2. PROBLEMA (QUE PERSISTE)
Estamos atravesando una pandemia por el virus SARS – COV2,
que sigue generando alto numero de pacientes (como nunca
antes hemos visto) y alta probabilidad de muerte en la
población local vulnerable. NO EXISTE NINGUN TRATAMIENTO
ESPECÍFICO A LA FECHA ACTUAL.
9. Huang, Y., Yang, C., Xu, Xf. et al. Structural and functional properties of SARS-CoV-2 spike protein: potential antivirus drug development for COVID-19. Acta Pharmacol Sin 41, 1141–1149
(2020). https://doi.org/10.1038/s41401-020-0485-4
10. Huang, Y., Yang, C., Xu, Xf. et al. Structural and functional properties of SARS-CoV-2 spike protein: potential antivirus drug development for COVID-19. Acta Pharmacol Sin 41, 1141–1149
(2020). https://doi.org/10.1038/s41401-020-0485-4
11. Date of download: 2/11/2021
Copyright 2020 American Medical Association.
All Rights Reserved.
From: Potential Effects of Coronaviruses on the Cardiovascular System: A Review
JAMA Cardiol. 2020;5(7):831-840. doi:10.1001/jamacardio.2020.1286
Coronaviruses Known to Cause Severe Viral PneumoniaAbbreviations: CVD, cardiovascular disease; MERS CoV, Middle East
respiratory syndrome coronavirus; R0, the basic reproduction number; SARS CoV, severe acute respiratory syndrome coronavirus;
SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Table Title:
18. PREDICTORES
DE SEVERIDAD
“Clinical course and risk factors for mortality
of adult inpatients with COVID-19 in Wuhan,
China: a retrospective cohort study “
The Lancet. Elsevier. Published March 11,
2020. DOI: https://doi.org/10.1016/S0140-
6736(20)30566-3
19. Estado sHLH
The HScore generates a probability
for the presence of secondary HLH.
HScores greater than 169 are 93%
sensitive and 86% specific for HLH.
Note that bone marrow
haemophagocytosis is not
mandatory for a diagnosis of HLH.
HScores can be calculated using an
online HScore calculator.
COVID-19: consider cytokine storm syndromes
and immunosuppression
www.thelancet.com Vol 395 March 28, 2020
20. EL PATÓLOGO TIENE LA ULTIMA PALABRA
www.thelancet.com/infection Published online June 8, 2020 https://doi.org/10.1016/S1473-3099(20)30434-5
31. HAY SDRA FENOTIPO L Y FENOTIPO H
Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different
phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2
32. CASO SOSPECHOSO DE COVID 19 (Síntomas) y/o
CASO PROBABLE (Síntomas + Imágenes compatibles en pruebas radiológicas)*
U07.2
≤7 días desde el inicio de los síntomas
Solicitar: P. Molecular o P. detección de antígenos
Positivo
Caso Confirmado (U07.1)
Aislamiento en área COVID
Negativo
Si tiene TAC con lesiones
compatibles informadas por
Radiología: Evaluación por
Infectología para definir pase a
área No COVID
Repetir P. Molecular a los 3 días o
detección de anticuerpos a los 7 días
Negativo
Descarte de Caso
COVID
Positivo Sólo
IgG
No es caso actual
de COVID19/
Probable infección
previa
pase a área No
COVID
Negativo
Si tiene TAC con
lesiones compatibles
informadas por
Radiología:
Evaluación por
Infectología para
definir pase a área
No COVID
Repetir P. de detección
de anticuerpos a los 7
días
Negativo
Descarte
de Caso
COVID
Positivo
Reevaluaci
ón por
Infectología
por Caso
Confirmado
>7 días desde inicio de los síntomas
Solicitar: P. detección de anticuerpos
Positivo Sólo
IgM o IgM/IgG
Caso Confirmado
(U07.1)
Aislamiento en
área COVID
Positivo
Aislamiento en
área COVID
Reevaluación por
Infectología por
Caso Confirmado
ALGORITMO 1.1. DIAGNÓSTICO Y LUGAR DE AISLAMIENTO DE CASOS QUE INGRESAN COMO SOSPECHOSOS O
PROBABLES DE INFECCIÓN POR COVID19 EN EL HOSPITAL III JOSÉ CAYETANO HEREDIA
33. CONTACTO DIRECTO CON DIAGNÓSTICO
SOSPECHOSO/PROBABLE/CONFIRMADO DE COVID19
• Persona que estuvo a <2m de un caso sospechoso/probable/confirmado durante al menos 15
minutos en un periodo que abarca desde 2 días antes del inicio de los síntomas, sin uso de
protección respiratoria ni ocular.
