The emergence in December 2019 of diseases caused by the new coronavirus (2019-nCoV) posed difficult challenges for healthcare professionals and doctors in relation to the rapid diagnosis and clinical management of patients with this infection.
Currently, information on the epidemiology, clinical features, prevention and treatment of this disease is limited.
Pneumonia is known to be the most common clinical manifestation of a new variant of coronavirus infection and a significant number of patients have developed the development of acute respiratory distress syndrome (ARDS).
The recommendations presented in the document are largely based on evidence published by WHO experts, the Chinese and American and European centers for the control of morbidity in materials for the treatment and prevention of this infection.
The methodical recommendations are intended for medical treatment doctors and prophylactic institutions with an infectious profile, as well as for resuscitation doctors of the intensive care units of an infectious disease hospital.
1. Etiology and pathogenesis
Coronaviridae (Coronaviridae) is a large family of RNA viruses that can infect humans and certain animals. In humans, coronaviruses can cause a variety of diseases, from mild forms of acute respiratory infection to severe acute respiratory syndrome (SARS).
Currently, four coronaviruses (HCoV-229E, -OC43, -NL63 and -HKU1) are known to circulate among the population, which are present throughout the year in the structure of acute respiratory viral infections and, as a rule, cause damage to the respiratory tract upper of mild and moderate severity.
According to the results of the serological and phylogenetic analysis, coronaviruses are divided into three genera: Alphacoronavirus, Betacoronavirus and Gammacoronavirus.
The natural hosts of most coronaviruses currently known are mammals.
Until 2002, coronaviruses were considered agents that caused mild upper respiratory tract diseases (with extremely rare lethal outcomes). In late 2002, coronavirus (SARS-CoV), a causative agent of SARS that caused SARS in humans, appeared.
This virus belongs to the Betacoronavirus genus.
The natural reservoir of SARS-CoV is made up of bats, intermediate hosts are camels and Himalayan civet. In total, over 8,000 cases were recorded during the outbreak period in 37 countries, including 774 fatal. No new cases of SARS associated with SARS-CoV have been reported since 2004.
In 2012 the world faced the new coronavirus MERS (MERS-CoV), a causative agent of the Middle East respiratory syndrome, also belonging to the Betacoronavirus genus.
Camels are the main natural reservoir of MERS-CoV coronaviruses.
Since 2012, 2,494 cases of coronavirus infection caused by the MERS-CoV virus have been recorded, 858 of which were fatal.
All cases are geographically associated with the Arabian Peninsula (82% of cases are reported in Saudi Arabia). Currently, MERS-CoV continues to circulate and causes new disease cases.
The new coronavirus 2019-nCoV (a temporary name assigned by the World Health Organization on 12 January 2020) is a virus containing single-stranded RNA, belongs to the Coronaviridae family, belongs to the Beta-CoV B line.
The virus is assigned to pathogenetic group II, like some other representatives of this family (SARS-CoV virus, MERS-CoV virus).
Coronavirus 2019-nCoV is suspected to be a recombinant virus between bat coronavirus and a coronavirus of unknown origin. The 2019-nCoV genetic sequence is similar to the SARS-CoV sequence by at least 70%.
The pathogenesis of a new coronavirus infection is not well understood . Data on the duration and intensity of immunity compared to 2019-nCoV are not currently available. Immunity for infections caused by other members of the coronavirus family is not persistent and a new infection is possible.
2. Epidemiological characteristic
Currently, data on the epidemiological profile of the new 2019-nCoV coronavirus infection are limited.
The virus is most prevalent in China, where there is a spread in all the provinces with an epicenter in Wuhan, in the province of Hubei. Import cases have been reported in over 20 countries in Asia, North America and Europe.
The initial source of infection has not been established. The first cases of illness could be associated with a visit to the Wuhan fish market (PRC), which sold poultry, snakes, bats and other animals.
Currently, the main source of infection is a sick person, including those in the incubation period of the disease.
Routes of transmission: air (to cough, sneeze, speak), dust suspended in the air and contact.
Transmission factors: air, food and household items contaminated with 2019-nCoV.
As of January 23, 2020, 15 confirmed cases of illness among doctors who contacted 2019-nCoV patients were detected in one of the Wuhan hospitals.
Standard case definition for a new coronavirus 2019-nCoV infection
Suspected infection 2019-nCoV, case:
– the presence of clinical manifestations of acute respiratory infection, bronchitis, pneumonia in combination with the following epidemiological data:
– a visit in the last 14 days before the onset of epidemiologically unfavorable symptoms for the 2019-nCoV countries and regions (mainly Wuhan, China);
– the presence of close contacts in the last 14 days with people under surveillance for infection caused by the new coronavirus 2019-nCoV, which subsequently became ill;
– the presence of close contacts in the last 14 days with people who have been diagnosed with the 2019-nCoV diagnosis in the laboratory.
Probable case of infection 2019-nCoV:
– the presence of clinical manifestations of severe pneumonia, ARDS, sepsis in combination with data from an epidemiological history (see above).
Confirmed case of infection 2019-nCoV:
1. The presence of clinical manifestations of acute respiratory infection, bronchitis, pneumonia in combination with an epidemiological history (see above).
2. Positive laboratory test results for the presence of RNA 2019-nCoV by polymerase chain reaction (PCR).
3. Diagnosis of coronavirus infection
3.1. Algorithm for examining a patient with suspected new coronavirus infection caused by 2019-NCOV
If there are factors that indicate a suspected case of coronavirus infection caused by the 2019-nCov virus, a clinical examination is performed for patients, regardless of the type of medical care, to determine the severity of the condition.
Diagnosis is established on the basis of a clinical examination, data from an epidemiological history and the results of laboratory tests.
1. A detailed assessment of all complaints, medical history, epidemiological history. When collecting an epidemiological history, attention is drawn to visiting countries and regions (first of all, Wuhan, China) within 14 days before the first epidemically unfavorable symptoms for 2019-nCoV, the presence of close contacts in the last 14 days with people suspected of being infected with 2019- nCoV or people with confirmed laboratory diagnosis.
2. Physical examination, necessarily including:
– evaluation of visible mucous membranes of the upper respiratory tract,
– auscultation and percussion of the lungs,
palpation of lymph nodes,
– a study of the abdominal cavity with the determination of the size of the liver and spleen,
– thermometry
by determining the severity of the patient’s condition.
3. General laboratory diagnostics:
– general (clinical) blood test with the determination of the level of red blood cells, hematocrit, white blood cells, platelets, white blood cell count;
– biochemical analysis of blood (urea, creatinine, electrolytes, liver enzymes, bilirubin, glucose, albumin). A biochemical blood test does not provide any specific information, but anomalies detected can indicate the presence of organ dysfunction, decompensation of concomitant diseases and the development of complications, have a certain prognostic value, influence the choice of drugs and / or the dosage regimen ;
– a study of the level of C-reactive protein (CRP) in blood serum. The level of CRP is related to the severity of the course, the prevalence of inflammatory infiltration and the prognosis of pneumonia;
– Pulse oximetry with measurement (SpO2) to detect respiratory failure and assess the severity of hypoxemia. Pulse oximetry is a simple and reliable screening method that allows you to identify patients with hypoxemia who need respiratory support and evaluate their effectiveness;
– patients with acute respiratory insufficiency (ARF) (SpO2) (less than 90% according to pulse oximetry) recommended blood gas analysis at definition (PaO2), (PaCO2) pH, bicarbonate, lactate;
– patients with signs of ODN are recommended to perform a coagulogram with the determination of the prothrombin time, the international normalized ratio and the activated partial thromboplastin time.
4. Specific laboratory diagnosis:
– detection of 2019-nCoV RNA by PCR (information is presented in section 3.3 ).
5. Instrumental diagnostics:
– computed tomography of the lungs is recommended for all patients with suspected pneumonia, in the absence of the ability to perform computed tomography – a general radiography of the thoracic organs in the anterior direct and lateral projections with unknown localization of the inflammatory process, it is advisable to take a photo in the right lateral projection). Computed tomography of the lungs is a more sensitive method for diagnosing viral pneumonia. The main results in pneumonia are bilateral infiltrates in the form of “frosted glass” or consolidation, which are mainly distributed in the lower and middle areas of the lungs. When chest X-ray reveals bilateral confluent infiltrative darkening. Very often,
– Electrocardiography (ECG) in standard leads is recommended for all patients. This study does not contain any specific information, but it is now known that viral infection and pneumonia as well as the decompensation of concomitant chronic diseases increase the risk of rhythm disturbances and acute coronary syndrome, the timely detection of which significantly affects the prognosis . In addition, some changes in the ECG (e.g. prolongation of the QT interval) require attention when evaluating the cardiotoxicity of a number of antibacterial drugs.
