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Communique

Weekly Communique # 21

03 September, 2020

WEEK IN REVIEW

New recommendations for children and adolescents, and pregnant women

The Paediatric and Adolescent Care Panel have developed two new consensus recommendations for respiratory support covering high-flow nasal oxygen and prone positioning in children and adolescents receiving non-invasive respiratory support.

The sixth recommendation from the Pregnancy and Perinatal Care Panel addresses the use of antenatal corticosteroids for women at risk of preterm birth (see updated recommendations below).

Late breaking: New evidence of life-saving benefit of corticosteroids in critically ill people with COVID-19
A landmark meta-analysis conducted for the World Health Organisation was published in JAMA this week, reporting that corticosteroid use improves survival in critically ill patients with COVID-19. The analysis pooled the results of seven randomised controlled trials (1703 participants), including the world-first, Australian-led REMAP-CAP platform trial which was published concurrently.

The Disease-Modifying Treatments and Chemoprophylaxis Panel is currently reviewing the data to incorporate this important new evidence into Taskforce guidance.

Welcome to the Royal Australasian College of Surgeons
This week we welcomed the Royal Australasian College of Surgeons (RACS) as the 30th member of the Taskforce.  We look forward to working with the RACS and drawing on the expertise of its members to consider perioperative issues for people with COVID-19.

Taskforce is recruiting
The Taskforce Evidence Team is seeking two fill two new positions:

Interested candidates are invited to contact Taskforce Head of Operations, Bronwyn Morris-Donovan via email or mobile 0488 777 939.

 


QUICK STATISTICS

COVID-19 research pipeline:

  • 18,151 studies published or registered in Cochrane COVID-19 Study Register, 362 added this week
  • 1,686 randomised controlled trials registered (data from Covid-nma site), 19 added this week
  • 2,056 systematic reviews registered in PROSPERO, 47 added this week
  • 48 randomised controlled trials published (data from Covid-nma site), added this week

 


NEW OR UPDATED RECOMMENDATIONS

Version 20.0

Aprepitant
New recommendation

For people with COVID-19, do not use aprepitant outside of randomised trials with appropriate ethical approval.

Convalescent plasma
The evidence base has been updated with no change to the strength or direction of the recommendation.

Sofosbuvir plus daclatasvir
New recommendation

For people with COVID-19, do not use sofosbuvir plus daclatasvir outside of randomised trials with appropriate ethical approval.

Umifenovir
New recommendation

For people with COVID-19, do not use umifenovir outside of randomised trials with appropriate ethical approval.

High-flow nasal oxygen and non-invasive ventilation (Children and adolescents)
New recommendation

Consider using high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) therapy for neonates, children and adolescents with hypoxaemia or respiratory distress associated with COVID-19 and not responding to low-flow oxygen. Use it with caution and pay strict attention to staff safety including the use of appropriate PPE.

The preferred location for high-flow nasal oxygen is a negative pressure room or a single room with the door closed. If these locations are not immediately available then HFNO or NIV should not be withheld if indicated. However, it should be recognised that this therapy may pose an aerosol risk to staff and other patients, and appropriate precautions should be used. In children and adolescents with COVID-19 for whom HFNO or NIV is appropriate for an alternate clinical presentation (e.g. concomitant bronchiolitis or severe asthma), ensure airborne and other infection control precautions are also optimised. Consider early transfer in the deteriorating neonate, child or adolescent to a specialised paediatric or neonatal critical care unit.

Prone positioning in children and adolescents receiving non-invasive respiratory support
New recommendation

For children and adolescents with COVID-19 and respiratory symptoms who are receiving non-invasive respiratory support, consider prone positioning if patient co-operation is possible. When positioning a patient prone, ensure it is used with caution and close monitoring of the patient.

Antenatal corticosteroids
New recommendation

The use of antenatal corticosteroids for women at risk of preterm birth is supported as part of standard care, independent of the presence of COVID-19.

There are clear benefits to using antenatal corticosteroids for women at risk of preterm birth at less than 34 weeks gestation. There is currently no evidence to suggest that antenatal corticosteroids cause additional maternal or fetal harm in the setting of COVID-19 when used for this indication. They should therefore be given where indicated.
 
The Taskforce has separate recommendations regarding the use of dexamethasone as a disease-modifying treatment in pregnant or breastfeeding women for COVID-19. Women with COVID-19 who are on oxygen and receiving dexamethasone do not require additional doses of corticosteroids for fetal lung maturation.

 

The Taskforce is continually monitoring research to update recommendations weekly as new evidence accumulates.

 


CLINICAL FLOWCHARTS

Six clinical flowcharts have been developed by the Taskforce to cover:

  • Assessment for suspected COVID-19
  • Management of adults with mild COVID-19 UPDATED
  • Management of adults with moderate to severe COVID-19 UPDATED
  • Management of adults with severe to critical COVID-19 UPDATED
  • Respiratory support for adults with severe to critical COVID-19 UPDATED
  • Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment

Changes to flowcharts this week reflect:

  • Additional ‘only in clinical trials’ recommendations under disease-modifying treatments
  • Updated CDNA guideline reference to V3.8 and associated content
  • Update regarding negative pressure/single room/COVID-19 ward for HFNO and NIV

 


EVIDENCE UNDER REVIEW

We are currently reviewing evidence to develop recommendations and flowcharts to guide practice in areas including:

  • Remdesivir NEW
  • Corticosteroids NEW
  • Mesenchymal stem cells NEW
  • Convalescent plasma NEW
  • Non-invasive ventilation NEW
  • High-flow nasal oxygen NEW
  • ACE-I/ARBs in pregnant women
  • Anticoagulants for pregnant women
  • Breastfeeding
  • Cardiac arrest
  • Overarching principles of care for people who are receiving palliative care or older people living with frailty
  • Respiratory support for children and adolescents
  • Paediatric Multisystem Inflammatory Syndrome (PIMS-TS)

 


NEWS & EVENTS

Australian Commission on Safety and Quality in Healthcare
The Commission have recently published two new position statements regarding medicines management:

Taskforce on LinkedIn
The Taskforce now has a LinkedIn page. Please follow us to help broaden our reach, and share our guideline recommendations and flowcharts to your fellow clinicians.

 


NEW TOPICS & QUESTIONS

It is a core mission of the Taskforce to engage with frontline clinicians to rapidly identify and address priority clinical questions.

Each week we collect suggestions for new clinical questions or topics for consideration by the Taskforce. A document that lists all of the suggested questions, topics and new patient groups that we have received to date is updated weekly and available here.

Please encourage your clinical colleagues to provide their insights via the website.

 

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