the viral
nucleic acid is continuously detected at the later stage of the disease, the recovery period of
plasma treatment can also be tried.
(Two) treatment of light and ordinary patients
Supportive treatment needs to be strengthened to ensure sufficient heat; pay attention to water
and electrolyte balance to maintain internal environment stability; closely monitor patient vital
signs and finger oxygen saturation. Give effective oxygen therapy in time. Antibacterials and
glucocorticoids are not used in principle. The patient's condition needs to be closely monitored. If
the disease progresses significantly and there is a risk of turning into severe, it is recommended to
take comprehensive measures to prevent the disease from progressing to severe. Low-dose shortcourse
glucocorticoids can be used with caution (see the application section of glucocorticoids for
specific protocols). ). Heparin anticoagulation and high-dose vitamin C are recommended. Lowmolecular-
weight heparin 1 to 2 per day, continued until the patient's D-dimer level returned to
normal. Once fibrinogen degradation product (FDP) ≥10 μg / mL and / or D-dimer ≥5 μg / mL,
switch to unfractionated heparin. Vitamin C is administered at a dose of 50 to 100 mg / kg per day,
and the continuous use time is aimed at a significant improvement in the oxygenation index. If
lung lesions progress, it is recommended to apply a large-dose broad-spectrum protease inhibitor,
ulinastatin, at 600 to 1 million units / day until the pulmonary imaging examination improves. In
the event of a "cytokine storm", intermittent short veno-venuous hemofiltration (ISVVH) is
recommended.
(III) Organ function supportive treatment for severe and critically ill patients
1. Protection and maintenance of circulatory function: implement the principle of early active
controlled fluid replacement. It is recommended to evaluate the effective volume and initiate fluid
therapy as soon as possible after admission. Severe patients can choose intravenous or
transcolonic fluid resuscitation depending on the conditions. The preferred supplement is lactated
Ringer's solution. Regarding vasoactive drugs, noradrenaline and dopamine are recommended to
maintain vascular tone and increase cardiac output. For patients with shock, norepinephrine is the
first choice. It is recommended to start low-dose vasoactive drugs at the same time as fluid
resuscitation to maintain circulation stability and avoid excessive fluid infusion. Cardioprotective
drugs are recommended for severe and critically ill patients, and sedative drugs that inhibit the
heart are avoided as much as possible. For patients with sinus bradycardia, isoprenaline can be
used. For patients with sinus rhythm, a heart rate of <50 beats / min and hemodynamic instability,
intravenous pumping of low-dose isoproterenol or dopamine is recommended to maintain the
heart rate at about 80 beats / min.
2. Reduce pulmonary interstitial inflammation: 2019-nCoV leads to severe pulmonary interstitial
lesions that can cause pulmonary function deterioration. It is recommended to use a large dose of
a broad-spectrum protease inhibitor ulinastatin.
3. Protection of renal function: Reasonable anticoagulant therapy and appropriate fluid therapy
are recommended as soon as possible. See chapter "Cytokine storm" for prevention, protection
and maintenance of circulatory function.
4. Protection of intestinal function: Prebiotics can be used to improve the intestinal microecology
of patients. Use raw rhubarb (15-20 g plus 150 ml warm boiling water) or Dachengqi decoction for
oral administration or enema.
5. Nutritional support: parenteral nutrition is preferred, via nasal feeding or via jejunum. The
whole protein nutrient preparation is preferred, and the energy is 25 to 35 kcal / kg (1 kcal = 4.184
kJ) per day.
6. Prevention and treatment of cytokine storm: It is recommended to use large doses of vitamin C
and unfractionated heparin. Large doses of vitamin C are injected intravenously at a dose of 100 to
200 mg / kg per day. The duration of continuous use is to significantly improve the oxygenation
index. The use of large Dose of the broad-spectrum protease inhibitor ulinastatin, given 1.6 million
units, once every 8 h, under mechanical ventilation, when the oxygenation index> 300 mmHg can
be reduced to 1 million units / d. Anticoagulation can be taken The treatment protects endothelial
cells and reduces the release of cytokines. When FDP ≥ 10 μg / mL and / or D-dimer ≥ 5 μg / mL,
heparin (3-15 IU / kg per hour) is given anticoagulation. Heparin is used for the first time. The
patient's coagulation function and platelets must be re-examined 4 h later. ISVVH is used for 6 to
10 h every day.