Decide on the need for hospitalization:
a) with anamnestic data indicating the probability of infection caused by 2019-nCoV, regardless of the severity of the patient’s condition, admission to a hospital / infectious disease department with all the anti-epidemic measures observed;
b) in the absence of suspicion of an infection caused by 2019-nCoV, the decision on hospitalization depends on the severity of the condition and the likely other diagnosis.
3.2. Clinical features of coronavirus infection
The incubation period is from 2 to 14 days.
The new coronavirus infection caused by 2019-nCoV is characterized by the presence of clinical symptoms of acute respiratory viral infection (as of 31/01/2020):
– increase in body temperature (> 90%);
– cough (dry or with a small amount of sputum) in 80% of cases;
– shortness of breath (55%);
– myalgia and fatigue (44%);
– choking sensation in the chest (> 20%),
The most severe shortness of breath develops within 6-8 days from the time of infection. It was also found that myalgia (11%), confusion (9%), headache (8%), hemoptysis (5%), diarrhea (3%), nausea, vomiting, palpitations may be among the first symptoms. These symptoms in the onset of infection can be observed in the absence of fever.
Clinical options and manifestations of the 2019-nCoV infection:
1. Acute respiratory viral lung infection.
2. Pneumonia without respiratory failure.
3. Pneumonia with UNO.
4. ARDS.
5. Sepsis.
6. Septic shock (infectious-toxic).
Hypoxemia (a decrease (SpO2) of less than 88%) develops in over 30% of patients.
There are mild, moderate and severe forms of 2019-nCoV infection.
The average age of patients in Wuhan patients was around 41 years, the most severe forms developed in elderly patients (60 years or more), among the patients there were frequent concomitant diseases: diabetes mellitus (20%), high blood pressure (15%) and other cardiovascular diseases (15%).
25% of confirmed cases registered in the PRC were classified by the public health authorities of the PRC as serious (16% of serious patients, 5% in critical conditions and 4% of deaths).
In severe cases, rapidly progressing lower respiratory tract disease, pneumonia, ARF, ARDS, sepsis and septic shock are observed.
In Wuhan, almost all patients with a severe course of the disease develop progressive UNO: pneumonia is diagnosed in 100% of patients and ARDS in over 90% of patients.
3.3. Laboratory diagnosis of coronavirus infection
1. Laboratory diagnosis is performed in accordance with Rospotrebnadzor’s temporary recommendations of January 21, 2020 for laboratory diagnosis of a new coronavirus infection caused by 2019-nCoV.
2. For the laboratory diagnosis of infections caused by 2019-nCoV, the PCR method is used. The detection of 2019-nCoV RNA by PCR is performed for patients with clinical symptoms of a respiratory disease suspected of being infected with 2019-nCoV, in particular those arriving from epidemiologically disadvantaged regions immediately after the initial examination, as well as to contact people.
3. The biological materials for the study are: material obtained by taking a smear from the nose, nasopharynx and / or oropharynx, bronchial lavage, obtained by fibrobronchoscopy (bronchoalveolar lavage), (endo) tracheal, nasopharyngeal aspirate, sputum, lung biopsy or autopsy material , whole blood, serum, urine. The main type of biomaterial for laboratory research is a smear from the nasopharynx and / or oropharynx.
4. All samples obtained for laboratory research must be considered potentially infectious and, when working with them, the requirements of SP 1.3.3118-13 “Work safety with microorganisms of pathogenicity groups (danger) I- must be respected. II “. Healthcare professionals who collect or transport clinical samples in the laboratory must be trained in the safe handling of biomaterial, strictly observe safety precautions and use Personal Protective Equipment (PPE).
5. The collection of clinical material and its packaging are carried out by an employee of a medical organization trained in the requirements and rules of biological safety during work and the collection of material suspected of being infected by pathogenicity group II microorganisms, in compliance with temporary recommendations for laboratory diagnosis.
6. Samples from patients with coronavirus infection or contact persons are taken for laboratory diagnostics in accordance with the temporary recommendations for laboratory diagnostics of a new coronavirus infection caused by the 2019-nCov virus, sent to the executive authorities in health field. Specimens must be transported in accordance with the requirements of the “Procedure for registration, storage, transmission and transport of microorganisms of pathogenicity groups I-IV”.
7. The name of the ARI suspect must be indicated in the accompanying form, upon notification to the laboratory about the sample to be transported. Transportation is possible on ice.
8. Samples of biological material must be sent to the research organization or to the Center of Hygiene and Epidemiology for the laboratory diagnosis of a new coronavirus infection caused by 2019-nCoV), taking into account the convenient transportation scheme.
9. The transport of samples must be carried out in accordance with the requirements of the sanitary legislation in relation to the microorganisms of the II pathogenetic group.
10. For the differential diagnosis in all patients, PCR studies are conducted on the causative agents of respiratory infections: influenza viruses of type A and B, respiratory syncytial virus (RSV), parainfluenza viruses, rhinovirus, adenovirus, human metapneumovirus, MERS-CoV . Microbiological diagnostics (culture studies) and / or PCR diagnostics for Streptococcus pneumoniae, Haemophilus influenzaetype B, Legionella pneumophila, as well as other pathogens of bacterial respiratory tract infections of the lower respiratory tract are mandatory. For rapid diagnosis, rapid tests can be used to identify pneumococcal and legionella antigenuria.
11. When biological samples are sent from patients with suspected 2019-nCoV coronavirus infection for laboratory testing, as well as when a positive result is obtained at any stage of diagnosis, the information is immediately sent to the Department of Medical Emergency and Risk Management. health of the Ministry of Health.
4. Treatment of coronavirus infection
To date, there is no evidence of the effectiveness of using any drugs with 2019-nCoV.
As part of the provision of medical care, the patient’s condition must be monitored for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and appointment of therapy based on the patient’s condition. 2019-nCoV infected patients should receive supportive symptomatic therapy.
Treatment of diseases, conditions and complications of comorbidities is carried out in accordance with clinical recommendations, standards of medical care for these diseases and conditions, complications – these guidelines provide only the main significant features of providing medical assistance to this group of patients with comorbid diseases, conditions and complications based on the results analysis of the treatment of patients with other coronavirus infections.
4.1. Etiotropic therapy
An analysis of the literature on the clinical experience in the management of patients with SARS associated with SARS-CoV and MERS-CoV coronavirus allows us to identify several etiological drugs that were usually used in combination.
These include ribavirin, lopinavir + ritonavir and interferon preparations.
According to published data, these drugs are also used today in the treatment of patients with the 2019-nCoV infection.
The data on treatment results published today using these drugs do not allow an unequivocal conclusion on their efficacy / inefficiency, and therefore their use is allowed by the decision of the medical commission in the prescribed way if the possible benefit for the patient outweighs the risk.
The combined drug lopinavir + ritonavir is used to treat HIV infection and is a protease inhibitor of the virus.
Studies have shown that it is also capable of inhibiting coronavirus protease activity.
This drug has found its use in the treatment of MERS-CoV infection and is currently used to treat infections caused by the new 2019-nCoV coronavirus.
Currently, a randomized controlled trial on the efficacy and safety of lopinavir + ritonavir in patients with coronavirus 2019-nCov infection has been initiated in the PRC.
Interferon beta-1b has antiproliferative, antiviral and immunomodulatory activity. In current clinical trials of infection, MERS-CoV interferon beta-1b is used in combination with lopinavir.
Previous in vitro studies have shown that it exhibits maximum activity compared to other interferon variants (interferon alfa-1a, interferon alfa-1b and interferon beta-1b).
Due to the ability to stimulate the synthesis of anti-inflammatory cytokines, interferon beta-1b drugs can have a positive pathogenetic effect.
In contrast, the use of interferon alpha in severe acute respiratory infections (SARI) may be associated with the risk of developing acute respiratory distress syndrome due to the increased expression of pro-inflammatory factors.
Ribavirin is an antiviral drug that has a wide range of applications for viral etiology infections.
Ribavirin has been used in the treatment of SARS-CoV infection in China, Singapore and other countries, but its use should be treated with caution, given the potential for the drug to cause serious side effects (mainly anemia and hypoxemia). .
The combination of the above drugs can be more effective than their use in monotherapy.
The experience of using the following treatment regimens is described: three-component (ribavirin, lopinavir / ritonavir, IFN) and two-component (ribavirin, lopinavir / ritonavir; lopinavir / ritonavir, IFN; ribavirin, IFN).
The use of etiotropic drugs is guaranteed in the case of moderate to severe infection, when the expected benefit outweighs the potential risk of adverse events.