• Personal de salud que no ha usado equipo de protección personal (protección respiratoria y
ocular) o no ha aplicado el protocolo para ponerse, desechar o quitarse el EPP durante la
evaluación de un caso confirmado de COVID19.
VIGILAR Durante los siguientes 14 días desde el último
día de exposición presentación de síntomas de
sospecha de infección.
EXÁMENES Si se sospecha de caso asintomático, solicitar
prueba de detección de antígenos a partir del
día 3° de la última fecha de contacto y hasta los
7 días.
SI PRESENTA SÍNTOMAS
DE SOSPECHA
Solicitud de exámenes será según los
algoritmos de diagnóstico presentados.
36. Surviving Sepsis Campaign: guidelines on the
management of critically ill adults with COVID-19
Intensive Care Med. https://doi.org/10.1007/s00134-020-06022-5 . March 28, 2020
37. Infectious Diseases Society of America Guidelines COVID-19
Infection
1. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel
recommends hydroxychloroquine/chloroquine in the context of a clinical trial. (Knowledge gap)
2. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel
recommends hydroxychloroquine/chloroquine plus azithromycin only in the context of a clinical trial.
(Knowledge gap)
3. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel
recommends the combination of lopinavir/ritonavir only in the context of a clinical trial. (Knowledge
gap)
4. Among patients who have been admitted to the hospital with COVID-19 pneumonia, the IDSA guideline
panel suggests against the use of corticosteroids. (Conditional recommendation, very low certainty of
evidence)
5. Among patients who have been admitted to the hospital with ARDS due to COVID-19, the IDSA
guideline panel recommends the use of corticosteroids in the context of a clinical trial. (Knowledge gap)
6. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel
recommends tocilizumab only in the context of a clinical trial. (Knowledge gap)
7. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel
recommends COVID-19 convalescent plasma in the context of a clinical trial. (Knowledge gap)
Last updated April 11, 2020 at 10:58 AM EDT and posted online at www.idsociety.org/COVID19guidelines.
46. “Acute Respiratory Distress Syndrome and Death in Patients With COVID-19 in Wuhan, China”
JAMA Intern Med. doi:10.1001/jamainternmed.2020.0994. Published online March 13, 2020.
54. USO DE ANTICUERPO MONOCLONAL CONTRA R –IL 6 (TOCILIZUMAB) EN
COVID-19…. ¿ALGUIEN HIZO EL CHECK LIST ANTES DE …?
55.
56. ANALISIS DE LABORATORIO
¿SE PUDO HACER?
• En la analítica básica se considerará además del recuento de células
sanguíneas, pruebas de funcionalidad de los diferentes órganos o sistemas
(completar SOFA) y valoración de medio interno. Así mismo, en estudios
realizados principalmente en China se ha documenta una correlación
directa entre el nivel de diversos biomarcadores y la progresión a la
severidad. También la probabilidad de desarrollar Hemofagocitosis
Linfohistiocitosis secundaria (sHLH), procesos microtromboticos y síndrome
antifósfolipico.
58. L. Caly, et al. Antiviral Research 178 (APRIL 03, 2020) 1047872 “The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro”
IVERMECTINA
59. Ivermectin: a systematic review from antiviral effects
to COVID-19 complementary regimen
June 12, 2020. SPRINGER NATURE
60. Journal of Clinical Pharmacology, 2002;42:1122-1133
HIGH DOSES OF IVERMECTIN IN ADULTS
61. Safety and mosquitocidal efficacy of high-dose ivermectin when co-administered with
Dihydroartemisinin-piperaquine in Kenyan adults with uncomplicated malaria
(IVERMAL)
www.thelancet.com/infection Published online March 27, 2018 http://dx.doi.org/10.1016/S1473-3099(18)30163-4
Five (11%) of 45 patients
receiving ivermectin 600
μg/kg per day, two (4%) of
48 patients receiving
ivermectin 300 μg/kg per
day, and none of 46 patients
receiving placebo had one or
more treatment-related
adverse events.
