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Hospital admission

During the pandemic, it is difficult to take children to hospital. However, a critically sick child needs to be evaluated and admitted without delay.

Protocol for Admission

Home-ventilated patients on CPAP or BiPAP and those with tracheostomy (with or without ventilation) who have suspected viral respiratory tract infection should be tested for coronavirus, and managed with airborne precautions until confirmed to be negative.
Approach to a sick child with either of the following:
(Adapted from resource1)
    • COVID-19 by RT-PCR positive
    • A suspected case in whom SARS-oV-2 virus test is inconclusive or
    • A severely ill patient whose RT-PCR results are awaited

Criteria for admission (Any ONE of the following criteria):

  • Respiratory distress
  • SpO2 < 92% on room air
  • Shock/ poor peripheral perfusion
  • Poor oral intake, especially in infants and young children
  • Lethargic, especially in infants and young children
  • Seizures/ encephalopathy

Children with Neuromuscular Diseases –including SMA require more intensive monitoring and early therapy.All children with SMA should be managed in a hospital setting irrespective of the clinical status – in lieu of poor respiratory reserve.

Mild Illness:

These Children Have No Respiratory Difficulty, Feeding Well, Have SpO2> 92%
  • The child would have to be isolated at home with hospital teleconsultationsat frequent intervals and continuous monitoring
  • Appropriate antibiotic may be prescribed, if respiratory rate is high.
  • Supportive care: Control of fever using paracetamol (10–15 mg/kg/ dose SOS/ q 4–6 hourly if required); avoid ibuprofen and other NSAIDs.
  • Ensure adequate hydration
  • Danger signs should be explained
  • The parent/ caregiver should take the necessary precautions, use appropriate PPE including a mask.

The parent/ caregiver should take the necessary precautions, use appropriate PPE including a mask

  • General Measures
  • Oxygen supplementation to maintain SpO2 > 92%.
  • Conservative fluid management is followed in mechanically ventilated patients (restrict fluid to 70–80% maintenance, if there is no evidence of hypovolemia).
  • Symptomatic treatment: Paracetamol for fever ((10–15 mg/kg/ dose SOS/ q 4–6 hourly if required); avoid ibuprofen and other NSAIDs
  • Blood culture sample should be sent at time of admission before starting anti-microbials.
  • Empirical antimicrobials (e.g., Ceftriaxone) within 1 h of admission in case of suspected sepsis and septic shock.
  • Oseltamivir may be considered after sending appropriate investigation if influenza is suspected.
  • Systemic corticosteroids are not recommended, unless indicated for any other reason.
  • MDI with spacer is preferred for administration of inhaled medication over nebulizati
    on, as nebulization is associated with increased risk of aerosolization.
  • Close monitoring for worsening clinical status is of paramount importance. Children who have significant distress may be managed in a HDU setting; those needing intubation and mechanical ventilation or other organ support should be managed in an ICU.

Respiratory Support

Low flow oxygen cannula is utilized with flows up to 1–2 L/min in infants, 2–4 L/min in young children and 4–6 L/min in older children and adolescents. Heated humidified high flow nasal cannula (HHHFNC) is not favoured as there are concerns of an increased aerosol formation.
Similarly use of NIV is discouraged in view of potential for aerosol generation, though clinical evidence is not definitive.
Similarly use of NIV is discouraged in view of potential for aerosol generation, though clinicalevidence is not definitive.
Airborne precautions (full PPE including N95 mask) must be maintained if child requires high-flow oxygen, non-invasive ventilation or nebulised therapy.Do not withhold these therapies ifindicated.
A medical mask should be secured on face of the child receiving oxygen therapy with nasalprong or HHHFNC, if the child tolerates.
Child should be monitored frequently including for SpO2, change in respiratory rate and heart rate, hemodynamic parameters, sensorium and urine output.
Respiratory support should be promptly hiked to mechanical ventilation if there is no benefit of NIV trial on respiratory rate, heart rate and respiratory efforts, or respiratory status worsens.

Criteria for ICU Admission

  • Requiring mechanical ventilation
  • Shock requiring vasopressor support
  • Worsening mental status

Indications for Intubation

  • Severe respiratory distress; exhaustion
  • Not able to maintain SpO2 > 90% on non-invasive oxygen supplementation
  • PaO2/FiO2 < 200 &PaO2/FiO2 < 300 with hypotension requiring vasopressorsupport &GCS < 8 with threatened airway & Decision to intubate should be taken on a case by casebasis based on the clinician’s discretion

How to Intubate

  • Pre-oxygenation with 100% FiO2 with non-rebreathing mask or nasal prongs.
  • Try to avoid bag and mask ventilation (risk of aerosol generation). If needed, can be used by connecting a viral filter.
  • The most skilled member of the team should be identified at the beginning of each shift for performing intubations.
  • If readily available, intubation should be performed using a video-laryngoscope.
  • Cuffed endotracheal tubes should be used to avoid peritubal leak and dissemination of secretions.
  • Rapid sequence intubation should be done.
  • During induction, monitor for hemodynamic instability and use fluids and vasopressors, if required.
  • Get X-ray chest to confirm correct position of tube.
  • After intubation, appropriate cleaning/disinfection of equipment and environment should be done

Management Strategies for ARDS

  • The general principles of management of child with ARDS apply to a child with COVID-19 related ARDS.
  • The principles include lung protective ventilation: appropriate high PEEP; and low tidal volume (4–6 ml/kg)
  • Children with refractory hypoxemia may benefit from ventilation in prone position. For more details, readers may refer to management protocols.

Care of Ventilated Patient

  • Fresh, preferably disposable ventilator circuit to be used for every new patient.
  • Use viral filter in expiratory limb of the circuit & Heat and moisture exchanger (HME) to be changed every
    48 h or when visibly soiled.
  • Use closed suctioning technique and avoid routine suctioning.
  • Appropriate sedation should be ensured and intermittent muscle relaxants may be used.
  • Chest compression and bag and mask ventilation should be started only after wearing PPE for aerosol transmission protection.
  • Minimize the number of people inside the room during high aerosol generating events like cardiopulm onary resuscitation.
  • One airway specialist, one nurse/doctor for chest compression and one nurse for administering medications are essential.
  • Other assistants may remain outside the room and may enter only if necessary, after donning full PPE.
  • Hand bagging needs to be avoided; if essential use a viral filter with the bag.

Resource:

1.  Sankar J, Dhochak N, Kabra SK, Lodha R. COVID-19 in Children: Clinical Approach and Management.
Indian J Pediatr. 2020;87(6):433-442. doi:10.1007/s12098-020-03292- 1

 

2.  WHO -Clinical management of COVID-19 interim guidance 27 May 2020 accessed 27thJuly 2020.COVID-19: Clinical care.
3.  https://www.mohfw.gov.in/pdf/ClinicalManagementProtocolforCOVID19.pdf.

 

4.  Simonds AK, Hanak A, Chatwin M, et al. Evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebuliser treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other air-borne infections. Health Technol Assess. 2010;14:131–72.

 

5.  Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the pediatric acute lung injury consensus conference. PediatrCrit Care Med. 2015;16:428–39.

 

6.Kabra SK, Lodha R. Pediatric Intensive Care Protocols of AIIMS, 2nd ed. India: Indian J Pediatr; 2017