Tableau 1: Outil de prise en charge du patient COVID-19 pour les patients candidats à une approche conservative (de Fusi-Schmidhauser T, Preston NJ, Keller N, Gamondi C. Conservative Management of COVID-19 Patients-Emergency Palliative Care in Action. J Pain Symptom Manage. 2020 Apr 8:S0885-3924(20)30183-4. doi: 10.1016/j.jpainsymman.2020.03.030. Epub ahead of print. https://www.sciencedirect.com/journal/journal-of-pain-and-symptom-management © 2020 American Academy of Hospice and Palliative Medicine. Reproduction avec l’aimable permission de Elsevier.). |
Recommendations for Conservative and Palliative Care Management of COVID-19 Patients (3D-TiCoS) |
Phase of Illness | Monitoring (Nursing) | Drugs for Symptom Control |
Stable: EWS: ≤7 RR: ≤25/minute O2 Sat: >88% (with Venturi mask up to 60%) | • 3D assessment and vital signs once per shift • Evaluate pressure areas & need for pressure relieving mattress • Intensify communication with the family and prepare that sick enough to die | Dyspnea/pain: Morphine PO 2−5 mg, 4 hourly with rescue doses (10%−20% of the total daily dose) or PRN |
Anxiety: Lorazepam sublingual 1−2,5 mg, 8 hourly or PRN or Levomepromazine PO 5−10 mg, 6 hourly or PRN |
Fever: Paracetamol PO 1 g, 6 hourly or PRN |
Shivers: Morphine 2−5 mg IV/SC PRN or Pethidine 25−50 mg SC PRN |
Prescribing opioids in renal insufficiency: choose Hydromorphone (accordingly to palliative care consultation). Temporary de-prescribing of usual drugs. |
Unstable: EWS >7 RR: >25/minute O2 Sat: <88% | • 3D assessment twice per shift and≈stop vital signs measurement • O2 delivery maximum 4 L • Observe respiratory effort • Inform the family that patient now unstable and propose visit | Dyspnea/pain: Morphine IV/SC 5 mg, 2−4 hourly with rescue doses (10%−20% of the total daily dose) or PRN |
Anxiety/delirium/distress: Diazepam 2,5−5 mg IV or rectal 10 mg 8−12 hourly with rescue doses PRN or chlorpromazine 12,5−25 mg IV PRN or levomepromazione 6,25−25 mg SC PRN |
Fever: Diclofenac 75 mg IV with rescue doses PRN or paracetamol rectal 600 mg, 6 hourly |
Shivers: Morphine 5 mg IV/SC PRN or pethidine 25−50 mg SC PRN |
Hydration maximum 250 mL/day |
Suspend futile treatments |
End-of-Life: ARDS O2 Sat: <70% | • 3D assessment twice per shift if patient alert • Assess ABDT2 twice per shift if patient does not communicate • Stop O2 • Inform the family and re-evaluate for family visits • Basic care and mouth care | Terminal dyspnea−Respiratory distress: • Morphine IV/SC 5 mg (up to every hour) with rescue doses (10%−20% of the total daily dose) or PRN. Evaluate continuous infusion with palliative care team. • Diazepam 2,5−5 mg IV or rectal 10 mg 8−12 hourly with rescue doses PRN |
Hyperactive delirium: • Diazepam 2,5−5 mg IV or rectal 10 mg 8−12 hourly with rescue doses PRN • Chlorpromazine 12,5−50 mg IV PRN or levomepromazione 12,5−50 mg SC PRN |
Fever: Diclofenac 75 mg IV with rescue doses PRN or paracetamol rectal 600 mg, 6 hourly |
Shivers: Morphine 5 mg IV/SC PRN or pethidine 25−50 mg SC PRN |
COVID-19 = coronavirus disease 2019; 3D-TiCoS = 3D-Ticino 2019-nCov Score; EWS = Early Warning Score and rules for 2019-novel coronavirus-infected patients; RR = respiratory rate; O2 sat = oxygen saturation; 3D = dyspnea, distress, and discomfort/pain (from Italian: Dispnea, Distress, and Dolori); Vital signs = blood pressure, oxygen saturation, pulse, and body temperature; PRN = pro re nata (as needed); PO = per os (by mouth); SC = subcutaneously; IV = intravenous; ARDS = acute respiratory distress syndrome; ABDT2 = agitation, shivering (hyperthermia), distress, tachycardia, and tachypnea (from Italian: Agitazione, Brividi [ipertermia], Distress, Tachicardia e Tachipnea). |