The list of drugs that can be prescribed for the etiotropic treatment of coronavirus coronavirus 2019 infection is shown in the table (Appendix 1).
According to WHO recommendations, it is possible to prescribe drugs with the alleged etiotropic efficacy of the off-label, while their use must comply with the ethical standards recommended by WHO.
Patients with clinical forms of coronavirus infection that occur with lesions of the lower respiratory tract (pneumonia) may be prescribed antimicrobial agents (amoxicillin / clavulanate, respiratory fluoroquinolones – levofloxacin, moxifloxacin, cephalosporins 3 and 4 generations, carbapene, drenezene and others) . due to a high risk of superinfection.
The choice of antibiotics and the method of administration are based on the severity of the patient’s condition, on the analysis of risk factors for meeting resistant microorganisms (presence of concomitant diseases, previous use of antibiotics, etc.)
And on the results of microbiological diagnostics.
In critically ill patients, it is advisable to start administration of one of the following antibiotics: protected aminopenicillins, ceftaroline fosamil and “respiratory” fluoroquinolones. Beta-lactam antibiotics should be prescribed in combination with intravenous macrolides.
In the absence of positive dynamics during the disease, with proven staphylococcal infection (in the case of detection of methicillin-resistant staphylococci), it is recommended to use drugs with high antistaphylococcal and anti-pneumococcal – linezolid, vancomycin activity.
4.2. Pathogenetic therapy
A sufficient amount of liquid (2.5-3.5 liters per day or more, if there are no contraindications for somatic pathology).
With severe intoxication, as well as with discomfort in the abdomen, nausea and / or vomiting, edematous syndrome that prevents the intake of liquids, enterosorbents (colloidal silicon dioxide, polymethylsiloxane polyhydrate and others) are shown.
In severely ill patients (intensive care unit), if indicated, infusion therapy is performed under mandatory monitoring of the patient’s condition, including blood pressure, lung auscultation, hematocrit (not less than 0.35 l / l) and diuresis.
Exercise caution in infusion therapy, as excessive liquid transfusion may impair oxygen saturation in the blood, especially under conditions of limited mechanical ventilation.
In order to prevent brain edema and pulmonary edema, patients are advised to carry out infusion therapy against the background of forced diuresis (lasix / furosemide 1% 2-4 ml IM or intravenous bolus).
In order to improve sputum discharge during a productive cough, mucoactive drugs (acetylcysteine, ambroxol, carbocysteine, combined drugs,
Inhalation therapy of bronchodilator (using a nebulizer) using salbutamol, fenoterol, combined drugs (ipratropium bromide + fenoterol) is recommended in the presence of obstructive bronchial syndrome.
4.3. The basic principles of symptomatic therapy
Symptomatic therapy includes:
– stop the fever (antipyretic medicines – paracetamol, ibuprofen);
– complex therapy of rhinitis and / or nasopharyngitis (moisturizing / eliminating drugs, nasal decongestants);
– complex therapy of bronchitis (mucoactive, bronchodilators and other drugs).
Antipyretic drugs are prescribed at temperatures above 38.0-38.5 ° C.
With poor tolerance to feverish syndrome, headache, increased blood pressure and severe tachycardia (especially in the presence of ischemic changes or rhythm disturbances), lower-numbered antipyretics are also used. The safest medications are ibuprofen and paracetamol.
For the topical treatment of rhinitis, pharyngitis, in case of nasal congestion and / or secretion from the nose, they begin with saline preparations for topical administration based on sea water (isotonic and for congestion – hypertonic).
In case of inefficiency, nasal decongestants are indicated. With inefficiency or severe symptoms, various solutions with an antiseptic effect can be used.
4.4. Characteristics of clinical manifestations and treatment of the disease in children
4.4.1. Characteristics of clinical manifestations
Isolated cases of the disease in children are currently described, etiologically associated with the 2019-nCoV coronavirus.
The known cases of coronavirus infection in children caused by the 2019-nCoV virus do not allow an objective assessment of the characteristics of the disease, as well as the characteristic manifestations of this clinical form of the disease at all stages of the disease.
According to reports, young people and children are less sensitive to a new type of coronavirus.
The clinical picture of coronavirus infections in children (according to the analysis of seasonal coronavirus infections caused by coronavirus) is characterized by damage to both the upper respiratory tract (nasopharyngitis) and the lower respiratory tract (bronchitis, bronchiolitis, pneumonia).
No clinical differences have been established in infection with a particular coronavirus strain. Monoinfection caused by the HCoVs virus often occurs as a mild or moderate injury to the upper respiratory tract, co-infection with other respiratory viruses (RSV, rhinovirus, bocavirus, adenovirus) may occur, which complicates the course of the disease and leads to damage to the lower parts of the respiratory tract (pneumonia, bronchiolitis).
Main complaints: fever, runny nose, sore throat.
Clinical syndromes:
– sub-febrile fever (with mild diseases) to febrile with serious and associated infections;
– catarrhal syndrome: cough, rhinorrhea, hyperemia of the posterior pharyngeal wall;
– respiratory syndrome occurs with shortness of breath, decreased oxygen saturation in the blood, tachycardia, signs of respiratory failure (perioral cyanosis, participation of auxiliary muscles in the act of breathing, retraction of compatible points of the chest); bronchitis and pneumonia develop more often when combined with other respiratory viruses (rhinovirus, RSV), they are characterized by the corresponding auscultatory and percussive manifestations;
– possible abdominal syndrome (nausea, vomiting, abdominal pain) and / or diarrhea, which often occurs in children with respiratory infections in the first 5-6 days, including infections caused by SARS-CoV and MERS-CoV.
SARS-associated coronavirus infection had a milder clinical course and positive results in children younger than 12 years of age compared to adolescents and adults.
Risk factors for serious diseases in children, regardless of the coronavirus variant:
– first age (1-4 years);
– unfavorable pre-morbid background (lung disease, Kawasaki disease);
– immunodeficiency states of different genesis (children over 5 years of age get sick more often, pneumonia is recorded 1.5 times more often);
– RSV coinfection.
The severity of the clinical manifestations of coronavirus infection varies from the absence of symptoms (asymptomatic) or mild respiratory symptoms to severe acute respiratory infections (SARI), proceeding with:
– high fever;
– a pronounced violation of health up to a violation of conscience;
– chills, sweating;
– headache and muscle pain;
– dry cough, shortness of breath, rapid and difficult breathing;
– heart palpitations.
In the early stages of the disease, vomiting, frequent loose stools (gastrointestinal syndrome) may occur.
The most common manifestation of SARI is bilateral viral pneumonia complicated by adult ARDS or pulmonary edema. It is possible to stop breathing, which requires artificial ventilation of the lungs and assistance in the conditions of the department of anesthesia and intensive care.
Adverse outcomes develop with progressive respiratory failure, the attachment of a secondary infection that occurs in the form of sepsis.
Possible complications:
– pulmonary edema;
– adult ARDS;
– acute cardiac arrest;
– acute renal failure;
– infectious toxic shock;
– hemorrhagic syndrome against the background of a decrease in blood platelets (DIC),
– multiple organ failure (dysfunction of many organs and systems).
Laboratory diagnosis of coronavirus infection in children has no characteristics.
4.4.2. Characteristics of the treatment
Therapeutic goals:
– temperature normalization;
– relief from infectious intoxication;
– elimination of a catarrhal syndrome;
– prevention and / or relief of complications.
Treatment should begin immediately after the onset of the first symptoms of the disease, characteristic of coronavirus infection, taking into account their severity and in the presence of epidemic prerequisites for suspected diagnosis of coronavirus infection.
Treatment of severe coronavirus infection with damage to the lower respiratory tract.
Indications for conversion to intensive care:
– increased cyanosis and shortness of breath at rest;
– Pulse oximetry indicators lower than 92% -94%;
– shortness of breath: children under the age of 1 year – more than 60 per minute, children under the age of 5 years – more than 40 per minute, more than 5 years – more than 30 per minute;
– the appearance of a cough with a mixture of blood in the sputum, pain or heaviness in the chest;
– the appearance of signs of hemorrhagic syndrome;
– changes in mental state, confusion or agitation, convulsions;
– repeated vomiting;
– a decrease in blood pressure and a decrease in urination;
– maintenance of high fever (more than 4-5 days) with refractory to antipyretic drugs and development of serious complications.
Drug treatment methods:
– etiotropic treatment means;
– pathogenetic means of treatment;
– means of symptomatic treatment;
Etiotropic treatment has no evidence for the treatment of children with coronavirus infection caused by the 2019-nCoV virus.
In this regard, the appointment of antiviral drugs is based on available data on their efficacy in the treatment of seasonal SARS caused by coronavirus.
