DECISION

GUIDANCE FOR DIAGNOSIS AND TREATMENT OF ACUTE RESPIRATORY SYNDROME CAUSED BY SARS-COV-2 (COVID-19)

MINISTER OF HEALTH

Pursuant to the Government's Decree No. 75/2017/ND-CP dated June 20, 2017 defining functions, tasks, entitlements and organizational structure of the Ministry of Health;

According to the minutes of the meeting on March 23, 2020 on updates to the Guidance for diagnosis and treatment of Covid-19.

At the request of Director of Medical Examination and Treatment Administration – the Ministry of Health,

DECIDES:

Article 1. The Guidance for diagnosis and treatment of Covid-19 is promulgated together with this Decision and replaces the Guidance promulgated together with Decision No. 322/QD-BYT dated 06/02/2020 of the Minister of Health.

Article 2. This Decision comes into force from the day on which it is signed.

Article 3. Chief of the Ministry Office, Director of Medical Examination and Treatment Administration – the Ministry of Health; the Ministerial Chief Inspector, Directors of Departments of the Ministry of Health, Directors of hospitals and inpatient treatment facilities affiliated to the Ministry of Health; Directors of Provincial Departments of Health; heads of health departments of other ministries are responsible for implementation of this Decision.

GUIDANCE

DIAGNOSIS AND TREATMENT OF COVID-19

I. OVERVIEW

Coronavirus is a group of viruses that transmit from animals to humans and cause a variety of diseases from mild diseases, such as common cold, to life threatening ones, such as serious acute respiratory syndrome (SARS-CoV) in 2002 and Middle East Respiratory Syndrome (MERS-CoV) in 2012. In December 2019, a new strain of coronavirus (SARS-CoV-2) causes a novel acute respiratory disease named Covid-19 in Wuhan city (Hubei province of China) and spreads all over China and most countries in the world. On March 11, 2020, WHO declared Covid-19 a pandemic. SARS-CoV-2 is transmitted from animal to human and from human to human, primarily through respiratory droplets and physical contact.  Aerosol transmission is also another mode of transmission, especially at health facilities. There has been no clear evidence of faecal-oral transmission of this disease.

A Covid-19 patient may have a variety of clinical manifestations: no symptoms, common flu symptoms, serious pneumonia, respiratory failure, septic shock, multi-organ failure, death, especially in old people and people having chronic diseases or immunodeficiency.

There have been no specific medicines and vaccines for Covid-19, thus treatment primarily involves supportive treatment and symptom treatment.  Primary preventive measures include early detection and isolation of confirmed cases.

II. DIAGNOSIS

1. Definitions of cases

1.1. Suspected cases

A suspected case means:

A. A person who has a fever and/or acute respiratory infection WHICH does not have any other causation AND/OR he or she has visited, stayed in or returned from an affected area (*) within 14 days before onset of symptoms.

OR

B. A person who does not have any respiratory symptoms AND has close contact (**) with a person with confirmed or suspected COVID-19 infection within 14 days before onset of symptoms.

*Affected area: a country or territory that has local transmission of Covid-19, or an area in Vietnam that has an active Covid-19 cluster according to the “Interim Guidance for Prevention and Control of Covid-19” of the Ministry of Health, updated by General Department of Preventive Medicine.

** Close contacts include:

- At health facilities: carers of a confirmed case; co-workers of a health worker is a confirmed case; visitors and people who stay in the same room as a confirmed case.

- People who come have contact within a 2-meter distance with a confirmed case or suspected case with observed symptoms.

- People in the same house with a confirmed case or suspected case with observed symptoms.

- People in the same working group or room as a confirmed case or a suspected case with observed symptoms.

- People in the same travel group, business trip group, party, meeting etc. as a confirmed case or a suspected case with observed symptoms.

- People in the same vehicle (on the same and the next two rows) as a confirmed case or a suspected case with observed symptoms.

1.2. Confirmed cases

A confirmed case means a suspected case or any person who tests positive for SARS-CoV-2 by a laboratory assigned by the Ministry of Health to perform confirmatory Covid-19 testing.

III. SYMPTOMS

1. Clinical

- Incubation period: 2 - 14; 5 – 7 days on average.

