key: cord-0062133-4ywlbkfm authors: Wang, Gui-Qiang; Zhao, Lei; Wang, Xia; Jiao, Yan-Mei; Wang, Fu-Sheng title: Diagnosis and Treatment Protocol for COVID-19 Patients (Tentative 8th Edition): Interpretation of Updated Key Points date: 2021-04-20 journal: nan DOI: 10.1097/id9.0000000000000002 sha: c72bf0c383979831f806a7cecac5eae4f80dcf3a doc_id: 62133 cord_uid: 4ywlbkfm nan Asymptomatic infected individuals or patients have been recognized as an important source of further infection. Current research has shown that the asymptomatic are similarly as infectious as COVID-19 patients. Simultaneously, since asymptomatic infected individuals or patients do not take the initiative to seek medical treatment, their infectivity is more insidious. In this regard, large-scale active nucleic acid screening is an essential means to eliminate the potential transmission of the asymptomatic, and it is an effective measure in clinical practice. Moreover, following novel coronavirus infection, the infectivity during the incubation period is similar to that after the onset of illness, thus the statement that "infectivity occurs during the incubation period, but is highly infectious within five days after the onset of illness" was added. During the incubation period, transmission risk control is the key to quickly control the epidemic. Therefore, monitoring the mobility of the high-risk population and actively using nucleic acid detection are effective ways to eliminate the risk of latent infection. Imported frozen food and outer packaging has tested positive for the SARS-CoV-2 nucleic acid, thus was added to the transmission route that included "contact with virus-contaminated items can also cause infection", which is a reminder that epidemiological information should be paid attention to in clinical diagnosis. Furthermore, regular nucleic acid screening for employees can detect infected persons early and help control transmission before spread. The new guidelines give an update on pathological characteristics of COVID-19. Anatomical features and microscopic findings of the main affected organs, such as the lungs, spleen, hilar lymph nodes, bone marrow, heart, blood vessels, liver, gallbladder, kidneys, brain tissue, esophagus, stomach, intestinal mucosa, and testes were described in detail, which provides a basis for understanding the clinical manifestations and therapeutic interventions of COVID-19. For example, the characteristics of extensive thrombosis provide a basis for clinical anticoagulation therapy, and the decrease of lymphocytes in the spleen and lymph nodes is consistent with the appearance of peripheral blood, which provides a basis for clinical immunological intervention. A new guideline adds that "in some patients, decrease or loss of smell and taste is the first symptom." Since decrease of smell and taste is common in upper respiratory diseases, this chief complaint is often neglected if not carefully questioned. Simultaneously, "a small number of patients can also have central nervous system involvement and avascular necrosis of the extremities" and other manifestations, prompting clinicians to pay attention to the monitoring and intervention of consciousness change and coagulation mechanisms. A multi-system inflammatory syndrome in children (MIS-C) has been reported by many countries worldwide, and the clinical manifestations of MIS-C were generalized in the new guideline. Thus, clinicians should be aware of this new addition. The updated guidelines added that "SARS-CoV-2-specific IgM and IgG antibodies have a low positive rate within 1 week of onset". It was suggested that patients who are clinically suspected to have COVID-19 and those in convalescence with a negative nucleic acid result should be diagnosed by the antibody test to offset the false-negative nucleic acid result. Given the possibility of a false negative in nucleic acid detection and to further strengthen the screening of cases, which will effectively control the epidemic situation, "those who have no clear epidemiological history and meet any two clinical manifestations, and who are positive for novel coronavirus specific IgM antibody" should be added to "suspected cases". However, attention should be paid to the false-positive results of the IgM antibody test. The diagnostic criteria for severe cases in adults and children have been appropriately modified. For example, some ordinary patients may not experience fever or respiratory symptoms, but have the appearance of pneumonia in image. The people who have been identified as high-risk of severe and critical cases are as follows: (1) elderly people, age >65; (2) Patients with cardiovascular and cerebrovascular diseases (including hypertension), chronic lung diseases (chronic obstructive pulmonary disease, moderate to severe asthma), diabetes, chronic liver, kidney diseases, tumors, and other primary diseases; (3) Immunodeficiency (eg, AIDS patients, people treated by chronic use of corticosteroids or other immunosuppressive drugs); (4) Obesity (BMI ≥ 30); (5) Women in the third trimester of pregnancy and perinatal period; and (6) Heavy smokers. Thus, identifying high-risk groups provides the basis for early clinical intervention. For the high-risk patients, more active disease observation and timely oxygen therapy are needed to reduce the risk of disease progression. It is