The appointment of antiviral agents for children with coronavirus infection should be justified in any case by a collegiate infectious disease specialist and a pediatrician from a medical organization.
Pathogenetic treatment is recommended in the initial (febrile) period of the disease, detoxification, antioxidant therapy with severe intoxication.
For the purpose of detoxification, the use of a 5-10% dextrose solution, isotonic saline solutions and, in the most serious cases of the disease, additional colloidal solutions.
Together with dextrose, isotonic saline solutions (physiological solution) are used to stop intoxication, in addition to colloidal solutions in the most serious cases of the disease.
The introduction of excess liquid parenterally, in particular isotonic sodium chloride solution, is fraught with the danger of developing pulmonary edema and brain.
The total amount of liquid administered parenterally must be applied according to physiological needs.
For the antioxidant purpose, the introduction of a 5% solution of ascorbic acid (intravenously) and other solutions for infusion with a similar effect is recommended.
Recommended for correcting electrolyte disturbances – potassium preparations, 10% calcium gluconate, magnesium.
Symptomatic treatment: the use of antitussive, mucolytic and expectorant drugs is recommended for the development of tracheitis, bronchitis, pneumonia. The action of these drugs is intended to suppress cough or improve the elimination of sputum from the tracheobronchial tree, improving mucociliary clearance.
The use of anti-congestion agents in the development of rhinitis is recommended. The action of these drugs is intended to improve nasal breathing, relieve swelling of the nasal mucosa and improve the outflow of the contents of the sinuses.
The use of antipyretic drugs, including nonsteroidal anti-inflammatory drugs (paracetamol, ibuprofen, sodium metamizole), antispasmodic drugs (papaverine) is recommended in patients with fever.
In patients with a history of seizure syndrome or with the development of seizures against the background of the current disease, a decrease in subfebrile temperature is also shown.
In children with an antipyretic and analgesic purpose, paracetamol is used in a daily dose of 60 mg / kg, ibuprofen in a daily dose of 30 mg / kg. Metamizole sodium in a single dose of 5-10 mg / kg intramuscularly or intravenously and in children up to 3-12 months. (5-9 kg) only intramuscularly with persistent temperature rise of over 38.5 degrees. With or without effect on acetaminophen, ibuprofen. Antispasmodics in combination with analgesics are used maintaining a stable febrile temperature,
4.5. The basic principles of the treatment of emergency conditions in coronavirus infection
4.5.1. Intensive care for acute respiratory failure
Indications for conversion to intensive care (one of the criteria is sufficient)
– initial manifestations and clinical picture of rapidly progressive acute respiratory failure:
– growing and severe shortness of breath;
– cyanosis;
– BH> 30 per minute;
– SpO2 <90%;
– ADsyst blood pressure <90 mm RT. st;
– shock (marbling of the limbs, acrocyanosis, cold limbs, symptom of a delayed vascular point (> 3 sec.), Lactate more than 3 mmol / l);
– central nervous system dysfunction (Glasgow coma score less than 15 points);
– acute renal failure (urination <0.5 ml / kg / h for 1 hour or increase in the creatinine level twice compared to the normal value);
– liver dysfunction (an increase in bilirubin content greater than 20 μmol / l for 2 days or an increase in transaminase levels two or more times than normal);
– coagulopathy (platelet count <100 thousand / μl or their decrease by 50% of the highest value within 3 days).
It is necessary to guarantee a sufficient amount of liquid in the absence of contraindications and a decrease in diuresis (5-6 ml / kg / h), the total quantity of which can be increased with greater losses from the gastrointestinal tract (vomiting, loose stools). The use of enterosorbents (colloidal silicon dioxide, polymethylsiloxane polyhydrate, etc.).
In severely ill patients, if indicated, infusion therapy is performed on the basis of calculations of 5-6-8 ml / kg / h with mandatory control of urine production and assessment of the distribution of fluids.
Infusion therapy solutions:
Isotonic crystalloid preparations (electrolytic solutions) (Ringer’s solution, saline solution, crystalloid-succinate preparations based on succinic acid
Carbohydrate solutions (10% dextrose solutions)
With a decrease in the level of albumin – 10% albumin solution at 10 ml / kg / day
Infusion therapy is performed under the mandatory control of patients’ conditions, their blood pressure, evaluation of the auscultatory picture in the lungs, with the control of hematocrit and urine production (hematocrit not less than 0.35 and diuresis not less at 0.5 ml / kg / h)
For the prevention of brain edema with a decrease in urine production and fluid retention, it is advisable to prescribe furosemide 0.5-1 mg / kg bolus IM or IV.
Intensive care ODN
With the development of the first signs of ARF, oxygen therapy begins through a mask or nasal catheters. The optimal level of effectiveness of oxygen therapy is to increase oxygen saturation above 90% or the presence of an evident and persistent increase in this indicator. In this case, the lower threshold PaO2 must not be less than 55-60 mm RT. Art.
In the absence of the effect of primary respiratory therapy – oxygen therapy, it is advisable to solve the problem of the use of mechanical ventilation. When choosing mechanical ventilation, it is allowed to use non-invasive ventilation of the lungs according to the rules and techniques generally accepted as an initial tactic.
Perhaps the onset of respiratory support in patients with ARDS who use non-invasive ventilation while maintaining consciousness, patient contact, a PaO2 / FiO2 index of over 150 mmHg. Art., Stable hemodynamics (see the clinical recommendations of the PHA “The use of non-invasive ventilation”). With low efficacy and / or poor NIVL tolerance, an alternative NIVL can also be a high speed nasal flow.
Indications for non-invasive ventilation:
– tachypnea (more than 25 movements per minute for adults), does not disappear after a decrease in body temperature;
– PaO2 <60 mm Hg. Art. PaO2 / FiO2 <300;
– PaCO2> 45 mmHg. st;
– pH <7.35;
– Vt <4 ml / kg (tidal volume (ml) / body weight (kg) of the patient);
– SpO2 <92%;
Absolute contraindications for NIVL: severe encephalopathy, lack of consciousness; anomalies and deformations of the facial skeleton, preventing the application of a mask.
If non-invasive ventilation is ineffective – hypoxemia, metabolic acidosis or there is no increase in the PaO2 / FiO2 index for 2 hours, high respiratory work (desynchronization with a respirator, involvement of the auxiliary muscles, “lowering” during activation of the inspiration on the pressure-time curve), tracheal intubation is shown.
If there are tests, the start of “invasive” mechanical ventilation must be performed immediately (respiratory rate greater than 35 in 1 minute, loss of consciousness, decrease in PaO2 less than 60 mm Hg or reduction of SpO2 <90% against the background of the oxygen insufflation. that the progression of respiratory failure can occur very quickly.
The strategic goal of respiratory support is to ensure adequate gas exchange and minimize potential iatrogenic damage to the lungs.
Indications for mechanical ventilation:
– inefficiency of non-invasive ventilation of the lungs;
– the impossibility of non-invasive ventilation of the lungs (respiratory arrest, impaired consciousness, the patient’s psyche);
– increased shortness of breath, tachypnea (more than 35 movements per minute) – does not disappear after a decrease in body temperature;
– PaO2 <60 mm Hg. Art. PaO2 / FiO2 <100;
– PaCO2> 60 mmHg. st;
– pH <7.25;
– Vt <4 ml / kg (tidal volume (ml) / body weight (kg) of the patient);
– SpO2 <90%.
Recommended ventilation features:
– Peak P <35 cm of water. st;
– Plateau P <30 cm of water. st;
– The PEEP level is regulated by the SpO2 value (minimum sufficient – 92%) and by the hemodynamic parameters.
Algorithm: 5-8-10 cm of water. Art.
In the process of conducting respiratory support, the following key points should be used:
Tidal volume (DO, Vt) – no more than 4-6 ml / kg of ideal body weight (“protective” mechanical ventilation) (B);
Respiratory rate and minute volume of ventilation (MVE) are the minimum necessary to maintain PaCO2 at less than 45 mm Hg. Art. (Except for the “eligible hypercapnia” method) (C);
The choice of PEEP is minimally sufficient to guarantee the maximum recruitment of the alveoli and a minimum excessive inflation of the alveoli and the inhibition of hemodynamics (“protective” mechanical ventilation) (A);
Patient synchronization with a respirator: the use of sedative therapy (in accordance with the sedation protocol) and in severe ARDS with short myopia (usually less than 48 hours) and non hyperventilation (PaCO2 <35 mm Hg) (C) ;
Compliance with the protocol for patient excommunication from the ventilator – the criteria for terminating the ventilator (C) must be assessed daily.
