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Covid19 oct 2020
- 1. Col Bharat Malhotra SeniorAdvisor (Medicine) Virus – SARS CoV 2 SARS CoV 1 caused epidemic of 2003 Disease – COVID-19
- 2. Virus Size: (0.12 μm) (3Important Aspects) MASK-95 (Protect upto 0.3 μm) HANDWASH (Avoid Contamination) DISTANCE (> 1 to 2 meters) Infectivity 2d prior symptoms last 8d
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- 4. IT IS ACLINICAL DIAGNOSIS BASED ON SPO2 AND RESPIRATORY RATE MILD URTI SPO2 (>97%) NORMAL (<20/MIN) MODERATE PNEUMONIA SPO2 90-94 % RR 24 – 30 /MIN SEVERE SEVERE PNEUMONIA SPO2 <90 % RR > 30/MIN REQUIRES CXR, ABG, SOMETIMES ECHO (ALSO NOTE IF ABG IN ROOM AIR OR O2) ARDS ONSET < 7 D CXR B/L OPACITIES ORIGIN OF PUL INFILTERATES ABG PaO2/FiO2 <300 ON CPAP > 5 mmH2O CLINICAL ASSESSMENT, LAB PARAMETERS SEPSIS ACUTE LIFE THREATENING ORGAN DYSFUNCTION + DYSREGULATED HOST RESPONSE SEVERE SEPSIS PERSISTENT HYPOTENSION DESPITE VOLUME RESUCITATION REQUIRE VASOPRESSORS MOHFW DT 03 JUL 20 CXR to rule out complications
- 5. Room Air Fio2= 0.21 On Oxygen FiO2 = can be from 0.21 to 0.6 PaO2 is most important info FiO2 is Required Other Parameters EXAMPLE - ABG
- 6. Used by NHS (UK) <4 LowRisk 5-6 Medium Risk > 7 High Risk NEWS (2012) updated NEWS-2 (2017) by NHS(UK) implemented using NEWS-2 score for picking high risk COVID19 cases (2020)
- 7. (In our MH) HAEMAT/BIOCHEM IFSpo2 < 97% ECG, CXR MARKERS IF Spo2 < 95%CRP D DIMER LDH FERRITI N IL-6 Laboratory findings in COVID-19 diagnosis and prognosis Clinica Chimica Acta Aug 20
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- 12. Gupta, A., Madhavan,M.V., Sehgal, K. et al. Extrapulmonary manifestations of COVID-19. Nat Med 26, 1017–1032 (Jul 2020).
- 14. PARACETAMOL – FEVER& FATIGUE ANTITUSSIVE – FOR COUGH HYDRATION NUTRITION TAB HCQS FOR HIGH RISK ONLY MONITOR FOR SIGN SYMPTOMS OF COMPLICATIONS • CLINICAL • RESPIRATORY RATE • PULSE OXYMETER – SPO2
- 15. PARACETAMOL – FEVER& FATIGUE ANTITUSSIVE – FOR COUGH HYDRATION NUTRITION * Oxygen support (if Spo2 < 92%) * Awake proning (Prone Lt Lateral Supine Rt Lateral Prone every 30 to 120 mins) * LMWH (Enoxaparin 40 mg SC OD) * Steroid (Dexamethasone 6 mg IV OD) * Remdesivir 200mg IV OD day 1 then 100 mg OD day 2 to 5. (EUA) * Convalescent Plasma (OFF LABEL USE) Do lab test (Basic - Daily) / (Markers - 72h), MONITOR carefully
- 16. PARACETAMOL – FEVER& FATIGUE ANTITUSSIVE – FOR COUGH HYDRATION (conservative fluid – if no shock is present) (N/S or R/L in shock) NUTRITION Oxygen support - O2 Therapy (if Spo2 < 92%), HFNC Ventilatory Support (lung protective strategy ARDSNet Protocol & Prone Ventilation) LMWH (Enoxaparin 40 mg SC BD) Steroid (Dexamethasone 6 mg IV BD) (max 0.4 mg/kg) Remdesivir 200mg IV OD day 1 then 100 mg OD day 2 to 5. (EUA) Convalescent Plasma 200 ml single dose over 2 hours (OFF LABEL USE) TOCILIZUMAB (OFF LABEL USE) Do lab test (Basic - Daily) / (Markers - 72h), MONITOR carefully
- 17. • Moderate Illness/Severe Illness Steroids – Dexamethasone IV Methylprednisolone IV • Prophylactic dose – Moderate • High Prophylactic Dose - Severe LMWH – LMWH (Enoxaparin) UFH Moderate or Severe Moderate or Severe
