How does Wuhan respond to 2019-nCoV outbreak when the Spring Festival comes?

SARI

An ARI with history of fever or measured temperature ≥38 C° and cough; onset within the last ~10 days; and requiring hospitalization. However, the absence of fever does NOT exclude viral infection.

Surveillance case definitions for nCoV

1. Severe acute respiratory infection (SARI) in a person, with history of fever and cough requiring admission to hospital, with no other etiology that fully explains the clinical presentation1 (clinicians should also be alert to the possibility of atypical presentations in patients who are immunocompromised);

AND any of the following:

a) A history of travel to Wuhan, Hubei Province China in the 14 days prior to symptom onset; or

b) the disease occurs in a health care worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, without regard to place of residence or history of travel; or

c) the person develops an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, without regard to place of residence or history of travel, even if another etiology has been identified that fully explains the clinical presentation.

2. A person with acute respiratory illness of any degree of severity who, within 14 days before onset of illness, had any of the following exposures:

a) close physical contact2 with a confirmed case of nCoV infection, while that patient was symptomatic; or

b) a healthcare facility in a country where hospital-associated nCoV infections have been reported

Uncomplicated illness

Patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed may present with atypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of breath

Mild pneumonia

Patient with pneumonia and no signs of severe pneumonia.

Child with non-severe pneumonia has cough or difficulty breathing + fast breathing: fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia

Severe pneumonia

Adolescent or adult: fever or suspected respiratory infection, plus one of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2<90% on room air

Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 <90%; severe respiratory

distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be present: chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40. The diagnosis is clinical; chest imaging can exclude complications.

Acute Respiratory Distress Syndrome

Onset: new or worsening respiratory symptoms within one week of known clinical insult.

Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.

Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.

Oxygenation (adults):

• Mild ARDS: 200 mmHg < PaO₂/FiO₂ ≤ 300 mmHg (with PEEP or CPAP ≥5 cmH2O, 7 or non-ventilated8)

• Moderate ARDS: 100 mmHg < PaO₂/FiO₂ ≤200 mmHg with PEEP ≥5 cmH₂O, 7 or non-ventilated)

• Severe ARDS: PaO₂/FiO₂ ≤ 100 mmHg with PEEP ≥5 cmH₂O,  or non-ventilated)

• When PaO₂ is not available, SpO₂/FiO₂ ≤315 suggests ARDS (including in non-ventilated patients)

Oxygenation (children; note OI = Oxygenation Index and OSI = Oxygenation Index using SpO₂):

• Bilevel NIV or CPAP ≥5 cmH₂O via full face mask: PaO₂/FiO₂ ≤ 300 mmHg or SpO₂/FiO₂ ≤264

• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5

• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3

• Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Sepsis

Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection, with organ dysfunction. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

Children: suspected or proven infection and ≥2 SIRS criteria, of which one must be abnormal temperature or white blood cell count

Septic shock

Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L.

Children: any hypotension (SBP 2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR 160 bpm in infants and HR 150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia

At triage

Give suspect patient a medical mask and direct patient to separate area, an isolation room if available. Keep at least 1meter distance between suspected patients and other patients. Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for others. Perform hand hygiene after contact with respiratory secretions

Apply droplet precautions

Droplet precautions prevent large droplet transmission of respiratory viruses. Use a medical mask if working within 1-2 meters of the patient. Place patients in single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatial separation. When providing care in close contact with a patient with respiratory symptoms (e.g. coughing or sneezing), use eye protection (face-mask or goggles), because sprays of secretions may occur. Limit patient movement within the institution and ensure that patients wear medical masks when outside their rooms.

Apply contact precautions

Droplet and contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). Use PPE (medical mask, eye protection, gloves and gown) when entering room and remove PPE when leaving. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect between each patient use. Ensure that health care workers refrain from touching their eyes, nose, and mouth with potentially contaminated gloved or ungloved hands. Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Ensure adequate room ventilation. Avoid movement of patients or transport. Perform hand hygiene.

Apply airborne precautions when performing an aerosol generating procedure

Ensure that healthcare workers performing aerosol-generating procedures (i.e. open suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation) use PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection). (The scheduled fit test should not be confused with user seal check before each use.) Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary individuals in the room. Care for the patient in the same type of room after mechanical ventilation commences.    

Anticipated Outcome

Interventions

Reduce days of invasive mechanical ventilation

• Use weaning protocols that include daily assessment for readiness to breathe spontaneously

• Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless contraindicated) or with daily interruption of continuous sedative infusions

Reduce incidence of ventilator-associated pneumonia

• Oral intubation is preferable to nasal intubation in adolescents and adults

• Keep patient in semi-recumbent position (head of bed elevation 30-45º)

• Use a closed suctioning system; periodically drain and discard condensate in tubing

• Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or damaged but not routinely

• Change heat moisture exchanger when it malfunctions, when soiled, or every 5–7 days

Reduce incidence of venous thromboembolism

• Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000 units subcutaneously twice daily) in adolescents and adults without contraindications. For those with contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices).

Reduce incidence of catheter-related bloodstream infection

• Use a checklist with completion verified by a real-time observer as reminder of each step needed for sterile insertion and as a daily reminder to remove catheter if no longer needed

Reduce incidence of pressure ulcers

• Turn patient every two hours

Reduce incidence of stress ulcers and gastrointestinal bleeding

• Give early enteral nutrition (within 24–48 hours of admission)

• Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI bleeding. Risk factors for gastrointestinal bleeding include mechanical ventilation for ≥48 hours, coagulopathy, renal replacement therapy, liver disease, multiple comorbidities, and higher organ failure score

Reduce incidence of ICU-related weakness

• Actively mobilize the patient early in the course of illness when safe to do so