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Latest 7vs 6th edition of the new coronary pneumonia treatment plan comparison

SIFIC Infection Team SIFIC Infection Evidence-Based Information 4 days ago

The new part below is marked with bold red, please note
Time is short, if there is a omission please understand

Key points of the seventh update:

1. Increase the reminder for importing new cases
2. Increased child and pregnancy concerns
3. Increased support for patients with severe illness
4. Increased pathological changes
5. Increase in early warning indicators for critical and critical illness
6. Serological diagnostic methods incorporated

Comparison of the sixth and seventh editions of the new coronary pneumonia treatment plan

Wei Yanni, Zhou Miaoqing, Shi Qingfeng, Zhou, Han Ling-like
Proofreading

Since December 2019, a new type of coronavirus pneumonia outbreak has occurred in Wuhan, Hubei Province, and with the spread of the epidemic, such cases have been detected in other parts of China and in many countries abroad. As an acute respiratory infectious disease, the disease has been included in the "Chinese People's Republic of Infectious Diseases Prevention and Control Act" provisions of the Class B infectious diseases, according to the management of Class A infectious diseases. Through a series of preventive control and medical treatment measures, the rising momentum of the epidemic in China has been curbed to a certain extent, the epidemic in most provinces has eased, but the number of cases abroad is on the rise. With the in-depth clinical manifestations of the disease, pathological understanding and the accumulation of medical experience, in order to further strengthen the early diagnosis and treatment of the disease, improve the cure rate, reduce the mortality rate, the greatest possible avoidance of hospital infection, while reminding attention to the spread and spread of imported cases abroad, we revised the "new coronavirus pneumonia diagnosis and treatment program (trial sixth edition) " to form a new coronary disease pneumonia treatment program (trial seventh edition).

01
PART
Pathogen characteristics

The new coronavirus belongs to the beta genus coronavirus, has a film, particles are round or oval, often polymorphic, diameter 60-140 nm. Its genetic characteristics are significantly different from SARS-CoV and MERS-CoV (SARSr-CoV and MERSr-CoV in version 6). Current studies have shown that the bat-SL-CoVZC45 is more than 85% homogenous. In vitro isolation culture, the new coronavirus can be found in the human respiratory epithelial cells for about 96 hours, while in the Vero E6 and Huh-7 cell lines isolated culture takes about 6 days.

Much of the understanding of coronary virus physical and chemical properties comes from the study of SARS-CoV and MERS-CoV. Viruses are sensitive to UV rays and heat, 56 degrees C for 30 minutes, ether, 75% ethanol, chlorine disinfectants, peroxyacetic acid and chloroform and other lipid solvents can effectively inactivate the virus, chlorine can not effectively inactivate the virus.

02
PART
Epidemiological characteristics

(i) The source of infection.
At present, the main sources of infection seen are patients with new coronavirus infection. Asymptomatic infected people can also be a source of infection.

(ii) Means of communication.
Transmission through respiratory droplets and close contact is the main route of transmission. There is a possibility of aerosol propagation in a relatively closed environment exposed to high concentrations of aerosols for long periods of time. Increase: Because new coronaviruses can be isolated in feces and urine, it should be noted that feces and urine cause aerosols or contact transmission to environmental pollution.

(iii) Vulnerable groups.
Crowds are generally susceptible.

03
PART
Pathological changes

This chapter is all new, please note

According to the limited autopsy and puncture hispathological observations, the results are summarized below.

(i) The lungs.

The lungs showed varying degrees of real change.

The alveolar cavity is characterized by slurry, fibrin oozing and transparent membrane formation; Type II alveoli epithelial cells significantly increased, and some cells fell off. Type II alveoli epithelial cells and macrophages are visible in the inclusion. The alveoli is filled with blood vessels and edema, and it can be seen that mononucleosis and lymphocytes are immersed and transparent thrombosis in the blood vessels. Pulmonary tissue lesions bleed, necrosis, and hemorrhagic infarction can occur. Partial alveolar cavity oozing metabolites and pulmonary fibrosis.

The epithelial part of the branch branch mucosa part of the lung falls off, and mucus and mucus hydrants are visible in the cavity. A small number of alveoli is overinflated, alveoli breaks or cysts are formed.

Coronary virus particles are visible in the broncochle mucous epithelial and type II alveoli epithelial cytoplasm under the electroscope. Immunohislification staining showed that partial alveoli epithelial and macrophages were positive for the new coronavirus antigen, and RT-PCR tested positive for the new coronavirus nucleic acid.

(ii) Spleen, pulmonary lymph nodes and bone marrow.

The spleen is significantly reduced. The number of lymphocytes was significantly reduced, lesions of hemorrhage and necrosis, macrophages in the spleen were proliferation and visible phage; Immunized staining showed a decrease in both CD4-T and CD8-T cells in the spleen and lymph nodes. The number of three-line cells in the bone marrow decreased.

(iii) Heart and blood vessels.

Myocardial cells are visible to denaturation, necrosis, and a small number of mononucleocytes, lymphocytes, and/or neutrophils are immersed in the interstitial. Part of the endothelial fall, inflammation of the lining and thrombosis.

(iv) Liver and gallbladder.

The volume increases and the dark red. Hepatocellular denaturation, lesions necrosis accompanied by neutrophil leaching; hepatic blood sinuses are congested, conciliator areas see lymphocytes and monocytocell leaching, microthofcardia formation. The gallbladder is highly charged.

(v) Kidneys.

The glomerular balloon cavity sees protein oozing, the epithelial degeneration of the kidney tube, shedding, visible transparent tube type. Interstitial congestion, microthrombostosis and lesions fibrosis can be seen.

(vi) Other organs.

Brain tissue is congestive, edema, and part of the neurons are denatured. Adrenal glands see lesionne. The epithelial epithelial of the esophagus, stomach and intestinal tract is denatured, necrosis, and shedding to varying degrees.

04
PART
Clinical characteristics

(i) Clinical performance.

Based on the current epidemiological investigation, the incubation period is 1 to 14 days, mostly 3 to 7 days.

To fever, dry cough, fatigue as the main performance. A small number of patients have symptoms such as nasal congestion, runny nose, sore throat, myalgia and diarrhea. Most of the seriously ill patients appear breathing difficulties and/ or hypoxemia after one week of the onset of the disease, the severe case can quickly progress to acute respiratory distress syndrome, sepsis shock, difficult to correct metabolic acidosis and blood clotting dysfunction and multi-organ failure. It is worth noting that the course of heavy, critical patients can be low-to-medium fever, or even no obvious fever.

New: Some children and newborn cases of symptoms may be atypical, as vomiting, diarrhea and other digestive symptoms or only manifested as mental weakness, shortness of breath.

Light patients showed only low fever, mild fatigue, and no pneumonia.

From the current case situation, most patients have a good prognosis, a few patients are in critical condition. Older people and people with chronic underlying diseases have a poorer prognosis. New: The clinical process of maternal pneumonia with the new coronavirus is similar to that of patients of the same age. The symptoms in children are relatively mild.

(ii) Laboratory examination.

1. General check (new subheading)

The total number of peripheral white blood cells in the early stages of the disease is normal or decreased, it can be seen (new) lymphocyte count decreased, some patients can appear hepatic enzymes, lactic acid dehydrogenase (LDH), myosise and myoglobin increase; Most patients have C-reactive protein (CRP) and elevated blood, and calcite is normal. Severed D-dipolymer selevated, peripheral blood lymphocytes reduced sexuality. Heavy, critically ill patients often have elevated inflammatory factors.

2. Pathogen and serological examination (new subheading)

(1) Pathogen examination: New coronavirus nucleic acid can be detected in samples of nasopharyngeal swabs, sputum and other lower respiratory secretions, blood, feces, etc. using RT-PCR or/and NGS (new examination methods). It is more accurate to detect lower respiratory tract specimens (sputum or airway extracts). The specimen is collected and sent for examination as soon as possible. (Revised text)

New: (2) Serological examination: The new coronavirus-specific IgM antibody is more positive after 3-5 days of onset, And the Recovery period of IgG antibody is 4 times and above higher than that of the acute period.

