深圳市成人新型冠状病毒奥密克戎变异株感染重症临床救治专家共识

doi:10.19871/j.cnki.xfcrbzz.2023.01.019

摘要/Abstract

摘要： 随着新型冠状病毒奥密克戎（Omicron）变异株的出现和进化分支上的多种变异株流行,全球新型冠状病毒感染（COVID-19）疫情防控形势发生了变化。我国人群目前感染的主要变异株是新型冠状病毒BA.5及其分支亚型BA.5.2和BF.7,感染后可发展为重型/危重型,甚至导致高危人群死亡。本共识基于国内外新型冠状病毒感染的流行病学、临床研究等方面数据,以及循证医学证据,聚焦新型冠状病毒Omicron变异株感染成人重型或危重型患者的临床特点、病情进展的相关指标、影像学特征、抗病毒治疗、呼吸支持治疗、抗凝及血液净化治疗、中医治疗、转出ICU标准等内容,提炼出10条共识建议。特别是对抗病毒治疗选择、疗程等提出了新的见解。

关键词: 奥密克戎变异株, 新型冠状病毒, 重症, 治疗, 专家共识

Abstract: The global pandemic has changed with the emergence of omicron strains and the prevalence of multiple variants on their evolutionary branches. Infection in China is currently dominated by BA.5 and its sub-lineage variants BA.5.2 and BF.7. Infection may lead to severe/critical situation, and even to death in high-risk groups. Based on the epidemiological and clinical research data of COVID-19 infection both in and outside China, as well as evidence-based medical information, this consensus focuses on the clinical characteristics of severe or critical COVID-19 adults with Omicron subvariant infection, related indicators of disease progression, imaging characteristics, antiviral treatment, respiratory support, anticoagulation and blood purification treatment, Traditional Chinese medicine (TCM) treatment, standards for ICU discharge, etc., summarizes 10 recommendations. In particular, new insights into the selection and duration of antiretroviral therapy have been provided.

Key words: Omicron subvariant, Severe acute respiratory syndrome coronavirus 2, Severe/critical, Treatment, Expert consensus

中图分类号:

R511

深圳市第三人民医院, 国家感染性疾病临床医学研究中心, 深圳市感染性疾病质量控制中心. 深圳市成人新型冠状病毒奥密克戎变异株感染重症临床救治专家共识[J]. 新发传染病电子杂志, 2023, 8(1): 93-101.

Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Diseases, Shenzhen Infectious Disease Quality Control Center. Expert consensus on clinical management of severe/critical Omicron subvariant infection in adults in Shenzhen[J]. Electronic Journal of Emerging Infectious Diseases, 2023, 8(1): 93-101.

