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Other Monoclonal Antibodies

Other Monoclonal Antibodes

Casirivimab, Imdevimab and Sotrovimab are US FDA approved recombinant neutralizing human IgG1 monoclonal antibodies that target the receptor binding domain of the spike protein of SARS-CoV-2. Whilst not yet evaluated and NICE approved in UK, they may become available for use in the near future; updates to follow.
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COVID Sarilumab (IL-6 inhibitor)

COVID Sarilumab

(IL-6 inhibitor)

Definition

Invasive mechanical ventilation: any method of controlled ventilation delivered through a translaryngeal or tracheostomy tube, or other methods as defined by the Intensive Care National Audit & Research Centre definition of ‘advanced respiratory support’.

Conditional recommendation

Consider sarilumab for adults in hospital with COVID-19 only if tocilizumab cannot be used or is unavailable. Use the same eligibility criteria as those for tocilizumab. That is, if all of the following apply:
  • they are having or have completed a course of corticosteroids such as dexamethasone, unless they cannot have corticosteroids
  • they have not had another interleukin-6 inhibitor during this admission
  • there is no evidence of a bacterial or viral infection (other than SARS-CoV-2) that might be worsened by sarilumab.
And they either:
  • need supplemental oxygen and have a C-reactive protein level of 75 mg/litre or more, or
  • are within 48 hours of starting high-flow nasal oxygen, continuous positive airway pressure, non-invasive ventilation or invasive mechanical ventilation.
In April 2021, the marketing authorisations for sarilumab do not cover use in COVID-19. See NICE’s information on prescribing medicines for more about off-label and unlicensed use of medicines. The recommended dosage for sarilumab is a single dose of 400 mg by intravenous infusion. For sarilumab use in pregnancy, follow the Royal College of Obstetrics and Gynaecology guidance on coronavirus (COVID-19) infection and pregnancy. For full details of adverse events and contraindications, see the summaries of product characteristics. See NHS England’s Interim Clinical Commissioning Policy on sarilumab for critically ill patients with COVID-19 pneumonia (adults) for further information. COVID-19 rapid guideline: managing COVID-19 (NG191) © NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-andconditions#notice-of-rights). Last updated 3 June 2021
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Definitions of terminology used

Definitions of terminology used

VTE

  • Expired tidal volume
  • Amount of gas passing in and out of the lungs in one cycle

PEEP

  • Positive end expiratory pressure
  • Increases the surface area of the alveoli

PIP

  • Peak inspiratory pressure
  • The highest level of  pressure applied to the lungs during inspiration

Flex

  • Enhances patient comfort
  • It will lower the pressure when the patient exhales and slowly increase the pressure on inspiration

Ramp

  • Allows the machine to start at a lower pressure and then increases the pressure over a set time frame
  • This allows the patient to get use to the mask at lower pressures first

Leak

  • The amount of air escaping from the mask
  • Should be less than 60 if possible
  • Usually due to the fit/size of the mask

FiO2

  • Fraction of inspired oxygen
  • Amount of oxygen being delivered to the patient
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Patient anxiety

Patient anxiety

Anxiety related to syncing with the mask, finding the mask uncomfortable, feeling claustrophobic and/or feeling like they can’t breath when using the machine
  • Check with doctors if medication can be given to help with this
  • Ensure regular breaks are discussed with the patient
  • Ensure the patient has their call bell within reach
  • Regular reassurance and encouragement
If the patient has had the mask on for a few days they may be anxious when we are weaning down the pressures and oxygen
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Continence

Continence

  • Does the patient need a catheter?
  • Will the patient be short of breath when using the commode?
  • Does the patient want/need a pad for comfort?
  • Consider that patient will become short of breath when using the toilet/commode/bedpan so oxygenation needs to be monitored.
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Dry eyes/mouth

Dry eyes/mouth

Does the patient need eye drops/artificial tears? Consider using mouth care pack to moisten lips and mouth.
  • Do not use a paraffin-based product if the patient is on oxygen.
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Pressure sores

Pressure sores

Pressure areas to consider when patient is in bed:
  • Any bony prominence on a patient e.g. sacrum, shoulders, heels
  • Facial pressure sores due to NIV mask
Areas to consider:
  • Cheeks
  • Nose bridge
  • Forehead
  • Back of head where the straps come into contact with the skin
  • Chin
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Oral intake

Oral intake

Fluid

  • Is the patient drinking enough?
  • Do IV fluids need to be considered?

Food

  • Is the patient able to have breaks off of the CPAP to eat, and do they maintain their oxygen saturations while eating?
  • If not consider NGT/dietician referral.
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Gastric distention

Gastric distention

A consequence of tight fitting mask around mouth and nose is that pressurised air delivered by CPAP is sometimes swallowed (aerophagia) resulting in a progressively swollen/distended stomach. This most often results in patients experiencing more flatulence, but there remains a serious risk of vomiting and aspirating.