- 18. • Progressing towardsModerate Illness Favipiravir (Not recommended by MOHFW) (Weak Evidence) • O2 REQUIREMENT Remdesivir • O2, Steroids, (Not Improving) Convalescent Plasma • O2 , Steroids, ventilator TOCILIZUMAB Early Mod Mod Mod Sever e
- 19. Remdesivir (Emergency useAuthorization) WHEN CONTRAINDICATION DOSE MED STORE – PROCUREMENT ISSUE O2 Requirement Spo2 90-94% spO2 < 90% AST/ALT > 5 times eGFR < 30ml/min/m2 Pregnancy Lactation Child < 12 years 200 mg IV day 1 100 mg IV day 2-5 Give slow over 2h Total doses required 6 per patient Cost 5k/vial Shelf life 3 months Prodrug (active form - remdesivir triphosphate) RNA-dependent RNA polymerase (RdRp) – blocks replication by placing remdesivir triphosphate in place of adenosine Remdesivir sometimes doesn’t work: Coronaviruses has exoribonuclease proof reading ability Note: Not Permitted empirically
- 20. Remdesivir (Benefit in patientusing Oxygen) 1062 patients -randomization 541 assigned to remdesivir 521 to placebo John H. Beigel et al. Remdesivir for the Treatment of Covid-19 — Final Report. NEJM October 8, 2020 CONCLUSION Remdesivir was superior to placebo in shortening the time to recovery in adults who were hospitalized with Covid-19 and had evidence of lower respiratory tract infection.
- 21. Plasma Therapy (OffLabel) WHEN SPECIAL PREREQUISITES DOSE LAB– PROCUREMENT ISSUE O2 Requirement + Steroid use Spo2 90-94% spO2 < 90% ABO Compatibility Cross matching – donor plasma Neutralizing titer of donor plasma should be above the specific threshold 200 ml Give slow over 2h Watch for Transfusion related adverse events Bring from blood bank facility authorized for its use and storage. Plasma donated by people who've recovered from COVID-19 has antibodies to the virus that causes it
- 22. Tocilizumab (Off Label) WHENSPECIAL PREREQUISITES DOSE PROBLEMS O2 Requirement + Steroid use + Mechanical ventilation SpO2 < 90% High CRP , Ferritin High IL6 No TB, HIV No bacterial/fungal infection No Hepatitis ANC < 2000/mm3 Platelet count < 1,00,000/mm3 8mg/kg (400-800mg) IV Slow over 1h Cost Secondary infection Neutropenia Recombinant human monoclonal antibody IL-6 inhibitor (helpful during the intense cytokine storm due to release of IL, TNF)
- 23. GOI MOHFW ClinicalGuidelines on Diabetes Management dt 26 Aug 20. COVID19 DPP4 (Vildagliptin) (Permitted) METFORMIN (caution) GLIMEPERIDE (caution) Basal Bolus regimen (mod & severe COVID19) Pioglitazone SGLT2 (dapagliflozin) Sugar (R) by glucometer (>180mg/dL) Next day HBA1C ( > 6.5 %) Next day Sugar Fasting (>126 mg/dL) BASAL BOLUS REGIMEN WHEN MOD / SEVERE COVID-19 PREMEAL > 180 POST MEAL > 250 HOW MUCH 0.4 U/Kg/Day DIVIDED IN 4 DOSES (25% EACH) STEROIDS MAY REQUIRE HIGHER AFTERNOON DOSE TARGET PREMEAL 100 – 140 POSTMEAL 140-180 Avoid < 100 (Hypoglycemia) NORMAL STRESS HYPERGLYCEMIA DIABETES
- 24. Cardiovascular Considerations forPatients, Health Care Workers, and Health Systems During the COVID-19 Pandemic J Am Coll Cardiol. 2020 May, 75 (18) 2352-2371 PREEXISTING DISEASE MORE ADVERSE OUTCOME HYPERTENSION – Existing Rx (ACE I & ARBs permitted) (NEJM May 2020) STEMI – Primary PCI/Thrombolysis STABLE ANGINA – Continue Rx HEART FAILURE - masquerade as covid19 OAC – shift to LMWH ECG – LOOK FOR QTc INTERVAL CABG, Catheter Ablation postponed
