作者投稿
专家审稿
编辑办公
邮件订阅
RSS
Diagnosis and Clinical Management of COVID-19 Infection in Adults: Operational Recommendations of Peking Union Medical College Hospital (2023)
-
摘要: 随着我国疫情防控措施的科学调整，新型冠状病毒感染患者尤其是重症、危重症患者的救治成为医务人员现阶段的工作重点。疫情发生以来，北京协和医院在新型冠状病毒感染救治方面积累了较多经验，在结合众多国际循征医学证据的基础上，新型冠状病毒感染诊疗多学科专家组编写了《北京协和医院成人新型冠状病毒感染实用诊疗建议(2023)》。秉承循证、简洁、临床可操作的原则，本诊疗建议对目前最新研究证据进行整合，对于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临床工作经验和专家意见给出一定推荐，旨在提升医务人员对新冠病毒感染及其危重症的认识，提高患者救治水平。Abstract: With the adjustment of China's COVID-19 policies and measures, the treatment of infected patients, especially the severe and critically ill patients, has become the focus of all medical staff at this stage. Since the outbreak of the pandemic, Peking Union Medical College Hospital has accumulated rich experience in this field. Based on the updated international evidence-based knowledge, the multidisciplinary expert group of COVID-19 at Peking Union Medical College Hospital has compiled a set of operational recommendations. Adhering to the evidence-based, concise, and clinically operable principles, these recommendations for diagnosis and treatment integrate the latest research evidence. For clinical issues that lack evidence, certain recommendations are given based on the frontline clinical working experience and expert opinions. The purpose is to enhance medical staff's understanding of COVID-19 infection and its critical illness and improve patient care.作者贡献：本诊疗建议由北京协和医院新型冠状病毒感染诊疗多学科协作组发起并完成，张抒扬领导和组织了本编写小组，并任命王孟昭全权负责编写小组对本建议的撰写工作；范俊平、留永健、徐燕、田欣伦、王京岚共同起草了建议初稿，并在张抒扬和王孟昭的组织下对本建议进行讨论和修订，凝练推荐意见；杜斌、范俊平、黄慧、韩江娜、李太生、隆云、留永健、马小军、施举红、田欣伦、王京岚、翁利、王珞、王孟昭、谢怀娅、徐燕、徐英春、杨燕丽、张波、张弘、朱华栋、赵静、张抒扬共同参与了本建议的第2次商讨修订工作；王孟昭对全文进行最终审校后形成终稿。利益冲突：所有参与本建议制定的人员均声明不存在利益冲突本建议编写组成员 (按姓氏首字母排序)：杜斌(中国医学科学院北京协和医院内科ICU)，范俊平(中国医学科学院北京协和医院呼吸与危重症医学科)，韩江娜(中国医学科学院北京协和医院呼吸与危重症医学科)，黄慧(中国医学科学院北京协和医院呼吸与危重症医学科)，李太生(中国医学科学院北京协和医院感染科)，留永健(中国医学科学院北京协和医院呼吸与危重症医学科)，隆云(中国医学科学院北京协和医院重症医学科)，马小军(中国医学科学院北京协和医院感染科/医务处)，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)，田欣伦(中国医学科学院北京协和医院呼吸与危重症医学科)，王京岚(中国医学科学院北京协和医院呼吸与危重症医学科)，翁利(中国医学科学院北京协和医院内科ICU)，王珞(中国医学科学院北京协和医院呼吸与危重症医学科)，王孟昭(中国医学科学院北京协和医院呼吸与危重症医学科)，谢怀娅(中国医学科学院北京协和医院内科)，徐燕(中国医学科学院北京协和医院呼吸与危重症医学科)，徐英春(中国医学科学院北京协和医院检验科)，杨燕丽(中国医学科学院北京协和医院呼吸与危重症医学科)，张波(中国医学科学院北京协和医院药剂科)，张弘(中国医学科学院北京协和医院呼吸与危重症医学科)，赵静(中国医学科学院北京协和医院呼吸与危重症医学科)，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)，朱华栋(中国医学科学院北京协和医院急诊科)执笔人：范俊平，留永健，徐燕，田欣伦，王京岚
-
图 2 成人新冠病毒感染患者住院治疗流程图(改编自uptodate.com/COVID-19: Management in hospitalized adults)
HFNC：经鼻高流量氧疗；NIV：无创通气；ECMO：同表 2
表 1 成人新冠病毒感染患者门诊治疗推荐[4]
患者情况 推荐 不需要住院 所有患者： 不需要吸氧 ①对症治疗
②不推荐常规加用糖皮质激素，建议主诊医师根据具体病情决定是否使用
有发展为重症/危重症危险的人群：
①奈玛特韦/利托那韦(Paxlovid)
②莫诺拉韦(Molnupiravir)病情稳定的出院患者(即使需要吸氧) 不推荐出院后继续使用糖皮质激素或巴瑞替尼 
下载: 导出CSV
表 2 成人新冠病毒感染住院患者的治疗推荐[15]
病情严重度 抗病毒/免疫调节治疗 抗凝治疗
(无禁忌证的住院患者均建议抗凝治疗)临床情况 建议 无需吸氧 所有患者
有重症高危因素者不常规推荐使用激素
抗病毒治疗*预防量肝素抗凝：适用于无其他指征、需要治疗量抗凝的患者；妊娠期患者 常规吸氧(鼻导管、面罩) 只需小量常规吸氧
大部分患者
激素治疗中吸氧需求迅速增加，伴炎症指标显著升高抗病毒治疗*
①激素
②尽量联合抗病毒治疗*
加用托珠单抗或巴瑞替尼治疗量肝素抗凝：D-二聚体升高者(非妊娠，无明显出血风险者
预防量肝素抗凝：其他患者；妊娠期患者高流量吸氧或无创通气 大部分患者 ①激素
②尽量加用托珠单抗或巴瑞替尼
③酌情联合抗病毒治疗预防量肝素抗凝：适用于无其他需要治疗量抗凝指征的患者；妊娠期患者；由普通病房转ICU者，若原先已接受治疗量抗凝，则改为预防量抗凝，除非有其他指征需要治疗量抗凝 机械通气或ECMO 大部分患者 ①激素
②尽量加用托珠单抗或巴瑞替尼*NIH指南中推荐的抗病毒治疗药物主要为瑞德西韦(Remdesivir)，国内尚未上市；ECMO：体外膜肺氧合
下载: 导出CSV
-