crucial to discern the signs of severe or critical cases and transfer patients to the ICU in time to minimize the fatality rate. Through the analysis and summary of a large number of cases, studies have shown that many indicators can predict the occurrence of severe/critical cases, such as lymphocyte count, inflammation indicators, etc. It is worth noting that those indicators differ among children and adults, which provides evidence for early clinical intervention. In addition, some indicators, such as lactate dehydrogenase level and troponin, can be used as warning indicators. In clinical practice, it is necessary to dynamically monitor the patient to discover changes in disease for timely intervention and quickly transfer patients into ICU for treatment. In clinical practice, suspected cases are often negative for nucleic acid detection, but due to false-negative results of nucleic acid detection, SARS-CoV-2 infection cannot be ruled out for such patients. Therefore, patients may be excluded from a COVID-19 diagnosis when (i) the nucleic acid test results of suspected cases were negative for two consecutive novel coronavirus nucleic acid tests (the sampling time was at least 24 hours apart) and (ii) the specific IgM and IgG antibodies remain negative seven days after onset. This information provides criteria for exclusion of suspected cases, avoiding the problem of indefinite detention. Currently, there are no recognized specific antiviral drugs. Some antiviral drugs with safety data have been reserved for clinical trial use for the treatment of pneumonia in patients with COVID-19. However, the necessity of further randomized, double-blind, placebo-controlled studies has been emphasized. Lopinavir/ ritonavir and ribavirin alone, hydroxychloroquine, or azithromycin in combination are clearly not recommended. A low dose of hormone and a short course of treatment have been recommended for patients with progressive deterioration of oxygenation index, rapid imaging progression, and excessive activation of inflammatory reaction. (1) The timely assessment of improvement in respiratory distress and/or hypoxemia should be performed. If no signs of improvement, additional respiratory support measures should be taken. The treatment using prone position ventilation has been emphasized for patients receiving oxygen therapy. If there are no complications, prone position ventilation (ie, awake in the prone position) should be simultaneously recommended. The treatment time while in the prone position should be more than 12 hours. (2) The contents related to airway management were added and include the initiation timing, extracorporeal membrane oxygenation (ECMO) indications, ECMO mode selection, and recommended initial setting of ECMO. (3) Indications for preventive "anticoagulant therapy" have been added, and in the event of a thromboembolic event, anticoagulant therapy should be administered using the appropriate guidelines. (4) Principles of the treatment in MIS-C have been added, such as the usage of intravenous gamma globulin (IVIG), glucocorticoids, and aspirin. Because pulmonary fibrosis may occur in COVID-19 patients with severe pneumonia and patients generally have emotional states, such as anxiety and tension, it has been recommended to "pay attention to early rehabilitation intervention of patients, actively carry out rehabilitation training and intervention for respiratory function, physical function and psychological dysfunction of patients with pneumonia in COVID-19, and restore physical fitness, physique, immunity and mental health as much as possible". TCM plays an important role in the treatment of pneumonia in COVID-19 patients. The eighth-edition guidelines have refined the TCM treatment principle based on syndrome differentiation and highlighted the "three drugs and three schemes" for clinical treatment. The nursing of critically-ill patients is a vital link to improve prognosis. Therefore, "nursing" has been added to the eighthedition of the guidelines, which has stressed the importance of "closely monitoring vital signs and state of consciousness, emphasizing oxygen saturation" in severe/critical patients with COVID-19. Nursing is necessary to prevent pressure injury in bedridden patients and strengthen the prevention and management of pressure injury in prone ventilation patients. Moreover, reducing nosocomial infection is the key to decreasing criticallyill patients' mortality rate due to prevention and control of hospital infection. The eighth-edition of the guidelines has suggested to keep good personal and environmental hygiene, improve health literacy, keep adequate indoor ventilation, perform personal protection that has been scientifically proven, and visit the doctor when illness is suspected. None. Recommendations and guidance for providing pharmaceutical care services during COVID-19 pandemic: a China perspective Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study Clinical characteristics and treatment outcome of COVID-19 patients with stroke in China: a multicenter retrospective study COVID-19 in China: risk factors and R0 revisited Update on the outbreak of Covid-19 as at 24:00 Diagnosis and treatment protocol for COVID-19 patients (Tentative 8th Edition) Diagnosis and treatment protocol for COVID-19 patients (tentative 8th edition): Interpretation of updated key points