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Diagnosis and Treatment Plan for Serious and Critical Cases of Novel Coronavirus Pneumonia (Provisional) (5th Ed.)

I. Definition of Serious and Critical Cases of Pneumonia from Novel Coronal Virus Infection

(1) Serious cases.

Meet any of the following requirements:

1. respiratory rate (≥30 / min), difficulty breathing, cyanosis of the lips;

2. When inhaling air, oxygen saturation ≤93%;

3. The arterial partial pressure of oxygen (PaO2) / oxygen concentration (FiO2) ≤300mmHg (1mmHg = 0.133kPa);

4. Lung imaging reveals multiple leafy lesions or lesions progress >50% within 48 hours;

5. Other clinical circumstances that require in-patient care when taken together.

(2) Critical Cases.

Those meeting any of the following conditions:

1. Respiratory failure requiring mechanical ventilation;

2. Shock;

3. Combined with other organ failures, require ICU care treatment.

II. Treatment of Serious and Critical Cases

(1) Treatment Principles. On the basis of symptomatic treatment, actively carry out life support, prevent organ dysfunction, treatment of the underlying illness, and actively prevent and treat complications.

(2) Active Oxygen Therapy. 重症、危重症患者应提供积极的氧疗,维持 SpO2在 90%以上,或 PaO2在 60mmHg 以上;通过储氧面罩吸氧(流量为 10-15L/min,吸入氧浓度60-95%)方便、快捷,但不适合于存在 CO2潴留的患者。

经鼻高流量氧疗可以提供 60L/min 的流量和高达 100%的吸入氧浓度。 Patients with hypercapnia, hemodynamic instability, multiple organ failure, or irregular cognition are not suitable for nasal high-flow oxygen therapy.

(3) Mechanical Ventilation. Mechanical ventilation shall be carried out for patients that oxygen therapy is unable to improve. 可首选无创机械通气,治疗时应逐步提高无创通气的压力水平,以使患者逐步适应。 无创机械通气需要更细致的观察,重点是面罩是否漏气以及患者是否与呼吸机有良好的同步。 如密切观察 2 小时,病情无改善,或患者不能耐受无创通气、气道分泌物增多、剧烈咳嗽,或血流动力学不稳定,应及时行气管插管进行有创机械通气。

有创机械通气时应采取“肺保护性通气策略”,即给予较低的潮气量(预计体重 4–8ml/kg)和较低的吸气压力(平台压<30cmH2O),以降低呼吸机相关肺损伤。 重度的 ARDS 应使用较高的 PEEP,每天进行>12 小时的俯卧位通气,必要时可采取肺泡复张等治疗方法。 如机械通气仍无法改善患者氧合,则应进行体外外膜氧合(ECMO)治疗。

For patients with circulatory obstructions, fluid intake should be appropriately limited to reduce pulmonary edema.

(4) Circulatory Support. Consider septic shock when persistent hypotension continues under full fluid resuscitation, vasoactive drugs are required to maintain mean arterial pressure (MAP)≥65mmHg, and serum lactic acid levels are still ≥ 2 mmol/L. Adequate fluid resuscitation is the key to the treatment. During the initial recovery period of 3 hours, at least 30ml / kg of isotonic crystalloid solution .should be given. Hypotonic crystalloid solution, starches or gelatins should not be used for resuscitation. During treatment, hemodynamic monitoring should be carried out to prevent excessive volume load caused by excessive fluid. If shock continues after ample fluid resuscitation, the use of vasoactive drugs may be required. The target average arterial pressure for adults is ≥65mmHg.

Adrenal glucocorticoid therapy should be used for serious patients where appropriate. Supportive care is essential to the treatment of patients, and they should be given adequate calories and nutrients.

General Office of the National Health Commission

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