7. Sedation and artificial hibernation: Patients undergoing mechanical ventilation or receiving
ECMO need to be sedated on the basis of analgesia. For patients with severe man-machine
confrontation during the establishment of artificial airways, short-term application of low-dose
muscle relaxants is recommended. Hibernation therapy is recommended for severe patients with
oxygenation index <200 mmHg. Artificial hibernation therapy can reduce the body's metabolism
and oxygen consumption, and at the same time dilate the pulmonary blood vessels to significantly
improve oxygenation. It is recommended to use continuous intravenous bolus medication, and the
patient's blood pressure should be closely monitored. Use opioids and dexmedetomidine with
caution. Because severely ill patients often have elevated IL-6 levels, which can easily lead to
bloating, opioids should be avoided; 2019-nCoV can still inhibit sinus node function and cause
sinus bradycardia, so it should be used with caution on the heart. Inhibitory sedatives. In order to
prevent the occurrence and exacerbation of lung infections, and to avoid prolonged excessive
sedation, try to withdraw muscle relaxants as soon as possible. It is recommended to monitor the
depth of sedation closely.
8. Oxygen therapy and respiratory support:
① nasal cannula or mask oxygen therapy, SaO2 ≤93% under resting air condition, or SaO2 <90%
after activity, or oxygenation index (PaO2 / FiO2) 200-300 mmHg; With or without respiratory
distress; continuous oxygen therapy is recommended.
② High flow oxygen through the nose High-flow nasal cannula oxygen therapy (HFNC), receiving
nasal cannula or mask oxygen therapy for 1 to 2 hours, oxygenation fails to meet the treatment
requirements, and there is no improvement in respiratory distress; Increased distress; or
oxygenation index of 150-200 mmHg; HFNC is recommended.
③ Noninvasive positive pressure ventilation (NPPV), receiving 1 to 2 h of HFNC oxygenation does
not achieve the treatment effect, and there is no improvement in respiratory distress; or
hypoxemia and / or exacerbation of respiratory distress during treatment; or When the
oxygenation index is 150 ～ 200 mmHg; NPPV can be selected.
④ Invasive mechanical ventilation, HFNC or NPPV treatment does not meet the treatment
requirements for 1 to 2 hours of oxygenation, and respiratory distress does not improve; or
hypoxemia and / or exacerbation of respiratory distress during treatment; or oxygenation index
<150 mmHg; invasive ventilation should be considered. Protective ventilation strategies with a
small tidal volume (4-8 mL / kg ideal body mass) as the core are preferred.
9. Implementation of ECMO: Those who meet one of the following conditions may consider
implementing ECMO.
① PaO2 / FiO2 <50 mmHg for more than 1 h;
② PaO2 / FiO2 <80 mmHg for more than 2 h;
③ Arterial blood pH <7.25 with PaCO2> 60 mmHg for more than 6 h. #
ECMO mode is preferred for intravenous-venous ECMO.
(4) Special problems and treatment in treatment
1. Application of glucocorticoids: Use glucocorticoids with caution. Imaging showed significant
progress in pneumonia. Patients with SaO2 ≤ 93% or shortness of breath (respiratory frequency ≥
30 breaths / min) or oxygenation index ≤ 300 mmHg in the state of no oxygen inhalation.
Glucocorticoids can be added at the risk of intubation. Patients are advised to withdraw promptly
from glucocorticoid use when intubation or ECMO support can maintain effective blood oxygen
concentrations. For non-severe patients using methylprednisolone, the recommended dose is
controlled at 20 to 40 mg / d, severe patients are controlled at 40 to 80 mg / d, and the course of
treatment is generally 3 to 6 days. Can be increased or decreased according to the body weight.
2. Use of immunoregulatory drugs: Subcutaneous injection of thymosin 2 to 3 times per week has
certain effects on improving patients' immune function, preventing the disease from becoming
worse, and shortening the time of detoxification. Due to the lack of specific antibodies, high-dose
intravenous immunoglobulin therapy is currently not supported. However, some patients have low
levels of lymphocytes and the risk of co-infection with other viruses. Human immunoglobulin can
be infused intravenously at 10 g / d for 3 to 5 days.
3. Accurate diagnosis and treatment of combined bacterial and fungal infections: clinical
microbiological monitoring of all severe and critically ill patients. The sputum and urine of the
patients are kept daily for culture, and the patients with high fever should be cultured in time. All
patients with suspected sepsis who have indwelling vascular catheters should be sent for
peripheral venous blood culture and catheter blood culture at the same time. All patients with
suspected sepsis may consider collecting peripheral blood for molecular diagnostic tests for
etiology, including PCR-based molecular biology testing and next-generation sequencing.
Elevated procalcitonin levels have implications for the diagnosis of sepsis / septic shock. When
patients with new type of coronavirus pneumonia get worse, there is an increase in the level of
CRP, which is not specific for the diagnosis of sepsis caused by bacterial and fungal infections.