- Common symptoms include fever, dry cough, fatigue and muscle pain. In some cases, there can be sore throat, stuffy nose, runny nose, headache, expectoration, vomiting and diarrhea.

- Developments:

+ Most patients (about 80%) only have mild fever, cough, fatigue, no pneumonia, and recover after about 1 week.

+ About 14% of the confirmed cases are severe and have to be hospitalized with pneumonia or severe pneumonia; about 5% of patients have to be admitted to an intensive care unit (ICU) with acute respiratory failure (rapid breathing, difficult breathing, cyanosis, etc.), acute respiratory distress syndrome (ARDS), septic shock, failure of the kidney and heart muscles, which may lead to death.

+ The average time from onset of symptom to severity is about 7 – 8 days.

+ The death rate is higher in old people, people having immunodeficiency and underlying chronic diseases. In adults, prognostic indicators include old age, high Sequential Organ Failure Assessment (SOFA) score upon hospitalization and d-dimer > 1 μg/L.

- Recovery stage: If ARDS does not develop within 7 – 10 days after the full development stage, the fever will end and clinical indicators will gradually go back to normal, and the patient recovers.

- There is no evidence about different clinical manifestations of Covid-19 in pregnant women.

- In children, most clinical symptoms are less severe or non-existent. Common symptoms in children include fever and cough, or pneumonia symptoms. The percentage of severe cases rates in children is lower than that in adults.

2. Subclinical testing

Non-specific blood tests:

- Leukocyte count may be normal or reduced; lymphocyte count usually reduces, especially in severe cases.

- C-reactive protein (CRP) is normal or increased; procalcitonin PCT is usually normal. ALT, AST, CK, LDH may slightly increase in some cases.

- In severe cases, organ failure, coagulation disorder, electrolyte and alkali disorder are observed.

3. Lung x-ray and tomography

- In early stages or respiratory infection, x-ray images are normal.

- In case of pneumonia, injuries are usually found in both lungs signs of interstitial pneumonia or spreading frosted glass effect in the periphery or lower lobe of the lung. The injuries may rapidly develop during ARDS. Cavity formation, effusion or pneumothorax are rare.

4. Confirmatory testing

- SARS-CoV-2 is detected by Real-time RT-PCR tests or gene sequence analysis from the specimens.

IV. Clinical classification

Covid-19 has the following clinical manifestations:

1. Upper respiratory tract infection

The patient has non-specific symptoms such as fever, dry cough, sore throat, stuffy nose, fatigue, headache, muscle pain. Old people and people having immunodeficiency may have atypical symptoms.

2. Mild pneumonia

- In adults and children: pneumonia without signs of severe pneumonia.

- In children: cough or difficult breathing and rapid breathing. Rapid breathing means respiratory rate is ≥ 60 breaths/minute in children aged under 2 months; ≥ 50 breaths/minute in children aged 2 – 11 months;  ≥ 40 breaths/minute in children aged 1 – 5 years without signs of severe pneumonia.

- X-ray images show interstitial pneumonia.

3. Severe pneumonia

- In adults and children: fever or suspected respiratory infection accompanied by any of the following signs: respiratory rate > 30 breaths/minute, difficulty breathing, or SpO2 ≤ 93% breathing room air.

- In small children: cough or difficult breathing and one of the following signs: cyanosis or SpO2 < 90%; severe respiratory failure (agonal breathing, sunken chest);

+ Or a child is diagnosed with pneumonia and has any of the following signs of severity: inability to drink/suck; impaired consciousness (lethargy or coma), convulsions. There might be other signs of pneumonia such as sunken chest or rapid breathing (with respiratory rate as described above). Complications are diagnosed according to clinical and lung x-ray.

4. Acute respiratory distress syndrome (ARDS)

- Onset: new or worsening respiratory symptoms  within one week from the onset of clinical symptoms.

- Lung x-ray, CT scan or ultrasound images show diffuse haziness in both lung fields that is not caused by pleural effusion, pneumothorax or pulmonary fibrosis.

- The cause of pneumocystis is not heart failure or fluid overload. Objective assessment (heart ultrasound) is necessary to exclude hydrostatic pressure if risks factors are not observed.