[1] 国务院联防联控机制综合组. 新型冠状病毒感染诊疗方案(试行第十版)[EB/OL]. (2023-01-06) [2023-01-06]. http://www.nhc.gov.cn/ylyjs/pqt/202301/32de5b2ff9bf4eaa88e75bdf7223a65a/files/460b0e7b19bd42f3bba00c1efb9b6811.pdf. [2] WHO. Therapeutics and COVID-19: living guideline[EB/OL]. (2022-07-14)[2023-01-03]. https://www.who.int/publications/i/item/WHO-2019-nCoV-therapeutics-2022.4. [3] Singh AP, Finkelstein M, Chung M, et al. Review of Thoracic Imaging Manifestations of COVID-19 Coronaviruses and Other Pathologic [J]. Radiol Clin North Am, 2022, 60: 359-369. doi: 10.1016/j.rcl.2022.01.004 [4] CDC. Risk for COVID-19 infection, hospitalization, and death by age group[EB/OL]. (2022-12-28)[2023-01-03]. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html. [5] Fisman DN, Bogoch I, Lapointe-Shaw L, et al. Risk factors associated with mortality among residents with coronavirus disease 2019 (COVID-19) in long-term care facilities in Ontario, Canada [J]. JAMA Netw Open, 2020, 3: e2015957-e. doi: 10.1001/jamanetworkopen.2020.15957 [6] Suthar AB, Wang J, Seffren V, et al. Public health impact of covid-19 vaccines in the US: observational study [J]. BMJ, 2022, 377: e069317. [7] Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus disease 2019 case surveillance-United States, January 22-May 30, 2020 [J]. MMWR Morb Mortal Wkly Rep, 2020, 69: 759. doi: 10.15585/mmwr.mm6924e2 [8] Lighter J, Phillips M, Hochman S, et al. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission [J]. Clin Infect Dis, 2020, 71: 896-897. doi: 10.1093/cid/ciaa415 [9] Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area [J]. JAMA, 2020, 323: 2052-2059. doi: 10.1001/jama.2020.6775 [10] Goldman JD, Robinson PC, Uldrick TS, et al. COVID-19 in immunocompromised populations: implications for prognosis and repurposing of immunotherapies [J]. J Immunother Cancer, 2021, 9: e002630. doi: 10.1136/jitc-2021-002630 [11] Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China [J]. JAMA, 2020, 323: 1061-1069. doi: 10.1001/jama.2020.1585 [12] Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [J]. Lancet, 2020, 395: 1054-1062. doi: 10.1016/S0140-6736(20)30566-3 [13] Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study [J]. Lancet, 2020, 395: 507-513. doi: 10.1016/S0140-6736(20)30211-7 [14] Rubin GD, Ryerson CJ, Haramati LB, et al. The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society [J]. Radiology, 2020, 296: 172-180. doi: 10.1148/radiol.2020201365 [15] NIH. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines[EB/OL]. (2022-12-06)[2023-01-03]. https://www.ncbi.nlm.nih.gov/books/NBK570371/. [16] Bradley MC, Perez-Vilar S, Chillarige Y, et al. Systemic Corticosteroid Use for COVID-19 in US Outpatient Settings From April 2020 to August 2021 [J]. JAMA, 2022, 327: 2015-2018. doi: 10.1001/jama.2022.4877 [17] EUA HOEUA. Fact Sheet for Healthcare Providers: Emergency Use Authorization for EvusheldTM(Tixagevimab Co-Packaged with Cilgavimab)[EB/OL]. (2022-12)[2023-01-03]. https://www.fda.gov/media/154701/download. [18] Food UATJL, Cooperative PA. Evidence used to update the list of underlying medical conditions that increase a person's risk of severe illness from COVID-19[EB/OL]. (2022-12)[2023-01-03]. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/evidence-table.html. [19] Hiremath S, McGuinty M, Argyropoulos C, et al. Prescrib-ing nirmatrelvir/ritonavir for COVID-19 in advanced CKD [J]. Clin J Am Soc Nephrol, 2022, 17: 1247-1250. doi: 10.2215/CJN.05270522 [20] 辉瑞公司. PAXLOVID(奈玛特韦/利托那韦)—经肠内饲管给药[Z]. 2022. [21] 卫生健康委办公厅, 中医药局办公室. 