(iii) Chest imaging.

Early appearance of multiple small patch shadow and interstitial changes, with lung band obvious. Then developed into double lung multiple grinding glass shadow, soaked shadow, serious can appear lung real change, chest cavity fluid is rare.

05
PART
Diagnostic standards

(i) Suspected cases.

Combined with the following epidemiological history and clinical manifestations:

Epidemiological history

(1) The travel or residence history of Wuhan City and surrounding areas, or other reported communities, within 14 days of the onset of the disease;
(2) A history of exposure with a new coronavirus infection (nucleic acid detection) within 14 days prior to the onset of the disease;
(3) Have been exposed to patients from Wuhan city and surrounding areas within 14 days of the onset of the disease, or from patients with fever or respiratory symptoms in the community with case reports;
(4) New incidence of clustering: (2 cases of fever and above and/or respiratory symptoms occurred within 2 weeks in small areas such as homes, offices, school classes, etc.).

2. Clinical performance

(1) Fever and/or respiratory symptoms;
(2) with the imaging characteristics of the above-mentioned new coronavirus pneumonia;
(3) The total number of white blood cells in the early stages of the disease is normal or decreased, and the lymphocytes count is normal or decreased.

There is any one in the history of epidemiology and conforms to any 2 in clinical performance. If there is no clear epidemiological history, it is consistent with the 3 articles in clinical performance.

(ii) Confirmed cases. (Added simultaneous and or serological)

Suspected cases have one of the following pathogen or serological evidence:

1. Real-time fluorescent RT-PCR testpositive for new coronavirus nucleic acid;
2. Viral gene sequencing, highly homologous with known new coronaviruses;
3. New: Serum new coronavirus-specific IgM antibodies and IgG antibodies positive;

06
PART
Clinical type

(i) Light.

Clinical symptoms were mild, and no manifestations of pneumonia were seen in imaging.

(ii) Normal type.

With fever, respiratory tract and other symptoms, imaging can be seen pneumonia performance.

(iii) Heavy duty.

Adults are eligible for any of the following:
1. Air shortness, RR s 330 times /min;
2. In the state of rest, the oxygen saturation is 93%;
3. Arterial oxygen fractional pressure (PaO2)/oxygen absorption concentration (FiO2) s 300mmHg (lmmHg s.133kPa)

High altitude (more than 1000 m) areas should be schooled in accordance with the following formula: PaO2/FiO2 x (mmHg) /760

Pulmonary imaging showed significant progress in the lesions within 24 to 48 hours , with 50% being managed by heavy duty.

New: Children meet any of the following:

1. Appears shortness of breath (2 months old, RR 60 times/min; 2 to 12 months old, RR s 50 times/min; 1 to 5 years old, RR s 40 times/min; 5 years old, RR s 30 times/min), except for the effects of fever and crying;

2. In the state of rest, the oxygen saturation is 92%;

3. Auxiliary breathing (moaning, nasal wing flaps, three concave signs), hair, intermittent apnea;

4. Drowsiness and convulsions;

5. Difficulty refusing food or feeding, with dehydration.

(4) Critical type.

Those who:
1. Respiratory failure and the need for mechanical ventilation;
2. The occurrence of shock;
3. Combining other organ failure requires ICU monitoring therapy.

07
PART
Heavy-duty, critical clinical early warning indicators

This section is all new

(i) Adults.

1. Peripheral blood lymphocytes undergo sexual decline;
2. Peripheral blood inflammatory factors such as IL-6 and C-reactive proteins were positive;
3. Elevated lactic acid;
4. Lung lesions progress rapidly in the short term.

(ii) Children.

1. Faster breathing frequency;
2. Poor mental response and drowsiness;
3. Elevated lactic acid;
4. Imaging shows rapid progression of double-sided or multi-pulmonary leaf dipping, thoracic fluid or short-term lesions;
5. Infants under 3 months of age may have underlying diseases (congenital heart disease, bronchial pulmonary dysplasia, respiratory malformation, abnormal hemoglobin, severe malnutrition, etc.), have immunodeficiency or low levels (long-term use of immunosuppressants).

08
PART
Differential diagnosis

(i) The light manifestations of the new coronavirus infection need to be distinguished from upper respiratory tract infections caused by other viruses.

(ii) The identification of new coronavirus pneumonia mainly with influenza viruses, adenosis, respiratory syncytial viruses and other known viral pneumonia and mycoplasma infections of pneumonia, especially for suspected cases, including rapid antigen testing and multi-PCR nucleic acid testing, to detect common respiratory pathogens.

(iii) Identification of non-infectious diseases, such as vasculitis, dermatitis and metastasis.

09
PART
Case finding and reporting
Medical personnel at all levels of medical institutions at all levels found suspected cases that meet the definition of cases, should immediately carry out single-room isolation treatment, in-hospital expert consultation or the visiting physician consultation, still consider the suspected case, within 2 hours of the network direct reporting, and collect specimens for new coronavirus nucleic acid testing, at the same time to ensure the safety of transport under the premise of the suspected case stoistomy to the designated hospital. Patients who have close contact with new coronavirus infection, even if the common respiratory pathogentest sat positive, it is recommended to promptly enter the new coronavirus pathogen test.

New:
The suspected cases were tested negative for two consecutive new coronavirus nucleic acids (at least 24 hours apart) and 7 days after the onset of the new coronavirus-specific antibodies IgM and IgG were still negative and the suspected cases could be ruled out.

 

 

 

10
PART
Treatment

(i) Determining the place of treatment on the basis of the condition.

1. Suspected and confirmed cases shall be treated in isolated hospitals with effective isolation and protective conditions, suspected cases shall be treated in single-room isolation, and confirmed cases may be treated in the same room by multiple persons.
2. Critical cases should be treated with ICU as early as possible.

(ii) General treatment.

1. Bed rest, strengthen support for treatment, ensure adequate heat, pay attention to water, electrolyte balance, maintain internal environmental stability, closely monitor vital signs, refertos to oxygen saturation, etc.

2. Monitor blood routine, urinary routine, CRP, biochemical indicators (hepatic enzyme, cardiomyotic enzyme, kidney function, etc.), blood clotting function, arterial blood gas analysis, chest imaging, etc. Conditional is possible cytokine testing.

3. Timely and effective oxygen therapy measures, including nasal catheterization, mask oxygen feed and high-flow oxygen therapy through the nose. New: Conditional treatment of hydrogen-oxygen mixture inhalation gas (H2/O2: 66.6%/33.3%).

4. Antiviral therapy: a-interferon can be tried (adults 5 million U or meta-dose, addster injection water 2nd, 2 times daily atomized inhalation), lopinavir/litonavir (adult 200mg/50mg/capsule, 2 capsules per time, 2 times daily, Treatment not more than 10 days), ribavirin (recommended in combination with interferon or lopinavir/litonnavir, adults 500 mg/time, 2 to 3 intravenous injections per day, treatment not more than 10 days), modified use method: chloroquine phosphate (18-65 years of adults. Those who weigh more than 50 kg, 500 mg each time, 2 times a day, 7 days of treatment, weight less than 50 kg, the first and second day each 500 mg. 2 times a day, the third to seventh day each 500 mg. 1 time per day), Abidor (adult 200 mg, 3 times a day, no more than 10 days of treatment).

Modification: Be aware of adverse reactions to the above drugs, contraindications (e.g. the prohibition of chloroquine in people with heart disease), and interactions with other drugs.

Further evaluation of the efficacy of the drug currently being tested in clinical applications. It is not recommended to apply 3 or more antiviral drugs at the same time, and stop using the relevant drugs in the event of intolerable side effects.

New: The treatment of pregnant patients should consider the number of weeks of pregnancy, as far as possible to choose drugs that have a low impact on the fetus, and whether to terminate the pregnancy after treatment and other issues, and inform informed.

5. Antibacterial drug treatment: Avoid the blind or inappropriate use of antimicrobial drugs, especially the combined use of broad-spectrum antimicrobial drugs.

(iii) Treatment of heavy and critical cases.