When choosing a ventilation regimen, the clinical decision is made mainly taking into account four important factors: possible excessive elongation of the lungs by volume or pressure, degree of arterial saturation of hemoglobin with oxygen, arterial pH, fractional oxygen concentration (effect toxic to oxygen).
The realization of a “safe” mechanical ventilation is possible both in controlled pressure mode (PC) and in controlled volume mode (VC).
In addition, in controlled volume regimens, it is desirable to use a descending form of the inspiratory flow, as it provides better gas distribution in different parts of the lungs and less pressure in the airways.
At present there is no convincing evidence of the benefits of any of the respiratory supportive support regimens. When using controlled respiratory support modes, you should switch to auxiliary ventilation modes as soon as possible.
Respiratory cessation
The issue of cessation of mechanical ventilation can only be posed under regression conditions of the patient’s respiratory failure. The key points of readiness are:
– The absence of neurological signs of cerebral edema (for example, it is possible to wean patients in a vegetative state) and pathological respiratory rhythms,
– The complete cessation of muscle relaxants and other drugs that depress breathing,
– The stability of hemodynamics and the absence of life-threatening disorders,
– the absence of signs of heart failure (increased cardiac output in the process of decreasing respiratory support – an indicator of successful weaning),
– The absence of hypovolemia and serious metabolic disorders,
– The absence of violations of the acid-base state,
– PvO2> 35 mmHg. Art.,
– The absence of pronounced manifestations of DIC syndrome (clinically significant bleeding or hypercoagulation),
– Full nutritional support of the patient before and during the process of “excommunication” from the respirator, compensated electrolyte disturbances,
– Temperature below 38 degrees C.
In any case, with the development of severe respiratory insufficiencies, it is advisable to start traditional mechanical ventilation.
It is impossible to delay the use of mechanical ventilation, since the development of severe pneumonia becomes uncontrollable and severe hypoxemia develops. Therefore, the assessment of the state of breathing and gas exchange is constantly carried out in the patient’s treatment process.
In a situation of attempts to guarantee acceptable oxygenation, excessively “rigid” ventilation regimes (MAP not exceeding 30 cm of water column) should not be chosen.
In the absence of stabilization of the gas exchange during mechanical ventilation, a further tightening of the ventilation modes can cause mechanical lung damage (pneumothorax, bulla formation).
In this case, it is advisable to transfer the patient to ECMO with a decrease in ventilation modes and to guarantee the effect of pulmonary “rest”. Venous-venous ECMO can be used in the absence of heart failure and, with its development, veno-arterial ECMO.
The main indications are presented in the tables (it does not change, only the contraindications are shown below).
Contraindications:
1. the presence of bleeding complications and a decrease in platelet levels below critical values (less than 50,000), the presence of an intracranial hemorrhage clinic;
2. Age (weight) less than 2 kg.
The oxygenation targets are saturated by at least 90%. With the development of septic shock, the treatment is standard and traditional, aimed at stabilizing the volemic state (crystalloids at a rate of 10-20 ml / kg / h, the appointment of vasopressors and inotropes).
The appointment of vasopressors is advisable with a decrease in blood pressure. Adrenaline is administered at a dose of 0.2 to 0.5 mcg / kg / min. However, the adrenaline dose can be increased to 1 or even 1.5 μg / kg / min.
The introduction of norepinephrine, dopamine and dobutamine is advisable to reduce myocardial contractility and the development of heart failure. It is particularly important when evaluating the blood volume to prevent the possible development of hypervolemia.
On the whole of the treatment, with the development of oliguria and renal failure in septic shock, the hemodiafiltration procedure begins promptly.
As pulse therapy in the short course regimen, glucocorticoids (hydrocortisone 5 mg / kg / s and prednisolone (0.5-1 mg / kg / s) can be used.
4.5.2. Extracorporeal membrane oxygenation
In severe refractory hypoxemia, the (PO2 / FiO2 <50) patients with ARDS have extracorporeal membrane oxygenation (ECMO). At present, there is a sufficient amount of data indicating the possible perspectives of this method. The rate of progression of acute DN in patients with severely community-acquired pneumonia requires early contact with an ECMO-capable center.
ECMO is performed in departments with experience in the use of this technology: hospitals where there are specialists, including surgeons, perfusionists who know the cannulation technique of the central vessels and the settings of the ECMO. Indications and contraindications for ECMO are presented in table 2.
Table 2. Indications and contraindications for ECMO
| Potential ECMO indications | – Refractory hypoxaemia PaO2 / FiO2 <50 mm RT. Art., Persistent * ; despite FiO2> 80% + PEEP (<= 20 cm H2O) at Pplat = 32 cm H2O + prone position +/- inhaled NO; – Plateau pressure of <= 35 cm H2O despite a reduction of PEEP to 5 cm H2O and reduction of VT to a minimum value (4 ml / kg) and pH> = 7.15. |
| Contraindications to ECMO | – Serious concomitant diseases with expected life expectancy of the patient not exceeding 5 years; – Multiple organ failure or SOFA> 15 points; – Non-pharmacological coma (due to stroke); – technical impossibility of venous or arterial access; – Body mass index> 40 kt / M2. |
______________________________
* The nature of persistence depends on the dynamics of the process (several hours for rapidly progressing states and up to 48 hours in case of stabilization)
According to known data, the involvement of ECMO saved a number of coronavirus-infected patients in a Wuhan hospital.
4.5.3. Treatment of patients with septic shock
1. In septic shock, intravenous infusion therapy with crystalloid solutions should be performed immediately (30 ml / kg, the infusion of one liter of solution should be performed within 30 minutes or less).
2. If the patient’s condition following a bolus infusion of solutions does not improve and signs of hypervolemia appear (eg wet rales during auscultation, pulmonary edema according to the chest X-ray), it is necessary to reduce the volume of solutions inject or stop the infusion. The use of hypotonic solutions or starch is not recommended.
3. In the absence of the effect of initiating infusion therapy, vasopressors (noradrenaline (norepinephrine), adrenaline (epinephrine) and dopamine are prescribed. It is recommended to administer vasopressors at the lowest doses that support perfusion (ie systolic blood pressure> 90 mmHg), through a central venous catheter under close control of the rate of administration, with frequent monitoring of blood pressure, with signs of reduced tissue perfusion, dobutamine is administered.
4. Patients with persistent shock who require an increase in vasopressor doses, it is recommended to administer intravenous hydrocortisone (up to 200 mg / day) or prednisone (up to 75 mg / day). WHO experts recommend using low doses and short courses whenever possible when coronavirus infection.
5. In case of hypoxemia with SpO2 <90%, oxygen therapy is indicated, starting from a rate of 5 l / min followed by a titration to reach the target level SpO2> = 90% in adults and children not pregnant, in pregnant patients – up to SpO2> = 92 – 94%.
5. Prevention of coronavirus infection
5.1. Specific prevention of coronavirus infection
Currently, no specific means have been developed to prevent coronavirus infection.
5.2. Non-specific prevention of coronavirus infection
Non-specific prophylaxis is an activity aimed at preventing the spread of infection and is carried out in relation to the source of the infection (a sick person), the transmission mechanism of the causative agent of the infection, as well as the potentially sensitive contingent ( protection of people who are and / or were in contact with a sick person).
Measures regarding the source of infection:
– isolation of patients in the closed rooms / wards of the hospital for infectious diseases;
– the use of masks in patients who need to be replaced every 2 hours,
– transport of patients with special transport,
– respect for patients’ cough hygiene,
– the use of disposable medical instruments.
Activities aimed at the transmission mechanism of the pathogen of the infection:
– to wash hands
– the use of medical masks,
– the use of overalls for healthcare professionals,
– implement disinfection measures,
– ensure air disinfection,
– Class B waste disposal
Activities targeting the sensitive contingent:
1) Elimination therapy, which is an irrigation of the mucous membrane of the nasal cavity with an isotonic sodium chloride solution, reduces the number of viral and bacterial pathogens of infectious diseases and can be recommended for non-specific prophylaxis.
2) The use of drugs for local use with barrier functions.
3) Timely contacting medical institutions for medical assistance in the event of symptoms of acute respiratory infection is one of the key factors in preventing complications.
When planning trips abroad, Russian citizens need to clarify the epidemiological situation. When visiting countries reporting incidents of the 2019-nCoV infection, the following precautions should be observed:
– Do not visit the markets where animals, seafood are sold;
– use only heat-treated foods, bottled water;
– Do not attend zoos, cultural events involving animals;
– use respiratory protection devices (masks);
– wash your hands after visiting crowded places and before eating;
– at the first sign of a disease, consult a doctor from medical organizations, do not allow self-medication;
– when requesting medical assistance in the territory of the Russian Federation, inform the medical staff about the time and place of stay.