- 25. Parinita Dherange etal. Arrhythmias and COVID-19: A review J Am Coll Cardiol EP 2020;J. Jacep.2020.08.002 Daily ECG
- 26. DRUG INTERACTION ACTION HCQSB Blocker Hypoglycemic drugs QT prolong drugs Monitor ECG Remdesivir HCQ QT prolong drugs Formulation has Beta-cyclodextrin. It may accumulate in CKD Do not Combine with HCQS Monitor ECG Urea, Creatinine LFT Steroids Warfarin Manage hyperglycemia (No OHA) Monitor INR Sugar checks Favipiravir Tocilizumab Do not combine with HCQ Safe in CV disease Unsafe in renal/liver disease --
- 27. MENTAL HEALTH ISSUES Fear,Stress Anxiety Low mood Sleep & Appetite Headache PERSON IN ISOLATION FAMILY MEMBERS OF PATIENT COVID-19 PATIENT HEALTH CARE WORKERS OTHER FRONT LINE WORKERS VULNERABLE POPULATIONS PSYCHIATRIC DISORDERS Depression Anxiety PTSD Delirium Psychosis SERIOUS ISSUES: Substance Abuse, Drug Withdrawal, Suicide
- 28. HOME SCENARIO (COVIDERA) COVID SCENARIO TELE MEDICINE Telepsychiatry Operational Guidelines NIMHANS-2020 Lockdown No College Worry About Future Decrease Sleep Stopped Going Out No Fruits, No Sunshine, Erratic Cooking Appetite Affected Watched News Stress of disease information/misinformation Stopped TV Less movement outside No Outdoor Games, Socializing, Outings, Party, Friends interactions Low mood , Reduced Self care DELIRIUM is very Common Substance abuse, Alcohol Abuse and withdrawal, Suicidal, preexisting psy disorder Organic medical problem – encephalopathy, seizures, delusion, hallucinations Security & Monitoring Issues SLEEP: Clonazepam MOOD: Escitalopram Mood Stabilizer: Valproate Antipsychotics: Olanzapine Minimum 10 min of videoconference (Give only A schedule)
- 29. . SOURCE: AIIMS GRANDROUNDS DATED 14 Sep 20
- 30. Chest Physiotherapy Avoid Exercise Avoidsmoking, Alcohol B complex supplements Psy Counselling Follow-up – HRCT Chest & Post Lung Sequel – When ?? What to do?? Steroids (up to 10 days in hospital only) (post discharge not required) Oral Anticoagulants (routine not required) (2 to 6 weeks for high risk)
- 31. . ENVIRONMENTAL FACTORS SMOKING CESSATION PERFINIDONE?? , NITENDINIB ?? MONITOR SPO2, 6MWT, SPIROMETRY, HRCT CHEST
- 32. WHAT IS RADIOLOGICALCOURSE OF COVID PNEUMONIA? WAIT 4-6 WEEKS IF PERSISTENT LOW SPO2 THINK OF PUL EMBOLISM OR FIBROSIS 14 D 30 D 51 PATIENT S Chest CT and Clinical Follow-up of Discharged Patients with COVID-19 in Wenzhou City, Zhejiang, China | Annals of the American Thoracic Society 2020 JUL 21 D
- 33. ROUTINE POST DISCHARGEVENOUS THROMBOEMBOLISM PROPHYLAXIS – (NOT REQ) POST DISCHARGE VENOUS THROMBOEMBOLISM PROPHYLAXIS- ONLY IN HIGH RISK CASES (for 2 to 6 wks) • OLDER AGE • D DIMER > 2 TIMES • MODIFIED IMPROVE-VTE SCORE > 4 PROPHYLAXIS –DURATION?? VTE – (3 MONTHS) Scientific and Standardization Committee communication: Clinical guidance on the diagnosis, prevention, and treatment of venous thromboembolism in hospitalized patients with COVID‐19. JTH May 2020
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