1. Principles of treatment: On the basis of treatment of the disease, actively prevent and control complications, treat underlying diseases, prevent secondary infections, and provide timely organ functional support.

2. Breathing support:

(1) Oxygen therapy: Heavy patients should receive nasal catheters or masks to absorb oxygen and promptly assess respiratory distress and/or hypoxemia for relief.

(2) High-flow nasal catheter oxygen therapy or noninvasive mechanical ventilation: When the patient is undergoing standard oxygen therapy breathing distress and/or hypoxemia is unable to relieve, consider using high-flow nasal catheter oxygen therapy or noninvasive ventilation. If the condition does not improve or even worsen within a short period of time (1-2 hours), the trachea intubation and invasive mechanical ventilation should be carried out in a timely manner.
(3) Invasive mechanical ventilation: the use of pulmonary protective ventilation strategy, i.e. low tide air volume (6-8mL/kg ideal weight) and low-level airway platform pressure (platform pressure 30cmH2O) for mechanical ventilation to reduce ventilator-related lung damage.

New: In ensuring that the airway platform pressure W 35cmH2O, can be appropriate lying high PEEP, to maintain the airduction wet, avoid long-term sedation, early wake up patients and lung rehabilitation treatment.

More patients exist in the human machine out of sync, should be timely use of sedatives and muscle loose agent.

New: According to the airway secretion situation, choose closed sputum, if necessary, bronchoscopy examination to obtain the appropriate treatment.

(4) Rescue treatment: For patients with severe ARDS, pulmonary resuscitation is recommended. Where adequate human resources are available, more than 12 hours of lying-down ventilation should be performed daily. Those with poor mechanical ventilation in the lying position should consider the in vitro membrane pulmonary oxygenation (ECMO) as soon as possible if conditions permit.

New: Its related indications: (1) at 90% of FiO, oxygenation index is less than 80mmHg, lasting more than 3-4 hours;
For patients with pure respiratory failure, the VV-ECMO model is preferred, and the VA-ECMO model is preferred if circulatory support is required. When the underlying disease is under control and cardiopulmonary function shows signs of recovery, the withdrawal test can begin.

3. Circulation support: improve microcirculation on the basis of adequate liquid resuscitation, use of vascularly active drugs, added: close monitoring of changes in blood pressure, heart rate and urine volume in patients, as well as lactic acid and alkali surplus in arterial blood gas analysis, noninvasive or invasive hemodynamic monitoring, such as ultrasound doppler method, echocardiogram, invasive blood pressure or persistent cardiolycation (PiCCO) monitoring. In the course of treatment, pay attention to the liquid balance strategy, to avoid excessive and inadequate.

New: If it is found that the sudden increase in the patient's heart rate is greater than the base value of 20% or blood pressure drop of about 20% of the base value, if accompanied by poor skin perfusion and decreased urine, etc. , patients should be closely observed whether there is sepsis shock, gastrointestinal bleeding or heart failure.

New: 4. Renal failure and renal replacement therapy: Kidney impairment in critically ill patients should actively look for causes of renal impairment, such as low perfusion and medication. Treatment of patients with renal failure should pay attention to body fluid balance, acid-base balance and electrolyte balance, and should pay attention to nitrogen balance, heat and trace elements in nutritional support treatment. Patients with severe illness can choose continuous renal replacement therapy (continuous renal therapy, CRRT). Its signs include: (1) hyperkalemia; (2) acidosis; (3) pulmonary edema or overburdened water; and (4) liquid management when multi-organ insufficiency is inexhaustive.

5. Rehabilitation plasma treatment: suitable for patients with rapid progress, heavy and critical conditions. The usage reference is the Clinical Treatment Plan for Plasma In the Recovery period of The New Coronary Pneumonia Recovery (Trial 2nd Edition).

Added: 6. Blood purification treatment: blood purification system includes plasma replacement, adsorption, irrigation, blood/plasma filtration, etc., can remove inflammatory factors, block "cytokine storm", thus reducing the damage of the inflammatory reaction to the body, can be used for heavy, critical patients in the early and medium period of treatment of cytokinetic factor storm.

7. Immunotherapy: For patients with widespread lesions of double lung and heavy patients, and laboratory tests for elevated LEVELs of IL-6, tocoamono-resistance therapy can be tried. The first dose is 4-8 mg/kg, the recommended dose is 400 mg, 0. 9% physiological saline diluted to 100 ml, the injection time is greater than 1 hour, the first drug treatment is not good, can be applied once after 12 hours (the dose is the same, the cumulative number of doses up to 2 times, the maximum amount of a single dose does not exceed 800 mg. Be aware of allergic reactions, which are disabled by people with TB and other activities.

8. Other treatment measures:
For oxygenation index sexual deterioration, rapid progress in imaging, body inflammation should be overactivated in patients, as appropriate in the short term (3 to 5 days) the use of glucocorticoids, the recommended dose does not exceed the equivalent of metastasis nylon 1 to 2 mg / kg / day, should pay attention to the larger dose of glucocorticoiddue due to immunosuppressive effect, will delay the removal of coronavirus; (Delete section and new duplicates above)

New: Heavy, critical cases in children may, as appropriate, consider giving intravenous drips of C globulin.

Pregnant women with severe or critical new coronavirus pneumonia should actively terminate their pregnancy, with caesarean section being the first choice.

Patients often have anxiety and fear, should strengthen psychological guidance.

(4) Chinese medicine treatment.

This disease belongs to the category of Chinese medicine "epidemic" disease, because the disease feels the "epidemic" gas, all places can be based on the disease, local climate characteristics and different physical conditions, reference to the following programs for dialectical treatment. When it comes to superpharma dosages, they should be used under the guidance of a physician.

1 . . Medical observation period

Clinical Performance 1: Weakness with Gastrointestinal Discomfort
Recommended Chinese medicine: fennel positive gas capsule (pills, water, oral liquid)

Clinical Performance 2: Weakness with Fever
Recommended Chinese traditional medicine: golden flower clear sense particles, even flower saffron capsules (particles), dredging detoxification capsules (particles)

2. Clinical treatment period (confirmed cases)

2.1 Clear Lung Detox Soup

Scope of application: combined with the clinical observation of multi-site doctors, suitable for light, ordinary, heavy patients, in the treatment of critical patients can be combined with the actual situation of patients reasonable use.

Basic prescriptions: ephedrine 9g, roast licorice 6g, almond s9g, raw gypsum 15 to 30g (fried first), cinnamon 9g, Zeai 9g, pig 9g, white 9g, slug 15g, Chaihu 16 g, Huang Qi 6g, ginger half summer 9g, ginger 9g, purple 9g, winter flower 9g, shot dry 9g, fine xin 6g, yam 12g, shizi 6g, Chen Pi 6g, incense 9g.

Service: traditional Chinese medicine drink tablets, water frying. Pay one every day, one morning (forty minutes after the meal), warm, three pay a course of treatment.

If conditions, each time after taking the medicine can be added to the rice soup half a bowl, tongue dry liquor loss can be more than a bowl. (Note: If the patient does not have fever, the amount of raw gypsum should be small, heat or strong heat can increase the amount of raw gypsum). If the symptoms improve and not heal, take the second course of treatment, if the patient has special circumstances or other underlying diseases, the second course of treatment can modify the prescription according to the actual situation, the symptoms disappear then stop taking the drug.

Prescription source: The Office of the National Administration of Traditional Chinese Medicine of the General Office of the National Health and Health Commission, "On the recommendation of Chinese and Western medicine in combination with the treatment of a new type of coronary virus infection in pneumonia to make use of the "clear lung detox soup" notice (The State Administration of Traditional Chinese Medicine Medical Administration Letter (2020) No. 22).

2.2 Light

(1) Cold wet lung certificate

Clinical manifestations: fever, fatigue, soreness, cough, sputum, chest tight ache, nasomuch, nausea, vomiting, stool stickiness. The tongue is pale fat tooth marks or light red, moss white thick and greasy or white, veinor or slippery.

