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浙江大学学报(医学版)  2020, Vol. 49 Issue (2): 147-157    DOI: 10.3785/j.issn.1008-9292.2020.02.02
指南与实践     
2019冠状病毒病(COVID-19)诊疗浙江经验
徐凯进1,2(),蔡洪流1(),沈毅弘1,倪勤1,2,陈瑜1,胡少华1,李剑平1,王华芬1,俞亮1,2,黄河1,裘云庆1,魏国庆1,方强1,*(),周建英1,*(),盛吉芳1,2,*(),梁廷波1,*(),李兰娟1,2,*()
1. 浙江大学医学院附属第一医院, 浙江 杭州 310003
2. 浙江大学医学院附属第一医院传染病诊治国家重点实验室 国家感染性疾病临床医学研究中心 感染性疾病诊治协同创新中心, 浙江 杭州 310003
Management of COVID-19: the Zhejiang experience
XU Kaijin1,2(),CAI Hongliu1(),SHEN Yihong1,NI Qin1,2,CHEN Yu1,HU Shaohua1,LI Jianping1,WANG Huafen1,YU Liang1,2,HUANG He1,QIU Yunqing1,WEI Guoqing1,FANG Qiang1,*(),ZHOU Jianying1,*(),SHENG Jifang1,2,*(),LIANG Tingbo1,*(),LI Lanjuan1,2,*()
1. The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
2. State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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摘要:

当前2019冠状病毒病(COVID-19)疫情仍处于胶着状态。浙江大学医学院附属第一医院是国家感染性疾病临床医学中心,浙江省COVID-19患者救治中心。疫情一线的专家集智攻关,以国家卫生健康委员会和国家中医药管理局发布的COVID-19诊治指南为依据,以抗病毒、抗休克、抗低氧血症、抗继发感染、维持水电解质和酸碱平衡、维持微生态平衡的“四抗二平衡”救治策略为核心,总结完善诊治方案,聚焦临床实践的一些具体问题,为COVID-19患者临床诊治提供借鉴。推荐以多学科协作诊治个性化治疗提高COVID-19患者救治质量。建议病原学检测、炎症指标监测和肺部影像学动态观察指导临床诊治。痰液的病毒核酸检测阳性率最高,约10%的急性期患者血液中检测到病毒核酸,50%的患者粪便中检测到病毒核酸,粪便中可分离出活病毒,须警惕粪便是否具有传染性;开展细胞因子等炎症指标监测有助于发现是否出现细胞因子风暴,判断是否需要人工肝血液净化治疗。通过以“四抗二平衡”为核心的综合治疗提高治愈率、降低病死率;早期抗病毒治疗能减少重症、危重症发生,前期使用阿比多尔联合洛匹那韦/利托那韦抗病毒显示出一定效果。休克和低氧血症多为细胞因子风暴所致,人工肝血液净化治疗能迅速清除炎症介质,阻断细胞因子风暴,对维持水电解质酸碱平衡也有很好的作用,可以提高危重型患者的疗效。重型病例疾病早期可适量、短程应用糖皮质激素。氧疗过程中,患者氧合指数小于200 mmHg时应及时转入重症医学科治疗;采用保守氧疗策略,不推荐常规进行无创通气;机械通气患者应严格执行集束化呼吸机相关性肺炎预防管理策略;氧合指数大于150 mmHg时,及早减、停镇静剂并撤机拔管。不推荐预防性使用抗菌药物,对于病程长,体温反复升高和血降钙素原水平升高的患者可酌情使用抗菌药物;要关注COVID-19患者继发真菌感染的诊治。COVID-19患者有肠道微生态紊乱,肠道乳酸杆菌、双歧杆菌等有益菌减少,推荐对所有患者进行营养和胃肠道功能评估,以营养支持和补充大剂量肠道微生态调节剂,纠正肠道微生态失衡,减少细菌移位和继发感染。COVID-19患者普遍存在焦虑和恐惧心理,应建立动态心理危机干预和处理。提倡中西医结合辨证施治;优化重型患者护理促进康复。严重急性呼吸综合征冠状病毒2(SARS-CoV-2)感染后病毒清除规律仍不明了,出院后仍须居家隔离2周,并定期随访。以上经验和建议在本中心实行,取得较好效果,但COVID-19是一种新的疾病,其诊治方案及策略仍有待进一步探索与完善。

关键词: 2019冠状病毒病严重急性呼吸综合征冠状病毒2新型冠状病毒感染危重病综合疗法多学科诊疗    
Abstract:

The current epidemic situation of coronavirus disease 2019 (COVID-19) still remained severe. As the National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital of Zhejiang University School of Medicine is the primary medical care center for COVID-19 in Zhejiang province. Based on the present expert consensus carried out by National Health Commission and National Administration of Traditional Chinese Medicine, our team summarized and established an effective treatment strategy centered on "Four-Anti and Two-Balance" for clinical practice. The "Four-Anti and Two-Balance" strategy included antivirus, anti-shock, anti-hyoxemia, anti-secondary infection, and maintaining of water, electrolyte and acid base balance and microecological balance. Meanwhile, integrated multidisciplinary personalized treatment was recommended to improve therapeutic effect. The importance of early viralogical detection, dynamic monitoring of inflammatory indexes and chest radiograph was emphasized in clinical decision-making. Sputum was observed with the highest positive rate of RT-PCR results. Viral nucleic acids could be detected in 10%patients' blood samples at acute period and 50%of patients had positive RT-PCR results in their feces. We also isolated alive viral strains from feces, indicating potential infectiousness of feces.Dynamic cytokine detection was necessary to timely identifying cytokine storms and application of artificial liver blood purification system. The "Four-Anti and Two-Balance" strategy effectively increased cure rate and reduced mortality. Early antiviral treatment could alleviate disease severity and prevent illness progression, and we found lopinavir/ritonavir combined with abidol showed antiviral effects in COVID-19. Shock and hypoxemia were usually caused by cytokine storms. The artificial liver blood purification system could rapidly remove inflammatory mediators and block cytokine storm.Moreover, it also favored the balance of fluid, electrolyte and acid-base and thus improved treatment efficacy in critical illness. For cases of severe illness, early and also short period of moderate glucocorticoid was supported. Patients with oxygenation index below 200 mmHg should be transferred to intensive medical center. Conservative oxygen therapy was preferred and noninvasive ventilation was not recommended. Patients with mechanical ventilation should be strictly supervised with cluster ventilator-associated pneumonia prevention strategies. Antimicrobial prophylaxis was not recommended except for patients with long course of disease, repeated fever and elevated procalcitonin (PCT), meanwhile secondary fungal infection should be concerned.Some patients with COVID-19 showed intestinal microbial dysbiosis with decreased probiotics such as Lactobacillus and Bifidobacterium, so nutritional and gastrointestinal function should be assessed for all patients.Nutritional support and application of prebiotics or probiotics were suggested to regulate the balance of intestinal microbiota and reduce the risk of secondary infection due to bacterial translocation. Anxiety and fear were common in patients with COVID-19. Therefore, we established dynamic assessment and warning for psychological crisis. We also integrated Chinese medicine in treatment to promote disease rehabilitation through classification methods of traditional Chinese medicine. We optimized nursing process for severe patients to promote their rehabilitation. It remained unclear about viral clearance pattern after the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Therefore, two weeks' quarantine for discharged patients was required and a regular following up was also needed.The Zhejiang experience and suggestions have been implemented in our center and achieved good results. However, since COVID-19 was a newly emerging disease, more work was warranted to improve strategies of prevention, diagnosis and treatment for COVID-19.

Key words: Coronavirus disease 2019    Severe acute respiratory syndrome coronavirus 2    Novel coronavirus infection    Critical illness    Combined modality therapy    Multi-disciplinary team
收稿日期: 2020-02-15 出版日期: 2020-02-21
:  R512.99  
通讯作者: 方强,周建英,盛吉芳,梁廷波,李兰娟     E-mail: zdyxyxkj@zju.edu.cn;1193001@zju.edu.cn;1183005@zju.edu.cn;zjyhz@zju.edu.cn;jifang_sheng@zju.edu.cn;liangtingbo@zju.edu.cn;ljli@zju.edu.cn
作者简介: 徐凯进(1974-), 男, 博士, 主任医师, 博士生导师, 主要从事感染性疾病研究; E-mail:zdyxyxkj@zju.edu.cn; https://orcid.org/0000-0001-8126-5008|蔡洪流(1970-), 男, 硕士, 副主任医师, 主要从事重症医学领域相关疾病研究; E-mail:1193001@zju.edu.cn; https://orcid.org/0000-0003-3783-8328
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引用本文:

徐凯进,蔡洪流,沈毅弘,倪勤,陈瑜,胡少华,李剑平,王华芬,俞亮,黄河,裘云庆,魏国庆,方强,周建英,盛吉芳,梁廷波,李兰娟. 2019冠状病毒病(COVID-19)诊疗浙江经验[J]. 浙江大学学报(医学版), 2020, 49(2): 147-157.

XU Kaijin,CAI Hongliu,SHEN Yihong,NI Qin,CHEN Yu,HU Shaohua,LI Jianping,WANG Huafen,YU Liang,HUANG He,QIU Yunqing,WEI Guoqing,FANG Qiang,ZHOU Jianying,SHENG Jifang,LIANG Tingbo,LI Lanjuan. Management of COVID-19: the Zhejiang experience. J Zhejiang Univ (Med Sci), 2020, 49(2): 147-157.

链接本文:

http://www.zjujournals.com/med/CN/10.3785/j.issn.1008-9292.2020.02.02        http://www.zjujournals.com/med/CN/Y2020/V49/I2/147

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