- Hypoxemia in adults is classified according to PaO2/FiO2 (P/F) and SpO2/FiO2 (S/F) when PaO2 is not available:

+ Mild ARDS: 200 mmHg < P/F ≤ 300 mmHg with PEEP or CPAP ≥ 5 cm H2O.

+ Medium ARDS: 100 mmHg <P/F ≤ 200 mmHg with PEEP ≥ 5 cm H2O).

+ Severe ARDS: P/F ≤ 100 mmHg with PEEP ≥ 5 cm H2O.

+ PaO2 not available: S/F ≤ 315 (including patients that are not on ventilators).

- Hypoxemia in children is classified according to: OI=MAP* x FiO2 x 100/PaO2) (MAP*: Mean Airway Pressure) or OSI (Oxygen Saturation Index by SpO2: OSI = MAP x FiO2 x 100/SpO2) for patients on ventilation, and PaO2/FiO2 or SPO2/FiO2 for CPAP or non-invasive ventilation (NIV):

+ NIV BiLevel or CPAP ≥5 cmH2O through mask: PaO2/FiO2 ≤ 300 mmHg or SPO2/FiO2 ≤ 264

+ Mild ARDS (invasive ventilation): 4 ≤ OI<8 or 5≤ OSI<7,5

+ Medium ARDS (invasive ventilation): 8 ≤ OI<16 or 7,5≤ OSI<12,3

+ Severe ARDS (invasive ventilation): OI ≥ 16 or OSI ≥ 12,3.

5. .

- In adults: signs of organ dysfunction:

+ Impaired consciousness: drowsiness, coma.

+ Difficult or rapid breathing, low oxygen saturation

+ High heart rate, low pulse, cold limbs or hypotension, superficial thrombophlebitis

+ Oliguria or anuria

+ Coagulation disorder, thrombocytopenia, acidosis, increased lactate, increased bilirubine, etc.

- In children: suspected or confirmed sepsis by infection and there are at least 2 manifestations of systemic inflammatory response syndrome (SIRS), including unusual change in body temperature or leukocyte count.

6. Septic shock

- In adults: prolonged hypotension, vasoactive drugs have to be used to maintain MAP ≥ 65 mmHg and serum lactate concentration >2 mmol/L.

- In children: septic shock is diagnosed in case of:

+ Any type of hypotension: Systolic pressure < 5 percentile or > 2 SD below average by age, or (children aged <1 year: < 70 mmHg; children aged 1-10 years: < 70 + 2 x age; children aged > 10 years: <90 mmHg); or

+ 2 or 3 of the following signs: impaired consciousness, fast or slow heart rate (< 90 bpm in infants, < 70 bpm or >150 bpm in small children); long capillary refill time (> 2 seconds); rapid breathing; superficial thrombophlebitis or skin hemorrhages; increased lactate concentration; oliguria; increased or decreased body temperature.

V. Differential diagnosis

- Covid-19 should be distinguished from acute respiratory infection caused by other factors, including known epidemics:

+ Seasonal influenza viruses (A/H3N2, A/H1N1, B), parainfluenzavirus, respiratory syncytial virus (RSV), rhinovirus, myxovirrus, adenovirus.

+ Flu caused by common coronavirus strains.

+ Common bacteria, including atypical bacteria such as Mycoplasma pneumonia etc.

+ Other causes of severe acute respiratory infection such as avian influenza A/H5N1, A/H7N9, A/H5N6, other strains of coronavirus such as SARS-CoV-1 and MERS-CoV.

- Differential diagnosis is necessary for severity of the patient (respiratory failure, organ dysfunction, etc.) by other causes or their chronic comorbidities.

VI. Investigation, monitoring, testing and reporting infection cases

- All health facilities need to classify and promptly quarantine suspected and confirmed cases of Covid-19 infection.

- Suspected cases must undergo confirmatory testing.

- Collect upper respiratory tract samples (nasopharyngeal  and oropharyngeal swab specimens) and send them to confirmatory testing laboratories. If they test negative but infection is still suspected, collect lower respiratory tract samples (sputum, bronchus fluid,  bronchoalveolar lavage). If the patient is on ventilation, only lower respiratory tract samples are needed. Blood and stool samples may be collected if necessary.