关于将阿兹夫定片纳入新型冠状病毒肺炎诊疗方案的通知[EB/OL]. (2022-08-09)[2023-01-03]. http://www.gov.cn/zhengce/zhengceku/2022-08/10/content_5704788.htm. [22] Agarwal A, Rochwerg B, Lamontagne F, et al. A living WHO guideline on drugs for covid-19 [J]. BMJ, 2020, 370: n2219. [23] Chu VT, Schwartz NG, Donnelly MAP, et al. Comparison of Home Antigen Testing With RT-PCR and Viral Culture During the Course of SARS-CoV-2 Infection [J]. JAMA Intern Med, 2022, 182: 701-709. doi: 10.1001/jamainternmed.2022.1827 [24] White H, McDonald SJ, Barber B, et al. Care for adults with COVID-19: living guidelines from the National COVID-19 Clinical Evidence Taskforce [J]. Med J Aust, 2022, 217: 368-378. doi: 10.5694/mja2.51718 [25] Mohammadi M, Khafaee Pour Khamseh A, Varpaei HA. Invasive Airway "Intubation" in COVID-19 Patients; Statistics, Causes, and Recommendations: A Review Article [J]. Anesth Pain Med, 2021, 11: e115868. [26] El-Boghdadly K, Wong DJN, Owen R, et al. Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study [J]. Anaesthesia, 2020, 75: 1437-1447. doi: 10.1111/anae.15170 [27] Camous L, Pommier JD, Martino F, et al. Very late intubation in COVID-19 patients: a forgotten prognosis factor? [J]. Crit Care, 2022, 26: 1-4. doi: 10.1186/s13054-021-03885-y [28] Ospina-Tascon GA, Calderón-Tapia LE, Garcia AF, et al. Effect of high-flow oxygen therapy vs conventional oxygen therapy on invasive mechanical ventilation and clinical recovery in patients with severe COVID-19: a randomized clinical trial [J]. JAMA, 2021, 326: 2161-2171. doi: 10.1001/jama.2021.20714 [29] Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure [J]. N Engl J Med, 2015, 372: 2185-2196. doi: 10.1056/NEJMoa1503326 [30] Bellani G, Laffey JG, Pham T, et al. Noninvasive ventila-tion of patients with acute respiratory distress syndrome. Insights from the LUNG SAFE study [J]. Am J Respir Crit Care Med, 2017, 195: 67-77. doi: 10.1164/rccm.201606-1306OC [31] Ding L, Wang L, Ma W, et al. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study [J]. Crit Care, 2020, 24: 1-8. doi: 10.1186/s13054-019-2683-3 [32] Thompson AE, Ranard BL, Wei Y, et al. Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure [J]. JAMA Intern Med, 2020, 180: 1537-1539. doi: 10.1001/jamainternmed.2020.3030 [33] Weiss TT, Cerda F, Scott JB, et al. Prone positioning for patients intubated for severe acute respiratory distress syndrome (ARDS) secondary to COVID-19: a retrospective observational cohort study [J]. Br J Anaesth, 2021, 126: 48-55. doi: 10.1016/j.bja.2020.09.042 [34] Horby P, Lim WS, Emberson JR, et al. Dexamethasone in Hospitalized Patients with COVID-19 [J]. N Engl J Med, 2021, 384: 693-704. doi: 10.1056/NEJMoa2021436 [35] NHS. Interleukin-6 inhibitors (tocilizumab or sarilumab) for hospitalised patients with COVID-19 pneumonia (adults) [EB/OL]. (2021-02-17)[2023-01-03]. https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103144. [36] Kramer A, Prinz C, Fichtner F, et al. Janus kinase inhibitors for the treatment of COVID-19 [J]. Cochrane Database Syst Rev, 2022, 6: CD015209. [37] Gordon AC, Mouncey PR, Al-Beidh F, et al. Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19 [J]. N Engl J Med, 2021, 384: 1491-1502. doi: 10.1056/NEJMoa2100433 [38] Schiff MH, Kremer JM, Jahreis A, et al. Integrated safety in tocilizumab clinical trials [J]. Arthritis Res Ther, 2011, 13: 1-13. [39] Guimarães PO, Quirk D, Furtado RH, et al. Tofacitinib in Patients Hospitalized with Covid-19 Pneumonia [J]. N Engl J Med, 2021, 385: 406-415. doi: 10.1056/NEJMoa2101643 [40] Han MK, Antila M, Ficker JH, et al. Ruxolitinib in addition to standard of care for the treatment of patients admitted to hospital with COVID-19 (RUXCOVID): a randomised, double-blind, placebo-controlled, phase 3 trial [J]. Lancet Rheumatol, 2022, 4: e351-e361. doi: 10.1016/S2665-9913(22)00044-3 [41] Lansbury L, Lim B, Baskaran V, et al. Co-infections in people with COVID-19: a systematic review and meta-analysis [J]. J Infect, 2020, 81: 266-275. doi: 10.1016/j.jinf.2020.05.046 [42] Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19 [J]. J Thromb Haemost, 2020, 18: 1023-1026. doi: 10.1111/jth.14810 [43] Sullivan DJ, Gebo KA, Shoham S, et al. Early Outpatient Treatment for Covid-19 with Convalescent Plasma [J]. N Engl J Med, 2022, 386: 1700-1711. doi: 10.1056/NEJMoa2119657 [44] Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research [J]. Crit Care Med, 2016, 44: 1553-1602. doi: 10.1097/CCM.0000000000001856 [45] Poon LC, Yang H, Dumont S, et al. ISUOG Interim Guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium: information for healthcare professionals-an update [J]. Ultrasound Obstet Gynecol, 2020, 55: 848. doi: 10.1002/uog.22061 [46] Pfizer Lab. Fact sheet for healthcare providers: emergency use authorization for paxlovid[EB/OL]. (2022-03-18) [2023-01-03]. https://www.fda.gov/media/155050/down-load. [47] McCreary EK, Lemon L, Megli C, et al. Monoclonal Antibodies for Treatment of SARS-CoV-2 Infection During Pregnancy: A Cohort Study [J]. Ann Intern Med, 2022, 175: 1707-1715. doi: 10.7326/M22-1329 [48] Kabinger F, Stiller C, Schmitzová J, et al. Mechanism of molnupiravir-induced SARS-CoV-2 mutagenesis [J]. Nat Struct Mol Biol, 2021, 28: 740-746. doi: 10.1038/s41594-021-00651-0 [49] CDC. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic[EB/OL]. (2022-09-23)[2023-01-03]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. [50] Zhang M, Zheng H, Wang J. Strategy of using personal protective equipment during aerosol generating medical procedures with COVID-19 [J]. J Clin Anesth, 2020, 66: 109911. doi: 10.1016/j.jclinane.2020.109911 [51] Hong K, Cao W, Liu Z, et al. Prolonged presence of viral nucleic acid in clinically recovered COVID-19 patients was not associated with effective infectiousness [J]. Emerg Microbes Infect, 2020, 9: 2315-2321. doi: 10.1080/22221751.2020.1827983 [52] Kim MC, Cui C, Shin KR, et al. Duration of culturable SARS-CoV-2 in hospitalized patients with Covid-19 [J]. N Engl J Med, 2021, 384: 671-673. doi: 10.1056/NEJMc2027040 [53] Yahav D, Yelin D, Eckerle I, et al. Definitions for coronavirus disease 2019 reinfection, relapse and PCR re-positivity [J]. Clin Microbiol Infect, 2021, 27: 315-318. doi: 10.1016/j.cmi.2020.11.028 [54] Abu-Raddad LJ, Chemaitelly H, Bertollini R. Severity of SARS-CoV-2 reinfections as compared with primary infections [J]. N Engl J Med, 2021, 385: 2487-2489. doi: 10.1056/NEJMc2108120 [55] CDC. Interim Clinical Considerations for Use of COVID-19 Vaccines: Appendices, References, and Previous Updates[EB/OL]. (2022-12-09)[2023-01-03]. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us-appendix.html. [56] CDC. Ending Isolation and Precautions for People with COVID-19: Interim Guidance[EB/OL]. (2022-08-31)[2023-01-03]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html. -
点击查看大图
图(3) / 表(2)
计量
- 文章访问数: 678
- HTML全文浏览量: 112
- PDF下载量: 407
- 被引次数: 0