Recommended prescriptions: raw ephedrine 6g, raw gypsum 15g, almonds 9g, live 15g, grass hazel15g, 9g, dilong 15g, Xu Changqing 15g, Lei Xiang 15g, Peran 9g, heron 15g, cloud 45g, raw white art 30g, Jo Sanxian 9g each, thick 15g, joo-betel 9g, grass fruit 9g, ginger 15g.

Service: 1 dose daily, water frying 600 ml, 3 times to take, morning and evening 1 time, before meals.

(2) Wet and hot lung certificate

Clinical manifestations: low fever or no fever, mild cold, fatigue, heavy head, muscle soreness, dry cough sputum less, sore throat, dry mouth do not want to drink more, or accompanied by chest tightness, no sweat or sweating, or see bad, stool or stool sticky. The tongue is light red, mossy thick or thin yellow, the pulse slip sliver or the stoic.

Recommended prescriptions: Penang 10g, grass fruit 10g, thick park 10g, mother 10g, huang Qi 10g, Chaihu 10g, chia 10g, Lianjun 15g, artemisinin 10g (back down), heron 10g, large green leaves 10g, raw licorice 5g.

Service: 1 dose daily, 400ml of water frying, 2 times to take, 1 time each early.

2.3 Normal

(1) Wet toxic depression lung certificate

Clinical manifestations: fever, cough sputum less, or yellow sputum, suffocation, bloating, constipation is not good. Dark red tongue, fat tongue body, moss yelmed or yellow, pulse slip or string slip.

Recommended prescriptions: raw ephedrine 6g, bitter almonds 15g, raw gypsum 30g, raw molybdenum 30g, mahogany 10g, Guanglei Xiang 15g, artemisinin 12g, tiger cane 20g, horse whip grass 30g, dried reed root 30g, grass 15g, orange red 15g, raw licorice 10g.

Service: 1 dose daily, 400ml of water frying, 2 times to take, 1 time each early.

(2) Cold and wet lung resistance certificate

Clinical performance: low heat, body heat is not high, or not hot, dry cough, less sputum, burnout fatigue, chest tightness, month lyummy, or nausea, then. The tongue is light or light red, mossy or white, and veins.

Recommended prescriptions: heron 15g, Chen Pi 10g, thick 10g, Lei Xiang 10g, grass fruit 6g, raw ephedrine 6g, live 10g, ginger 10g, betel nut 10g.

Service: 1 dose daily, 400ml of water frying, 2 times to take, 1 time each early.

2.4 Heavy

(1) Epidemic poison closed lung certificate

Clinical manifestations: fever red, cough, sputum yellow sticky, or sputum with blood, wheezing, tired burnout, dry and dry mouth sticky, nausea not eating, stool is not smooth, short ness. Red tongue, mossy, vein slippery.

Recommended Prescription: Wet And Detox

Basic prescriptions: raw ephedrine 6g, almond 9g, raw gypsum 15g, licorice 3g, incense 10g (back down), thick 10g, heron 15g, grass fruit 10g, French half summer 9g, slug 15g, raw yellow 5g (back), raw yellow 10g, hazelnut 10g, red 10g.

Service: 1 to 2 doses daily, water frying, 100 to 200 ml, 2 to 4 times a day, oral or nasal feeding.

(2) Gas Camp Two Certificates

Clinical manifestations: fever and thirst, wheezing, fainting, mis-monitoring, or a rash, or vomiting blood, blood, or limb convulsions. The tongue is mossless or mossless, the veins are heavy, or floating large and numerous.

Recommended prescriptions: raw gypsum 30 to 60g (fried first), mother 30g, raw land 30 to 60g, buffalo horn 30g (first fry), chia 30g, ginseng 30g, lian 15g, Dan pi 15g, Huanglian 6g, bamboo leaves 12g, grass house 15g, raw licorice 6g.

To serve: 1 dose daily, water frying, first fried gypsum, buffalo horn after the following medicine, each 100 ml to 200 ml, 2 to 4 times a day, oral or nasal feeding.

Recommended Chinese medicine: Heyan flat injection, blood must net injection, hot venom injection, sputum hot-clean injection, wake-up brain static injection. Drugs with similar efficacy can be selected according to individual condition, or can be combined according to clinical symptoms. Chinese medicine injectioncan can be used in combination with Chinese medicine soup.

2.5 Critical type (internal and external clearance)

Clinical manifestations: breathing difficulties, breathing or the need for mechanical ventilation, accompanied by faint, irritable, sweating out of the limb cold, tongue purple dark, moss thick or dry, veins floating rootless.
Recommended prescriptions: ginseng 15g, black shun tablets 10g (fried first), hawthorn 15g, served with Suhexiang pills or Angong oxen pills.

New: the appearance of mechanical ventilation with bloating constipation or stool is not smooth, can be used to produce large yellow 5 to 10g. In the case of human-machine out-of-sync conditions, in the case of sedatives and muscle loose agents, can be used to produce large yellow 5 to 10g and mannitus 5 to 10g.

Recommended Chinese medicine: blood must net injection, thermotoxic infusion, sputum hot-clearing injection, wake-up brain static injection, ginseng injection, pulse injection, ginseng injection. Drugs with similar efficacy can be selected according to individual condition, or can be used in combination according to clinical symptoms. Chinese medicine injectioncan can be used in combination with Chinese medicine soup.

Note: Recommended use of heavy and critical Chinese medicine injections

The use of Chinese medicine injections in accordance with the drug instructions from a small dose, step-by-step dialectical adjustment principles, recommended use as follows:

Virus infection or combined mild bacterial infection: 0.9% sodium chloride injection 250ml gysyme flat injection 100mg bid, or 0.9% sodium chloride injection 250ml heated poison injection 20ml, or 0. 9% sodium chloride injection 250ml plus sputum hot-clear injection 40ml bid.

High heat companion consciousness disorder: 0.9% sodium chloride injection 250ml plus wake-up brain static injection 20ml bid.

Systemic inflammatory response syndrome or/and organ failure: 0. 9% sodium chloride injection 250 ml plus blood must be net injection 100 ml bid.
Immunosuppressive: glucose injection 250ml plus ginseng injection 100ml or pulse injection 20 to 60ml bid (new)

2.6 Recovery period

(1) Lung temper false evidence

Clinical performance: shortness of breath, burnout fatigue, bad, full, stool powerless, then unhappy. The tongue is fat and mossy.

Recommended prescriptions: French half summer 9g, Chen Pi 10g, party ginseng 15g, red yellow Mao 30g, fried white 10g, sage 15g, Lei Xiang 10g, sand kernel 6g (back), licorice 6g.

Service: 1 dose daily, 400ml of water frying, 2 times to take, morning and evening 1 time.

(2) Gasy and two false evidence

Clinical manifestations: weakness, shortness of breath, dry mouth, thirst, palpitations, sweating, poor, low or not hot, dry cough less sputum. The tongue is dry and less powerful, the pulse is fine or nihilistic.

Recommended prescriptions: 10g of north and south sand ginseng, 15g of wheat winter, 6g western ginseng, 5g, raw gypsum 15g, light bamboo leaves 10g, mulberry leaves 10g, reed root 15g, danss15g, raw licorice 6g.

Service: 1 dose daily, 400ml of water frying, 2 times to take, morning and evening 1 time.

11
PART
Hospital standards and post-hospital precautions

The seventh edition changed the original "de-segregation or discharge standard" to "discharge standard" and removed "de-isolation".

(i) Discharge standards.

Article 4 of the standard modified the original respiratory specimen to a respiratory specimen such as sputum and nasopharyngeal swabs, and the sampling time was changed from at least one interval to at least 24 hours.

1. Body temperature returns to normal for more than 3 days;
2. There has been a marked improvement in respiratory symptoms;
3. Pulmonary imaging showed a significant improvement in acute oozing lesions;
4. Two consecutive respiratory samples such as sputum and nasopharyngeal swabs tested negative for nucleic acid (at least 24 hours apart).

Those who meet the above conditions may be discharged from the hospital.

(2) Precautions after discharge from hospital.

