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Practical Recommendations of Peking Union Medical College Hospital for Assessment and Management of COVID-19 in Primary Care (2023)
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摘要: 随着疫情防控政策的科学调整，越来越多的临床医生尤其基层医生已面临接诊新型冠状病毒感染患者的情形。北京协和医院秉承“以人为本、全人照顾”的理念，依据世界卫生组织等国际指南、国家卫生健康委员会最新发布的《新型冠状病毒感染诊疗方案(试行第十版)》及《关于对新型冠状病毒感染实施“乙类乙管”总体方案》，坚持循证、简明、临床可操作的原则，编写了《北京协和医院新型冠状病毒感染基层诊疗建议(2023)》。对于目前尚缺乏循证医学证据的关键临床问题，结合北京协和医院一线工作经验及多学科专家意见，给出了相应诊疗建议。本诊疗建议强调在社区筛查重症高危人群，并尽早予以药物以及加强营养、心理治疗、睡眠支持等非药物干预，构筑家庭、社区、医院三道防线，以期实现“保健康、防重症”的总体目标。Abstract: Following the recent adjustments to coronavirus disease 2019 (COVID-19) prevention and control policies, an increasing number of medical staffs, especially those in primary care facilities are confronted with rapid growth of COVID-19 patients. Peking Union Medical College Hospital (PUMCH) has therefore compiled this recommendation for COVID-19 primary care practices based on a patient-centered perspective and following recommendations from domestic and international guidelines as well as the latest Chinese government policies. Further, PUMCH's conception and compilation of this recommendation strictly adhere to evidence-based, concise and clinically applicable principles of practice. For the critical clinical questions with insufficient medical evidence, the recommendation offers insights on the basis of experience from PUMCH multi-disciplinary expert team and first-line medics' practices. Emphasizing on screening community residents with higher risk of severe illness, implementing early interventions including pharmaceutical treatment, enhancing nutritional support and improving sleep quality, we aim to construct a "Household-Community-Hospital" tertiary defense, with the hope of promoting health and reducing severe cases.作者贡献：本诊疗建议由北京协和医院新型冠状病毒基层诊疗建议多学科专家组发起并完成，张抒扬、吴沛新、杜斌牵头并指导该诊疗建议编写工作；曾学军、张昀负责制定诊疗建议框架并对终稿进行审定；编写工作组成员负责查阅文献；张昀、张冰清、徐娜、沙悦共同起草初稿，李雪梅、吴东、张文、施举红、朱惠娟、曹玮、张波、高劲松、沈敏、林雪、赵静、田国庆、吕威在张抒扬和曾学军的组织下对本诊疗建议进行讨论和修订。利益冲突：所有参与本诊疗建议制定的人员均声明不存在利益冲突编写专家组成员：顾 问：张抒扬(中国医学科学院北京协和医院心内科/疑难重症及罕见病国家重点实验室)，吴沛新(中国医学科学院北京协和医院)，杜斌(中国医学科学院北京协和医院内科ICU)组 长：曾学军(中国医学科学院北京协和医院全科医学科/普通内科)成 员(按姓氏首字母排序)：曹玮(中国医学科学院北京协和医院感染内科)，高劲松(中国医学科学院北京协和医院妇产科)，李雪梅(中国医学科学院北京协和医院肾内科)，林雪(中国医学科学院北京协和医院心内科)，吕威(中国医学科学院北京协和医院耳鼻喉科)，沙悦(中国医学科学院北京协和医院全科医学科/普通内科)，沈敏(中国医学科学院北京协和医院风湿免疫科)，施举红(中国医学科学院北京协和医院呼吸与危重症医学科)，田国庆(中国医学科学院北京协和医院中医科)、吴东(中国医学科学院北京协和医院消化内科)，徐娜(中国医学科学院北京协和医院全科医学科/普通内科)，张冰清(中国医学科学院北京协和医院全科医学科/普通内科)，张波(中国医学科学院北京协和医院药剂科)，张文(中国医学科学院北京协和医院风湿免疫科)，张昀(中国医学科学院北京协和医院全科医学科/普通内科)，赵静(中国医学科学院北京协和医院呼吸与危重症医学科)，朱惠娟(中国医学科学院北京协和医院内分泌科)。编写工作组：狄虹，韩欣欣，黄程锦，焦洋，李智凯，王硕林，王一博，王悠扬，武娟，尹月，赵赫，朱卫国(中国医学科学院北京协和医院全科医学科/普通内科)执笔人：张昀，张冰清，徐娜，沙悦
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图 1 新冠病毒感染患者基层诊疗流程建议
T：体温；BP：血压；SBP：收缩压；HR：心率；RR：呼吸频率；SpO2：血氧饱和度；PaO2：动脉血氧分压；FiO2：吸氧浓度；ESR：红细胞沉降率；CRP：C-反应蛋白；ARDS: 急性呼吸窘迫综合征；DKA：糖尿病酮症酸中毒；HHS：高血糖高渗综合征；HIV：人类免疫缺陷病毒
表 1 奈玛特韦/利托那韦与常见药物联合应用速查表
药物种类 禁止合用 最好停用 可以使用 降脂药 辛伐他汀 阿托伐他汀、瑞舒伐他汀 依折麦布、非诺贝特、匹伐他汀、普伐他汀 降压药 乐卡地平 特拉唑嗪、地尔硫、氨氯地平、硝苯地平、缬沙坦 β-受体阻滞剂、ACEI/ARB、呋塞米、氢氯噻嗪 降糖药 - 格列本脲 二甲双胍、胰岛素、达格列净、恩格列净、吡格列酮 抗凝/抗血小板药 替格瑞洛、氯吡格雷、利伐沙班 华法林、艾多沙班 肝素、依诺肝素、阿司匹林、双嘧达莫 痛风相关药 秋水仙碱 - 非布司他、别嘌醇 镇静催眠药 地西泮、艾司唑仑 唑吡坦、佐匹克隆 劳拉西泮 镇痛药 - 曲马多、羟考酮、吗啡、芬太尼 双氯芬酸、布洛芬、对乙酰氨基酚、塞来昔布、丁丙诺啡、可待因、依托考昔 支气管扩张剂 沙美特罗 - 氨茶碱、异丙托溴铵、沙丁胺醇、噻托溴铵、福莫特罗、孟鲁司特 镇咳/化痰药 - - 右美沙芬、愈创甘油醚、麻黄碱、伪麻黄碱、乙酰半胱氨酸 胃肠道用药 多潘立酮 洛哌丁胺 奥美拉唑、泮托拉唑、法莫替丁、甲氧氯普胺 抗组胺药 - 氯雷他定 西替利嗪 抗感染药 利福平、利福喷丁 伏立康唑、泊沙康唑 阿奇霉素、西多福韦 免疫抑制剂 他克莫司、环孢素 - 甲氨蝶呤、霉酚酸酯 精神类药物 氯氮平 - 阿米替林、西酞普兰、氟西汀、加巴喷丁、奥氮平、舍曲林 ACEI/ARB：血管紧张素转化酶抑制剂/血管紧张素Ⅱ受体阻滞剂；-：无 
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