Critically ill patients with open airways are often prone to bacterial and fungal infections at a later
stage. If sepsis occurs, empirical anti-infective treatment should be given as soon as possible. For
patients with septic shock, empirical antibacterial drugs can be used in combination before
obtaining an etiological diagnosis, while covering the most common Enterobacteriaceae,
Staphylococcus and Enterococcus infections. Patients with infection after hospitalization can
choose β-lactamase inhibitor complex. If the treatment effect is not good, or the patient has
severe septic shock, it can be replaced with carbapenem drugs. If considering enterococci and
staphylococcal infections, glycopeptide drugs (vancomycin) can be added for empirical treatment.
Daptomycin can be used for bloodstream infections, and linezolid can be used for lung infections.
Attention should be paid to catheter-related infections in critically ill patients, and treatment
should be empirically covered with methicillin-resistant staphylococci. Glycopeptide drugs
(vancomycin) can be used for empirical treatment. Candida infection is also more common in
critically ill patients. Candida should be covered empirically when necessary. Echinocin drugs can
be added. With the length of hospitalization of critically ill patients, drug-resistant infections have
gradually increased. At this time, the use of antibacterial drugs must be adjusted according to drug
sensitivity tests.
4. Nosocomial infection prevention and control:
① In accordance with the Basic System for Infection Prevention and Control of Medical
Institutions (Trial) of the National Health and Health Commission in 2019, actively implement
evidence-based infection prevention and control clustering intervention strategies to effectively
prevent ventilator-related pneumonia and Multidrug-resistant bacteria and fungal infections such
as catheter-related bloodstream infections, catheter-related urinary tract infections, carbapenemresistant
gram-negative bacilli.
② Strictly follow the National Health and Health Commission's "Technical Guide for the
Prevention and Control of New Coronavirus Infection in Medical Institutions (First Edition)",
"Guidelines for the Use of Common Medical Protective Products in the Prevention and Control of
Pneumonia of New Coronavirus Infection (Trial)" and "New Coronary Pneumonia" During the
epidemic period, the technical guidelines for protection of medical personnel (trial
implementation), strengthened process management, correctly selected and used personal
protective equipment such as masks, gowns, protective clothing, eye masks, protective masks,
gloves, and strict implementation of various disinfection and isolation measures. Minimize the risk
of nosocomial infections and prevent 2019-nCoV infections in hospitals by medical staff.
5. Treatment of infants and young children: Only mild symptomatic oral treatment is needed for
mild children. In addition to symptomatic oral administration for children with common type,
treatment with syndrome differentiation can be considered. If combined with bacterial infection,
antibacterial drugs can be added. Severely ill children are mainly symptomatic and supportive
treatment. Ribavirin injection was given antiviral therapy empirically at 15 mg / kg (2 times / day).
The course of treatment did not exceed 5 days.
(V) Treatment plan of integrated traditional Chinese and western medicine
The combination of traditional Chinese and western medicine for the treatment of new
coronavirus pneumonia can improve the synergistic effect. For adult patients, the condition can be
improved through TCM syndrome differentiation. For light patients, those with a syndrome of
wind-heat type are given the traditional Chinese medicine Yinqiaosan plus and minus treatment;
those with gastrointestinal symptoms and those with damp-wetting and yang-type syndrome are
given the addition and subtraction of Zhipu Xialing Decoction and Sanren Decoction. For ordinary
patients, those with syndromes of hot and evil stagnation of lungs can be treated with Chinese
medicine Ma Xing Shi Gan Decoction; those with syndromes of dampness and stagnation of lungs
can be treated with traditional Chinese medicine Da Yuan Yin, Gan Lu Fang Dan, etc., which can be
controlled to some extent Progression of the disease, reducing the occurrence of common to
severe; for anorexia, nausea, bloating, fatigue, anxiety and insomnia, the addition and subtraction
of Chinese medicine Xiao Chai Hu Tang can significantly improve symptoms. For severe patients, if
the fever persists, or even the high fever, bloating, and dry stools are closed, and those who are
heat-tolerant and the lungs are closed, give the Chinese medicine Dachengqi Decoction enema to
relieve fever or reduce fever, or use Chinese medicine. The treatment of Baihu Decoction,
Shengjiang San and Xuanbai Chengqi Decoction were added and subtracted to cut off the condition
and reduce the occurrence of heavy to critical illness. Children with light patients, when the
disease belongs to the defender, can be added or subtracted from Yinqiaosan or Xiangsusan.
Ordinary children, those with damp heat and closed lungs, are given Ma Xing Shi Gan Decoction
and Sanren Decoction; those with moderate scorching dampness and heat such as bloating and
vomiting with abdominal distension can be added or subtracted without changing Jinzhengqi San.
For severe patients with epidemic and closed lung (currently rare in the country), please refer to
adult Xuanbai Chengqi Decoction and Manna Disinfection Danjiao; if the poison is hot, the gas
can't pass, and the medicines are not good, the Rhubarb Decoction is given to enema for
emergency.