5.3. Pharmacological prophylaxis of coronavirus infection
To date, there is no evidence of the effectiveness of use in the prevention of 2019-nCoV of any drug.
It is possible to use drugs for the non-specific prophylaxis of the 2019-nCoV infection, aimed at reducing the probability of disease in a potentially susceptible population, because the evidence of their clinical efficacy or inefficiency is currently insufficient.
6. Patient routing and characteristics of evacuation measures for patients or people with suspected new coronavirus infection caused by 2019-nCoV
6.1. Routing of patients and people suspected of a new coronavirus infection caused by 2019-nCoV
The routing procedure regulates the provision of medical care for patients with coronavirus infection caused by 2019-nCoV in medical organizations.
Medical care for patients with a new coronavirus infection caused by 2019-nCoV is provided in the form of emergency, primary health care and specialized medical care in medical organizations and their structural divisions, operating under orders from the Ministry of Health .
Ambulance, including emergency, specialized medical care for patients with an infectious disease is provided by ambulance ambulance teams, medical ambulance teams, specialized ambulance teams and emergency teams from territorial disaster medicine centers .
The team’s activities aim to put in place measures to eliminate life-threatening conditions resulting in medical evacuation to a medical organization that provides in-patient medical care to patients with infectious diseases.
Medical care for patients with infectious diseases with acute life-threatening conditions, including infectious-toxic, hypovolemic shock, brain swelling, acute renal and hepatic failure, acute cardiovascular and respiratory failure, appear to be teams outside the organization medical (including resuscitation) ambulance.
In order to ensure anti-epidemic preparedness for events in the event of the import or onset of a new coronavirus infection caused by 2019-nCoV, medical organizations must have an operational plan for initial anti-epidemic measures when identifying a suspected patient. of this disease, be guided by applicable regulations, methodological documents and health legislation according to the prescribed modalities, including the regional plan of health organization and epidemiologist measures to prevent the import and spread of new coronavirus infections caused by 2019-nCoV , as per the Ministry of Health provisions.
Samples of patients or contact persons are collected for laboratory diagnostics in accordance with the temporary recommendations for laboratory diagnosis of a new coronavirus infection caused by the 2019-nCov virus, sent to executive authorities as per the Ministry of Health provisions.
The collection of clinical material and its packaging are carried out by an employee of a medical organization trained in the requirements and rules of biological safety during work and the collection of material suspected of being infected by pathogenicity group II microorganisms, in accordance with temporary recommendations for laboratory diagnostics.
The transport of samples must be carried out in accordance with the requirements of the sanitary legislation in relation to the microorganisms of the II pathogenicity group.
In the case of a probable coronavirus infection caused by the 2019-nCov virus, a clinical and laboratory diagnostic complex is performed after isolation of the patient.
Depending on the severity of the condition, when confirming the diagnosis of coronavirus infection, treatment is carried out in the department for the treatment of infected patients of a medical organization according to the List, including intensive care from a medical organization (if indicated). With the development of life-threatening conditions, hospitalization is carried out in the intensive care of a medical organization.
Treatment of a confirmed case of coronavirus infection caused by the 2019-nCov virus is carried out in a medical organization according to the List (department of a medical organization) that provides medical care to infected patients in stationary conditions.
Medical evacuation of patients must be carried out immediately by specialized vehicles dedicated for the transport of these patients in compliance with a strict anti-epidemic regime.
Contact patients are transported to medical organizations according to the list in accordance with a strict anti-epidemic regimen.
Healthcare professionals must immediately submit the information according to the notification scheme approved to the executive authority of a constituent entity of the Russian Federation in the field of health regarding the hospitalization of patients (suspect) and the cases of death of these patients in the prescribed way.
6.2. Characteristics of evacuation measures for patients or persons suspected of having a new coronavirus infection caused by 2019-nCoV and general principles for hospitalization of a patient suspected of having a new coronavirus infection
1. The hospitalization of a patient suspected of coronavirus infection caused by 2019-nCoV is carried out in medical organizations (MO) according to the List, which includes Meltzer boxes or in medical organizations reassigned to specialized institutions of the administrative territory where the patient has been identified.
The requirements for work in hospitals, isolators and observers in outbreaks of diseases caused by microorganisms of pathogenicity groups I-II are specified in in the protocols identified by the Ministry of Health.
The provision of medical care to patients with an infectious disease during the preparation and conduct of medical evacuation is carried out in accordance with current procedures, clinical recommendations and standards.
In the presence of life-threatening syndrome complexes, resuscitation measures and intensive care are performed according to approved schedules in the prescribed manner.
2. Transportation of patients with an infectious disease is performed without or in a transport isolation box (TIB).
a) Transportation of a patient with an infectious disease without an isolation box for transportation
Events of epidemiological and / or ambulance teams before transport * .
The members of the epidemiological team and / or the medical evacuation team, on arrival at the patient’s identification site, before entering the room where the patient is located, wear protective suits according to the procedure established * under the supervision of a doctor – the team leader.
Team team:
– clarifies the patient’s data on the epidemiological history, the circle of people who spoke with him (indicating the date, degree and duration of contact);
– determines the contingents of people subject to isolation, medical supervision, emergency prevention;
– provides control over the evacuation of the patient and those in contact with him;
– defines the objects to be tested in the laboratory;
– immediately reports the updated patient information, contact with the patient and the primary measures adopted to locate the focus according to the approved scheme (senior shift doctor).
The team performing the medical evacuation of the infected patient should be composed of a doctor and two assistants (paramedic, nurse) trained in compliance with the anti-epidemic regime and who have undergone further disinfection instructions.
The patient is transported in a mask with all precautions.
The driver of the vehicle in which the medical evacuation is carried out, in the presence of an insulated cabin, must be dressed in a suit, in the absence of it, with protective clothing.
Ambulance drivers (paramedical drivers, orderly drivers) work in protective clothing in the prescribed manner.
The glass and air ducts between the driver’s cab and the passenger compartment are hermetically sealed with tape-like adhesive tape.
Ambulance personnel together with an infectious disease doctor in personal protective equipment determine the number and sequence of evacuation of contaminants.
Clarify the path of the medical organization according to the list and perform the medical evacuation.
The transport of two or more infected patients on the same machine is not allowed.
The transport of people in contact with patients with the patient in the same car is not allowed.
Departure of personnel for evacuation and final disinfection on the same car is not allowed.
In some cases (with lack of transport), a disinfection team can be delivered to the center for final disinfection on an ambulance designed to transport the patient to the hospital. The arrived team performs disinfection and the car takes the patient to the hospital, without waiting for the end of the treatment.
After an infected patient is hospitalized, the car drives into the hearth for the disinfection team and collects things for disinfection of the room.
The ambulance is equipped with medical, technical, medicinal, medications, epidemiological dressings (if necessary), for resuscitation.
The ambulance must be equipped with a hydraulic console or a manual sprayer, cleaning rags, a container with a lid to prepare a working solution of a disinfectant and keep the rags for cleaning; a container for the collection and disinfection of secretions.
The necessary set of disinfectants per day:
– means for disinfection of secretions;
– a means of disinfecting internal surfaces;
– a tool for processing staff hands (1-2 packs);
– bactericidal irradiator.
The consumption of disinfectants required for 1 shift is calculated on the basis of the available means and the possible number of visits.
It is forbidden to accompany the patient with relatives and friends. After the patient has been delivered to the hospital for infectious diseases, the team undergoes a comprehensive health treatment in the hospital with disinfection of protective clothing.
The machine, the patient care items are subjected to final disinfection for hospital reasons by the hospital itself or by the teams of the disinfection facility (according to a global plan).
All members of the brigade are required to undergo sanitation in a specially designed room of the hospital for infectious diseases.
Members of teams conducting medical evacuation are monitored for a period equal to the incubation period of the suspected infection.
b) Transport of a patient with an infectious disease by means of an insulated transport box
Patients or persons suspected of having an illness due to a new coronavirus infection are transported using a transport isolation box (TIB) equipped with a ventilation unit with filter, windows for visual monitoring of the patient’s condition, two pairs of integrated gloves for basic procedures during transport.
For the medical evacuation of the patient, a medical team consisting of 3 specialists is trained: 1 medical specialist, 1 paramedic, 1 paramedic and driver trained in accordance with the anti-epidemic regime and also trained on disinfection problems. Healthcare professionals administer the patient, place it in the TIB and follow up.
Healthcare workers and the driver must be dressed in protective clothing with the addition of a glued apron (polyethylene) in the prescribed manner.
The patient is ready for transportation to the TIB facility: at the evacuation site, the team doctor assesses the patient’s condition at the time of transportation and decides on further medical procedures.
