COVID-19 Curbside Consults

The hospitalized patient with COVID-19 on the medical ward: Cleveland Clinic approach to management

Maria Miklowski, MD, FACP, Bruce Jansen, MD, Moises Auron, MD, FAAP, FACP, SFHM and Christopher Whinney, MD, FACP, SFHM
Cleveland Clinic Journal of Medicine November 2020, DOI: https://doi.org/10.3949/ccjm.87a.ccc064

Article Figures & Data

Tables

  • TABLE 1

    Cleveland Clinic COVID-19 non-ICU order set

    TypeOrders
    RespiratoryOxygen management
    Oxygen device: [eg, nasal cannula]
    Flow
    Target SpO2 range
    Laboratory testsGeneral prognostic markers for COVID-19a

    • C-reactive protein

    • D-dimer

    • Ferritin, blood

    • Lactate dehydrogenase


    General labs and cultures

    • Complete blood cell count with differential

    • Complete metabolic panel

    • Lupus anticoagulant, plasma

    • Magnesium, blood

    • Phosphorus, inorganic

    • Procalcitonin

    • Prothrombin time and International Normalized Ratio

    • Activated partial thromboplastin time

    • SARS-CoV-2

    • Rapid polymerase chain reaction assay for influenza and respiratory syncytial virus

    • Urinalysis with microscopic examination, reflex culture

    • Blood culture x 2 panel (STAT Lab Collect)


    Cardiac prognostic markers for COVID-19b

    • High-sensitivity troponin T for 5 days

    • N-terminal pro-B-type natriuretic peptide

    • Creatine kinase

    • Creatine kinase MB fraction only

    ImagingcChest radiograph 2 views (front and lateral)
    Chest radiograph 1 view (front, portable)
    CardiologyElectrocardiography

    • ↵a Inflammatory markers (ferritin, lactate dehydrogenase, D-dimer, C-reactive protein) may be tracked daily or every other day initially.

    • ↵b Severely elevated cardiac markers, without acute ischemic changes on an electrocardiogram, suggest inflammatory injury rather than acute coronary syndrome.

    • ↵c Portable imaging is preferred to reduce caregiver exposure.

  • TABLE 2

    Thromboprophylaxis for patients with COVID-19 or patients under investigation

    If D-dimer is < 3,000 FEU or unknown, and:

    • No renal impairment: enoxaparin 40 mg every 24 hours

    • Creatinine clearance 10–30 mL/hour: enoxaparin 30 mg every 24 hours

    • Creatinine clearance < 10 mL/hour, acute kidney injury, or dialysis: heparin 5,000 units every 12 hours

    If D-dimer is ≥ 3,000 FEU or critically ill patient (independent of D-dimer level), and:

    • No renal impairment: enoxaparin 40 mg every 12 hours

    • Creatinine clearance 10–30 mL/hour: enoxaparin 40 mg every 24 hours

    • Creatinine clearance < 10 mL/hour, acute kidney injury, or dialysis: heparin 7,500 units every 12 hours

  • TABLE 3

    Summary of treatment recommendations for patients with COVID-19 at Cleveland Clinic

    Mild to moderate illness (no hypoxia, no radiographic pneumonia, oxygen saturation (SpO2) > 94% on room air)
    Supportive care
    Severe illness (hypoxia [SpO2 < 94% on room air], radiographic evidence of pneumonia, not critically ill)
    Supportive care
    Dexamethasone
    Remdesivir
    Infectious disease consult
    Possibly emerging therapies
    Possible enrollment in clinical trials
    Critically ill (mechanically ventilated)
    Dexamethasone
    Remdesivir
    Infectious disease consult
    Possibly convalescent plasma (in the context of a clinical trial)
    Possibly emerging therapies
    Possible enrollment in clinical trials
    Immunosuppressed patients
    Consider reduction in immunosuppression in conjunction with rheumatology or oncology consultant
    Dexamethasone
    Remdesivir
    Pregnant patients
    As above, consider risks and benefits of glucocorticoids and remdesivir
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