参考文献

[1] 廖康生, 卢洪洲. 新型冠状病毒奥密克戎变异株的研究进展:对其科学防控措施的启示[J/CD]. 新发传染病电子杂志, 2022, 7(1): 1-5.
[2] 中国老年医学学会重症医学分会. 老年重症新型冠状病毒肺炎治疗专家共识[J/CD]. 中华老年病研究电子杂志, 2020, 7(2): 1-4.
[3] 山东省新冠病毒感染重症救治专家组. 山东省新冠病毒感染重症肺炎诊疗专家共识(第一版)[J]. 山东第一医科大学(山东省医学科学院)学报, 2022, 43(12): 881-885.
[4] PHILLIPS B, BALL C, SACKETT D, et al. 0xford Centre for Evidence-based Medicine: Levels of Evidence (March2009). 0CEBM, 2009[EB/OL]. https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.
[5] 中华人民共和国国家卫生健康委员会. 新型冠状病毒感染诊疗方案(试行第十版)[J]. 中国合理用药探索, 2023, 20(1): 1-11.
[6] ROMAN GC, REIS J, SPENCER PS, et al.COVID-19 international neurological registries[J]. Lancet Neurol, 2020, 19(6): 484-485.
[7] GUAN WJ, NI ZY, HU Y, et al.Clinical Characteristics of Coronavirus Disease 2019 in China[J]. N Engl J Med, 2020, 382(18): 1708-1720.
[8] YANG S, LING Y, ZHAO F, et al.Hymecromone: a clinical prescription hyaluronan inhibitor for efficiently blocking COVID-19 progression[J]. Signal Transduct Target Ther, 2022, 7(1): 91.
[9] KUMAR A, ARORA A, SHARMA P, et al.Clinical Features of COVID-19 and Factors Associated with Severe Clinical Course: A Systematic Review and Meta-Analysis[J]. SSRN, 2020: 3566166.
[10] ZIADI A, HACHIMI A, ADMOU B, et al.Lymphopenia in critically ill COVID-19 patients: A predictor factor of severity and mortality[J]. Int J Lab Hematol, 2021, 43(1): e38-e40.
[11] 丁金立, 章礽荫. 新型冠状病毒肺炎放射检查方案与感染防控专家共识(试行第一版)[J/CD]. 新发传染病电子杂志, 2020, 5(2): 65-73.
[12] 中华医学会放射学分会传染病学组, 中国医师协会放射医师分会感染影像专委会, 中国研究型医院学会感染与炎症放射学分会, 等. 新型冠状病毒感染的肺炎影像学诊断指南(2020第一版)[J]. 医学新知, 2020, 30(1): 22-34.
[13] 马琼, 石秀东, 陆阳, 等. 新型冠状病毒肺炎临床及影像学研究进展[J]. 中国临床医学, 2020, 27(1): 23-26.
[14] KEMP SA, COLLIER DA, DATIR RP, et al.SARS-CoV-2 evolution during treatment of chronic infection[J]. Nature, 2021, 592(7853): 277-282.
[15] COREY L, BEYRER C, COHEN MS, et al.SARS-CoV-2 Variants in Patients with Immunosuppression[J]. N Engl J Med, 2021, 385(6): 562-566.
[16] JEONG JH, CHOKKAKULA S, MIN SC, et al.Combination therapy with nirmatrelvir and molnupiravir improves the survival of SARS-CoV-2 infected mice[J]. Antiviral Res, 2022, 208: 105430.
[17] GIDARI A, SABBATINI S, SCHIAROLI E, et al.The Combination of Molnupiravir with Nirmatrelvir or GC376 Has a Synergic Role in the Inhibition of SARS-CoV-2 Replication In Vitro[J]. Microorganisms, 2022, 10(7): 1475.
[18] BIAN H, CHEN L, ZHENG ZH, et al.Meplazumab in hospitalized adults with severe COVID-19 (DEFLECT): a multicenter, seamless phase 2/3, randomized, third-party double-blind clinical trial[J]. Signal Transduct Target Ther, 2023, 8(1): 46.
[19] SHEN C, WANG Z, ZHAO F, et al.Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma[J]. JAMA, 2020, 323(16): 1582-1589.
[20] TABARSI P, BARATI S, JAMAATI H, et al.Evaluating the effects of Intravenous Immunoglobulin (IVIg) on the management of severe COVID-19 cases: A randomized controlled trial[J]. Int Immunopharmacol, 2021, 90: 107205.
[21] GROUP IS.Hyperimmune immunoglobulin for hospitalised patients with COVID-19 (ITAC): a double-blind, placebo-controlled, phase 3, randomised trial[J]. Lancet, 2022, 399(10324): 530-540.
[22] XIANG HR, CHENG X, LI Y, et al.Efficacy of IVIG (intravenous immunoglobulin) for corona virus disease 2019 (COVID-19): A meta-analysis[J]. Int Immunopharmacol, 2021, 96: 107732.
[23] KALIL AC, PATTERSON TF, MEHTA AK, et al.Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19[J]. N Engl J Med, 2021, 384(9): 795-807.
[24] INVESTIGATORS RC, GORDON AC, MOUNCEY PR, et al.Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19[J]. N Engl J Med, 2021, 384(16): 1491-1502.
[25] ZEIHER BG, MATSUOKA S, KAWABATA K, et al.Neutrophil elastase and acute lung injury: prospects for sivelestat and other neutrophil elastase inhibitors as therapeutics. Crit Care Med, 2002, 30:S281-S287.
[26] GAO X, ZHANG R, LEI Z, et al.Efficacy, safety, and pharmacoeconomics of sivelestat sodium in the treatment of septic acute respiratory distress syndrome: a retrospective cohort study[J]. Ann Palliat Med, 2021, 10(11): 11910-11917.
[27] SONG Y, YAO C, YAO Y, et al.XueBiJing Injection Versus Placebo for Critically Ill Patients With Severe Community-Acquired Pneumonia: A Randomized Controlled Trial[J]. Crit Care Med, 2019, 47(9): e735-e743.