The patient is positioned inside the camera of the transport module in a horizontal position on the back and fixed with straps; the equipment and medicines needed for transportation and medical care are located in the TIB; then close the zipper. Check the reliability of the filter fixing, switch on the filter ventilation unit for the negative pressure.
After the patient has been placed on the TIB, the team’s medical staff:
– she wipes her hands with rubber gloves and the surface of the glued apron, irrigates the external surface of the transport module with a disinfectant solution with exposure according to the instructions for use;
– performs the treatment of the protective suits by irrigation with a disinfectant solution according to the instructions for use, then removes the protective suits and inserts them in bags for hazardous waste;
– irrigates the external surface of the bags with protective overalls used with a disinfectant and transports them to the vehicle.
In the hospital box for infectious diseases, the TIB patient is transferred to the hospital’s medical staff.
After the patient has been delivered to the hospital, medical transportation and the TIB, as well as the items used in transportation, are disinfected by the disinfection team in the hospital for infectious diseases at a special site equipped with drainage and disinfection pit. of vehicles used to transport patients in accordance with the applicable methodological document provisions. The internal and external surfaces of the transport module and vehicles are treated by irrigation from the hydraulic panel, disinfectants approved for work with dangerous viruses in concentration according to the instructions.
TIB filter elements and other medical waste are disposed of in the prescribed way.
At the end of patient transport, protective and work clothes are subjected to a special treatment by immersing them in a disinfectant solution according to the viral regime according to the instructions for use.
All members of the brigade are required to undergo sanitation in a specially designed room of the hospital for infectious diseases.
Members of teams conducting medical evacuation are monitored for a period equal to the incubation period of the suspected infection.
c) Activities of the disinfection team
Upon arrival at the disinfection site, team members wear protective clothing, depending on the expected diagnosis. Final disinfection in the vehicle is performed immediately after evacuation of the patient.
For disinfection, two members of the brigade enter the outbreak; a disinfectant remains out of the blast. It is the responsibility of the latter to receive items from the chamber for disinfection, the preparation of disinfectant solutions, a tray of the necessary equipment.
Before disinfection, it is necessary to close the windows and doors in the rooms to be treated. Final disinfection starts from the main door of the building, processing all the rooms in sequence, including the room where the patient was staying. In each room from the threshold, without entering the room, thoroughly disinfect the floor and air with a disinfectant solution.
The head of the medical organization in which the patient who is suspected of coronavirus infection caused by 2019-nCoV is identified performs primary anti-epidemic measures according to the medical organization’s operational plan, such as identifying a patient with a particularly dangerous infection (OOI), in order to ensure timely information, temporary isolation, advice, evacuation, disinfection, providing the patient with the necessary medical care (in accordance with the applicable legislation and sanitation legislation, including health and epidemiological standards for the “Health protection of the territory” Organization and conduct of primary anti-epidemic measures in case of identification of a patient (corpse).suspicion of infectious diseases that cause emergency situations in the field of health and epidemiological well-being of the population
3. The head of the medical organization in which the patient suspected of coronavirus infection caused by 2019-nCoV is hospitalized, the operational plan available in this medical organization immediately enters into force, such as in the case of detection of acute respiratory infections, anti-epidemic measures and re-profiling of the hospital base, including the use of instructions on the provision of measures to prevent the introduction and spread of infectious (parasitic) diseases that require health measures Polar protection of the territory necessary for the organization of health and fight against the epidemic (preventive) measures and ensure the degree of practical preparation of the medical organization, plan the evacuation of patients from the medical institution.
4. Sampling of laboratory research material on patients is performed by healthcare professionals from the hospital where the patient is hospitalized, in accordance with the safety requirements when working with pathogens of the II hazard group and in accordance with with temporary recommendations for laboratory diagnostics. The material taken must be immediately sent for research to the laboratory or kept in accordance with the requirements of the current health regulations for safety at work until the arrival of a specialist.
5. The further routing of a patient suspected of coronavirus infection caused by 2019-nCoV is determined by the decisions of the medical commission, the results of the team of consultants who arrived to confirm the diagnosis at the patient’s place of identification or hospitalization .
In a medical organization that provides medical assistance in the profile of “infectious diseases”, according to health standards, the presence of
– minimum stock of PPE personnel (protective clothing, masks and more);
– laying for the collection of biological material from the patient (suspect);
– laying with emergency preventive measures for health workers;
– a monthly supply of disinfectants and equipment;
– test systems for laboratory diagnostics in case of identification of people with suspected coronavirus infection;
– medical personnel trained to act to identify a patient (suspect) of a disease caused by a new coronavirus.
When using PPE, it is essential to follow the requirements of the health standards. Dispose of the materials used in the prescribed way, disinfect the patient’s work surfaces and biological fluids using disinfectants containing chlorine.
Sources used
1. Al-Tawfiq JA, Memish ZA Update on therapeutic options for Middle East respiratory syndrome Coronavirus (MERS-CoV) // Expert review of anti-infectious therapy. 2017.15 N 3.P. 269-275.
2. Behzadi MA, Leyva-Grade VH Overview of current therapies and new candidates for influenza, respiratory syncytial virus and respiratory syndrome of the Middle East. Coronavirus infections // Frontiers in microbiology. 2019.10., P. 1327.
3. Canada.ca. 2019 coronavirus novel: symptoms and treatment The official government of Canada website URL: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/symptoms.html
4. CDC. 2019 Coronavirus novel URL: https://www.cdc.gov/coronavirus/2019-ncov/index.html
5. Chen N. et al. Epidemiological and clinical characteristics of 99 cases of pneumonia 2019-Novel Coronavirus (2019-nCoV) in Wuhan, China. – 2020.
6. Chong YP, Song JY, Seo YB, Choi J.-P., Shin H.-S. Guidelines for antiviral treatment for Middle Eastern respiratory syndrome // I nection & chemo. 2015. 47. N 3. S. 212-222.
7. Cinatl J., Morgenstern B., Bauer G., Chandra P., Rabenau H., Doerr HW Treatment of SARS with human interferons // Lancet (London, England). 2003,362. N 9380.S. 293-294.
8. Clinical management of severe acute respiratory infection when Middle East respiratory syndrome (MERS-CoV) coronavirus infection is suspected: Provisional Guide. Updated July 2, 2015. WHO / MERS / Clinician / 15.1
9. Commonwealth of Australia Department of Health. New coronavirus URL (2019-nCoV): https://www.health.gov.au/health-topics/novel-coronavirus-2019-ncov
10. Corman VM et al. Detection of the novel coronavirus 2019 (2019-nCoV) via real-time RT-PCR // Eurosurveillance. – 2020. – T. 25. – N. 3. – S. 2000045.
11. Coronavirus.URL: https://multimedia.scmp.com/widgets/china/wuhanvirus/?fbclid=IwAR2hDHzpZEh5Nj360i2 O% 201ES78rXRFymAaFaUK6ZG4m0UTCV1xozulxX1jio
12. Dayer MR, Taleb-Gassabi S., Dayer MS Lopinavir; A powerful drug against coronavirus infection: insights from the study on molecular coupling // Archives of clinical infectious diseases. 2017.12 N 4.
13. Dyall J., Gross R., Kindrachuk J., Johnson RF, Olinger GG, Hensley LE, Frieman MB, Middle East Respiratory Syndrome Jahrling PB and Acute Severe Respiratory Syndrome: current treatment options and potential targets for new therapies // Medicines. 2017. 77. N 18. S. 1935-1966.
14. ENGLISH.GOV.CN. THE STATE COUNCIL THE PEOPLE’S REPUBLIC OF CHINA URL: http://english.www.gov.cn/
15. European Commission. New coronavirus 2019-nCoV URL: https://ec.europa.eu/health/coronavirus_en
16. The FDA. New coronavirus URL (2019-nCoV): https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/novel-coronavirus-2019-ncov
17. Federal Ministry of Health. Current information on the coronavirus URL: https://www.bundesgesundheitsministerium.de/en/en/press/2020/coronavirus.html
18. Hart BJ, Dyall J., Postnikova E., Zhou H., Kindrachuk J., Johnson RF, Olinger GG, Frieman MB, Holbrook MR, Jahrling PB, Hensley L. and mycophenolic acid are potent inhibitors of Middle respiratory syndrome East coronavirus in cell-based tests // The Journal of general virology. 2014.95.Pt 3.P. 571-577.
19. Huang C. et al. Clinical features of patients infected with the 2019 coronavirus novel in Wuhan, China // The Lancet. – 2020.
20. Ji W. et al. Homologous recombination within the spike glycoprotein of the newly identified coronavirus may increase transmission between snake species to the human Journal of Medical Virology. – 2020.