1. The designated hospital should make good contact with the primary medical institutionwhere where the patient lives, share the medical records, and promptly push the patient's information to the patient's jurisdiction or place of residence, the neighborhood committee and the primary health care institution.

2. After the patient is discharged from the hospital, it is recommended that 14 days of isolation management and health monitoring should continue, wear ingestain, live in a well-ventilated single room with conditions, reduce close contact with family close contact, eat and drink, do a good job of hand hygiene, avoid out-of-office activities.

3. It is recommended to follow up and re-visit to the hospital during the second and fourth weeks after discharge from the hospital.

Deleted after discharge from the hospital to continue self-monitoring of the reasons explained in part of the part "due to the recovery period of the body's immune function is low, there is a risk of infection with other pathogens"

12
PART
Transit principles
In accordance with the National Health and Health Commission issued the "new coronary virus infection of pneumonia cases transshipment work programme (trial)" implementation.

13
PART
Infection prevention and control in medical institutions

Strictly in accordance with the National Health and Health Commission "new coronavirus infection prevention and control of new medical institutions technical guidelines (first edition)", new coronary virus infection in the prevention and treatment of pneumonia common medical protective supplies use guidelines (trial)" requirements.

Please click on:

The sixth edition of the original

The seventh edition of the original

 

 

 

 

 

 

最新丨第七 vs 第六版新冠肺炎诊疗方案比对
SIFIC感染团队 SIFIC感染循证资讯 4 days ago

下文中新增部分标红加粗，请留意

时间仓促，如有疏漏请谅解

 

第七版更新要点：

 

 

1. 增加对于输入新病例的提醒

2. 增加儿童和妊娠期关注

3. 增加重症患者的支持

4. 增加病理改变

5. 增加重症、危重症预警指标

6. 血清学诊断方法纳入

 

 

新冠肺炎诊疗方案第六、七版对比

 

韦艳妮、周谋清、史庆丰、周密、韩玲样

校对

 

2019年12月以来，湖北省武汉市出现了新型冠状病毒肺炎 疫情，随着疫情的蔓延，我国其他地区及境外多个国家也相继 发现了此类病例。该病作为急性呼吸道传染病已纳入《中华人 民共和国传染病防治法》规定的乙类传染病，按甲类传染病管理。通过釆取一系列预防控制和医疗救治措施，我国境内疫情 上升的势头得到一定程度的遏制，大多数省份疫情缓解，但境外的发病人数呈上升态势。随着对疾病临床表现、病理认识的 深入和诊疗经验的积累，为进一步加强对该病的早诊早治，提 高治愈率，降低病亡率，最大可能避免医院感染，同时提醒注意境外输入性病例导致的传播和扩散，我们对《新型冠状病毒 肺炎诊疗方案（试行第六版）》进行修订，形成了《新型冠状病 毒肺炎诊疗方案（试行第七版）》。

 

 

01
PART
病原学特点

 

新型冠状病毒属于 β属的冠状病毒，有包膜，颗粒呈圆形 或椭圆形，常为多形性，直径60-140nm。其基因特征与SARS-CoV 和MERS-CoV有明显区别（第6版为SARSr-CoV 和MERSr-CoV）。目前研究显示与蝙蝠SARS样冠状病 毒（bat-SL-CoVZC45）同源性达85%以上。体外分离培养时，新 型冠状病毒96个小时左右即可在人呼吸道上皮细胞内发现，而 在Vero E6和Huh-7细胞系中分离培养需约6天。

 

对冠状病毒理化特性的认识多来自对SARS-CoV和MERS-CoV 的研究。病毒对紫外线和热敏感，56°C 30分钟、乙醚、75%乙醇、含氯消毒剂、过氧乙酸和氯仿等脂溶剂均可有效灭活病毒， 氯己定不能有效灭活病毒。

 

 

02
PART
流行病学特点

（一）   传染源。

目前所见传染源主要是新型冠状病毒感染的患者。无症状 感染者也可能成为传染源。

 

（二）   传播途径。

经呼吸道飞沫和密切接触传播是主要的传播途径。在相对封闭的环境中长时间暴露于高浓度气溶胶情况下存在经气溶胶 传播的可能。增加：由于在粪便及尿中可分离到新型冠状病毒，应注 意粪便及尿对环境污染造成气溶胶或接触传播。

 

（三）   易感人群。

人群普遍易感。

 

03
PART
病理改变

 

本章节全部为新增，请留意

 

根据目前有限的尸检和穿刺组织病理观察结果总结如下。

 

（一）肺脏。

 

肺脏呈不同程度的实变。

 

肺泡腔内见浆液、纤维蛋白性渗出物及透明膜形成；渗出 细胞主要为单核和巨噬细胞，易见多核巨细胞。II型肺泡上皮 细胞显著增生，部分细胞脱落。II型肺泡上皮细胞和巨噬细胞 内可见包涵体。肺泡隔血管充血、水肿，可见单核和淋巴细胞 浸润及血管内透明血栓形成。肺组织灶性出血、坏死，可出现 出血性梗死。部分肺泡腔渗出物机化和肺间质纤维化。

 

肺内支气管黏膜部分上皮脱落，腔内可见黏液及黏液栓形成。少数肺泡过度充气、肺泡隔断裂或囊腔形成。

 

电镜下支气管黏膜上皮和II型肺泡上皮细胞胞质内可见冠 状病毒颗粒。免疫组化染色显示部分肺泡上皮和巨噬细胞呈新 型冠状病毒抗原阳性，RT-PCR检测新型冠状病毒核酸阳性。

 

（二）脾脏、肺门淋巴结和骨髓。

 

脾脏明显缩小。淋巴细胞数量明显减少，灶性出血和坏死， 脾脏内巨噬细胞增生并可见吞噬现象；淋巴结淋巴细胞数量较少，可见坏死。免疫组化染色显示脾脏和淋巴结内CD4+T和CD8+T 细胞均减少。骨髓三系细胞数量减少。

 

（三）心脏和血管。

 

心肌细胞可见变性、坏死，间质内可见少数单核细胞、淋巴细胞和（或）中性粒细胞浸润。部分血管内皮脱落、内膜炎症及血栓形成。

 

（四）      肝脏和胆囊。

 

体积增大，暗红色。肝细胞变性、灶性坏死伴中性粒细胞浸润；肝血窦充血，汇管区见淋巴细胞和单核细胞细胞浸润， 微血栓形成。胆囊高度充盈。

 

（五）      肾脏。

 

肾小球球囊腔内见蛋白性渗出物，肾小管上皮变性、脱落， 可见透明管型。间质充血，可见微血栓和灶性纤维化。

 

（六）      其他器官。

 

脑组织充血、水肿，部分神经元变性。肾上腺见灶性坏死。食管、胃和肠管黏膜上皮不同程度变性、坏死、脱落。

 

 

04
PART
临床特点

 

（一）临床表现。

 

基于目前的流行病学调查，潜伏期1～14天，多为3～7天。

 

以发热、干咳、乏力为主要表现。少数患者伴有鼻塞、流 涕、咽痛、肌痛和腹泻等症状。重症患者多在发病一周后出现 呼吸困难和/或低氧血症，严重者可快速进展为急性呼吸窘迫综 合征、脓毒症休克、难以纠正的代谢性酸中毒和出凝血功能障 碍及多器官功能衰竭等。值得注意的是重型、危重型患者病程 中可为中低热，甚至无明显发热。

 

新增：部分儿童及新生儿病例症状可不典型，表现为呕吐、腹泻 等消化道症状或仅表现为精神弱、呼吸急促。

 

轻型患者仅表现为低热、轻微乏力等，无肺炎表现。

 

从目前收治的病例情况看，多数患者预后良好，少数患者病情危重。老年人和有慢性基础疾病者预后较差。新增：患有新型冠状病毒肺炎的孕产妇临床过程与同龄患者相近。儿童病例症状相对较轻。

 

（二）  实验室检查。

 

1.       一般检查（新增小标题）

 

