PMC:7103696 / 9146-12838 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7103696","sourcedb":"PMC","sourceid":"7103696","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7103696","text":"Professor Wenhong Zhang (responsible for Shanghai’s overall clinical management of the COVID-19 cases)\nSince late January, I have been working to ensure the high-quality care of COVID-19 patient by building a highly experienced clinician team, Shanghai Clinical Treatment Expert Group, based on group members’ clinical and scientific expertise to provide the advice to complicated clinical management.\n\nA team approach to manage COVID-19 patients\nCurrently, there have been more than 330 laboratory-confirmed adult cases of COVID-19 in Shanghai [7]. Most patients (\u003e90%) are in mild or moderate states, and more than 90% of them have been cured and discharged by now. Because no specific drugs have been shown with clear effectiveness in helping the human body to clear the SARS-CoV-2 viruses, the disease severity rate in Shanghai (26 cases, around 9–10%) actually objectively reflected the natural history of the disease, and was comparable with the severity rate at other places outside Hubei Province. All critically ill patients received invasive mechanical ventilation, and six patients received extracorporeal membrane oxygenation (ECMO). We found that in addition to the involvement of the respiratory system, critically ill patients often had systemic involvement of multiple organs, including the heart, kidney, and coagulation system in the early disease course. Sometimes multiple system involvement was observed even at the time of initial hospital admission. Therefore, in addition to the respiratory supportive treatment, timely multiorgan evaluation and treatment is very crucial.\nEvery critically ill COVID-19 patient in Shanghai is managed by a group of healthcare providers which includes at least a pulmonologist, an infectious diseases expert, a critical care specialist, and an ECMO specialist if necessary. Nephrologists, psychiatrists, physicians of traditional Chinese medicine, experienced nurses also actively participate in managing these patients as well. Besides, substantial heterogeneity among severe patients was noted. Mild patients are more alike, but each severe case is severe in his/her own way. There may be multiple pathophysiological mechanisms in these critically ill patients. The types of critically ill patients need to be more carefully classified in order to perform more individualized treatment, in addition to conducting more dedicated research to develop a unique management plan. In Shanghai, medical decisions and interventions are carefully tailored to the unique characteristics of each severe patient.\n\nEarly and effective treatment of mild cases is critical\nThe overall mortality rate is about 0.9% in Shanghai. However, we have found that once the disease course progressed to the critical illness state (requiring mechanical ventilation), the prognosis of the patients would become significantly worse. From this perspective, treatments that can prevent mild state from progressing to the severe or critical state will significantly improve the overall prognosis of the clinical courses. Such effective treatments include intermittent short-term haemofiltration (ISVVH), low-dose short-course glucocorticoids therapy, among other approaches. The use of glucocorticoids is rather controversial and there is no general agreement by now. Based on our experiences, stably mild patients could self-manage the infection effectively and corticosteroid would not be recommended for them considering its potential risks. For patients who have an overly exuberant inflammatory response or are at high risk of developing ARDS, early-start of corticosteroids could be helpful. The benefit of corticosteroids as rescue treatment remains 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