21. Junqiang Lei, Junfeng Li, Xun Li. CT Imaging of the novel Coronavirus 2019 (2019-nCoV) Pneumonia https://doi.org/10.1148/radiol.2020200236 URL: https://pubs.rsna.org/doi/10.1148/radiol.2020200236
22. Li Q et al. Dynamics of early transmission to Wuhan, China, of new pneumonia infected with coronavirus N Engl J Med. January 29, 2020. doi: 10.1056 / NEJMoa2001316
23. Li X et al. Large transmission potential ″ first generation ′ from man to man of 2019-nCoV. J Med Virol. January 30, 2020. doi: 10.1002 / jmv.25693. [Epub before printing]
24. Lu H. Drug treatment options for the new coronavirus 2019 (2019-nCoV). Biosci Trends. January 28, 2020. doi: 10.5582 / bst.2020.01020. [Epub before printing]
25. Mandell LA et al. Infectious Diseases Society of America / American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults // Clinical infectious diseases. – 2007. – T. 44. – N. Supplement_2. – S. S27-S72.
26. Matteo Bassetti The new Chinese Coronavirus infections (2019-nCoV): challenges to fight the storm https://doi.org/10.1111/eci.13209 URL: https://onlinelibrary.wiley.com/doi/abs/ 10.1111 /eci.13209
27. des et de la: Question-answer URL: https://solidarites-sante.gouv.fr/soins-et-maladies/maladies/maladies-infectieuses/coronavirus/coronavirus-questions-reponses
28. Mo Y., Fisher D. A review of the modalities of treatment of Middle Eastern respiratory syndrome // The Journal of antimicrobial chemotherapy. 2016. 71. N 12.P. 3340-3350.
29. National Health Commission of the People’s Republic of China. URL: http://en.nhc.gov.cn
30. NHS. Coronavirus (2019-nCoV) URL: https://www.nhs.uk/conditions/wuhan-novel-coronavirus/
31. Omrani AS et al. Ribavirin and interferon alfa-2a for severe Middle Eastern respiratory syndrome coronavirus infection: a retrospective cohort study // The Lancet Infectious Diseases. – 2014. – T. 14. – N. 11. – S. 1090-1095.
32. Outbreak of acute respiratory syndrome associated with a new coronavirus, China: first local transmission in the EU / EEA – third update URL: https://www.ecdc.europa.eu/sites/default/files/documents/novel – coronavirus-risk assessment-china-31-January-2020_0.pdf
33. Phan LT et al. Man-to-man import and transmission of a new coronavirus to Vietnam // New England Journal of Medicine. – 2020.
34. Phylogeny of betacoronaviruses similar to SARS, including the new coronavirus (nCoV). URL: https://nextstrain.org/groups/blab/sars-like-cov
35. Public Health England. Initial clinical study and management of possible cases of new coronavirus infection URL (2019-nCoV): https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases / investigation -and-initial-clinical-management-of-possible-cases-of-Wuhan-novel-coronavirus-wn-VOC-infection
36. Royal Pharmaceutical Society of Great Britain Trade as Royal Pharmaceutical Society. Wuhan coronavirus novel URL: https://www.rpharms.com/resources/pharmacy-guides/wuhan-novel-coronavirus
37. The Centers for Disease Control and Prevention (CDC). Provisional guide for healthcare professionals on human infections with the new coronavirus 2019 (2019-nCoV). URL: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
38. Upchurch CP et al. Community-acquired pneumonia displayed on CT scans, but not on chest radiographs: pathogens, severity and clinical outcomes // Chest. – 2018. – T. 153. – N. 3. – S. 601-610.
39. World Health Organization. Management of ethical problems in infectious disease epidemics. Publication date: 2016. URL: https://www.who.int/ethics/publications/infectious-disease-outbreaks/en/
40. Wu P. et al. Provisional real-time evaluation of the epidemiological characteristics of the new coronavirus infections in Wuhan, China, as of 22 January 2020 // Eurosurveillance. – 2020. – T. 25. – N. 3. – S. 2000044.
41. Zumla A., Chan JFW, Azhar EI, Hui DSC, Yuen K.-Y. Coronavirus: drug discovery and therapeutic options // Nature reviews. Drug discovery. 2016. 15. N 5.P. 327-347.
42. World Health Organization. Clinical guidelines for the management of patients with severe acute respiratory infections with suspected infection with a new coronavirus (2019-nCoV). Temporary recommendations. Publication date: 25 January 2020 URL: http://www.euro.who.int/__data/assets/pdf_file/0020/426206/RUS-Clinical-Management-of-Novel_CoV_Final_without-watermark.pdf?ua=1.
43. World Health Organization. Clinical guidelines for the management of patients with severe acute respiratory infections in cases of suspected MERS-CoV infection. Temporary recommendations. Publication date: July 2015 URL: https://www.who.int/csr/disease/coronavirus_infections/case-management-ipc/en/ 44. Federal supervisory service for the protection of consumer rights and human well-being. Information on a new coronavirus infection.
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* Events are also performed during the transport of patients with an infectious disease using an insulating transport box
Appendix 1
List of medications that can be prescribed for the treatment of coronavirus infection in adults
| Drug (DCI) | Mechanism of action | Release forms | Destination schemes |
| Antiviral medicines | |||
| Lopinavir + Ritonavir | Lopinavir is an inhibitor of HIV-1 and HIV-2 proteases; Ritonavir – Aspartyl protease inhibitor HIV-1 and HIV-2 | Tablets / suspension | Treatment: 400 tablets of lopinavir / 100 mg of ritonavir are prescribed every 12 hours for 14 days in tablets. If oral drug administration is not possible, Lopinavir / ritonavir (400 mg lopinavir / 100 mg ritonavir) is administered as a suspension (5 ml) every 12 hours for 14 days through a nasogastric tube. |
| Recombinant interferon Beta-1b | recombinant IFN – beta 1b interferon increases the suppression activity of peripheral blood mononuclear cells and reduces the resistance of T lymphocytes to apoptosis, triggers the expression of a number of proteins with antiviral, antiproliferative and anti-inflammatory effects , moves the balance of cytokines in favor of anti-inflammatory cytokines, inhibits the rate of leukocytes and reduces the rate of leukocytes the leukocytes through the BBB reducing the expression of metalloproteases that increase the permeability of the BBB, It has the binding capacity and the expression of interferon-gamma receptors, and also improves their decay, is an interferon-gamma antagonist | Subcutaneous preparation | Treatment: 0.25 mg / ml (8 million IU) subcutaneously for 14 days (total 7 injections) |
| ribavirin | Antiviral agent. Quickly penetrates cells and acts within virus infected cells. Ribavirin inhibits the replication of new virions, which reduces viral load, selectively inhibits the synthesis of viral RNA without inhibiting the synthesis of RNA in normally functioning cells | Pills, capsules | 2000 mg – loading dose. So 4 days, 1200 mg every 8 hours, 4-6 days, 600 mg every 8 hours. |
Appendix 2
List of abbreviations used
2019-nCoV is a new coronavirus that caused an outbreak of infection in 2019-2020.
WHO – World Health Organization
DN – respiratory failure
Mechanical ventilation
IFN – interferon
KIE – inactivating units of kallikrein
PRC – People’s Republic of China
MO – medical organization
NVL – non-invasive ventilation
ONE – acute respiratory failure
OOI – a particularly dangerous infection
ARVI – acute respiratory viral infection
ARI – acute respiratory infection
ARDS – acute respiratory distress syndrome
ICU – intensive care unit
PCR – polymerase chain reaction
RNA – ribonucleic acid
RSV – Respiratory syncytial virus
PPE – personal protective equipment
CRP – C reactive protein
SS – septic shock
TIB – insulating box for transport
Bulls – severe acute respiratory infection
SARS (SARS) – severe acute respiratory syndrome
ECG – electrocardiography
ECMO – extracorporeal membrane oxygenation
MERS – Middle East respiratory syndrome
MERS-CoV – Coronavirus that causes a Middle Eastern respiratory syndrome outbreak
SARS-CoV – coronavirus that caused a severe acute respiratory syndrome outbreak
Appendix 3
Information on suspicion or case of coronavirus infection
1. Name of the patient
2. Gender of the patient
3. Date of birth of the patient
4. The diagnosis
5. Date of diagnosis
6. Laboratory confirmation of diagnosis: yes / no
7. Epidemiological history:
to. Departure for the People’s Republic of China – yes / no
b. Contact with a patient with coronovirus infection – yes / no
c. Healthcare worker – yes / no
8. Name of the person who sent the information
9. Post information
10. Contact the telephone number
11. The medical organization that sent the information
