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Communique

Weekly Communique # 23

17 September, 2020

WEEK IN REVIEW

New recommendations on VTE prophylaxis for pregnant and postpartum women

The Pregnancy and Perinatal Care Panel together with the Expert Advisory Group have developed four new consensus recommendations on venous thromboembolism (VTE) prophylaxis that cover:

  • pregnant or postpartum women admitted to hospital (for any indication) and who have COVID-19
  • pregnant women with severe or critical COVID-19, or where there are additional risk factors for VTE
  • pregnant or postpartum women who are self-isolating at home with mild COVID-19 and where there are additional risk factors for VTE.
  • postpartum women who have had COVID-1 (see below).

Updated recommendation on dexamethasone

As a result of the recent landmark meta-analysis of corticosteroids in COVID-19 conducted for the World Health Organisation, the Taskforce has updated its recommendation to include additional advice on alternative corticosteroids (hydrocortisone or prednisolone) where dexamethasone is not available. The evidence base has been updated with no change to the strength or direction of the recommendation.

Consumer panel update

This week’s guideline update includes introductory statements on consumer-centred care and informed consent. The statements were developed by the Consumer Panel and Consumers Health Forum of Australia (CHF) to provide an overarching statement of core principles the panel takes into consideration in its work to inform the development or revision of all Taskforce recommendations.

The Panel meets every fortnight to develop preferences and values statements for guideline recommendations and to provide advice to support other Taskforce initiatives such as the development of flowcharts. The Panel has a unique and challenging role to consider the consumer perspective across the broad scope of COVID-19 disease severity, care settings and treatment/management options that are addressed by the Taskforce. We are very fortunate and grateful to be working with such a dedicated panel of consumer representatives convened by CHF.

Welcome to the Australasian College of Paramedicine

The Taskforce has welcomed its 31st member – the Australasian College of Paramedicine (ACP). We look forward to working with the ACP and drawing on the expertise of its members to consider the application of Taskforce guidance in the pre-hospital setting and address key clinical questions for people with COVID-19 requiring paramedic care.

 


QUICK STATISTICS

COVID-19 research pipeline

  • 20,320 studies published or registered in Cochrane COVID-19 Study Register, 1221 added this week
  • 1,686 randomised controlled trials registered (data from Covid-nma site), 0 added this week
  • 2,120 systematic reviews registered in PROSPERO, 19 added this week
  • 61 randomised controlled trials published (data from Covid-nma site), added this week

 


NEW OR UPDATED RECOMMENDATIONS

Australian guidelines for the clinical care of people with COVID-19: Version 22.0

NEW RECOMMENDATIONS

  • Calcifediol

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

  • Human umbilical cord mesenchymal stem cells

For people with COVID-19, do not use human umbilical cord mesenchymal stem cells outside of randomised trials with appropriate ethical approval.

  • High-frequency oscillatory ventilation (HFOV)

Do not routinely use HFOV as a first line mode of mechanical ventilation in neonates, children and adolescents with severe COVID-19. HFOV should be limited to a rescue therapy in neonates and children not responding to conventional mechanical ventilation in a specialist centre with experience with HFOV.

HFOV delivers gas at very high flow rates. This may increase the aerosol-generating potential compared to other forms of respiratory support used in intensive care. This may limit the suitability of HFOV in patients with COVID-19 unless strict attention to staff safety and infection control measures can be applied.

  • Videolaryngoscopy (neonates, children and adolescents)

In neonates, children and adolescents with COVID-19 undergoing endotracheal intubation, consider using videolaryngoscopy over direct laryngoscopy if available and the operator is trained in its use.

  • VTE prophylaxis for pregnant and postpartum women

 – For pregnant or postpartum women who are admitted to hospital (for any indication) and who have COVID-19, use prophylactic doses of anticoagulants, preferably LMWH (e.g. enoxaparin 40 mg once daily or dalteparin 5000 IU once daily) unless there is a contraindication, such as risk for major bleeding or imminent birth.

Prophylactic anticoagulants should be continued for at least 14 days after discharge or until COVID-19-related morbidity (including immobility, dehydration and/or shortness of breath) has resolved.

 – For pregnant women with severe or critical COVID-19, or where there are additional risk factors for VTE, consider using increased prophylactic dosing of anticoagulants, preferably LMWH (e.g. enoxaparin 40 mg twice daily or dalteparin 5000 IU twice daily) unless there is a contraindication, such as risk for major bleeding or platelet count < 30 x 109/L.

Prophylactic anticoagulants should be continued for at least four weeks after discharge or until COVID-19-related morbidity (including immobility, dehydration and/or shortness of breath) has resolved.

 – For pregnant or postpartum women who are self-isolating at home with mild COVID-19 and where additional risk factors for VTE are present, consider using prophylactic doses of anticoagulants, preferably LMWH (e.g. enoxaparin 40 mg once daily or dalteparin 5000 IU once daily) unless there is a contraindication, such as risk for major bleeding or imminent birth. Prophylactic anticoagulants should be continued for at least 14 days or until COVID-19-related morbidity (including immobility, dehydration and/or shortness of breath) has resolved.For pregnant or postpartum women who are self-isolating at home with mild COVID-19 and who have no additional risk factors for VTE, routine pharmacological prophylaxis is not recommended.

 – For postpartum women who have had COVID-19 during pregnancy, consider using at least 14 days of prophylactic dosing of anticoagulants, preferably LMWH (e.g. enoxaparin 40 mg once daily or dalteparin 5000 IU once daily) unless there is a contraindication, such as risk for major bleeding. Increased duration of six weeks should be considered if severe or critical COVID-19 and/or additional risk factors for VTE are present.

UPDATES TO EXISTING GUIDANCE

  • Introduction: Text has been added on consumer-centred care in the context of COVID-19 and on informed consent.
  • Corticosteroids for adults, pregnant or breastfeeding women and children or adolescents: The recommendation on dexamethasone now includes advice on alternative corticosteroids. The evidence base has been updated with no change to the strength or direction of the recommendation on dexamethasone use.
  • Remdesivir for adults, pregnant or breastfeeding women and children or adolescents: The evidence base for remdesivir has been updated with no change to the strength or direction of the recommendation.
  • Respiratory management of the deteriorating patient: The remark under the recommendation has been updated with no change to the strength or direction of the recommendation.
  • Prone positioning for adults: The key information and remark under the recommendation has been updated with no change to the strength or direction of the recommendation.
  • ECMO for adults: The key information and remark under the recommendation has been updated with no change to the strength or direction of the recommendation.

 

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

 


CLINICAL FLOWCHARTS

Seven 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
  • Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment
  • Management of people with COVID-19 who are receiving palliative care

Changes to flowcharts this week reflect:

  • Added new drugs to the ‘only in research’ category: Calcifediol and mesenchymal stem cells
  • Corticosteroids recommendation updated to reflect changes in the guideline

 


 EVIDENCE UNDER REVIEW

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

  • Tocilizumab NEW
  • Recombinant human granulocyte colony-stimulating factor NEW
  • Umifenovir
  • Cardiac arrest
  • Paediatric Multisystem Inflammatory Syndrome (PIMS-TS)

 


NEWS & EVENTS

Cochrane

This week Cochrane published or updated rapid reviews on three major components of the global public health response to COVID-19:

The full list of Cochrane Reviews and related content from the Cochrane Library relating to the COVID-19 pandemic can be found here.

 


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 available here.

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

 

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