Promulgation Date: 2020-1-22 Title: 国家卫生健康委办公厅关于加强新型冠状病毒感染的肺炎重症病例医疗救治工作的通知 Document Number:国卫办医函〔2020〕64号 Expiration date: Promulgating Entities:General Office of the National Health Commission Source of text: http://www.nhc.gov.cn/yzygj/s7653p/202001/9fbefc9a5fe747e98ea5baeedfb68158.shtml
To the health commissions of each province, autonomous region, directly-governed municipality, and municipalities with independent planning status and that of the Xinjiang production and construction corps.
Recently, there has been an outbreak of pneumonia from a novel coronavirus in some of our nation's provinces. In order to further strengthen national efforts to treat serious cases of pneumonia from infection by the novel coronavirus (hereinafter 'serious cases') to ensure that serious cases receive prompt and effective medical care, and to truly protect the health of the people, the following notice on completing relevant efforts is given:
I. Emphasize organizational work on medical treatment for serious cases
Each area should put great emphasis on strengthening efforts on the treatment of serious cases of pneumonia from the novel Coronavirus, increasing the extent of organizational coordination, making overall plans for medical resources, earnestly organizing efforts to do a good job of treating serious cases. The principle of 'centralizing patients, experts, resources, and treatment' should be strictly implemented, to arrange for the strongest and most able medical forces and medical establishments are giving care. Further augment the forces of fever clinics, emergency rooms, and key departments such as respiratory and critical departments, and ensure personnel, medicine, and material resources. A provincial-level experts group on the treatment of serious cases should be established to quickly organize expert consultations and formulation of effective medical treatment plans.
II. Regulate the Carrying Out of Medical Treatment
Strengthen the training of medical personnel at all levels and types of medical establishment, increasing capacity for the early recognition and diagnosis of pneumonia from the novel coronavirus, emphasizing attention to the elderly and special populations with underlying illness, closely observing changes in their conditions. Relevant medical establishments should establish working groups for the treatment of serious cases, following the requirements of the "Diagnosis and Treatment Plan for Intensive and Critical Cases of Pneumonia from the Novel Coronavirus" (Provisional) (see Attachment) to, on a foundation of treatment, also actively prevent and treat complications, and promptly carrying out organ function support to reduce the mortality rate as much as possible. Key consultations for severe cases should be strengthened to discuss difficult critical and serious cases, and to carry out dynamic assessment of serious cases to promptly adjust treatment plans.
Determine the place for treatment based on the severity of the symptoms, suspected and confirmed cases should be given isolated treatment in designated hospitals with the capacity for effective isolation and protection, hospitals for the treatment of serious cases should establish a working group for treatment in that hospital, and appoint core skilled forces that have a strong sense of responsibility and high skill level to participate in treatment efforts.
III. Strictly implement measures such as for the transport of series cases and the prevention and control of contagion in hospitals
Serious cases shall be transported as quickly as possible to the hospital in that jurisdiction which is the strongest overall and has the best capacity for protection against respiratory tract infections. Serious cases are to be transported by special vehicles, which are to be promptly and scientifically decontaminated in a standardized fashion; and personnel aboard the cases should take precautions in accordance with regulations. Medical establishments should strengthen training on the prevention and control of infections in hospital, implement the duties of their posts, and strictly enforce disinfection and quarantine, and scientifically cary out personal protection measures. At the same time, medical establishments should strengthen the management of clinical and experimental biological security, work as hard as possible to avoid the occurrence of contagion within the hospital.
IV. Correctly understand information on serious cases
Each provincial-level administrative department for health should have a grasp of the treatment of severe cases in the jurisdiction, and promptly follow procedures to report the on the area's severe cases. Each province should clarify the numbers and circumstances of serious cases in the region, truly increasing the accuracy of reported data, preventing reports with errors and ommissions, and rejecting concealment. Analysis and assessment of serious cases should be enhanced, and if it is necessary for the state to appoint experts to support medical treatment, applications may be made to this Commission.
Contacts: Bureau for Medical Administration; Cao Yulong, Du Qingyang
Attachment: "Diagnosis and Treatment Plan for Intensive and Critical Cases of Pneumonia from the Novel Coronavirus" (Provisional)
General Office of the National Health Commission
January 22, 2020
Diagnosis and Treatment Plan for Intensive and Critical Cases of Pneumonia from the Novel Coronavirus (Provisional)
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), trouble breathing, cyanosis of 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 shows leafy lesions or the focus of infection progresses > 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;
3. Combined with other organ failure requiring 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. Active oxygen therapy should be provided to serious and critical patients to maintain SpO2 above 90%, or PaO2 above 60mmHg; oxygen inhalation through oxygen mask (flow rate 10-15L/min, oxygen concentration 60-95%) is convenient and fast, but it is not suitable for patients with CO2 retention.
Nasal high-flow oxygen therapy can provide 60L/min flow and up to 100% inhaled oxygen concentration. 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. At least 30ml / kg of isotonic crystalloid solution should be given in the first 3 hours of resuscitation. 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.