- If Covid-19 infection is confirmed, collect and test respiratory samples at an interval of 2-4 days or shorter if necessary until the result is negative.

- Consult with specialists in the hospital or experienced physicians about suspected cases or confirmed cases where necessary.

- If a suspected case is diagnosed with another common disease, at least one confirmatory test for SARS-CoV-2 is still necessary.

- Perform blood culture is infection is suspected or there is septicemia. Blood culture should be performed before use of antibiotics.

- Perform all subclinical tests and frequently update on the health status of each patient to make diagnosis and prognosis.

- Promptly inform the Ministry of Health or local CDC when a patient tests positive for SARS-CoV-2 (now a confirmed case).

- Identify the residence, workplace, travel route, close contacts of the confirmed case; comply with the guidance of the Ministry of Health on monitoring, prevention and treatment of Covid-19.

VII. IMMEDIATE PRECAUTIONS

Precautions are an important step in diagnosis and treatment of Covid-19. This must be performed as soon as a patient arrives at a health facility. Precautions shall be implemented in every area of the health facility.

1. At classification area

- Request the suspected case to wear facemask and take him/her to the quarantine area.

- Maintain a distance of 2 meters between the patients.

- Request patients to cover their mouth and nose when coughing and sneezing, and immediately wash their hands after touching respiratory fluids.

2. Droplet precautions

- Wear medical masks when staying within the distance of 1 – 2 m from the patient.

- It is best if each patient is quarantined in a separate room, or patients with the same causation in the same room. If causation is not identified, arrange patients by clinical symptoms and epidemiological factors. The quarantine rooms must be well ventilated and disinfected with UV rays. Do not close doors to use air conditioners.

- Carers of patients having respiratory symptoms (cough, sneezing) must wear eye protectors.

- Patients must avoid moving in the health facility and wear facemasks outside of their rooms.

3. Contact precautions

- Health workers shall wear personal protective equipment (PPE), which include medical mask, eye goggles, gloves, coat, before entering the patient's room and remove them after leaving the room; avoid putting the hands on the eyes, nose and mouth.

- Clean and disinfect the devices (stethoscope, thermometer) before using them on a new patient.

- Avoid contaminating surfaces such as doors, switches, etc.

- The quarantine rooms must be well ventilated and disinfected with UV rays. Open all windows. Do not close doors to use air conditioners.

- Avoid moving the patients.

- Keep hands clean.

4. Implementation of airborne precautions during performance of relevant procedures

- PPE, including gloves, coat, eye goggles, N95 masks or equivalent masks, must be worn during performance of procedures such as endotracheal intubation, respiratory tract suction, bronchoscopy, cardiopulmonary resuscitation (CPR), etc.

- Perform these procedures in a separate room or negative pressure room if possible.

- Restrict unauthorized personnel from entering the room during performance of procedures.

VIII. TREATMENT

1. General rules for treatment

- Classify patients and determine the treatment facility according to severity:

+ Suspected cases (can be considered emergencies) shall be examined, monitored and quarantined in a separate area at the health facility; collect samples properly for testing.

+ Confirmed cases shall be monitored and treated in complete isolation. Mild cases (upper respiratory tract infection, mild pneumonia) may be treated in common inpatient rooms; Severe cases (severe pneumonia, septicemia) shall be treated in emergency rooms or ICU; Severe-critical cases (severe respiratory failure, ARDS, septic shock, multiple organ dysfunction syndrome) shall be admitted to ICU.

- Due to unavailability of specific medicines, treatment primarily involves supportive treatment and symptom treatment.

- Individualize treatments for each case, especially severe-critical cases.

- Certain experimental treatment regimens may be applied if permitted by the Ministry of Health.

- Monitor, detect and promptly respond to severity and complications.

2. General treatment and monitoring measures

- Rest in the room. The quarantine room must be well ventilated and disinfected with UV rays. Do not close doors to use air conditioners.

- Clean the nose and throat. Moisten the nose with saline. Gargle with common mouthwash.

- Keep the body warm.

- Drink enough water, ensure fluid and electrolyte balance.

- Be cautious when giving infusion to a pneumonia patient without signs of shock.

