Systemic Corticosteroids

Professional societies recommend using systemic corticosteroids in the treatment of severe and critical COVID-19 (see the DoD COVID-19 PMG for more details).  If unfamiliar with corticosteroid treatment regimens, discuss with advanced provider via telehealth prior to initiating therapy.

Antimicrobial Therapy (to treat possible bacterial pneumonia co-infection)

• 1) Consider early use of azithromycin (500mg PO or IV daily for a minimum of 5 days) to treat mild to moderate community acquired pneumonia (CAP) in patients with lower respiratory tract symptoms and fever.
• 2) If azithromycin is not available, doxycycline (100mg PO or IV q12h) can be substituted for empiric treatment of bacterial pneumonia.
• 3) For patients with severe symptoms, recommend adding ceftriaxone (IV 2gm q24h is the best option) or ampicillin-sulbactam (3gm IV q6hr is a good alternative) or ertapenem (1g IV or IM q24h if it is the only available option).
• 4) Levofloxacin (750mg PO or IV q24h) is another reasonable option for empiric treatment of severe community-acquired pneumonia.

Fever Management

Fever management with acetaminophen every 6 hours (1000mg IV or 975mg PO or PR) as needed for temperature over 38°C.

Sedation and Analgesia

• 1) Sedation goal is Richmond Agitation and Sedation Scale (RASS) -1 to -2 (comfortable, transiently responsive to verbal stimulation) and synchronous with the ventilator. Increase sedation and/or add narcotics to improve patient-ventilator synchrony.  Use of paralytics may be required for very severe cases (as discussed below).
• 2) Ketamine may cause increased secretions which may require more frequent suctioning. If medication options are limited, consider more frequent dosing of midazolam to decrease the dose of ketamine required and potentially decrease the secretion burden.
• 3) A reference guide for starting and titrating a ketamine drip along with useful adjuncts is provided in JTS Analgesia and Sedation Management during Prolonged Field Care CPG.
• 4) Combined use of multiple sedatives (i.e. propofol, dexmedetomidine and/or midazolam) may act synergistically to decrease the total sedative dose and help to mitigate the hypotensive effects of propofol, however multiple continuous drips is not recommended outside of an ICU setting. A ketamine drip may be combined with bolus doses of additional medications.
• 5) Caution should be used with combining propofol and dexmedetomidine, especially in younger patients with higher vagal tone due to increased risk of bradycardia and hypotension.
• 6) Intermittent or doses of fentanyl or hydromorphone may be useful for analgesia and optimizing ventilator synchrony.
• 7) Low dose vasopressors may be necessary to support hemodynamics in the face of deeper sedation and higher PEEP. (See Appendix D.)

Bronchodilation

• 1) Use of metered-dose-inhalers (MDIs) over nebulized bronchodilators to treat wheezing will help to minimize risk for infectious aerosol.
• 2) If the ventilator tubing does not have a capped inlet for medication administration (aka MDI adapter) -- 1) clamp the ETT, 2) disconnect the ventilator, and 3) administer the MDI (6 puffs) directly into the INHALATION circuit. Then, reconnect the ventilator and unclamp ETT to insufflate the medication.
• 3) Magnesium Sulfate 2gm IV over 20 minutes (similar to treatment of an asthma exacerbation) may be a safer alternative for treatment of bronchospasm given the risks of disconnecting the circuit.