发病早期外周血白细胞总数正常或减少，可见（新增）淋巴细胞计 数减少，部分患者可出现肝酶、乳酸脱氢酶（LDH）、肌酶和肌 红蛋白增高；部分危重者可见肌钙蛋白增高。多数患者C反应 蛋白（CRP）和血沉升高，降钙素原正常。严重者D-二聚体升高、 外周血淋巴细胞进行性减少。重型、危重型患者常有炎症因子 升高。

 

2.       病原学及血清学检查（新增小标题）

 

（1） 病原学检查：釆用RT-PCR或/和NGS方法（新增检查方法）在鼻咽拭子、 痰和其他下呼吸道分泌物、血液、粪便等标本中可检测出新型 冠状病毒核酸。检测下呼吸道标本（痰或气道抽取物）更加准确。标本采集后尽快送检。(修订文字)

 

新增：（2） 血清学检查：新型冠状病毒特异性IgM抗体多在发病 3-5天后开始出现阳性，IgG抗体滴度恢复期较急性期有4倍及 以上增高。

 

（三）  胸部影像学。

 

早期呈现多发小斑片影及间质改变，以肺外带明显。进而 发展为双肺多发磨玻璃影、浸润影，严重者可出现肺实变，胸 腔积液少见。

 

 

05
PART
诊断标准

 

(一)   疑似病例。

 

结合下述流行病学史和临床表现综合分析：

 

     流行病学史

 

(1)  发病前14天内有武汉市及周边地区，或其他有病例 报告社区的旅行史或居住史；

(2)   发病前14天内与新型冠状病毒感染者(核酸检测阳 性者)有接触史；

(3)   发病前14天内曾接触过来自武汉市及周边地区，或 来自有病例报告社区的发热或有呼吸道症状的患者；

(4)   聚集性发病新增：(2周内在小范围如家庭、办公室、学校 班级等场所，出现2例及以上发热和/或呼吸道症状的病例)。

 

2.     临床表现

 

(1)  发热和/或呼吸道症状；            ’

(2)  具有上述新型冠状病毒肺炎影像学特征；

(3)  发病早期白细胞总数正常或降低，淋巴细胞计数正常 或减少。

 

有流行病学史中的任何一条，且符合临床表现中任意2条。无明确流行病学史的，符合临床表现中的3条。

 

(二)   确诊病例。（新增同时和或血清学）

 

疑似病例同时具备以下病原学或血清学证据之一者：

 

1.     实时荧光RT-PCR检测新型冠状病毒核酸阳性；

2.     病毒基因测序，与已知的新型冠状病毒高度同源；

3.     新增：血清新型冠状病毒特异性IgM抗体和IgG抗体阳性；血 清新型冠状病毒特异性IgG抗体由阴性转为阳性或恢复期较急性期4倍及以上升高。

 

 

06
PART
临床分型

（一）   轻型。

 

临床症状轻微，影像学未见肺炎表现。

 

（二）   普通型。

 

具有发热、呼吸道等症状，影像学可见肺炎表现。

 

（三）   重型。

 

成人符合下列任何一条：

1.     出现气促，RR≥330次/分；

2.     静息状态下，指氧饱和度≤93%；

3.     动脉血氧分压（PaO2）/吸氧浓度（FiO2）≤300mmHg （ lmmHg=0.133kPa）

 

高海拔（海拔超过1000米）地区应根据以下公式对PaO2/FiO2 进行校：PaO2/FiO2 × [大气压（mmHg） /760] 

 

肺部影像学显示24 - 48小时内病灶明显进展＞50%者按重型管理。

 

新增：儿童符合下列任何一条：

 

1.出现气促（＜2月龄，RR≥60次/分；2〜12月龄，RR≥ 50次/分；1〜5岁，RR≥40次/分；＞5岁，RR≥30次/分），除外发热和哭闹的影响；

 2.静息状态下，指氧饱和度≤92%；

 

3.辅助呼吸（呻吟、鼻翼扇动、三凹征），发紺，间歇性呼吸暂停；

 

4.出现嗜睡、惊厥；

 

5.拒食或喂养困难，有脱水征。

 

（四）危重型。

 

符合以下情况之一者：

1.     出现呼吸衰竭，且需要机械通气；

2.     出现休克；

3.     合并其他器官功能衰竭需ICU监护治疗。

 

 

07
PART
重型、危重型临床预警指标

 

本节全部为新增内容

 

（一）成人。

 

1.     外周血淋巴细胞进行性下降；

2.     外周血炎症因子如IL-6、C反应蛋白进行性上升；

3.     乳酸进行性升高；

4.     肺内病变在短期内迅速进展。

 

（二）儿童。

 

1.     呼吸频率增快；

2.     精神反应差、嗜睡；

3.     乳酸进行性升高；

4.     影像学显示双侧或多肺叶浸润、胸腔积液或短期内病变快速进展；

5.     3月龄以下的婴儿或有基础疾病（先天性心脏病、支气管肺发育不良、呼吸道畸形、异常血红蛋白、重度营养不良等），有免疫缺陷或低下（长期使用免疫抑制剂）。

 

 

08
PART
鉴别诊断

 

（一）   新型冠状病毒感染轻型表现需与其他病毒引起的上呼吸道感染相鉴别。

 

（二）   新型冠状病毒肺炎主要与流感病毒、腺病毒、呼吸道合胞病毒等其他已知病毒性肺炎及肺炎支原体感染鉴别，尤其是对疑似病例要尽可能采取包括快速抗原检测和多重PCR核酸检测等方法，对常见呼吸道病原体进行检测。

 

（三）   还要与非感染性疾病，如血管炎、皮肌炎和机化性肺炎等鉴别。

 

 

09
PART
病例的发现与报告
各级各类医疗机构的医务人员发现符合病例定义的疑似病例后，应当立即进行单人间隔离治疗，院内专家会诊或主诊医师会诊，仍考虑疑似病例，在2小时内进行网络直报，并釆集标本进行新型冠状病毒核酸检测，同时在确保转运安全前提下立即将疑似病例转运至定点医院。与新型冠状病毒感染者有密切接触的患者，即便常见呼吸道病原检测阳性，也建议及时进 行新型冠状病毒病原学检测。

 

新增：

疑似病例连续两次新型冠状病毒核酸检测阴性（釆样时间至少间隔24小时）且发病7天后新型冠状病毒特异性抗体IgM 和IgG仍为阴性可排除疑似病例诊断。

 

 

10
PART
治疗

 

（一）      根据病情确定治疗场所。

 

1.    疑似及确诊病例应在具备有效隔离条件和防护条件的定点医院隔离治疗，疑似病例应单人单间隔离治疗，确诊病例可多人收治在同一病室。

2.    危重型病例应当尽早收入ICU治疗。

 

（二）      一般治疗。

 

1.    卧床休息，加强支持治疗，保证充分热量；注意水、电解质平衡，维持内环境稳定；密切监测生命体征、指氧饱和度等。

 

2.    根据病情监测血常规、尿常规、CRP、生化指标（肝酶、 心肌酶、肾功能等）、凝血功能、动脉血气分析、胸部影像学等。有条件者可行细胞因子检测。

 

3.    及时给予有效氧疗措施，包括鼻导管、面罩给氧和经鼻高流量氧疗。新增：有条件可釆用氢氧混合吸入气（H2/O2：66.6%/33.3%）治疗。

 

4.    抗病毒治疗：可试用a-干扰素（成人每次500万U或相 当剂量，加入灭菌注射用水2nd,每日2次雾化吸入）、洛匹那韦/利托那韦（成人200mg/50mg/粒，每次2粒，每日2次，疗程不超过10天）、利巴韦林（建议与干扰素或洛匹那韦/利托那韦联合应用，成人500mg/次，每日2至3次静脉输注，疗程不超过10天）、修改使用方法：磷酸氯喹（18岁-65岁成人。体重大于50公斤者， 每次500mg、每日2次，疗程7天；体重小于50公斤者，第一、 二天每次500mg.每日2次，第三至第七天每次500mg.每日1 次）、阿比多尔（成人200mg,每日3次，疗程不超过10天）。

 

修改表述：要注意上述药物的不良反应、禁忌症（如患有心脏疾病者禁用氯喹）以及与其他药物的相互作用等问题。

 