- Ensure nutrition and improve overall health. In severe-critical cases, apply nutrition guidance of Vietnam National Association of Emergency, Intensive Care and Clinical Toxicology.

- Reduce fever (if any); paracetamol may be used at 10-15 mg/kg/time, not more than 60 mg/kg/day for children and 2 g/day for adults.  

- Use common cough medicines if necessary. Use traditional medicines if prescribed by physicians.

- Assess and treat the comorbidities (if any).

- Rehabilitate the patient to improve the lung condition and other organs, prevent degradation of physical and mental health, improve mobility.

- Provide counseling for and encourage the patient.

- Closely monitor clinical manifestations and developments of lung injuries on the x-ray and/or CT images. Early Warning Score (EWS) may be used for early detection of severity signs, especially during day 7 – 10, such as respiratory failure or circulatory failure to make timely interventions.

- Facilities treating mild cases (upper respiratory tract infection, pneumonia) shall have: oxygen concentration monitor, oxygen supply system, oxygen breathing apparatus (nasal cannula, normal mask, mask with spare bag), endotracheal intubation instruments for various ages, infusion machine, electric syringe pump, ECG machine, x-ray machine.

- In addition to the aforementioned devices, facilities treating severe cases shall have: multi-parameter monitor, high-flow oxygen ventilator, non-invasive and invasive ventilators, high-frequency oscillatory (HFO)ventilator, continuous renal replacement therapy (CRRT) machine, invasive hemodynamic monitor, ECMO machine, etc. (if practicable)

3. Respiratory failure treatment

3.1. Oxygenation and monitoring

- Immediately administer oxygenation to patients with severe acute respiratory syndrome, respiratory failure, hypoxemia shock to achieve SpO2 >94%

- If there are emergency signs in adults (exertion, sunken chest, cyanosis, reduced lung ventilation), immediately ventilate the airway and administer oxygenation to achieve SpO2 ≥ 94 % during resuscitation. Administer oxygenation through nasal cannula (2-4 l/min), normal mask or mask with bags, initially at 5 l/min and increase to 10-15 l/min if necessary. When the patient’s condition is more stable, adjust the machine to achieve SpO2 ≥ 90% in adults, SpO2 ≥ 92-95% in pregnant women.

- If there are emergency signs in children such as severe breathing difficulty,  cyanosis, shock, coma, convulsion, etc., immediately administer oxygenation to achieve SpO2 ≥ 94%. When the child’s condition is more stable, adjust the machine to achieve SpO2 ≥ 90%.

- Closely monitor the patient to detect severity signs or oxygenation failure and make timely interventions.

3.3. Critical respiratory failure and ARDS treatment

- If hypoxemia does not improve after oxygenation, SpO2 ≤ 92%, and/or dyspnea on exertion is observed, consider administration of high flow nasal oxygen, CPAP, or bilevel positive airway pressure (BiPAP) non-invasive ventilation.

- Do not administer non-invasive ventilation in patients with hemodynamic disorder, multi-organ dysfunction, and impaired consciousness.

- Closely monitor the patient to detect failure signs and make timely interventions. If non-invasive ventilation is not effective, administer endotracheal intubation and invasive ventilation.

- Endotracheal intubation must be performed by an experienced physician; take airborne precaution during endotracheal intubation procedure.

- Respiratory assistance: apply the respiratory assistance regimen to treatment of ARDS in both adults and children. Notes:

+ Mechanical ventilation: used for lung protection; low circulation volume (4-8 ml/kg of ideal weight) and low inhale pressure (maintain plateau pressure < 30 cmH2O, in children, maintain plateau pressure < 28 cmH2O). Initial cycle volume 6 ml/kg, regulate it according to the patient’s response and treatment targets.

+ CO2 increase is acceptable, keep pH ≥ 7.20.

+ In case of severe ARDS in adults, consider ventilation in prone (face-down) position for 12-16 hours/day if possible.

+ Apply high PEEP in both mild and severe ARDS.

+ Avoid disconnecting the patient from the ventilator, which may lead to PEEP decrease and collapsed lung. It is recommended to use closed endotracheal suction system.

+ In children and infants, high frequency oscillatory ventilation (HFOV) may be used early (if practicable) or when normal ventilation has failed.  Do not use HFOV for adults.