63. HIDROXICLOROQUINA: LA NOVELA
www.thelancet.com Published online May 22, 2020 https://doi.org/10.1016/S0140-6736(20)31180-6
Data from 671 hospitals in six
continents.
96 032 patients with COVID-19
were hospitalised during the
study period and met the
inclusion criteria.
Of these, 14 888 patients were
in the treatment groups (1868
received chloroquine, 3783
received chloroquine with a
macrolide, 3016 received
hydroxychloroquine, and 6221
received hydroxychloroquine
with a macrolide) and 81 144
patients were in the control
group.
64. www.thelancet.com Published online June 4, 2020 https://doi.org/10.1016/S0140-6736(20)31324-6
After publication of our Lancet Article,1 several concerns
were raised with respect to the veracity of the data and
analyses conducted by Surgisphere Corporation and its
founder and our co-author, Sapan Desai, in our
publication….
…Based on this development, we can no longer vouch for
the veracity of the primary data sources. Due to this
unfortunate development, the authors request that the
paper be retracted.
67. Ten trials involving 6548 patients were pooled in our final analysis.
Significant heterogeneity was found in all outcome measures except for
ICU LOS (I2 = 38%, P = 0.21). Compared with placebo, corticosteroids
were associated with higher mortality (risk ratio [RR] 1.75, 95%
confidence interval [CI] 1.30 ~ 2.36, Z = 3.71, P = 0.0002), longer ICU LOS
(mean difference [MD] 2.14, 95% CI 1.17 ~ 3.10, Z = 4.35, P < 0.0001), and
a higher rate of secondary infection (RR 1.98, 95% CI 1.04 ~ 3.78, Z = 2.08,
P = 0.04) but not MV days (MD 0.81, 95% CI − 1.23 ~ 2.84, Z = 0.78, P =
0.44) in patients with influenza pneumonia.
68. Corticoides en MERS
Am J Respir Crit Care Med Vol 197, Iss 6, pp 757–767, Mar 15, 2018
Patientes who received
corticosteroids weremore likely to
receive invasive ventilation (141 of
151 [93.4%] vs. 121 of 158 [76.6%];
P,0.0001) and had higher 90-day
crude mortality (112 of 151 [74.2%]
vs. 91 of 158 [57.6%]; P = 0.002).
Usingmarginal structuralmodeling,
corticosteroid therapy was not
significantly associated with 90-day
mortality (adjusted odds ratio,
0.75; 95% confidence interval,
0.52–1.07; P = 0.12) but was
associated with delay inMERS
coronavirus RNA clearance
(adjusted hazard ratio, 0.35; 95%
CI, 0.17–0.72; P = 0.005).
69. A total of 2104 patients were assigned to receive
dexamethasone and 4321 to receive usual care. Overall, 482
patients (22.9%) in the dexamethasone group and 1110
patients (25.7%) in the usual care group died within 28 days
after randomization (age-adjusted rate ratio, 0.83; 95%
confidence interval [CI], 0.75 to 0.93; P<0.001).
July 17, 2020. DOI: 10.1056/NEJMoa2021436
DEXAMETASONA 6MG EV CADA 24H X 10 DIAS.
70. Remdesivir for the Treatment of Covid-19 — Final Report
November 5, 2020; N Engl J Med 2020; 383:1813-1826. DOI: 10.1056/NEJMoa2007764
Those who received remdesivir had a median recovery time
of 10 days (95% confidence interval [CI], 9 to 11), as
compared with 15 days (95% CI, 13 to 18) among those who
received placebo (rate ratio for recovery, 1.29; 95% CI, 1.12 to
1.49; P<0.001, by a log-rank test).
The Kaplan–Meier estimates of mortality were 6.7% with
remdesivir and 11.9% with placebo by day 15 and 11.4% with
remdesivir and 15.2% with placebo by day 29 (hazard ratio,
0.73; 95% CI, 0.52 to 1.03). Serious adverse events were
reported in 131 of the 532 patients who received remdesivir
(24.6%) and in 163 of the 516 patients who received placebo
(31.6%).