在临床应用中进一步评价目前所试用药物的疗效。不建议同时应用3种及以上抗病毒药物，出现不可耐受的毒副作用时应停止使用相关药物。 

 

新增：对孕产妇患者的治疗应考虑妊娠周数，尽可能选择对胎儿影响 较小的药物，以及是否终止妊娠后再进行治疗等问题，并知情告知。

 

5.    抗菌药物治疗：避免盲目或不恰当使用抗菌药物，尤其是联合使用广谱抗菌药物。

 

（三）重型、危重型病例的治疗。

 

1. 治疗原则：在对症治疗的基础上，积极防治并发症，治疗基础疾病，预防继发感染，及时进行器官功能支持。

2.   呼吸支持：

 

（1）     氧疗：重型患者应当接受鼻导管或面罩吸氧，并及时评估呼吸窘迫和/或低氧血症是否缓解。

 

（2）     高流量鼻导管氧疗或无创机械通气：当患者接受标准氧疗后呼吸窘迫和/或低氧血症无法缓解时，可考虑使用高流量鼻导管氧疗或无创通气。若短时间（1-2小时）内病情无改善甚至恶化，应当及时进行气管插管和有创机械通气。

（3）     有创机械通气：釆用肺保护性通气策略，即小潮气量 （6-8mL/kg理想体重）和低水平气道平台压力（平台压<30cmH2O）进行机械通气，以减少呼吸机相关肺损伤。

 

新增：在保证气道平台压W 35cmH2O时，可适当釆用高PEEP,保持气道温化湿化，避免长时间镇静，早期唤醒患者并进行肺康复治疗。

 

较多患者存在人机不同步，应当及时使用镇静以及肌松剂。

 

新增：根据气道分泌物情况, 选择密闭式吸痰，必要时行支气管镜检查釆取相应治疗。

 

（4）     挽救治疗：对于严重ARDS患者，建议进行肺复张。在人力资源充足的情况下，每天应当进行12小时以上的俯卧位通气。俯卧位机械通气效果不佳者，如条件允许，应当尽快考虑体外膜肺氧合（ECMO）。

 

新增:其相关指征：①在FiO2>90%时，氧 合指数小于80mmHg,持续3-4小时以上；②气道平台压≥35cmH2O。

单纯呼吸衰竭患者，首选VV-ECMO模式；若需要循环 支持，则选用VA-ECMO模式。在基础疾病得以控制，心肺功能 有恢复迹象时，可开始撤机试验。

 

 

3.    循环支持：在充分液体复苏的基础上，改善微循环，使用血管活性药物，新增：密切监测患者血压、心率和尿量的变化，以及动脉血气分析中乳酸和碱剩余，必要时进行无创或有创血流 动力学监测，如超声多普勒法、超声心动图、有创血压或持续 心排血量（PiCCO）监测。在救治过程中，注意液体平衡策略，避免过量和不足。

 

新增：如果发现患者心率突发增加大于基础值的20%或血压下降大约基础值20%以上时，若伴有皮肤灌注不良和尿量减少等表现时，应密切观察患者是否存在脓毒症休克、消化道出血或心功能衰竭等情况。

 

新增：4. 肾功能衰竭和肾替代治疗：危重症患者的肾功能损伤应 积极寻找导致肾功能损伤的原因，如低灌注和药物等因素。对 于肾功能衰竭患者的治疗应注重体液平衡、酸碱平衡和电解质 平衡，在营养支持治疗方面应注意氮平衡、热量和微量元素等 补充。重症患者可选择连续性肾替代治疗（continuous renal replacement therapy, CRRT）。其指征包括：①高钾血症；② 酸中毒；③肺水肿或水负荷过重；④多器官功能不全时的液体管理。

 

5.    康复者血浆治疗：适用于病情进展较快、重型和危重型患者。用法用量参考《新冠肺炎康复者恢复期血浆临床治疗方案（试行第二版）》。

 

新增：6. 血液净化治疗：血液净化系统包括血浆置换、吸附、灌流、血液/血浆滤过等，能清除炎症因子，阻断“细胞因子风暴”, 从而减轻炎症反应对机体的损伤，可用于重型、危重型患者细 胞因子风暴早中期的救治。

 

7.    免疫治疗：对于双肺广泛病变者及重型患者，且实验室检测IL-6水平升高者，可试用托珠单抗治疗。首次剂量 4-8mg/kg,推荐剂量为400mg、0. 9%生理盐水稀释至100ml,输 注时间大于1小时；首次用药疗效不佳者，可在12小时后追加 应用一次（剂量同前），累计给药次数最多为2次，单次最大剂 量不超过800mg。注意过敏反应，有结核等活动性感染者禁用。

 

8.     其他治疗措施     ：

对于氧合指标进行性恶化、影像学进展迅速、机体炎症反 应过度激活状态的患者，酌情短期内（3〜5日）使用糖皮质激素，建议剂量不超过相当于甲泼尼龙1〜2mg/kg/日，应当注意较大剂量糖皮质激素由于免疫抑制作用，会延缓对冠状病毒的清除；可静脉给予血必净100ml/次，每日2次治疗；可使用肠道微生态调节剂，维持肠道微生态平衡，预防继发细菌感染。（删除部分和上面新增重复内容）

 

新增：儿童重型、危重型病例可酌情考虑给予静脉滴注丙种球蛋白。

 

患有重型或危重型新型冠状病毒肺炎的孕妇应积极终止妊娠，剖腹产为首选。

 

患者常存在焦虑恐惧情绪，应当加强心理疏导。

 

（四）中医治疗。

 

本病属于中医“疫”病范畴，病因为感受“疫戾"之气，各地可根据病情、当地气候特点以及不同体质等情况，参照下列方案进行辨证论治。涉及到超药典剂量，应当在医师指导下使用。

 

1 .医学观察期

 

临床表现1:乏力伴胃肠不适

推荐中成药：藿香正气胶囊（丸、水、口服液）

 

临床表现2：乏力伴发热

推荐中成药：金花清感颗粒、连花清瘟胶囊（颗粒）、疏风解毒胶囊（颗粒）

 

2.    临床治疗期（确诊病例）

 

2.1 清肺排毒汤

 

适用范围：结合多地医生临床观察，适用于轻型、普通型、 重型患者，在危重型患者救治中可结合患者实际情况合理使用。

 

基础方剂：麻黄9g、炙甘草6g、杏仁9g、生石膏15〜30g （先煎）、桂枝9g、泽泻9g、猪苓9g、白术9g、茯苓15g、柴胡16g、黄苓6g、姜半夏9g、生姜9g、紫蒐9g、冬花9g、射干9g、细辛6g、山药12g、枳实6g、陈皮6g、着香9g。

 

服法：传统中药饮片，水煎服。每天一付，早晩各一次（饭后四十分钟），温服，三付一个疗程。

 

如有条件，每次服完药可加服大米汤半碗，舌干津液亏虚 者可多服至一碗。（注：如患者不发热则生石膏的用量要小，发 热或壮热可加大生石膏用量）。若症状好转而未痊愈则服用第二 个疗程，若患者有特殊情况或其他基础病，第二疗程可以根据实际情况修改处方，症状消失则停药。

 

处方来源：国家卫生健康委办公厅国家中医药管理局办公 室《关于推荐在中西医结合救治新型冠状病毒感染的肺炎中使 用“清肺排毒汤”的通知》(国中医药办医政函〔2020) 22号)。

 

2.2轻型

 

(1)   寒湿郁肺证

 

临床表现：发热，乏力，周身酸痛，咳嗽，咯痰，胸紧憋气，纳呆，恶心，呕吐，大便粘膩不爽。舌质淡胖齿痕或淡红, 苔白厚腐腻或白腻，脉濡或滑。

 

推荐处方：生麻黄6g、生石膏15g、杏仁9g、羌活15g、 草蘭子15g、贯众9g、地龙15g、徐长卿15g、蕾香15g、佩兰 9g、苍术15g、云苓45g、生白术30g、焦三仙各9g、厚朴15g、 焦槟榔9g、煨草果9g、生姜15g。

 