+ Appropriately administer sedative and analgesic during ventilation. Muscle relaxants may be used in case of mild-severe ARDS, but should not be used regularly.

- Closely control fluid balance to avoid fluid overload, especially during rehydration for circulatory flow restoration.

- In case of severe hypoxemia and failure of common therapies, consider using extracorporeal membrane oxygenation (ECMO) on a case-by-case basis if practicable.

- Because ECMO is only available in some major facilities, the patient should be transported early and following the patient transport procedures established by the Ministry of Health.

4. Septic shock treatment

Apply the septic shock treatment regimen for adults and children. Some notes:

4.1. Fluid resuscitation

- Use isotonic crystalloid fluids such as saline or Ringer lactate. Avoid using hypotonic crystalloid solutions, haes-steril, gelatin solution for fluid resuscitation.

- Dosage:

+ In adults: infuse 250-500 ml for the first 15-30 minutes, evaluate signs of fluid overload after each quick rehydration.

+ In children: 10-20 ml/kg, intravenous infusion for the first 30 minutes, repeat if necessary, evaluate signs of fluid overload after each quick rehydration.

- Closely monitor the signs of fluid overload during fluid resuscitation such as worsened respiratory failure, hepatomegaly, fast heart rate, swollen jugular veins, moist rales, pneumochysis etc., in which case stop infusion.

- Monitor signs of improved perfusion: average blood pressure > 65 mgHg in adults or acceptable for the child’s age; urine volume >0.5 ml/kg/hour in adults and >1 ml/kg/hour in children, improved capillary refill time, skin color, consciousness and blood lactate concentration.

4.2. Vasoactive drugs

Prescribe vasoactive drugs if hemodynamics and perfusion do not improve.

- In adults: use nor-adrenaline is the first choice, regulate the dose to achieve mean arterial pressure (MAP) ≥ 65 mmHg and improve perfusion. In children: adrenaline is the first choice; dopamine or dobutamine may be prescribed In case of vasodilatory shock (venous pressure or difference of maximum and minimum blood pressure > 40 mmHg), consider prescribing nor-adrenaline. Regulate dose of vasoactive drugs to achieve MAP > 50th according to the patient’s age.

- Infuse vasoactive drugs through central venous lines. If infusion through central venous lines is not available, infuse through peripheral venous lines or intraosseous route. Monitor signs of vein rupture and necrosis.

- Invasive or non-invasive hemodynamics monitoring may be performed if practicable for evaluation of hemodynamics and regulation of fluid and vasoactive drugs according to the patient’s condition.

4.3. Prescribe blood cultures and broad-spectrum antibiotics within one hour after septic shock is diagnosed.

4.4. Control blood sugar level (maintain blood sugar level at 8-10 mmol/L), blood calcium, blood albumin (infuse albumin when albumin level <30 g/L, maintain albumin in blood ≥ 35 g/L).

4.5. In case of risk of acute adrenal insufficiency or catecholamine-dependent septic shock: administer a low dose of hydrocorticone: in adults: 50 mg by intravenous injection every 6 hours; in children: 2 mg/kg for first dose, then 0,5 -1,0 mg/kg every 6 hours.

4.6. Prescribed erythrocyte infusion when necessary, maintain hemoglobin concentration  ≥ 10 g/dl.

5. Organ support therapy

The type of support should be suitable for the patient’s condition.

- Kidney support:

+ Ensure hemodynamics, fluid and electrolyte balance; prescribe diuretics if necessary.

+ In case of severe renal failure, multi organ failure and/or fluid overload, prescribe kidney replacements such as continuous renal replacement therapy, intermittent renal replacement therapy or peritoneal dialysis, whichever is practicable.

- Administer liver support therapy if there is liver failure.

- Coagulation disorder: infuse platelet, plasma and coagulation factors if necessary.

6. Other therapies

6.1. Antibiotics

- Do not prescribe common antibiotics solely for upper respiratory tract infection.

- In case of pneumonia, consider prescribing antibiotics that are effective against bacteria causing pneumonia.

- In case of septicemia, prescribe broad-spectrum antibiotics within one hour. Regulate the doses of antibiotics when bacteria test result and antibiotic chart are available.