[28] LUO Z, CHEN W, XIANG M, et al.The preventive effect of Xuebijing injection against cytokine storm for severe patients with COVID-19: A prospective randomized controlled trial[J]. Eur J Integr Med, 2021, 42: 101305.
[29] WANG T, CHEN RC, LIU CL, et al.Attention should be paid to venous thromboembolism prophylaxis in the management of COVID-19[J]. Lancet Haematol, 2020, 7(5): E362-E363.
[30] LEVY JH, CONNORS JM.Heparin Resistance - Clinical Perspectives and Management Strategies[J]. N Engl J Med, 2021, 385(9): 826-832.
[31] 中华医学会呼吸病学分会呼吸治疗学组. 新型冠状病毒感染重型及危重型患者呼吸治疗相关操作防护措施专家共识[J] . 中华结核和呼吸杂志, 2020, 43(4): 288-296.
[32] ATTAWAY AH, SCHERAGA RG, BHIMRAJ A, et al.Severe covid-19 pneumonia: pathogenesis and clinical management[J]. BMJ, 2021, 372: n436.
[33] GUERIN C, ALBERT R K, BEITLER J, et al.Prone position in ARDS patients: why, when, how and for whom[J]. Intensive Care Med, 2020, 46(12): 2385-2396.
[34] ALHAZZANI W, MOLLER MH, ARABI YM, et al.Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)[J]. Crit Care Med, 2020, 48(6): e440-e469.
[35] SUBGROUP OF CRITICAL RESPIRATORY D. Standardized protocol of prone position ventilation in patients with acute respiratory distress syndrome[J]. Zhonghua Nei Ke Za Zhi, 2020, 59(10): 781-787.
[36] COPPO A, BELLANI G, WINTERTON D, et al.Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study[J]. Lancet Respir Med, 2020, 8(8): 765-774.
[37] BASKARAN V, LAWRENCE H, LANSBURY LE, et al.Co-infection in critically ill patients with COVID-19: an observational cohort study from England[J]. J Med Microbiol, 2021, 70(4):1350.
[38] KURRA N, WOODARD PI, GANDRAKOTA N, et al.Opportunistic Infections in COVID-19: A Systematic Review and Meta-Analysis[J]. Cureus, 2022, 14(3): e23687.
[39] FELDMAN C, ANDERSON R.The role of co-infections and secondary infections in patients with COVID-19[J]. Pneumonia (Nathan), 2021, 13(1): 5.
[40] ABDOLI A, FALAHI S, KENARKOOHI A.COVID-19-associated opportunistic infections: a snapshot on the current reports[J]. Clin Exp Med, 2022, 22(3): 327-346.
[41] ELABBADI A, TURPIN M, GEROTZIAFAS G T, et al.Bacterial coinfection in critically ill COVID-19 patients with severe pneumonia[J]. Infection, 2021, 49(3): 559-562.
[42] VONG T, YANEK L R, WANG L, et al.Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19[J]. Nutrients, 2022, 14(6): 1310.
[43] BHATT K, AGOLLI A, PATEL MH, et al.High mortality co-infections of COVID-19 patients: mucormycosis and other fungal infections[J]. Discoveries (Craiova), 2021, 9(1): e126.
[44] MCCLAVE SA, TAYLOR BE, MARTINDALE RG, et al.Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)[J]. JPEN J Parenter Enteral Nutr, 2016, 40(2): 159-211.
[45] WELLS MULHERIN D, WALKER R, HOLCOMBE B, et al.ASPEN Report on Nutrition Support Practice Processes With COVID-19: The First Response[J]. Nutr Clin Pract, 2020, 35(5): 783-791.
[46] REIGNIER J, BOISRAME-HELMS J, BRISARD L, et al.Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)[J]. Lancet, 2018, 391(10116): 133-143.
[47] WEIJS PJM, MOGENSEN KM, RAWN JD, et al.Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study[J]. J Clin Med, 2019, 8(1): 43.
[48] VAN ZANTEN ARH, DE WAELE E, WISCHMEYER PE.Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases[J]. Crit Care, 2019, 23(1): 368.
[49] REINTAM BLASER A, STARKOPF J, ALHAZZANI W, et al.Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines[J]. Intensive Care Med, 2017, 43(3): 380-398.
[50] SAVIO RD, PARASURAMAN R, LOVESLY D, et al.Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position[J]. J Intensive Care Soc, 2021, 22(1): 41-46.
[51] WAN LM, GAO Q, DENG YQ, et al.GP73 is a glucogenic hormone contributing to SARS-CoV-2-induced hyperglycemia[J]. Nat Metab, 2022, 4(1): 29.
[52] MARLIES, OSTERMANN, MICHAEL, et al. Patient Selection and Timing of Continuous Renal Replacement Therapy[J]. Blood Purification, 2016, 42(3):224-237.
[53] 国家感染性疾病临床医学研究中心,传染病诊治国家重点实验室. 人工肝血液净化系统应用于重型、危重型新型冠状病毒肺炎治疗的专家共识[J]. 中华临床感染病杂志, 2020, 13(1):1-3.
[54] DAVIDSON AC, BANHAM S, ELLIOTT M, et al.BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults[J]. Thorax, 2016, 71(Suppl.2): 1-35.
[55] CHUN HS, CHOI SH, SONG HS.A Meta-Analysis of Treatment Effects on Viral Pneumonia Using TCM Injections Specified in the Clinical Guideline for COVID-19 in China[J]. J Pharmacopuncture, 2021, 24(3): 107-121.