Based on MOHFW - basics of management of mild mod and severe cases along with management of comorbidity and post discharge medications

1. Col Bharat Malhotra
Senior Advisor (Medicine)
Virus – SARS CoV 2
SARS CoV 1 caused epidemic of 2003
Disease – COVID-19

2. Virus
Size: (0.12 μm)
(3 Important Aspects)
MASK-95
(Protect upto 0.3 μm)
HANDWASH
(Avoid Contamination)
DISTANCE
(> 1 to 2 meters)
Infectivity
2d prior symptoms last 8d

3. ASYMPTOMATIC
80%
HOSPITALIZATION
15%
CRITICAL
5%
ASSESS RISK
FACTORS
DYSNOEA
RESPIRATORY
RATE
Mortality 1.5 to 4%

4. IT IS A CLINICAL 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
Low Risk
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
IF Spo2 < 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

8. AB
C

9. .

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 towards Moderate 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 use Authorization)
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
patient using 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 (Off Label)
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)
WHEN SPECIAL 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 Clinical Guidelines 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 for Patients, 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 et al. Arrhythmias and COVID-19: A review J Am Coll Cardiol EP 2020;J. Jacep.2020.08.002
Daily
ECG

26. DRUG INTERACTION ACTION
HCQS B 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 (COVID ERA)
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 GRAND ROUNDS DATED 14 Sep 20

30. Chest Physiotherapy
Avoid Exercise
Avoid smoking, 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 RADIOLOGICAL COURSE 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 DISCHARGE VENOUS
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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