- In case of secondary infections, choose antibiotics according to their causes, epidemiology characteristics and antibiotic resistance of the patient.

6.2. Antiviral drugs

- It is not recommended to use specific antibiotics for SARS-CoV-2 (outside clinical trials) due to insufficient evidence of efficacy and safety of antiretroviral and other antiviral drugs such as Chloroquine/Hydroxychloroquine, Remdesivir, Ribavirin.

- The Ministry of Health will publish recommendations after considering the clinical trial results of these drugs in Vietnam and in the world.

6.3. Systemic corticosteroids

- Do not use common systemic corticosteroids for upper respiratory tract infection or viral pneumonia unless otherwise prescribed.

- In case of septic shock, use a low dose of hydrocortisone if prescribed (see septic shock treatment).

- Depending on clinical developments and lung x-ray images, consider using methylprednisolone at 1-2 mg/kg/day for 3-5 days (may be prescribed before having signs of respiratory failure).

6.4. Extracorporeal blood purification

In case of severe ARDS and/or severe septic shock without responding or responding well to common therapies (probably due to cytokine storms): Consider extracorporeal blood purification using filters that can absorb cytokines.

6.5. Intravenous immunoglobulin (IVIG)

Consider prescribing IVIG for severe cases and on a case-by-case basis.

6.6. Interferon

Consider prescribing interferon on a case-by-case basis (if any).

6.7. Rehabilitation

Rehabilitate the patient to improve the lung condition and other organs, prevent degradation of physical and mental health, improve mobility.  

7. Complication precautions

For severe cases in ICU, prepare for these common complications:

7.1. Ventilator-associated pneumonia

Apply the following preventive measures:

- Perform endotracheal intubation through oral route.

- Place the patient’s head at 30 – 45 degree position.

- Clean the mouth.

- Use a closed suction system; periodically drain stagnant water in the ventilator pipe.

- Use a new set of ventilator pipes for each patient; only replace the pipes when they are dirty or damaged during mechanical ventilation.

- Replace the heater/humidifier that is damaged or dirty or after every 5-7 days.

7.2. Precaution against venous thrombosis

- In adults or big children: If there are no contraindications, administer low-molecular-weight heparin if available, or heparine 5000 UI by subcutaneous injection twice a day.

- If there are contraindications, implement mechanical measures.

7.3. Septicemia associated with central line infusion

Use a monitoring table to take precautions when placing central line catheters.  Remove central line catheter when it is no longer necessary.

7.4. Pressure ulcer due to immobility

Frequently change the patient’s position

7.5. Gastric ulcer due to stress and gastrointestinal hemorrhage

- Allow the patient to eat through GI tract early (within 24-48 hours after hospitalization)

7.6. Muscle weakness associated with resuscitation

Let the patient move during treatment process whenever possible.

8. Special populations

8.1. Pregnant women

Pregnant women with suspected or confirmed SARS-CoV-2 infection shall be treated as instructed above, with attention paid to their physiological changes due to pregnancy.

8.2. Old people

Old people with underlying medical conditions are at higher risk of severity and death. Various wards should cooperate in caring and treating old people; pay attention to physiological changes in old people as well as drug interactions during treatment.

IX. CRITERIAL FOR DISCHARGE

1. A patient may be discharged from hospital after the following criteria are  fully satisfied:

- No fever for at least 3 days.

- Clinical symptoms have improved; vital signs are stable; organs are functional; blood test result is normal, lung x-ray images show improvements.

- At least two consecutive respiratory tract fluid samples (nasopharyngeal specimen and oropharyngeal specimen), taken at interval of at least 24 hours, test negative for SARS-CoV-2.

2. Post-discharge monitoring

- The facility that treated a patient shall inform the Center for Disease Control (CDC), health authority and local authority in charge of the patient’s area for continued monitoring the patient’s home quarantine process for 14 days after discharge.

- The patient should stay in a separate and ventilated room, wear facemasks, frequently wash hands, eat separately and avoid having contact with his/her family.

- Instruct the patient to take his/her own body temperature twice a day and visit a health facility if the body temperature exceeds 37,5°C two consecutive times or there is any unusual sign.