服法：每日1剂，水煎600ml,分3次服用，早中晚各1次, 饭前服用。

 

(2)   湿热蕴肺证

 

临床表现：低热或不发热，微恶寒，乏力，头身困重，肌肉酸痛，干咳痰少，咽痛，口干不欲多饮，或伴有胸闷脱痞，无汗或汗出不畅，或见呕恶纳呆，便澹或大便粘滞不爽。舌淡红，苔白厚腻或薄黄，脉滑数或濡。

 

推荐处方：槟榔10g、草果10g、厚朴10g、知母10g、黄 苓10g、柴胡10g、赤芍10g、连翘15g青蒿10g (后下)、苍 术10g、大青叶10g、生甘草5g。

 

服法：每日1剂，水煎400ml,分2次服用，早晩各1次。

 

2.3普通型

 

(1)   湿毒郁肺证

 

临床表现：发热，咳嗽痰少，或有黄痰，憋闷气促，腹胀, 便秘不畅。舌质暗红，舌体胖，苔黄腻或黄燥，脉滑数或弦滑。

 

推荐处方：生麻黄6g、苦杏仁15g、生石膏30g、生蕙茂仁 30g、茅苍术10g、广蕾香15g、青蒿草12g、虎杖20g、马鞭草 30g、干芦根30g、草蘭子15g、化橘红15g、生甘草10g。

 

服法：每日1剂，水煎400ml,分2次服用，早晩各1次。

 

(2)   寒湿阻肺证

 

临床表现：低热，身热不扬，或未热，干咳，少痰，倦怠乏力，胸闷，月完痞，或呕恶，便澹。舌质淡或淡红，苔白或白腻，脉濡。

 

推荐处方：苍术15g、陈皮10g、厚朴10g、蕾香10g、草果6g、生麻黄6g、羌活10g、生姜10g、槟榔10g。

 

服法：每日1剂，水煎400ml,分2次服用，早晩各1次。

 

2.4重型

 

(1)疫毒闭肺证

 

临床表现：发热面红，咳嗽，痰黄粘少，或痰中带血，喘憋气促，疲乏倦怠，口干苦粘，恶心不食，大便不畅，小便短赤。舌红，苔黄腻，脉滑数。

 

推荐处方：化湿败毒方

 

基础方剂：生麻黄6g、杏仁9g、生石膏15g、甘草3g、着 香10g （后下）、厚朴10g、苍术15g、草果10g、法半夏9g、茯 苓15g、生大黄5g （后下）、生黄芷10g、葶苈子10g、赤芍10g。

 

服法：每日1〜2剂，水煎服，每次100蔺〜200ml, 一日2〜 4次，口服或鼻饲。

 

（2）气营两燔证

 

临床表现：大热烦渴，喘憋气促，谑语神昏，视物错督， 或发斑疹，或吐血、衄血，或四肢抽搐。舌绛少苔或无苔，脉沉细数，或浮大而数。

 

推荐处方：生石膏30〜60g （先煎）、知母30g、生地30〜 60g、水牛角30g （先煎）、赤芍30g、玄参30g、连翘15g、丹 皮15g、黄连6g、竹叶12g、草房子15g、生甘草6g。

 

服法：每日1剂，水煎服，先煎石膏、水牛角后下诸药， 每次100ml〜200ml,每日2〜4次，口服或鼻饲。

 

推荐中成药：喜炎平注射液、血必净注射液、热毒宁注射液、痰热清注射液、醒脑静注射液。功效相近的药物根据个体情况可选择一种，也可根据临床症状联合使用两种。中药注射剂可与中药汤剂联合使用。

 

2.5危重型（内闭外脱证）

 

临床表现：呼吸困难、动辄气喘或需要机械通气，伴神昏，烦躁，汗出肢冷，舌质紫暗，苔厚腻或燥，脉浮大无根。

推荐处方：人参15g、黑顺片10g （先煎）、山茱萸15g,送 服苏合香丸或安宫牛黄丸。

 

新增：出现机械通气伴腹胀便秘或大便不畅者，可用生大黄5〜 10g。出现人机不同步情况，在镇静和肌松剂使用的情况下，可用生大黄5〜10g和芒硝5〜10g。

 

推荐中成药：血必净注射液、热毒宁注射液、痰热清注射 液、醒脑静注射液、参附注射液、生脉注射液、参麦注射液。功效相近的药物根据个体情况可选择一种，也可根据临床症状 联合使用两种。中药注射剂可与中药汤剂联合使用。

 

注：重型和危重型中药注射剂推荐用法

 

中药注射剂的使用遵照药品说明书从小剂量开始、逐步辨证调整的原则，推荐用法如下：

 

病毒感染或合并轻度细菌感染：0.9%氯化钠注射液250ml 加喜炎平注射液100mg bid,或0.9%氯化钠注射液250ml加热毒宁注射液20ml,或0. 9%氯化钠注射液250ml加痰热清注射液 40ml bid.

 

高热伴意识障碍：0.9%氯化钠注射液250ml加醒脑静注射液 20ml bid。

 

全身炎症反应综合征或/和多脏器功能衰竭：0. 9%氯化钠注射液250ml加血必净注射液100ml bid。

免疫抑制：葡萄糖注射液250ml加参麦注射液100ml或生脉注射液20〜60ml bid（新增）

 

2.6恢复期

 

（1）     肺脾气虚证

 

临床表现：气短，倦怠乏力，纳差呕恶，痞满，大便无力， 便澹不爽。舌淡胖，苔白腻。

 

推荐处方：法半夏9g、陈皮10g、党参15g、炙黄茂30g、 炒白术10g、茯苓15g、蕾香10g、砂仁6g （后下）、甘草6g。

 

服法：每日1剂，水煎400ml,分2次服用，早晚各1次。

 

（2）     气阴两虚证

 

临床表现：乏力，气短，口干，口渴，心悸，汗多，纳差, 低热或不热，干咳少痰。舌干少津，脉细或虚无力。

 

推荐处方：南北沙参各10g、麦冬15g、西洋参6g,五味子 6g、生石膏15g、淡竹叶10g、桑叶10g、芦根15g、丹参15g、 生甘草6g。

 

服法：每日1剂，水煎400ml,分2次服用，早晚各1次。

 

 

 

 

11
PART
岀院标准和出院后注意事项

 

 

第七版将原来的“解除隔离或出院标准”改为“出院标准”，删除了“解除隔离”。

 

（一）出院标准。

 

该标准中第四条将原来的呼吸道标本修改为痰、鼻咽拭子等呼吸道标本，采样时间由原来的至少间隔1天改为至少间隔24小时。

 

1.     体温恢复正常3天以上；

2.     呼吸道症状明显好转；

3.     肺部影像学显示急性渗出性病变明显改善；

4.     连续两次痰、鼻咽拭子等呼吸道标本核酸检测阴性（釆样时间至少间隔24小时）。

 

满足以上条件者可出院。

 

（二）出院后注意事项。

 

1.   定点医院要做好与患者居住地基层医疗机构间的联系，共享病历资料，及时将出院患者信息推送至患者辖区或居住地 居委会和基层医疗卫生机构。

 

2.     患者出院后，建议应继续进行14天的隔离管理和健康状 况监测，佩戴口罩，有条件的居住在通风良好的单人房间，减少与家人的近距离密切接触，分餐饮食，做好手卫生，避免外出活动。

 

3.     建议在出院后第2周和第4周到医院随访、复诊。

 

删掉了出院后对继续自我监测的原因解释部分内容“因恢复期机体免疫力功能低下，有感染其它病原体风险”

 

 

 

 

12
PART
转运原则
按照国家卫生健康委印发的《新型冠状病毒感染的肺炎病 例转运工作方案（试行）》执行。

 

 

13
PART
医疗机构内感染预防与控制

 

严格按照国家卫生健康委《医疗机构内新型冠状病毒感染 预防与控制技术指南（第一版）》、《新型冠状病毒感染的肺炎防 护中常见医用防护用品使用范围指引（试行）》的要求执行。

 

原文请点击：

 

 

第六版原文

 

第七版原文