REMDESIVIR 200MG EV DOSIS DE CARGA DIA 1.
LUEGO 100MG EV CADA 12H, DIAS 2 A 10.
71. November 5, 2020; N Engl J Med 2020; 383:1813-1826. DOI: 10.1056/NEJMoa2007764
72. November 5, 2020; N Engl J Med 2020; 383:1813-1826. DOI: 10.1056/NEJMoa2007764
73.
74. Hospitalizados SDRA (Pa/FiO2 < 300; daño bilateral) - UCI
• TTO DIRIGIDO.
• Ivermectina VO (gotas o tabletas) 400 microgramos
x Kg x día x 2 dias, luego valorar dosis adicional
(3era) según evolución.
• Anticoagulación: Enoxaparina 1mg/kg/12 hrs (ajuste
por edad y Función renal) durante hospitalización.
• TTO COMPLEMENTARIO:
• Analgésico/ antipirético: Paracetamol 1g VO /EV
solo pRN o máximo cada 8 hrs.
• Gastroprotección EV
• Aporte Vitamina C 4 a 6g/d x 10 dias según
tolerancia
• Aporte de Zinc VO 80 mg/Día (Preparados 20 mg/5
cc) x 10 días.
• Aporte de Vitamina D VO mínimo 2000 UI/Día
(pacientes mayores de 60 años o riesgo alto de
déficit de Vit D)
• VENTILACION MECANICA PROTECTIVA
• Sedoanalgesia RASS -4.
• Determinar Fenotipo de compromiso Pulmonar y
terapia dirigida: Fenotipo H – L.
• Pronación y relajante muscular si tiene indicaciones
• VALORAR RIESGO DE TORMENTA DE CITOCINAS o
sHLH Y CONSIDERAR:
• Si no se cuenta con Tocilizumab, usar
Metilprednisolona 250 a 500mg ev cada 24 hrs x 3
días, luego completar 1-2 mg/Kg/día x 5 días más.
CAPTACIÓN HASTA DÍA 7 DESDE EL INICIO DE SÍNTOMAS Y NO HOSPITALIZACIÓN PREVIA ≥ 48HRS
75. Captación después del día 7 de inicio de síntomas u hospitalización previa ≥ 48hrs:
• Descarte sobreinfección (Pancultivos) sobre todo en pacientes referidos de otros centros.
• Solicitar Procalcitonina sérica.
• Cobertura antibiótica con Cefalosporina 3era generación ó Fluorquinolona ó
betalacatamico con inhibidor de b-lactamasa MAS Vancomina Y/O Amikacina,
• Ivermectina.
• Iguales consideraciones para Anticoagulación y tto complementario
• Solo si hay Tormenta Citoquinas o sHLH; si no se cuenta con Tocilizumab, VALORACION
INDIVIDUALIZADA minipulsos Metilprednisolona 250 a 500mg ev cada 24 hrs x 3 días,
luego completar 1-2 mg/Kg/día x 5 días más, o solo esto último.
77. Patient self-inflicted lung injury
Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support.
Minerva Anestesiol 2019;85:1014-23. DOI: 10.23736/S0375-9393.19.13418-9
78. Patient self-inflicted lung injury
Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support.
Minerva Anestesiol 2019;85:1014-23. DOI: 10.23736/S0375-9393.19.13418-9
79. CONSIDERACIONES AL ALTA
• En todo paciente recuperado de IRA x neumonia valora uso extendido de
antitrombóticos por 30 dias, en coordinación con Hematologia y/o Cardiología:
• Enoxaparina 1mg / Kg/dia SC
• RIvaroxaban 20mg/ dia VO (en > 75 mg dar 15mg/d)
• Apixabam 5mg cada 12 hrs VO (en > 75 mg dar 2.5mg cada 12hrs)
• En todo paciente recuperado de IRA x neumonia valora uso de terapia inhalatoria,
en coordinación con Neumología:
• Bromuro Ipatropio 2puff cada 8 hrs x aerocamara.
• SAlmeterol / Fluticasona 2 puff cada 12 hrs x aerocamara.
• Evaluación por Medicina Física y Rehabilitación para terapia física y fisioterapia
respiratoria.
• Evaluación por departamento de Psicología – Psiquiatria para manejo de Stress
post traumatico.